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As a complex treatment, with many contextual aspects of the visit being potentially therapeutic, acupuncture has long been assumed to be more effective among those patients who believe that it will help them. A number of studies have indeed shown that acupuncture is more effective among such patients.1–3 However, not all rigorously conducted studies have found this to be true. For example, in a large 638 person trial we conducted of acupuncture for chronic back pain with acupuncture-naïve participants, we found that those with high pretreatment expectations for acupuncture showed greater expectations of improvement in general and showed greater preference for acupuncture.4 They were more likely to have heard that acupuncture was a very effective treatment and to have a very or moderately positive impression of acupuncture. However, such favourable beliefs towards acupuncture did not predict improvement in back-related function or pain at the end of 7 weeks of treatment or at the end of a year of follow-up. Measured again after one treatment, participants’ revised expectations were associated with improvement in pain, though not function, at the end of the treatment period. Halfway through the treatment period (after five sessions of acupuncture), revised expectations were predictive of improvements in function and pain at 8 and 52 weeks. Our data suggest that the relationship between expectations about treatment outcomes and the actual outcomes is more nuanced than many believe. This, in turn, suggests that acupuncture does not work simply because people expect that it will.
So, how do we resolve these inconsistent findings? One challenge in the literature on acupuncture and expectations to date is that virtually all these studies have used homegrown measures of expectations. In fact, until recently, no validated measures of expectations explicitly developed for acupuncture existed. With the publication and validation of the ‘Acupuncture Expectancy Scale’, first in Chinese,5 then in English6 and now in Korean,7 there now exists an expectancy scale exclusively for acupuncture. However, many questions remain about the validity of the validated scale. For example, in the original Chinese validation, the participants were recruited from the waiting room of acupuncture clinics. No information was given regarding whether they were starting a new course of treatments or had been having treatments for weeks. For the Korean validation study, no clear description of the population was provided, leading to questions of whether they were currently patients or not. Certainly, they were not attending acupuncture treatments and roughly one-third had never sought acupuncture. Validating a scale for a hypothetical treatment is not the same as validating it in a clinical population. Furthermore, the test–retest was performed roughly 5 weeks later, when the gold standard for such procedures is several days. Finally, there is always the question of whether the scale is comprehensive enough to truly capture the domains related to outcomes expectations.
Our approach has been to use a multistep process to develop a questionnaire to assess the outcome expectations of patients with chronic back pain receiving one of four complementary therapies, including acupuncture, for their back pain. Using a semistructured interview guide, we first interviewed a total of 32 acupuncturists, chiropractors, massage therapists and yoga teachers about how they treated patients and worked with their expectations.8 Much to our surprise, acupuncturists and the other clinicians tried to ensure that their patients’ expectations were realistic regarding the role of the provider (and the patient) in the healing process, the likely outcomes and the timeframe for improvement.
We then interviewed patients regarding their expectations of treatment, and a manuscript on this topic is currently under review. After reviewing the most important outcome domains related to these treatments, we put together a draft questionnaire that was tested for understandability in seven rounds of cognitive interviews and vetted with experts in questionnaire design, acupuncture and other complementary therapies, expectations and complementary medicine research. A manuscript describing our findings is currently under review. Our final product of this process was a questionnaire with 2 probable domains: 18 items assessing patient expectations and hopes related to treatment and 8 items assessing beliefs about the need for self-care.
Currently, our full 26-item draft questionnaire is being administered via the internet to persons actively seeking or just starting acupuncture, chiropractic, massage or yoga for their chronic back pain. We are also testing this questionnaire in three clinical trials of non-pharmacological therapies for chronic back pain in the US and hope to add a few more trials. We plan to perform a comprehensive psychometric analysis before making the final, hopefully shorter, questionnaire available to researchers and clinicians.
Funding Our research was supported by grant #R01 AT005809 from the National Institute of Health National Center for Complementary and Alternative Medicine (NCCAM) at the US National Institutes of Health.
Competing interests None.
Provenance and peer review Not commissioned; internally peer reviewed.
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