Is physio a placebo…?

No one likes to think what they do is worthless. No one likes to think that their role is meaningless. No one likes to think what they have worked hard to achieve is pointless. But this could be what many physiotherapists, including myself are facing if our interventions are found to be nothing more than placebo.

The placebo effect is defined as a beneficial effect that can not be attributed to the treatment but rather to the patients expectations. The placebo effect is getting a lot of attention and creating a lot of debate and discussion recently, and there is no doubting that the placebo effect is present in all healthcare interventions, and patient expectations are extremely important in all we do as physios and they should always be recognised. However, is the placebo effect the only thing that occurs with physiotherapy?

To answer this we need placebo controlled research. Unfortunately good quality placebo controlled research in physiotherapy is scarse. The convenient excuse for this is that it’s hard to find convincing placebos for physiotherapy treatments, or that we can’t study the effects of our interventions within the sterile confines of randomised placebo controlled trials when dealing with complex issues such as humans and pain.

As much as I understand this argument it stands on weak and shaky ground. Surgery, medicine, and physiotherapy all deal with people in pain, yet surgery and medicine do placebo controlled research. Physios are often quick to highlight how some surgery or medication is no more effective than a placebo, yet we are less keen to turn the placebo lens onto our own interventions coming up with these lame excuses instead.

When placebo controlled studies are done within physiotherapy we see that a lot of what we do to help people in pain doesn’t appear to create any significant benefits from those we don’t help. One of the most recent papers that highlighted this was a small trial here looking at McKenzie treatments for low back pain verses sham electrotherapy.

It demonstrated that McKenzie exercises had only a slight, and I mean very slight benefit on pain levels after 5 weeks of treatment, but no difference on levels of pain or disability at 3, 6, or 12 months follow up. That’s right using a machine that wasn’t even connected worked just as well as one of physiotherapy’s most popular active interventions for low back pain

Although this is only a small trial these results should make you feel uncomfortable if you’re a physio. Surely we should expect a popular and often used intervention that is active and encourages self management to show more effect than a crappy decommissioned machine!

And there are other papers that show many of our physiotherapy interventions, mainly the passive ones for back, hip, knee, shoulder pain do nothing more than doing nothing or sham interventions. So as the famous French philosopher Voltaire once said, is physiotherapy “amusing the patient whilst nature cures the disease”?

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Yes… sort of, probably!

I have had doubts for years that what I do as a physiotherapist is effective or reliable despite my hardest efforts. I often see patients day in day out get better after an injury or episode pain who clearly have not done anything I suggested nor followed any of the advice I gave. But I have also seen the opposite. I see patients day in day out who don’t get better after an injury or illness despite doing everything I ask of them and following all of the advice I give.

Why is this? Why despite my best efforts do some patients get better and others do not?

Well I don’t know is the simple yet frustrating answer as this is a huge and complex question with many different explanations and theories. There is no doubt it’s due to, in part, at times, things just get better on their own. It’s also no doubt due to, in part, at times, many of the interventions we give as physiotherapists don’t work the way we think. It’s also no doubt due to, in part, at times, that our interactions are more important than our interventions. And finally it’s also no doubt due to, in part, at times, that the ability to get better or not ultimately lies with the patients and not solely our interventions.

Understanding placebo

A discussion I often hear within physiotherapy circles is that we need to understand, harness and utilise the placebo effect more as a treatment. Many think that we shouldn’t even call it the placebo effect any more due to its negative stigma, rather we should call this effect ‘non specific’ or ‘contextual’. Some think the placebo effect is just things we haven’t understood yet. Regardless of what you want to call it, we should never be satisfied to treat people with placebos, and we shouldn’t confuse placebo with other non specific effects such as natural history, regression to the mean, or the host of other weird things that can occur when we treat people, more on that here.

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These discussions around the placebo effect by physiotherapists often make me want to smash my face against a hard surface repeatedly. First because I find it amusing that some dumb arsed physios have a genuine belief that they can unlock the mysteries of the placebo effect when many far cleverer people have been unable to for decades. The placebo effect has been surrounded by uncertainty ever since Beecher first tried to highlight it’s role in healthcare back in the 1950s (ref).

The other reason these discussions around the placebo effect frustrate me is that some physios think it’s a mighty powerful untapped potential miracle treatment. It isn’t. Despite Beecher’s attempt to quantify the placebo effect, famously quoting it as being ‘powerful’, it’s actually quite weak, short lasting, and really unreliable. The strongest non-specific effect that tends to occur is natural history. Therefore we need to question why do we want to waste our time, efforts, and resources on investigating something that ultimately we will never fully control and even if we do it will have questionable impact on outcomes.

More than a placebo

Now before I make all the physios reading this feel depressed, worthless, and surplus to requirements, there is no doubt that some of our interventions are more than placebo. Exercise being the key one. There are a few good placebo controlled studies on the effect of exercise in those with pain and pathology and they do often (but not always) show benefits over placebo (ref, ref, ref)

The how and why our exercise interventions work however is still not fully understood. It maybe the process of exercising rather than the outcome thats more important (ref), and it may be the volume and frequency rather than the type of exercise that is key (ref). But regardless, I do think our roles as physiotherapists in supporting, guiding, encouraging, advising, educating, reassuring, motivating, confronting, challenging, cajoling people in pain and disability to move more is more than just placebo. But I’m biased.

Let me make it crystal clear that I am not looking to beat down on our profession when I question if we are just a placebo. Believe it or not I am, and always will be one of physiotherapy’s strongest advocates. I truly believe that physiotherapy can have an important role within modern healthcare, but only if it gets its head out of its arse and evolves.

Evolve or die

Just as I am one of physios strongest advocates, I am also one of its strongest critics. Many think that I and others are harming our profession by questioning, challenging, debating, bickering and squabbling so much over our interventions so publicly. Some think it will be the end of us, and then there are the snow flakes who think all this questioning and challenging is just too mean and nasty, and that we all simply need to agree and get along!

Bull shit, nothing changes if we don’t question and challenge what we do. I for one am glad that we have a profession that appears to be in turmoil, and things that have often been overlooked and avoided critique such as some of our shitty ineffective treatments are being dragged into the light and discussed more. And if it takes a few feelings to be hurt, a few dinosaurs to be fossilised, even a few cuts in physiotherapy services, perhaps even the death of physiotherapy as we know it completely, then so be it… I would rather burn down my own rotten house than carry on working in a profession that is ineffective and only a placebo.

More physios need to accept that most, if not all the passive interventions and adjuncts we do such as massage, manipulations, machines, tapes, needles, etc can not be separated from the placebo effect and so do not belong in modern evidence based healthcare. Yes, ok we all have anecdotes of patients who have had fabulous results with some of these treatments, but we all tend to remember the successes and forget the rest, our biases should NOT over ride the evidence.

I have said it before, but I will say it again and again. If physiotherapy as a profession wants to survive and be a valued part of modern evidence based healthcare then we have to distance ourselves away from the low value interventions, including placebos. If we continue to defend these dubious and unreliable treatments then I fear that physiotherapy stands the very real risk of being cast into the world of ‘alternative medicine’ with the other quacks and nut jobs, and I for one have worked too hard and have no desire to be called an ‘alternative’ healthcare provider.

As always, thanks for reading

Adam

 

 

14 thoughts on “Is physio a placebo…?

  1. Interesting post adam. Physio is a complex skill . A diagnostic skill , a talking therapy, a physical therapy , a liaison service, a referral service . How well we do all of these will impact on recovery and outcome but measurement of relative value of each area is complex. If you define which skill you are focussing on , and it’s relative contribution to recover then quantification of efficacy may make more sense.

    However adam – annoying as it is- some Physios don’t have ‘it’ . ‘it’ being an innate intuition/ knowledge of next steps and in which order !!!
    I’m not so sure that specific ‘techniques’ or ‘skills’ will ever rank much higher than placebo ( no matter how hard the guru led physio profession try to tell us otherwise) . So to focus on them is to underplay the real skill of complete patient management

  2. Hi Adam, great post this week! As a newly qualified physio about to enter my first band-5 role, this certainly gives me some food for thought! ;-/ As well as being slightly alarming (i.e. the idea that we may not be able to help all patients) it also reassures me in a sense, especially the first part you mentioned about some patients getting better despite doing nothing you prescribed, and some not getting better despite doing everything. This really puts the onus on us to educate patients about their condition and reassure them about the importance of getting moving (sometimes any movement is better than none). Just been listening to an audio book called explain pain that was riffing on a similar theme. I know I’ve got slightly off topic here, but just wanted to say thanks for the great posts! Cheers, Joe.

  3. Adam,

    Great post as usual. I think about this often, as a newish grad (3 years out), did I just waste 7 years of my life and over a hundred thousand in debt in pursuit of a skill set that in later years will be looked back to be on par with crystal healing and alchemy. I now primarily encourage activity and exercise of any and all kinds combined with reassurance and so on when needed.

    In my own experience when reflecting I have no idea what makes people recover from general musculoskeletal problems other than having a somewhat positive mindset and being a semi active individual. Hopefully adherence to the exercise protocols I give have something to do with the process.

    Cheers.

  4. It’s like you read my mind Adam.. I’ve been in this profession for 6 years not too long but I keep questioning what We do as Physio’s everyday
    Do we actually treat what we think we are treating or it’s just placebo
    its like all the stuff you were taught in uni like manual therapy , specific muscle techniques
    Mean anything at all.

    It’s a very interesting read to reflect on what we do
    Thanks Adam

  5. Great blog as always. Suppose the problem you always have with EBP (which isn’t medicine where acute effects can be objectively measured relatively simply) is…
    1. There’s so much research out there that wasn’t published/published yet biased towards shitty interventions due to vested interests it’s hard to know exactly where you’re up to as a profession sometimes.
    2. A lack of good quality studies generally makes it hard to apply results to the general population… cherry picking participants for studies is never going to be quite the same as real life clinical settings.
    3. Despite how hard we try, pain is subjective. It’s experience is totally dependent on how a patient feels, quantifying how a patient has improved is very difficult Ie. the patient who couldn’t flex their arm halfway due to excruciating pain who still feels they’ve not improved after 12 weeks because their arm still hurts slightly in the night or when they carry 12 shopping bags (fuck me that happens a lot haha).

    Curious as to where you see physio, in it’s current state being in 15 years or so? Part private like dentistry or moving towards integrated therapists like 20-30yrs ago?

    • Good question George and I don’t honestly know. I think the more we learn the more chance the MSK professions have of becoming more intergrated into one all encompassing therapist

  6. I think we need to distinguish between placebo effect and a placebo response. Placebo effect is primarily due to the psychosocial context around the patient which involves expectation. Whereas a placebo response is usually only able to be measured in laboratory trials and is a biological phenomonen. As you mentioned Adam the placebo effect can be erroneously used inappropriately if we fail to consider natural history or regression to the mean. I gave an inservice to pain specialists on this very topic, indicating in a subtle way that their injection therapies were no better than a placebo effect, I do prefer the term contextual effect though. Keep up the good work.

  7. Yep, hard as it is to accept, placebo is a big part of what we do. I’m not sure I know what the alternative to our treatment is though. While I’m a strong advocate of self efficacy and onus of responsibility on the client to help themselves, the reassurance and letting them know what to do and why still allows us a very important role. Hand on can if used wisely allow a patient who had been through “exercise physio’s and failed a controlled environment to allow for progression. The real question for me isn’t if what we do is placebo, exercise or hands on. It’s what is the honest alternative offering a holistic perspective bispoked to the individual in front of us. I would strongly argue we have a very positive role in improving a patients function and pain. I figure my views aren’t too far away from yours but less black and white ?

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