was similar to that of Haddon et al1 and conducted on the same mountain, with the same physi¬ cian evaluating the injuries, we felt justified in comparing our data with that from the earlier work. The fact that the overall injury rate of 3.4/ 1,000 skier-days found in our study was not measurably different from that found by Haddon in 1962 indicates to us that the prevention of ski injuries will take more than improving in¬ struction; it will take more precise binding adjustment and increased skiing exposure and experience of those engaged in the sport. Our major conclusion is that the shift in injury site, from the lower ex¬ tremity to the upper extremity, over the past decade has occurred because modern equipment shifts the energyabsorbing capacity of the leg-bootbinding-ski system to the relatively less-protected upper extremity. Ex¬ changing a leg injury for arm trauma may be a salutory shift, but sound principles of preventive medicine would urge the development of meth¬ ods to reduce upper body injury -as well. We agree that education, better binding adjustment, increased expe¬ rience, and conditioning would all benefit skiing and the skier and, pre¬ sumably, reduce injuries to the lower extremity. We also agree that more analytic studies of the type described by Pope and Johnson,2 with an ade¬ quate control population, must be per¬ formed to tease out other causal fac¬ tors in this complex health problem. But, since we believe that the major culprit is kinetic energy or its major component, velocity, the reduction of ski injuries will not occur until methods are developed to absorb total energy transfer in a fall, on control of the speed of individual skiers. We are not optimistic that skiers will reduce their speed; other nonpersonal meth¬ ods must be developed to increase the ability of the skier to absorb injury-
from the standpoint of the pharmacist who can unknowingly nullify the desired placebo effect. A significant number of prescriptions are now paid for by third-party carriers (welfare departments and company insurance plans). These carriers will not pay for inert placebos; therefore, the pharmacist must charge the patient for these prescriptions. Patients made aware of the fact that a non-legend drug has been prescribed usually consider themselves "duped" by their physicians and refuse the prescription (and usually seek another physician). If the physician has determined that the patient is one of those fastdisappearing individuals, the cash customer, it would prevent problems if the doctor would telephone the prescription to the pharmacist and explain the circumstances so that the pharmacist can support the claims of the physician. Even if the patient does not pay for his own prescriptions, there is an increasing demand by the patient to know exactly what he is taking. This occurs because the patient has in¬
With such developments, descrip¬ tive data on ski injuries in 1982 will show little or no reduction in the crude skiing trauma rate of 4 to 5 in¬
by Acupuncture
sign of our study
producing
juries
per
stresses.
1,000 skier-days.
Jonathan B. Weisbuch, MD Boston
1. Haddon W
Jr, Ellison AE, Carrol RE: Ski injuries: Public Health Rep 77:975-985,
Epidemiologic study. 1962. 2. Johnson
RJ, Pope MH, Ettlinger C: Ski injuries and equipment function. J Sports Med 2:299-307, 1974.
The Placebo Effect To the Editor.\p=m-\Iwrite to remark your
COMMENTARY
on
(232:1225, 1975)
creasingly sophisticated knowledge about drugs and because many busy physicians simply do not take the time to explain the drug prescribed. The pharmacist's reply of old, "talk to your physician," is no longer ac¬ cepted by most patients. This places the pharmacist in the position of try¬ ing to elicit from the patient what symptoms the doctor is treating and then supporting the relevant aspect of the drug prescribed. Since it is time consuming and dif¬ ficult for the busy physician to deter¬ mine if the patient is covered under a prescription drug plan, it would prob¬ ably make the placebo most effective if it were dispensed by the physician from his office.
Laurence W. Akron, Ohio
Fligor, RPh
Treatment of Chronic Pain To the Editor.\p=m-\Thearticle (232:1133, 1975) by Lee et al concluded that acupuncture is a placebo and that it is hardly worth the time to employ such a technique, since there is no lasting pain relief after four treatments. They did admit that there is an increasing degree of pain relief with each subsequent treatment. I would like to point out the fallacies of that study and its conclusion: (1) The so-called arbitrary distant points used in the study may not be arbitrary at all. The points employed
were
not
nique is
published, and faulty techpossibility. (2) A course
a
of four acupuncture treatments is
hardly adequate for the average case, not to mention one involving rheuma-
toid arthritis. This was the reason for a low percentage of lasting pain relief in that study. (3) It is common practice for a physician to order physical therapy for three times a week for four weeks, and yet this group expects to perform miracles in four acu¬ puncture treatments. I must conclude that that particular study was a waste of time because of preconceived conclusions to discredit
acupuncture.
Pui Lam Tsang, MD San Jose, Calif
Reply.\p=m-\DrTsang states that we "concluded that acupuncture is a placebo and that it is hardly worth the time to employ such a technique, since there is no lasting pain relief after four treatments." Nowhere in our manuscript did we make this statement. We did mention in the discussion that the incidence of lasting pain relief that we saw in our patients was no greater than that reported by others from placebos. Thus, the reader was left to reach his own conclusions. We stated, "On the basis of our study, we conclude that a moderate number of patients have relief of chronic pain after a series of four acupuncture treatments. However, it does not matter whether the needles are placed in the typical meridian locations or in arbitrary distant In
points."
We also suggested that there are two ways of interpreting these data in regard to their potential usefulness in treating patients with chronic pain: (1) to eliminate it from our armamentarium because of the rela¬ tively low incidence of lasting pain relief or (2) since 18% of the patients received pain relief for at least a month and other therapy had failed, to add this technique to our arma¬ mentarium in an attempt to bring pain relief to that segment of our pa¬
tients.
Dr Tsang also claims that the use of arbitrary distant points as a con¬ trol for traditional meridians could have been faulty technique and, therefore, is invalid. We used the same two points in all patients re¬ gardless of the location or cause of their pain. Obviously, these were not points customarily thought of as ly¬ ing on traditional meridians. We be¬ lieve, therefore, that these were a valid control. He also criticizes that we used only four acupuncture treat¬ ments and states that this was the
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from the standpoint of the pharmacist who can unknowingly nullify the desired placebo effect. A significant number of prescriptions are now paid for by third-party carriers (welfare departments and company insurance plans). These carriers will not pay for inert placebos; therefore, the pharmacist must charge the patient for these prescriptions. Patients made aware of the fact that a non-legend drug has been prescribed usually consider themselves "duped" by their physicians and refuse the prescription (and usually seek another physician). If the physician has determined that the patient is one of those fastdisappearing individuals, the cash customer, it would prevent problems if the doctor would telephone the prescription to the pharmacist and explain the circumstances so that the pharmacist can support the claims of the physician. Even if the patient does not pay for his own prescriptions, there is an increasing demand by the patient to know exactly what he is taking. This occurs because the patient has in¬
With such developments, descrip¬ tive data on ski injuries in 1982 will show little or no reduction in the crude skiing trauma rate of 4 to 5 in¬
by Acupuncture
sign of our study
producing
juries
per
stresses.
1,000 skier-days.
Jonathan B. Weisbuch, MD Boston
1. Haddon W
Jr, Ellison AE, Carrol RE: Ski injuries: Public Health Rep 77:975-985,
Epidemiologic study. 1962. 2. Johnson
RJ, Pope MH, Ettlinger C: Ski injuries and equipment function. J Sports Med 2:299-307, 1974.
The Placebo Effect To the Editor.\p=m-\Iwrite to remark your
COMMENTARY
on
(232:1225, 1975)
creasingly sophisticated knowledge about drugs and because many busy physicians simply do not take the time to explain the drug prescribed. The pharmacist's reply of old, "talk to your physician," is no longer ac¬ cepted by most patients. This places the pharmacist in the position of try¬ ing to elicit from the patient what symptoms the doctor is treating and then supporting the relevant aspect of the drug prescribed. Since it is time consuming and dif¬ ficult for the busy physician to deter¬ mine if the patient is covered under a prescription drug plan, it would prob¬ ably make the placebo most effective if it were dispensed by the physician from his office.
Laurence W. Akron, Ohio
Fligor, RPh
Treatment of Chronic Pain To the Editor.\p=m-\Thearticle (232:1133, 1975) by Lee et al concluded that acupuncture is a placebo and that it is hardly worth the time to employ such a technique, since there is no lasting pain relief after four treatments. They did admit that there is an increasing degree of pain relief with each subsequent treatment. I would like to point out the fallacies of that study and its conclusion: (1) The so-called arbitrary distant points used in the study may not be arbitrary at all. The points employed
were
not
nique is
published, and faulty techpossibility. (2) A course
a
of four acupuncture treatments is
hardly adequate for the average case, not to mention one involving rheuma-
toid arthritis. This was the reason for a low percentage of lasting pain relief in that study. (3) It is common practice for a physician to order physical therapy for three times a week for four weeks, and yet this group expects to perform miracles in four acu¬ puncture treatments. I must conclude that that particular study was a waste of time because of preconceived conclusions to discredit
acupuncture.
Pui Lam Tsang, MD San Jose, Calif
Reply.\p=m-\DrTsang states that we "concluded that acupuncture is a placebo and that it is hardly worth the time to employ such a technique, since there is no lasting pain relief after four treatments." Nowhere in our manuscript did we make this statement. We did mention in the discussion that the incidence of lasting pain relief that we saw in our patients was no greater than that reported by others from placebos. Thus, the reader was left to reach his own conclusions. We stated, "On the basis of our study, we conclude that a moderate number of patients have relief of chronic pain after a series of four acupuncture treatments. However, it does not matter whether the needles are placed in the typical meridian locations or in arbitrary distant In
points."
We also suggested that there are two ways of interpreting these data in regard to their potential usefulness in treating patients with chronic pain: (1) to eliminate it from our armamentarium because of the rela¬ tively low incidence of lasting pain relief or (2) since 18% of the patients received pain relief for at least a month and other therapy had failed, to add this technique to our arma¬ mentarium in an attempt to bring pain relief to that segment of our pa¬
tients.
Dr Tsang also claims that the use of arbitrary distant points as a con¬ trol for traditional meridians could have been faulty technique and, therefore, is invalid. We used the same two points in all patients re¬ gardless of the location or cause of their pain. Obviously, these were not points customarily thought of as ly¬ ing on traditional meridians. We be¬ lieve, therefore, that these were a valid control. He also criticizes that we used only four acupuncture treat¬ ments and states that this was the
Downloaded From: http://jama.jamanetwork.com/ by a Florida International University Medical Library User on 05/25/2015
