The burden of proof

'I'm sorry Mr Simmonds but I really don't know what else to suggest for your sciatica'

It's not often that I find myself holding my hands up to this extent, but it happened yesterday. Mr Simmonds' spine is 'shot'. He is too old and frail to contemplate any further operations. Epidural injections, physiotherapy, osteopathy and acupuncture (provided by the local Pain Clinic) have all been tried without success. He takes paracetamol several times a day (stronger painkillers give him unacceptable side effects) and a nightly dose of amitriptyline which is partially effective in alleviating longstanding pain such as his.

If his pain were severe enough to prevent him from sleeping or leaving his home then I suppose I would prevail upon him to take opioids, and try to help him deal with the accompanying problems of dry mouth, constipation etc. For him however, pain is more like an irritating companion on a long journey, something he has simply learned to tolerate, hour by hour.

So what should I do? There are plenty of possibilities on offer from the complementary sector - homoeopathy, herbalism, reiki and yoga spring to mind straight away. I am not opposed to any of these, and never discourage any patient who shows an inclination to try them out. I am glad that they are available to those who choose them, many of whom seem to receive real benefit as a result.

However as a practitioner of conventional Western medicine, and one who purports to be scientifically based, I feel ethically bound not to recommend or prescribe any intervention unless I have good reason to believe that it is likely to be effective. Mr Simmonds has money in the bank, and he respects my advice to the extent that he probably would pay Central London rates to go and see any therapist that I recommended to him. With this influence comes responsibility, and  I have yet to see or read anything that persuades me that aromatherapy, for example, is any more effective than placebo in treating chronic sciatica. I would not be acting responsibly were I to send Mr Simmonds to a aromatherapist simply because to do so would be less humiliating than the admission that my cupboard of bona fide suggestions is bare.

This applies to more conventional remedies as well: you will be hard-pushed to find a GP who will recommend to you a 'tonic', such as used to be prescribed wholesale on the NHS, if you complain of fatigue or loss of appetite, since the lack of evidence for their effectiveness is now widely recognised.

Now, I realise that I am at risk of getting up some readers' noses here, and I am not seeking to allege that complementary therapies are ineffective for chronic pain. In fact, acupuncture does have some fairly compelling research findings in its favour as a treatment for persistent pain (e.g. Thomas et al, BMJ 333:623, 2006), which is why it is quite readily available on the NHS in many parts of the country and why I commonly recommend that patients try it. This is in spite of the difficulty that Western science has in trying to explain how it might work. Other complementary therapies may have genuine clinical efficacy that is merely waiting to be revealed by a high-quality clinical trial, and if readers wish to point me towards research findings that I appear to be ignorant of, then I would be glad to be informed.

I am also fully aware that not everything that is real or true can be demonstrated by scientific method (you prove to me that you love your spouse, and I will prove to you the existence of a personal creator God), so please do not dismiss me as just another closed mind. I am simply a jobbing doc who is aware that there are as many examples of wishful thinking out there as there are genuine solutions, and I find the approach of objective scientific enquiry is the least flawed method yet devised for improving people's health.

So where does this leave me and Mr Simmonds? Well, since sitting down to write this I have realised that I have yet to fully explore the psycho-social factors that might be contributing to his experience of pain.  The next time we meet it is just possible that the two of us might find a way forward along these lines.

Perhaps I have stumbled upon evidence, albeit purely anecdotal, in support of Writing Therapy, even for poor unenlightened GPs. Thanks, readers.