Kimberly Burnham, IMTC, PhD Candidate

Essays and articles written by Kimberly Burnham, whose interests include Integrative Manual Therapy (IMT), CenterIMT, Neurodegenerative Disorders, Parkinson's Disease, Vision, VisionIMT, Eye Disorders, Travel, Languages, PhD Candidate, Westbrook University, Connecticut School of Integrative Manual Therapy.

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Location: Bloomfield, Connecticut, United States

Wednesday, January 05, 2005

The Importance of How We Communicate with Our Clients

Communicating with Our Clients and the Placebo Effect

How we communicate with our clients, the tone of voice we use, the confidence we have, the knowledge we convey, is important to the continuation of our business. It is also significant to the health and well being of our clients. If our clients respect us as practitioners, the placebo effect will enable them to feel and function even better. The placebo effect is enhanced by our talking to them about how the treatment we are doing with them will help them feel better, function better and look better. It is, of course, important for the treatment we are doing to be effective, as well. Mayberg noted, "clinical improvement in the group receiving placebo as part of an inpatient study is consistent with the well-recognized effect that altering the therapeutic environment may significantly contribute to reducing clinical symptoms." (Mayberg, 2002).

How well an individual’s brain is functioning and what areas are activated influences their experience of the pain. In research on pain, the somatosensory cortex and the insula have been implicated in intensity and location of pain, while the unpleasantness of pain is connected with the anterior cingulate gyrus and the amygdala. "Patients who have had their anterior cingulate surgically removed report they are still able to feel the intensity of pain, but are no longer bothered by it. In contrast, a patient who had his somatosensory cortex removed could still report pain distress despite difficulties in reporting on sensory aspects of the pain." (Lieberman, 2004). A 2003 study suggested that the anterior cingulate and the right ventral prefrontal cortex regulates the distress of social exclusion by disrupting anterior cingulate activity." (Eisenberger, 2003).

Researchers are also looking into the way we respond to events (both physical and emotional) based on our expectation of what might happen. What do your client’s expect? "The ability to predict the likelihood of an aversive event is an important adaptive capacity. Certainty and uncertainty regarding pain cause different adaptive behavior, emotional states, attentional focus, and perceptual changes." (Plogaus, 2003). Certain expectations (such as specific phobias) are mediated through the rostral anterior cingulate cortex and posterior cerebellum. Uncertain expectations (such as generalized anxiety disorder) contribute to activation changes in the ventromedial prefrontal cortex, mid-cingulate cortex and hippocampus. (Plogaus, 2003).

People with Parkinson’s disease seem to respond particularly well to placebo treatments from pills and injections to sham brain surgeries. Researchers have demonstrated in patients with Parkinson's disease, the placebo effect produces the same results as pharmaceuticals. "Findings indicate that the placebo effect in Parkinson’s disease is powerful and is mediated through activation of the damaged nigrostriatal dopamine system." (de la Fuente-Fernandez, 2001).

It is intriguing that people with Parkinson’s are powerfully affected by placebo treatments since the cingulate gyrus, which is involved in the placebo effect, is often dysfunctional in Parkinson’s disease. "A defect in anterior cingulate cortex contributes to the cognitive impairments observed in Parkinson’s disease." (Grossman, 1992). "Lewy body densities in the entorhinal cortex and anterior cingulate cortex were significantly associated with clinical dementia rating scores." (Kovari, 2003). In a study on gait, the control group had an increase in brain activity in the medial and lateral premotor areas, primary sensorimotor areas, anterior cingulate contex, superior parietal cortex, visual cortex, dorsal brainstem, basal ganglia and cerebellum. The Parkinson's disease patients revealed relative underactivation in the left medial frontal area, right precuneus and left cerebellar hemisphere, whereas they showed relative overactivity in the left temporal cortex, right insula, left cingulate cortex and cerebellar vermis. (Hanakawa, 1999). In radiosurgery the cingulate gyrus or the anterior internal capsule is targeted for pain or psychiatric illness. Other anatomic targets include "the trigeminal nerve (for trigeminal neuralgia), the thalamus (for tremor or pain), the globus pallidus (for symptoms of Parkinson's disease), and the hippocampus (for epilepsy)." (Kondziolka, 2003).

A 1997 study referred to the "concept that the striatum and the anterior cingulate gyrus are involved in mood regulation. Dopamine-D2 receptors may constitute a central role in this domain." (Larisch, 1997). Dopamine released is linked to the expectation of a reward. If the expected reward is a therapeutic benefit from treatment, the release of dopamine helps the person feel better whether they are getting the really treatment, a placebo or sham treatment. "We conclude that the release of dopamine in the ventral striatum (nucleus accumbens) is related to the expectation of reward (ie clinical benefit) and not to the reward itself." (de la Fuente-Fernandez, 2002).

More recent research suggests, "a great variety of medical conditions are subject to the placebo effect. ...Positron emission tomography studies have recently shown that the placebo effect in Parkinson's disease, pain, and depression is related to the activation of the limbic circuitry. The relative contribution of the different neurotransmitters and neuropeptides that are known to be involved in modulating the activity of the limbic system may be disease-specific. Thus, while the placebo-induced clinical benefit observed in Parkinson's disease would mostly reflect the release of dopamine in the dorsal striatum, the activation of opioid and serotonin pathways could be particularly implicated in mediating placebo responses encountered in pain and depression, respectively. (De la Fuente-Fernandez, 2004). In 2002, Mayberg, noted that the "administration of placebo can result in a clinical response indistinguishable from that seen with active antidepressant treatment. (Mayberg, 2002).

The significance of the placebo effect calls into question that use of blinding in studies. Dean Fergusson, found that only 15 of 191 "gold standard studies" - randomized, placebo-controlled and double blind - published between 1998 and 2001 provided any evidence that the researchers assessed whether the blinding had been effective. Nine of the 15 that studied the effectiveness of the blinding reported that it hadn’t worked perfectly. Someone who knows they are getting the real treatment may expect to feel better. The person who is administering the treatment, may unconsciously communicate information and expectations to the patient. (Fergusson, 2004).

References
1. de la Fuente-Fernandez, R., Ruth, T. J., Sossi, V., Schulzer, M., Calne, D. B., & Stoessl, A. J. (2001). Expectation and dopamine release: mechanism of the placebo effect in Parkinson's disease. Science, 293(5532), 1164-1166.
2. de la Fuente-Fernandez, R., & Stoessl, A. J. (2002). The placebo effect in Parkinson's disease. Trends Neurosci, 25(6), 302-306.
3. de la Fuente-Fernandez, R., & Stoessl, A. J. (2004). The biochemical bases of the placebo effect. Sci Eng Ethics, 10(1), 143-150.
4. Eisenberger, N. I., Lieberman, M. D., & Williams, K. D. (2003). Does rejection hurt? An FMRI study of social exclusion. Science, 302(5643), 290-292.
5. Fergusson, D., Glass, K. C., Waring, D., & Shapiro, S. (2004). Turning a blind eye: the success of blinding reported in a random sample of randomised, placebo controlled trials. Bmj, 328(7437), 432.
6. Grossman, M., Crino, P., Reivich, M., Stern, M. B., & Hurtig, H. I. (1992). Attention and sentence processing deficits in Parkinson's disease: the role of anterior cingulate cortex. Cereb Cortex, 2(6), 513-525.
7. Hanakawa, T., Katsumi, Y., Fukuyama, H., Honda, M., Hayashi, T., Kimura, J., et al. (1999). Mechanisms underlying gait disturbance in Parkinson's disease: a single photon emission computed tomography study. Brain, 122 ( Pt 7), 1271-1282.
8. Kondziolka, D. (1999). Functional radiosurgery. Neurosurgery, 44(1), 12-20; discussion 20-12.
9. Kovari, E., Gold, G., Herrmann, F. R., Canuto, A., Hof, P. R., Bouras, C., et al. (2003). Lewy body densities in the entorhinal and anterior cingulate cortex predict cognitive deficits in Parkinson's disease. Acta Neuropathol (Berl), 106(1), 83-88.
10. Larisch, R., Klimke, A., Vosberg, H., Loffler, S., Gaebel, W., & Muller-Gartner, H. W. (1997). In vivo evidence for the involvement of dopamine-D2 receptors in striatum and anterior cingulate gyrus in major depression. Neuroimage, 5(4 Pt 1), 251-260.
11. Lieberman, M. D., Jarcho, J. M., Berman, S., Naliboff, B. D., Suyenobu, B. Y., Mandelkern, M., et al. (2004). The neural correlates of placebo effects: a disruption account. Neuroimage, 22(1), 447-455.
12. Mayberg, H. S., Silva, J. A., Brannan, S. K., Tekell, J. L., Mahurin, R. K., McGinnis, S., et al. (2002). The functional neuroanatomy of the placebo effect. Am J Psychiatry, 159(5), 728-737.
13. Petrovic, P., Kalso, E., Petersson, K. M., & Ingvar, M. (2002). Placebo and opioid analgesia-- imaging a shared neuronal network. Science, 295(5560), 1737-1740.
14. Ploghaus, A., Becerra, L., Borras, C., & Borsook, D. (2003). Neural circuitry underlying pain modulation: expectation, hypnosis, placebo. Trends Cogn Sci, 7(5), 197-200.
15. Wager, T. D., Rilling, J. K., Smith, E. E., Sokolik, A., Casey, K. L., Davidson, R. J., et al. (2004). Placebo-induced changes in FMRI in the anticipation and experience of pain. Science, 303(5661), 1162-1167.

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