Measuring expectations of benefit from treatment in acupuncture trials: A systematic review

Temporal Summation but Not Expectations of Pain Relief Predict Response to Acupuncture Treatment in Fibromyalgia

Fibromyalgia (FM) is a common chronic pain condition for which acupuncture treatment is increasingly utilized. However, there is no universally accepted measure to predict whether a specific patient will benefit from acupuncture. This is a single-center, single-blind, sham-controlled, randomized, noncrossover, longitudinal trial of 76 subjects with FM, assigned to either electroacupuncture (EA) or a placebo control, mock laser (ML) acupuncture. Outcome measures included clinical pain severity (Brief Pain Inventory [BPI]), degree of nociplastic pain (Fibromyalgia Survey Questionnaire), and pressure pain tolerance (PPtol). Baseline measures of temporal summation of pain and expectations for treatment relief were used as predictors. Individuals in both treatment groups experienced significant reductions in BPI (EA: P < .001, ML: P = .018) and Fibromyalgia Survey Questionnaire (EA: P = .032, ML: P = .002) after treatment; however, neither group showed a significant increase in PPtol. Lower temporal summation at baseline was correlated with greater post-treatment improvement in BPI in the EA group (rho = .389, P = .025) but not in the ML group (rho = -.272, P = .109). Lower-baseline temporal summation was correlated with greater decreases in PPtol following EA (rho = .400, P = .040), whereas the opposite was seen for ML (rho = -.562, P = .001). Treatment expectancy at baseline was not correlated with any outcome after EA or ML treatments. Our results support using a quantitative sensory testing metric, temporal summation of pain, but not expectations, to predict analgesia following acupuncture treatment for pain. PERSPECTIVE: A randomized study of acupuncture in FM found baseline temporal summation, but not expectations of pain relief, to be predictive of treatment response. CLINICAL TRIAL REGISTRATION: Registered under ClinicalTrials.gov identifier NCT02064296.

The Efficacy of Neuromodulation Interventions for Chemotherapy-Induced Peripheral Neuropathy: A Systematic Review and Meta-Analysis

Purpose

To determine the efficacy and safety of a neuromodulation intervention regimen in the treatment of chemotherapy-induced peripheral neuropathy (CIPN).

Patients and Methods

Systematic searches were conducted in seven English databases. Randomized controlled trials of all neuromodulation interventions (both invasive and non-invasive) for the treatment of CIPN were selected. Group comparisons of differences between interventions and controls were also made. We divided the outcomes into immediate-term effect (≤3 weeks), short-term effect (3 weeks to ≤3 months), and long-term effect (>3 months).

Results

Sixteen studies and 946 patients with CIPN were included. Among immediate-term effects, neuromodulation interventions were superior to usual care for improving pain (SMD=-0.77, 95% CI -1.07~ 0.47), FACT-Ntx (MD = 5.35, 95% CI 2.84~ 7.87), and QOL (SMD = 0.44, 95% CI 0.09~ 0.79) (moderate certainty); neuromodulation loaded with usual care was superior to usual care for improving pain (SMD=-0.47, 95% CI -0.71 ~ -0.23), and QOL (SMD = 0.40, 95% CI 0.12 ~ 0.69) (moderate certainty). There were no statistically significant differences between the neuromodulation interventions regimen vs usual care in short- and long-term outcomes and neuromodulation vs sham stimulation from any outcome measure. There were mild adverse events such as pain at the site of stimulation and bruising, and no serious adverse events were reported.

Conclusion

Neuromodulation interventions had significant immediate-term efficacy in CIPN but had not been shown to be superior to sham stimulation; short-term and long-term efficacy could not be determined because there were too few original RCTs. Moreover, there are no serious adverse effects of this therapy.

Cross-Cultural Adaptation and Measurement Properties of the Expectations for Treatment Scale (ETS) for Greek-Speaking Patients

Introduction Patients' treatment expectations are key factors influencing the health outcomes in various medical conditions. Using validated measures to capture these expectations has been strongly suggested to improve the prognosis of the health outcome and promote research investigations. The Expectations for Treatment Scale (ETS) is a well-established questionnaire designed to accurately measure treatment expectations in patients with low back pain; however, it is not available in Greek yet. We aimed to translate and cross-culturally adapt the ETS in Greek (ETS-Gr) and evaluate its reliability and validity in a Greek-speaking population with musculoskeletal disorders. Methods We followed published recommendations for the translation and cross-cultural adaptation process of the scale. Face and content validity were evaluated using interviews with patients and experts. Internal consistency, test-retest reliability, and measurement error were evaluated in 52 patients with musculoskeletal conditions. Results During forward and backward translation minor linguistic discrepancies were detected and effectively adapted for Greek-speaking patients. The ETS-Gr presented a high level of content validity (item content validity index: 0.88-1; and average scale content validity index: 0.90), acceptable internal consistency (Cronbach's alpha: 0.84), and excellent test-retest reliability (intraclass correlation coefficient: 0.96, 95% confidence interval: 0.93-0.98). Conclusions The ETS-Gr is a short, reliable, and valid instrument to measure pre-treatment expectations in patients with musculoskeletal disorders. Future investigations including other medical conditions are required.

Does expectancy affect insomnia treatment response in cancer survivors receiving acupuncture and cognitive behavioral therapy?

PURPOSE

Insomnia negatively affects quality of life in cancer survivors. Expectations of insomnia treatment efficacy may influence response to intervention. We sought to determine whether pre-treatment outcome expectancy predicts response to two non-pharmacological interventions for insomnia among cancer survivors.

METHODS

We analyzed data from a randomized clinical trial that compared acupuncture versus cognitive behavioral therapy for insomnia (CBT-I) in cancer survivors. Patient expectancy was measured by the Mao Treatment Expectancy Scale (MTES) at baseline. Insomnia severity was assessed using the Insomnia Severity Index (ISI) at treatment completion (week 8). Multivariate linear regression was used to evaluate the associations between pre-treatment expectancy and ISI score at week, 8 adjusting for co-variates.

RESULTS

Expectancy for acupuncture and CBT-I were similar at baseline (acupuncture: 13.3 ± 4.0; CBT-I: 13.2 ± 2.9, p = 0.17). Greater baseline expectancy scores were associated with a greater and statistically significant insomnia severity reduction at week 8 in the acupuncture group (beta coefficients [Coef.] =  - 0.35, 95% confidence interval [CI] =  - 0.6 to - 0.1, p = 0.016) adjusted for co-variates. Baseline expectancy was not statistically associated with insomnia severity reduction in the CBT-I group (Coef. =  - 0.2, 95% CI =  - 0.7 to 0.2, p = 0.31). High expectancy was significantly associated with greater proportion of treatment responders at week 8 in the acupuncture group (76% vs. 38%, p = 0.001) but not in the CBT-I group (83% vs. 70%, p = 0.21).

CONCLUSIONS

Higher pre-treatment outcome expectancy predicted significantly greater insomnia improvement in patients receiving acupuncture but not in those receiving CBT-I.

IMPLICATIONS FOR CANCER SURVIVORS

Aligning treatment provision with expected outcomes may lead to personalized non-pharmacological insomnia management for cancer survivors.

Impact of Baseline Expectancy on Outcome Prediction of Real and Sham Acupuncture for Persistent Chemotherapy-Induced Peripheral Neuropathy Pain in Solid Tumor Survivors: A Secondary Analysis of a Randomized Clinical Trial

BACKGROUND

Chemotherapy-induced peripheral neuropathy (CIPN) pain significantly worsens cancer survivors' quality of life. Expectancy may play an important role in acupuncture response. We sought to explore whether expectancy predicts pain outcome in real acupuncture (RA) and sham acupuncture (SA) in cancer survivors.

METHODS

We analyzed data from a randomized clinical trial that evaluated the effect of RA on CIPN symptoms compared to SA and wait list control (WLC) in 75 cancer survivors. This secondary analysis was limited to CIPN pain measured by the Numeric Rating Scale (NRS), graded from 0 to 10. Interventions were delivered over 8 weeks. SA was implemented using a combination of non-acupuncture points and a non-insertion procedure. Patient expectancy was measured by the Acupuncture Expectancy Scale (AES) 3 times during the study. We used a linear regression model to evaluate if the NRS score was associated with the baseline AES score at the end of treatment (week 8), adjusting for baseline NRS score.

RESULTS

AES was similar among 3 groups at baseline (RA: 11.8 ± 2.7; SA: 12.1 ± 3.8.; WLC: 14.6 ± 4.2; P = .062). Baseline AES was not found to be significantly associated with the week 8 NRS score among patients in all RA, SA, and WLC groups (all P > .05). However, we found a trend that higher baseline AES predicted lower NRS score at week 8 in the SA group: a one-point higher score on baseline expectancy was associated with a 0.3-point reduction in NRS pain score (P = .059) at week 8.

CONCLUSIONS

The association of baseline expectancy and acupuncture response was similar between RA and SA. However, SA seemed to rely more on expectancy than RA. Further studies with larger sample sizes are needed to confirm this finding.

The impact of expectancy on the efficacy of acupuncture treatment for postprandial distress syndrome: Secondary analysis of a randomized clinical trial

BACKGROUND

Expectancy is an important source of the placebo effect. However, it is unclear whether this has an effect on the efficacy of acupuncture and sham acupuncture in the treatment of postprandial distress syndrome (PDS).

AIM

To evaluate the effects of high expectancy (HE) and low expectancy (LE) on the efficacy of acupuncture and sham acupuncture in the treatment of PDS.

METHODS

This post hoc secondary analysis used data from our previous randomized controlled trial. Patients were, respectively, enrolled in the HE group and LE group according to expectancy assessments. The composite primary outcomes were the response rate and the elimination rate after 4 weeks of treatment. Expectancy was considered a factor affecting the efficacy of acupuncture treatment only if both primary outcomes achieved significance.

RESULTS

For the acupuncture group, the response rate was 84.5% in the HE group and 78.8% in the LE group (p = 0.458), and the elimination rate was 32.1% in the HE group and 21.2% in the LE group (p = 0.241). For the sham acupuncture group, the response rate at week 4 was 52.3% in the HE group and 53.1% in the LE group (p = 0.936), and the elimination rate at week 4 was 23.1% in the HE group and 10.6% in the LE group (p = 0.090).

CONCLUSION

In this study, the response rate and elimination rate were higher in the high-expectancy group, but no conclusive evidence was found for an association between expectancy and the efficacy of acupuncture and sham acupuncture.

Do patients’ pre-treatment expectations about acupuncture effectiveness predict treatment outcome in patients with chronic low back pain? A secondary analysis of data from a randomised controlled clinical trial

Objective

This secondary analysis of a randomised controlled patient-blinded trial comparing effectiveness and side effect briefings in patients with chronic low back pain (CLBP) investigated the association between patients’ pre-treatment expectations about minimal acupuncture treatment and pain intensity as outcome during and after the end of the treatment.

Methods

Chronic low back pain patients with a pain intensity of at least 4 on a numeric rating scale from 0 to 10 received eight sessions of minimal acupuncture treatment over 4 weeks. The primary outcome was change in pain intensity rated on a Numerical Rating Scale (NRS 0–10) from inclusion visit to treatment session 4 and to the end of the treatment. Patients’ expectations about the effectiveness of acupuncture were assessed using the Expectation for Treatment Scale (ETS) before randomization. Linear regression was applied to investigate whether patients’ pre-treatment expectations predicted changes in pain intensity during and after treatment.

Results

A total of 142 CLBP patients (40.1 ± 12.5 years; 65.5% female) were included in our analysis. Patients’ pre-treatment expectations about acupuncture treatment were associated with changes in pain intensity after four sessions of minimal acupuncture treatment (b = -0.264, p = 0.002), but not after the end of the treatment. This association was found in females and males.

Conclusions

Our results imply that higher pre-treatment expectations only lead to larger reductions in pain intensity in the initial phase of a treatment, with a similar magnitude for both females and males. As the treatment progresses in the second half of the treatment, adapted expectations or other non-specific effects might play a more important role in predicting treatment outcome.

Patients' Expectancies to Acupuncture: A Systematic Review

Objective: This systematic review aimed to document and describe how and when to assess patients' expectancies to acupuncture and the relationship between patients' expectancies and clinical effects. Materials and Methods: Three English databases, including PubMed, Cochrane Central Register of Controlled Trials, and EMBASE, and four Chinese databases, including the Chinese Biomedicine Literature Database, Chinese Journal Full-text Database, Chinese Scientific Journal Full-text Database, and Wanfang Database, were searched up to February 2020. Studies involving patients' expectancies to acupuncture were included. Based on the detailed situations of patients' expectancies, we made a standardized data extraction table that included the basic information of articles, study design details, and measurement of expectations. Based on the data, a descriptive analysis was performed, covering the characteristics of studies, measuring methods of expectations and the relationship between patients' expectancies and clinical effects. Methodology quality assessment was also performed by the risk of bias and the standards for reporting interventions in controlled trials of acupuncture. Results: There were 61 randomized controlled trials included in our analysis. The number of articles increased gradually over time and grew significantly after 2008. About half of trials focused on pain alleviation. Expectancies were measured before the treatment (N = 43), after the treatment (N = 3), and both before and after the treatment (N = 10), and five studies did not mention it. The measurement of expectancies used self-made questionnaires or scales (N = 27), the Acupuncture Expectations Scale (N = 6), and other scales (N = 11), while 17 studies did not describe what scale they used. The used questionnaires or scales mostly tried to ascertain the strength of confidence that acupuncture would help. Patients' expectancies and clinical effects were relevant in 19 studies, irrelevant in 21 studies, and were not mentioned in 21 studies. Conclusions: Patients' expectations to acupuncture have received increasing attention in recent years, but there is still no recognized measurement time and methods. It is critical to develop questions and answers regarding patients' expectations with better discrimination and reliability to accurately assess expectations and to explore the relationship between patients' expectations and acupuncture outcomes in future trials.

Acupuncture in Patients Undergoing Cancer Therapy: Their Interest and Belief in Acupuncture is High, But Few are Using It

OBJECTIVES

Since pre-existing expectations, that is, beliefs, in a treatment may modify outcomes, and acupuncture studies often fail to measure expectations, we wanted to investigate the use of acupuncture, interest, and belief in acupuncture effects among patients undergoing cancer therapy.

METHOD

A cross-sectional design, where the participants answered a study-specific questionnaire with questions regarding their use of, interest and belief in acupuncture treatment.

RESULTS

A total of 457 patients with cancer (48% men, mean age 65 years) answered the questionnaire. Acupuncture was used by 4 (1%) patients during their cancer therapy, and 368 (83%) expressed an interest in receiving acupuncture. Of the 457 patients, 289 (63%) believed acupuncture to be effective for at least 1 of 17 requested symptoms, most commonly pain (56% of the patients) and muscle tension (40%). They believed acupuncture to be effective for a mean value 3 of the 17 requested symptoms. Women (P < .001), and patients 41 to 65 years (P < .001), expressed a stronger belief in acupuncture effects than others.

CONCLUSIONS

Men and older patients expressed weaker beliefs in acupuncture effects than other patients, indicating the importance of collecting expectancy data in future randomized sham-controlled acupuncture studies to be able to treat expectancy as an effect-modifier. The high interest and beliefs in acupuncture effects found also indicate that acupuncture should be available for patients with cancer, for side effects where acupuncture has shown to be effective. In a clinical setting, older men might need more encouragement regarding positive expected outcomes of the acupuncture treatment than younger women.

Ear acupuncture as an adjunct in a treatment protocol for anorexia nervosa: utilization rate and nurses' experience

BACKGROUND

Anorexia nervosa (AN) is a life-threatening illness. Sometimes long inpatient treatment is necessary, increasing the anxiety that comes with hospitalization and the necessary weight gain. Safe, non-pharmacological adjunctive therapies that improve subjective health are called for.

OBJECTIVE

The aim of this non-randomized, mixed-methods observational study was to describe the utilization rate and nurses' experiences of ear acupuncture in a highly specialized clinic for eating disorders in Sweden, in which acupuncture had been implemented as part of routine clinical care. Twenty-five patients with AN-treated voluntarily or by law were included. The semi-standardized National Acupuncture Detoxification Association (NADA) ear acupuncture protocol, sometimes combined with needling at 2 traditional acupuncture point locations on the body, had been implemented as a voluntary adjunct to usual care, twice weekly. To evaluate the acceptance of acupuncture, the study examined how often patients chose acupuncture when offered on schedule, and how often they asked for extra acupuncture sessions. Patients rated their subjective health using the hospital anxiety and depression scale (HADS) and visual analogue scale (VAS), treatment satisfaction with usual care and acupuncture, and health-related quality of life with the RAND36 instrument. A credibility/expectancy questionnaire (CEQ) was used to measure confidence in treatment. Body mass index (BMI) was calculated to follow the patients' recovery. Nurses' experiences of giving acupuncture as a part of routine care were captured in interviews, and analysed with content analysis. Ethical approval was obtained.

RESULTS

Despite an initially moderate level of trust in acupuncture, the utilization rate of the scheduled acupuncture was 89% and patients asked for extra acupuncture sessions on 28 occasions. No serious side effects were reported. Nurses' experiences of providing acupuncture were positive. They were generally enthusiastic, although they reported finding it difficult to organize group treatments and to find time for acupuncture sessions if they were not scheduled.

CONCLUSION

Further research into the effectiveness and costs of acupuncture in psychiatric care is needed. This study provides relevant information for clinicians as well as researchers planning future randomized controlled trials.

Perspectives of patients on medical acupuncture in a primary care setting in Lebanon: a cross-sectional study

INTRODUCTION

There is paucity of data on the knowledge of acupuncture and its use among patients in Lebanon and the Arab countries.

OBJECTIVES

The primary objectives of this study were to determine the knowledge and attitude of patients in a primary care setting in Lebanon toward Western medical acupuncture and to determine factors that may affect their attitudes toward acupuncture use. The secondary objective was to compare the attitudes and knowledge of patients who had tried acupuncture with those who had not.

METHODS

This was a cross-sectional descriptive study about the perspectives of patients in a primary care setting in Lebanon on medical acupuncture.

RESULTS

A total of 212 surveys were completed (78.5% response rate). 24% of participants had not tried and were unwilling to try acupuncture (group 1), 63.5% of participants had not tried but indicated they would be willing to try acupuncture (group 2), and 12.5% of participants had previously tried acupuncture (group 3). Most participants in group 1 (55.6%) stated they would be unwilling to try acupuncture even if referred for it by a physician. Participants who had tried acupuncture (12.5%) had done so for pain conditions.

DISCUSSION

Group 3 scored higher on knowledge questions and had a more positive attitude toward the acupuncture procedure. Most patients who had tried it had done so to treat pain complaints.

CONCLUSION

Patients in groups 2 and 3 were more knowledgeable about acupuncture, had tried more complementary and alternative medicine (CAM) modalities, and were more likely to try acupuncture as an add-on or last resort treatment, compared to group 1.

Does patient's expectation benefit acupuncture treatment?: A protocol for systematic review and meta-analysis

BACKGROUND

Patients' expectation to treatment response is one source of placebo effects. A number of randomized controlled trials (RCTs) reported that expectation benefits to acupuncture treatment, while some did not. Previous systematic reviews failed to draw a confirmative conclusion due to the methodological heterogeneity. It is necessary to conduct a new systematic review to find out whether expectation can influence acupuncture outcomes.

METHODS

We systematically search English and Chinese databases from their inception to 3rd October, 2020, including MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Chinese BioMedical Literature Database (CBM), Chinese National Knowledge Infrastructure (CNKI), and Chinese Science and Technology Periodical Database (VIP). RCTs that evaluated the relationship between expectation and treatment response following acupuncture for adults will be included. Study selection, data extraction, and risk of bias assessment will be conducted independently. Risk of bias will be assessed by the Cochrane risk of bias assessment tool. Data synthesis will be performed by Review Manager (RevMan) software if the data is suitable for synthesis.

RESULTS

This systematic review will provide evidence that whether patients' expectation impacts on the therapeutic effects of acupuncture. This protocol will be performed and reported according to the Preferred Reporting Items from Systematic Reviews and Meta-analysis Protocols (PRISMA-P) statement. The findings of this review will be disseminated through peer-reviewed publications and conference presentations.

CONCLUSION

This systematic review aims to assess whether a higher level of patient's expectation contributes to a better outcome after acupuncture treatment, and in which medical condition this contribution will be more significant.

INPLASY REGISTRATION NUMBER

INPLASY2020100020 on International Platform of Registered Systematic Review and Meta-analysis Protocols.

Treatment expectations seem to affect bowel health when using acupuncture during radiotherapy for cancer: Secondary outcomes from a clinical randomized sham-controlled trial

OBJECTIVE

To investigate if frequent stools ("diarrhoea"), infrequent stools ("constipation"), capacity in daily activities and Quality of Life (QoL) differed between patients treated with verum or sham acupuncture, and if patients with more positive treatment expectations differed regarding frequent stools and infrequent stools from patients with less positive treatment expectations.

METHODS

In this randomized sham controlled trial, 200 patients received verum traditional penetrating acupuncture or sham acupuncture using a telescopic non-penetrating sham-needle 2-3 times a week during abdominal-pelvic radiotherapy (12 needling sessions during median 5 radiotherapy weeks). The patients registered stool frequency once a week, and registered capacity in daily activities and QoL at the start and end of radiotherapy, and at a one-month follow-up.

RESULTS

In the verum acupuncture group, 29 of 96 answering patients (30 %) experienced frequent stools and 7 (7 %) experienced infrequent stools at least one week of radiotherapy. In the sham acupuncture group, 21 of 97 (22 %) experienced frequent stools (p = 0.175) and 10 (10 %) experienced infrequent stools (p = 0.613). Patients with low treatment expectancy were more likely than other patients to experience frequent stools (60 % versus 26 %, p = 0.014) but not to experience infrequent stools (25 % versus 12 %, p = 0.334).

CONCLUSION

Penetrating acupuncture was not effective for frequent stools or for infrequent stools and did not improve capacity in daily activities or QoL in patients undergoing pelvic-abdominal irradiation for cancer more than non-penetrating acupuncture. Since patients with low acupuncture treatment expectations were more likely to experience frequent stools compared to other patients, non-specific treatment effects warrant further studies.

Placebos in chronic pain: evidence, theory, ethics, and use in clinical practice

Despite their ubiquitous presence, placebos and placebo effects retain an ambiguous and unsettling presence in biomedicine. Specifically focused on chronic pain, this review examines the effect of placebo treatment under three distinct frameworks: double blind, deception, and open label honestly prescribed. These specific conditions do not necessarily differentially modify placebo outcomes. Psychological, clinical, and neurological theories of placebo effects are scrutinized. In chronic pain, conscious expectation does not reliably predict placebo effects. A supportive patient-physician relationship may enhance placebo effects. This review highlights "predictive coding" and "bayesian brain" as emerging models derived from computational neurobiology that offer a unified framework to explain the heterogeneous evidence on placebos. These models invert the dogma of the brain as a stimulus driven organ to one in which perception relies heavily on learnt, top down, cortical predictions to infer the source of incoming sensory data. In predictive coding/bayesian brain, both chronic pain (significantly modulated by central sensitization) and its alleviation with placebo treatment are explicated as centrally encoded, mostly non-conscious, bayesian biases. The review then evaluates seven ways in which placebos are used in clinical practice and research and their bioethical implications. In this way, it shows that placebo effects are evidence based, clinically relevant, and potentially ethical tools for relieving chronic pain.

Local and Systemic Analgesic Effects of Nerve-Specific Acupuncture in Healthy Adults, Measured by Quantitative Sensory Testing

OBJECTIVE

This study aims to assess whether acupuncture analgesia's effects are local or systemic and whether there is a dose response for these effects.

METHODS

Twenty-eight healthy volunteers aged 18-45 were randomized to two doses of acupuncture using points closely associated with peripheral nerves in the legs. The lower-dose group involved acupoints overlying the deep peroneal nerve (DP), and the higher-dose involved acupoints overlying the deep peroneal and posterior tibial nerves (DPTN). Baseline and acupuncture quantitative sensory testing (QST) assessments were obtained locally in the calf and great toe and systemically in the hand. Results were analyzed using factorial repeated-measures analysis of variance for each of the QST variables-cold detection threshold (CDT), vibration detection threshold (VDT), heat pain threshold (HP0.5), and heat pain perception of 5/10 (HP5.0). Location (leg/hand) and time (baseline/acupuncture) were within-subject factors. Intervention (DP/DPTN) was a between-subject factor.

RESULTS

CDT was increased in the calf (P < 0.001) and in the hand (P < 0.001). VDT was increased in the toe (P < 0.001) but not in the hand. HP0.5 was increased in the calf (P < 0.001) and in the hand (P < 0.001). HP5.0 was increased in the calf (P = 0.002) and in the hand (P < 0.001), with the local effect being significantly greater than the systemic (P = 0.004). In all of the above QST modalities, there was no difference between the low-dose (DP) and high-dose (DPTN) acupuncture groups.

CONCLUSIONS

Acupuncture caused comparable local and systemic analgesic effects in cold detection and heat pain perception and only local effects in vibration perception. There was no clear acupuncture dose response to these effects.

Electroacupuncture plus on-demand gastrocaine for refractory functional dyspepsia: Pragmatic randomized trial

BACKGROUND AND AIM

Treatment options for functional dyspepsia (FD) refractory to pharmacological treatments are limited but the effectiveness of electroacupuncture (EA) is uncertain. We assessed the effectiveness of EA combined with on-demand gastrocaine.

METHODS

We conducted a single-center, assessor-blind, randomized parallel-group 2-arm trial on Helicobacter pylori negative FD patients of the postprandial distress syndrome subtype refractory to proton pump inhibitor, prokinetics, or H₂ antagonists. Enrolled participants were block randomized in a 1:1 ratio, with concealed random sequence. The treatment and control groups both received on-demand gastrocaine for 12 weeks, but only those in treatment group were offered 20 sessions of EA over 10 weeks. The primary endpoint was the between-group difference in proportion of patients achieving adequate relief of symptoms at week 12.

RESULTS

Of 132 participants randomly assigned to EA plus on-demand gastrocaine (n = 66) or on-demand gastrocaine alone (n = 66), 125 (94.7%) completed all follow-up at 12 weeks. The EA group had a compliance rate 97.7%. They had a significantly higher likelihood in achieving adequate symptom relief at 12 weeks, with a clinically relevant number needed to treat (NNT) value of 2.36 (95% CI: 1.74, 3.64). Among secondary outcomes, statistically and clinically significant improvements were observed among global symptom (NNT = 3.85 [95% CI: 2.63, 7.69]); postprandial fullness and early satiation (NNT = 5.00 [95% CI: 2.86, 25.00]); as well as epigastric pain, epigastric burning, and postprandial nausea (NNT = 4.17 [95% CI: 2.56, 11.11]). Adverse events were minimal and nonsignificant.

CONCLUSION

For refractory FD, EA provides significant, clinically relevant symptom relief when added to on-demand gastrocaine (ChiCTR-IPC-15007109).

No Effect of Acupuncture as Adjunctive Therapy for Patients with Total Knee Replacement: A Randomized Controlled Trial

Objective

Acupuncture is a low risk option in pain management following total knee replacement as an alternative to opioid analgesics. Therefore, the benefit of acupuncture as adjunct to an exercise program was investigated. Furthermore, the modifying effect of previous benefit from acupuncture was explored.

Design

Three weeks postoperatively, eligible patients were randomized to acupuncture and exercises or exercises alone.

Setting

An outpatient rehabilitation centre in the municipality of Copenhagen, Denmark.

Subjects

A total of 172 patients were included.

Methods

Main outcome was proportion of patients that reported a clinically important change in pain at night following each treatment. Secondary outcomes were change in disability measured after termination of the course of treatment and at three months follow-up. Also consumption of medication and walking distance after termination of the course of treatment were assessed.

Results

No additional benefit of acupuncture was found on any of the main outcomes. Between-group differences were non-significant in proportions of patients with a clinically important reduction of night pain (Relative Risk: 0.98; 95% Confidence Interval (CI): 0.86-1.11) or evening pain (Relative Risk: 0.94; 95% CI: 0.81-1.0.

Conclusions

Our results do not support the addition of acupuncture to routine rehabilitation. Previous benefit from acupuncture was not able to identify those likely to respond to acupuncture. Future studies to investigate whether subgroups of patients would benefit from acupuncture are needed.

Assessment of patients' expectations: development and validation of the Expectation for Treatment Scale (ETS)

OBJECTIVE

To develop a short self-report instrument for the assessment of expectations (Expectation for Treatment Scale(ETS)) using acupuncture as a case example.

DESIGN

A cross-sectional assessment with retest after 1 week.

SETTING

A web-based survey with patients suffering from pain.

METHODS

In a three-step approach, we reduced the initially collected number of items from 17 to 9 and to 5, including expectations about coping ability, vitality, physical health and reduction of patient complaints. Items were selected according to internal consistency (Cronbach's alpha); convergent and divergent validities with related constructs (optimism, pessimism, resilience, perceived sensitivity to medicines, depression and others); 1-week retest reliability (intraclass correlation coefficient (ICC)); and exploratory and confirmatory factor analysis (CFA).

RESULTS

A total of 102 patients suffering from pain were included, and 54 of these patients completed the retest assessment. The final version of the ETS consisted of five items and had an excellent Cronbach's alpha (0.90), with 72.33% variance on one single factor. Depression, pessimism and perceived sensitivity to medicines showed positive correlations with our expectation measure (r=0.23, r=0.20 and r=0.34, respectively); the correlation between the ETS and optimism was low (r=-0.07) and no correlation between the ETS and resilience was found (r=-0.07). Convergent validity was confirmed with a high correlation (r>0.90) between ETS and a treatment-specific measure of expectations. The retest ICC was 0.86, which showed high stability over 1 week. A CFA (n=439) with data from patients with low back pain confirmed the single-factor structure of the instrument.

CONCLUSION

The ETS showed strong psychometric properties and covered a distinct construct. As the next step, the ETS might be implemented in different clinical conditions and settings to investigate psychometrics and its predictive power for treatment outcomes.

Auricular Acupuncture for Chronic Pain and Insomnia: A Randomized Clinical Trial

Objective: In the United States, ∼1.6 million adults use complementary and alternative or integrative medicine for treating pain and insomnia. However, very few studies have tested the use of auricular acupuncture using a standard protocol for chronic pain and insomnia. The aims of this research were to assess the feasibility and credibility of auricular acupuncture, and to evaluate the effects of auricular acupuncture on pain severity and interference scores, and on insomnia severity over an 8-day study period. Materials and Methods: Forty-five participants were randomized to either an auricular acupuncture group (AAG) or a usual care group (CG) on study day 4. A standard auricular acupuncture protocol was administered, with penetrating semipermanent acupuncture needles in place for up to 4 days. The main outcome measures were feasibility of conducting the study, credibility of auricular acupuncture as a treatment modality, Brief Pain Inventory pain severity and interference scores, and Insomnia Severity Index (ISI) scores. Results: There was high interest in the study and the retention was 96%. Credibility of auricular acupuncture as a treatment was high in both groups. The use of the standard auricular acupuncture protocol in the AAG led to significant within- and between-group reduced pain severity and interference scores, compared to the CG. Both groups showed within-group decreased ISI scores. However, the AAG showed significant between-group reduced ISI severity scores compared to the CG. Conclusions: With the heightened focus on the opioid crisis in the United States, this easy-to-administer protocol may be an option for treating military beneficiaries who have chronic pain and insomnia.

Introducing a Standardized Acupuncture Protocol for Peripheral Neuropathy: A Case Series

Background: Peripheral neuropathy (PN) is defined as damage to the peripheral nervous system caused by a primary lesion or dysfunction. Multiple recent trials have suggested that acupuncture is beneficial for treating neuropathic pain. One challenge in acupuncture research is the lack of standardization of point selection, number of needles used, needle-retention time, needling depth, amount of needle manipulation, and use of moxibustion and electroacupuncture (EA). Objectives: This article presents a standardized acupuncture protocol for the treatment of PN that incorporates structural acupuncture principles based on proximity to peripheral nerves and on traditional approaches to the treatment of neuropathic pain. Materials and Methods: Ten consecutive patients diagnosed with large- or small-fiber neuropathy of various etiologies were treated with a standardized protocol, based on anatomical correlations of peripheral nerves and acupuncture points. Manual acupuncture was applied to left LR 4, LU 5; bilateral LI 11, KI 27, ST 36, GB 34, SP 6, SP 9, LI 4, TE 5, and BaFeng (except for the space between the first and second digits of the toes; LR 3 was used for that space). EA was applied to bilateral KI 3-1 and bilateral ST 41-LR 3. Patients underwent at least six acupuncture sessions, although the total number of sessions varied. Outcomes were measured using a visual analogue scale (VAS) and clinical signs and symptoms. Results: All 10 patients indicated improvement on the VAS and in clinical presentation. Conclusions: This standardized protocol appears to be effective for the treatment of neuropathy of various causes, including large- and small-fiber involvement. Further studies with larger sample sizes and randomized comparisons against sham acupuncture and other acupuncture regimens will be helpful to determine if this protocol could be established as a guideline for approaching peripheral neuropathy.

Expectancy after the first treatment and response to acupuncture for menopausal hot flashes

Background

Evidence on the impact of expectancy on acupuncture treatment response is conflicting.

Objectives

This secondary analysis of a randomized sham-controlled trial on acupuncture for menopausal hot flashes investigated whether treatment expectancy score was associated with hot flash score at end-of-treatment. Secondary analyses investigated whether there were associations between other pre-specified factors and hot flash score.

Study design

Women experiencing moderately-severe hot flashes were randomized to receive 10 sessions of real or sham acupuncture over eight weeks. Hot flash score was collected using a seven-day hot flash diary, and expectancy using the modified Credibility and Expectancy Questionnaire immediately after the first treatment. Linear mixed-effects models with random intercepts were used to identify associations between expectancy score and hot flash score at end-of-treatment. Regression was also used to identify associations between pre-specified factors of interest and hot flash score. Because there was no difference between real and sham acupuncture for the primary outcome of hot flash score, both arms were combined in the analysis.

Results

285 women returned the Credibility and Expectancy Questionnaire, and 283 women completed both expectancy measures. We found no evidence for an association between expectancy and hot flash score at end-of-treatment for individual cases in either acupuncture or sham group. Hot flash scores at end-of-treatment were 8.1 (95%CI, 3.0 to 13.2; P = 0.002) points lower in regular smokers compared to those who had never smoked, equivalent to four fewer moderate hot flashes a day.

Conclusion

In our study of acupuncture for menopausal hot flashes, higher expectancy after the first treatment did not predict better treatment outcomes. Future research may focus on other determinants of outcomes in acupuncture such as therapist attention. The relationship between smoking and hot flashes is poorly understood and needs further exploration.

What intrinsic factors influence responsiveness to acupuncture in pain?: a review of pre-clinical studies that used responder analysis

BACKGROUND

Not many studies have investigated individual sensitivity to acupuncture. To explore the intrinsic factors related to individual responses to acupuncture, we reviewed published pre-clinical studies using responder analysis on pain.

METHODS

We searched the PubMed and EMBASE databases to June 2015. We included pre-clinical reports describing responders and non-responders to anti-nociceptive and analgesic effects of acupuncture in animal study. We identified the potential intrinsic factors which might be related with the response to acupuncture.

RESULTS

Totally, 216 potentially relevant articles were retrieved and 14 studies met our inclusion criteria. Rat (n = 1348) and rabbit (n = 56) were used, and only electroacupuncture (EA) was applied as an intervention. Results showed that high levels of cholecystokinin-8 and receptors were associated with poor responsiveness to EA. Endogenous opioids including β-endorphin and met-enkephalin, descending inhibitory norepinephrine and serotonin system, and hypothalamic 5'-AMP-activated protein kinase seemed to be associated with high-level responses. Spinal levels of neurotransmitters and pro-inflammatory cytokines were also differentially expressed depending on the EA sensitiveness. In the central nervous system, hypothalamus, periaqueductal grey, pituitary gland, and spinal cord were suggested to be involved in the EA responsiveness. Identified individual variations did not seem to be accidental, as the responsiveness to EA was replicated over time. However, methodological issues such as reproducibility, cut-off criteria, and clinical relevance need to be further elaborated.

CONCLUSION

Our study suggests that the identification of the biological factors differentiating responders from non-responders is necessary and it may aid in understanding how acupuncture modulates pain.

Development and Validation of the EXPECT Questionnaire: Assessing Patient Expectations of Outcomes of Complementary and Alternative Medicine Treatments for Chronic Pain

BACKGROUND

Patient expectations may be associated with outcomes of complementary and alternative medicine (CAM) treatments for chronic pain. However, a psychometrically sound measure of such expectations is needed.

OBJECTIVES

The purpose of this study was to develop and evaluate a questionnaire to assess individuals' expectations regarding outcomes of CAM treatments for chronic low back pain (CLBP), as well as a short form of the questionnaire.

METHODS

An 18-item draft questionnaire was developed through literature review, cognitive interviews with individuals with CLBP, CAM practitioners, and expert consultation. Two samples completed the questionnaire: (1) a community sample (n = 141) completed it via an online survey before or soon after starting a CAM treatment for CLBP, and (2) participants (n = 181) in randomized clinical trials evaluating CAM treatments for CLBP or fibromyalgia completed it prior to or shortly after starting treatment. Factor structure, internal consistency, test-retest reliability, and criterion validity were examined.

RESULTS

Based on factor analyses, 10 items reflecting expectations (used to create a total score) and three items reflecting hopes (not scored) were selected for the questionnaire. The questionnaire had high internal consistency, moderate test-retest reliability, and moderate correlations with other measures of expectations. A three-item short form also had adequate reliability and validity.

CONCLUSIONS

The Expectations for Complementary and Alternative Medicine Treatments (EXPECT) questionnaire can be used in research to assess individuals' expectations of treatments for chronic pain. It is recommended that the three hope questions are included (but not scored) to help respondents distinguish between hopes and expectations. The short form may be appropriate for clinical settings and when expectation measurement is not a primary focus.

The effectiveness of dry-cupping in preventing post-operative nausea and vomiting by P6 acupoint stimulation: A randomized controlled trial

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common complication after general anesthesia, and the prevalence ranges between 25% and 30%. The aim of this study was to determine the preventive effects of dry cupping on PONV by stimulating point P6 in the wrist.

METHODS

This was a randomized controlled trial conducted at the Imam Reza Hospital in Kermanshah, Iran. The final study sample included 206 patients (107 experimental and 99 controls). Inclusion criteria included the following: female sex; age>18 years; ASA Class I-II; type of surgery: laparoscopic cholecystectomy; type of anesthesia: general anesthesia. Exclusion criteria included: change in the type of surgery, that is, from laparoscopic cholecystectomy to laparotomy, and ASA-classification III or more. Interventions are as follows: pre surgery, before the induction of anesthesia, the experimental group received dry cupping on point P6 of the dominant hand's wrist with activation of intermittent negative pressure. The sham group received cupping without activation of negative pressure at the same point. Main outcome was that the visual analogue scale was used to measure the severity of PONV.

RESULTS

The experimental group who received dry cupping had significantly lower levels of PONV severity after surgery (P < 0.001) than the control group. The differences in measure were maintained after controlling for age and ASA in regression models (P < 0.01).

CONCLUSION

Traditional dry cupping delivered in an operation room setting prevented PONV in laparoscopic cholecystectomy patients.

Acupuncture for patients with lumbar spinal stenosis: a randomised pilot trial

OBJECTIVE

To assess the safety and feasibility of acupuncture for participants with symptomatic lumbar spinal stenosis (LSS) in a pilot study.

METHODS

50 participants with a clinical and radiological diagnosis of LSS were randomised to receive acupuncture combined with usual care (acupuncture group), or usual care alone (control group). Participants in the acupuncture group were offered 12-16 sessions of manual acupuncture±electroacupuncture over 6 weeks and maintained their usual self-management. The control group was provided with physical therapy as required and maintained their usual self-management. The primary outcome was the change in back-specific functional status, as measured by the Oswestry disability index (ODI) at the 3-month follow-up. Secondary outcomes included symptoms and other relevant domains. Outcome assessors were not blinded.

RESULTS

39 participants (78%) completed the trial with 524 treatment visits. There were no significant differences between the two groups in back-specific function (ODI: mean difference -2.5, 95% CI -8.9 to 3.8). Pain in the back and/or leg showed small improvements at 3 months, while there were no significant differences in other secondary outcomes. The total number of adverse events was 61 (12% of 524 treatment visits). All but one were minor and transient. The one severe adverse event was deemed to be unrelated to acupuncture.

CONCLUSIONS

The study was feasible. Acupuncture combined with usual care did not confer significant functional improvements over usual care alone. Further randomised trials with adequate sample sizes and outcome assessor blinding are warranted to evaluate the role of acupuncture for LSS.

TRIAL REGISTRATION NUMBER

NCT01987622.

Overlap and Differences Between Patient and Provider Expectations for Treatment Outcomes: The Case of Acupuncture

Our study aimed to identify patient-provider clusters with different patterns of expectations for treatment outcomes. All patients (n = 885) received acupuncture treatment from physicians for their migraine, headache, osteoarthritis, or chronic low back pain. We identified 6 robust patient-provider expectation clusters (PPECs; interclassification reliability >.89) showing differences between patients and providers in their expected treatment responses (eg, unrealistic optimists, optimistic doubters). For example, the optimistic doubters had high expectations for their treatment outcomes but were skeptical of the benefits of acupuncture in general. The providers expected good improvements for these patients. These 6 PPECs differed in their clinical characteristics and in the associated treatment responses. For example, unrealistic optimists showed the weakest treatment benefits after 6 months; other PPECs and clinical patterns are also presented in the report. Our study suggests that comparing the expectations of patients and providers is a valuable approach to identify groups of patients with greater responsiveness and those with limited treatment benefits.

PERSPECTIVE

Patients and providers of acupuncture might vary in their expectation of the treatment effect and in clinical practice the overlap of expectations of patients and providers should be considered as important in initial consultations.

Clinical Studies of Biofield Therapies: Summary, Methodological Challenges, and Recommendations

Biofield therapies are noninvasive therapies in which the practitioner explicitly works with a client's biofield (interacting fields of energy and information that surround living systems) to stimulate healing responses in patients. While the practice of biofield therapies has existed in Eastern and Western cultures for thousands of years, empirical research on the effectiveness of biofield therapies is still relatively nascent. In this article, we provide a summary of the state of the evidence for biofield therapies for a number of different clinical conditions. We note specific methodological issues for research in biofield therapies that need to be addressed (including practitioner-based, outcomes-based, and research design considerations), as well as provide a list of suggested next steps for biofield researchers to consider.