Patient expectations influence success of treatments for low back pain

July 02, 2001

St. Louis, June 29, 2001 - Investigators from Washington University in St. Louis and the University of Washington in Seattle have found that whether a patient expects a treatment to work may help determine that treatment's eventual success.

In the July issue of the journal Spine, the researchers report on the influence expectations had in patients receiving acupuncture or massage therapy for the treatment of back pain. They asked 135 low back pain patients at the Group Health Cooperative of Puget Sound a series of questions about their expectations for acupuncture and massage. Then, they randomly assigned patients to receive either acupuncture or massage therapy or into a control group that received self-care educational material. Participants in the acupuncture and massage therapy groups received up to 10 treatments in 10 weeks.

The investigators then used a measurement called the Roland-Morris disability scale to determine whether the treatments had helped relieve low back pain and improve patients' ability to function.

Among those who thought that their therapy would help them, 86 percent showed significant improvement. But in patients with lower expectations of either acupuncture or massage therapy, only 68 percent improved after treatment.

"It was really striking that patients who thought their treatment would work had significantly greater improvement," says the study's lead author Donna A. Kalauokalani, M.D., M.P.H., an assistant professor of anesthesiology, medicine and psychiatry at Washington University School of Medicine in St. Louis. "These findings clearly show that patient expectations play a key role in clinical and functional outcomes."

Kalauokalani gathered her data as part of a separate study that compared acupuncture to massage. The study was conducted in Washington State, where there has been a great deal of interest in alternative therapies such as acupuncture.

Because pain can be so subjective and individual, Kalauokalani believes that it is especially difficult to determine whether a particular treatment will help a patient with chronic low back pain. Since there is no single treatment that works best for all patients, she believes clinicians may do well to learn about their patients' expectations prior to the start of therapy.

"It's very difficult to design a treatment study for low back pain in which the patient is 'blinded' to the type of therapy they will receive," she explains. "With drug studies, it's relatively easy to have patients take identical-looking pills. But when comparing treatments as different as massage and acupuncture, a patient will be aware that they are being treated with a particular therapy. Now we have shown patient expectations for a therapy's success help to predict functional outcomes. Therefore, the clinical decision-making process becomes very important - it seems crucial that the patient be included when a course of therapy is chosen, not just to improve patient satisfaction with the process but to improve clinical and functional outcomes."
Kalauokalani DA, et al. Lessons from a Trial of Acupuncture and Massage for Low Back Pain: Patient Expectations and Treatment Effects. Spine, vol. 22, number 13 pp. 1418-1424, July 1, 2001.

This research was supported by grants from the Group Health Cooperative of Puget Sound, the Group Health Foundation, the Agency for Health Care Policy and Research, the John E. Fetzer Institute and the Robert Wood Johnson Clinical Scholars Program.

The full-time and volunteer faculty of Washington University School of Medicine are the physicians and surgeons of Barnes-Jewish and St. Louis Children's hospitals. The School of Medicine is one of the leading medical research, teaching and patient care institutions in the nation. Through its affiliations with Barnes-Jewish and St. Louis Children's hospitals, the School of Medicine is linked to BJC HealthCare.

Washington University in St. Louis

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