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Defining Placebo: the Saint Jude Thaddeus of Medical Terminology

February 15th, 2011 Leave a comment Go to comments

I have recently begun calling the placebo effect the Saint Jude Thaddeus of Medical Terminology.  This is not because placebo effects are miraculous – although they might sometimes seem to be – but because the placebo effect (or things even remotely connected to it) has gotten a bad rap for something it didn’t do. So what’s the connection to Saint Jude?  Note this excerpt from a traditional prayer:

…faithful servant and friend of  Jesus, the name of the traitor who delivered your beloved Master into the hands of the enemies has caused you to be forgotten by many, but the Church honors and invokes you universally as the patron of hopeless cases and of things despaired of…

stjude Defining Placebo: the Saint Jude Thaddeus of Medical Terminology So basically, Judas Thaddeus got a bad rap because of Judas Iscariot, so much so that there are now two ways of translating the name into English, Judas and Jude. So what does this have to do with placebo?  First we define placebo and placebo effect:

Placebo:
a. a substance having no pharmacological effect but given merely to satisfy a patient who supposes it to be a medicine.
b. a substance having no pharmacological effect butadministered as a control in testing experimentally or clinically the efficacy of a biologically active preparation.
Placebo effect:
a reaction to a placebo manifested by a lessening of symptoms or the production of anticipated side effects.
Hence, what is at play here: first, a true placebo must have NO BIOLOGICAL EFFECT.  You give it and there should be no physiologic change in the body.
Here are some beauts from the article:
In Acupuncture For Chronic Low Back Pain, the authors reviewed clinical trials done to assess if acupuncture actually helps in chronic low back pain. The most important meta-analysis available was a 2008 study involving 6,359 patients, which “showed that real acupuncture treatments were no more effective than sham acupuncture treatments.”
The authors then editorialized: “There was nevertheless evidence that both real acupuncture and sham acupuncture were more effective than no treatment and that acupuncture can be a useful supplement to other forms of conventional therapy for low back pain.”
In Acupuncture For Chronic Low Back Pain, the authors reviewed clinical trials done to assess if acupuncture actually helps in chronic low back pain. The most important meta-analysis available was a 2008 study involving 6,359 patients, which “showed that real acupuncture treatments were no more effective than sham acupuncture treatments.” The authors then editorialized: “There was nevertheless evidence that both real acupuncture and sham acupuncture were more effective than no treatment and that acupuncture can be a useful supplement to other forms of conventional therapy for low back pain.”
Okay, Mr Ho, the author, correctly states that the studies show that real acupuncture and sham acupuncture both have a better effect than no acupuncture.  The problem with this meta analysis is that the definitions of sham are not universal, as correctly pointed out by at least one commenter “japariesw”:
Dear writer (Mr. Ho), this controversy emerges from clinical trials comparing real and sham acupuncture. What you did not elaborate in your article is what is meant by ‘sham’ acupuncture? As acupuncture can be done not merely by piercing needles like in the photo, but also using laser, ultrasound, even with pressure or touch/ stroking the body surface. So, is the ‘sham’ acupuncture really sham? The modality of action is through neurophysicoendocrine pathway, by any modes of stimuli like stroking, piercing, etc. our body will react by showing the therapeutic effects like wellbeing, pain relieving, blood pressure downregulating (for hypertension, but not for normotensive)
So what the commenter is saying is that acupuncture is not just sticking needles in.  I’ve blogged on this topic extensively.  Also, sham still involves either putting needles in, albeit in false points, or stroking the skin.  Either way, neuro pathways are activated and thus, there is still a net physiologic effect.  Yet Mr. Ho says:
First, they admit that pooled clinical trials of the best sort show that real acupuncture does no better than sham acupuncture. This should mean that acupuncture does not work – full stop. But then they say that both sham and real acupuncture work as well as the other and thus is useful. Translation: Please use acupuncture as a placebo on your patients; just don’t let them know it is a placebo.
The authors trotted out the same conclusion after they reviewed an important German trial which also showed acupuncture to be merely a placebo.
Note how Mr. Ho  - loves to hammer the word home: Placebo placebo placebo! Yet there are some points of his that deserve critique.  He says that acupuncture is “no better” than sham.  That is not true.  I’ve seen those studies, they are slightly better than sham.  Second, he says that that “should mean acupuncture does not work” – that is skipping too many steps in the thinking process, and a perfect illustration of my article’s point.
Acupuncture no better than sham = acupuncture is placebo = it doesn’t work. This is their creed.
As long as a physiologic effect is seen, then by definition it cannot be a placebo.  Since there are physiologic effects (albeit different ones, which I mention in my above quoted blog posts) in both sham and real acupuncture, then even sham acupuncture is not a true placebo.
Also, I want to take a closer look at placebo.  By definition it doesn’t mean doing nothing, it means no physiologic effect yet the patient having a perceived OR REAL benefit.  Hence, if I wave my hands and nothing happens it’s not placebo.  If I dress well in clinic, with my dapper tie and crisp white white coat, speak with kind, reassuring words, and the patient already feels a bit better, that’s placebo.  Heck, there is a scene from the first season of Scrubs where the main female character flashes her breasts at a patient and the patient recovers.
And doctors do that all the time – use this placebo effect.  Why? Because a placebo effect is a placebo effect only if there is a perceived or real benefit – it is ERRONEOUS to say that placebo means no effect.
Yet placebo has become a buzzword for skeptics to attack acupuncture despite the fact that it cannot possibly apply to acupuncture.
Ho heaves on:
In any randomized and blinded clinical trial of any mode of treatment for any condition, the finding that the treatment is no better than a placebo always leads to one conclusion only: It is therapeutically useless. Acupuncture, it would seem, is exempted from this rule.
Again, this is true if sham acupuncture is a true placebo, meaning it has no physiologic effect.  Common sense shows that merely touching the skin creates physiologic responses.
The rest of the article by Ho elaborates on the skeptic’s next usual attack on acupuncture and chinese medicine: it is based on astrology and thus cannot work.
For someone with a Chinese surname, I find it appalling that Ho can have such a misconception about what Qi is:
In Chinese cosmology, all life is animated by a numinous force called qi, the flow of which mirrors the sun’s apparent “movement” during the year through the ecliptic. (The ecliptic is the imaginary plane of the earth’s orbit around the sun).
Qi flow does not mirror the sun’s movement.  Duh  See my immediately preceding article for explaining what Qi is.
Moreover, everything in the Chinese zodiac is mirrored on Earth and in Man. This was taught even in the earliest systematised TCM text, the Yellow Emperor’s Canon Of Medicine, thus: “Heaven is covered with constellations, Earth with waterways, and man with channels.”
If we translated channels as blood vessels, which is a possible interpretation, would Ho be so fast as to make a supernatural component?  The mythical author of the Canon was merely using words to help the reader grasp the concept.  Instead of focusing on “waterways” Ho focuses on “constellations”
This means that if there is qi flowing around in the imaginary closed loop of the zodiac, there is qi flowing correspondingly in the body’s closed loop of imaginary meridians as well.
These meridians run from head to toe to form a network interlinking 361 points on the skin. But why are there 361 points? Since the earth takes three minutes under 24 hours to rotate 360 degrees on its axis, the sun appears to revolve through 361 degrees on the ecliptic every 24 hours. Hence 361 points. This factoid alone is sufficient to nail down the acupuncture-astrology linkage.
Since qi flows around in a closed loop, needles can be inserted at one of these points far removed from your site of pain to rechannel qi. If done well, this supposedly can cure your spot of trouble.
Who said there are 361 points?  There are more than 400.  In the Yellow Emperor’s Canon, less than 200 are mentioned.  The point is that it evolved through time, not the product of some mathemagician. Therefore, for Mr. Ho to attempt to use acupuncture point number to try to create a numerology reference is out of date.  Also, no studious TCM practitioner will say that Qi flows in a “closed loop”.  Qi interacts with environment.
It’s arguably OXYGEN or breath.  Would we say oxygen flows in our body in a closed loop?
His last line: “So should doctors check the daily horoscopes of their patients?”
My answer: I certainly don’t.
Poor poor placebo effect, it’s gotten a bad rap.
Maybe we should ask St. Jude to help enlighten the minds who know not the Placebo effect and don’t bother to really learn about TCM before trying to debunk it.
References:
“placebo.” Dictionary.com Unabridged. Random House, Inc. 14 Feb. 2011. <Dictionary.com http://dictionary.reference.com/browse/placebo>
“placebo effect.” Dictionary.com Unabridged. Random House, Inc. 14 Feb. 2011.
Ho, Andy “Pinning down Acupuncture: It’s an Illusion” 13 Feb 2001 <http://www.thejakartaglobe.com/home/pinning-down-acupuncture-its-an-illusion/422438>
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