I recently find myself debating the placebo effect a lot more, and as usual I often find myself having some rather lively and interesting discussions on it. Such as, does it exist in therapy, if so, should we utilise or harness it more, is it ethical to do so, and does it work. So I thought I would write a quick little blog on giving my own views and opinions on the placebo effect.
So first what do we mean by the term placebo and/or the placebo effect?
Well take a look at this three minute video it explains placebo brilliantly, its clear, concise and entertaining. It even contains the phrase “all shinny and shit“
Welcome back, so hopefully that explained things a bit more, but I still think there can be confusion at times around the definition and description of placebo, for example a common definition is…
A treatment that has no physiological effects and is used only for a patients psychological benefit
However, another definition can be…
A beneficial effect following a treatment that arises from a patient’s beliefs and expectations
Now although similar, these two definitions describe two different things! The first describes a placebo. The second a placebo effect. This subtle difference in definition is crucial in my opinion.
The first definition of a placebo is what I would class as a ‘clear’ placebo. This is when there is absolutely no question that there are NO physiological effects at all from an intervention or treatment, for example, taking a sugar pill in a drug trial or using toothpicks in an acupuncture trail. This clearly means that any positive effects are only due to a patients psychological responses.
The second definition of a placebo effect is what I would class as a ‘cloudy’ placebo, This is when there maybe ‘some’ small physiological effects but they can be increased or ‘amplified’ by a patients psychological responses.
Now in the world of physiotherapy I’m under no illusion that placebo effects EVERYTHING we do, from manual therapy, taping, needles, electrotherapy and even exercise.
Patients expectations and beliefs of seeing a health care professional in a clinical environment will always produce a placebo effect to a lesser or greater extent in people. Most therapists tend to be caring, warm, compassionate, empathetic and, dare I say, rather attractive individuals, so they produce placebo effects even before they have have done or recommended anything.
However, I do think it’s hard to say we have any ‘clear’ placebo treatments in physiotherapy, although I dont disagree there is a lot of quackery around them.
It can be argued, and it is often is, that there is always some physiological response with everything we do. For example we can’t give a placebo exercise without it creating some sort of physiological response to the cardiovascular and neuromusculoskeletal systems. We can’t give a placebo manual therapy treatment without it creating some sort of peripheral or central physiological response due to interaction with the skin and its neural and vascular systems.
This means that ‘clear’ placebo in physiotherapy is pretty much impossible, we dont have any sugar pills.
However, physiotherapy certainly does have lots of ‘cloudy’ placebo effects! There are many treatments and techniques that do have some small physiological effects that can be ‘amplified’ and ‘increased’ by a patients beliefs and expectations to create more significant and meaningful effects that have nothing to do with the treatment.
For example, lets look at manual therapy, it doesn’t matter which one, let’s say good old standard soft tissue massage. As I mentioned, touching the skin will undoubtably create some changes in the central nervous system and some small superficial physiological effects (source). But patients past experiences, beliefs and perceptions of what massage feels can or could do will enhance these effects (source)
And it’s not just manual therapy, let’s look at acupuncture. Again we know sticking a needle into someone will cause a physiological response, it’s been seen in fMRI studies (source) but are these physiological neural effects significant?
I doubt it!
Place anyone into an fMRI machine and do anything to them, you will see changes light up. Are these physiological changes meaningful and relevant to the condition we are trying to address? Thats the harder question to answer, but let’s not get into that debate now, instead let’s just stick to looking at if these small physiological effects seen on fMRI of being pricked with a needle are enhanced by placebo effects.
Well simply put, yes they are!
Many studies have shown this. One of my favourites is this one done by the prominent, some say infamous placebo researcher Ted Kaptchuk. He gave a group of patients sham acupuncture with minimal therapist interaction and information, but another group were given exactly the same sham acupuncture, but with what he describes as ‘schmaltzy’ care by the therapist for 20 minutes. That being lots of empathy, warm, caring, shared emotion with detailed information about what acupuncture is expected to achieve, and although both groups having exactly the same sham treatment the group which had the extra clinican attention had significantly increased positive results comapred to the other group.
And there are many, many other studies that show similar results. Lots of physiotherapy treatments are enhanced when a patient has greater expectations, beliefs or positive past experiences about the treatment, such as taping (source), massage and manipulation (source), even rehabilitation exercises (source) and even ice baths (source)
But now we get to the crux of the argument I find myself having the most when discussing the placebo effect! Should we be looking to actively promote, harness and increase the placebo effects?
Well, if according to Ted Kaptchuk just being a nice, caring, considerate or ‘schmaltzy’ therapist promotes a placebo effect and gets a better result from a back rub, a joint poke or even a bit of exercise then of course yes, enhance that effect, be a nicer person, nothing wrong with that, I would activiely encourage that, but more importantly there are no ethical conflicts from just being a nicer person, and no risks to the patient!
But to harness a placebo effect by embellishing, exaggerating or just bullshitting the benefits of what a treatment can do is, in my opinion, simply unethical and wrong. It involves the need for a clinician to decieve and deliberately mislead, misinform and dupe patients. This means they cannot make a fully informed decision, and so informed patient consent is not gained. This fundamentally breaks a key code of our professional conduct and destroys the bonds and trust between the clinican and their patient.
Now, there has been a lot of debate around this, many argue that they are not misleading or duping patients as the research and evidence is so inconclusive on many areas within physiotherapy, and a lot doesn’t show with any certainty what the effects or outcomes of a lot of treatments are, and I agree, there are many grey areas.
So in situations like this, some say that its only fair and natural for them to use their own interpretation of the research explaining what the expected effects and outcomes will be.
I disagree. We must not let our own personal opinions, interpretations and so biases interfere with patients choices. We must try and give the patient the facts and allow them the chance to make an informed decision based on these as best as we can present them in an unbiased way.
Now this is much easier to say than do, bias is everywhere and its strong. I have to bite my lip, hard, everytime someone asks me about acupuncture or stretchy tape so as not to let my own bias against them destort the patient from deciding if they want to try them.
So what do I say in situations like these where my own bias is against a treatment but the patient has asked for some more information or directly requests it? Well its simple, I just say whats is known, and that is usually along the lines of we just dont know…
Those four words are not used often enough… ‘we just dont know’
I will of course give a little more information, clear up any misunderstandings or incorrect beliefs, but thats about it. If then patient wants to continue with said modality then fair enough, if not, also fair enough!
Sounds a bit long-winded for a back rub or some stretchy tape I understand that, but I think this open, honest discussion with patients around any treatment is fundemental.
But does this long-winded approach do me any favours? Am I potentially removing the positive effects of the placebo effect? Well possibly yes, but through choice I’d rather practice this way, it allows me to sleep at night and be at peace with my own ethics, I have no desire to be a promoter or a pedaler of placebo.
So there you go, my own personal views on placebo and placebo effects, clear and cloudy. I’m sure some will disagree, and a few may argue that if there is no harm or risk to the patient, why not try to harness placebo and its effects?
Well in a nutshell I think it comes down to this, utilizing or harnessing placebo ‘effects’ from a treatment which has other known physiological effects, be they large or small, is possibly ok if clear explanation is given, but promoting and using placebo without any clear physiological benefit is fraught with ethical dilemmas and in my opinion destroys the patient / clinician relationship!
I’d be interested to hear your views on this!
As always thanks for reading