yet in others, acupuncture was no better than a “sham” version of acupuncture used for comparison.

“It’s difficult to interpret the results of the review,” said lead researcher Eric Manheimer, of the Center for Integrative Medicine at the University of Maryland School of Medicine.

for now, he told Reuters Health, “I think the evidence is equivocal.”

IBS is a digestive disorder that causes repeated bouts of abdominal cramps, bloating, and either diarrhea or constipation. It’s different from the similar-sounding inflammatory bowel disease — an umbrella term for ulcerative colitis and Crohn’s disease, two more-serious digestive disorders that damage the lining of the colon.

In many cases, IBS can be managed with diet changes, along with anti-diarrheal medication or, for constipation, laxatives or fiber supplements.

but people with tougher-to-treat IBS may need more. There are a few drugs for the condition — including alosetron (Lotronex), which works on nerves to relax the colon, and lubiprostone (Amitiza), which helps with constipation.

Doctors sometimes also prescribe low-dose antidepressants, anti-anxiety medications or drugs called antispasmodics, which may help with abdominal pain.

but those drugs are often limited in their effectiveness, and can have side effects.

So researchers are looking at different non-drug options. Two — namely, cognitive behavioral therapy and hypnosis — have proven effective for some people in clinical trials.

a fairly small number of studies have begun looking at acupuncture. and so far, Manheimer’s team found, those trials have yielded mixed results.

In their review, the researchers found five clinical trials that tested “true” acupuncture against a sham version of the procedure.

some studies use sham procedures to try to account for the “placebo effect” — where people feel better simply because they expect a treatment to work.

overall, Manheimer’s team found, none of the five trials showed that real acupuncture was any better than the fake version when it came to improving patients’ ratings of their symptoms or quality of life.

on the other hand, five trials done in China did find that patients reported bigger gains from acupuncture when it was tested against certain medications — which included certain anti-diarrheal, antispasmodic and anti-inflammatory drugs.

but there are limitations to both types of studies, Manheimer said.

with the trials that pitted acupuncture against drugs, the patients were recruited at hospitals for traditional Chinese medicine.

“So it’s possible that patients’ expectations played a role” in acupuncture’s higher success odds, Manheimer explained. That is, many may have believed acupuncture to be effective, or had a preference for it over medication.

with the sham-acupuncture trials, the study groups tended to be small, which may have limited their ability to pick up small benefits of true acupuncture, the researchers say.

There’s also debate over what makes for a good sham version of acupuncture. In some studies, it may involve inserting needles in the skin at sites that are not considered acupuncture points according to traditional Chinese medicine.

In others, it means using a dull needle that doesn’t penetrate the skin.

“It’s not clear that they (shams) are all inert,” Manheimer said.

That means some sham acupuncture tactics may have biological effects that are close to the real thing. no one is sure how acupuncture works, but some research suggests the needle stimulation triggers the release of pain- and inflammation-fighting chemicals in the body — even if the acupuncture doesn’t strictly follow traditional principles.

Of the five trials in this review, two were judged as having sham acupuncture that might have had real biological effects. but that doesn’t explain why the other three studies showed no benefit, the researchers say.

NOT a ‘GO-TO’ TREATMENT

In the future, Manheimer said it might be helpful to do trials that compare acupuncture against other treatments, but do it with a more general population of IBS sufferers than the Chinese studies used.

it would also be a good idea, he said, to measure patients’ expectations going into the study. That way, researchers can look at whether people who expected to improve were more likely to report benefits from acupuncture.

“This is an interesting study,” said Jeffrey M. Lackner, an associate professor at the University at Buffalo School of Medicine in New York, who was not involved in the work.

In the U.S., he noted, acupuncture would not be considered a “go-to” IBS treatment right now anyway.

Abraham Verghese, the Stanford physician and writer, has a beautiful piece in the New York Times that’s worth unpacking a bit.

He starts off by marveling about the performance of IBM’s Watson supercomputer on Jeopardy, and thinking about how such a machine could change medicine:

THE other day as I walked through a wing of my hospital, it occurred to me that Watson, I.B.M.’s supercomputer, would be more at home here than he was on “Jeopardy!” Perhaps it’s good, I thought, that his next challenge, with the aid of the Columbia University Medical Center and the University of Maryland School of Medicine, will be to learn to diagnose illnesses and treat patients.

via Treat the Patient, not the CT Scan – NYTimes.com.

Verghese doesn’t shortchange the potential power of the computer one iota, envisioning a world where Watson-like machine might pick up side effects in ways that human doctors would not.

For example, Watson might recognize that the kidney failure in our patient is linked to kidney failure in a patient in Buffalo and another in San Antonio; all three patients, he might inform me, were taking a “natural” weight loss supplement that contained a Chinese herb, aristolochia, that has been associated with more than 100 cases of kidney failure.

via Treat the Patient, not the CT Scan – NYTimes.com.

But he also describes doctors being glued to their computers “like piglets at a sow’s teats,” and worries that this is both causing misdiagnosis and damaging the doctor-patient relationship. the “iPatient,” he writes, is replacing the real one.

Verghese first complaint is that being overly dependent on machines leads patients to get too much radiation from CT scans and also leads physicians to miss things they should have notice. One example is a woman who had been to doctors several times. the physicians missed tumors that were large enough to feel in a physical exam.

But his second worry is that, by not going through the ritual of a physical examination, doctors are depriving patients and their families of something that makes them feel better.

After introducing myself to the patient and to her daughter, I did a thorough but quick neurologic exam. I put the patient through her paces: mental status, cranial nerves, motor and sensory function, used my reflex hammer and pointed out interesting things along the way to my interns and students. I then said to the daughter that her mother seemed back to normal. to our surprise, the daughter seemed comforted, and now had no objection to her mother’s return to the nursing home.

via Treat the Patient, not the CT Scan – NYTimes.com.

This is one of the great quandaries, it seems to me, in medicine. a lot of doctoring could probably be improved by better use of computers, or of algorithms and checklists. Applying better techn0logy and evidence is important.

These kinds of improvements also have the benefit of improving the worst care. a lot of the best doctors are probably already combining the kinds of things computers do well with a very human capacity for creative thinking.

But there’s another part of medical care that seems detached from this kind of evidence collection and deduction. It has to do with how the doctor uses his senses, and how he interacts with a patient on an emotional level. For some ailments, such as pain, stomach problems, or depression, every word choice, intonation, and body movement might be a potential treatment. they are not treatments whose effectiveness anyone knows how to measure.

The closest I’ve seen anyone come has been the research into the placebo effect done by Ted Kaptchuk at Harvard University. He studied traditional Chinese medicine and has worked at figuring out how the way doctors interact with patients helps them feel better. my favorite of his experiments compared waiting, fake acupuncture, and fake acupuncture with warm, caring talk from the physician as treatments for irritable bowel syndrome.

In a trial of 262 patients with severe IBS, 62% of those who received the fake treatment got better, according to results published in the British Medical Journal. by comparison, only 28% of a control group of patients put on a waiting list saw their symptoms improve markedly. a third group who got the fake acupuncture, but without any warm talk, showed in-between results: 44% improved.

The result, says Kaptchuk, shows just how much the expectation of a cure–and the rituals associated with medical treatment–can improve real-world symptoms. “our own will, imagination and belief can modulate the course of illness,”

via The Nothing Cure – Forbes.com.

Orac, a physician-blogger I usually admire, dismissed Kaptchuk’s most recent study, which showed patients benefiting from a sugar pill when they knew it was fake, as not showing high quality evidence and deceiving patients. (See: More dubious statements about placebo effects.) I think he missed Kaptchuk’s cleverest idea — that the placebo effect might be a way to capture the effect of ritual in medicine.

Kaptchuk’s studies still suffer from many failings, most importantly that they are all being done by one researcher. It’s always hard to know how to trust a result when it hasn’t really been independently verified.

Still, I wonder if there are rigorous ways to establish the power of medical rituals, and to figure out how to teach doctors how to best perform them. One of my favorite medical stories is of the effort to improve how quickly patients who have had heart attacks have their arteries cleared with the angioplasty devices made by Johnson & Johnson, Boston Scientific, and Medtronic. the key was not just establishing that there was a problem, but figuring out what the best doctors did differently, and teaching that  difference to doctors. I wonder if there’s some way to do something similar with the ritual of the medical exam.