I have previously written about the role of expectation and suggestion in the use of Medical Acupuncture (MA) and how this may positively influence local pain relief.
This is a subject I have always been interested in. In clinical practice such non specific effects no doubt play a very significant role in treatment outcomes, no matter what technique you are using.
As such when I came across a study by Sherman KJ, et al (2010) considering expectations and preferences as predictors of MA outcomes in low back pain, I was quick to take a read.
The study involved 638 low back pain sufferers who had never had MA as a treatment in other words ‘Acupuncture naive’. They underwent a 7 week course of treatment using MA, and the findings were as follows:
- Those with high pre-treatment expectations of MA showed greater expectations of improvement in general and showed greater preference for MA
- Those with high pre-treatment expectations were more likely to have heard that MA was a very effective treatment and to have a moderately positive impression of MA
- However, those with such favourable beliefs towards MA did not predict improvement in back related function or pain at the end of the 7 weeks of treatment, nor after 1 year follow up
- After the participants had received one session of MA, revised expectations were associated with an improvement in pain but not function at the end of the treatment period
- After the participants had received 5 sessions, revised expectations were predictive of improvements in pain and function at 8 and 52 weeks
The research team therefore concluded “the relationship between expectations about treatment outcomes, and the actual treatment outcomes is more nuanced than many believe. This in turn suggests that acupuncture does not work simply because people expect it will.
These results reflect my experiences in clinical practice. Certainly a positive view of and expected therapeutic effect of MA is helpful and can result in quicker and better pain and function outcomes (This also holds true for manual therapy and exercise as treatment approaches I find).
However the results are not always consistent. Some patients with great expectations of a good result using MA do not do well, in fact at times I have had to abandon MA altogether due to poor tolerance of the technique.
Then other patients who did not attend my clinic expecting to receive MA have done exceptionally well when I have introduced it as whole or part of an integrated treatment approach.
This simple clinical observation would suggest that although non specific effects relating to expectation and suggestion may influence treatment outcomes, they are only part of the treatment effect. If MA was all ‘placebo’ would you not expect all patients with great expectation of a therapeutic effect with MA (delivered correctly) to do well? This does not seem to be the case.
This complex relationship of expectation and treatment outcomes requires further investigation.
Before this can be done, a validated measure of expectancy is required. Karen Sherman at the Group Health Research Institute and her team are working on such a measure which is based on a multi-step process involving a questionnaire. Should this make its way into mainstream research we could extract some very useful and interesting information which may help optimise treatment outcomes.
by Simon.
