Believing does make it so

Believing does make it so

Well not really acupuncture, at last not as the ancient Chinese did it. I do not think they had electricity to apply to the needles. But this was an interesting study, Expectancy in Real and Sham Electroacupuncture: Does Believing Make It So?

The took patients with joint pain due to aromatase inhibitors being used to treat breast cancer.

The patients had either sham electroacupuncture (no current applied) or electroacupuncture and a wait list control group, only about 20 in each group.

No surprise, those who had an intervention, be it sham or electoacupncture, had more pain relief than the weight list control. An intervention, even if worthless, usually changes the subjective complaint for the better.

But here is where it is interesting. They used the Acupuncture Expectancy Score (AES), a measure of how much the patient thought acupuncture would help their problem.


Over all, the higher the AES score, the better the pain response

Each point increase in Baseline expectancy in the SA group is significantly associated with a greater percent pain reduction at Week 8 (regression coefficient = 7.9, SE= 2.8, P = .007).

In the sham group those with a high AES had a better pain response. What is also interesting is that in the sham group there was no increase in the AES score over time and the decrease in the pain was constant. 

Some in the electroacupuncture group increased their AES score with time and with a concomitant decrease in pain.  Those who maintained a low AES scores had a pain response that was unchanged over time.

What they do not mention, which is a flaw, is whether blinding was effective. A little current across an acupuncture needle could easily be noticed by some of the patients and might have affected their perception of the intervention.

They say in the discussion

Expecting a positive outcome (expectancy) at the beginning of the trial was associated with the response to SA. In contrast, patients who responded to EA had increased expectancy over the course of their acupuncture treatment as compared with nonresponders, suggesting that positive responses during the process of EA increased the expectations of positive outcomes. Our findings imply that distinct mechanisms underlie the apparently similar clinical effect of EA and SA. These findings have important implications for acupuncture and pain research as well as for clinical practice.

It may be the responders to electroacupuncture were the ones who noticed a tingling from the current and responded accordingly. Electroacupuncture is just a TENS unit tarted up with Traditional Chinese Medicine and this study has no implications for acupuncture except to reinforce its mechanism as an elaborate placebo.

I will mention here that I had always been taught that TENS was a legitimate form of pain relief. A quick review suggests TENS may be nothing but a placebo as well. Since more elaborate placebos yield better responses, it may be that those with the increase AES score were also those who knew they were getting TENS, a more elaborate placebo.

I wish they had tested for effectiveness of blinding, it would have been a nice addition to understanding what happened in evaluating two different placebos.

The authors say in the introduction that

Although the response to SA has led skeptics to consider the acupuncture effect no more than placebo

and conclude with

Our findings suggest that distinct mechanisms exist between SA and EA and challenge the notion that acupuncture is “all placebo.”

Methinks you doth protest to much. I see the study has variations of placebo effect, all placebo and nothing but placebo.

There were four kinds of beer goggles evaluated in this study; sham with low or high AES, electroacupuncture with low or high AES with the added potential confounder that some in the high AES group may have known what they were getting TENS. The increasing AES and subsequent improved pain response may be no more than the effects of a more elaborate placebo with a positive feedback loop.

To my mind this is more data to support the notion that the effects of acupuncture, like the effects of all of CAM, is simply the patient deciding they are getting better, the pseudo-medical equivalent of kissing a boo boo to make it feel all better. 

Points of Interest 11/14/2014
Points of Interest 11/13/2014

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