Story of Stress and Disease: Robert Ader Pioneering Psychologist

This is the story of Robert Ader who first coined the term "psychoneuroimmunology" or PNI. If you're interested in stress and disease, as I am, you probably would like to read the whole article. A few excerpts here.

Robert Ader, Who Linked Stress and Illness, Dies at 79
By PAUL VITELLO

Dr. Robert Ader, an experimental psychologist who was among the first scientists to show how mental processes influence the body’s immune system, a finding that changed modern medicine, died on Tuesday in Pittsford, N.Y. He was 79...

His initial research, in the 1970s, became a touchstone for studies that have since mapped the vast communications network among immune cells, hormones and neurotransmitters. It introduced a field of research that nailed down the science behind notions once considered magical thinking: that meditation helps reduce arterial plaque; that social bonds improve cancer survival; that people under stress catch more colds; and that placebos work not only on the human mind but also on supposedly insentient cells.

At the core of Dr. Ader’s breakthrough research was an insight already obvious to any grandmother who ever said, “Stop worrying or you’ll make yourself sick.” He demonstrated scientifically that stress worsens illness — sometimes even triggering it — and that reducing stress is essential to health care...
“My father used to say, ‘I just didn’t know any better,’ ” she said, recounting how he had described his pioneering research.

He told her, she recalled, “I didn’t know the immune system wasn’t supposed to be connected to the brain.”

Information on my practice here.

Placebo and Acupuncture vs Acupuncture for Dogs

Compare and contrast.
A study looking AGAIN at acupuncture for osteoarthritis after the biggest study ever done on acupuncture put the placebo issue to rest. Why don't we see this scrutiny with anti-depressant studies? Or stents? There can actually be some hazards with either of those...
Meanwhile other groups are moving on and using acupuncture in dogs for post operative pain. Because it's all about the placebo effect...

Practice, practitioner, or placebo? A multifactorial, mixed-methods randomized controlled trial of acupuncture.
White P, Bishop FL, Prescott P, Scott C, Little P, Lewith G
Faculty of Health Sciences, University of Southampton, Highfield, Southampton, UK.
Abstract
The individual practitioner and the patient's belief had a significant effect on outcome. The 2 placebos were equally as effective and credible as acupuncture. Needle and nonneedle placebos are equivalent. An unknown characteristic of the treating practitioner predicts outcome, as does the patient's belief (independently). Beliefs about treatment veracity shape how patients self-report outcome, complicating and confounding study interpretation.

Electroanalgesia for the postoperative control pain in dogs.
Cassu RN, Silva DA, Genari Filho T, Stevanin H.Acta Cir Bras. 2012 Jan;27(1):43-8.
Unoeste, Presidente Prudente, SP, Brazil.
To evaluate the analgesic and neuroendocrine effects of electroanalgesia in dogs undergoing ovariohysterectomy.
RESULTS: EA and EAD- treated dogs had lower pain scores than DER treated dogs one hour postoperatively. Fewer EA and EAD-treated dogs required rescue analgesia. Serum cortisol did not differ among treatments.
CONCLUSION:Preoperative application of electrical stimuli to acupuncture points isolated or in combination with peri-incisional dermatomes provides a reduced postoperative opioid requirement and promotes an effective analgesia in dogs undergoing ovariohyterectomy.

So do dogs' beliefs influence outcomes too?

Info on my practice here.

Another Alternative Medicine Critic Speaks

Here is the link to an article by David Colquhoun from Britain. It's called "America, the land of the Health Hucksters." I am not familiar with him, and he doesn't seem to be an MD, but he has very staunch opposition to alternative medicine practitioners. His criticisms seem to break down as follows.
1. Traditional Medicine can't cure everything, but that's no reason to adopt fairy tales. We need more research, not alternative medicine.
2. Big Pharma made mistakes and concealed negative data, but hey, no biggie.(Let's ignore those needless heart attacks from Vioxx, and teen suicides from Prozac, for example.) But it was scientists who discovered the bad studies, so no need to distrust the science or Big Pharma.
3. This paragraph, I simply must copy in its entirety because is so appalling, that I don't know where to start.
"I write from the perspective of someone who lives in a country that achieves health care for all its citizens at half the cost of the U.S. system, and gets better outcomes in life expectancy and infant mortality. The view from outside is that U.S. medicine rather resembles U.S. religion. It has been taken over by fundamentalists who are becoming very rich by persuading a gullible public to believe things that aren't true."
The U.S. is unique among developed nations in that we have for profit health care, that excludes many because of the cost. A majority of bankruptcies in this country are due to healthcare costs, and half of those actually had health insurance. So the religion in question is certainly not alternative medical practitioners, if there is a religion. The religion is for-profit-market-driven health care.
4. Placebo, placebo, placebo.
5. $2billion of taxpayer money for alternative medicine and not one useful treatment. Hookay. I thought he was all about research and the scientific method, and yet when a relatively tiny amount of money is appropriated to explore the bases of alternative practices, it is money ill spent. Does he have any idea how much money is spent on R and D in the pharmaceutical industry to produce drugs that don't work? Or drugs that make it to the market and then harm instead of help. Please.
6. "This is all very sad for a country that realized quite early that the interests of patients were best served by using treatments that had been shown to work." His own country's NICE now pays for acupuncture over other treatments for back pain because it has been shown to work.
7. Alternative Medicine is leading America down, like the decline and fall of the Roman Empire. Or are as bad as the torture allowed by Dick Cheney. (No. I'm not making these up. These are his arguments.) And why are we destroying America? Because of the vast amounts of money! Wow. Just wow. Hyperbole much?

So, in apologies for this long post I will limit my questions to Mr.Colquhoun, PhD. , er DR. Colquhoun, with just three questions.
1. Does he realize that just because alternative medicine is a Billion dollar business, that doesn't mean that individual practitioners make anything close to a billion dollars. Does he have any idea of the individual salary of an acupuncturist or chiropractor?
2. Is he even familiar with the NICE findings and their acceptance of acupuncture cited above?
3. What is in his mouth in the photo?? Is that really a cigarette?? I'll just leave it there...

(for more info on my practice link here...)

Letter to the Economist

Just for the sake of completeness, I will post my letter to the Economist here. I didn't get it in in a timely fashion because of my last Spain trip in May, but I'll "publish" it here instead. It is in response to the Economist articles about Alternative Medicine, here and here.
Sir:I was amused and bemused by the full-throated condemnation of alternative medicine as no more than placebo in the May 21st Economist.. I can only address the acupuncture literature, since that is my area of interest and expertise. The author makes no mention whatsoever of the significant number of reputable acupuncture studies done on animals to delineate physiological pathways involved in acupuncture(no placebo there). Nor did he mention numerous fMRI studies done on acupuncture subjects, nor of the exhaustive studies performed on knee osteoarthritis nor of the extensive studies funded by the German insurance companies which lead to their including acupuncture as a covered benefit. Nor did he mention that the British NHS has recently included acupuncture as a first line treatment for back pain because “they want to fund only treatments that work.”
Placebos will always be with us both in traditional and alternative medicine, but without irony he mentions that fake surgery for the knee (it was actually arthroscopy) was no better than the real thing, but somehow never admits the obvious that surgery itself may be quite a powerful placebo. He also stated that Ernst, in debunking alternative medicine is addressing “a serious public-health problem.” “Conventional medicines must be safe and effective before licensed for sale.” In the last decade alone, Vioxx and Prozac, as the most egregious examples, were on the market for years and it took quite a bit of morbidity and mortality before the problems came to light or were even admitted.
There is nothing courageous, new, nor noteworthy in attacking alternative medicine. The fact is that acupuncture research is poorly funded, with no huge lobbying or industrial backing, since it is currently not easily scalable so remains unattractive to corporate interests. Admittedly, acupuncture’s mode of action has not been adequately explained and the results not yet entirely reproducible. The same could be said of some traditional modes of therapy. But patients seek safe treatment options, and vote with their feet. This fact alone seems to enrage some critics.


(For more information about my practice please click here.)

Monitoring the Autonomic Nervous System and HRV in rats after Acupuncture

I often don't know what to make of these studies, but find them super interesting nonetheless, and somehow can't help but incorporate their findings into my practice for better or for worse. What I love about this study is that they actually saw a difference between electroacupuncture on Stomach 36 and Pericardium 6, both in pain reduction and autonomic response as measured by heart rate, LF(low frequency portion of HRV) and LF/HR (low frequency to high frequency ratio-a common measure of stress response.) They saw no reduction when using Liver 3 nor the sham, non-acupoint. I wish we had more studies like this, comparing one set of points and another. For one, it helps get away from the ever present placebo problem in research, and for two it might help inform our practice!!
The study model is 4 groups, sham point, Stomach 36, Pericardium 6, Liver 3, 9 rats in each group. They used alternating 2Hz/15Hz electro, (got to haul out my alternating device again...)
The abstract for the study follow. The emphases are mine. Poor rats...

(To read more about acupuncture, HRV, and my practice, please click here.

Zhen Ci Yan Jiu. 2010 Oct;35(5):335-41.
[Effects of electroacupuncture of different acupoints on changes of blood pressure and autonomic nerve system after colorectal distension in rats].

Chen SP, Gao YH, Yu XC, Liu JL.
Institute of Acu-moxibustion, China Academy of Chinese Medical Sciences, Beijing 100700, China.
Abstract

OBJECTIVE: To observe the influence of electroacupuncture (EA) of different acupoints on changes of mean arterial pressure (MAP), heart rate (HR) and heart rate variability (HRV) in colorectal distension (CRD) rats, so as to analyze the specificity of actions of acupoints in relieving visceral pain and regulating activities of the autonomic nerve system.

METHODS: Forty-five Wistar rats were randomized into control, Zusanli (ST 36), non-acupoint, Neiguan (PC 6) and Taichong (LR 3) groups (n = 9/group). Under anesthesia, CRD was given to the rats by using an aerostat for 5 min. EA (2 Hz/15 Hz, 2 mA) was applied to bilateral ST 36, non-acupoint (1.0 cm lateral to ST 36), PC 6 and LR 3 for 15 min, respectively. Electrocardiogram of the cervico-chest lead was recorded by using a bioelectric amplifier, and MAP recorded by using a pressure transducer and an amplifier. Low frequency and high frequency of HRV were analyzed by Chart 5.0.

RESULTS: Following CRD, the HR, MAP, LF and LF/HF levels increased significantly in all the 5 groups (P <> 0.05). Compared with the control group, 5 min and 15 min after EA ,and 10 min after ceasing EA, MAP values of ST 36 and PC 6 groups were decreased obviously (P < style="font-weight: bold;">The LF levels of both ST 36 and PC 6 groups at 5 min after EA, and those of ST 36, PC 6 and LR 3 at 15 min after EA were significantly lower than those of control group (P <> 0.05).

CONCLUSION: EA of ST 36 and PC 6 can suppress CRD-induced increase of MAP, HR and LF/HF, suggesting beneficial effects of EA in relieving visceral pain and mediating autonomic nerve system. The aforementioned effects of EA of LR 3 and non-acupoint are not obvious.

Even More Placebo Issues

This placebo study was reported on here and here. The results were somewhat surprising to me, that placebos worked even though the participants knew they were fake. I'm guessing now, but I wonder if the cultural ritual of taking pills is so powerful that the mere act of taking a pill, no matter its contents, encourages healing. And in the study, the participants were told that the "pills had been shown to be effective in clinical studies" even though they were inert. Which isn't the same as saying the pills are fake. Another observation is that it was canny of the researchers to use IBS, or "irritable bowel syndrome," since this condition is multi-factorial and subject to overall stress levels since there are so many nerve endings in the gut. It is also interesting that Ted Kaptchuk took on this study. He is an acupuncturist at Harvard and has done seminal work on the topic, authored "The Web That Has No Weaver," a basic explanation and text on acupuncture.
The acupuncture community, by necessity, is irrevocably involved in the discussion of placebo because our studies are scrutinized on every level for placebo bias. So I shouldn't be surprised that Kaptchuk would involve himself in this complicated topic. I would suggest, however, that all physicians should be interested in this topic given the poor track record of very popular and widely prescribed medications against placebo. (My next blog post will discuss the possible negative effects of cortisone injections for tendonitis, such as tennis elbow.)And there are many procedures which have never been challenged by a placebo procedure. And since the first tenet of the Hippocratic Oath is to do no harm, it is a phenomenon that deserves to be treated with respect.
The quote from Kaptchuk at the end of the article brings up questions, however.

“The magnitude of effect here is very large,” said the lead author, Dr. Ted J. Kaptchuk, a researcher at Beth Israel Deaconess Medical Center in Boston. The goal, he added, would be to develop a clinical strategy to use the placebo effect ethically, without lying to a patient.

Of course, we all want positive outcomes and would like to enhance any and all contributions to our therapeutic modality. But if one can't determine how much of any procedure IS actually placebo, it raises all sorts of questions for the practitioner, if not for the patient. If a large part of what the practitioner is doing is causing the patient to heal themselves, then it behooves them to do the safest option first, I would think. Then there's the whole other aspect of whether one would choose to practice a certain therapeutic modality if it really is all placebo. In my own case the answer would be an unequivocal "No." Of course there is some placebo in some patients when coming for acupuncture, but I suspect that there is much "nocebo" also. Nocebo is when the patients don't really think it will help, but will try anything. Fortunately, we know that acupuncture works on animals and babies, who aren't affected by placebo nor nocebo.

Here is the article from the NYTimes.

Perceptions: Positive Spin Adds to a Placebo’s Impact
By NICHOLAS BAKALAR

Can taking a placebo be effective even if the patient knows it is a placebo? A new report suggests the answer is yes.

In a study published online last week in the online journal PLoS One, researchers explained to 80 volunteers with irritable bowel syndrome that half of them would receive routine treatment and the other half would receive a placebo. They explained to all that this was an inert substance, like a sugar pill, that had been found to “produce significant improvement in I.B.S. symptoms through mind-body self-healing processes.” The patients, all treated with the same attention, warmth and empathy by the researchers, were then randomly assigned to get the pill or not.

At the end of three weeks, they tested all the patients with questionnaires assessing the level of their pain and other symptoms. The patients given the sugar pill — in a bottle clearly marked “placebo” — reported significantly better pain relief and greater reduction in the severity of other symptoms than those who got no pill. The authors speculate that the doctors’ communication of a positive outcome was one factor in the apparent effectiveness of the placebo.

“The magnitude of effect here is very large,” said the lead author, Dr. Ted J. Kaptchuk, a researcher at Beth Israel Deaconess Medical Center in Boston. The goal, he added, would be to develop a clinical strategy to use the placebo effect ethically, without lying to a patient.


(To read more about acupuncture and my practice, please click here.)

Acupuncture article in NYtimes: Acupuncture and Osteoarthritis of the Knee Another Look

I've been meaning to comment on this blog post from the New York Times http://well.blogs.nytimes.com/2010/08/23/studying-acupuncture-one-needle-prick-at-a-time/?scp=4&sq=acupuncture&st=cse for some time now. It covers a number of issues concerning acupuncture research. It first cites a recent study from MD Anderson School of Medicine exploring osteoarthritis of the knee and the effectiveness of acupuncture. The link to that article is here.http://onlinelibrary.wiley.com/doi/10.1002/acr.20225/abstract. The study is actually trying to determine if the clinical attention given to the patients affected outcome, thus getting at the ever present problem of "placebo" in acupuncture research. What they found in the study is that acupuncture worked about the same as sham acupuncture. Because of that, the study's lead author concludes that acupuncture does not work, since in your typical drug study if the drug works the same as a placebo the determination is that the drug does not work. ( We will leave aside the issue that many drugs on the market now,Prozac for example, work no better than placebo and still enjoy widespread use.) But another way to parse the outcome of the study is that acupuncture works even if poorly administered. In this particular study the sham acupuncture was less stimulative, shallow needling, so the acupuncture defenders can claim that acupuncture was performed. The NYTimes article goes on to mention the German Insurance Company studies which showed that drug (analgesic) usage was dramatically reduced with acupuncture and sham acupuncture in back pain patients versus the controls, and that only 15% of acupuncture patients needed pain medication versus 29% of sham 59% of controls. German Insurance Companies now pay for acupuncture as a result of these studies, btw. The article also mentions the study comparing effexor to acupuncture covered in this blog post.(http://www.blogger.com/post-edit.g?blogID=6188135334037051688&postID=1694074355474832229)
The placebo issue still plagues acupuncture research, and keeps the discussion from going further than whether we can trust the studies, and then whether acupuncture really works or not. It gets tiresome, especially given the scant funding for acupuncture research. One veteran British acupuncture researcher I met at the latest Society for Acupuncture Research conference is recommending that we simply design studies comparing one dosage of acupuncture (time, frequency, length of treatment, point selection) to another so we can finally get beyond the underlying premise of the MD Anderson study, ie that it's the clinical setting or attitude that is determining outcome. You would think that the animal studies would put some of the placebo chatter to rest a bit, but it doesn't seem to.
I have no interest in dispensing placebos, nor am I interested in delivering acupuncture using specific points, if it would be just as effective to use any random points on everyone. It would save lots of time and the effort of charting. I am dedicated to studying and learning what the actual mechanisms of acupuncture are so that we can use it more effectively in a no nonsense approach. If studies repeatedly indicate that one point is as good as another, so be it. But I don't think we're there yet.
In the spirit of "first doing no harm" however, I wish that other treatment modalities were held to the high standard that acupuncture is and were better scrutinized for bias, placebo and safety.

Growing Attention to Placebo

A fascinating article from Wired magazine (http://www.wired.com/medtech/drugs/magazine/17-09/ff_placebo_effect) addresses the curious problem that the placebo effect seems to be increasing in clinical trials and has torpedoed the launch of several new medications. Any new drug coming to market needs to demonstrate significant efficacy compared to a "dummy" pill, or placebo. Recently new "blockbuster" medications ranging from anti-depressants, to Parkinson medications, to medications for Crohn's disease have been shown to be effective, but not as effective as placebo, so have had to be pulled. Even Prozac, the work horse of mood enhancers, has not shown effectiveness compared to placebo in recent clinical studies.
The NIH and Big Pharma alike are (finally) looking into the science of placebos, though Big Pharma is reluctant to pay for the studies (natch.)
"Ironically, Big Pharma's attempt to dominate the central nervous system has ended up revealing how powerful the brain really is. The placebo response doesn't care if the catalyst for healing is a triumph of pharmacology, a compassionate therapist, or a syringe of salt water. All it requires is a reasonable expectation of getting better. That's potent medicine."
I actually had the opportunity to speak to the author of this article on a recent radio call-in talk show to discuss how the keen attention paid to placebo effect in acupuncture research is glaringly absent from surgery research. Surgeries are often compared to other surgeries or conservative treatment, but rarely are "sham" surgeries performed. see posts http://ksparrowmd.blogspot.com/2009/08/another-popular-back-procedure-found-to.html and http://ksparrowmd.blogspot.com/2009/04/believing-in-treatments-that-dont-work.html
He reminded me of the open heart procedure called Mammary Artery Ligation which had finally been debunked. But that is one of very few surgical procedures that have been subjected to any sort of even handed scrutiny. I would add that open heart surgery has to be one of the most powerful, ritualistic procedures performed in medicine and must have extremely powerful placebo properties.
My interest in this topic is because of my involvement in acupuncture research, but I also am interested in therapies that don't fit the medical model and are therefore unexplained. The Western Medical Model is phenomenally valuable, but it does have its limits and there is a tyranny of the mechanistically rational when it comes to alternatives. I also think that the placebo effect is the ultimate testament to the power of "mind-body" medicine. I think it is high time that it should be studied and hopefully harnessed, not ridiculed.
I, personally, have no interest in handing out placebos for a living, but studying what is happening physiologically interests me no end.

P.S.
I happened on another article from Wired about the effectivenes of sham acupuncture for back pain. http://www.wired.com/wiredscience/2007/09/for-back-pain-e/ Even sham acupuncture worked better than physical therapy or medications, as the NHS in Britain is now acting on.