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, and patient expectations are important in all we do and should always be recognised. However, the placebo effect is getting a lot of attention and creating a lot of discussions recently with some asking is it the only thing that occurs with physiotherapy treatments?

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 randomised 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. Physios are often quick to highlight how some surgery or medication is no more effective than placebo, yet we are less keen to turn the lens onto our own interventions coming up with 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 versus sham electrotherapy.

This trial 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 in levels of pain or disability at 3, 6, or 12 months follow up when compared to sham electrotherapy. Yep, that’s right, using a machine that wasn’t even connected worked just as well as one of physiotherapys most popular active movement based interventions for low back pain

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

And there are other papers that show many 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”?

fullsizeoutput_6ee

Yes… sort of!

I have had doubts for years that what I do as a physiotherapist is effective or reliable despite my best efforts. I often see patients get better after an injury or an episode pain who clearly have not done anything I suggested nor followed any of the advice I gave. But I have seen the opposite as well. I have seen patients who don’t get better after an injury or episode of pain 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. There is, no doubt, it is due to, in part, at times, things just get better on their own. It is also due to, in part, at times, many of the interventions we give as physiotherapists don’t work the way we think they do. It is also due to, in part, at times, that our interactions are more important than our interventions in getting results. And finally, it is also due to, in part, at times, that the ability to get better or not ultimately lies with the patients and not 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 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 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.

placebo-chart-3

These discussions around the use of the placebo effect by physiotherapists often 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 far 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 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 good 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

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 the snow flakes who think all this questioning is just too mean and nasty, and that we all simply need to agree and get along!

This is 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 has started to ask itself some tough and awkward questions. I am happy that the things that have often been overlooked and avoided critique such as some of our shittier passive 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, or even the death of physiotherapy 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 need to accept that most, if not all the interventions and adjuncts we do such as massage, manipulations, machines, tapes, needles, etc cannot be separated from the placebo effect. 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.

As always, thanks for reading

Adam

 

 

17 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

Please leave your comments here...

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s