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The Placebo effect
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The Placebo effect - May 12, 2001 11:04:00 AM
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mcap
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Why is it that everyone is so afraid to discuss this topic. Why, when posting to another section of this forum was my placebo comment sensored.
Let me give you my take.....PTs are either intellectually lazy or scared of invalidation. Any time you touch a patient or devise a treatment approach, the potential for placebo response is tremendous. I am convinced that some manual therapies benefit from this reponse quite a bit. That is why in trials, they patients demonstrate short term benefits and no long term benefits.
Differentiating placebo response from a therapeutic response is the most crucial issue in any medical therapy. In medicine, they are discovering just how powerful it can be. In a recent study, sham arthroscopies proved just as effective as the real thing for knee patients with OA.
Yet......in PT......we are somehow different. We are above it all. Placebo.....no not us!!!!!!!!!
The point is that we need to consider this effect and acknowledge the possibility on a daily basis. We have an obligation to our patients because if what we do is placebo, perhaps we are preventing them from seeking other, more effective therapies (PT or non PT). I know this isn't easy and designing sham interventions isn't always possible. But some of the things that PTs say and write make me think we aren't even considering the placebo response.
WHY!!!!!!!!!!!!!!!!!!!!!!!!!!
MCAP
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Re: The Placebo effect - May 13, 2001 3:51:00 PM
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Andrew Horrocks
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From: Australia
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This is a great topic to discus. I have a few questions regarding the placebo effect. Unfortunately I don't have the answers.
1) What is happening neurologically when a placebo effect is occuring? Is it neurological at all?
2) If we educate a patient on what we consider is wrong with them and they improve as a result of that information can that be considered a placebo effect?
3) Is a placebo improvement always short lived?
4) If you accept that pain states can be maintained by central process's then maybe the placebo effect has a direct influence on this and should actually be encouraged?
5) Are there any papers in which a placebo effect has been studied rather than as a secondary unwanted effect?
As Physiotherapists it is beholden to us to attempt to distinguish between placebo and actual effect. The distinction is important, we may find that the placebo effect turns out to be of equal vitality to mechanical dysfunction as a method of pain management. If this is the case should we charge for it?
This is a great topic that has been subdued for far to long by our profession. Well done mcap for bringing it up
------------------
Andy
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Re: The Placebo effect - May 14, 2001 4:10:00 AM
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henryryry
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From: Brisbane, Australia.
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Interesting discussion topic and one worth talking about. I often wonder as well whether simply putting my hands on the client was enough to make them better, or was it what I did which really made the difference.
Recently, I come across Patrick Wall's 1992 editorial (Pain, 51 p1-3) entitled "The Placebo Effect: an unpopular topic." Wall proposes four reasons why the topic of placebo provokes "a shudder of discomfort like a cold hand in the dark." JI will just quoting out of the article:
1. We charge for our expertise
2. It is seen as tiresome and expensive artefact that prolongs and complicates true effect of therapy
3. Placebo effect tends to be taken as a hostile questioning of the validity of the logic on which a therapy is based
4. We all trust our sensation as a reflection of objective reality and yet the placebo changes the sensation without affecting the objective reality - in a sense it shakes our belief in the reliability of our sensory experience.
As well, he proposes 3 hypothesis on possible mechanisms of the placebo effect.
1. Decreased anxiety
2. Expectations leads to a cognitive readjustment of appropriate behaviour - thus explaining why blind trials are used in clinical studies
3. Conditioning hypothesis (ie, the classical conditioned Pavlovian response)
This is the only good paper so far I could find, and keep in mind, it is a 1992 paper, so it is probably out-of-date. HOwever, it is one worth reading. Thank you for bringing up this topic.
Henry***
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Re: The Placebo effect - May 14, 2001 4:21:00 PM
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sarty
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Joined: April 22, 2001
From: Florida, USA
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I am so glad this thread is here. I have often wondered just what I was doing for my patients, and how much their minds were doing for them.
I noticed that whenever I return from a course, all 'fired-up' about a new technique, that the results I get from it are consistently good. However, as the weeks and months go the results tend to diminish in frequency and in intensity; which, of course, makes me suspicious of whether it was the technique, or just the effect of my self-confidence with the new technique combined with the patient's high expectations based on my demeanor that affected the patient's symptoms.
Very interesting [IMG]http://www.rehabedge.com/forums/wink.gif[/IMG]
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Re: The Placebo effect - May 14, 2001 5:29:00 PM
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Diane
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Hi.
Some of Bird's comments hit the mark for me. I would concur that placebo is involved in much of what we do as PTs. Maybe even in everything we do.
In a private practice we generally deal with patients who are conscious and ambulatory, but who are not satisfied with how their bodies behave or feel or perform. For the most part they want enhanced function and usually less pain. I recall reading in Butler's first book that the ratio of axons in the CNS to the those in the PNS is 1000:1. Why not harness all that brainpower to the greater purpose of giving the patient what they have come for, a stress-minimized experience (i.e. listening, validation, concern, eyecontact, careful and considerate handling both physical and psychological, some sort of tool to take away so they can be an active player in their recovery). A much smoother theraputic relationship will form and a desired outcome will have more opportunity to flourish if the patient develops the right kind of neuropeptide cascade in response to our intervention, whatever it is.
I want to mention the opposite of placebo, which is "nocebo". Stedman's medical dictionary defines it as "An unpleasant side effect attributable to administration of a placebo.; jargon. (L. I shall harm, fr. noceo, to harm, by analogy with placebo, I shall please.)"
I have a short cautionary tale about this. Many years ago I was working in a typical busy minimum-4-patients/hour sort of clinic, the sort that I would never work in again as long as I live. As usual I was rushing around changing electrodes on people, dash of ultrasound here, little interferential there. I got a new patient with Idon'trememberwhat, and I decided to apply interferential, explained what I thought he had, what the interferential would do, etc. I got him all hooked up and (very importantly) in control of turning it up as accommodation occurred or down if he was uncomfortable. A little while later I went back in and checked on him. Everything was working perfectly, but he had a very weird look on his face. When I asked him if everything was OK he mentioned how much this treatment reminded him of torture he had recieved in his country of origin! OFF came that equipment immediately and I reassured him that however routine this form of treatment was he would not have to have any electical treatment if he didn't want it. From then on we worked manually, with the one iota of skill I posessed not having much time at work to hone that skill... He provided a turnaround for me. I worked toward having my own clinic that was strictly hands-on, nothing that plugged in, no USound or anything. I've had this dream clinic now for 7 years. The placebo effect on me has been terrific, no boredom or job dissatisfaction, most patients graduate to being painfree full functioning non-patients, lots of income. No shortage of referrals or satisfied patients. The placebo effect on them? Way better than being left alone in a curtained space attached to a bunch of unfamiliar zapping stuff plugged into a wall or having a cold metal wand sliding around through cold gel on their skin and their therapist nodding off.
Diane.
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Re: The Placebo effect - May 14, 2001 7:19:00 PM
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mcap
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It is late and I am sleepy so I don't have time to fully respond to these excellent posts!!!
Sarty!!!
I could not agree with you more!!!! As I return from courses with new enthusiasm, the techniques seem to work very well. Then.......as time goes on, they don't work as well. All of those I know who use one "particular intervention" regularly have observed the same thing - diminshing returns.
I think the phenomenon we are seeing is exactly what you said and what we all fear.....that our enthusiasm and beleif in the technique has a lot to do with how well it works. Ever see experts get great results in courses??? Well......what is the potential for placebo when you bring a patient in before a group for treatment by a bonified "expert." Very high.
More on this later......
mcap
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Re: The Placebo effect - May 16, 2001 7:58:00 AM
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mcap
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Cat:
Is there something wrong with delivering placebo treatments?? Tough to say. A lot of medicine is placebo and I don't think there is anything wrong with it. BUT...the questions are 1. Are we denying the patient some other treatment with proven efficacy? If the power of the mind is sufficient for healing, might there be a better way of harnassing it? 2. Should someone pay for this treatment.
Not telling the patient it may be placebo??? Don't know. For me personally, I don't go out of my way to discourage the placebo effect - why go out of your way to ruin it. But if the patient asks directly, then you must be honest with them. Also, I always try to combine what may or may not be placebo with those things that work well.
Does it work better if both don't know? I would assume it does. The placebo effect depends on the "sell" and the sell is always better if the therapist truly beleives in the treatment also.
SJ:
Is the placebo effect always short lived?? NO.....I certainly agree. But in some of the therapies we employ, where the I think the placebo effect is at work, the benefits seemed to be short lived.
If anyone wants to explore how truly sick and well the mind can make someone then I recommend Shorter's From Paralysis to Fatigue....the history of psychosomatic illness in the modern era. A truly great book and a must read for anyone who works with people in pain.
The bottom line is that PT needs more well designed RCTs. Well designed studies involve control treatments that are comprehensive and where the patient gets the same amount of attention as the interventional group. This is important because it is difficult to have "sham" treatments for certain interventions.
This is what the literature reviewers are looking for. And that is where we come up very short. However, being involved with research, I am realizing how truly difficult it can be to get subjects.
mcap
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Re: The Placebo effect - May 17, 2001 2:53:00 AM
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Sebastian Asselbergs
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From: Barrie, Canada
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I always tell my patients that the belief in a certain technique may have a "motivating" effect on the patient and might explain the positive results they get. By telling them, it ceases to be true placebo, but becomes an cognitive awareness of the power of the neurophysiological aspects of the mind. Funny enough, years ago I felt I should never tell the patients that the effects of my treatment could be influenced by both my AND their attitude - for fear that their awareness would screw it up. I've found out that almost every patient is much more in tune with the concept, and in agreement than I could imagine. Now that I listen differently to my patients, I find some come to me specifically for my "honesty" in therapy - funny, honesty in business and in placebo-discussion = good for caseload....
I seem to remember a study a few years ago about therapist attitude in effectiveness of treatment - supporting the (almost logical) notion that when I believe strongly in what I do (despite NOT knowing the proof of the technique), I will be more effective.
sebastian
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Re: The Placebo effect - May 17, 2001 11:26:00 AM
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ian stevens
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From: Dunblane Scotland UK
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great topic ...!
In the Uk Maureen Simmonds (a lecturer in Texas I think) wrote an excellent essay on the subject.
Simmonds M (2000) 'Pain and the placebo in physiotherapy : A benevolent lie ?' Physiotherapy,86,12,631-637.
The most'succesful' people I know seem to be walking 'placebos' and maybe attract patients to them with a similar belief system to themselves? The key is to often tap into a persons belief system for a while anyhow but to improve many in chronic pain needs a radical change in the dominant orthopaedic model as in many instances it can be totally disabling ....
ian
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Re: The Placebo effect - May 17, 2001 7:15:00 PM
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edilling
Posts: 139
Joined: January 10, 2000
From: pullman,wa,usa
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It is known that drugs produce their most favorable results soon after thier introduction. As their "newness" wanes, so does their effectiveness.
Dr. Andrew Weil advocagtes,in his book "Health and Healing" the concept of the active placebo. "Whatever may be the direct effect of a drug, surgical operation, or other physical intervention given by a medical practitioner to a sick person with the intention of promoting cure, it can also indirectly bring about healing by eliciting a placebo response. Placebo responses may result in total cure in combination with, independent of. or in spite of the direct effect of treatment. It is impossible ever to specify the individual contributions of these two aspects of therapy." He goes on to encourage all health practitioners to reguard placebo as their ally and work to evoke it as frequently and strongly as possible.
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