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”?
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.
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.
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