Psychological correlates of the placebo that is acupuncture

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If there’s one thing that’s become clear to me over the years about acupuncture, it’s that it’s nothing more than a theatrical placebo. Many are the times that I’ve asked: Can we finally just say that acupuncture is nothing more than an elaborate placebo? Most recently, I asked this question in 2012. What science-based medicine answers is yes. However, there’s a large contingent of physicians under the sway of practitioners of traditional Chinese medicine (TCM) who have fallen under the spell of that theatrical placebo, leading to a whole subdiscipline of quackademic medicine in which tooth fairy science is used to try to convince people that acupuncture actually works, even if they involve misinterpreting adenosine signaling or rebranding regional anesthesia as a form of acupuncture they dubbed PAPupuncture.

While I grudgingly admire the imaginative creativity of some of the attempts to torture acupuncture into seeming scientific, I also take note of studies that go against the seeming flow of propaganda designed to convince you that acupuncture has real, specific effects. Remember, it wasn’t so long ago that I considered acupuncture, of all alternative medical treatments, as the one that might actually have something to it. The reason, at the time at least, was that acupuncture actually involved sticking needles into people. Perhaps there was some sort of physiological effect. Then I actually started paying close attention to the acupuncture literature. There, I learned that it doesn’t matter where you stick the needles, thus invalidating any concepts of acupuncture meridians. Nor does it even matter if you stick the needles in at all; twirling toothpicks against the skin produces a similar effect. Basically, when compared to usual care or wait list controls, patients treated with acupuncture report improvement in pain and other subjective measures. However, when a rigorous sham acupuncture control is included in such studies, the apparent differences between acupuncture and control disappear. Acupuncture effects are virtually all nonspecific placebo effects.

With that in way of background, I just saw another study that sheds light on acupuncture effects by way of story in Medical News Today story entitled Acupuncture back pain success determined by psychological factors. It’s a story about study by George T. Lewith’s group at the University of Southhampton. He’s bit of a controversial figure, as no doubt David Colquhoun could tell you, given that he apparently still prescribes homeopathy even though he’s published studies showing that it isn’t effective. Be that as it may, this study is called Psychological Covariates of Longitudinal Changes in Back-related Disability in Patients Undergoing Acupuncture.

Basically, it’s longitudinal study using a questionnaire mailed to patients undergoing acupuncture for chronic back pain. Data were collected at baseline (pretreatment), 2 weeks and then at three and six months on a total of 485 patients from 83 different acupuncturists. The questionnaires were designed to measure variables from four theories (fear-avoidance model, common-sense model, expectancy theory, social-cognitive theory). In addition, clinical and sociodemographic characteristics, and disability were surveyed. The primary outcome was back pain-related disability. This was assessed using the 24-item Roland Morris Disability Questionnaire (RMDQ), which asks patients to think about “today” and to indicate whether their back pain interferes with 24 activities. An example: “I stay at home most of the time because of my back.” High scores indicate greater back-related disability. At the same time, a variety of psychosocial scales were also examined to try to hone in on what psychological factors most contribute to the patient-perceived efficacy of acupuncture.

You can tell that Lewith is a believer by the introduction to the study:,

Personally, economically, and socially, back pain is costly. Acupuncture is recommended by UK clinical guidelines for low back pain (LBP) and is commonly used for LBP. In randomized clinical trials acupuncture has shown large effects on chronic pain compared with usual care or waiting list controls but often only small effects compared with sham acupuncture. This suggests acupuncture has large nonspecific effects, that is, factors other than needling characteristics contribute to patients’ outcomes. Indeed, acupuncture can be conceptualized as a complex intervention in which changes in patients’ health are produced not only by needling but also by more psychosocial factors such as empathic therapeutic relationships and holistic consultations in which discussions of lifestyle and self-care can trigger changes in how patients think and feel about their symptoms and their ability to manage them. However, little is known about the psychosocial factors and processes that might be involved in acupuncture for LBP: established psychological models have not been applied to understand acupuncture’s effects. Although variables from such models may not be explicitly addressed by acupuncturists, this does not mean they are not involved in patients’ ongoing LBP in this treatment context. Therefore, a comprehensive and theoretically informed investigation of psychological covariates of acupuncture’s effects on LBP was designed, drawing on major theoretical frameworks that have predicted LBP outcomes in patients undergoing other interventions: the fear-avoidance model (FAM), common-sense model (CSM), expectancy theory, and social-cognitive theory (SCT).

It is rather interesting to me that UK clinical guidelines for LBP would include the use of a placebo. One wonders why, if acupuncture is viewed as an acceptable clinical option for LBP in the UK, UK medical authorities don’t also allow doctors to prescribe placebo sugar pills. It’s basically the same thing. Of course, homeopathy is still common in the UK, albeit not recommended, and that’s a placebo, too. Be that as it may, it’s interesting that Lewith admits to conceptualizing acupuncture as an interaction in which it’s not “just” the needling that causes supposed therapeutic effects but also the empathetic therapeutic relationship and the “holistic” consultation. In fact, reading the introduction, I could tell that this would be almost certainly what Lewith’s group found, particularly given that a more rigorously designed study from a few years ago found that an empathetic acupuncturist expressing high expectations for the treatment would do better; i.e., that patient expectation and practitioner attitude influence the placebo effect caused by the whole theatrical placebo that is acupuncture.

So what were the findings? Within individuals (individuals compared to themselves), reductions in back-related disability compared to the individual’s mean were associated with reductions in fear-avoidance beliefs about physical activity, consequences, concerns, emotions, and pain identity. Similarly, within person reductions in disability were associated with increases in personal control, comprehension, and self-sufficiency for coping. It was also noted that people who were less disabled had more positive outcome expectancies. In other words, they expected to get better.

These results are, of course, completely consistent with acupuncture being a theatrical placebo. Unfortunately, instead of making the most obvious conclusion (that acupuncture is a placebo and that these various psychological constructs modulate placebo effects), the authors just can’t let acupuncture go. As lead author of the study, Felicity Bishop, said in an interview:

People who started out with very low expectations of acupuncture – who thought it probably would not help them – were more likely to report less benefit as treatment went on.

Which is, of course, an unremarkable observation that is usually true for any treatment with a large placebo component. In the paper itself, Bishop et al write:

The findings also have implications for understanding acupuncture’s large nonspecific effects and, more generally, for understanding the processes whereby acupuncture may result in decreased disability. Given that similar variables predict disability in other settings, patients’ perceptions of pain and self-efficacy could be influencing disability outcomes in patients receiving both real and sham acupuncture in clinical trials. These psychological variables offer one means by which major components of acupuncture as a complex intervention, such as ritual, the therapeutic relationship, and lifestyle advice, could trigger positive clinical outcomes. In the context of a warm relationship and therapeutic ritual, providing positive self-help advice encouraging physical activity could help patients to develop more positive illness perceptions, confront their fear of activities and become more active, breaking the negative cycle proposed in the fear-avoidance model and triggering a more positive perception of back pain as controllable and enabling an increasing sense of self-efficacy for coping. According to social-cognitive theory, enhanced self-efficacy for coping could then trigger a positive feedback loop increasing actual coping ability and reducing disability.

And at the very end:

Acupuncture patients experience less back-related disability when they are less afraid and avoidant of physical activity and work, perceive fewer symptoms emotions and consequences of LBP, perceive their LBP as less threatening, and when they feel greater control over, understanding of, and ability to cope with their back pain. Future studies should test whether integrating acupuncture and psychological interventions targeting these constructs can enhance patient outcomes.

Of course, the science-based view would be to ask this: Why is acupuncture even needed at all in this model? All of these observations could be used to use placebo mechanisms to accentuate the perceived benefits of science- and evidence-based treatments. Given that rigorous studies of acupuncture for low back pain routinely fail to find a difference between the acupuncture group and a well-designed sham control while finding significant differences between both sham control and acupuncture groups versus usual treatment or wait list controls, the results of this study can best be viewed as what psychological factors modulate placebo effects, and, to be honest, not a very rigorous study given that there is no control group, waitlist or sham, and the data were all collected using various questionnaires designed to assess back-related disability and various model measures.

I have an idea. Placebo effects are definitely a worthy area of study, even though in the world of “complementary and alternative medicine” (CAM), or, as it’s becoming more commonly called, “integrative medicine” (really the integration of pseudoscience with science-based medicine) they are often endowed with downright magical, mystical, and even religious properties that far outstrip the magnitude and utility that placebo effects are, in fact, likely to have. The problem with CAM practitioners is that, rather than seeking ways by which placebo effects might enhance the patient-perceived effectiveness of actual medical interventions that have been shown to work, they just can’t give up their ineffective modalities like acupuncture despite all the evidence showing they don’t work.

Quackademic medicine marches on.