Keeping up to date in chronic back pain research is a busy process and yet it is rare that a new paper really catches the eye. A while back a trial of methylene blue injections appeared to demonstrate surprisingly impressive results. I blogged on it (here) and mused on how results that good really need to be independently replicated before we can confidently accept them. But today a trial of a new therapeutic approach was dredged up in my search alerts. It is clearly novel and ground breaking. It is…. wait for it….woollen knickers.
In this RCT 48 CLBP patients were randomised to wear either woollen knickers (technically 75% merinos wool and 25% acrylic) or “placebo” knickers. Really. Not a “no treatment” or “going commando” control for this study, but 100% cotton underkeks. Now a placebo condition ideally has to have the same credibility as the active treatment. The question is, which do you think would be better for your back pain? I am undecided. What I am decided on is that the concept of “placebo underwear” for some reason gives me great joy. I must try to grow up.
Anyway participants had to wear these particular undercrackers for a 2 month experimental period. The study took place in Turkey in spring. I would imagine it might get quite warm? Given that, one question that bothers me is “how many pairs were they given?”. I am hoping numerous. There is no mention of adverse events in the report but I have concerns that the risk of sweaty gusset syndrome may well be higher with the active treatment.
But what of the results? Well brace yourselves and put this in the context that all treatments struggle to achieve meaningful effect sizes in CLBP. I have extracted the data from the report and made some graphs. The labelling is mine (apologies in advance).
First pain (0-100 visual analogue scale):
This represents a 90% (95%CI to 80-99%) reduction in pain from baseline. Read that again.
Now disability (Oswestry Disability Index)
That is a 64% (95% CI 50 to 77%) improvement in disability.
Hold the phones people! Chronic back pain virtually cured? All from wearing woolly panties? How could this work? What is the “active ingredient” of robust , thick (and potentially itchy) hosiery? The authors suggest that it is down to the role that being cold has to play in chronic back pain and the heat trapping qualities of woollen underwear. I’m going to come right out and say I don’t buy into this hypothesis that the problem of CLBP is largely temperature related. And because I have difficulty believing the proposed mechanism of action I have difficulty being confident in the results.
There are some methodological quibbles with the trial too. The method of randomisation and allocation concealment is not clear, there is no information on dropouts, it isn’t clear if the process of gathering the primary outcomes was properly blinded (easy to do- just get them to keep their trousers on!). But even if these issues were resolved I would still be troubled by scepticism. Any number of complex, multimodal and arguably (?) more plausible therapies have failed to produce astounding effects like these. It is simply hard to believe that something as simple as woolly grundies could or would. It is a rare case where the very size of the effect makes it harder to believe. Reassuringly though there does not appear to have been a sinister corporate funding influence from Big Pants-a (sorry).
Marcello Truzzi once said said “extraordinary claims require extraordinary proof”. I think these results are extraordinary. I would need to see bigger better trials (but won’t hold my breath for the first international multicentre mega-trial of woollen y-fronts for CLBP). Maybe we need some other observational studies to test the underlying hypothesis. Would we predict a higher incidence of CLBP in thong wearers (NB: not the Aussie meaning of thong) or those with a predilection for sporting insubstantial lacy numbers? Suggestions for future tests are welcome!
About Neil
As well as writing for Body in Mind, Neil O’Connell is a researcher in the Centre for Research in Rehabilitation, Brunel University, West London, UK. He divides his time between research and training new physiotherapists and previously worked extensively as a musculoskeletal physiotherapist. He also tweets! @NeilOConnell
He is currently fighting his way through a PhD investigating chronic low back pain and cortically directed treatment approaches. He is particularly interested in low back pain, pain generally and the rigorous testing of treatments. Link to Neil’s published research here. Downloadable PDFs here.
References
Kiyak E (2012). The impact of wool in the patients with chronic non-specific low back pain. Collegium antropologicum, 36 (2), 623-6 PMID: 22856254
Neal,
Thanks for the report. I just wrote a post last week about something I called the “Comfort Hypothesis.” It is based on the hygiene hypothesis, and speculates that the low level of minor irritating skin contact that we experience in the modern world compared to the one in which we evolved in, which is scratchy, poky and hard, could somehow disregulate the pain alarm system, making it more sensitive to other nociceptive inputs. Just as regular exposure to dirt might give the immune system something to do besides attack unnecessary targets, perhaps the woolen underwear provides a low level of constant mildly nociceptive peripheral contact which is more “natural”, and distracts the pain alarm system from other issues, such as the low back. So perhaps the comfort hypothesis explains the results here. Here is a link to my post:
http://www.bettermovement.org/2012/the-comfort-hypothesis/
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Neil O'Connell Reply:
August 28th, 2012 at 7:46 pm
Thanks Tim & Todd,
Even if irritation had some influence (and I don’t reckon it does personally) it would be amazing if it would have an effect of that size. Also our own Mark Catley fessed up to owning some merino pants and claims they offer comfort and style rather than irritation!
Curious.
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Betsan Corkhill Reply:
August 29th, 2012 at 7:33 pm
Perhaps the irritation made them move more and made sitting for long periods uncomfortable so encouraged them to get up and walk around??
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soula Reply:
August 29th, 2012 at 10:19 pm
perfect Neil!
“Placebo underwear” – that made my day!! Also reminded me of this dream I had once…… ahh, better not.
If only it was this simple – some robust reg grundies and goodbye to CLBP.
Seems the author has a little track record with wool:
http://www.ncbi.nlm.nih.gov/pubmed/19388862
“A new nonpharmacological method in fibromyalgia: the use of wool.” J Altern Complement Med. 2009 Apr;15(4):399-405. Kiyak EK. Atatürk University, School of Nursing, Erzurum, Turkey
“BACKGROUND:
Various studies concerning the treatment of patients with fibromyalgia using nonpharmacological methods have been carried out. There are, however, no reports on the use of wool clothing and bedding in treating these patients.”
“Conclusion: The use of woolen underwear and woolen bedding were effective in reducing the symptoms of patients suffering from fibromyalgia. The use of wool is recommended as a means of treatment for alleviating the pain of fibromyalgia.”
The sentence “There are, however, no reports on the use of wool clothing and bedding in treating these patients” stands out as perhaps one of the best lines I have read in any article for a long time.
Tim
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Grundies, ummmnahh, not woollen, even thinking of that and the itch factor causes me stress.
Perhaps it is beneficial along the lines of distraction?
Settling the high sensitivity of my skin in fibromyalgia was helped by lycra garments. A little gentle squeezing seemed to suppress the sensitivity. A feeling of being supported, perhaps. And much moisturiser.
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I think Todd has an interesting point here. This underwear certainly looks a little prickly and I would also say highly distracting to the wearer – focusing the brain’s attention elsewhere!
We’ve been using the activity of knitting with chronic pain patients since 2006 and I’ve noticed that they are particularly sensitive to different textures – the fibromyalgia patients in particular. Pure wool is often regarded as too course or prickly. Some of them are also uncomfortable with bright colours. I haven’t tried getting them to knit their own underwear…….maybe we should give it a go!
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Seems that the style of undies would matter. If they wear solid black versus the fine style posted in your post it could be a game changer. A super hero style or a Victoria Secret style juicy written across the butt area depending on belief systems might sway the results. Of course we haven’t even started on the type of waistband. Sorry I didn’t read the actual study–that may have been revealed. Your post is so entertaining I hate to ruin my experience with the real thing.
I particularly like thinking about it as part of the marketing campaign for a Pain Clinic. The best doctors with the most recent advances in pain management including the magic wooly knickers.
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Betsan Corkhill Reply:
August 29th, 2012 at 1:55 am
There are knitters who suffer from depression who knit and wear very brightly coloured (and patterned) socks because it makes them feel good. It’s something slightly daring which makes them smile in an ‘only I know I’m wearing these, unless I decide to flash my ankles’ kinda way. Could work with underwear too!
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Given the authors prediliction for woolly trials I reckon they might own a sheep farm! Big Pants-a; its possible!
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Working in a pain clinc recently the consultant produced some info that knitting groups were a beneficial activity for chronic pain sufferers – now if we encouraged the knitting of ones own knickers just imagine the results!! silver bullet methinks
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Betsan Corkhill Reply:
August 29th, 2012 at 1:59 am
I run a knitting group in a pain clinic and put this very question to them this afternoon. There was much hilarity and discussion particularly when they were deciding whether to ‘model’ their knicker creations in our show and tell session! In fact they had two whole hours of pain free laughter thanks to this study.
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2 hrs !!! thats better efficacy than Pregabalin
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Surely there is a link here with polishing certain other “products” mentioned in a previous post?
regards
ANdy
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there is much to be said for the ‘aaagh’ feeling? but from my experience, pudendal neuralgia loves cold. my pelvic nerve switches off its pain signal when i sit in a huge bowl of cold water. heat sets me into a flare. a recent discovery after a trip to italy where i had access to a bidet!.
i know one thing and that’s a g-string version would definitely not work for pudendal neuralgia sufferers, woolly or not!
lets see where this road leads. when it comes to nerve related chronic pain, nothing will surprise me.
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I run Therapeutic Knitting groups attached to the NHS Chronic Pain team in Kent. I’ll be giving them the link to your piece for guaranteed laughter induced pain relief next time I see them! Maybe all the groups could join together in Knitting Knitted Knickers for a bigger better trial…..
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Wool and acrylic both passively irritate my skin – feel not weal. That barrage of prickliness. Imagine all that C fibre activity. This makes huge sense within the construct of distraction. Which for non-specific chronic low back pain is what you need if you are resistent to increasing your top down inhibitory influences.
Top drawer(s) research concept.
Kind thoughts,
Steve
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There is an older study somewhere (I couldn’t locate it right off), that concluded fibromyalgia patients had less pain when sleeping on wool fleece mattress toppers. The study lookedat how the wool modulated body temperature by preventing excessive heating and cooling, thus keeping a more stable body tempreature, and this was the proposed mechanism for the decrease in fibromyalgia pain and better sleep. Ever since I read this, I have consdered sleeping on a sheep.
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Coincidently I was asked to speak at a Knitting/Textile conference last week. One of the speakers before me was talking about the history of knitted swimwear and underclothes. It appears that people linked various health benefits to their underclothes eg important to keep the kidneys warm. Knitted items, and particularly merino wool ones were seen to be particularly beneficial.
She then went on to talk about the particular qualities of Merino wool.
It’s a fine fabric which has tiny air pockets which trap air very efficiently. This keeps the wearer warm in cold weather and cool in hot weather. It also ‘wicks away’ moisture from the body. So it’s a breathable, efficient climate and moisture regulator which has natural anti-bacterial and odour resistant qualities.
To add to the discussion, a member of the audience commented to say that she wore merino underwear and stockings! She said there was an initial ‘itch factor but it was only an issue for the first week, then the skin and body got used to it – the brain starts ignoring it. It only gets itchy again if you get particularly hot, perhaps when sitting for long periods, so it prompts you to get up and walk around.
I wonder if the periodic ‘itch factor’ is also a reminder of where your back is in space, giving your brain a reminder of the actual space your back occupies??
On another point – the brains of Shetland Island knitters!
We also heard from Shetland Islanders about how knitting was so entwined in their culture. Girls learn to knit at the age of four. By the age of seven they are adept at using four needles to knit jumpers without seams. None of their traditional (read highly complicated!) fairisle and lace patterns are written down, they are just passed from generation to generation and are kept in their heads. By the age of 12 girls will be knitting them from memory which is extraordinary.
It struck me that it would be fascinating to ‘see’ what their brains look like and whether this affects the type of medical condition they get in later life.
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