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INSIDE HEALTH

Programme 1.

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TX:听 25.06.13听 2100-2130

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PRESENTER:听 MARK PORTER

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PRODUCER:听 ERIKA WRIGHT

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Porter

Hello and welcome to a new series of Inside Health 鈥� the programme that takes a quizzical, evidence based look at the real stories behind the headlines, providing clarity where there is confusion.

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And a couple of stories caught our eye while we were off air, one over egged:

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Headlines clip

The stuff of Nobel prizes 鈥� half a million sufferers of back pain could be cured with antibiotics!

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Porter

And another that might have a little more to it:

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Headlines clip

Iodine deficiency may lower UK children鈥檚 IQ.

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Porter

We will be taking a closer look at iodine in pregnancy, and asking if antibiotics really do have a role in back pain later on.听 But first something that is all over this week鈥檚 headlines 鈥� the latest guidance from the National Institute for Health and Care Excellence (NICE) on protecting women from breast cancer.

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For the first time NICE is advocating that preventative medicines 鈥� in this case the oestrogen blockers tamoxifen and raloxifene 鈥� be offered to women at higher than average risk in light of evidence that they reduce the chances of developing breast cancer by more than a third.

But what鈥檚 striking is how NICE defines which women might benefit.听 It is not just the small number at very high risk, like Angelina Jolie, who carry comparatively rare genetic mutations like the breast cancer gene BRCA1. NICE is suggesting that the bar for offering preventative medication be set much lower 鈥� at a threshold that is likely to include half a million or more women. So, could you could be one of this new group deemed to be at moderate risk?

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Professor Gareth Evans is Consultant in Clinical Genetics at St Mary鈥檚 Hospital in Manchester, and helped develop the new recommendations.

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Evans

The biggest risk factor that identifies women is family history.听 So if you have a family history, particularly if you have a close relative 鈥� mother or sister under 40 or two relatives on the same side of the family 鈥� you鈥檙e at least going to be considered to be possibly in that moderate risk category.听 If you have a more extensive history, say two close relatives under 50 鈥� say mother, maternal grandmother, mother, sister or for instance sister and paternal grandmother because it can be inherited from the father鈥檚 side of the family 鈥� then that鈥檚 going to be starting to push you towards a high risk category.

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Porter

The Americans are looking at doing a similar thing and they鈥檙e using an online calculator that the general public can access to decide whether they鈥檙e at low, moderate or high risk 鈥� is there a similar tool here in the UK?

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Evans

There are similar tools and in fact people can go on some of the online tools that exist to assess risk.

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Porter

Because family history鈥檚 quite complicated isn鈥檛 it, there鈥檚 lots of different variants, quite a difficult thing to get your head round.

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Evans

That鈥檚 right and if 鈥� if for instance there are half-sisters and half-brothers and it starts to get quite complicated.听 Ideally it should be input by someone who knows about family history into an appropriate program and there are programs around such as Tyrer-Cuzick which calculates risk including other risk factors like when you started your family, when you had your first pregnancy, the younger you have your children the more protected you are, having more children may also add a further layer of protection and breastfeeding, although breastfeeding you need to do it for quite a long time to get substantial risk reduction, is also protective.听 When your periods started, when your menopause is, whether you鈥檝e used HRT your weight and potentially we鈥檙e starting to introduce other risk factors like alcohol.

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Porter

Because I鈥檓 thinking if there are hundreds of thousands, possibly millions of women out there who this guidance might apply to they鈥檙e going to have to work it out for themselves or discuss it with their GP, they鈥檙e not going to have access to you.听 If they鈥檙e already seeing somebody like you and getting advice then they鈥檙e probably in the high risk category and that鈥檚 a bit of a no brainer 鈥� we keep a close eye on those women anyway 鈥� this larger group is a new group and I mean they鈥檒l be ignorant of the fact at the moment, they won鈥檛 know?

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Evans

Yes I mean the guideline specifically is about women with a family history.听 So if you have a family history of breast cancer 鈥� so in a blood relative 鈥� you can ask your GP about whether you can be referred and if 鈥� the GPs have a fairly specific algorithm which says if there鈥檚 this sort of history they can referred at least to secondary care 鈥� so that鈥檚 your local breast unit, your local family history clinic.听 And then if you鈥檙e high risk you can be referred on to tertiary care 鈥� to genetic centres 鈥� and potentially gain access to things like MRI screening.

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Porter

And these women at moderate risk are they going to be offered increased surveillance as well 鈥� so breasts scans etc?

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Evans

Yes, so women at moderate risk potentially qualify for annual mammography screening between 40 and 49 years of age and鈥�

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Porter

As opposed to starting it at 50?

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Evans

As opposed to starting at 47-50 which is when the national screening programme kicks in and it鈥檚 annual rather than three yearly because we need to do it a little bit more frequently in younger women because of the slightly more rapid growth of the breast cancers and the fact that the tissue is a bit denser, so it鈥檚 harder to pick up the cancers.

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Porter

And in terms of impact of looking at the tamoxifen and the use of similar drugs like that, I mean how much protection is it likely to offer these women?

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Evans

Tamoxifen nearly halves the risk, so if you were looking at 10 women who would have developed breast cancer you will save four of those women from developing breast cancer, so it鈥檚 a substantial reduction in risk.听 I mean for instance we know that women who have their ovaries removed at 40 halve their risk but most women would maybe rather take tamoxifen for five years than have their ovaries out at 40.

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Porter

But the tamoxifen is providing protection in a similar way to removing 鈥� you鈥檙e removing the female hormone oestrogen effectively, which is like a 鈥渁 fertiliser鈥� for breast cancer, is it that simple?

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Evans

It鈥檚 pretty much that simple, essentially what鈥檚 happening is oestrogen and progesterone stimulate the breast cells, the breast cells divide and they divide more frequently and that increases the likelihood of accumulating genetic changes which then eventually lead to a cancer.听 So the more a woman is exposed to oestrogen in her lifetime, the earlier she starts her periods, the later she finishes her periods, the more risk that she鈥檚 at.

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Porter

The figures suggested in the guidance is five years for duration of therapy, has that been chosen for a specific reason, might there be more benefit from taking the drug longer or is it simply we don鈥檛 know yet?

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Evans

We don鈥檛 really know because those studies haven鈥檛 been done.听 I mean most of the evidence previously suggested for instance for women with breast cancer that there wasn鈥檛 much difference between taking tamoxifen for five years and 10 years.听 There鈥檚 a recent study that suggests there might be slightly more benefit from taking it but for women where you鈥檙e actually preventing breast cancer what we know is five years of taxmoxifen continues to protect you up to nearly 20 years into the future.听 So certainly at the moment we haven鈥檛 got the evidence to say take it for longer, five years clearly has major benefits.

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Porter

Do we have much experience of women鈥檚 response to this concept, I mean are they keen to take tamoxifen, looking at the early trials, looking at what鈥檚 happening in other countries?

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Evans

It鈥檚 mixed at the moment.听 If you look at some of the data out there then it suggests the uptake of these sorts of chemopreventive measures are quite small.听 But if you mine down on it and actually look at where it鈥檚 properly offered and women are given the ability to make a proper informed decision then it starts to go up to above one in five women, about 20%, that would opt to take a chemopreventive agent like tamoxifen or raloxifene.

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Porter

Professor Gareth Evans. Well to discuss the implications of the new guidance I am joined by Inside Health鈥檚 Dr Margaret McCartney; Professor Jack Cuzick from the Wolfson Institute of Preventive Medicine 鈥� and one of the team behind the Tyrer-Cuzick online risk calculator we have just heard about and Head of Policy at Breakthrough Breast Cancer Dr Caitlin Palframan.

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Palframan

This group of moderate risk women are often very concerned about their health and do want to know what they can do to reduce their risk of breast cancer.听 I think unlike when we鈥檙e talking about people who have a faulty BRCA gene and the people in very high risk categories, in this category of moderate risk the discussions become maybe even more nuanced 鈥� so how high actually is this person鈥檚 risk, is the discussion that the doctor should be having with their patient, what are the options that are available to them and what are the benefits and risk of those options.听 And I think having a frank discussion of all of that is really important when you鈥檙e talking people who are maybe not at that much higher risk than the general population.

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Porter

Jack, can you put the benefits in context 鈥� how effective is this drug if used in the right groups of women?

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Cuzick

The evidence in our overview shows that overall you get about a 40% reduction in breast cancer.听 To put that in context:听 if you took a thousand women who were aged 50 at double the population risk, which is kind of the number we would start with, there would be 11 fewer breast cancers over the first five years and it looks like another 11 in the next five years.听 Now the downsides, the most common downside, are blood clots, so called thromboembolisms or blood clots and they would increase from about six in the general population up to 12, so there鈥檇 be about six more of those.听 And there鈥檒l be an increase in womb cancer, which typically over that period there would be two in the general population and that would go up to about five.

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Palframan

I think though it鈥檚 important that what Jack was saying is about that population that鈥檚 at twice the risk of the general population and actually a considerable number of people that the NICE guidelines are recommending get this treatment are actually at much higher risk than that.听 So we think in the highest risk population the benefits are perhaps more clearly outweigh the risk.

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Cuzick

Yeah I think that鈥檚 a good point, that at a higher risk of course the benefits are going to go up and the risks are going to stay the same, so the balance is going to be more favourable.

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Porter

I can understand this being done in a specialist breast clinic where people have expertise in working out risks and calculations but Margaret, this could be happening in your GP鈥檚 surgery when someone comes in and goes well I鈥檝e heard on the radio they鈥檙e giving tamoxifen, am I one of the women who might benefit?

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McCartney

I suppose one of the problems that we have and one of the uncertainties that persists, even after these trials, is that we haven鈥檛 really looked at all cause mortality, so we haven鈥檛 looked at the play off between deaths from breast cancer versus deaths from the side effects of the prophylactic taxmoxifen and where that interacts and where the balance of risk and harm is there. So well obviously it鈥檚 much better to prevent breast cancer if you can and it鈥檚 important to note that鈥檚 very different from screening for breast cancer because using tamoxifen you鈥檙e trying to stop a breast cancer in the first place.听 If you鈥檙e screening for breast cancer y ou鈥檙e trying to detect an early breast cancer, so they鈥檙e kind of two different processes.听 But I think it鈥檚 still very, very important that we look at the overall risk benefit calculation after 20, after 30 years and make sure that we are still benefiting women rather than creating a disadvantage.听 And these are the kind of really big issues 鈥� are we more likely to die taking tamoxifen or not?听 So yes preventing breast cancer, that鈥檚 the ideal, that鈥檚 what you would like to do but you also have to know is that actually going to be more likely to save my life or not.听 So it鈥檚 really big questions we need to ask I think and until we鈥檝e really done these long term studies that are powerful enough to look for all cause of deaths, not just breast cancer deaths but also blood clot risk, also womb cancer risk, so there鈥檚 lots of other factors I think needed to be added in to give women properly informed choices.

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Porter

And presumably that鈥檚 going on, it鈥檚 just that 鈥� you have to start from somewhere.

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Cuzick

We will continue to do this, I mean the trial follow up in one of the trials is now after 20 years.听 We don鈥檛 have complete data but we do know a lot about the side effects of tamoxifen, we know that the main risk is blood clots and that stops once you stop taking treatment, it鈥檚 not a long term effect.听 The benefits of reducing breast cancer are long term benefit.听 Probably the womb cancers are also long term risk which will go on after you stop.听 We don鈥檛 yet have clear figures about the fact that the reduction in incidence of breast cancer is going to be translated into a reduction in mortality, that will take more time.听 And so there is a certain amount of uncertainty there but it has been the case in every other treatment.

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Palframan

We also 鈥� I mean tamoxifen has been used for years and years for breast cancer treatment, so this isn鈥檛 a drug that鈥檚 being just used for the first time in England, so I think鈥�

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McCartney

Sure but every time I give it it鈥檚 not really for the experts to decide where the benefits and the risks lie in terms of an individual woman鈥檚 choice.听 I think it鈥檚 fair enough for there to be a conclusion that we think overall this is likely to be beneficial but I think we have to be absolutely honest with women about the side effects, about the unknowns and about the uncertainties that we will need further detail for many years to know.

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Palframan

I completely agree with you Margaret and I think that is clear in the guideline, I mean they鈥檙e saying for this population of people at high risk the benefits outweigh the risk but for any given women that may not be the right choice and it may be they don鈥檛 want to do anything and may be they prefer to take鈥�

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Cuzick

I mean there are clear statements in the guidelines that for example for women who鈥檝e had a blood clot previously they鈥檙e at an increased risk of developing another one and that鈥檚 鈥� those are women that should not take tamoxifen.

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Porter

Given that the vast majority of women won鈥檛 be at high risk of developing breast cancer, Margaret, would you advocate people going online and using a calculating tool like the one that Jack鈥檚 helped developed so that they can decide whether they鈥檙e at risk or not?

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McCartney

Yeah it鈥檚 an interesting one, I mean generally information is good and patients鈥�

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Porter

Because most will be reassured by it won鈥檛 they?

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McCartney

Yeah, yeah that鈥檚 true.听 Risk calculators are free to use, they鈥檙e openly available, so anyone can go online and use them but I suppose if someone is concerned that they do have a family history they鈥檙e open to speak to their GP about it.听

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Palframan

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I think when in doubt it鈥檚 a good idea to go to your GP, better to be safe than sorry.

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Porter

Jack, how confident are you that your online risk calculator works?

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Cuzick

It鈥檚 been validated in many, many populations now and widely used.听 It gives a very accurate prediction, we鈥檙e continuing to refine it as new risk factors come in but for the standard factors, based on family history, weight, hormone replacement therapy use, it鈥檚 really quite accurate.

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Porter

In summary do you think this is a major step forward 鈥� this guidance?

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Cuzick

I think it is a major step forward.听 Heart disease 鈥� we鈥檝e talked about diet and exercise for decades but what鈥檚 really had an impact on heart disease is use of statins.听 And we now are beginning to take that same idea into cancer.听 Diet is important, exercise is important but for the high risk individual you need to do more and in some cases that will be tamoxifen.

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Porter

Caitlin?

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Palframan

Yeah I think we want to prevent breast cancer in everyone ultimately, we鈥檝e been able to chip off this small population of people who are at higher risk that we may be able to give them drug treatment that can reduce their risk and I think that is a really historic step for breast cancer, it鈥檚 the first time that we鈥檝e been able to offer drug treatment that can reduce people鈥檚 risk for breast cancer.

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McCartney

I mean I think it is definitely a step forward but it鈥檚 a small step forward even though it鈥檚 only going to affect a small part of our population overall.听 I think we have to be really careful about taking care to ensure that we address the uncertainties, I think we have to be really careful that we give balanced information to women about whether or not they want to take this or not.听 And I think we have to be I think very careful as well about what direction we鈥檙e going down in in terms of how we鈥檙e trying to prevent breast cancer, are there other things we should be looking at as well in terms of how we look after our population.

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Porter

Dr Margaret McCartney, Professor Jack Cuzick and Dr Caitlin Palframan, thank you all very much.

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If you want to find out if you may be at increased risk of breast cancer there is a link to the online calculator developed by Professor Cuzick on our website 鈥� along with the new guidance from NICE. Go to bbc.co.uk/radio4 and click on I for Inside Health.

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Now back to those headlines.听 First concerns about iodine deficiency, prompted last month by a paper published in the Lancet highlighting a link between a lack of iodine in mothers and low IQ in their children.听 Which may come as a surprise to many doctors who are likely to think of iodine deficiency as a thing of the past.

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Iodine is essential for the normal functioning of the thyroid gland in the neck, and as a medical student I was always taught that deficiency used to be common, but that it hadn鈥檛 been a major issue in the UK since the mid-20th Century. My predecessors may have seen lots of people with swollen thyroid glands or goitres 鈥� so common in the midlands, where levels of iodine in the soil are particularly low, that it became known as Derbyshire neck 鈥� but I wouldn鈥檛.

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So why is iodine deficiency making a comeback now - and what should we be doing about it?

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Mark Vanderpump is a Consultant Endocrinologist at the Royal Free Hospital in London.

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Vanderpump

Historically post-war it was recognised that the country and particularly the children were particular malnourished and so there was a focus on encouraging all children to have milk in their first break at school.听 And at the same time there was a change in agricultural and farming practice so that iodine was entered into the food chain through the cows鈥� milk, through artificial feeds.听 And so over 鈥� between the 1950s to the sort of 1970s to 鈥�80s this was described as an accidental public health triumph in that the actual issue seems to have disappeared and goitre as an issue has disappeared within this country as a clinical problem.

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Porter

So a goitre is a swelling in the neck, it鈥檚 a swelling of the thyroid gland, and it鈥檚 a sign that the glands are not getting enough iodine?

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Vanderpump

And that鈥檚 the thyroid gland鈥檚 response to growing up or living in an iodine deficient environment, so it鈥檚 our main clinical sign.听 What we have found and other industrialised countries have found is that despite there being no change in the iodine content in the milk is that we鈥檙e now finding that iodine deficiency is being found again in the school children of this country.听 There are various explanations for that but it seems most likely that dietary habits have changed and that milk intake is much lower in our children than it would have been鈥�

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Porter

No school milk for many children, yeah.

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Vanderpump

鈥� would have been in previous generations.

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Porter

So we were accidentally reinforcing children with iodine.

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Vanderpump

And the World Health Organisation argues that you should just iodise all salt, so we鈥檙e not talking about taking anymore salt but just introducing iodised salt, which tastes exactly the same as ordinary salt, that enters into our diet about 10% of the salt we add at the table is our salt intake.听 So one of the issues this has got wrapped up a bit with is the focus on reducing salt in the diet to prevent hypertension and strokes.听 But you can very effectively iodise your salt and still have the same low salt message to treat both problems.

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Porter

But is salt in the UK not routinely iodised?

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Vanderpump

So the last survey that was done in Cardiff in Wales took 36 different salt preparations and only two were iodised.

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Porter

So what do you think the consequences of potential iodine deficiency are for the UK population at the moment?

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Vanderpump

Well the main issue really now is looking and targeting pregnant women because those are the most susceptible group, where mum鈥檚 thyroid status is key to the mental and neurological development of the baby and the foetus, particularly in the first 12 weeks of the pregnancy, when the baby鈥檚 thyroid hasn鈥檛 yet grown and is not making any thyroid hormone, so mother鈥檚 thyroid status in that first 12 weeks is completely key.听 One of the problems in the UK is that it鈥檚 probably only about 50% of pregnancies are planned and so most women will only know that they鈥檙e pregnant in the middle of that crucial first 12 weeks of the pregnancy.听 There is evidence to suggest that if you introduce iodine supplements at that particular point you might be too late in doing something about it.听 You probably need to be taking an iodine supplement at least three months before the pregnancy to allow that phase of transient sort of settling down to happen, so that you conceive when your thyroid iodine status is optimised.

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Porter

In much the same way as you might do with folic acid for instance 鈥� start taking it before conception.

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Vanderpump

Or even 鈥� even vitamin D, it鈥檚 exactly the same type of story.听 And you can make an argument for a folic acid, vitamin D and iodine supplement as an ideal supplement to be taking three months pre-pregnancy.

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Porter

Is there a downside to taking iodine, is there any harm in doing it?

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Vanderpump

Well there have been now historical studies looking at large populations where the iodine levels which are similar to ours have been addressed and those are mostly in Scandinavia and particularly in Denmark and what they鈥檝e demonstrated is that although you improve the situation for the younger people and the pregnant women you do have a slight increase in thyroid disease in the more elderly members of the community 鈥� they tend to have a rise in their rate of thyrotoxicosis or an overactive thyroid.听 So there is a balance but you can do it in a way that鈥檚 very gradual and raises your level quite subtly without inducing a big problem in your older age group.听 So the World Organisation think it鈥檚 quite simple 鈥� you should just iodise all salt because in that way you just do the whole population.听 The alternative argument is that you pick your targeted group pre-conception but you have to be aware that that doesn鈥檛 cover 50% of pregnancies.

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Porter

What proportion of pregnant women in the UK do you think might be iodine deficient to some degree?

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Vanderpump

Well when we looked at 12-14 year old schoolgirls we found that two-thirds were significantly iodine deficient and bearing in mind that鈥檚 pre-conception, because we were looking at the group who are going to be the mums in the next five to 10 years or so.听 And of course the important point to make is that when you become pregnant your thyroid hormone requirements go up significantly and your iodine levels need to match that production.听 So if you鈥檙e finding a problem pre-pregnancy it鈥檚 only going to get worse during the pregnancy, so we might be talking about the majority of women entering pregnancy in this country being iodine deficient.

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Porter

Dr Mark Vanderpump, and you will find some useful links on iodine, including a guide to supplementation during pregnancy, on our website. Head for the Inside Health page at bbc.co.uk/radio4.

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The other story that had us champing at the bit was new research from Denmark suggesting that some types of back pain can be treated with antibiotics. It created quite a stir, but the findings were massively overblown by the resulting coverage in the media.

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Headline clip

Antibiotics could cure 40% of chronic back pain patients.

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Porter

The researchers found that a three month course of antibiotics seemed to ease pain and improve mobility in people who had ongoing problems after disc prolapse 鈥� a so called slipped disc 鈥� and who showed particular changes on their MRI scan.听听 Known as Modic changes they suggest inflammation in the bone which researchers believe to be caused by a low grade bacterial infection. Quite how the bacteria get into the spine and damaged disc remains unclear, but one theory is that they gain entry via the gums when people brush their teeth.

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So - a small study suggests some benefit in a group of people with very specific type of back pain and characteristic MRI changes. How does that justify headlines suggesting antibiotics are a cure for back pain, that could help half a million people in the UK alone, and be the stuff of Nobel prizes?

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Inside Health鈥檚 Dr Margaret McCartney has been examining the evidence and the lead author from the study 鈥� Hanne Albert who is Associate Professor at the University of Southern Denmark听听 - is on the line.

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Dr Albert, do you think the coverage of your research here in the UK accurately reflected what you actually found?

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Albert

No that is not precise but this is headlines and headlines are never precise.听 I think it鈥檚 very important to understand that this cure is only for a specific group of patients with chronic low back pain who have modic changes after a previous slipped disc.听 This is not for everybody.听 This is only for a very small group and that is very important to remember.

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Porter

Margaret, you as a GP, I certainly had lots of people coming to the surgery with cuttings form the Daily Mail and other newspapers saying look I want some antibiotics for my back pain, did you have a similar response?

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McCartney

Absolutely, I think the headlines were extraordinary, there was a huge amount of extremely uncritical press attention paid to this paper.听 I think primarily because of the press release that was sent out by a PR company who were acting for the people that had been behind the study whose title was 鈥淎nnouncement of breakthrough medical cure for the cause of one of the world鈥檚 most debilitating diseases鈥�.听 The press release was sent out by a company who were acting for Mass Medical who are an organisation who are offering to train doctors to provide these antibiotics for patients.听 Dr Albert, that company is co-owned by yourself, the headline was announcement of breakthrough medical cure and I just wonder really how you鈥�

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Albert

But I think it is a breakthrough.

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McCartney

Well the problem with this trial is that a lot of the outcomes weren鈥檛 significant.听 There was no placebo response which was quite unusual and the other problem is that at the end of the day there were no more people on the antibiotic group who actually returned back to work, had less sick leave, compared with the other group, there was no statistical difference between the two groups.听 Which means that calling it a cure I think is somewhat premature.听 And normally a study like this would have to be replicated first of all by some other researchers, somewhere else, to show that it does actually 鈥� is actually a real effect and it wasn鈥檛 just produced by chance.

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Albert

When you say there鈥檚 no difference in sick leave, yes, well but there was a significant reduction in everything else 鈥� in pain, in hours with pain, in low back pain, and back pain and so forth.听 And true 鈥� it鈥檚 true that you should replicate this but should I keep my mouth shut for 10 years until this was replicated?听 I don鈥檛 think so.

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Porter

How鈥檚 it been 鈥� what鈥檚 the response been from specialist working in this area?

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Albert

I think that the response has been incredible 鈥� positive.听 I had expected response like the thing that I get today but I think that a lot of surgeons they realise that they have very good results with some groups of their patients and some groups of patients it doesn鈥檛 work what they do, even they do their very, very best.听 And I think that a lot of surgeons saw a kind of hope here.听 Okay may be there鈥檚 a sub-group of low back pain patients here that maybe I should give them a try first if they have modic changes to give them antibiotics which is a much less problematic thing than doing surgery and putting in metal things.

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Porter

So what happens next Margaret to convince you that this is more than a happy accident?

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McCartney

Well I mean the obvious thing is to try and do a replication trial and do it somewhere else and do it big enough and powerful enough that can be really pretty certain about what the effects are and to look at real life patient effects.听 The other thing they have to do is look for the harms as well, particularly about antibiotic use and we鈥檙e all very concerned about the amount of antibiotics we use quite rightly, so we have to be sure that we鈥檙e doing the right thing 鈥� we鈥檙e not increasing antibiotic resistance in our community without actually benefiting people.听 So I think we have to do bigger trials, better trials and trials in other centres.听 I also think that it is a problem if people publish research when they have a clinic behind them that鈥檚 seeking to really make money out of training people for this and that to me is a conflict of interest that interestingly wasn鈥檛 declared in the actual paper when it went to publication.

听

Porter

So what鈥檚 happening now in terms of your research in Denmark, are we going to see a bigger trial, a multicentre trial 鈥� where鈥檚 this going now?

听

Albert

I think the important thing is to take it out of Denmark.听 Now we鈥檝e tried this on a part of the Danish population and there鈥檚 a huge group in Norway who鈥檚 trying to replicate this, there鈥檚 people in Birmingham working together with other people and there鈥檚 a big thing coming up in Holland and probably also in Spain.听 And I also think that it鈥檚 important to think that was the first step in this direction.听 But it鈥檚 very important to understand that this is not when you and I we go out in the garden and we dig our garden and we have low back pain, this is not for us because we are 鈥� we do the exercises and it鈥檚 all over in a couple of weeks 鈥� it鈥檚 only for this very, very severely affected group of patients.

听

Porter

Dr Hanne Albert - and you will find a link to her research on the Inside Health page of bbc.co.uk/radio4.听

听

And please do get in touch if there is a health issue that is confusing you and that you would like us to look in to. You can send a tweet to @bbcradio4 including the hashtag insidehealth or e-mail us via insidehealth@bbc.co.uk.

听

Just time to tell you about next week鈥檚 programme when I鈥檒l be finding out about the latest developments in pacemakers and investigating why some private clinics continue to offer steroid jabs for hay fever even though they鈥檝e fallen out of favour in the NHS.听 Join us next week to find out why.

听

ENDS