Lessons from a trial of acupuncture & massage for LBP: patient expectations & treatment effects.

(Kalauokalani, Cherkin, Sherman, Koepsell, & Deyo, 2001)

Aims: To evaluate the association of a patient’s expectation for benefit from a specific treatment with improved functional outcome.

Methods: Secondary analysis from a RCT comparing massage, acupuncture, and self-care material (control group) used for patients with chronic LBP. 135 patients, 10 treatments within 10 weeks. The participants were asked to rate how helpful they believed each treatment would be for their current back problems on a (0-10) scale. They also were asked to describe their expectations for improvement of their back pain without regard to treatment using a 7-point Likert scale. Measures of expectation for treatment benefit (each high / low) / relative expectation (which ttt has higher expectation) / average expectation for treatment benefit (general benefit) and / general expectation regarding prognosis (optimism about improvement) were analysed.

Results: No ≠ in proportion of patients who improved in each group. More improved Roland scores were found among participants with higher expectations for benefit from their assigned treatment than among those with lower expectations. The improvement in Roland disability scores from baseline to follow-up assessment also was significantly greater in the higher expectations group than in the lower expectation group. Among the participants with higher relative expectations for massage estimates of 10-week Roland scores were better (lower) if the participants had received massage than if they had received acupuncture. Thus, regardless of the treatment received, the effect of the treatment depended on the magnitude of relative expectations. Neither average expectations for treatment benefit nor general expectations regarding prognosis had a significant association with the 10-week functional outcome as measured by the Roland score.

Limitations: Confounding variable / small sample / only between 2 passive treatments / …

In Practice: ● Patient expectation for benefit from a specific treatment correlates significantly with improved clinical outcome ● The relative odds of improvement are five times greater among those with high expectations for treatment benefit compared with those with low expectations for benefit after adjusting for sociodemographic, health status, and physical factors. ● General optimism regarding prognosis does not appear to have an important influence on out- comes. ● These findings may have implications for both physicians and patients regarding treatment choice, particularly when no treatment is clearly superior and when the relative safety and costs of each treatment are similar. ● These findings may also indicate a role of assessing patient expectations in the interpretation and design of clinical trials.

Kalauokalani, D., Cherkin, D. C., Sherman, K. J., Koepsell, T. D., & Deyo, R. A. (2001). Lessons from a trial of acupuncture and massage for low back pain: Patient expectations and treatment effects. Spine, 26(13), 1418–1424.

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