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”?
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.
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.
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