THE POWER OF PLACEBO

Simulated Acupuncture May Be Even More Effective Than Real Acupuncture in Treatment For Lower Back Pain.

The Seattle Post-Intelligencer (5/12/09, Ho) reports, "In the country's largest study of back pain and acupuncture, researchers at Group Health found that an acupuncture-like treatment involving toothpicks relieved chronic low-back pain better than tradition acupuncture and customary medical care, which included medication and physical therapy." For the study, researcher Dan Cherkin, PhD, a senior investigator at Group Health Center for Health Studies in Seattle, and colleagues "assigned 638 men and women with chronic low back pain who had never before had acupuncture to one of four groups." The toothpick method, which involved no piercing of skin, was just as effective as needle insertion.

WebMD (5/11/09, Doheny) called it a "surprising" finding, that “a 'sham' technique with toothpicks and no skin puncturing -- worked better than real acupuncture and better than the “usual care” given for the problem."

Details of the study:
In the country's largest study of back pain and acupuncture, researchers at Group Health found that acupuncture and an acupuncture-like treatment involving toothpicks relieved chronic low-back pain better than customary medical care, which included medication and physical therapy. The study also found that the toothpick method, which involved no piercing of skin, was just as effective as needle insertion.

Published in the 5/11/09 Archives of Internal Medicine, the study randomly assigned more than 600 people with uncomplicated, low-back pain to three types of treatment. The treatments, which lasted seven weeks, included:
• A standardized acupuncture plan for back pain
• An individually customized acupuncture plan
• Toothpicks used to stimulate, but not pierce, acupuncture points
• A fourth group of people received no treatment and was allowed to seek any medical care they would normally seek for back pain.

The participants, who came from Group Health and a nonprofit health plan in California, all initially rated their back pain's "bothersomeness" as at least a "3," on a 0-to-10 scale. Their pain had to have lasted for at least three months. Researchers found that 60 percent of the treated patients felt significantly better at eight weeks, versus only 40 percent of the untreated patients—a difference of 20%.

Why this is so is not known. One possibility is there is a physiological chain of events that occurs when you insert a needle or just stimulate the skin superficially. They may or may not be the same. Another possibility, he says, is "believing you are getting a treatment that will help your back pain helps it.

The good results with the "toothpick" acupuncture may very well be a placebo effect, Even going and talking to your doctor could have a strong, positive effect on your health," he says. "When people have chronic illness, they want to feel that someone cares for them, and that basically unloads the mind of the burden of disease."

What are we to make of this?

Bottom Line:
The study found no difference in outcomes from the various treatments. That finding echoed previous studies that found that acupuncture -- a traditional Chinese practice of inserting needles to release “qi,” or energy -- is no more effective in relieving pain than "sham" acupuncture used in control groups. Those sham methods have included relatively shallow needle insertion, insertion at non-acupuncture points, and no insertion at all. Is this a manifestation the “divine touch” explained below?

What does it all mean?
The study's authors, from Group Health's Center for Health Studies, offered a few theories.
• Simulation of acupuncture points -- without needle insertion -- may be enough to rouse physiological changes that reduce pain and improve functioning.
• Light touching of skin might induce emotional and hormonal reactions for pain reduction.
• The treatment "experience" itself made people feel better.

My Comments:
I often wondered about how Medicine was practiced before the modern era. While a lot of patients’ deaths were hastened because of the treatments themselves [e.g. George Washington] many patients were cured of their ailments and claimed their doctors were heroes.

But this is certainly not the first time that the placebo effect has been noted and documented by objective studies. Sham surgery and sham acupuncture, either with sham needles or on fake acupuncture points, have all exhibited the same placebo effects-the power of touch.

The basic physiological mechanism is speculated to be an outpouring of endogenous opioids, which can decrease pain and cause a euphoric state. Marathon runners are said to regularly experience this state and may even become addicted to it. [Levine JD, Gordon NC, Smith R, Fields HL. (1981) Analgesic responses to morphine and placebo in individuals with postoperative pain. Pain. 10:379-89.]

The word placebo, Latin for "I shall please,” dates back to a Latin translation of the Bible by St.Jerome. In its healing form, the “laying on of hands” is based on biblical precedent set by Jesus who offered his healing power of touch to all who would accept.

Today both Christian and non-Christian faith healers will lay hands on people when praying for healing. This laying on of hands, also known as "the Divine Touch," was performed by European kings commonly throughout the Middle Ages and was believed to cure many diseases.

The doctor himself has even been called a placebo—as perhaps was Jesus.

My mentor, Johns Hopkins professor Philip Tumulty –a true disciple of William Osler--believed that patient recovery could be increased by words that suggest the patient “would be better in a few days.” He, like Osler was always positive with his patients. His maxim was “never take away hope.” Moreover, if the patient is given treatment, he said that “the treatment would make him better.” He maintained this was preferential to negative words such as “"I am not sure that the treatment I am going to give you will have an effect.” He would always during an office visit get up from behind his desk and place his hand gently but reassuringly on a shoulder. He called this the “laying on of the hands.” Patients loved him—indeed worshiped him. But then again this was prior to the current defensive medicine days.

I’ll be writing a later column about defensive medicine.

Similarly a patient who disbelieves in a treatment or if he views a medicine or procedure as harmful, it can cause negative effects. The patient then may experience a worsening of symptoms. This effect, called by analogy the "nocebo effect” (Latin nocebo = "I will harm") can be measured in the same way as the placebo effect, e.g., when members of a control group receiving an inert substance report a worsening of symptoms.
[Kennedy WP. The nocebo reaction. Med Exp Int J Exp Med 1961; 95:203-5.]

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