Acupuncture Effects Depend on Expectations. Again.

Acupuncture Effects Depend on Expectations. Again.

Acupuncture is all in the mind

Does acupuncture work? Of course, it depends on what you mean by work. Acupuncture alters no underlying physiologic process so it will not treat cancer, asthma, or pneumonia. As as been said many times on this blog, it does not alter any objective outcome.

But it can change perception of a process like pain, and perception is important. Acupuncture, similar to all placebo based therapies, can alter the subjective appreciation of some symptoms and make the patient think they are better. It is the same as kiss a boo boo when your child has an injury.

There have been a number of studies that have demonstrated that the key characteristic in responding to acupuncture is belief in acupuncture and it's efficacy. The stronger the belief, the better the response.

This theme is expanded in Overlap and differences between patient and provider expectations for treatment outcomes: the case of acupuncture

They used data from four acupuncture trials:

304 patients with migraine with or without aura, 296 patients with tension-type headache, 301 patients with chronic low back pain, and 300 patients with chronic osteoarthritis of the kneee...Patients were blinded to the comparison of acupuncture to sham acupuncture.

and they asked the patients two questions

 "How effective do you consider acupuncture in general?" The answer options were "very effective," "effective," "slightly effective," "not effective," and "don't know.


"What do you personally expect from the acupuncture treatment you will receive?" The answer options were "a cure," "clear improvement," "slight improvement," "no improvement," and "don't know."

as well as asking the providers in two of the studies

"Irrespective of the following random group assignment, in general, what would you say are the chances of therapeutic success for this patient?" The answer options were "very good," "good," "moderate," and "bad". The categories "moderate" and "bad" were merged into the category "moderate".

The patients with the highest opinion of acupuncture and who also though they would respond had the best response.

They then characterized 6 types of patient expectations: Hesitant doubters, Unrealistic optimists, Maximum expectation matchers, Optimistic doubters, High expecting realistic optimists, and Realistic optimists, defined in detail in the paper.

The optimistic doubters had the poorest response to acupuncture, although there were variations in acupuncture response depending on the patient. For example

with patients stating that they "don't know" what to expect from acupuncture in general (PPEC 1 and 4) appeared to have less improvement in their symptoms compared with PPECs with patients who expected acupuncture to be effective or very effective in general (PPEC 3 and 5). This finding is interesting because these patients can be labelled skeptics from a general perspective, and the expected benefits for their health might be driven by hope rather than by positive expectations per se.

They conclude

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.

A curious conclusion if you consider deliberately using placebo medicine unethical. I do not really want to know how to make placebo more effective. But extending the results to science-based medicine is a good idea.

Strengthening expectations as a means of improving outcomes has been suggested previously , but reducing the mismatch in patient expectations might be considered equally important in clinical routines. However, unrealistically optimistic patients might be frustrated by missing early gains during treatment. Discussing expectations in an early stage of treatment might help to reduce frustration for both patients and providers.

Points of Interest 03/03/2016
Points of Interest 03/01/2016

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