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Expectancy must surely influence the response to virtually every medical treatment for virtually every condition—except perhaps a drug given while the patient is unconscious. And yet the topic of expectancy generates attitude, particularly in acupuncture.
At one end of the scale, some people dismiss acupuncture as ‘only expectation’ when all they understand about acupuncture is tradition, meridians and qi—which indicates that they haven't bothered to look at the evidence. Less extreme is to be embarrassed by the fact that much of the effect of acupuncture seems to come from expectation, since ‘real’ acupuncture effect is not much different from ‘sham’ effect, but both are much better than usual treatment. An alternative explanation is that sham acupuncture is itself effective, which is an understandable argument if expectancy doesn't feel like a ‘real’ or ‘honest’ treatment, and is somehow cheating because it is open to manipulation.
Expectancy floats around in these muddy waters, but we try to clarify some aspects of it with two articles in this issue: Sherman sets the scene in her editorial. She found that, when clinicians manipulate their patients’ expectations, they try to make them more realistic. And anyway, the evidence varies on whether expectancy does truly affect the clinical response, and some studies find no effect. This might be due to the context but more likely is due to lack of tools to measure it reliably. Sherman is involved in a detailed, theoretically driven development of a new scale for expectancy. Meanwhile, there is an Acupuncture Expectancy Scale, already validated in English and Chinese, and now validated here in its Korean version by Chae and colleagues. One way or another, expectations will be clearer.
Expectancy of a different kind of outcome is high among footballing nations as they head to Brazil for the World Cup. The razzmatazz just means more work for the Brazilian doctors, and the medical students there are already showing signs of burnout. But Dias and colleagues have scored already, showing electroacupuncture (EA) reduces burnout in students, particularly in improving their sleep. Da Silva and Batigalia net a second goal—treating de Quervain's. Two-nil already.
In another trial, Foroughipour and colleagues find acupuncture superior to sham acupuncture for migraine prevention in patients who have not responded to medication. This is interesting new data since the current evidence only shows that acupuncture is superior to drug prophylaxis, not sham acupuncture, for safety and effectiveness for migraine.
Expectancy is ‘trending’ in clinical acupuncture; neuroprotection is ‘trending’ in acupuncture mechanisms. Acupuncture is used for deafness and tinnitus in the East though clinical evidence is sparse. But the letter by Miyata and colleagues nicely demonstrates a possible mechanism: as the figure 1 shows, EA protects the hair cells in the organ of Corti from degeneration, at least in an animal model.
Sanchez-Araujo and Luckert-Barela provide clever insight into the fundamental approach to acupuncture's mode of action—meridian or nerve. They note that on the trunk, meridians run vertically whereas nerves run horizontally. Now traditional acupuncture books assign acupuncture points individual functions: so do these functions follow the vertical or horizontal lines? See their comment on ‘cutting the foot to fit the shoe’.
Aren't we all just a little tempted to cut the foot, when reality does not meet our expectations?
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.