PT - JOURNAL ARTICLE AU - Espay, Alberto J. AU - Norris, Matthew M. AU - Eliassen, James C. AU - Dwivedi, Alok AU - Smith, Matthew S. AU - Banks, Christi AU - Allendorfer, Jane B. AU - Lang, Anthony E. AU - Fleck, David E. AU - Linke, Michael J. AU - Szaflarski, Jerzy P. TI - Placebo effect of medication cost in Parkinson disease AID - 10.1212/WNL.0000000000001282 DP - 2015 Feb 24 TA - Neurology PG - 794--802 VI - 84 IP - 8 4099 - http://n.neurology.org/content/84/8/794.short 4100 - http://n.neurology.org/content/84/8/794.full SO - Neurology2015 Feb 24; 84 AB - Objective: To examine the effect of cost, a traditionally “inactive” trait of intervention, as contributor to the response to therapeutic interventions.Methods: We conducted a prospective double-blind study in 12 patients with moderate to severe Parkinson disease and motor fluctuations (mean age 62.4 ± 7.9 years; mean disease duration 11 ± 6 years) who were randomized to a “cheap” or “expensive” subcutaneous “novel injectable dopamine agonist” placebo (normal saline). Patients were crossed over to the alternate arm approximately 4 hours later. Blinded motor assessments in the “practically defined off” state, before and after each intervention, included the Unified Parkinson's Disease Rating Scale motor subscale, the Purdue Pegboard Test, and a tapping task. Measurements of brain activity were performed using a feedback-based visual-motor associative learning functional MRI task. Order effect was examined using stratified analysis.Results: Although both placebos improved motor function, benefit was greater when patients were randomized first to expensive placebo, with a magnitude halfway between that of cheap placebo and levodopa. Brain activation was greater upon first-given cheap but not upon first-given expensive placebo or by levodopa. Regardless of order of administration, only cheap placebo increased activation in the left lateral sensorimotor cortex and other regions.Conclusion: Expensive placebo significantly improved motor function and decreased brain activation in a direction and magnitude comparable to, albeit less than, levodopa. Perceptions of cost are capable of altering the placebo response in clinical studies.Classification of evidence: This study provides Class III evidence that perception of cost is capable of influencing motor function and brain activation in Parkinson disease.CGI=Clinical Global Impression; IRB=institutional review board; PD=Parkinson disease; S&E=Schwab and England; UPDRS-III=Unified Parkinson's Disease Rating Scale, Part III