When pain is not only pain: inserting needles into the body evokes distinct reward-related brain responses in the context of a treatment.

The aim of this study was to compare behavioral and functional brain responses to the act of inserting needles into the body in two different contexts, treatment and stimulation, and to determine whether the behavioral and functional brain responses to a subsequent pain stimulus were also context dependent. Twenty-four participants were randomly divided into two groups: an acupuncture treatment (AT) group and an acupuncture stimulation (AS) group. Each participant received three different types of stimuli, consisting of tactile, acupuncture, and pain stimuli, and was given behavioral assessments during fMRI scanning. Although the applied stimuli were physically identical in both groups, the verbal instructions differed: participants in the AS group were primed to consider the acupuncture as a painful stimulus, whereas the participants in the AT group were told that the acupuncture was part of therapeutic treatment. Acupuncture yielded greater brain activation in reward-related brain areas (ventral striatum) of the brain in the AT group when compared to the AS group. Brain activation in response to pain stimuli was significantly attenuated in the bilateral secondary somatosensory cortex and the right dorsolateral prefrontal cortex after prior acupuncture needle stimulation in the AT group but not in the AS group. Inserting needles into the body in the context of treatment activated reward circuitries in the brain and modulated pain responses in the pain matrix. Our findings suggest that pain induced by therapeutic tools in the context of a treatment is modulated differently in the brain, demonstrating the power of context in medical practice.

Decreased peripheral and central responses to acupuncture stimulation following modification of body ownership.

Acupuncture stimulation increases local blood flow around the site of stimulation and induces signal changes in brain regions related to the body matrix. The rubber hand illusion (RHI) is an experimental paradigm that manipulates important aspects of bodily self-awareness. The present study aimed to investigate how modifications of body ownership using the RHI affect local blood flow and cerebral responses during acupuncture needle stimulation. During the RHI, acupuncture needle stimulation was applied to the real left hand while measuring blood microcirculation with a LASER Doppler imager (Experiment 1, N = 28) and concurrent brain signal changes using functional magnetic resonance imaging (fMRI; Experiment 2, N = 17). When the body ownership of participants was altered by the RHI, acupuncture stimulation resulted in a significantly lower increase in local blood flow (Experiment 1), and significantly less brain activation was detected in the right insula (Experiment 2). This study found changes in both local blood flow and brain responses during acupuncture needle stimulation following modification of body ownership. These findings suggest that physiological responses during acupuncture stimulation can be influenced by the modification of body ownership.

Development and validation of acupuncture fear scale.

Objectives. Strong aversions to acupuncture have been an obstacle to understanding its intrinsic action of acupuncture. Thus, it is necessary to evaluate the nature and extent of fear of acupuncture treatment. Our study aims to develop and validate an instrument that evaluates a patient's fear of acupuncture treatment. Methods. We have developed an acupuncture fear scale, a 16-item instrument which assesses the acupuncture fear score and uses it to survey 275 participants in South Korea, thus testing the reliability and validity of the instrument. Results. Internal consistency was high (Cronbach's alpha = 0.935). Test-retest reliability (Spearman's rank correlation coefficient) among 33 participants out of 275 ranged from 0.565 to 0.797 (P < 0.001). Principal component analysis revealed two factors accounting for 68% of the variance, which are painful sensation and possible adverse events, respectively. The acupuncture fear scale was positively correlated with the total of fear of pain questionnaire-III (r = 0.423, P < 0.001). Conclusions. The acupuncture fear scale can be a valid and reliable instrument that can measure fear of acupuncture treatment. These results strongly suggest that it would be a clinically useful tool to assess fear of acupuncture in the acupuncture clinic setting and an important instrument to understand the complex social-behavioral component of acupuncture modality.

Modifying Bodily Self-Awareness during Acupuncture Needle Stimulation Using the Rubber Hand Illusion.

Background. The rubber hand illusion (RHI) is an experimental paradigm that manipulates important aspects of body self-awareness. Objectives. We were interested in whether modifying bodily self-awareness by manipulation of body ownership and visual expectations using the RHI would change the subjective perception of pain as well as the autonomic response to acupuncture needle stimulation. Methods. Acupuncture needle stimulation was applied to the real hand during the RHI with (experiment 1) or without (experiment 2) visual expectation while measuring concurrent autonomic changes such as the skin conductance response (SCR). Subjective responses such as perception of the RHI and perceived pain were measured by questionnaires. Results. In experiment 1, the amplitude of the increase in SCR was visibly higher during the synchronous session compared with that of the asynchronous session. In experiment 2, the amplitude of the increase of SCR was lower for the synchronous session compared with that for the asynchronous session. Comparing these two experiments, the visual expectation of needle stimulation produced a greater autonomic response to acupuncture stimulation. Conclusions. Our findings suggest that the sympathetic response to acupuncture needle stimulation is primarily influenced by visual expectation rather than by modifications of body ownership.

Inserting needles into the body: a meta-analysis of brain activity associated with acupuncture needle stimulation.

UNLABELLED: Acupuncture is a therapeutic treatment that is defined as the insertion of needles into the body at specific points (ie, acupoints). Advances in functional neuroimaging have made it possible to study brain responses to acupuncture; however, previous studies have mainly concentrated on acupoint specificity. We wanted to focus on the functional brain responses that occur because of needle insertion into the body. An activation likelihood estimation meta-analysis was carried out to investigate common characteristics of brain responses to acupuncture needle stimulation compared to tactile stimulation. A total of 28 functional magnetic resonance imaging studies, which consisted of 51 acupuncture and 10 tactile stimulation experiments, were selected for the meta-analysis. Following acupuncture needle stimulation, activation in the sensorimotor cortical network, including the insula, thalamus, anterior cingulate cortex, and primary and secondary somatosensory cortices, and deactivation in the limbic-paralimbic neocortical network, including the medial prefrontal cortex, caudate, amygdala, posterior cingulate cortex, and parahippocampus, were detected and assessed. Following control tactile stimulation, weaker patterns of brain responses were detected in areas similar to those stated above. The activation and deactivation patterns following acupuncture stimulation suggest that the hemodynamic responses in the brain simultaneously reflect the sensory, cognitive, and affective dimensions of pain. PERSPECTIVE: This article facilitates a better understanding of acupuncture needle stimulation and its effects on specific activity changes in different brain regions as well as its relationship to the multiple dimensions of pain. Future studies can build on this meta-analysis and will help to elucidate the clinically relevant therapeutic effects of acupuncture.

Do not judge according to appearance: patients' preference of a doctor's face does not influence their assessment of the patient-doctor relationship.

OBJECTIVES: The aim of this study was to investigate whether a patient's preference for a doctor's face is associated with better assessments of relational empathy in the patient-doctor relationship after the first clinical consultation. METHODS: A total of 110 patients enrolled in a traditional Korean medical clinic participated in the study. Patients' preference for doctors' faces was assessed by a two alternative forced choice (2AFC) task, with 60 different pairs of six different Asian male doctors' faces. One of the six doctors then carried out the initial clinical consultation for these patients. The patient-doctor relationship was assessed using the Consultation and Relational Empathy (CARE) measure. RESULTS: The data of all patients' simulated preferences for a doctor's face and their assessment values of a doctor's relational empathy was compared, and no significant correlation was found between both values (r=-0.024, p>0.809). CONCLUSIONS: These findings suggest that the perceived empathy in the patient-doctor relationship is not influenced by the patient's preference for a certain doctor's face. The first impression of a doctor is often determined by his appearance and look. However, whether or not the patient particularly prefers a doctor's face does not seem to matter in developing a good patient-doctor relationship.

Doctor's attire influences perceived empathy in the patient-doctor relationship.

OBJECTIVE: This study investigated whether doctors' attire influences the perception of empathy in the patient-doctor relationship during a therapeutic encounter. METHODS: A total number of 143 patients were divided into four groups when they were consulting a Traditional Korean Medicine doctor. Depending on the group, the same doctor was wearing four different attires--Casual, Suit, Traditional dress, White coat--when having a clinical consultation with the patients. RESULTS: The patients preferred white coat and traditional dress more than other attires, giving highest scores to white coat in competency, trustworthiness and preference of attire and to traditional dress in comfortableness and contentment with the consultation. The "Consultation and Relational Empathy (CARE)" score was significantly higher in the "White coat" and "Traditional" groups, compared to the "Casual" and "Suit" groups. CONCLUSION: The strong association between the patients' preference of doctors' attire and the CARE score indicates that the doctor's attire plays not only an important role for establishing confidence and trustworthiness but also for the perception of empathy in the patient-doctor relationship. PRACTICE IMPLICATIONS: The doctor's attire can function as an effective tool of non-verbal communication in order to signal confidence, trust and empathy and establish a good patient-doctor relationship.

Pre-existing beliefs and expectations influence judgments of novel health information.

The present study examined whether health information is judged differently depending on pre-existing beliefs and expectations. People's initial beliefs and expectations were assessed by a questionnaire about acupuncture and a trustworthiness and preference rating task of doctors' faces. Then, newspaper headlines about novel acupuncture treatment were shown and rated for their feasibility in a normal and framed condition. The judged feasibility of the newspaper headlines correlated strongly with initial beliefs about acupuncture in the normal condition, and with initial expectations towards a doctor's face in the framed condition. Thus, as suggested by Bayes Theorem, pre-existing beliefs and expectations influence judgments of novel health information.

What factors are influencing preferences toward conventional versus complementary and alternative medical clinic advertisements?

OBJECTIVES: The present study aimed to determine whether health service advertisements are perceived differently depending on advertising conventional or complementary and alternative medicine clinics. METHODS: A total of 42 adults (male=21, female=21) recruited through advertisements in Seoul, South Korea participated in this study. A standardized health service advertisement was designed with three controlled visual components such as (1) medical treatment information, (2) medical practitioner, and (3) medical facilities and it was shown to subjects while their eye movements were tracked and they were asked to rate their preferences for the different advertisements and their separate components. A multiple regression analysis was performed to see the correlation of the preferences for each of the three visual components with the overall preference rating of each health service advertisement. RESULTS: Preferences for the advertisement depended mostly on the preference for the medical treatment information, whereas advertisements for complementary and alternative medical clinics depended also on the preference for the medical practitioner. CONCLUSIONS: These results imply that the same health service advertisement will be perceived differently depending on whether it advertises Western or Oriental medical clinics.

What to wear when practicing oriental medicine: patients' preferences for doctors' attire.

OBJECTIVES: The patient's impression of the doctor is an important factor in a clinical consultation, and the doctor's attire also plays a great role in promoting trust and confidence in the patients. Previous studies have shown that a doctor in a white coat will appear more professional, confident, and trustworthy. The objective of this study was to investigate whether the influence of a doctor's attire applies for both Western and Oriental medical doctors. METHODS: Before a clinical consultation, 153 patients were asked to assess photographs showing an identical doctor wearing four different dress styles. The patients were divided into two groups: One group was told that the doctor in the photograph was a Western doctor, whereas the other group was told that the doctor was an Oriental medical doctor. Patients' ratings of preference for competency, trustworthiness, comfortableness, and treatment choice were then measured and compared. RESULTS: Patients preferred a doctor in a white coat the most, giving highest ratings for competency and trustworthiness, while reporting to feel most comfortable with a doctor in traditional dress. No difference was found between Western and Oriental medical doctors. Patients prefer their doctors to wear white coats, regardless of whether the doctor is a Western or Oriental medical doctor, even though patients feel more comfortable with doctors wearing traditional dress. CONCLUSIONS: The preference about doctors' attire symbolizes the perception of patients regarding their doctor's image. Taking the historical and symbolic meaning of the doctor's white coat together, this clear preference of patients for the white coat might imply that patients require a more scientific and professional image, regardless of whether the doctors are Western or Oriental medical doctors.

Comparison of biomechanical properties between acupuncture and non-penetrating sham needle.

OBJECTIVES: A non-penetrating sham needle has been considered as a reliable control treatment in the field of acupuncture research. However, some concerns with regard to the credibility of sham needles have also been raised. We investigated whether there were differences in biomechanical properties and acupuncture sensation ratings in the process of needling between verum acupuncture (VA) and sham acupuncture (SA). METHODS: To quantify biomechanical force during needling in a cross-over design, we used a computer-controlled needling system. Fourteen participants received VA or SA at acupuncture point LI4, with no visual impact. They were asked to complete an acupuncture sensation form, including penetration, acute pain and DeQi sensations, and to identify the needling type they received. RESULTS: We found that there was a significant difference in insertion force between VA and SA (68.5 ± 12.2 vs. 27.2 ± 3.9 gf; p < 0.001). Participants clearly distinguished between the two kinds of stimulation and rated higher sensory ratings in the VA session (penetration sensation: 4.9 ± 3.1 vs. 1.7 ± 2.3, acute pain: 4.9 ± 2.7 vs. 1.9 ± 2.6, respectively; p < 0.01). CONCLUSIONS: Our findings demonstrate that differential biomechanical forces such as insertion and pullout force contribute to the sensation of real and non-penetrating sham needles.

Autonomic and subjective responses to real and sham acupuncture stimulation.

This study compared verum acupuncture (VA) and sham acupuncture (SA) stimulation by assessing autonomic and subjective responses. Autonomic responses such as skin conductance response (SCR) and heart rate (HR) were measured. Subjective pain ratings were collected and evaluated. A correlation analysis was performed for SCR and HR changes and subjective pain ratings. In both VA and SA sessions, SCR increased, and HR decreased. Subjective responses were different for VA and SA. The SCR changes correlated with subjective responses for VA, but not SA. The present results suggest that VA and SA do not fundamentally differ in their autonomic response patterns.