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Attitude and outcome: is there a link in complementary medicine?

I read with interest the recent article by Lewith et al., “Do Attitudes Toward and Beliefs About Complementary Medicine Affect Treatment Outcomes?”1 I have recently completed a clinical trial examining the use of acupuncture for the treatment of chronic neck pain.2 Sixty-three subjects who had been randomly assigned to either real or placebo treatment completed the Attitude Toward Alternative Medicine Scale (AAMS)3 both before and after a course of treatment. There was no significant difference between groups at baseline in terms of mean AAMS score (60.3 for acupuncture and 61.0 for the placebo group; P = .731, t test). 
 
I used an analysis of covariance in which attitude was used as a covariate against change in pain and change in the summary scales of the SF36 quality-of-life questionnaire (physical and mental component summary) before and after treatment. This analysis yielded P values of .84, .09, and .98, respectively—that is, not significant. This would indicate, similar to the findings of Lewith et al., that there was no evidence to suggest that attitude toward complementary and alternative medicine (CAM) prior to treatment had any bearing on treatment outcomes. 
 
Contrary to the findings of Lewith et al., however, I noted a significant change in attitude after the course of treatment. Both groups experienced a rise in AAMS scores of approximately 2 points; posttreatment scores were 62.3 (SD = 7.3) for the acupuncture group and 63.0 (SD = 9.5) for the placebo group. This was a statistically significant improvement in scores (P = .007, paired t test) and indicated increased belief in CAM. To ascertain whether the improvement in outcome had been responsible for the improved AAMS score, I performed another analysis of covariance, using change in pain after treatment and treatment type as covariates against posttreatment AAMS score. Again, I found no significant relationship in terms of either change in pain or treatment type (P = .48 and .70, respectively). While the AAMS scores improved significantly, this lack of a relationship suggests that neither decrease in pain nor treatment type was the prime factor in facilitating this change. 
 
These data suggest that attitude toward CAM does not predict the outcome of pain or scores on the physical or mental components of the SF-36 as a consequence of receiving acupuncture or placebo. Furthermore, degree of pain relief or improvement in quality of life obtained as a consequence of treatment does not, in turn, affect attitude toward CAM. This was a curious finding, as clearly “attitude” had changed, but not as a result of a favorable outcome. This might suggest that some factor other than improvement in symptoms could be responsible for increasing a positive attitude toward CAM. These factors might include familiarization with the process of CAM or the fact that CAM was the subject of a scientific trial, thus lending it more credibility. 
 
It should also be noted, however, that although the change was statistically significant, no data are as yet available to enable an evaluation to be made as to whether this rise is meaningful in “real terms.” For instance, would such a change in attitude result in different behavior? Finally, the failure of these trials to demonstrate any link between preexisting attitude and outcome might suggest an insensitive questionnaire, and it must be noted that few studies have been conducted into the validity, repeatability, and sensitivity of the AAMS. The relationship between belief and treatment outcome, particularly in CAM, is important and does require further thought and investigation.