The power of nonspecific effects in healing: Implications for psychosocial and biological treatments

Assessing Meaningful Improvement: Focus on the Tinnitus Functional Index

Many studies have attempted to determine methodology for interpreting change on outcome instruments that result from an intervention. The objective of these studies has been to devise methods to identify the minimal level of change that would be consistent with actual benefit perceived by the patient, and not just statistically significant change. With respect to intervention for bothersome tinnitus, the authors of the original study to develop and validate the Tinnitus Functional Index (TFI) suggested that a minimum 13-point reduction in the TFI score was likely to reflect a change perceived as meaningful to an individual. The 13-point estimation of meaningful change for an individual is appropriate for use with any adult seeking care for tinnitus. However, it cannot be relied upon in isolation to determine if an individual believes that there has been a noticeable, or meaningful improvement in their quality of life. It is important to use subjective impressions elicited from the patient to assist in interpreting the meaning of TFI data for an individual. For clinicians engaging in care for tinnitus, we recommend using the TFI and pairing it with the patient's belief/impression as to whether they are doing better than they were before care for tinnitus was provided. Ideally, the outcome assessment would be conducted by someone other than the clinician who provided the intervention.

Innovations in Technology and Mechanisms of Change in Behavioral Interventions

The purpose of this manuscript is to provide an overview of, and rationale for, the increasing adoption of a wide range of cutting-edge technological methods in assessment and intervention which are relevant for treatment. First, we review traditional approaches to measuring and monitoring affect, behavior, and cognition in behavior and cognitive-behavioral therapy. Second, we describe evolving active and passive technology-enabled approaches to behavior assessment including emerging applications of digital phenotyping facilitated through fitness trackers, smartwatches, and social media. Third, we describe ways that these emerging technologies may be used for intervention, focusing on novel applications for the use of technology in intervention efforts. Importantly, though some of the methods and approaches we describe here warrant future testing, many aspects of technology can already be easily incorporated within an established treatment framework.

Chasing the Ghost: Hyperinflammation Does Not Cause Sepsis

Sepsis is infection sufficient to cause illness in the infected host, and more severe forms of sepsis can result in organ malfunction or death. Severe forms of Coronavirus disease-2019 (COVID-19), or disease following infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are examples of sepsis. Following infection, sepsis is thought to result from excessive inflammation generated in the infected host, also referred to as a cytokine storm. Sepsis can result in organ malfunction or death. Since COVID-19 is an example of sepsis, the hyperinflammation concept has influenced scientific investigation and treatment approaches to COVID-19. However, decades of laboratory study and more than 100 clinical trials designed to quell inflammation have failed to reduce sepsis mortality. We examine theoretical support underlying widespread belief that hyperinflammation or cytokine storm causes sepsis. Our analysis shows substantial weakness of the hyperinflammation approach to sepsis that includes conceptual confusion and failure to establish a cause-and-effect relationship between hyperinflammation and sepsis. We conclude that anti-inflammation approaches to sepsis therapy have little chance of future success. Therefore, anti-inflammation approaches to treat COVID-19 are likewise at high risk for failure. We find persistence of the cytokine storm concept in sepsis perplexing. Although treatment approaches based on the hyperinflammation concept of pathogenesis have failed, the concept has shown remarkable resilience and appears to be unfalsifiable. An approach to understanding this resilience is to consider the hyperinflammation or cytokine storm concept an example of a scientific paradigm. Thomas Kuhn developed the idea that paradigms generate rules of investigation that both shape and restrict scientific progress. Intrinsic features of scientific paradigms include resistance to falsification in the face of contradictory data and inability of experimentation to generate alternatives to a failing paradigm. We call for rejection of the concept that hyperinflammation or cytokine storm causes sepsis. Using the hyperinflammation or cytokine storm paradigm to guide COVID-19 treatments is likewise unlikely to provide progress. Resources should be redirected to more promising avenues of investigation and treatment.

Restoring patient trust in healthcare: medical information impact case study in Poland

BACKGROUND

This study empirically evaluates the influence of medical information on patient trust at the physician level, the medical profession, hospitals, and with the payer. Restoring patient trust in a medical setting in Poland appears to be significantly affected due to the COVID-19 pandemic. Patient trust improves results from medical treatment, raises perception of healthcare performance, and smoothens the overall functionality of healthcare systems.

METHODS

In order to study trust volatility, patients took part in a three-stage experiment designed via: (1) measured level of trust, (2) randomly dividing participants into two groups-control (i.e., re-examination of level of trust) and experimental (i.e., being exposed to a piece of certain manipulative information), and (3) checking whether observational changes were permanent.

RESULTS

Results indicate that in the experimental group the increase of trust was noticed in the payer (27.7%, p < 0.001), hospitals (10.9%, p = 0.011), and physicians (decrease of 9.2%, p = 0.036).

CONCLUSION

The study indicated that in Poland medical information is likely to influence patient trust in healthcare while interpersonal and social trust levels may be related to increases of trust in hospitals and in the payer versus decreases in physicians.

Palliative Care for Stroke Patients and Their Families: Barriers for Implementation

Stroke is a leading cause of death, disability and is a symptom burden worldwide. It impacts patients and their families in various ways, including physical, emotional, social, and spiritual aspects. As stroke is potentially lethal and causes severe symptom burden, a palliative care (PC) approach is indicated in accordance with the definition of PC published by the WHO in 2002. Stroke patients can benefit from a structured approach to palliative care needs (PCN) and the amelioration of symptom burden. Stroke outcome is uncertain and outlook may change rapidly. Regarding these challenges, core competencies of PC include the critical appraisal of various treatment options, and openly and respectfully discussing therapeutic goals with patients, families, and caregivers. Nevertheless, PC in stroke has to date mainly been restricted to short care periods for dying patients after life-limiting complications. There is currently no integrated concept for PC in stroke care addressing the appropriate moment to initiate PC for stroke patients, and the question of how to screen for symptoms remains unanswered. Therefore, PC for stroke patients is often perceived as a stopgap in cases of unfavorable prognosis and very short survival times. In contrast, PC can provide much more for stroke patients and support a holistic approach, improve quality of life and ensure treatment according to the patient's wishes and values. In this short review we identify key aspects of PC in stroke care and current barriers to implementation. Additionally, we provide insights into our approach to PC in stroke care.

The Efficacy and Safety of Dorsal Root Ganglion Stimulation as a Treatment for Neuropathic Pain: A Literature Review

OBJECTIVE

Dorsal root ganglion stimulation (DRGS) received its first regulatory approval (CE marking in Europe) in late 2011, and so its use is now almost six years old. Several thousand patients have already been treated, and a landmark trial in lower limb complex regional pain syndrome (CRPS) and causalgia has recently been published.

METHODS

In this review we have summarized the literature to date on the use of DRGS in the treatment of neuropathic pain.

RESULTS

The results so far are encouraging, with reports of successful use in treating a wide range of indications including postsurgical pain, CRPS, and phantom pain. Treatment of failed back surgery syndrome (FBSS) appears less successful. The therapy is still young, and long term results are not yet available. There is now good randomized clinical trial (RCT) evidence that DRGS provides superior pain relief to spinal cord stimulation for CRPS and causalgia of the lower limb, and produces stimulation that is more posturally stable, with more precise paraesthesia coverage. However evidence of this quality for other indications and pain locations is lacking.

CONCLUSION

There is now Class A RCT evidence that DRGS provides superior pain relief to SCS for CRPS and causalgia of the lower limb. In the coming years we hope that randomized controlled trials will be performed on an indication-by-indication basis, which, together with the publication of longer term follow-up data, will provide a more complete understanding of the role of DRGS in the treatment of neuropathic pain syndromes.

Measuring Multiple Dimensions of Religion and Spirituality for Health Research

Progress in studying the relationship between religion and health has been hampered by the absence of an adequate measure of religiousness and spirituality. This article reports on the conceptual and empirical development of an instrument to measure religiousness and spirituality, intended explicitly for studies of health. It is multidimensional to allow investigation of multiple possible mechanisms of effect, brief enough to be included in clinical or epidemiological surveys, inclusive of both traditional religiousness and noninstitutionally based spirituality, and appropriate for diverse Judeo-Christian populations. The measure may be particularly useful for studies of health in elderly populations in which religious involvement is higher. The measure was tested in the nationally representative 1998 General Social Survey ( N = 1,445). Nine dimensions have indices with moderate-to-good internal consistency, and there are three single-item domains. Analysis by age and sex shows that elderly respondents report higher levels of religiousness in virtually every domain of the measure.

Placebo-induced somatic sensations: a multi-modal study of three different placebo interventions

Somatic sensations induced by placebos are a frequent phenomenon whose etiology and clinical relevance remains unknown. In this study, we have evaluated the quantitative, qualitative, spatial, and temporal characteristics of placebo-induced somatic sensations in response to three different placebo interventions: (1) placebo irritant solution, (2) placebo laser stimulation, and (3) imagined laser stimulation. The quality and intensity of evoked sensations were assessed using the McGill pain questionnaire and visual analogue scales (VAS), while subjects' sensation drawings processed by a geographic information system (GIS) were used to measure their spatial characteristics. We found that all three interventions are capable of producing robust sensations most frequently described as "tingling" and "warm" that can reach consider-able spatial extent (≤ 205 mm²) and intensity (≤ 80/100 VAS). Sensations from placebo stimulation were often referred to areas remote from the stimulation site and exhibit considerable similarity with referred pain. Interestingly, there was considerable similarity of qualitative features as well as spatial patterns across subjects and placebos. However, placebo laser stimulation elicited significantly stronger and more widespread sensations than placebo irritant solution. Finally, novelty seeking, a character trait assessed by the Temperament and Character Inventory and associated with basal dopaminergic activity, was less pronounced in subjects susceptible to report placebo-induced sensations. Our study has shown that placebo-induced sensations are frequent and can reach considerable intensity and extent. As multiple somatosensory subsystems are involved despite the lack of peripheral stimulus, we propose a central etiology for this phenomenon.

Placebo effects in trials evaluating 12 selected minimally invasive interventions: a systematic review and meta-analysis

OBJECTIVES

To analyse the impact of placebo effects on outcome in trials of selected minimally invasive procedures and to assess reported adverse events in both trial arms.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES AND STUDY SELECTION

We searched MEDLINE and Cochrane library to identify systematic reviews of musculoskeletal, neurological and cardiac conditions published between January 2009 and January 2014 comparing selected minimally invasive with placebo (sham) procedures. We searched MEDLINE for additional randomised controlled trials published between January 2000 and January 2014.

DATA SYNTHESIS

Effect sizes (ES) in the active and placebo arms in the trials' primary and pooled secondary end points were calculated. Linear regression was used to analyse the association between end points in the active and sham groups. Reported adverse events in both trial arms were registered.

RESULTS

We included 21 trials involving 2519 adult participants. For primary end points, there was a large clinical effect (ES≥0.8) after active treatment in 12 trials and after sham procedures in 11 trials. For secondary end points, 7 and 5 trials showed a large clinical effect. Three trials showed a moderate difference in ES between active treatment and sham on primary end points (ES ≥0.5) but no trials reported a large difference. No trials showed large or moderate differences in ES on pooled secondary end points. Regression analysis of end points in active treatment and sham arms estimated an R(2) of 0.78 for primary and 0.84 for secondary end points. Adverse events after sham were in most cases minor and of short duration.

CONCLUSIONS

The generally small differences in ES between active treatment and sham suggest that non-specific mechanisms, including placebo, are major predictors of the observed effects. Adverse events related to sham procedures were mainly minor and short-lived. Ethical arguments frequently raised against sham-controlled trials were generally not substantiated.

On the observed specific and non-specific effects of complex therapeutic interventions: truly separate or complementary?

Specific and non-specific effects observed in randomised controlled trials (RCTs) are generally treated implicitly as ontologically separate and purely additive. Building on the notions of Heisenberg uncertainty and complementarity from the discourse of quantum theory, and using a simple arithmetic argument, it is demonstrated how this separation enables results of RCTs (particularly of complex interventions) to be treated in a convenient but ultimately incorrect manner. Conclusions drawn from RCTs (that justify--and are justified by--a reductionist approach to therapeutic efficacy) should therefore be open to question.

Research on traditional medicine: what has been done, the difficulties, and possible solutions

Traditional medicine (TM) is being used more frequently all over the world. However most often these are choices made by the patient. Integrating TM into mainstream health care would require research to understand the efficacy, safety, and mechanism of action of TM systems. This paper describes research done on TM and difficulties encountered in researching TM, especially when an attempt is made to conform to the model for conventional medicine. The research articles were PubMed searched and categorized as experimental, quasiexperimental, reviews, descriptive, historical, interviews, case histories, and abstract not available. The last part of the report provides suggestions to make research on TM more acceptable and useful, with the ultimate goal of integrating TM into mainstream healthcare with sufficient knowledge about the efficacy, safety, and mechanism of action of TM systems.

Spinal cord stimulation for complex regional pain syndrome type 1 with dystonia: a case report and discussion of the literature

Background: Complex Regional Pain Syndrome type 1 (CRPS-1) is a debilitating chronic pain disorder, the physiopathology of which can lead to dystonia associated with changes in the autonomic, central and peripheral nervous system. An interdisciplinary approach (pharmacological, interventional and psychological therapies in conjunction with a rehabilitation pathway) is central to progress towards pain reduction and restoration of function.Aim: This case report aims to stimulate reflection and development of mechanism-based therapeutic strategies concerning CRPS associated with dystonia.Case description: A 31 year old female CRPS-1 patient presented with dystonia of the right foot following ligamentoplasty for chronic ankle instability. She did not have a satisfactory response to the usual therapies. Multiple anesthetic blocks (popliteal, epidural and intrathecal) were not associated with significant anesthesia and analgesia. Mobilization of the foot by a physiotherapist was not possible. A multidisciplinary approach with psychological support, physiotherapy and spinal cord stimulation (SCS) brought pain relief, rehabilitation and improvement in the quality of life.Conclusion: The present case report demonstrates the occurrence of multilevel (peripheral and central) pathological modifications in the nervous system of a CRPS-1 patient with dystonia. This conclusion is based on the patient’s pain being resistant to anesthetic blocks at different levels and the favourable, at least initially, response to SCS. The importance of the bio-psycho-social model is also suggested, permitting behavioural change.

Phenotypic characterisation of canine epileptoid cramping syndrome in the Border terrier

OBJECTIVES

To characterise the phenotype of Border terriers suspected to be affected by canine epileptoid cramping syndrome and to identify possible contributing factors.

METHODS

Owners of Border terriers with suspected canine epileptoid cramping syndrome were invited to complete an online questionnaire. The results of these responses were collated and analysed.

RESULTS

Twenty-nine Border terriers were included. Most affected dogs had their first episode before 3 years of age (range: 0·2 to 7·0 years). The majority of episodes lasted between 2 and 30 minutes (range: 0·5 to 150 minutes). The most frequent observations during the episodes were difficulty in walking (27 of 29), mild tremor (21 of 29) and dystonia (22 of 29). Episodes most frequently affected all four limbs (25 of 29) and the head and neck (21 of 29). Borborygmi were reported during episodes in 11 of 29 dogs. Episodes of vomiting and diarrhoea occurred in 14 of 29, with 50% of these being immediately before or after episodes of canine epileptoid cramping syndrome (7 of 14). Most owners (26 of 29) had changed their dog's diet, with approximately 50% (14 of 26) reporting a subsequent reduction in the frequency of episodes.

CLINICAL SIGNIFICANCE

This study demonstrates similarities in the phenotype of canine epileptoid cramping syndrome to paroxysmal dystonic choreoathetosis, a paroxysmal dyskinesia reported in humans. This disorder appears to be associated with gastrointestinal signs in some dogs and appears at least partially responsive to dietary adjustments.

Are all placebo effects equal? Placebo pills, sham acupuncture, cue conditioning and their association

Placebo treatments and healing rituals have been used to treat pain throughout history. The present within-subject crossover study examines the variability in individual responses to placebo treatment with verbal suggestion and visual cue conditioning by investigating whether responses to different types of placebo treatment, as well as conditioning responses, correlate with one another. Secondarily, this study also examines whether responses to sham acupuncture correlate with responses to genuine acupuncture. Healthy subjects were recruited to participate in two sequential experiments. Experiment one is a five-session crossover study. In each session, subjects received one of four treatments: placebo pills (described as Tylenol), sham acupuncture, genuine acupuncture, or no treatment rest control condition. Before and after each treatment, paired with a verbal suggestion of positive effect, each subject's pain threshold, pain tolerance, and pain ratings to calibrated heat pain were measured. At least 14 days after completing experiment one, all subjects were invited to participate in experiment two, during which their analgesic responses to conditioned visual cues were tested. Forty-eight healthy subjects completed experiment one, and 45 completed experiment two. The results showed significantly different effects of genuine acupuncture, placebo pill and rest control on pain threshold. There was no significant association between placebo pills, sham acupuncture and cue conditioning effects, indicating that individuals may respond to unique healing rituals in different ways. This outcome suggests that placebo response may be a complex behavioral phenomenon that has properties that comprise a state, rather than a trait characteristic. This could explain the difficulty of detecting a signature for "placebo responders." However, a significant association was found between the genuine and sham acupuncture treatments, implying that the non-specific effects of acupuncture may contribute to the analgesic effect observed in genuine acupuncture analgesia.

The placebo effect: why we should care

Contrary to its definition, a placebo is far from an inert substance but carries meaningful responses that can mediate significant outcome results in pharmacotherapeutic studies. The advent of detailed studies and modern imaging techniques have provided the basis to understand the underlying mechanisms of the placebo effect, as well as its localization to determined brain centers. Designing clinical trials using principles of classical conditioning to mediate placebo effects may enhance treatment outcomes and provide novel pharmacotherapeutic modalities.

The placebo in the context of scientific theories

Placebo is not a unitary concept. It can have different meanings, depending on the scientific discipline in which it is used. The placebo exists in psychology, medicine, and other sciences, and in each case it is assumed that the results obtained by the placebo are unexplainable. But the results that can’t be explained by a scientific discipline could be explained by another. For example, a sugar pill used in the treatment of pain could be a pharmacological placebo, but it isn’t a psychological placebo, because there is an explanation of its effects based in psychological principles. In this work, a conceptual analysis of placebo in the context of scientific theories is presented.

Reframing placebo in research and practice

The terms 'placebo' and 'placebo effects' cause confusion among patients, practitioners and scientists. This confusion results in both the adoption of practices that have no evidence of specificity yet considerable risk (such as surgery for low back pain) or the elimination of clinical practices proven to facilitate healing because they are not 'better than placebo' (such as acupuncture for low back pain). In this article, I discuss these issues and introduce the concept of optimal healing environment as a framework for disentangling what is useful from placebo research for adopting into clinical practice in a manner that is ethical and evidence-based.

The silent healer: the role of communication in placebo effects

Placebo effects have an ambiguous reputation, as they are associated with sham treatment and deceit on the one hand and as interesting phenomena, which might be clinically relevant on the other. The goal of this paper is to demonstrate that placebo effects are relevant and can be used as an effective part of many treatments by using communication targeting placebo effect mechanisms. We examined the history of placebos and the placebo effect, addressing common misconceptions and disentangling ambiguities. We then reviewed whether the placebo effect can be robustly shown in the current literature, and zoomed in on the plausible mechanisms (conditioning, expectancies and affect manipulation) through which the placebo effect might be produced. Observing the link with the doctor-patient communication literature, and pleading for a better integration of the two research traditions we conclude by setting out a research agenda for testing the role of communication in placebo effects.

Neurofeedback outcomes in clients with Asperger's syndrome

This paper summarizes data from a review of neurofeedback (NFB) training with 150 clients with Asperger's Syndrome (AS) and 9 clients with Autistic Spectrum Disorder (ASD) seen over a 15 year period (1993-2008) in a clinical setting. The main objective was to investigate whether electroncephalographic (EEG) biofeedback, also called neurofeedback (NFB), made a significant difference in clients diagnosed with AS. An earlier paper (Thompson et al. 2009) reviews the symptoms of AS, highlights research findings and theories concerning this disorder, discusses QEEG patterns in AS (both single and 19-channel), and details a hypothesis, based on functional neuroanatomy, concerning how NFB, often paired with biofeedback (BFB), might produce a change in symptoms. A further aim of the current report is to provide practitioners with a detailed description of the method used to address some of the key symptoms of AS in order to encourage further research and clinical work to refine the use of NFB plus BFB in the treatment of AS. All charts were included for review where there was a diagnosis of AS or ASD and pre- and post-training testing results were available for one or more of the standardized tests used. Clients received 40-60 sessions of NFB, which was combined with training in metacognitive strategies and, for most older adolescent and adult clients, with BFB of respiration, electrodermal response, and, more recently, heart rate variability. For the majority of clients, feedback was contingent on decreasing slow wave activity (usually 3-7 Hz), decreasing beta spindling if it was present (usually between 23 and 35 Hz), and increasing fast wave activity termed sensorimotor rhythm (SMR) (12-15 or 13-15 Hz depending on assessment findings). The most common initial montage was referential placement at the vertex (CZ) for children and at FCz (midway between FZ and CZ) for adults, referenced to the right ear. Metacognitive strategies relevant to social understanding, spatial reasoning, reading comprehension, and math were taught when the feedback indicated that the client was relaxed, calm, and focused. Significant improvements were found on measures of attention (T.O.V.A. and IVA), core symptoms (Australian Scale for Asperger's Syndrome, Conners' Global Index, SNAP version of the DSM-IV criteria for ADHD, and the ADD-Q), achievement (Wide Range Achievement Test), and intelligence (Wechsler Intelligence Scales). The average gain for the Full Scale IQ score was 9 points. A decrease in relevant EEG ratios was also observed. The ratios measured were (4-8 Hz)(2)/(13-21 Hz)(2), (4-8 Hz)/(16-20 Hz), and (3-7 Hz)/(12-15 Hz). The positive outcomes of decreased symptoms of Asperger's and ADHD (including a decrease in difficulties with attention, anxiety, aprosodias, and social functioning) plus improved academic and intellectual functioning, provide preliminary support for the use of neurofeedback as a helpful component of effective intervention in people with AS.

Evaluation and treatment of sleep complaints: patients' subjective responses

BACKGROUND

This study set out to evaluate whether patients' expectations affected their responses to treatment of a sleep disorder.

METHODS

Fifty consecutive patients attending a sleep clinic for the first time and who had different diagnoses of sleep disorders were included in this study. The patients completed a set of 6 questionnaires on 7 occasions as they progressed through the process of a sleep clinic referral, assessment and treatment. Self-report questionnaires were used to assess their sleepiness, fatigue and alertness. Predictor measures included mental health and individual items assessing expectation regarding the seriousness of the sleep problem. A battery of questions dealt with mental health issues, patients' expectation and their commitment to the sleep investigation and treatment process. Each patient's responses were examined over a period of 6 months.

RESULTS

Immediately following their interview with the sleep consultant, the patients' concern regarding their sleep problem was higher than the first measures obtained at baseline. Compared to prior to their first consultation with a sleep specialist, while on treatment they directed more attention to their sleep problem when problems associated with fatigue were reduced. Although there was a lessening in fatigue with treatment, subjectively rated sleepiness (Epworth Sleepiness Scale) did not vary over the study. Contact with a sleep center and the diagnosis and treatment of individual sleep problems also resulted in improved satisfaction with life.

CONCLUSIONS

Contact with and treatment at a sleep clinic was found to be beneficial. The fatigue levels were reduced and the patients had greater life satisfaction regardless of the diagnosis and treatment of their sleep disorder, although subjective sleepiness did not change. Patient expectations were not critical in determining the outcome of the sleep clinic assessment.

Mind-set matters: exercise and the placebo effect

In a study testing whether the relationship between exercise and health is moderated by one's mind-set, 84 female room attendants working in seven different hotels were measured on physiological health variables affected by exercise. Those in the informed condition were told that the work they do (cleaning hotel rooms) is good exercise and satisfies the Surgeon General's recommendations for an active lifestyle. Examples of how their work was exercise were provided. Subjects in the control group were not given this information. Although actual behavior did not change, 4 weeks after the intervention, the informed group perceived themselves to be getting significantly more exercise than before. As a result, compared with the control group, they showed a decrease in weight, blood pressure, body fat, waist-to-hip ratio, and body mass index. These results support the hypothesis that exercise affects health in part or in whole via the placebo effect.

Clinical attrition due to biased preclinical assessments of potential efficacy

Unless it is carefully controlled, bias often distorts the results of clinical trials, usually exaggerating the magnitude of true efficacy. For that reason, procedures to limit bias have been mandated by the FDA when assessing efficacy in clinical trials. The present review shows that the effects of bias in preclinical studies are at least as large as in clinical trials, and since bias is not usually controlled in preclinical proof of concept studies, compounds that actually have little or no therapeutic potential may often be advanced into clinical trials. This possibility is supported by the fact that lack of efficacy is the single biggest reason why compounds fail in the clinic. The shift to target-based discovery during the last 10-15 years may have further increased the effects of bias on preclinical assessments of potential efficacy, and contributed to the continuing decline in clinical success rates. Procedures are available to control for bias during preclinical assessments of potential efficacy, and their use could dramatically increase clinical success rates and substantially reduce the costs of drug discovery and development.

[Placebo effects]

The following article presents a discussion of the widely used terms placebo and placebo effect. Traditional definitions are demonstrated to be insufficient, and a new definition is proposed. The widely cited size of placebo effects is discussed and shown to be questionable, especially due to serious methodological flaws in the underlying studies. We suggest that instead of using the global term placebo effect the concept of specific context-dependent effects should be considered both in practice and research.

Specialist supportive clinical management for anorexia nervosa

OBJECTIVE

This article presents the rationale for, and description of, a nonspecialized therapy for anorexia nervosa, called specialist supportive clinical management (SSCM).

METHOD

Clinical management and supportive psychotherapy models of treatment are outlined. SSCM is described, as it was delivered in a clinical trial of psychotherapies for adult women with anorexia nervosa.

RESULTS

The primary focus of SSCM for anorexia nervosa is the resumption of normal eating and the restoration of weight. Therapy aims to maintain a therapeutic relationship that facilitates the return to normal eating, and to enable other life issues that may impact on the eating disorder to be addressed.

CONCLUSION

Possible effective components of SSCM are discussed.

Circular instead of hierarchical: methodological principles for the evaluation of complex interventions

BACKGROUND

The reasoning behind evaluating medical interventions is that a hierarchy of methods exists which successively produce improved and therefore more rigorous evidence based medicine upon which to make clinical decisions. At the foundation of this hierarchy are case studies, retrospective and prospective case series, followed by cohort studies with historical and concomitant non-randomized controls. Open-label randomized controlled studies (RCTs), and finally blinded, placebo-controlled RCTs, which offer most internal validity are considered the most reliable evidence. Rigorous RCTs remove bias. Evidence from RCTs forms the basis of meta-analyses and systematic reviews. This hierarchy, founded on a pharmacological model of therapy, is generalized to other interventions which may be complex and non-pharmacological (healing, acupuncture and surgery).

DISCUSSION

The hierarchical model is valid for limited questions of efficacy, for instance for regulatory purposes and newly devised products and pharmacological preparations. It is inadequate for the evaluation of complex interventions such as physiotherapy, surgery and complementary and alternative medicine (CAM). This has to do with the essential tension between internal validity (rigor and the removal of bias) and external validity (generalizability).

SUMMARY

Instead of an Evidence Hierarchy, we propose a Circular Model. This would imply a multiplicity of methods, using different designs, counterbalancing their individual strengths and weaknesses to arrive at pragmatic but equally rigorous evidence which would provide significant assistance in clinical and health systems innovation. Such evidence would better inform national health care technology assessment agencies and promote evidence based health reform.

Überschätzen Ärzte die Effekte der Akupunkturbehandlung?

BACKGROUND

Physicians' ratings about their patients' pain prove to be invalid compared to patients' ratings. This is especially true if pain rating acts as an indicator for therapy outcome. The aim of this study was to compare physicians' and patients' ratings of pain relief following acupuncture and to identify correlations between patient characteristics and potential miscalibrations.

PATIENTS AND METHODS

In a cross-sectional study 291 pain patients with gonarthrosis or chronic low back pain and their attending physicians were asked to give their rating of patients' pain relief following acupuncture. Patients were interviewed by telephone, and doctors responded to questionnaires.

RESULTS

The proportion of false-positive physicians' ratings was 81% referring to patients without self-reported benefit from acupuncture. Just every fifth patient without pain relief was correctly classified by his physician. There was no correlation between patients' characteristics and false-positive ratings of physicians.

CONCLUSIONS

Evaluation of treatment in daily medical routine should be primarily based on information provided by patients.

General review of tinnitus: prevalence, mechanisms, effects, and management

Tinnitus is an increasing health concern across all strata of the general population. Although an abundant amount of literature has addressed the many facets of tinnitus, wide-ranging differences in professional beliefs and attitudes persist concerning its clinical management. These differences are detrimental to tinnitus patients because the management they receive is based primarily on individual opinion (which can be biased) rather than on medical consensus. It is thus vitally important for the tinnitus professional community to work together to achieve consensus. To that end, this article provides a broad-based review of what is presently known about tinnitus, including prevalence, associated factors, theories of pathophysiology, psychological effects, effects on disability and handicap, workers' compensation issues, clinical assessment, and various forms of treatment. This summary of fundamental information has relevance to both clinical and research arenas.

P6 acupressure increases tolerance to nauseogenic motion stimulation in women at high risk for PONV

PURPOSE

In a previous study we noticed that P6 acupressure decreased postoperative nausea and vomiting (PONV) more markedly after discharge. As motion sickness susceptibility is increased by, for example, opioids we hypothesized that P6 acu-pressure decreased PONV by decreasing motion sickness susceptibility. We studied time to nausea by a laboratory motion challenge in a group of volunteers, during P6 and placebo acupressure.

METHODS

60 women with high and low susceptibilities for motion sickness participated in a randomized and double-blind study with an active P6 acupressure, placebo acupressure, and a control group (n = 20 in each group). The risk score for PONV was over 50%. The motion challenge was by eccentric rotation in a chair, blindfolded and with chin to chest movements of the head. The challenge was stopped when women reported moderate nausea. Symptoms were recorded.

RESULTS

Mean time to moderate nausea was longer in the P6 acu-pressure group compared to the control group. P6 acupressure = 352 (259-445), mean (95% confidence interval) in seconds, control = 151 (121-181) and placebo acupressure = 280 (161-340); (P = 0.006). No difference was found between P6 and placebo acupressure or placebo acupressure and control groups. Previous severity of motion sickness did not influence time to nausea (P = 0.107). The cumulative number of symptoms differed between the three groups (P < 0.05). Fewer symptoms were reported in the P6 acupressure compared to the control group P < 0.009. Overall, P6 acupressure was only marginally more effective than placebo acupressure on the forearms.

CONCLUSION

In females with a history of motion sickness P6 acu-pressure increased tolerance to experimental nauseogenic stimuli, and reduced the total number of symptoms reported.

Look before you leap

Learning to critically evaluate therapeutic claims is vital to the success of the practicing veterinarian and the veterinary profession as a whole. Until such time as good scientific data in support of therapies are obtained, veterinarians should be careful in their advocacy and employment of new and unproved practices. They should also be aware of the many reasons why therapeutic "success" may be the result of a variety of factors unrelated to the treatment modality itself. Only by relying on rigorous standards of evidence can equine veterinarians prevent a return to the sincere but misguided ways of yesteryear.

The Healing Presence: Can It be Reliably Measured?

Religious and spiritual traditions from all cultures and times describe a spiritual or loving presence as a contributor to healing. In addition, there is a common belief that a special "presence" can exude from certain practitioners. Is it possible to measure a healing presence in an objective and reliable way? Most research on healing has focused on trying to prove spiritual and "energy" healing in comparative tests. However, if a measure of healing presence is to be sensitive and reliable, objective and real-time indicators of such a presence will be needed rather than comparative and statistical outcomes. This paper discusses what healers from various traditions have felt are the primary components of a healing presence, summarizes various attempts to measure healing, and describes two recently published approaches that have potential to provide such an objective and realtime indicator of a healing presence.

Paradoxical results in the cure of chronic illness: the "burden of normality" as exemplified following seizure surgery

Little has been written about processes of recovery following life-changing medical interventions for chronic illness. This article reviews our research with chronic epilepsy patients undergoing neurosurgery for the relief of intractable partial seizures. This research has given rise to a new conceptualization of adjustment and outcome following effective treatment of chronic illness, representing the first, detailed characterization of this process from a psychological and psychosocial perspective. Crucial to outcome are patient and family expectations prior to treatment, and learning to discard roles associated with chronic illness after treatment. These and the posttreatment affective functioning of the patient temper the view of medical outcome, and can account for paradoxical clinical effects, such as worsening patient psychosocial functioning in the context of medical treatment success. Our results have clear implications for the clinical management of chronically ill patients and their families to optimize treatment outcome.

The concept of placebo

This paper attempts to define the concept of placebo as it is used in the clinical context The author claims that X is a placebo if and only if X has such a property dp, that whenever in a therapeutic situation T a stimulus S appears, then in attending conditions A, it will cause a beneficial reaction R in the patient. Formally, the same structure may be used to define any pharmacologically active drug. The main difference between the drug and a placebo is in the range of possible substitutions for X and the property d. For the active drug there is only one possible substitution for X and property d and it can be scientifically explained why, and how the drug works. In the case of a placebo a set of possible substitutions for X and d is open, and so far it is impossible to offer any scientifically valid explanation of the action mechanism of placebo.

Specific and nonspecific treatment factors in the experimental analysis of behavioral treatment efficacy

Interest in the empirical demonstration of the clinical efficacy of psychosocial treatments has been rekindled by societal concerns over accountability and cost-effectiveness in the delivery of mental health services. Behavior therapy has had a long history of experimental research on treatment efficacy and enjoys a visible presence in contemporary mental health practice. The demonstration of behavioral treatment efficacy, however, requires experimental evidence that shows the efficacy of prescriptive structured procedures beyond nonspecific factors in delivery of such procedures. The authors provide an analysis of the nature of nonspecific treatment factors and nonspecific effects and suggest experimental procedures testing the incremental validity of specific treatments. They examine two widely promoted, prescriptive structured treatments to analyze the specificity of their clinical efficacy: eye movement desensitization and reprocessing for anxiety disorders and cognitive-behavioral treatment of generalized anxiety disorder. They conclude that the treatments show different levels of efficacy and different degrees of specificity.

Perceptions and attitudes of clinical oncologists on complementary and alternative medicine: a nationwide survey in Japan

BACKGROUND

The prevalence of complementary and alternative medicine (CAM) is increasing worldwide because of the growing public interest in natural or holistic therapies and because of the flow of information through the Internet. However, there is a lack of communication between cancer patients and their physicians on topics relating to CAM. The authors performed a cross-sectional survey to evaluate the perceptions and attitudes of Japanese clinical oncologists toward cancer CAM.

METHODS

The CAM questionnaires were sent to 2118 clinical oncologists. The questionnaires gathered data on background (age, gender, years in practice, specialty, and knowledge of cancer CAM), perception (effectiveness/ineffectiveness, scientific evidence, and drug interactions), and attitude (experience with and response to CAM users). Questions about oncologists' perceptions and attitudes to CAM were limited to herbs and other natural products that were sold over the counter.

RESULTS

One hundred sixty-six questionnaires were returned as undeliverable. Of the remaining questionnaires, 751 were returned (a response rate of 39%). Two-thirds of the responders were surgical oncologists and most of the remaining responders were medical oncologists. The majority of oncologists (82%) believed that CAM products were ineffective against cancer. The main reason for this belief was a lack of reliable information (as cited by 85% of oncologists). Only 13% of oncologists had experienced CAM-associated disease improvement in their cancer patients. Of all the oncologists, 84% considered the possibility of drug interactions between anticancer drugs and CAM products. The majority of oncologists (80%) replied that they could neither promote the use of CAM products nor recommend quitting the products, when they were asked about the use of CAM products by cancer patients.

CONCLUSIONS

Negative perceptions of CAM products persist among clinical oncologists. A lack of proven effectiveness of CAM products and concerns about drug interactions with anticancer treatment suggest a need for both accurate information on CAM products and clinical trials.