Is physio a placebo…?

No one likes to think what they do is pointless. No one likes to think that their role is meaningless. No one likes to think what they have worked hard to achieve is worthless. 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 patient’s expectations or other unknown non-specific effects. There is no doubt that the placebo effect is present in all healthcare interventions, however, it is getting a lot of attention and creating a lot of discussions recently with some asking is placebo the only thing that occurs with physiotherapy?

To answer this we need really placebo-controlled research, but 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 physio interventions within the sterile confines of placebo-controlled trials when we are dealing with complex issues such as humans and pain.

As much as I understand this argument it stands on very weak and shaky ground. Surgery, medicine, and physiotherapy all deal with people in pain, yet surgery and medicine do placebo-controlled research. And physios are often quick to highlight how some surgery or medication is no more effective than placebo, yet are less keen to turn the critical lens onto their own interventions.

When placebo-controlled studies are done within physiotherapy we see that a lot of what we do doesn’t appear to create any significant benefits when compared to shams or placebos. One of the most recent papers that highlighted this was a small trial here looking at McKenzie treatments for low back pain versus sham electrotherapy.

This trial demonstrated that McKenzie exercises had only a slight, and I mean very slight benefit on pain after 5 weeks of treatment, but no difference in levels of pain or disability at 3, 6, or 12 months when compared to sham electrotherapy. Yep, that’s right, using a machine that wasn’t even plugged in worked just as well as one of our most popular movement based interventions for low back pain.

Although this is only a small trial these results should make physios feel uncomfortable, surely we would expect a popular and often used intervention that encourages movement and self-management to show more effect than a bloody decommissioned electrotherapy machine!

And there are other papers that also show many other physiotherapy interventions, mainly the passive ones for back, hip, knee, shoulder pain also 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!

I have had doubts for years that most of what I do as a physiotherapist is nothing more than placebo despite my best efforts. This is often reinforced when I read papers like the one above but also when in my clinic and I often see patients get better who clearly have not done anything I suggested nor followed any of the advice I gave. But then I also see patients who don’t get better 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 don’t?

Well I don’t know is the simple yet frustrating answer. There is no doubt it is due to things just getting better on their own, but it is also due to many of the interventions we give don’t work the way we have been taught or believe they do. It is also due to our interactions are often more important than our interventions in getting results, with the act of treatment being more important than the treatment itself. And finally, it is also due to that the ability to get better or not often ultimately lies with our patients and not just our interventions.

Understanding placebo

A discussion I often hear within physiotherapy is that we need to understand, harness and utilise the placebo effect more as a treatment. Many physios think that we shouldn’t even call it the placebo effect any more due to the negative stigma around it, and rather we should call it ‘non specific’ or ‘contextual’ effects. Some even think the placebo effect is just things we don’t understand yet.

Regardless of what you want to call it, in my opinion, we should NEVER be satisfied to treat people with placebos, and we should NEVER confuse the placebo effect with non specific or contextual 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.

placebo-chart-3

These discussions about using placebos knowingly and actively in physiotherapy make me want to smash my head up against a hard surface repeatedly. First because I find it amusing that some physios have a genuine belief that they can unlock the mysteries of the placebo effect when many much more cleverer people have been unable to for decades 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 powerful untapped potential miracle treatment. Well, it simply isn’t.

Despite Beecher’s first attempt to quantify the placebo effect, famously quoting it as being ‘powerful’, it is actually quite weak, short lasting, and really, really unreliable. The strongest non-specific effect that tends to occur is natural history, and not placebo, 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 worthless as a sugar pill and surplus to requirements, there is no doubt that some of our interventions are more than placebo. Exercise being the main one. There are a few placebo controlled studies on the effects 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, and it may be the process of exercising rather than the outcome thats more important (ref). It may also 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, educating, reassuring, motivating, confronting, challenging, cajoling people in pain and disability to move more is more than placebo. But remember, I’m a physio, so I’m biased.

Let me make it crystal clear that I am not looking to beat down on the physio profession when I question if it’s 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

But 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, bickering and squabbling so much over our interventions so publicly. Some think it will be the end of us, and there are a few snow flakes who think all this questioning and arguing is just too mean and nasty, and we all simply need to get along!

Well these buttercups need to toughen up and learn to tolerate disagreements and differences because nothing will change if we don’t question and challenge what we do. I for one am glad that we have a profession that has started to ask itself some tough and awkward questions. I for one am happy that the things that have often been overlooked and avoided scrutiny and critique such as our passive treatments are now being dragged into the light kicking and screaming and being shown to be nothing more than shams. And if it takes a few feelings to be hurt, a few dinosaurs to be fossilised, and even a few cuts in physiotherapy services, or even the death of the profession as we know it, then so be it… I would rather burn down my own rotten house than carry on living in it.

More physios and its gurus need to accept that most, if not all the shitty adjuncts we do such as massage, manipulations, electotherapy machines, tapes, needles, etc are most likely nothing more than placebo. 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 NEVER override 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 no desire to be called an ‘alternative’ health care provider or a sugar pill.

As always, thanks for reading

Adam

21 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 ?

  8. Day One, Week One of physio degree. Course leader stands up. 80% are going to be better on their own. 10% will get better because of what you do. 10% will get worse.

    As true today as it was 20 years ago.

  9. Looked at your physio website.You say your treatments ” fully understand and restore many musculoskeletal conditions”.
    I enjoy your articles and agree with most of what you say but are you in a way the worst kind of physio.Those that still believe in McKenzie etc can go to work with a skip in their step.You go to work knowing your role has no purpose.Should you not in all honesty do something different as you are being dishonest to both yourself and your patients?.
    I have this same dilemma ( I’m an osteo- lets not go there!).I am retraining in Mindfulness and already practice hypnotherapy as they appear to have stronger evidence and it’s a way of bringing in the PS of BPS which I find no one wants in my field ( they come to me for a quick passive fix Not a 90 minute initial consultation -website 2 years old 0 takers to date).

    • This has to be the strangest comment I have had on here for a while and I get some really strange comments from the online nut jobs out there.

      It’s just as well that it is usually really hard to piss me off, otherwise, I would most have likely told you to go fuck yourself for calling me the ‘worst kind of physio’ or simply wouldn’t bother replying to you like I don’t to all the other nut jobs. However, I will give you the benefit of the doubt as I think you have mis-understood or mis-interpreted my position.

      I will state again that I question ALL that ALL healthcare professions do to help people and there is no doubt that placebo is present in everything, physio, surgery, medicine, osteopathy, even bloody mindfulness and hypnotherapy that you think has stronger evidence (BTW it doesn’t) and all the other pseudoscientific crap that lurks around the edges of healthcare.

      As a physio my role has a purpose. My role is to help people move who can’t or don’t want to due to pain or disability. This involves me getting people to move and exercise who don’t want to, or can’t, this means I have to think of different and novel ways to do this. Sometimes this works, sometimes this doesn’t. I will state again that I am well aware that the affects of what I do are mostly unknown but that doesn’t mean its not worth trying, worthless or has no purpose as you ridiculously state.

      I find my role as a physio who promotes simple honest advice guidance reassurance highly rewarding, I just argue that we abandon the bull shit and nonsense that surrounds all healthcare professions.

      Regards

      Adam

  10. Amen.

    As we profession we need leaders to embrace the challenge of the painful transition to EBM PT.
    To accept and move on.
    Steering away from manual approaches dominating to one where they are a tiny part of what do.
    But i fear in capacity of the professional bodies. Policing and regulating. Game keeper and poacher.
    The vested interests of MT, acupuncture et al. That the trade mag still permits advertising courses for craniosacral therapy !?!?! we have collectively so far to go.
    My fear has long been that our profession is so tied to its past and tradition that it will not go anywhere. There will be one hell of a reset when the public sees the scale of our willingness to be complicit in allowing such willful waste of time, money and hope on zombie snake oil approaches.

    Keep up the hard work in the vanguard Adam. I for one appreciate your time and effort.

  11. Hi, Adams, love your blog.

    I do have reservations towards what you said regarding the McKenzie method though.
    The MDT method often shows mixed results in studies because they just address cases without including only the 3 MDT syndromes (dysfunction, derangement and postural syndromes). Most MDT practicioners and experts have an approach extremely similar to yours, but only once they classified a patient as being outside of the 3 syndromes (so as being an OTHER). In other words, the quick and dramatic increases in function, ROM and strength we see with derangement are only for a small proportion of the population (40-70%) depending on the study and the joint (based on observational studies… I’ll just list this one https://www.tandfonline.com/doi/abs/10.1080/10669817.2017.1313929?journalCode=yjmt20, but others are available online on the MDT reference list). Therefore, I think you should look for a directional preference first (quick changes), if they are not present, then I think your philosophy is absolutely correct: unless someone shows a directional preference, people usually improve through guided movement and exercise rather than specific, expert physio.
    Here’s a recent paper that shows superior results for LBP by using MDT vs usual care.
    https://watermark.silverchair.com/milmed-d-17-00032.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAdkwggHVBgkqhkiG9w0BBwagggHGMIIBwgIBADCCAbsGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQM_bh5pL9Ff57lnFTrAgEQgIIBjPHvZjJK7WaONl7jR8_rqKiXrh-C30KGCOIrxDp0MmS35MoJ21T3axwARs7GrNWLMsZ-hA8Sory2x2WA1ah0tFkyQQi1cLDx3S837qboeVoStKXnUW9f4ChpEWwDrY5fjHcTevhk3zGAncRfiTmMOsJpzx1rSNb-XxnRwiOsIUznjsfYaT1P-6HUST2nYLhLe0gJDY9p60q9M80eea5HffNwX0NUjlPgZCdV9_usG–Wpj3ZrnToy4Qr06fadU8so4SdBNJjp_N-32Xc4QxT9hjZTirqpIpx3ACjfQVpsPvebQYrv8jlMei446zOSvI3XOec7D3TalNrkLQMrcpLo8Pcdj_otEQAmpfJFNzlKwnPNld0oRyj9oYXkT2kU4oG-Jx6nqfDq7aGvclTSgEiOGgnEp7g3EsSsdf6PA1gu3fbsLu6eUMfKNUYOF9WfhEuxvYFYPKPBw5JmCRCZVbOKVuBy7oNSmDUXV5xem2cYgOvPHbAYLPHCjf3Jrk54k56PK2YK7OyBIsefzmJGw

    Thank you,

    Alexis M. Léveillé, M.Sc.A., Pht

    • Thanks for the papers and comments Alexis, and I agree if pain can change quickly with a few repeated movements then use that, but I will still question as to the mechanism behind that change, for me the mechanical effects of derangement, dysfunction, postural syndromes are plausible but only one explanation. Thanks again, Adam

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