No one likes to think what they do is worthless. No one likes to think that their role is meaningless. But this could be what many musculoskeletal physiotherapists, 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 a patient’s expectations or other unknown effects. This should not be confused with natural history or contextual effects.
Contextual effects are described as the influence of environmental and/or psychological factors on patients perception of treatments. This can be things like rapport, empathy etc. Natural history is the usual course of a disease or condition in the absence of treatment.
There is no doubt that the placebo effect is present in all healthcare interventions, but just how much is something we don’t know despite many often quoting Beechers infamous 1955 study that suggested it was 30%. The placebo effect is getting more and more attention recently with many asking how much it affects our physiotherapy treatments?
Weak Argument
To answer this we need placebo-controlled research and studies. Unfortunately, these are rare in physiotherapy with the argument often being that it’s hard to find convincing placebos for physiotherapy treatments. Another argument is that we can’t study the effects of our physio interventions within the sterile confines of placebo-controlled trials because we are dealing with complex issues such as humans and pain.
However, these arguments stand on very weak ground. Surgery and medicine also deal with complex issues and people in pain, yet they do placebo-controlled trials far more than physiotherapy. Physios are often quick to highlight how surgery or medication is no more effective than placebo, yet are less keen to turn this critical lens onto their own interventions.
When placebo-controlled studies are occasionally done within physiotherapy we see that a lot of what we do doesn’t appear to create any significant benefits over or above shams or placebos. A recent study that highlighted this was a trial here looking at McKenzie based exercises for low back pain versus a detuned sham ultrasound machine.
Unplugged Machines
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 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 works just as well as one of our most popular movement-based interventions for low back pain.
Although this is a small trial these results should make all physios feel uncomfortable, I know it does for me. Surely we would expect a popular and often used intervention that encourages movement and self-management to have shown more effect than a bloody decommissioned ultrasound machine!
There are other papers that also highlight how 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”?
Doubts And Frustrations
I have had doubts for years that most of what I do as a physiotherapist is nothing more than a 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 see patients get better despite clearly having done nothing I suggested.
However, 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 and following all that the best current evidence tell me do some patients get better regardless and yet others don’t?
Well, I don’t know is the simple yet frustrating answer. There is no doubt its 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 often being more important than our interventions in getting results, with the act of treatment being more important than the treatment itself. Finally, I’m also sure it’s due to the ability of anyone to get better or not ultimately lies within an individual’s beliefs and attitudes, not treatments or interventions.
Understanding Placebo
A discussion I often hear within physiotherapy is that we need to understand and utilise the placebo effect more as a treatment. Many think that we shouldn’t even call it the placebo effect any more due to the negative stigma around it, rather we should just call it a ‘non-specific’ effect.
Regardless of what you want to call it, we should NEVER be happy o satisfied to treat people with placebos or non-specific effects, and we should NEVER confuse the placebo effect with other non-specific or contextual effects 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 face up against a hard surface repeatedly. First, because I find it frustrating as hell that some physios have a genuine belief that they can unlock the mysteries of the placebo effect that many much cleverer people have been unable to for decades ever since Beecher’s first attempt.
The other reason these discussions around the placebo effect frustrate me is that some physios think it’s a powerful untapped potential miracle treatment. It simply isn’t, the placebo effect is actually kind of weak and pathetic and we should never be happy to rely on it to help people.
Despite Beecher’s first attempt to quantify the placebo effect, famously quoting it as being ‘powerful’, it’s actually weak, short-lasting, and really, really unreliable. The strongest non-specific effect that tends to occur is natural history, not placebo as many think.
Therefore 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 small to minimal impact on outcomes.
More Than a Placebo
Now before I make all of you reading this feel worthless as a sugar pill and surplus to requirements, there is no doubt that some of our physio interventions are clearly more beneficial than placebo. Exercise being the main one. However, just not for the treatment of pain, only for improvements in health and well being
There are a few placebo-controlled studies on the effects of exercise in those with pain and pathology and again as with the McKenzie study they do not always show significant benefits over placebo (ref, ref, ref)
The how and why our exercise interventions help is still not fully understood, and it may be more about the process of exercising rather than the outcome that’s important (ref). It may also be the volume and frequency rather than the type of exercise that is key (ref).
Regardless, of these uncertainties, I think our roles as physiotherapists in supporting, encouraging, educating, reassuring, motivating, confronting, challenging, and cajoling people in pain and disability to move more is more beneficial than placebo. But remember, I’m biased, hugely.
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 will always be one of physiotherapy’s strongest advocates. I truly believe that physiotherapy can and does 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 harm our profession by questioning and challenging it so much so publicly. Some think this will be the end of us, and there are a few snowflakes who think all this is just too mean and nasty!
These individuals I think need to tolerate disagreements and differences better and recognise that if we don’t question and challenge what we do we will fail to progress and grow.
I am glad that more and more in the profession have started to ask some tough and awkward questions. I am happy that the things that have often been overlooked and avoided scrutiny and critique are now being dragged into the light kicking and screaming and being shown to be nothing more than placebos.
And if it takes a few feelings to be hurt, a few feathers ruffled and a few dinosaurs fossilised, or even the death of the profession as we know it, then so be it! I would rather burn down my own rotten house to the ground, and start afresh building a new more robust one.
More physios need to learn to accept that most, if not all of our shitty passive treatments and adjuncts such as massage, manipulations, electotherapy machines, tapes, needles, etc are most likely nothing more than placebo.
Summary
As I have said it before, if physiotherapy as a profession wants to 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 our profession stands the very real risk of being cast to the fringes of healthcare and the world of ‘alternative medicine’ with all the other quacks and nut jobs with their energy crystals and chakras.
And I have no desire to be an ‘alternative’ health care provider.
As always, thanks for reading
Adam
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
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.
Cheers Joe… yep using media tools to help explain pain is a really good way to help patients understand.
Great article!
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.
Thanks David… keep hoping… ;o)
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
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
I work as a Physio since nearly 30 years…..Adam, you hit the point! I still believe in this bl…Profession….if we are brave enough to change!!!
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.
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 ?
I always took you for a ’50 shades of grey’ type Tony… ;o)
Fantastic article,, so true 🙂
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.
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
Amen.
As we profession we need leaders to embrace the challenge of the painful transition to EBM PT.
To accept and move on.
Steering away from manual approaches dominating to one where they are a tiny part of what do.
But i fear in capacity of the professional bodies. Policing and regulating. Game keeper and poacher.
The vested interests of MT, acupuncture et al. That the trade mag still permits advertising courses for craniosacral therapy !?!?! we have collectively so far to go.
My fear has long been that our profession is so tied to its past and tradition that it will not go anywhere. There will be one hell of a reset when the public sees the scale of our willingness to be complicit in allowing such willful waste of time, money and hope on zombie snake oil approaches.
Keep up the hard work in the vanguard Adam. I for one appreciate your time and effort.
Thanks Ste5e
Hi, Adams, love your blog.
I do have reservations towards what you said regarding the McKenzie method though.
The MDT method often shows mixed results in studies because they just address cases without including only the 3 MDT syndromes (dysfunction, derangement and postural syndromes). Most MDT practicioners and experts have an approach extremely similar to yours, but only once they classified a patient as being outside of the 3 syndromes (so as being an OTHER). In other words, the quick and dramatic increases in function, ROM and strength we see with derangement are only for a small proportion of the population (40-70%) depending on the study and the joint (based on observational studies… I’ll just list this one https://www.tandfonline.com/doi/abs/10.1080/10669817.2017.1313929?journalCode=yjmt20, but others are available online on the MDT reference list). Therefore, I think you should look for a directional preference first (quick changes), if they are not present, then I think your philosophy is absolutely correct: unless someone shows a directional preference, people usually improve through guided movement and exercise rather than specific, expert physio.
Here’s a recent paper that shows superior results for LBP by using MDT vs usual care.
https://watermark.silverchair.com/milmed-d-17-00032.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAdkwggHVBgkqhkiG9w0BBwagggHGMIIBwgIBADCCAbsGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQM_bh5pL9Ff57lnFTrAgEQgIIBjPHvZjJK7WaONl7jR8_rqKiXrh-C30KGCOIrxDp0MmS35MoJ21T3axwARs7GrNWLMsZ-hA8Sory2x2WA1ah0tFkyQQi1cLDx3S837qboeVoStKXnUW9f4ChpEWwDrY5fjHcTevhk3zGAncRfiTmMOsJpzx1rSNb-XxnRwiOsIUznjsfYaT1P-6HUST2nYLhLe0gJDY9p60q9M80eea5HffNwX0NUjlPgZCdV9_usG–Wpj3ZrnToy4Qr06fadU8so4SdBNJjp_N-32Xc4QxT9hjZTirqpIpx3ACjfQVpsPvebQYrv8jlMei446zOSvI3XOec7D3TalNrkLQMrcpLo8Pcdj_otEQAmpfJFNzlKwnPNld0oRyj9oYXkT2kU4oG-Jx6nqfDq7aGvclTSgEiOGgnEp7g3EsSsdf6PA1gu3fbsLu6eUMfKNUYOF9WfhEuxvYFYPKPBw5JmCRCZVbOKVuBy7oNSmDUXV5xem2cYgOvPHbAYLPHCjf3Jrk54k56PK2YK7OyBIsefzmJGw
Thank you,
Alexis M. Léveillé, M.Sc.A., Pht
Thanks for the papers and comments Alexis, and I agree if pain can change quickly with a few repeated movements then use that, but I will still question as to the mechanism behind that change, for me the mechanical effects of derangement, dysfunction, postural syndromes are plausible but only one explanation. Thanks again, Adam