The Power of Patient Expectations
By Tina Beychok, Associate Editor
As acupuncturists, you certainly are aware of, and believe in, the benefits of acupuncture and Oriental medicine to help your patients. But what do your patients bring to the treatment table in terms of expectations and how might that affect their outcomes?
While the answers to these questions might seem difficult to quantify, a new study from the April issue of the journal Pain sheds light on how patients’ mindsets can affect the effectiveness of their treatment.1 Klause Linde and colleagues from the Centre for Complementary Medicine Research, Technische Universitat Munchen, took the results from four earlier studies that compared acupuncture to sham (“minimal acupuncture”) treatment for four different conditions (a total of 864 patients).2,3,4,5 Patients were asked the following two questions, both before treatment and after the completion of three sessions:
How effective do you consider acupuncture in general?
(Answer options: very effective, effective, slightly effective, not effective, don’t know.)
What do you personally expect from the acupuncture treatment you will receive?
(Answer options: cure, clear improvement, slight improvement, no improvement, don’t know.)
After three treatments, Linde and colleagues also asked patients:
How confident do you feel that this treatment can alleviate your complaint?
(Answers ranged on a scale from 0 [not certain at all] to 6 [totally certain].)
In analyzing the patients’ responses, the researchers found: “In our four randomized trials, patients with high expectations were more likely to report better outcomes than patients with lower expectations, both after treatment and four months later. The size of expectation effects is … clearly clinically relevant. This effect was observed both in patients receiving the ‘true’ and the minimal acupuncture.”1 In fact, for patients with migraines2, the number of patients who reported improvement was almost 60 percent and did not differ between those who got ‘true’ acupuncture and those who got “minimal acupuncture.”
In examining this interesting phenomenon further, they speculated that perhaps a nurturing environment helps foster this positive attitude: “Intense and frequent provider-patient interaction, touch, needling pain, and an ‘exotic’ framework could make acupuncture a strong ‘ritual’ which is associated with stronger expectation effects than other interventions.”1
Another possible explanation is that positive expectations can modify pain receptor pathways in the brain. As the researchers noted, “There is clear evidence from research on placebo analgesia showing that, in principle, expectations can modify pain perception in the brain. Several lines of research indicate that expectations associated with the application of placebos activate endogenous opioid systems, however, non-opioid pathways are also likely to play an important role … In summary, expectations of clinical benefit seem in general to be a major mechanism of placebo effects.”1
Clearly, these study findings seem to emphasize that fostering a positive patient attitude toward acupuncture and Oriental medicine can have a pronounced influence on clinical outcomes. If patients understand and appreciate AOM, that alone might contribute to healing as much as the actual acupuncture procedure itself.
Linde K, Witt CM, Streng A, et al. The impact of patient expectations on outcomes in four randomized controlled trials of acupuncture in patients with chronic pain. Pain, April 2007;128(3):264-71.
Linde K, Streng A, Jurgens S, et al. Acupuncture for patients with migraine. A randomized controlled trial. JAMA, May 4, 2005;293(17):2118-25.
Melchart D, Streng A, Hoppe A, et al. Acupuncture in patients with tension-type headache: randomized trial. BMJ, Aug. 13, 2005;331(7513):376-82.
Brinkhaus B, Witt C, Jena S, et al. Acupuncture in patients with chronic low back pain – a randomized controlled trial. Arch Intern Med, Feb. 27, 2006;166(4):450-7.
Witt C, Brinkhaus B, Jena S, et al. Acupuncture in patients with osteoarthritis of the knee: a randomised trial. Lancet, Jul 9-15, 2005;366(9480):136-43.