Placebo Nocebo

Placebo Nocebo

One of the interesting aspects of medicine is how interactions with patients, even if nothing is done, can have both good and bad effects. It is one of the characteristics of human behavior that makes it very difficult to know if an intervention works. I usually consider the patient-HCW interaction to be mostly positive and it is not unlike the salubrious effects that occur when one monkey grooms another. However, as a physician

in deference to a million years of evolution, I will not attempt to pick fleas off the patient.

Several years ago there was an acupuncture study that compared toothpicks to acupuncture for chronic low back pain. It was no surprise that toothpicks were equal to real acupuncture, but equally interesting was that toothpicks had zero adverse effects.

Rates of adverse experiences differed by treatment group: 6 of 157 participants for individualized acupuncture, 6 of 158 for standardized acupuncture, and 0 of 162 for simulated acupuncture (P = .04).

I would have thought there would have been some nocebo effects in the toothpick treated. I would argue that if you have two interventions of equal efficacy but different complication rates, you should go with the treatment that has fewer side effects.

Chiropractors often say their interventions have no complications. However, rather than call it adverse reactions, chiropractic induced symptoms of a stroke are called symptomatic reactions.

There was an interesting trial, of which I only have the abstract as it is behind a pay wall, Short-Term Usual Chiropractic Care for Spinal Pain: A Randomized Controlled Trial. Although touted as showing that chiropractic is superior to sham, the conclusion says

Short-term chiropractic treatment was superior to sham; however, treatment effects were not clinically important. Awareness of treatment assignment and clinically important reductions in pain were associated with chiropractic treatment satisfaction.

Awareness of treatment assignment suggests whatever the sham manipulation was, it was not very effective. But, like the acupuncture study, there were fewer side effect in the same group:

The researchers discovered that 33% of the sham group and 42% of the usual group reported at least one adverse event. Events that were commonly reported include headache, muscle stiffness and increased pain.

Fewer complications suggests that for treatment effects were not clinically important you should suggest sham chiropractic rather than real chiropractic.  One of the most common admonitions to science-based medicine proponents is "First, do no harm", a rule never, ever, applied to pseudo-medicine.    

I think I will start an Integrative Medicine clinic where I will only offer sham pseudo-medicine.  I wonder if anyone will be able to tell the difference.

Acupuncture as Gamma-hydroxybutyrate
Points of Interest: 2/1/2014

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