Placebo Research: The Evidence Base for Harnessing Self-Healing Capacities

Therapy With Local Anesthetics to Treat Vulvodynia. A Pilot Study

Introduction

Vulvodynia (chronic vulvar pain) is a sexually debilitating disorder with a prevalence of ∼10%.

Aim

To investigate the effectiveness of therapy with local anesthetics (TLA) in women with severe vulvodynia, we conducted a prospective, non-controlled observational study.

Methods

45 patients with severe chronic vulvodynia (primary and secondary vulvodynia, 0–10 numeric analogue scale (NAS) ≥6, median 7.9, duration ≥6 months, median 65.2 months) in an outpatient practice in Germany were treated with TLA in 3–12 sessions using procaine 1% as local anesthetic. Effectiveness was analyzed with Wilcoxon signed rank tests and Wilcoxon rank sum tests.

Outcomes

Therapeutic success as a reduction of pain to ≤4 NAS lasting for ≥6 months after end of therapy.

Results

TLA successfully reduced vulvodynia in 36 of 45 patients (80 %, responders). The NAS reduction was from 7.9 to 2.4 (P < .001). Even patients denominated as non-responders experienced a significant reduction in NAS (P = .03). In responders, long-term success was observed for 6.8–125 months (median 24.1 months). No adverse events occurred.

Clinical Translation

A promising new treatment for a hard-to-treat chronic female pain disorder.

Strengths and Limitations

Limitation: Monocentric, non-controlled observational design; Strength: the high number of patients treated.

Conclusion

The high success rate of TLA in this investigation offers new perspectives on the etiology of vulvodynia as a complex pain syndrome affecting several nerves of the pelvic floor, and also provides early insight into the effectiveness of TLA in women with vulvodynia.

Weinschenk S, Benrath J, Kessler E, et al. Therapy With Local Anesthetics to Treat Vulvodynia. A Pilot Study. Sex Med 2022;10:100482.

Context Effects in Western Herbal Medicine: Fundamental to Effectiveness?

Western herbal medicine (WHM) is a complex healthcare system that uses traditional plant-based medicines in patient care. Typical preparations are individualized polyherbal formulae that, unlike herbal pills, retain the odor and taste of whole herbs. Qualitative studies in WHM show patient-practitioner relationships to be collaborative. Health narratives are co-constructed, leading to assessments, and treatments with personal significance for participants. It is hypothesized that the distinct characteristics of traditional herbal preparations and patient-herbalist interactions, in conjunction with the WHM physical healthcare environment, evoke context (placebo) effects that are fundamental to the overall effectiveness of herbal treatment. These context effects may need to be minimized to demonstrate pharmacological efficacy of herbal formulae in randomized, placebo-controlled trials, optimized to demonstrate effectiveness of WHM in pragmatic trials, and consciously harnessed to enhance outcomes in clinical practice.

Widespread use of pure and impure placebo interventions by GPs in Germany

AIM

To collect data on the use of placebo interventions by GPs in Germany.

METHODS

A questionnaire was mailed to 400 randomly selected GPs in Bavaria. Non-responders were reminded by telephone after 4 weeks and were given a second copy of the questionnaire after a further 3 weeks.

RESULTS

In all, 208 completed questionnaires were returned. The majority of GPs (88%) have used a placebo at least once in their practice; 45% have used pure placebos, such as saline injections and sugar pills, at least once last year; the median frequency of use was 5 [interquartile range (IQR), 2-10]. The use of impure placebos during the past year was more common: 76% of GPs have used impure placebos, i.e. medical interventions that have pharmacological or physical activity but have no intrinsic effect (e.g. pharmacological or physical action) on the patient's disease or its symptoms, with a median frequency of 20 times per year (IQR, 10-50). The main reason for the use of placebo was a possible psychological effect, followed by the expectation of patients to receive a treatment. For the majority of GPs placebo interventions were ethically justified if they were used for a possible psychological effect.

CONCLUSIONS

Placebo interventions are a widely accepted part of medical treatment in German general practices and are used primarily for their psychological effects. Impure placebos are used much more frequently than pure placebos.

Spirituality: an overlooked predictor of placebo effects?

Empirical findings have identified spirituality as a potential health resource. Whereas older research has associated such effects with the social component of religion, newer conceptualizations propose that spiritual experiences and the intrapersonal effects that are facilitated by regular spiritual practice might be pivotal to understanding potential salutogenesis. Ongoing studies suggest that spiritual experiences and practices involve a variety of neural systems that may facilitate neural 'top-down' effects that are comparable if not identical to those engaged in placebo responses. As meaningfulness seems to be both a hallmark of spirituality and placebo reactions, it may be regarded as an overarching psychological concept that is important to engaging and facilitating psychophysiological mechanisms that are involved in health-related effects. Empirical evidence suggests that spirituality may under certain conditions be a predictor of placebo response and effects. Assessment of patients' spirituality and making use of various resources to accommodate patients' spiritual needs reflect our most current understanding of the physiological, psychological and socio-cultural aspects of spirituality, and may also increase the likelihood of eliciting self-healing processes. We advocate the position that a research agenda addressing responses and effects of both placebo and spirituality could therefore be (i) synergistic, (ii) valuable to each phenomenon on its own, and (iii) contributory to an extended placebo paradigm that is centred around the concept of meaningfulness.

Verfahren der Komplementärmedizin. Beispiel: Heilung durch Gebet und geistiges Heilen

Spiritual healing and healing through prayer have been among the methods for healing diseases of mankind since time immemorial. Even today they are quite popular in many parts of the Western world, as epidemiological data testify. Also in Germany, although less systematic data are available, spiritual healing is being used quite a lot. This interest is driven mainly by word of mouth and media presentation of spectacular single case descriptions of healing. Scientifically speaking, such cases present a challenge to science to understand the mechanisms at work. Systematic scientific studies, however, are rather sporadic and sometimes amateur-like efforts. However, the data available show two general results: patients seeking out healing normally profit to a clinically significant degree. At the same time, there is little evidence that these effects are specific in nature. It could be the case that the mechanisms at work--if there are any specific mechanisms at all--do not follow the normal expected causal routes of activity, and hence the methodology applied might be misguided or incapable of capturing the effects. If there are generalised non-local effects at work, a hypothesis worth testing, then this has profound consequences both for research and for the interpretation of results.