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The article by Woolf et al1 yields plenty of fascinating information. I was particularly interested to see the national differences in recommendations for acupuncture or herbal medicine (incidentally, herbal treatments are pharmacological by nature despite the affirmation to the contrary in fig 1 of the article). Throughout Europe, few doctors issue such recommendations, despite the fact that the evidence for both approaches is perhaps not conclusive but encouraging.2 Generally, acupuncture is recommended more frequently than herbal medicine. This too is somewhat contrary to the evidence on the efficacy of these approaches; the data for devil’s claw3 for instance are more convincing than those for acupuncture.4
Lastly, I found it interesting to see that doctors from the UK, Ireland, Sweden, and Italy do not seem to recommend either acupuncture or herbal medicines. Collectively, these data suggest that management of musculoskeletal pain in Europe is not always evidence based.
Professor Ernst’s letter highlights some interesting findings from our European survey about national variations in primary care physicians’ recommendations for alternative and herbal treatments in the management of musculoskeletal pain.1 Our survey of 5803 randomly selected people with musculoskeletal pain also highlighted how infrequently people with musculoskeletal pain use such remedies. For example, between 1 and 3% of people with musculoskeletal pain had used acupuncture, 0.6–4% had tried chiropractic, and up to 10% were treating themselves with a non-prescription preparation other than an analgesic or non-steroidal anti-inflammatory drug.
What is also interesting is that, although uptake in all countries was very low, use of acupuncture by people with musculoskeletal pain was greatest in the UK, Ireland, and Sweden, countries where, as Dr Ernst points out, very few physicians recommend acupuncture. The results of this survey suggest that the choices which people with musculoskeletal pain make about their treatment are influenced by many factors, one of which may be physician recommendation. A greater understanding of the social, cultural, and environmental context in which people make these choices is necessary to begin to establish explanations for the national variations in physician behaviour and the discrepancies between physician recommendation and the ways in which people actually manage their pain.