Patient treatment expectations can outweigh equivocal effectiveness data

I’m getting old and starting to fall apart. Recently, I suffered a lumbar radiculopathy when I injured myself sneezing. (No, really, I did.)

lolostock/Thinkstock

So, as time went by and I didn’t get better, I began looking stuff up. When patients come to me for this, I go through the standard conservative regimen of NSAIDs, physical therapy, steroid tapers ... the standard stuff.

But, when I began looking these things up, I was surprised to find out how much of what we do (at least for lumbar radiculopathy) is taken on faith.

I went through UpToDate, the modern Bible of medicine.

NSAIDs and acetaminophen, to my surprise, have only marginal proof of efficacy for acute lumbosacral radiculopathy pain. Several pooled analyses showed a nonsignificant trend to support their use, and the quality of the data was considered to be low.

Likewise, physical therapy also had “no convincing evidence that such treatments are effective for this indication.” Admittedly, some of the data may be affected by the difficulty in doing sham therapy as part of a placebo controlled-trial.

An oral steroid taper? Again, similar, equivocal data. Marginal improvement in functional capabilities, no improvement in pain, and no improvement in the rate of surgery at 1 year out.

But these are the things that I, and likely most family doctors, physiatrists, and other neurologists recommend on a daily basis. And, in all likelihood, will continue to do so.

Why?

Overall, they are benign when used correctly and in the right patients. That isn’t to say everyone should get them. All drugs have issues, and patients have to be carefully matched to specific treatments.

But, in the grand scheme of “do no harm,” physical therapy, NSAIDs, acetaminophen, or a few days of steroids are reasonably harmless. There certainly are some patients who will benefit, and none of these approaches have clearly been shown to be dangerous.

There’s also patient expectations. They didn’t come to us, or shell out a copay, to be told that “nothing helps, give it time.” We’re the doctors, and they want us to DO SOMETHING. So even if these treatments may be placebos, they still help if for no other reason than (as Voltaire said) to amuse the patient while nature cures the disease.

And getting them better is, after all, a big part of our job.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I’m getting old and starting to fall apart. Recently, I suffered a lumbar radiculopathy when I injured myself sneezing. (No, really, I did.)

lolostock/Thinkstock

So, as time went by and I didn’t get better, I began looking stuff up. When patients come to me for this, I go through the standard conservative regimen of NSAIDs, physical therapy, steroid tapers ... the standard stuff.

But, when I began looking these things up, I was surprised to find out how much of what we do (at least for lumbar radiculopathy) is taken on faith.

I went through UpToDate, the modern Bible of medicine.

NSAIDs and acetaminophen, to my surprise, have only marginal proof of efficacy for acute lumbosacral radiculopathy pain. Several pooled analyses showed a nonsignificant trend to support their use, and the quality of the data was considered to be low.

Likewise, physical therapy also had “no convincing evidence that such treatments are effective for this indication.” Admittedly, some of the data may be affected by the difficulty in doing sham therapy as part of a placebo controlled-trial.

An oral steroid taper? Again, similar, equivocal data. Marginal improvement in functional capabilities, no improvement in pain, and no improvement in the rate of surgery at 1 year out.

But these are the things that I, and likely most family doctors, physiatrists, and other neurologists recommend on a daily basis. And, in all likelihood, will continue to do so.

Why?

Overall, they are benign when used correctly and in the right patients. That isn’t to say everyone should get them. All drugs have issues, and patients have to be carefully matched to specific treatments.

But, in the grand scheme of “do no harm,” physical therapy, NSAIDs, acetaminophen, or a few days of steroids are reasonably harmless. There certainly are some patients who will benefit, and none of these approaches have clearly been shown to be dangerous.

There’s also patient expectations. They didn’t come to us, or shell out a copay, to be told that “nothing helps, give it time.” We’re the doctors, and they want us to DO SOMETHING. So even if these treatments may be placebos, they still help if for no other reason than (as Voltaire said) to amuse the patient while nature cures the disease.

And getting them better is, after all, a big part of our job.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I’m getting old and starting to fall apart. Recently, I suffered a lumbar radiculopathy when I injured myself sneezing. (No, really, I did.)

lolostock/Thinkstock

So, as time went by and I didn’t get better, I began looking stuff up. When patients come to me for this, I go through the standard conservative regimen of NSAIDs, physical therapy, steroid tapers ... the standard stuff.

But, when I began looking these things up, I was surprised to find out how much of what we do (at least for lumbar radiculopathy) is taken on faith.

I went through UpToDate, the modern Bible of medicine.

NSAIDs and acetaminophen, to my surprise, have only marginal proof of efficacy for acute lumbosacral radiculopathy pain. Several pooled analyses showed a nonsignificant trend to support their use, and the quality of the data was considered to be low.

Likewise, physical therapy also had “no convincing evidence that such treatments are effective for this indication.” Admittedly, some of the data may be affected by the difficulty in doing sham therapy as part of a placebo controlled-trial.

An oral steroid taper? Again, similar, equivocal data. Marginal improvement in functional capabilities, no improvement in pain, and no improvement in the rate of surgery at 1 year out.

But these are the things that I, and likely most family doctors, physiatrists, and other neurologists recommend on a daily basis. And, in all likelihood, will continue to do so.

Why?

Overall, they are benign when used correctly and in the right patients. That isn’t to say everyone should get them. All drugs have issues, and patients have to be carefully matched to specific treatments.

But, in the grand scheme of “do no harm,” physical therapy, NSAIDs, acetaminophen, or a few days of steroids are reasonably harmless. There certainly are some patients who will benefit, and none of these approaches have clearly been shown to be dangerous.

There’s also patient expectations. They didn’t come to us, or shell out a copay, to be told that “nothing helps, give it time.” We’re the doctors, and they want us to DO SOMETHING. So even if these treatments may be placebos, they still help if for no other reason than (as Voltaire said) to amuse the patient while nature cures the disease.

And getting them better is, after all, a big part of our job.
 

Dr. Block has a solo neurology practice in Scottsdale, Ariz.