Patient-Clinician Brain Response During Clinical Encounter and Pain Treatment

The patient-clinician relationship is known to significantly affect the pain experience, as empathy, mutual trust and therapeutic alliance can significantly modulate pain perception and influence clinical therapy outcomes. The aim of the present study was to use an EEG hyperscanning setup to identify brain and behavioral mechanisms supporting the patient-clinician relationship while this clinical dyad is engaged in a therapeutic interaction. Our previous study applied fMRI hyperscanning to investigate whether brain concordance is linked with analgesia experienced by a patient while undergoing treatment by the clinician. In this current hyperscanning project we investigated similar outcomes for the patient-clinician dyad exploiting the high temporal resolution of EEG and the possibility to acquire the signals while patients and clinicians were present in the same room and engaged in a face-to-face interaction under an experimentally-controlled therapeutic context. Advanced source localization methods allowed for integration of spatial and spectral information in order to assess brain correlates of therapeutic alliance and pain perception in different clinical interaction contexts. Preliminary results showed that both behavioral and brain responses across the patient-clinician dyad were significantly affected by the interaction style.Clinical Relevance- The context of a clinical intervention can significantly impact the treatment of chronic pain. Effective therapeutic alliance, based on empathy, mutual trust, and warmth can improve treatment adherence and clinical outcomes. A deeper scientific understanding of the brain and behavioral mechanisms underlying an optimal patient-clinician interaction may lead to improved quality of clinical care and physician training, as well as better understanding of the social aspects of the biopsychosocial model mediating analgesia in chronic pain patients.

Informed consent and clinical trials: where is the placebo effect?

Lack of knowledge about placebos affects participants’ understanding of trials and breaches the ethical obligations of researchers, argue C R Blease, F L Bishop, and T J Kaptchuk

Effects of subtle cognitive manipulations on placebo analgesia - An implicit priming study

Background

Expectancy is widely accepted as a key contributor to placebo effects. However, it is not known whether non‐conscious expectancies achieved through semantic priming may contribute to placebo analgesia. In this study, we investigated if an implicit priming procedure, where participants were unaware of the intended priming influence, affected placebo analgesia.

Methods

In a double‐blind experiment, healthy participants (n = 36) were randomized to different implicit priming types; one aimed at increasing positive expectations and one neutral control condition. First, pain calibration (thermal) and a credibility demonstration of the placebo analgesic device were performed. In a second step, an independent experimenter administered the priming task; Scrambled Sentence Test. Then, pain sensitivity was assessed while telling participants that the analgesic device was either turned on (placebo) or turned off (baseline). Pain responses were recorded on a 0–100 Numeric Response Scale.

Results

Overall, there was a significant placebo effect (p < 0.001), however, the priming conditions (positive/neutral) did not lead to differences in placebo outcome. Prior experience of pain relief (during initial pain testing) correlated significantly with placebo analgesia (p < 0.001) and explained 34% of placebo variance. Trait neuroticism correlated positively with placebo analgesia (p < 0.05) and explained 21% of placebo variance.

Conclusions

Priming is one of many ways to influence behaviour, and non‐conscious activation of positive expectations could theoretically affect placebo analgesia. Yet, we found no SST priming effect on placebo analgesia. Instead, our data point to the significance of prior experience of pain relief, trait neuroticism and social interaction with the treating clinician.

Significance

Our findings challenge the role of semantic priming as a behavioural modifier that may shape expectations of pain relief, and affect placebo analgesia.

The imagined itch: brain circuitry supporting nocebo-induced itch in atopic dermatitis patients

BACKGROUND

Psychological factors are known to significantly modulate itch in patients suffering from chronic itch. Itch is also highly susceptible to both placebo and nocebo (negative placebo) effects. Brain activity likely supports nocebo-induced itch, but is currently unknown.

METHODS

We collected functional MRI (fMRI) data from atopic dermatitis (AD) patients, in a within-subject design, and contrast brain response to nocebo saline understood to be allergen vs open-label saline control. Exploratory analyses compared results to real allergen itch response and placebo responsiveness, evaluated in the same patients.

RESULTS

Nocebo saline produced greater itch than open saline control (P < 0.01). Compared to open saline, nocebo saline demonstrated greater fMRI response in caudate, dorsolateral prefrontal cortex (dlPFC), and intraparietal sulcus (iPS) - brain regions important for cognitive executive and motivational processing. Exploratory analyses found that subjects with greater dlPFC and caudate activation to nocebo-induced itch also demonstrated greater dlPFC and caudate activation, respectively, for real allergen itch. Subjects reporting greater nocebo-induced itch also demonstrated greater placebo reduction of allergen-evoked itch, suggesting increased generalized modulation of itch perception.

CONCLUSIONS

Our study demonstrates the capacity of nocebo saline to mimic both the sensory and neural effects of real allergens and provides an insight to the brain mechanisms supporting nocebo-induced itch in AD, thus aiding our understanding of the role that expectations and other psychological factors play in modulating itch perception in chronic itch patients.

In Vitro Angiogenesis Effect of Xuefu Zhuyu Decoction () and Vascular Endothelial Growth Factor: A Comparison Study

OBJECTIVE

To compare the angiogenesis behaviors of vascular endothelial growth factor (VEGF) and Chinese medicine Xuefu Zhuyu Decoction (, XZD) treatments.

METHODS

Human microvascular endothelial cells (HMEC-1) were treated with various concentrations of either XZD-containing serum (XZD-CS) or VEGF for 24, 48, and 72 h, respectively. Cell viability, proliferation, migration, adhesion, and in vitro tube formation assays were used to assess their angiogenic effects.

RESULTS

VEGF promoted all cellular phases involved in angiogenesis including cell viability, proliferation, migration, adhesion, and tube formation (<0.05 or <0.01). Unlike the continuous promotion effects of VEGF at the above stages, XZD inhibited cell viability and proliferation (<0.05 or <0.01) and only promoted tube formation in the early phase of angiogenesis (<0.01).

CONCLUSIONS

These two medications promote different angiogenesis behaviors, which might be an important reason for their distinct therapeutic profile in clinical usage.

Meta-analysis: the effects of placebo treatment on gastro-oesophageal reflux disease

BACKGROUND

There appears to be a significant placebo response rate in clinical trials for gastro-oesophageal reflux disease. Little is known about the determinants and the circumstances associated with placebo response in the treatment of gastro-oesophageal reflux disease (GERD).

AIMS

To estimate the magnitude of the placebo response rate in randomized controlled trials for GERD and to identify factors that influence this response.

METHODS

A meta-analysis of randomized, double-blind, placebo-controlled trials, published in English language, which included >20 patients with GERD, treated with either a proton pump inhibitor or H(2)-receptor antagonist for at least 2 weeks. Medline, Cochrane and EMBASE databases were searched, considering only studies that reported a global response for 'heartburn'.

RESULTS

A total of 24 studies included 9989 patients with GERD. The pooled odds ratio (OR) for response to active treatment vs. placebo was 3.71 (95% CI: 2.78-4.96). The pooled estimate of the overall placebo response was 18.85% (range 2.94%-47.06%). Patients with erosive oesophagitis had a non-significantly lower placebo response rate than patients without it (11.87% and 18.31%, respectively; P = 0.246). Placebo response was significantly lower in studies of PPI therapy vs. studies of H(2) RAs (14.51% vs. 24.69%, respectively; P = 0.05).

CONCLUSIONS

The placebo response rate in randomized controlled trials for GERD is substantial. A lower placebo response was associated with the testing of PPIs, but not the presence of erosive oesophagitis.

A meta-analysis of the placebo response in complementary and alternative medicine trials of irritable bowel syndrome

Among patients with irritable bowel syndrome (IBS) enrolled in clinical trials of conventional medical therapy, the placebo response rate is high. IBS patients also frequently use complementary and alternative medicine (CAM), which may act through an 'enhanced placebo effect'. The purpose of this study was to estimate the magnitude of the placebo response rate in CAM trials for IBS and to identify factors that influence this response. We performed a systematic review and meta-analysis of randomized, placebo-controlled clinical trials of CAM therapies for IBS identified from MEDLINE/EMBASE/PsychLIT databases from 1970 to 2006. Placebo and active treatment response rates for global symptom improvement were assessed. Nineteen studies met the inclusion criteria. The pooled estimate of the placebo response rate was 42.6% (95% confidence interval, 38.0-46.5%). Significant heterogeneity existed across trials (range 15.0-72.2%, P < 0.00001). Higher placebo response rates correlated with a longer duration of treatment (r = 0.455, P = 0.05) and a greater number of office visits (r = 0.633, P = 0.03). Among IBS patients in CAM trials, the placebo response rate is high. That this rate is similar in magnitude to that seen in conventional medicine trials suggests that the placebo response is independent of the type of therapy used and that it is not particularly 'enhanced' in CAM trials.

A meta-analysis of the placebo response in complementary and alternative medicine trials of irritable bowel syndrome

Among patients with irritable bowel syndrome (IBS) enrolled in clinical trials of conventional medical therapy, the placebo response rate is high. IBS patients also frequently use complementary and alternative medicine (CAM), which may act through an 'enhanced placebo effect'. The purpose of this study was to estimate the magnitude of the placebo response rate in CAM trials for IBS and to identify factors that influence this response. We performed a systematic review and meta-analysis of randomized, placebo-controlled clinical trials of CAM therapies for IBS identified from MEDLINE/EMBASE/PsychLIT databases from 1970 to 2006. Placebo and active treatment response rates for global symptom improvement were assessed. Nineteen studies met the inclusion criteria. The pooled estimate of the placebo response rate was 42.6% (95% confidence interval, 38.0-46.5%). Significant heterogeneity existed across trials (range 15.0-72.2%, P < 0.00001). Higher placebo response rates correlated with a longer duration of treatment (r = 0.455, P = 0.05) and a greater number of office visits (r = 0.633, P = 0.03). Among IBS patients in CAM trials, the placebo response rate is high. That this rate is similar in magnitude to that seen in conventional medicine trials suggests that the placebo response is independent of the type of therapy used and that it is not particularly 'enhanced' in CAM trials.

Acupuncture trials and informed consent

Participants are often not informed by investigators who conduct randomised, placebo-controlled acupuncture trials that they may receive a sham acupuncture intervention. Instead, they are told that one or more forms of acupuncture are being compared in the study. This deceptive disclosure practice lacks a compelling methodological rationale and violates the ethical requirement to obtain informed consent. Participants in placebo-controlled acupuncture trials should be provided an accurate disclosure regarding the use of sham acupuncture, consistent with the practice of placebo-controlled drug trials.

The placebo effect in irritable bowel syndrome trials: a meta-analysis

BACKGROUND

Despite the apparent high placebo response rate in randomized placebo-controlled trials (RCT) of patients with irritable bowel syndrome (IBS), little is known about the variability and predictors of this response.

OBJECTIVES

To describe the magnitude of response in placebo arms of IBS clinical trials and to identify which factors predict the variability of the placebo response.

METHODS

We performed a meta-analysis of published, English language, RCT with 20 or more IBS patients who were treated for at least 2 weeks. This analysis is limited to studies that assessed global response (improvement in overall symptoms). The variables considered as potential placebo modifiers were study design, study duration, use of a run-in phase, Jadad score, entry criteria, number of office visits, number of office visits/study duration, use of diagnostic testing, gender, age and type of medication studied.

FINDINGS

Forty-five placebo-controlled RCTs met the inclusion criteria. The placebo response ranged from 16.0 to 71.4% with a population-weighted average of 40.2%, 95% CI (35.9-44.4). Significant associations with lower placebo response rates were fulfillment of the Rome criteria for study entry (P=0.049) and an increased number of office visits (P=0.026).

CONCLUSIONS

Placebo effects in IBS clinical trials measuring a global outcome are highly variable. Entry criteria and number of office visits are significant predictors of the placebo response. More stringent entry criteria and an increased number of office visits appear to independently decrease the placebo response.

The placebo effect in irritable bowel syndrome trials: a meta-analysis

BACKGROUND

Despite the apparent high placebo response rate in randomized placebo-controlled trials (RCT) of patients with irritable bowel syndrome (IBS), little is known about the variability and predictors of this response.

OBJECTIVES

To describe the magnitude of response in placebo arms of IBS clinical trials and to identify which factors predict the variability of the placebo response.

METHODS

We performed a meta-analysis of published, English language, RCT with 20 or more IBS patients who were treated for at least 2 weeks. This analysis is limited to studies that assessed global response (improvement in overall symptoms). The variables considered as potential placebo modifiers were study design, study duration, use of a run-in phase, Jadad score, entry criteria, number of office visits, number of office visits/study duration, use of diagnostic testing, gender, age and type of medication studied.

FINDINGS

Forty-five placebo-controlled RCTs met the inclusion criteria. The placebo response ranged from 16.0 to 71.4% with a population-weighted average of 40.2%, 95% CI (35.9-44.4). Significant associations with lower placebo response rates were fulfillment of the Rome criteria for study entry (P=0.049) and an increased number of office visits (P=0.026).

CONCLUSIONS

Placebo effects in IBS clinical trials measuring a global outcome are highly variable. Entry criteria and number of office visits are significant predictors of the placebo response. More stringent entry criteria and an increased number of office visits appear to independently decrease the placebo response.

Availability of acupuncture in the hospitals of a major academic medical center: a pilot study

BACKGROUND

Acupuncture is widely used by the American public, but little is known about its availability and use in academic medical settings. We performed a pilot study to compare acupuncture services provided by hospitals affiliated with a major academic teaching institution, and a parallel survey of services provided through an acupuncture school in one city in New England.

METHODS

Between December 2000 and July 2001, a telephone survey was conducted of the 13 hospitals affiliated with Harvard Medical School, and the clinics affiliated with the New England School of Acupuncture.

RESULTS

Acupuncture was available in 8 of the 13 hospitals. Acupuncture was provided in ambulatory clinics in all eight hospitals, but was available to inpatients in only one hospital. Six hospitals delivered acupuncture through an outpatient pain treatment service, one through a women's health center, one through an HIV clinic, and one hospital delivered acupuncture through two services; a program in the anesthesia department and a multi-disciplinary holistic program in a primary care department. In contrast, the acupuncture school clinics provided services through an on-site clinic at the school, through acupuncture departments at two community-based hospitals, and through a network of 12 satellite acupuncture-dedicated clinics operating throughout the state.

CONCLUSION

Acupuncture is available on a limited basis in a majority of the teaching hospitals in this city. At the acupuncture school clinics, there are few barriers to care. Future health care studies will need to examine the role of acupuncture in diverse geographic settings and to examine its impact on quality of care, teaching and its role in research in academic centers.

Perceptions about complementary therapies relative to conventional therapies among adults who use both: results from a national survey

BACKGROUND

Little is known about perceptions of complementary and alternative medical (CAM) therapy relative to conventional therapy among patients who use both.

OBJECTIVE

To document perceptions about CAM therapies among persons who use CAM and conventional therapies.

DESIGN

Nationally representative, random-household telephone survey.

SETTING

The 48 contiguous U.S. states.

PARTICIPANTS

831 adults who saw a medical doctor and used CAM therapies in 1997.

MEASUREMENTS

Perceptions about helpfulness and patterns of CAM therapy use relative to conventional therapy use and reasons for nondisclosure of CAM therapies.

RESULTS

Of 831 respondents who saw a medical doctor and used CAM therapies in the previous 12 months, 79% perceived the combination to be superior to either one alone. Of 411 respondents who reported seeing both a medical doctor and a CAM provider, 70% typically saw a medical doctor before or concurrent with their visits to a CAM provider; 15% typically saw a CAM provider before seeing a medical doctor. Perceived confidence in CAM providers was not substantially different from confidence in medical doctors. Among the 831 respondents who in the past year had used a CAM therapy and seen a medical doctor, 63% to 72% did not disclose at least one type of CAM therapy to the medical doctor. Among 507 respondents who reported their reasons for nondisclosure of use of 726 alternative therapies, common reasons for nondisclosure were "It wasn't important for the doctor to know" (61%), "The doctor never asked" (60%), "It was none of the doctor's business" (31%), and "The doctor would not understand" (20%). Fewer respondents (14%) thought their doctor would disapprove of or discourage CAM use, and 2% thought their doctor might not continue as their provider. Respondents judged CAM therapies to be more helpful than conventional care for the treatment of headache and neck and back conditions but considered conventional care to be more helpful than CAM therapy for treatment of hypertension.

CONCLUSIONS

National survey data do not support the view that use of CAM therapy in the United States primarily reflects dissatisfaction with conventional care. Adults who use both appear to value both and tend to be less concerned about their medical doctor's disapproval than about their doctor's inability to understand or incorporate CAM therapy use within the context of their medical management.

Long-term trends in the use of complementary and alternative medical therapies in the United States

BACKGROUND

Although recent research has shown that many people in the United States use complementary and alternative medical (CAM) therapies, little is known about time trends in use.

OBJECTIVE

To present data on time trends in CAM therapy use in the United States over the past half-century.

DESIGN

Nationally representative telephone survey of 2055 respondents that obtained information on current use, lifetime use, and age at first use for 20 CAM therapies.

SETTING

The 48 contiguous U.S. states.

PARTICIPANTS

Household residents 18 years of age and older.

MEASUREMENT

Retrospective self-reports of age at first use for each of 20 CAM therapies.

RESULTS

Previously reported analyses of these data showed that more than one third of the U.S. population was currently using CAM therapy in the year of the interview (1997). Subsequent analyses of lifetime use and age at onset showed that 67.6% of respondents had used at least one CAM therapy in their lifetime. Lifetime use steadily increased with age across three age cohorts: Approximately 3 of every 10 respondents in the pre-baby boom cohort, 5 of 10 in the baby boom cohort, and 7 of 10 in the post-baby boom cohort reported using some type of CAM therapy by age 33 years. Of respondents who ever used a CAM therapy, nearly half continued to use many years later. A wide range of individual CAM therapies increased in use over time, and the growth was similar across all major sociodemographic sectors of the study sample.

CONCLUSIONS

Use of CAM therapies by a large proportion of the study sample is the result of a secular trend that began at least a half century ago. This trend suggests a continuing demand for CAM therapies that will affect health care delivery for the foreseeable future.

Varieties of healing. 2: a taxonomy of unconventional healing practices

The first of two essays in this issue demonstrated that the United States has had a rich history of medical pluralism. This essay seeks to present an overview of contemporary unconventional medical practices in the United States. No clear definition of "alternative medicine" is offered because it is a residual category composed of heterogeneous healing methods. A descriptive taxonomy of contemporary unconventional healing could be more helpful. Two broad categories of unconventional medicine are described here: a more prominent, "mainstream" complementary and alternative medicine (CAM) and a more culture-bound, "parochial" unconventional medicine. The CAM component can be divided into professional groups, layperson-initiated popular health reform movements, New Age healing, alternative psychological therapies, and non-normative scientific enterprises. The parochial category can be divided into ethno-medicine, religious healing, and folk medicine. A topologic examination of U.S. health care can provide an important conceptual framework through which health care providers can understand the current situation in U.S. medical pluralism.

Varieties of healing. 1: medical pluralism in the United States

Medicine has become interested in unconventional healing practices, ostensibly because of recent demographic research that reveals a thriving medical market of multiple options. This essay presents a historical overview of medical pluralism in the United States. Consistent evidence is examined suggesting that unconventional medicine has been a persistent presence in U.S. health care. Despite parallels with the past, the recent widespread interest in alternative medicine also represents a dramatic reconfiguration of medical pluralism-from historical antagonism to what might arguably be described as a topical acknowledgment of postmodern medical diversity. This recent shift may have less to do with acknowledging "new" survey data than with representing shifts in medicine's institutional authority in a consumer-driven health care environment. This essay is an introduction to a discussion of a taxonomy of contemporary U.S. medical pluralism, which also appears in this issue.

The double-blind, randomized, placebo-controlled trial

The double-blind randomized controlled trial (RCT) is accepted by medicine as objective scientific methodology that, when ideally performed, produces knowledge untainted by bias. The validity of the RCT rests not just on theoretical arguments, but also on the discrepancy between the RCT and less rigorous evidence (the difference is sometimes considered an objective measure of bias). A brief overview of historical and recent developments in "the discrepancy argument" is presented. The article then examines the possibility that some of this "deviation from truth" may be the result of artifacts introduced by the masked RCT itself. Can an "unbiased" method produce bias? Among the experiments examined are those that augment the methodological stringency of a normal RCT in order to render the experiment less susceptible to subversion by the mind. This methodology, a hypothetical "platinum" standard, can be used to judge the "gold" standard. The concealment in a placebo-controlled RCT seems capable of generating a "masking bias." Other potential biases, such as "investigator self-selection," "preference," and "consent" are also briefly discussed. Such potential distortions indicate that the double-blind RCT may not be objective in the realist sense, but rather is objective in a "softer" disciplinary sense. Some "facts" may not exist independent of the apparatus of their production.

Randomized trial comparing traditional Chinese medical acupuncture, therapeutic massage, and self-care education for chronic low back pain

BACKGROUND

Because the value of popular forms of alternative care for chronic back pain remains uncertain, we compared the effectiveness of acupuncture, therapeutic massage, and self-care education for persistent back pain.

METHODS

We randomized 262 patients aged 20 to 70 years who had persistent back pain to receive Traditional Chinese Medical acupuncture (n = 94), therapeutic massage (n = 78), or self-care educational materials (n = 90). Up to 10 massage or acupuncture visits were permitted over 10 weeks. Symptoms (0-10 scale) and dysfunction (0-23 scale) were assessed by telephone interviewers masked to treatment group. Follow-up was available for 95% of patients after 4, 10, and 52 weeks, and none withdrew for adverse effects.

RESULTS

Treatment groups were compared after adjustment for prerandomization covariates using an intent-to-treat analysis. At 10 weeks, massage was superior to self-care on the symptom scale (3.41 vs 4.71, respectively; P =.01) and the disability scale (5.88 vs 8.92, respectively; P<.001). Massage was also superior to acupuncture on the disability scale (5.89 vs 8.25, respectively; P =.01). After 1 year, massage was not better than self-care but was better than acupuncture (symptom scale: 3.08 vs 4.74, respectively; P =.002; dysfunction scale: 6.29 vs 8.21, respectively; P =.05). The massage group used the least medications (P<.05) and had the lowest costs of subsequent care.

CONCLUSIONS

Therapeutic massage was effective for persistent low back pain, apparently providing long-lasting benefits. Traditional Chinese Medical acupuncture was relatively ineffective. Massage might be an effective alternative to conventional medical care for persistent back pain.

Do medical devices have enhanced placebo effects?

Although the placebo in a clinical trial is often considered simply a baseline against which to evaluate the efficacy of a clinical intervention, there is evidence that the magnitude of placebo effect may be a critical factor in determining the results of a trial. This article examines the question of whether devices have enhanced placebo effects and, if so, what the implications may be. While the evidence of an enhanced placebo effect remains rudimentary, it is provocative and therefore worthy of further study. Suggestions are made, therefore, for how such an effect can be investigated without violating the principles of informed consent.

Are randomized control trial outcomes influenced by the inclusion of a placebo group?: a systematic review of nonsteroidal antiinflammatory drug trials for arthritis treatment

Placebo groups are often included in randomized control trials evaluating drug therapy, yet we know little about the placebo effect. The purpose of our study was to evaluate how the presence of a placebo group in a randomized control trial (RCT) influences the patients' ratings of the efficacy of an active drug therapy and their reporting of its adverse effects. We identified studies published between 1966 and 1994 using MEDLINE. Randomized control trials evaluating acetylsalicylic acid, diclofenac, or indomethacin for the treatment of osteo or rheumatoid arthritis were included in our sample. Two investigators independently extracted data. Fifty-eight treatment arms met our inclusion criteria and were available for analysis. Twenty-five treatment arms evaluated a nonsteroidal antiinflammatory drug (NSAID) in placebo control trials and 33 in comparative trials. Using a logistic regression model to adjust for the differences between the evaluated drugs and between the types of arthritis, we found that patients receiving an NSAID in a placebo control trial were more likely to withdraw due to inefficacy (OR=1.3; 95% CI, 1.0 to 1.6; P=0.04). Using a similar model, withdrawals due to adverse effects were found to be more common when the NSAID was given in trials that did not include a placebo group (OR=1.5; 95% CI, 1.1 to 1.9; P=0.002) as were reports of cutaneous (OR=4.2; 95% CI, 1.7 to 9.9), gastrointestinal (OR=1.6; 95% CI, 1.3 to 2.0), and other types (OR=5.3; 95% CI, 3.8 to 7.4) of adverse effects. Although reports of central nervous system adverse effects were more frequent in the comparative trials, this difference was not significant. Including a placebo group in a RCT changes how patients rate the efficacy and adverse effects of their therapy. Our results highlight the need to consider the placebo effect in the design and analyses of clinical trials.

The persuasive appeal of alternative medicine

Alternative medicine has a major presence and persuasive attraction in the industrialized western world. The extent to which these practices have clinical efficacy according to biomedical criteria is a matter of ongoing research and debate. It may be that independent of any such efficacy, the attraction of alternative medicine is related to the power of its underlying shared beliefs and cultural assumptions. The fundamental premises are an advocacy of nature, vitalism, "science," and spirituality. These themes offer patients a participatory experience of empowerment, authenticity, and enlarged self-identity when illness threatens their sense of intactness and connection to the world. A discussion of these themes may enable conventionally trained clinicians to better understand their patients' attraction to and acceptance of alternative medical therapies.

Medical malpractice implications of alternative medicine

Although use of alternative therapies in the United States is widespread and growing, little is known about the malpractice experience of practitioners who deliver these therapies or about the legal principles that govern the relationship between conventional and alternative medicine. Using data from malpractice insurers, we analyzed the claims experience of chiropractors, massage therapists, and acupuncturists for 1990 through 1996. We found that claims against these practitioners occurred less frequently and typically involved injury that was less severe than claims against physicians during the same period. Physicians who may be concerned about their own exposure to liability for referral of patients for alternative treatments can draw some comfort from these findings. However, liability for referral is possible in certain situations and should be taken seriously. Therefore, we review relevant legal principles and case law to understand how malpractice law is likely to develop in this area. We conclude by suggesting some questions for physicians to ask themselves before referring their patients to alternative medicine practitioners.

Chiropractic: origins, controversies, and contributions

Chiropractic is an important component of the US health care system and the largest alternative medical profession. In this overview of chiropractic, we examine its history, theory, and development; its scientific evidence; and its approach to the art of medicine. Chiropractic's position in society is contradictory, and we reveal a complex dynamic of conflict and diversity. Internally, chiropractic has a dramatic legacy of strife and factionalism. Externally, it has defended itself from vigorous opposition by conventional medicine. Despite such tensions, chiropractors have maintained a unified profession with an uninterrupted commitment to clinical care. While the core chiropractic belief that the correction of spinal abnormality is a critical health care intervention is open to debate, chiropractic's most important contribution may have to do with the patient-physician relationship.

Courses involving complementary and alternative medicine at US medical schools

CONTEXT

With the public's increasing use of complementary and alternative medicine, medical schools must consider the challenge of educating physicians about these therapies.

OBJECTIVES

To document the prevalence, scope, and diversity of medical school education in complementary and alternative therapy topics and to obtain information about the organizational and academic features of these courses.

DESIGN

Mail survey and follow-up letter and telephone survey conducted in 1997-1998.

PARTICIPANTS

Academic or curriculum deans and faculty at each of the 125 US medical schools.

MAIN OUTCOME MEASURES

Courses taught at US medical schools and administrative and educational characteristics of these courses.

RESULTS

Replies were received from 117 (94%) of the 125 US medical schools. Of schools that replied, 75 (64%) reported offering elective courses in complementary or alternative medicine or including these topics in required courses. Of the 123 courses reported, 84 (68%) were stand-alone electives, 38 (31%) were part of required courses, and one (1%) was part of an elective. Thirty-eight courses (31%) were offered by departments of family practice and 14 (11%) by departments of medicine or internal medicine. Educational formats included lectures, practitioner lecture and/or demonstration, and patient presentations. Common topics included chiropractic, acupuncture, homeopathy, herbal therapies, and mind-body techniques.

CONCLUSIONS

There is tremendous heterogeneity and diversity in content, format, and requirements among courses in complementary and alternative medicine at US medical schools.

Complementary medicine--the case for dialogue

Complementary medicine (CM) is popular with patients but physicians do not feel at ease with this situation and some fear that the patient might be the loser. Their fear is based on the perception that some CM practitioners have dubious qualifications and competence and that too little is known about the efficacy and safety of many complementary therapies. It follows that, in the interest of the patient and all other parties involved, we urgently need more and better research to fill the void. Integration of complementary medicine into mainstream care requires a minimum of essential evidence. As in all areas of medicine, there can be no short cut to rigorous research.

Cognitive behavioral techniques for hypertension: are they effective?

PURPOSE

To assess by analysis of published controlled trials the efficacy of cognitive behavioral therapies (such as biofeedback, relaxation, meditation) for essential hypertension.

DATA IDENTIFICATION

Randomized controlled trials published in the English language between 1970 and 1991 identified from the MEDLINE database and bibliographic references from these articles.

STUDY SELECTION

Limited to studies involving randomized assignment to a treatment group consisting of one or more cognitive behavioral interventions or a concurrent control group consisting of no therapy, a waiting list, regular monitoring, or placebo intervention.

RESULTS OF DATA SYNTHESIS

Although we identified more than 800 published works, only 26 met entry criteria. We identified a number of methodologic short-comings, including small sample size, inconsistencies regarding baseline blood pressure determinations and types of control groups, and the possibility of confounding by multiple noncognitive cointerventions (diet, exercise) and expectancy (the placebo effect). In meta-analyses involving 1264 patients, differences in mean blood pressure reduction varied according to the duration of baseline blood pressure measurements and type of control groups studied. In 16 comparisons involving baseline periods of more than 1 day, with patients (n = 368) assigned to either a cognitive therapy or a placebo intervention (sham biofeedback, "pseudo-meditation"), systolic and diastolic blood pressures decreased by 2.8 mm Hg (95% CI, -0.8 to 6.4) and 1.3 mm Hg (CI, -1.3 to 3.8), respectively. These changes were neither statistically nor clinically significant.

CONCLUSION

Cognitive interventions for essential hypertension are superior to no therapy but not superior to credible sham techniques or to self-monitoring alone. The literature on this subject is limited by a variety of methodologic inadequacies. No single cognitive behavioral technique appears to be more effective than any other.