Practice, practitioner, or placebo? A multifactorial, mixed-methods randomized controlled trial of acupuncture

White P, Bishop FL, Prescott P, Scott C, Little P, Lewith G. Pain. 2011 Dec 12. [Epub ahead of print]

Every effective therapeutic intervention achieves its goal through specific (e.g., biochemical changes directly caused by the intervention) and nonspecific mechanisms (e.g., patient-clinician relationship, treatment process and rituals, expectations). We could potentially improve treatment outcomes if we had a better understanding of how to maximize the placebo effects. Therefore, White et al used a randomized, single-blind (patient), trial to investigate whether there is an enhanced treatment effect associated with the needling in acupuncture, the consultation process, and the practitioner. 221 participants, selected because they were waiting to receive a total hip or knee replacement for osteoarthritis, were randomized to one of three treatment types (real acupuncture, placebo acupuncture [used nonpenetrating needles], and mock electroacupuncture stimulation) and one of two consultation types (empathetic [traditional] or nonempathetic [cold, quiet, and efficient with minimal explanations]). Next, they were randomized to one of three practitioners (3 to 10 years of experience). Patient-reported pain was recorded daily for 7 days prior to treatments (100-mm visual analog scale). All of the treatments were 20 minutes (during a 30-minute appointment) twice a week for 4 weeks. Pain was recorded throughout the treatment and one week after the last session. Qualitative data was collected via a face-to-face interview among 27 participants at the end of the study. Compared to baseline, pain was reduced among all of the groups regardless of treatment type or consultation type. Participants with the third practitioner achieved greater pain relief, regardless of treatment or consultation type, compared to participants with the second practitioner. During the interviews, patients often referred to the practitioner who performed better as “doctor” and with more respectful than affectionate terms. Patients who thought their treatment was real reported lower pain scores than those who did not. The authors concluded that “an unknown characteristic of the treating practitioner predicts outcome, as does the patient’s belief (independently)” in the treatment.

This well designed study further confirms the importance of a patient’s belief in the treatment. Furthermore, the authors state “the clinical effect of acupuncture treatment and associated controls is not related to the use of an acupuncture needle, nor mediated by empathy, but is practitioner related and may be linked to the perceived authority of the practitioner. In this study, it is interesting to note that the more successful practitioner was also the primary investigator of the study. The qualitative data, from the interviews, suggested that the patients perceived this practitioner as a paternalistic authority figure; a perception that mat be enhanced because he was the primary investigator. This study highlights the importance of the clinician and the patient believing in the intervention. Rather than focus on the lack of differences between acupuncture and quasi-acupuncture (referred to above as placebo acupuncture) these authors focused on the idea that these treatments often outperform traditional treatment interventions (Cherkin DC et al, 2009; Haake M et al., 2007; Scharf H et al., 2006) and therefore they hypothesized that we could learn how to improve treatment benefits by understanding how these treatments get sometimes remarkable pain relief. Next time you initiate a treatment it might be worth having a conversation with your patient about why this treatment might be beneficial. It could improve the patient’s belief in the treatment as well as you, the clinician. Do you believe that you can influence a patient’s outcome by taking the time to explain the treatment?

Written by: Jeffrey Driban
Reviewed by:  Stephen Thomas

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Links of Interest:

White P, Bishop FL, Prescott P, Scott C, Little P, & Lewith G (2011). Practice, practitioner, or placebo? A multifactorial, mixed-methods randomized controlled trial of acupuncture. Pain PMID: 22169359