Placebo acupuncture as a form of ritual touch healing: a neurophenomenological model

ACURATE: A guide for reporting sham controls in trials using acupuncture

OBJECTIVE

To promote better reporting quality regarding sham acupuncture in clinical trials for a precise appraisal of the adequacy of the sham acupuncture procedure.

METHODS

A three-stage online Delphi survey was conducted to a group of experts. Items with higher than 80% consensus from the initial checklist were selected as the final candidates. Further discussion among the working group was convened to preclude potential redundancy among the items.

RESULTS

A total of 23 experts out of 35 (66%) responded to the Delphi process. The final checklist consists of 23 items in six categories: type of sham acupuncture, details of sham acupuncture manipulation, location of sham acupuncture, treatment regimen, practitioner, and protocol and settings.

CONCLUSION

This paper presents the Acupuncture Controls gUideline for Reporting humAn Trials and Experiments (ACURATE) checklist, an extension of The Consolidated Standards for Reporting of Trials (CONSORT) and to be used along with STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) when sham acupuncture needles are used in the study. This checklist focuses on a clear depiction of sham needling procedures to enhance replicability and enable a precise appraisal. We encourage researchers to use ACURATE in trials and reviews involving sham acupuncture to assist reporting sham acupuncture procedures and the related components.

Exploring Acupuncture Actions in the Body and Brain

Acupuncture's actions have been explained by biomedical research. However, the meridian system used in acupuncture needs further clarification. This review describes how acupuncture affects the body and brain. From the perspective of traditional East Asian medicine, the meridian system is closely connected with acupuncture's treatment effects. In the body, the indications of acupoints, primarily established based on the meridian system, have spatial symptom patterns. Spatial patterns of acupoint indications are distant from the stimulated sites and strongly associated with the corresponding meridian's route. Understanding how acupuncture works based on the original meridian system is important. From a neuroscience perspective, an acupuncture-induced sensation originates from the bottom-up action of simple needling in the peripheral receptor and the reciprocal interaction with top-down brain modulation. In the brain, enhanced bodily attention triggered by acupuncture stimulation can activate the salience network and deactivate the default mode network regardless of the actual stimulation. The application of data science technology to acupuncture research may provide new tools to uncover the principles of acupoint selection and enhance the clinical efficacy of acupuncture treatment in various diseases.

Therapeutic Sensations: A New Unifying Concept

Physical sensations of tingling, warmth, dull pain, and heaviness are a common phenomenon in mind-body interventions, such as acupuncture, hypnotherapy, osteopathy, qigong, meditation, and progressive muscle relaxation. Even though there are striking parallels between sensations produced by many different interventions, no attempt has yet been made to understand them from a unifying perspective that combines information from different therapies and practices. Therefore, this narrative systematic review introduces the concept of therapeutic sensations and summarizes studies of their sensory quality, bodily topography, and the meaning that patients attach to them. Furthermore, it highlights the essential role of therapeutic sensations in the development of vital energy concepts, such as qi, prana, pneuma, and orgone, in various traditional medicine systems, body-oriented psychotherapy, and so-called energy medicine. Finally, the assessment of therapeutic sensations may help to gain a deeper understanding of such concepts, finding a common language between scientists, patients and practitioners, and bridging the wide gap between materialistic and vitalistic views.

"Honorable Toward Your Whole Self": Experiences of the Body in Fatigued Breast Cancer Survivors

Introduction

Cancer Related Fatigue (CRF) is one of the most common and detrimental side effects of cancer treatment. Despite its increasing prevalence and severity CRF remains dismissed by the majority of clinicians. One reason for the apparent gap between clinical need and clinical undertaking is the penchant toward reductionist accounts of the disorder: a tendency to discount the interface between the lived experience of sufferers and the multi-dimensional etiology of CRF as it manifests adversely on a day-to-day basis.

Methods

In order to better understand the interplay between social, bodily, and emotional components of the disorder we undertook semi-structured interviews with thirteen Breast Cancer survivors suffering from CRF, and then subsequently analyzed their responses using Team Based Qualitative Analysis.

Results

Our analysis revealed multiple dimensions of the social and bodily underpinnings of fatigue. Most relevantly we found a consistent change in the level and quality of attention to bodily signals. This shift in awareness appeared to be directly connected to the experience of CRF and a newfound, “respect,” for the needs of the body. Furthermore, we found that many of the practices that were described as helpful in alleviating fatigue were oriented around eliciting a sense of embodied awareness, examples being: dance, yoga, and shamanic ritual. This relationship with bodily sensations existed in conjunction with the anxiety and trauma that arose as a result of cancer treatment.

Conclusion

Our analysis suggests that the quality of awareness and relationship to bodily experience in CRF is a functionally relevant component of the disorder and should be considered as an experiential target moving forward.

The response-time relationship and covariate effects of acupuncture for chronic pain: A systematic review and model-based longitudinal meta-analysis

BACKGROUND AND OBJECTIVE

Critical clinical questions regarding how soon and how long the analgesic effect will be achieved by acupuncture, as well as who will be responsive to acupuncture, need further address. The aim of the study was to investigate the response-time relationship and covariate effects of acupuncture.

DATABASES AND DATA TREATMENT

PubMed and EMBASE were searched up to December 2018 for randomized controlled trials that involved sham acupuncture, true acupuncture and conventional therapy. We used a model-based longitudinal meta-analysis to characterize the response-time profile of these treatments.

RESULTS

Seventy-seven randomized clinical trials involved chronic shoulder, neck, knee and low back pain were included. The response-time analysis suggested that the treatment duration of acupuncture will be 5 weeks or more to achieve 80% of maximum analgesic effect. Moreover a lower baseline pain intensity and the location of low back pain resulted in a lower pain relief of acupuncture intervention. The absolute maximum analgesic effects of sham acupuncture and conventional therapy were 22.6 and 15.8 points at a 0-100 NRS scale. The absolute effect of true acupuncture was 26.1 points for low back pain (relative effect of 3.5 and 9.4 points to sham and conventional therapy), 34.9 points for other pain body locations (relative effect of 12.3 and 19.1 points to sham and conventional therapy), in patients with a baseline pain intensity of 60 points.

CONCLUSION

The treatment duration of acupuncture will not be less than 5 weeks to achieve 80% maximum analgesic effect. Higher analgesic effect was related to higher baseline pain intensity and pain location of neck, shoulder and knee.

SIGNIFICANCE

Our systematic review and meta-analysis provides the clear evidence for the treatment duration and significant related covariates of acupuncture intervention for chronic pain. These results provide useful suggestion for acupuncture intervention in clinical pain management.

Non-specific effects of acupuncture and sham acupuncture in clinical trials from the patient's perspective: a systematic review of qualitative evidence

BACKGROUND

Previous clinical trials have demonstrated that both acupuncture and sham acupuncture exert significant, non-specific effects on treatment outcomes when compared to no-treatment controls. A recently developed framework (mechanisms in orthodox and complementary and alternative medicine-MOCAM) suggests that the non-specific effects of acupuncture originate from multiple domains (e.g. patient characteristics, acupuncturist skill/technique, the patient-acupuncturist relationship, and the acupuncture environment). However, it remains to be determined precisely how these domains influence the non-specific effects of treatment among patients receiving acupuncture and sham acupuncture in clinical trials. Therefore, we conducted a systematic review to synthesize existing qualitative evidence on how trial participants randomized to acupuncture and sham acupuncture groups experience non-specific effects, regardless of the types of medical condition investigated.

METHODS

This systematic review included primary qualitative studies embedded in randomized controlled trials designed to investigate acupuncture or sham acupuncture interventions. Eligible studies published in English were derived from a search of five international databases. The methodological quality of included studies was evaluated using the Critical Appraisal Skills Programme (CASP) tool. Using a framework synthesis approach, the identified MOCAM framework was adapted based on the synthesis of the available qualitative evidence.

RESULTS

A total of 20 studies of high methodological quality were included. Our proposed model indicated that the effects of acupuncture may be increased by maintaining a professional status, applying a holistic treatment approach, practicing empathy, and providing patients with an appropriate explanation of the theory behind acupuncture and sham acupuncture. From the patient's perspective, the efficacy of treatment can be increased by following the lifestyle modification advice provided by acupuncturists, maintaining a positive attitude toward treatment efficacy, actively engaging with acupuncturists during consultation, and making behavioral changes based on experience gained during the trial.

CONCLUSION

The results of this study may provide a basis for improving and standardizing key components of non-specific effects in acupuncture treatment, and for improving the isolation of specific effects in future clinical trials involving acupuncture and sham acupuncture.

Differential Influence of Acupuncture Somatosensory and Cognitive/Affective Components on Functional Brain Connectivity and Pain Reduction During Low Back Pain State

The underlying mechanism of pain reduction by acupuncture is still unclear, because acupuncture treatment involves multidimensional factors. In this study, we investigated the differential influence of acupuncture components on brain functional connectivity and on pain reduction. We used a specific form of sham acupuncture (phantom acupuncture; PHNT), which only has a needling-credibility (a belief that they were treated with real acupuncture needles), while real acupuncture (REAL) has a somatosensory needling stimulation, as well as a needling-credibility. Forty-three patients with low back pain were randomized into the REAL group (n = 25) and the PHNT group (n = 18). They underwent two pain steady-state fMRI runs implemented by a low back extension (LBE) pain model (lifting the low back using air-cuff inflation) before and after REAL or PHNT stimulation. Subjective pain ratings, perceived throughout the LBE runs due to the posture, were reported (LBEpain). The regions of interest (ROI) were (1) the main nodes of the default mode network (DMN) – the medial prefrontal cortex (mPFC), posterior cingulate cortex (PCC), (2) the main nodes of the salience network (SN) – the anterior/posterior insular cortices (a/pINS), and (3) the low back-specific region of sensorimotor network (SMN), S1_back. Significant reductions in LBEpain were observed in both groups (REAL = −1.02 ± 1.53, PHNT = −1.26 ± 2.20). In REAL group, decreased LBEpain was positively correlated with decreased functional connectivity between the mPFC and pINS (r = 0.58, P < 0.05). Reduced LBEpain in PHNT was negatively correlated with increased PCC–aINS connectivity (r = −0.48, P < 0.05) and tended toward positive correlation with decreased S1_back–pINS connectivity (r = 0.44, P = 0.07). Our findings might suggest different brain mechanisms of observed pain reduction; REAL seems to involve detachment of the self from the sensory aspect of pain, while PHNT does to shift attention to self and disengages physical pain processing hubs. This exploratory study proposes a sham methodology to dissociate the influence of different acupuncture components in acupuncture research. Further studies need to be followed with more elaborated hypothesis, study design, and analysis considering various cognitive/affective factors for better understanding of brain mechanisms of pain reduction regarding the different acupuncture aspects.

Placebo trials without mechanisms: How far can they go?

In this paper, I suggest that placebo effects, as we know them today, should be understood as experimental phenomena, low-level regularities whose causal structure is grasped through particular experimental designs with little theoretical guidance. Focusing on placebo interventions with needles for pain reduction -one of the few placebo regularities that seems to arise in meta-analytical studies- I discuss the extent to which it is possible to decompose the different factors at play through more fine-grained randomized clinical trials. My sceptical argument is twofold. On the one hand, I argue that experiments alone are not enough to standardize interventions, and that it is necessary to include theories. On the other hand, I argue that the social interactions that seem to be part of placebo effects are difficult, if not impossible, to blind. Therefore, the measurement biases arising from the participants' reactivity to the experimental setup cannot be controlled for. Further decomposition of placebo effects requires a theoretical account of the existing experimental regularities that may guide further tests.

[Use of placebo in French hospitals: data from polyvalent medicine units]

A placebo drug is defined as a treatment without any specific pharmacological efficacy, that works when the patient thinks to receive an active treatment, through a psychological and physiological mechanism. This study aimed to evaluate the use of placebo in French hospitals, in Polyvalent Medicine units. A questionnaire comprising 15 items was sent to 372 units. The analysis of 153 responses was conducted from dynamic crosstabs in Excel and using the R software available online. The survey confirmed that the use of placebos in hospital is frequent, with nearly 2/3 of professionals answering the questionnaire declared to use it. The oral capsule is the most commonly used form. Placebo is mainly administered at night, in case of pain, insomnia or anxiety, to so-called "difficult" patients. Placebo is not always given after medical prescription. In most cases, patients are not informed that they receive a placebo. The majority of professionals believed in the placebo effect but considered to be insufficiently informed and trained in the use of placebo in current practice. Although the placebo effect is now demonstrated, ethical and legal considerations recommend placebo treatment only on medical prescription, with the prior information of the patient. The placebo could be used as complementary therapy to conventional treatment in the cases of this therapeutic effectiveness has been demonstrated. Professionals should be trained in the use of placebo in order to avoid nocebo effect and potentiate beneficial effects of placebo.

Acupuncture using pattern-identification for the treatment of insomnia disorder: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Insomnia symptoms are common, affecting almost 30% of the population of the population. Many use medications that may be ineffective and cause substantial harm. In complementary and alternative medicine, acupuncture is widely used to manage mental health problems. Acupuncture therapy emphasizes individualized treatment according to TCM pattern diagnosis. Although there are some systematic reviews that acupuncture has the benefit for insomnia, there is no systematic review on acupuncture using pattern identification. This review aimed for evaluating acupuncture efficacy using pattern-identification to treat insomnia.

METHODS

We carried out a comprehensive review of randomized controlled trials (from 2000 to April 12, 2018), using PubMed, Cochrane CENTRAL, EMBASE, CINAHL, PsycINFO, CNKI, and 3 Korean (OASIS, NDSL, RISS4U) databases, comparing acupuncture using pattern identification (only) with medication in primary insomnia. Response rate and the Pittsburgh Sleep Quality Index (PSQI) were the primary outcomes. Risk of bias and publication biases were evaluated, and meta-analyses were conducted.

RESULTS

Nineteen RCTs were included (11 manual acupuncture (1079 patients), 8 electro-acupuncture (442 patients)) of low quality. Meta-analyses of all studies reveled that acupuncture improved total effectiveness rate (Risk Ratio [RR] = 1.23, 95% confidence intervals [CIs]: 1.12-1.35, p < 0.00001; I2 = 80%) and PSQI (MD = -1.92, 95% CI: -2.41-1.42, p < 0.00001; I2 = 30%) compared to medication. Results of overall risk of bias assessments were unclear or high.

CONCLUSIONS

Acupuncture using pattern identification led to significantly improved total effectiveness rate compared to medication. With regard to PSQI, as compared to the control group, acupuncture using pattern identification was similar to medication. However, this study has limitations of high risk of bias, not using a standardized pattern-diagnosis-treatment and not comparing with standarized acupuncture without pattern identification.

Systematic Review of Acupuncture Placebo Devices with a Focus on the Credibility of Blinding of Healthy Participants And/Or Acupuncturists

Background

An ideal placebo design in clinical research should resemble the intervention under investigation to facilitate blinding, yet remain clinically inert. With regard to physical interventions such as acupuncture, a true placebo device has not been developed and validated. Since 1998, researchers have designed several placebo acupuncture devices (PADs). The three most widely used PADs are the Streitberger, the Park and the Takakura device.

Aim

This review focuses on evaluating studies of these devices, in the context of credibility of blinding (COB), assessment of penetrating pain or sensation, and de qi sensation.

Methods

Electronic database searches were conducted in four English and two Chinese databases from their inception until November 2016. All studies included in the review were conducted on healthy participants and compared verum manual acupuncture with any of the aforementioned PADs with respect to one or more of the above three outcomes related to blinding effect.

Results

The synthesised analyses of the 15 included studies showed that the Streitberger and Park placebo devices may not blind participants successfully when tested at a sensitive acupuncture point (LI4). In terms of penetrating sensation, there were significant differences between these two placebo devices and verum acupuncture when applied at this point. The Takakura device was the only PAD that had the potential to blind the acupuncturist. However, the blinding analyses of all outcome measures were inconsistent.

Conclusion

Overall, there were insufficient data to confirm the blinding effects of these skin-contact PADs as each device was associated with limitations that warrant further design improvements.

Acupuncture and Neural Mechanism in the Management of Low Back Pain-An Update

Within the last 10 years, the percentage of low back pain (LBP) prevalence increased by 18%. The management and high cost of LBP put a tremendous burden on the healthcare system. Many risk factors have been identified, such as lifestyle, trauma, degeneration, postural impairment, and occupational related factors; however, as high as 95% of the cases of LBP are non-specific. Currently, LBP is treated pharmacologically. Approximately 25 to 30% of the patients develop serious side effects, such as drowsiness and drug addiction. Spinal surgery often does not result in a massive improvement of pain relief. Therefore, complementary approaches are being integrated into the rehabilitation programs. These include chiropractic therapy, physiotherapy, massage, exercise, herbal medicine and acupuncture. Acupuncture for LBP is one of the most commonly used non-pharmacological pain-relieving techniques. This is due to its low adverse effects and cost-effectiveness. Currently, many randomized controlled trials and clinical research studies have produced promising results. In this article, the causes and incidence of LBP on global health care are reviewed. The importance of treatment by acupuncture is considered. The efforts to reveal the link between acupuncture points and anatomical features and the neurological mechanisms that lead to acupuncture-induced analgesic effect are reviewed.

Cellular Reorganization Plays a Vital Role in Acupuncture Analgesia

Background: Acupuncture has a long history of relieving many forms of pain. However, many of acupuncture's mechanisms are still unknown and/or misunderstood. Objective: This review looks at past research on many different methods and targets of study related to acupuncture. The main focus is upon the importance of connective-tissue planes in and around acupuncture points. Method: Relevant articles from journals as well as books on the topic were searched manually for information related to the topic. Results: Various studies offered different (and sometimes interrelated) mechanisms for how acupuncture needling results in analgesia among other effects. Emerging evidence, however, has shown the increasing importance of extracellular matrix rearrangements that result in lower mechanical stress states of surrounding tissues. This leads to lower constant stimulation of regional mechanoreceptors, in turn, reducing chronic pain and discomfort. Conclusions: The extracellular matrix has emerged as an important area of study on the effects of acupuncture needling.

Phantom Acupuncture Induces Placebo Credibility and Vicarious Sensations: A Parallel fMRI Study of Low Back Pain Patients

Although acupuncture is an effective therapeutic intervention for pain reduction, the exact difference between real and sham acupuncture has not been clearly understood because a somatosensory tactile component is commonly included in the existing sham acupuncture protocols. In an event-related fMRI experiment, we implemented a novel form of sham acupuncture, phantom acupuncture, that reproduces the acupuncture needling procedure without somatosensory tactile stimulation while maintaining the credibility of the acupuncture treatment context. Fifty-six non-specific low back pain patients received either real (REAL) or phantom (PHNT) acupuncture stimulation in a parallel group study. The REAL group exhibited greater activation in the posterior insula and anterior cingulate cortex, reflecting the needling-specific components of acupuncture. We demonstrated that PHNT could be delivered credibly. Interestingly, the PHNT-credible group exhibited bilateral activation in SI/SII and also reported vicarious acupuncture sensations without needling stimulation. The PHNT group showed greater activation in the bilateral dorsolateral/ventrolateral prefrontal cortex (dlPFC/vlPFC). Moreover, the PHNT group exhibited significant pain reduction, with a significant correlation between the subjective fMRI signal in the right dlPFC/vlPFC and a score assessing belief in acupuncture effectiveness. These results support an expectation-related placebo analgesic effect on subjective pain intensity ratings, possibly mediated by right prefrontal cortex activity.

How Placebo Needles Differ From Placebo Pills?

Because acupuncture treatment is defined by the process of needles penetrating the body, placebo needles were originally developed with non-penetrating mechanisms. However, whether placebo needles are valid controls in acupuncture research is subject of an ongoing debate. The present review provides an overview of the characteristics of placebo needles and how they differ from placebo pills in two aspects: (1) physiological response and (2) blinding efficacy. We argue that placebo needles elicit physiological responses similar to real acupuncture and therefore provide similar clinical efficacy. We also demonstrate that this efficacy is further supported by ineffective blinding (even in acupuncture-naïve patients) which may lead to opposite guesses that will further enhances efficacy, as compared to no-treatment, e.g., with waiting list controls. Additionally, the manner in which placebo needles can exhibit therapeutic effects relative to placebo pills include enhanced touch sensations, direct stimulation of the somatosensory system and activation of multiple brain systems. We finally discuss alternative control strategies for the placebo effects in acupuncture therapy.

Open-label versus double-blind placebo treatment in irritable bowel syndrome: study protocol for a randomized controlled trial

BACKGROUND

Placebo medications, by definition, are composed of inactive ingredients that have no physiological effect on symptoms. Nonetheless, administration of placebo in randomized controlled trials (RCTs) and in clinical settings has been demonstrated to have significant impact on many physical and psychological complaints. Until recently, conventional wisdom has suggested that patients must believe that placebo pills actually contain (or, at least, might possibly contain) active medication in order to elicit a response to placebo. However, several recent RCTs, including patients with irritable bowel syndrome (IBS), chronic low back pain, and episodic migraine, have demonstrated that individuals receiving open-label placebo (OLP) can still experience symptomatic improvement and benefit from honestly described placebo treatment.

METHODS AND DESIGN

This paper describes an innovative multidisciplinary trial design (n = 280) that attempts to replicate and expand upon an earlier IBS OLP study. The current study will compare OLP to double-blind placebo (DBP) administration which is made possible by including a nested, double-blind RCT comparing DBP and peppermint oil. The study also examines possible genetic and psychological predictors of OLP and seeks to better understand participants' experiences with OLP and DBP through a series of extensive interviews with a randomly selected subgroup.

DISCUSSION

OLP treatment is a novel strategy for ethically harnessing placebo effects. It has potential to re-frame theories of placebo and to influence how physicians can optimize watch-and-wait strategies for common, subjective symptoms. The current study aims to dramatically expand what we know about OLP by comparing, for the first time, OLP and DBP administration. Adopting a unique, multidisciplinary approach, the study also explores genetic, psychological and experiential dimensions of OLP. The paper ends with an extensive discussion of the "culture" of the trial as well as potential mechanisms of OLP and ethical implications.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier: NCT02802241 . Registered on 14 June 2016.

Nonspecific Feelings Expected and Experienced during or Immediately after Electroacupuncture: A Pilot Study in a Teaching Situation

BACKGROUND

Some feelings elicited by acupuncture-type interventions are "nonspecific", interpretable as resulting from the placebo effect, our own self-healing capacities-or, indeed, the flow of qi. Expectation is thought to contribute to these nonspecific effects. Here we describe the use of two innovative 20-item questionnaires (EXPre₂₀ and EXPost₂₀) in a teaching situation.

METHODS

Respondents were acupuncture students or practitioners on electroacupuncture (EA) training courses (N = 68). EXPre₂₀ and EXPost₂₀ questionnaires were completed before and after receiving individualised treatment administered by colleagues. Respondents were also asked about their prior experience of EA or transcutaneous electroacupuncture stimulation (TEAS).

RESULTS

Respondents expected significantly more items to change than not to change, but significantly fewer were experienced as changing. Increases in given questionnaire items were both expected and experienced significantly more often than decreases. "Tingling", "Relaxation", and "Relief" or "Warmth" were most often expected to increase or were experienced as such, and "Pain" and "Tension" to decrease or experienced as decreasing. Expectations of change or no change were confirmed more often than not, particularly for "Tingling" and "Tension". This was not the result of the personal respondent style. Cluster analysis suggested the existence of two primary feeling clusters, "Relaxation" and "Alertness".

CONCLUSIONS

Feelings experienced during or immediately after acupuncture-type interventions may depend both on prior experience and expectation.

The role of touch in acupuncture treatment

Acupuncture is a therapeutic treatment that is characterised by the insertion of a needle at a particular location on the body. Acupuncture stimulation includes sensory-discriminative and affective-social touch dimensions. In this review, we discuss the role of touch during acupuncture stimulation with an emphasis on the therapeutic, sensory-discriminative and affective-social aspects. In the discriminative dimension, de qi, which is associated with needling, includes a combination of various sensations, such as heaviness, numbness, soreness and distension. Achieving the appropriate de qi sensation appears to be fundamental to the therapeutic outcome following acupuncture treatment. In the affective dimension, the acupuncture procedure typically includes gentle manual touch stimulation, which induces feelings of calm and well-being, perhaps by activating C tactile fibres. Enhanced activity of C tactile afferents may induce a 'limbic touch' response, resulting in emotional and hormonal reactions. Because acupuncture is a 'therapist intensive' and complex intervention, it is necessary to understand the role of social touch between the practitioner and patient. Both sensory-discriminative and affective-social touch aspects play an important role in the therapeutic effect of acupuncture treatment in clinical practice.

The Signaling Theory of Symptoms : An Evolutionary Explanation of the Placebo Effect

Placebo research shows that the subjective quality of care and social support, as well as the patients' expectations of treatment, influence therapeutic outcomes. However, this phenomenon, known as the placebo effect, does not usually cure the disease, but rather can provide symptomatic relief: It may soothe symptoms such as pain, swelling, or nausea that constitute part of an immune response. The function of this mechanism remains unclear. This article puts forward the Signaling Theory of Symptoms (STS) as a possible explanation. According to STS, discernible aspects of an immune response, such as pain, swelling, or nausea, not only serve a defensive and healing function but also a signaling function: symptoms signal the need for care and treatment to potential helpers. Once help and treatment are granted, the signaling function is fulfilled and the symptoms diminish. This mechanism may have been a significant advantage in preindustrial environments, when sufferers depended on extensive social support and personal treatment. Nowadays, from the point of view of modern materialist medicine, the mobilization of social support no longer seems so crucial, and thus the placebo effect has been assigned a somewhat mysterious quality.

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.

Clinical effectiveness of osteopathic treatment in chronic migraine: 3-Armed randomized controlled trial

OBJECTIVE

To assess the effectiveness of OMT on chronic migraineurs using HIT-6 questionnaire, drug consumption, days of migraine, pain intensity and functional disability.

DESIGN

3-Armed randomized controlled trial setting: all patients admitted in the Department of Neurology of Ancona's United Hospitals, Italy, with a diagnosis of migraine and without chronic illness, were considered eligible for the study.

INTERVENTIONS

Patients were randomly divided into three groups: (1) OMT+medication therapy, (2) sham+medication therapy and (3) medication therapy only. Patients received 8 treatments in a study period of 6 months.

MAIN OUTCOME MEASURES

Changing from baseline HIT-6 score.

RESULTS

105 subjects were included. At the end of the study, ANOVA showed that OMT significantly reduced HIT-6 score (mean change scores OMT-conventional care: -8.74; 95% confidence interval (CI) -12.96 to -4.52; p<0.001 and OMT-sham: -6.62; 95% CI -10.85 to -2.41; p<0.001), drug consumption (OMT-sham: RR=0.22, 95% CI 0.11-0.40; OMT-control: RR=0.20, 95% CI 0.10-0.36), days of migraine (OMT-conventional care: M=-21.06; 95% CI -23.19 to -18.92; p<0.001 and OMT-sham: -17.43; 95% CI -19.57 to -15.29; p<0.001), pain intensity (OMT-sham: RR=0.42, 95% CI 0.24-0.69; OMT-control: RR=0.31, 95% CI 0.19-0.49) and functional disability (p<0.001).

CONCLUSIONS

These findings suggest that OMT may be considered a valid procedure for the management of migraineurs. The present trial was registered on www.ClinicalTrials.gov (identifier: NCT01851148).

Canadian Orofacial Pain Team workshop report on the global year against orofacial pain

The year 2013-2014 has been designated the Global Year Against Orofacial Pain by the International Association for the Study of Pain. Accordingly, a multidisciplinary Canadian and international group of clinical, research and knowledge-transfer experts attended a workshop in Montreal, Quebec. The workshop had two aims: to identify new pathways for innovative diagnosis and management of chronic orofacial pain states; and to identify opportunities for further collaborative orofacial pain research and education in Canada. Three topics related to chronic orofacial pain were explored: biomarkers and pain signatures for chronic orofacial pain; misuse of analgesic and opioid pain medications for managing chronic orofacial pain; and complementary alternative medicine, topical agents and the role of stress in chronic orofacial pain. It was determined that further research is needed to: identify biomarkers of chronic orofacial post-traumatic neuropathic pain, with a focus on psychosocial, physiological and chemical-genetic factors; validate the short- and long-term safety (i.e., no harm to health, and avoidance of misuse and addiction) of opioid use for two distinct conditions (acute and chronic orofacial pain, respectively); and promote the use of topical medications as an alternative treatment in dentistry, and further document the benefits and safety of complementary and alternative medicine, including stress management, in dentistry. It was proposed that burning mouth syndrome, a painful condition that is not uncommon and affects mainly postmenopausal women, should receive particular attention.

Tai chi mind-body exercise in patients with COPD: study protocol for a randomized controlled trial

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic, progressively debilitating condition that is prevalent in the US and worldwide. Patients suffer from progressive dyspnea and exercise intolerance. Physical exercise is beneficial, but conventional pulmonary rehabilitation programs are underutilized. There remains a need for novel interventions that improve symptoms, quality-of-life, and functional capacity. Tai chi is an increasingly popular mind-body exercise that includes physical exercise, breathing training, mindful awareness, and stress management--components that are essential to the self-management of COPD. There are, however, limited data on the effectiveness of tai chi as a therapeutic intervention in this population.

METHODS/DESIGN

The Primary Aims are to evaluate the efficacy, safety, and feasibility of a 12-week tai chi program for patients with COPD. We utilize a randomized controlled trial design, with participants assigned in a 2:1 ratio to either a group tai chi program (N = 63) or a time/attention-matched education control (N = 31). Our primary outcomes are COPD-specific quality-of-life and exercise capacity. Secondary outcomes include dyspnea, mood, functional status, self-efficacy, and lung function. Cardiopulmonary exercise testing is done in a subset of patients (N = 50). To explore optimal training duration, a subgroup of patients in tai chi are randomly assigned to complete an additional 12 weeks training (total 24 weeks) (Exploratory Aim 1). To explore the impact of a simplified seated intervention including only a subset of tai chi's training components, a third randomly assigned group (N = 31) receives a 12- week mind-body breathing program (N = 31) (Exploratory Aim 2).

DISCUSSION

Results of the BEAM study (Breathing, Education, Awareness, Movement) will provide preliminary evidence regarding the value of tai chi for improving quality of life and exercise capacity in patients with COPD, including information regarding optimal duration. They will also inform the feasibility and potential benefit of an alternative mind-body breathing intervention, and provide insight regarding how isolated mind-body exercise components contribute to the overall effects of tai chi. Should the results be positive, tai chi and related mind-body practices may offer a novel exercise option that is potentially accessible to a large proportion of patients with COPD.

TRIAL REGISTRATION

This trial is registered in Clinical Trials.gov, ID number NCT01551953. Date of Registration March 1 2012.

Perceived outcomes of spiritual healing and explanations--a qualitative study on the perspectives of German healers and their clients

Background

Limited research has been conducted on contemporary spiritual healing in European countries. The aim of this article is to report how German healers and their clients experienced and perceived the outcomes of spiritual healing and which explanations they use to describe the perceived effects.

Methods

Semistructured interviews and participatory observation was used to collect data from spiritual healers and their clients. Analyses were based on the methodological concept of directed qualitative content analysis. Data was analyzed using MAXQDA software, discussed and reviewed by a multidisciplinary research team consisting of medical anthropologists, medical doctors and a religious studies scholar.

Results

In total 15 healers and 16 clients participated in this study, 24 interviews with healers, 20 interviews with clients and 8 participatory observations were analyzed. Healers and clients reported outcomes as positively perceived body sensations, increased well-being, positive emotions and symptomatic relief of medical complaints. Clients often described changes in their self-concepts and adapted life values. Explanations for perceived effects included connecting with transcendent sources, construction of meaning, as a result of the client-healer relationship, and as empowerment to make changes. Because the interviewed clients were recruited by the healers, a selection bias towards positive healing experiences is possible.

Conclusion

We hypothesize that concepts of meaning construction, resource activation and the utilization of the clients’ expectations help to explain the data. Grounded in the emic perspective, we propose to use the following outcomes for further prospective studies: positive body sensations, changes of self-concepts and values, changes of medical symptoms and complaints. From the etic perspective, physical, emotional, social and spiritual wellbeing, sense of coherence, meaningfulness of life, empowerment, resource activation, change and symptom control should be further explored as potential outcomes.

Conventional and complementary approaches to chronic widespread pain and its comorbidities

The concept of comorbidities as a challenge for healthcare systems has recently been given increasing attention in leading medical journals. Many patients suffering from chronic pain, especially those who are older or poorer, have more than one pathology (multimorbidity) or more than one set of manifestation of one pathology (comorbidity). These patients present a difficult problem in industrialised societies, with services that are highly specialised and compartmentalised. Systematic reviews of interventions for patients of this kind do not mention acupuncture. Acupuncturists claim that their treatment promotes general well-being and can help with multiple symptoms, but evidence for this claim is currently lacking. Longitudinal research with prospective data collection regarding the effect on morbidity burden is needed.

Acupuncture for treating fibromyalgia

BACKGROUND

One in five fibromyalgia sufferers use acupuncture treatment within two years of diagnosis.

OBJECTIVES

To examine the benefits and safety of acupuncture treatment for fibromyalgia.

SEARCH METHODS

We searched CENTRAL, PubMed, EMBASE, CINAHL, National Research Register, HSR Project and Current Contents, as well as the Chinese databases VIP and Wangfang to January 2012 with no language restrictions.

SELECTION CRITERIA

Randomised and quasi-randomised studies evaluating any type of invasive acupuncture for fibromyalgia diagnosed according to the American College of Rheumatology (ACR) criteria, and reporting any main outcome: pain, physical function, fatigue, sleep, total well-being, stiffness and adverse events.

DATA COLLECTION AND ANALYSIS

Two author pairs selected trials, extracted data and assessed risk of bias. Treatment effects were reported as standardised mean differences (SMD) and 95% confidence intervals (CI) for continuous outcomes using different measurement tools (pain, physical function, fatigue, sleep, total well-being and stiffness) and risk ratio (RR) and 95% CI for dichotomous outcomes (adverse events). We pooled data using the random-effects model.

MAIN RESULTS

Nine trials (395 participants) were included. All studies except one were at low risk of selection bias; five were at risk of selective reporting bias (favouring either treatment group); two were subject to attrition bias (favouring acupuncture); three were subject to performance bias (favouring acupuncture) and one to detection bias (favouring acupuncture). Three studies utilised electro-acupuncture (EA) with the remainder using manual acupuncture (MA) without electrical stimulation. All studies used 'formula acupuncture' except for one, which used trigger points.Low quality evidence from one study (13 participants) showed EA improved symptoms with no adverse events at one month following treatment. Mean pain in the non-treatment control group was 70 points on a 100 point scale; EA reduced pain by a mean of 22 points (95% confidence interval (CI) 4 to 41), or 22% absolute improvement. Control group global well-being was 66.5 points on a 100 point scale; EA improved well-being by a mean of 15 points (95% CI 5 to 26 points). Control group stiffness was 4.8 points on a 0 to 10 point; EA reduced stiffness by a mean of 0.9 points (95% CI 0.1 to 2 points; absolute reduction 9%, 95% CI 4% to 16%). Fatigue was 4.5 points (10 point scale) without treatment; EA reduced fatigue by a mean of 1 point (95% CI 0.22 to 2 points), absolute reduction 11% (2% to 20%). There was no difference in sleep quality (MD 0.4 points, 95% CI -1 to 0.21 points, 10 point scale), and physical function was not reported.Moderate quality evidence from six studies (286 participants) indicated that acupuncture (EA or MA) was no better than sham acupuncture, except for less stiffness at one month. Subgroup analysis of two studies (104 participants) indicated benefits of EA. Mean pain was 70 points on 0 to 100 point scale with sham treatment; EA reduced pain by 13% (5% to 22%); (SMD -0.63, 95% CI -1.02 to -0.23). Global well-being was 5.2 points on a 10 point scale with sham treatment; EA improved well-being: SMD 0.65, 95% CI 0.26 to 1.05; absolute improvement 11% (4% to 17%). EA improved sleep, from 3 points on a 0 to 10 point scale in the sham group: SMD 0.40 (95% CI 0.01 to 0.79); absolute improvement 8% (0.2% to 16%). Low-quality evidence from one study suggested that MA group resulted in poorer physical function: mean function in the sham group was 28 points (100 point scale); treatment worsened function by a mean of 6 points (95% CI -10.9 to -0.7). Low-quality evidence from three trials (289 participants) suggested no difference in adverse events between real (9%) and sham acupuncture (35%); RR 0.44 (95% CI 0.12 to 1.63).Moderate quality evidence from one study (58 participants) found that compared with standard therapy alone (antidepressants and exercise), adjunct acupuncture therapy reduced pain at one month after treatment: mean pain was 8 points on a 0 to 10 point scale in the standard therapy group; treatment reduced pain by 3 points (95% CI -3.9 to -2.1), an absolute reduction of 30% (21% to 39%). Two people treated with acupuncture reported adverse events; there were none in the control group (RR 3.57; 95% CI 0.18 to 71.21). Global well-being, sleep, fatigue and stiffness were not reported. Physical function data were not usable.Low quality evidence from one study (38 participants) showed a short-term benefit of acupuncture over antidepressants in pain relief: mean pain was 29 points (0 to 100 point scale) in the antidepressant group; acupuncture reduced pain by 17 points (95% CI -24.1 to -10.5). Other outcomes or adverse events were not reported.Moderate-quality evidence from one study (41 participants) indicated that deep needling with or without deqi did not differ in pain, fatigue, function or adverse events. Other outcomes were not reported.Four studies reported no differences between acupuncture and control or other treatments described at six to seven months follow-up.No serious adverse events were reported, but there were insufficient adverse events to be certain of the risks.

AUTHORS' CONCLUSIONS

There is low to moderate-level evidence that compared with no treatment and standard therapy, acupuncture improves pain and stiffness in people with fibromyalgia. There is moderate-level evidence that the effect of acupuncture does not differ from sham acupuncture in reducing pain or fatigue, or improving sleep or global well-being. EA is probably better than MA for pain and stiffness reduction and improvement of global well-being, sleep and fatigue. The effect lasts up to one month, but is not maintained at six months follow-up. MA probably does not improve pain or physical functioning. Acupuncture appears safe. People with fibromyalgia may consider using EA alone or with exercise and medication. The small sample size, scarcity of studies for each comparison, lack of an ideal sham acupuncture weaken the level of evidence and its clinical implications. Larger studies are warranted.

The effectiveness of acupuncture research across components of the trauma spectrum response (tsr): a systematic review of reviews

BACKGROUND

Co-morbid symptoms (for example, chronic pain, depression, anxiety, and fatigue) are particularly common in military fighters returning from the current conflicts, who have experienced physical and/or psychological trauma. These overlapping conditions cut across the boundaries of mind, brain and body, resulting in a common symptomatic and functional spectrum of physical, cognitive, psychological and behavioral effects referred to as the 'Trauma Spectrum Response' (TSR). While acupuncture has been shown to treat some of these components effectively, the current literature is often difficult to interpret, inconsistent or of variable quality. Thus, to gauge comprehensively the effectiveness of acupuncture across TSR components, a systematic review of reviews was conducted using the Samueli Institute's Rapid Evidence Assessment of the Literature (REAL©) methodology.

METHODS

PubMed/MEDLINE, the Cochrane Database of Systematic Reviews, EMBASE, CINAHL, and PsycInfo were searched from inception to September 2011 for systematic reviews/meta-analyses. Quality assessment was rigorously performed using the Scottish Intercollegiate Guidelines Network (SIGN 50) checklist and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. Adherence to the Standards for Reporting Interventions in Clinical Trials in Acupuncture (STRICTA) criteria was also assessed.

RESULTS

Of the 1,480 citations identified by our searches, 52 systematic reviews/meta-analyses, all high quality except for one, met inclusion criteria for each TSR component except post-traumatic stress disorder (PTSD) and sexual function. The majority of reviews addressed most STRICTA components, but did not describe safety.

CONCLUSIONS

Based on the results of our review, acupuncture appears to be effective for treating headaches and, although more research is needed, seems to be a promising treatment option for anxiety, sleep disturbances, depression and chronic pain. It does not, however, demonstrate any substantial treatment benefit for substance abuse. Because there were no reviews on PTSD or sexual function that met our pre-defined inclusion criteria, we cannot comment on acupuncture's effectiveness in treating these conditions. More quality data are also needed to determine whether acupuncture is appropriate for treating fatigue or cognitive difficulties. Further, while acupuncture has been shown to be generally safe, safety was not described in the majority of studies, making it difficult to provide any strong recommendations. Future research should address safety reporting in detail in order to increase our confidence in acupuncture's efficacy across the identified TSR components.

Time, touch, and compassion: effects on autonomic nervous system and well-being

OBJECTIVE

Compassion is critical for complementary and conventional care, but little is known about its direct physiologic effects. This study tested the feasibility of delivering two lengths of time (10 and 20 minutes) and two strategies (tactile and nontactile) for a practitioner to nonverbally communicate compassion to subjects who were blind to the interventions.

METHODS

Healthy volunteers were informed that we were testing the effects of time and touch on the autonomic nervous system. Each subject underwent five sequential study periods in one study session: (1) warm-up; (2) control-with the practitioner while both read neutral material; (3) rest; (4) intervention-with practitioner meditating on loving-kindness toward the subject; and (5) rest. Subjects were randomized to receive one of four interventions: (1) 10 minutes tactile; (2) 20 minutes tactile; (3) 10 minutes nontactile; or (4) 20 minutes nontactile. During all interventions, the practitioner meditated on loving-kindness toward the subject. For tactile interventions, the practitioner touched subjects on arms, legs, and hands; for nontactile interventions, the practitioner pretended to read. Subjects' autonomic activity, including heart rate, was measured continuously. Subjects completed visual analog scales for well-being, including relaxation and peacefulness, at warm-up; postcontrol; immediately postintervention; and after the postintervention rest and were asked about what they and the practitioner had done during each study period.

RESULTS

The 20 subjects' mean age was 24.3 ± 4 years; 16 were women. The practitioner maintained a meditative state during all interventions as reflected in lower respiratory rate, and subjects remained blind to the practitioner's meditative activity. Overall, interventions significantly decreased heart rate (P < .01), and although other changes did not reach statistical significance, they were in the expected direction, with generally greater effects for the tactile than nontactile strategies and for 20-minute than 10-minute doses.

CONCLUSIONS

Two strategies are feasible for blinding subjects to nonverbal communication of compassion; even with blinding, nonverbal communication of compassion affects subjects' autonomic nervous system. These results should be replicated in larger samples, including patient populations, and mechanisms sought to explain observed effects. Compassion is not only good care; it may also be good medicine.

Placebo and other psychological interactions in headache treatment

We present a theory according which a headache treatment acts through a specific biological effect (when it exists), a placebo effect linked to both expectancy and repetition of its administration (conditioning), and a non-specific psychological effect. The respective part of these components varies with the treatments and the clinical situations. During antiquity, suggestions and beliefs were the mainstays of headache treatment. The word placebo appeared at the beginning of the eighteenth century. Controversies about its effect came from an excessive interpretation due to methodological bias, inadequate consideration of the variation of the measure (regression to the mean) and of the natural course of the disease. Several powerful studies on placebo effect showed that the nature of the treatment, the associated announce, the patients' expectancy, and the repetition of the procedures are of paramount importance. The placebo expectancy is associated with an activation of pre-frontal, anterior cingular, accumbens, and periacqueducal grey opioidergic neurons possibly triggered by the dopaminergic meso-limbic system. In randomized control trials, several arms design could theoretically give information concerning the respective part of the different component of the outcome and control the natural course of the disease. However, for migraine and tension type headache attacks treatment, no three arm (verum, placebo, and natural course) trial is available in the literature. Indirect evidence of a placebo effect in migraine attack treatment, comes from the high amplitude of the improvement observed in the placebo arms (28% of the patients). This figure is lower (6%) when using the harder criterium of pain free at 2 h. But these data disregard the effect of the natural course. For prophylactic treatment with oral medication, the trials performed in the last decades report an improvement in 21% of the patients in the placebo arms. However, in these studies the duration of administration was limited, the control of attacks uncertain as well as the evolution of the co-morbid psycho-pathology. Considering the reviews and meta-analysis of complex prophylactic procedures, it must be concluded that their effect is mostly linked to a placebo and non-specific psychological effects. Acupuncture may have a slight specific effect on tension type headache, but not on migraine. Manual therapy studies do not exhibit difference between manipulation, mobilization, and controls; touch has no proven specific effect. A comprehensive efficacy review of biofeedback studies concludes to a small specific effect on tension type headache but not on migraine. A review of behavioral treatment conclude to an interesting mean improvement but did not demonstrated a specific effect with the exception of a four arm study including a pseudo meditation control group. Expectation-linked placebo, conditioning, and non-specific psychological effects vary according clinical situations and psychological context; likely low in RCT, high after anempathic medical contact, and at its maximum with a desired charismatic healer. The announcements of doctors strongly influence the beliefs of patients, and in consequence their pain and anxiety sensibilities; this modulates the amplitude of the placebo and the non-specific psychological effects and is therefore a major determinant of the therapeutic success. Furthermore, any repetitive contact, even through a placebo, may interfere positively with the psychopathological co-morbidity. One has to keep in mind that the non-specific psychological interactions play a major role in the improvement of the majority of the headache sufferers.