As a Sports Therapist using Physiotherapy techniques I am often asked when treatments work is it just the placebo effect? My instinctive answer would be no, it’s way too complicated for such a sweeping statement.
I would say, however, that the placebo effect can be useful in terms of getting the most out of any treatment. It’s also incredibly useful in research terms. It’s far more accurate to measure an approach versus the placebo effect than it is comparing it to nothing.
In this article we’ll dive deeper into just what the placebo effect is, not only from a psychological perspective but also from a physiological perspective. In plain English, how things in our biology actually change when we think they’re changing.
What Is The Placebo Effect?
Let’s start with Google’s definition:
“A medicine or procedure prescribed for the psychological benefit to the patient rather than for any physiological effect.”
But here’s the thing. The latest research suggests that something does happen. In this article here as well as the psychological effects it also talks about ‘neurophysiological’ mechanisms. Put plainly the placebo affect changes how our nervous system works. It affects pain pathways (endorphins), mood, sleep, appetite and memory (endocannabinoids) and also impacts one of our key neurotransmitters (chemicals that send messages to the brain) dopamine. (Dopamine being the neurotransmitter we’re trying to get more of when we keep picking up our phones!)
In short the placebo effect is a good thing. In terms of pain management we’ll have anything that works so it’s a yes please from us! You can see why it’s in our interests to work with the placebo effect to improve the therapeutic effects of our treatments and our outcomes. It’s just as important, if not more so, to compare our interventions with the placebo effect. Is it actually what we’re doing that’s making a difference or what people are believing?
Just as important is avoiding the opposite of the placebo effect. The dreaded nocebo effect as defined here in Wikipedia:
“A nocebo effect is said to occur when negative expectations of the patient regarding a treatment cause the treatment to have a more negative effect than it otherwise would have”
This is how you could get two different therapists performing the same kind of treatment but get two very different results. As backed up by this research here when it says:
“The difference in clinical success between two different physiotherapists, both practicing with reference to the scientific evidence and application of the clinical guidelines lies in the different level of implementation of the “art” component of the profession. This is probably mostly due to behaviours that have relevant effects on the clinical outcome through placebo or nocebo phenomenon”
I’ve gone very research based very quickly in this article so let’s bring it back to something real. I’ve just got off the phone to a new client I’ll be seeing tomorrow who has had some previous well-meaning physiotherapy that concluded the cause of his pain is osteoarthritis. Since then the symptoms have got worse.
Firstly no physiotherapist I know comes equipped with x-ray eyes. Secondly, many modern research papers suggest that the amount of arthritis in the joint is in no way a predictor of pain. The latest in pain science tells us that a more likely cause of pain is how much we fear something.
Consider how you would respond to being told that you have arthritis in your knee and you need to build up muscles to protect it. Versus being told that there are imperfections in your body which put increase load on your knee and we need to address these to help you towards a full recovery.
If you would like to look further into how our brain can change our physiology then then Bruce Lipton’s The Biology of Belief is an excellent read. Moving on from pain, and very much beyond the remit of this article, there is even some research out there that suggests that this kind thinking can help with cancer treatment. Of course I’m not advocating shunning any medical treatment at the expense of this alternative view. There’s a cynical, yet balanced, piece from the New York Times here from a journalist for whom the discussion is very relevant.
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 effect. 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 do understand their point. Placebo effect is a very effective treatment. Talking in pharmaceutical terms this article suggests:
“Placebos are extraordinary drugs. They seem to have some effect on almost every symptom known to mankind, and work in at least a third of patients and sometimes in up to 60 percent. They have no serious side-effects and cannot be given in overdose. In short, they hold the prize for the most adaptable, protean, effective, safe and cheap drugs in the world’s pharmacopeia.”
Placebo medication even works in depression 30-40% of time. So we’ve got a lot to beat here. But as with all statistics and research if we scratch beneath the surface the picture becomes more muddied. Are these people completely cured of depression? Are these 33-60% of people completely cured of pain. No. It helps reduce their symptoms in 33-60% of cases. We judge ourselves on complete resolution of symptoms. So we’re not really comparing apples with apples here are we?
When we use an intervention for treatment we could view it was working in a similar way to the placebo effect. For example, let’s consider a new client who has presented with pain in a joint that has been ‘confirmed’ or they fear might to be due to arthritis or something wrong with the joint. If I can use an intervention, usually my hands on techniques, after which the symptoms feel better then we start to alter someone’s beliefs.
If people feel the difference I would argue that this makes more difference to how the body moves and feels which not only calms the nervous system, and so pain, but over time affects the physiology as it does in the placebo effect, but even more so.
I frequently see this working on people who are, understandably, sceptical. When you see treatment approaches work on those of a more sceptical nature you begin to believe that the placebo effect is not everything. I still think the power of the mind is huge.
In fact people who are convinced that all of their pain is due to the bit that hurts simply won’t get any benefit from what we do. Their brain and so their pain is not able to change. We like people to come in to their first appointment cynical, yet open to give things a try. Let us do the rest. We’ll soon tell you if we think there is a genuine problem with the bit that hurts. As a rule of thumb if it’s been there a long time it’s not to do with the bit that hurts as it should have healed by now. But we do need to check!
It’s very easy to dismiss things that we don’t understand as placebo effect and all too often placebo is cited to explain things away that don’t 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 this must have been the case at some point.
Biologically plausible is one of my favourite expressions. We come up with our theories as to why. We test those theories to see if they are right or wrong and then we modify those theories to better improve our hypothesis. The definition of science.
Is There Anything Wrong With The Placebo Effect?
Traditionally the placebo effect has had a bad reputation being used by con artists to gain financially. However, with our new understanding of pain and the importance of psychology in pain and how that affects our physiology I feel the term placebo affect needs to be updated. How about “positive psychoneurophysiological effect.” A bit of a mouthful I know.
We can make it an even bigger mouthful if we wish! Gabor Mate in his excellent book When The Body Says No talks of the theory of psychoneuroendocrinoimmunology! Of how our psychology, nervous system, endocrine system and immune system are all one bit of a bigger regulatory system. And they have to be. They are all part of us. So if we start with the placebo effect and build on that to make lasting change then I’m all for it.
I’ve gone very theoretical here so let’s bring this to another relatable example:
Case 1 – Clinic A
You arrive, the receptionist barely acknowledges you, grunts at you, and waves in the vague direction of a chair. You’re made to wait 20 minutes past your appointment before the clinician sees you. They lead you into a very brightly lit room. They take one look at your knee and tell you it’s your fault for doing too much and waft a pre-printed sheet of generic exercises in your direction.
Case 2 – Clinic B
You’re greeted on arrival by your therapist and escorted through the treatment room which is decorated in a calming yet confident way. The therapist takes a full history of your condition and shows a real interest in you and helping you get over your condition. They explain how the treatment works and guide you through the process ensuring you’re happy and comfortable at each step. They use the treatment to inform a bespoke plan of action specifically for you to aid your recovery.
Put yourself in both of those situations. The first one if very much nocebo. The second one you could say would be utilising the placebo effect. Or you could view it as being treated as an important unique human being. Probably both.
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.
Placebo Effect Conclusion
My belief is that “contextual factors” can play a large 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 my experience. Things are just way too complicated for that.
I absolutely believe that client outcomes are influenced by all kinds of factors. Do you like the therapist? Do you believe they know their stuff? Do you like what they do? Does it feel good? 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 lesser impact of a purely placebo effect.
If you’d like to come in and try and judge for yourself whether our techniques are placebo, magic or somewhere in between we’d love to hear from you. Please fill out the form here and we’ll talk you through how we might be able to help.