Acupuncture, touch, and the placebo response

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ACUPUNCTURE, TOUCH, AND THE PLACEBO RESPONSE

 

read the full article at

http://homepage.ntlworld.com/anthony.campbell1/acupuncture/articles/touch.html

 

[snip]

....

 

Does this mean that acupuncture is " just placebo " ?

 

At this point, if not before, scientifically minded acupuncturists are

likely to feel uncomfortable, for we seem to be coming perilously near to

conceding the critics' case that acupuncture is nothing more than a

superior placebo. This is in fact still a possibility, as Ernst and White

have pointed out (p. 156)[6]. And what makes the critics' charge even more

telling is the fact that although there is a fair amount of scientific

evidence to show that acupuncture in the broad sense has some effect, there

is very little to show that any one method of doing it is better than

another. It is difficult to argue convincingly that traditional acupuncture

is better than modern acupuncture or vice versa, or that one version of

modern acupuncture is better than another. Unanswered quite basic questions

abound. Should the needles be left in for half a minute or twenty minutes?

Should the needle be placed accurately in the trigger point or is

superficial needling over the site enough[3]? Is manual stimulation

necessary? Is electrical stimulation more or less effective than manual

stimulation? Do classic acupuncture points have any real existence or

special properties? Not much reliable guidance is to be found in the

research literature on these or a host of other practical questions.

(Incidentally, the same is true of many other kinds of unorthodox medicine,

such as homeopathy, which also exist in a number of allotropic forms.) But

if they all work to much the same extent, is it possible that none of them

really works at all?

 

There seem to be two main strategies that might be adopted by therapists

who wish to refute the charge that what they offer is " mere placebo " . The

first is to take refuge in mysticism, and the second is to admit that much

of the effect may indeed be due to non-specific influences but to question

the generally received understanding of placebo. I shall look at each of

these in turn.

 

The mystical alternative

 

As Nathan points out, the mainstream manipulative professions have sought

to gain acceptance from orthodox medicine by explaining their procedures in

mechanical and physiological terms. The same is true of modern,

non-traditional, acupuncture. However, the founders of osteopathy and

chiropractic, Andrew Still and Daniel Palmer respectively, were vitalists,

as is a minority of their followers even today. There are also several less

conventional schools of manual therapy that are explicitly vitalistic.

Among the manual therapies that are based on ideas of this kind are

shiatsu, therapeutic touch, polarity therapy, and the various schools of

" laying on of hands " . Traditional Chinese acupuncture is expressly

vitalistic, depending as it does on the concepts of yin-yang polarity and chi.

 

The modern theories underlying such treatments often make mention of

" energy fields " , a metaphor derived from physics, but the origins of these

ideas are much older. Nathan connects them, I am sure correctly, with

mystical teachings such as those that were elaborated in great detail by

the Neoplatonists in Alexandria in the early centuries of the Christian

era, although it would be a monumental undertaking to trace the routes by

which these ideas have descended to their present form in unconventional

medicine. A more immediate source can be found in the work of Wilhelm

Reich. He was an associate of Freud and worked with him in Vienna after the

First World War. Like Freud, he was much preoccupied with sex and placed

the attainment of satisfactory orgasm at the root of his therapeutic

theory. Later in life he went to the USA, where he developed what sounds

like a complex delusional system concerned with " orgone " , a kind of cosmic

energy. This brought him into conflict with the US Food and Drug

Administration and eventually he was committed to prison, where he died.

Some of Reich's ideas were developed by others, notably Alexander Lowen,

and gave rise to a system of therapy called Bioenergetics. Other offshoots

include Biodynamic therapy and Biosynthesis.

 

Nathan is prepared to regard " energetics, field theory, subtle-body theory,

spirituality and even theosophy " as ideas that deserve to be researched and

taken seriously, because they offer " the only possibility for a

comprehensive understanding of human life - one that explicitly allows for

the wealth of history of human experience " . I can't follow him in this. It

seems to me that to allow oneself to be involved in these murky areas is to

risk submerging beyond hope of rescue in a sea of confusion. I prefer to

think that we will ultimately be able to offer an explanation of the

psychological and emotional effects of the manual therapies in

neurophysiological terms, though this will entail a considerably better

understanding of the way placebos work than we have at present.

 

Do not be frightened of the placebo

 

The placebo concept still requires a lot of elucidation[7], and indeed may

not be easily applicable to the manual therapies, but meanwhile we should

at least remember that the " placebo effect " is a neurophysiological

phenomenon. This may seem obvious when one thinks about it, but it is often

forgotten. As I have argued elsewhere, there seems to be an unwarranted

assumption on the part of many doctors that placebo effects are somehow

unreal and not very reputable[8]. They think in this way because they are

unconsciously using a dualistic model of the organism. They say, in effect,

that there is the body, which is a physiological system on which drugs and

other medical treatments are supposed to operate, and there is the mind,

which can be affected by suggestion to produce a spurious effect. Between

the mind and the body there is an ill-defined no-man's land rather

inadequately occupied by something called psychosomatic medicine. Doubtless

few would admit to holding a crude view of this kind, yet this is what

seems to be implied in the pronouncements of some medical critics of

complementary medicine. What is odd about it is that it is incompatible

with the materialism which otherwise characterizes most medical thinking,

even (or perhaps especially) in psychiatry. As a recent Lancet leading

article remarked: " With a few dissenters, psychiatry accepts that in

principle its disorders are disorders of the brain that can and should be

investigated as such. " [9]. Exactly the same applies to the placebo

phenomenon: it is produced by the brain and should be approached from that

direction.

 

There is good scientific evidence available to show that the endogenous

opioids are mediators of placebo analgesia although this may not be the

whole explanation, especially in view of the wide variations in what

constitutes a placebo[10]. We are not yet able to specify in any detail

which brain areas and mechanisms are important in relation to the

subjective phenomena that occur in patients receiving manual treatments. I

have elsewhere proposed that the limbic system may be involved in the

production of emotional phenomena such as euphoria, laughter, and crying in

acupuncture patients[11]. Should this idea turn out to be even partially

correct, there is no reason to think that acupuncture would be the only

treatment that is capable of modifying the activity of the system. Other

manipulative methods, such as those used in physiotherapy, osteopathy, and

chiropractic might act in the same way, and so too might less conventional

therapies, all of which can on occasion give rise to emotional abreactions.

There are numerous descriptions by patients of emotionally charged

experiences while receiving such treatments, especially the more vigorous,

such as Rolfing. The limbic system might thus represent a final common path

(though probably not the only one) by which such treatments work. The

touching that is entailed in examining a patient for TPs would then be

simply one more means of accessing the limbic system. To ask whether this

is a placebo effect seems to be almost meaningless in this context.

 

[snip]

 

This analysis seems to offer plenty of scope for the quite widespread

impression among acupuncturists that there is " something else " involved

besides the effects of the needle. That " something else " may indeed prove

to be what is often called the placebo effect, but this should be

understood to be a neurophysiological phenomenon and hence as " real " as

anything else.

 

On a practical level, this has important implications for how practitioners

of modern medical acupuncture think about what they are doing. Ernst and

White suggest that if it turns out that sham acupuncture is as effective as

" real " acupuncture, research should concentrate on how to maximize the

placebo effect and therapists should be trained in placebo acupuncture (p.

156)[6]. However, this seems to pose a problem for modern therapists, for

whom the placebo effect still retains a certain element of charlatanry.

Would it be ethical to deceive patients (in effect), even if it were for

their own good? And, if not, would telling the patient that this was a

placebo procedure negate its effectiveness? There seem to be serious

problems in the deliberate use of placebo today, though the practice was

widespread in medicine before the Second World War[10].

 

Perhaps, therefore, we should consider abandoning the use of the word

" placebo " in this context. If we could establish some of the mechanisms

that underlie the subjective phenomena produced by manual treatments, we

might be able to offer a description that avoids the dreaded word " placebo "

in favour of one that was both more accurate and more acceptable to both

patients and therapists. We might, for example, find ourselves able to say

something like this:

 

" " Our therapy is designed to help your brain to reprogram itself in a

more healthy way. It takes advantage of the inbuilt healing propensities of

the body, so rather than manipulating the body from outside we are working

with the mechanisms that exist and encouraging them to take over and

restore health. " "

 

This would be more than a verbal sleight of hand. It would not be simply a

matter of relinquishing the " placebo " terminology; rather, it would direct

the attention of scientists towards the subjective phenomena, in the hope

that research on these could be integrated with research on the local

tissue phenomena which at present are the main focus of scientific

interest. Admittedly, these subjective phenomena are more difficult to

research, which is one reason why they have been relatively neglected, but

there seems to be no good reason why they should not be integrated into our

general theoretical framework.

 

For full article, see

http://homepage.ntlworld.com/anthony.campbell1/acupuncture/articles/touch.html