Maximizing placebo response in neurological clinical practice

"A second birthday"? Experiences of persons with multiple sclerosis treated with autologous hematopoietic stem cell transplantation-a qualitative interview study

Introduction and objective

Autologous hematopoietic stem cell transplantation (aHSCT) is a promising treatment option for persons with multiple sclerosis (pwMS). Patients undergoing aHSCT face unique challenges in all aspects of life. In this study, we explored the lived experiences of pwMS undergoing aHSCT.

Methods

Semi-structured interviews of 12 pwMS treated with aHSCT were conducted using a maximum variation sampling strategy. Interviews were transcribed verbatim and analyzed thematically using inductive and deductive categories.

Results

Three major themes were identified: (1) preparing for aHSCT, (2) experiencing the procedure, and (3) post-treatment time. A difficult decision-making process, organizational effort, and funding difficulties characterized the preparation for transplantation. AHSCT was seen as a life-changing event accompanied by both psychological and physical stress, with an associated feeling of regaining control. The transplantation had a lasting positive effect on the lives of the interviewed pwMS. However, the early post-treatment time was characterized by successes and failures alike. Particularly the independently organized medical aftercare was perceived as challenging. Retrospective revaluation has led most pwMS to wish for earlier information provision about the treatment option of aHSCT during their treatment history.

Conclusion

AHSCT had a clear impact on patients' physical and psycho-social health, influencing their perception of life and its quality. Assessing and attending to unmet needs of patients before, during, and after transplantation may positively influence their experience of aHSCT.

Efficacy of manual acupuncture vs. placebo acupuncture for generalized anxiety disorder (GAD) in perimenopausal women: a randomized, single-blinded controlled trial

Background

Generalized anxiety disorder (GAD) is common among perimenopausal women. Acupuncture may be an effective treatment for GAD, but evidence is limited. The pathogenesis of GAD is not yet clear, but it is related to the hypothalamic-pituitary-adrenal axis and its excretion, cortisol (CORT), and the adrenocorticotropic hormone (ACTH). The objective of this study is to evaluate the efficacy of manual acupuncture (MA) vs. placebo acupuncture (PA) for perimenopausal women with GAD.

Methods

This study is a single-center, randomized, single-blind clinical trial conducted in the First Affiliated Hospital of Guangzhou University of Chinese Medicine. A total of 112 eligible patients with GAD were randomly assigned (1:1) to receive MA (n = 56) or PA (n = 56) three times per week for 4 weeks. The primary outcome measure was the HAMA score. The secondary outcome measures were the GAD-7 and PSQI scores and the levels of CORT and ACTH. The evaluation will be executed at the baseline, 2 weeks, the end of the treatment, and a follow-up 3-month period.

Results

Significant improvements in HAMA (p < 0.001, η2p = 0.465), GAD-7 (p < 0.001, η2p = 0.359) and ACTH (p = 0.050) values were found between T0 and T2 in the MA group compared to the PA group. No difference in PSQI (p = 0.613, η2p = 0.011) and CORT (p = 0.903) was found between T0 and T2 in the MA group compared to the PA group. Long-term improvements in HAMA (p < 0.001, p < 0.001) were found in the MA group and PA group.

Conclusion

This study was the first completed study to evaluate the efficacy of acupuncture and placebo acupuncture for GAD in perimenopausal patients. Results suggested that placebo acupuncture has a therapeutic effect, however, acupuncture had a greater therapeutic effect than placebo acupuncture. This study supports the effectiveness of acupuncture and thereby contributes to extended treatment options for GAD.Clinical trial registration:http://www.chictr.org.cn, Chinese Clinical Trial Registry, ID: ChiCTR2100046604. Registered on 22 May 2021.

Placebo: a brief updated review

Our aims were to provide updated information on placebo/nocebo effect and the potential use of placebo in clinical practice. This article can only provide a rough overview on the placebo and nocebo effect and is intended to serve as a starting point for the reader to go deeper into the corresponding literature. The placebo effect has been observed in multiple medical conditions, after oral administration, with manual therapies as well as with surgery and invasive procedures. The use of placebo in clinical trials is fundamental, although the ethics of its use is under discussion. The placebo may behave like a drug from the pharmacokinetic and pharmacodynamic point of view and can also be associated with adverse events (nocebo effect). Placebo can modify treatment by increasing or decreasing the effects of drugs. The factors associated with the occurrence of placebo effect are multiple, but in addition to those that depend on the placebo itself, the doctor-patient relationship would be the most important. As a result of findings that were published in the last two decades, the psycho-neurobiological basis of placebo is becoming better understood, although further studies are needed. In conclusion, the placebo effect in the clinic exhibits weak to moderate intensity. Placebo, in addition to its use in the clinical trial, should be considered another therapeutic remedy either as stand alone or in association with treatment, and could be useful in certain circumstances. The use of placebo should be regulated by the European health authorities through a guide in clinical practice that will improve patient care.

Conditioning to Enhance the Effects of Repetitive Transcranial Magnetic Stimulation on Experimental Pain in Healthy Volunteers

OBJECTIVE

In this proof-of-concept study we sought to explore whether the combination of conditioning procedure based on a surreptitious reduction of a noxious stimulus (SRPS) could enhance rTMS hypoalgesic effects [i.e., increase heat pain threshold (HPT)] and augment intervention expectations in a healthy population.

METHODS

Forty-two healthy volunteers (19-35 years old) were enrolled in a randomized crossover-controlled study and were assigned to one of two groups: (1) SRPS and (2) No SRPS. Each participant received two consecutive sessions of active or sham rTMS over the M1 area of the right hand on two visits (1) active, (2) sham rTMS separated by at least one-week interval. HPT and the temperature needed to elicit moderate heat pain were measured before and after each rTMS intervention on the right forearm. In the SRPS group, conditioning consisted of deliberately decreasing thermode temperature by 3°C following intervention before reassessing HPT, while thermode temperature was held constant in the No SRPS group. Intervention expectations were measured before each rTMS session.

RESULTS

SRPS conditioning procedure did not enhance hypoalgesic effects of rTMS intervention, neither did it modify intervention expectations. Baseline increases in HPT were found on the subsequent intervention session, suggesting variability of this measure over time, habituation or a possible "novelty effect."

CONCLUSION

Using a SRPS procedure in healthy volunteers did not enhance rTMS modulating effects on experimental pain sensation (i.e., HPT). Future studies are therefore needed to come up with a conditioning procedure which allows significant enhancement of rTMS pain modulating effects in healthy volunteers.

What is the role of placebo in neurotherapeutics?

INTRODUCTION

The widespread use of the word 'placebo' in the medical literature emphasizes the importance of this phenomenon in modern biomedical sciences. Neuroscientific research over the past thirty years shows that placebo effects are genuine psychobiological events attributable to the overall therapeutic context, and can be robust in both laboratory and clinical settings.

AREAS COVERED

Here the authors describe the biological mechanisms and the clinical implications of placebo effects with particular emphasis on neurology and psychiatry, for example in pain, movement disorders, depression. In these conditions, a number of endogenous systems have been identified, such as endogenous opioids, endocannabinoids, and dopamine, which contribute to the placebo-induced benefit.

EXPERT OPINION

Every effort should be made to maximize the placebo effect and reduce its evil twin, the nocebo effect, in medical practice. This does not require the administration of a placebo, but rather the enhancement of the effects of pharmacological and nonpharmacological treatments through a good doctor-patient interaction.