As a Sports Therapists using Physiotherapy techniques I am often asked when I fix people “Is this just the placebo effect?” I find it ironic that it’s the people that are on the receiving end of the treatment that don’t know whether it’s placebo or not! After all it’s their brain that’s making them feel different. It does however raise an interesting larger debate – how much of physiotherapy techniques actually does anything and how much is just placebo. After 12 years of tinkering with people’s bodies and minds here’s what I’ve discovered…
What Is Placebo?
To use Google’s definition it is: “a medicine or procedure prescribed for the psychological benefit to the patient rather than for any physiological effect.” I like this definition. If you look at this Wikipedia definition however it comes across as a little bit more sinister in the realms of the con artist. So before I get in trouble with the Chartered Society of Physiotherapists and the Society of Sports Therapists lets go with the Google definition!
Is Placebo Used As An Explanation Too Often?
Yes! As a clinic that is proud to adopt an anything that works approach to treatment we’re often asked whether our treatment works just by the placebo affect. This is usually by doctors I meet at dinner parties! There then ensues a lively debate about randomised controlled trials and we end the evening agreeing to disagree. I can understand their point. If I try to explain how yesterday I fixed someone’s pelvis pain that had been there for 20 years by waggling their foot (it is more technical than that I promise!) then anyone would reasonably sceptical. The more you see it work, the less sceptical you become.
It’s very easy to dismiss things that we don’t understand and I feel that the placebo affect is often cited in medical circles to explain things that don’t exactly fit into current medical beliefs. In fairness I think that’s healthy. I don’t particularly want open heart surgery where the surgeon is just giving things a go! But by definition, this must have been the case at some point. Eeeek!
Is There Anything Wrong With The Placebo Effect?
Traditionally the placebo affect has had a bad wrap. Used by con-men and women to gain, usually financially, for not doing very much. However, with our new understanding of pain and the importance of psychology in pain as we discuss in this previous post I feel the term placebo affect needs to be abandoned and changed to something more fluffy and nice. How about “positive psychological effect management.” I’m pretty sure that one is not going stick so here’s a couple of example scenario for fictitious long standing knee pain:
Case 1 – Visit To Doctor’s Surgery
You arrive, the receptionist barely acknowledges you, and grunts at you and waves in the vague direction of a chair. You’re made to wait 20 minutes past your appointment before the doctor sees you. The doctor takes one look at the knee and tells you it’s your fault for doing too much, it’s ‘wear and tear’, there’s nothing can be done and it will never get better.
Case 2 – Visit To Brighton Sports Therapy (or other such injury clinic though why would you want to go anywhere else?!)
You’re greeted on arrival by one of our lovely therapists. They sit you down, make you a nice cup of tea (you have to bring your own biscuits!) and show a real interest in you and your condition. They take a full history of your condition and spend time to assess the knee and all other factors that can affect the knee. They explain how our treatment works and how it has improved many similar cases before and that they see no reason why you should be any different.
At this point – and we’ve still done no treatment – which case is going to be happier about the knee? Which case is going to feel more positive? I have in the past tested people conditions before and after talking people through their condition and what we’re going to do about it. You can reasonably consistently get a measurable improvement in symptoms just by talking to people. If you can make people feel more positive and reassured about the condition this changes the mapping of this part of their body in the brain and their symptoms change. It’s not a massive shift but it is perceptible.
Is this placebo? I don’t think so. This is the impact of a more positive happier mindset on the level of pain and discomfort we feel. This is basic pain psychology. Do we use this at the clinic? Hell yeah! Is it all of what we do? No. Just a small part in fact. But the sooner we can get people feeling positive about their condition the quicker we can fix them.
When we back this positive vibe up with some treatment that immediately makes the client feels less pain then we’re onto a winner.
Conversely in case one this may have had a nocebo affect. That is the doctor has done nothing to physiologically make the knee worse. However, chances are the knee will feel a hell of lot worse after such an encounter – we have seen many cases like this where a medical diagnosis has actually increased the person’s level of pain.
This idea is really nicely summed up in this great piece of research: “Enhance placebo, avoid nocebo: How contextual factors affect physiotherapy outcomes.” Contextual factors being all of the details we discussed above.
My belief is that “contextual factors” can play a role in determining the outcomes of clients from all kinds of physiotherapy techniques. But to say that all physiotherapy techniques work simply using placebo is far from the truth. For a start everyone’s perception is different.
I absolutely believe that clients outcomes are influenced by all kinds of factors. Do you like the therapist? Do you believe they know there stuff? Are the surroundings comfortable and of standard you would expect? A topic covered really nicely by the NOI Group here. However, these affects only go so far. Quite simply if a client feels a profound affect after the application of some treatment that will hugely outweigh the minimal impact of a purely placebo effect.