So I am again very pleased to give you another guest blog from Ben Dean who has written for 'The Sports Physio' before here. He is an Orthopaedic Registrar studying for a PhD at Oxford and in keeping with my recent blog on the placebo effect here, Ben has given us his insight, opinion and a little controversy on some rather interesting research that should be making us all ask ourselves some hard and difficult questions, over to you Ben…
Mirror, mirror on the wall which is the greatest placebo of them all…?
Looking in the mirror can be unpleasant, especially on a bad day, but despite an excessive emphasis on meaningless reflective practice paperwork, regular genuine reflection on our own practice is a vital part of learning and becoming better at what we all do, ie treating patients and trying to make them ‘better’.
The title of this piece is designed to provoke, to stir, because I want to open your minds for a brief moment, as we cannot ever improve if we do not look at ourselves from outside the box, and to do this, walls need to be torn down.
Recently this fascinating trial published in JAMA got me to open my eyes, it is a brave and worthwhile piece of work that will have many of us scratching our heads. Essentially sham therapy was just as effective as physical therapy in the treatment of painful hip osteoarthritis.
This study from Bennell et al in the 2010 BMJ is also worth a read, it showed that manual therapy and home exercise conferred no immediate benefits over placebo in patients with rotator cuff related pain. Here’s another Bennell study along similar lines, this time on knee osteoarthritis.
I am not picking on physiotherapy, this theme runs across the board and by that I mean that the better placebo controlled trials become, the more likely we are to see treatments we once thought to be very effective to be rather less impressive and often no better than a placebo.
Our recent BMJ review on the use of placebo controlled trials in surgery here demonstrated this is very much the case for surgical interventions; many procedures were shown to be no better than placebo for specific groups of patients.
Obviously some things are much harder to trial against a placebo. The placebo controlled trial has been the gold standard for drugs for many a moon but in other areas, such as physiotherapy and surgery, we have been far too slow to cotton on to the use of this powerful tool, and traditionally we have relied on much weaker methodology which has resulted in us not really knowing what works.
One could also argue that if one cannot create a placebo arm for a particular treatment then this may well mean that you don’t really understand your treatment very well!
Going forward I don’t think we have any excuse not to look in the mirror, it may be hard to conduct the best placebo controlled trials, and indeed sometimes it is ethically indefensible or logistically impossible, but this should not stop us trying, as if we do not we are simply failing our patients because we are becoming just the same as some of the people we love to criticise, ie the charlatans who hand out placebo tablets and pretend they are far more effective than just a placebo.
Do not misunderstand me, the placebo effect is a powerful part of many effective treatments and it is vital we maximise this effect in our patients.
Fascinating recent work here is showing that the expectation of our patients can have powerful effects on the periphery in terms of increasing inflammatory change.
Simply communicating well and reassuring our patients, educating them well about unknowns, and letting time do its thing can have powerful effects on pain symptomatology. What does not work well is giving patients false hope and false expectation, falsely reassuring them that treatments are genuinely efficacious when they are not, as they will often end up disillusioned, disappointed and let down.
After all if we don’t look hard at ourselves in the mirror on a regular basis, we are simply living in denial and hiding from the truth, and in the process we are failing our patients.
We have to work hard to rise above our subconscious bias and professional self-interest, it is not easy and it can often make one very unpopular, but so be it, I do not want to be a charlatan, I do not want to be a disingenuous peddler of placebo, if a surgical intervention is just a placebo, I simply have no wish to inflict it upon my patients.
Coming soon on 'The Sports Physio' an Osteopath and Chriopractors views on professional working and boundaries
Hi Ben,
I think it’s reasonable to say that in the field of healthcare, surgery is by far the least scientific discipline. On the odd occasion sham surgery is included in the mix, it’s almost always been shown to be as effective as the “real thing”.
As a physio, I’m quite happy to be a peddler of placebo, although it depends a bit on how the ‘p’ word is defined. I would be happy to be a patient to a peddler, so long as the cost was reasonable and the technique was non-invasive. I just want something that works, and I think patients are the same.
Some techniques on the surface look hard to test against placebo. Spinal manipulation for example. But there are ways around this. You show the patient how to manipulate himself. Lumbar and thoracic manipulations are very easy to do on oneself. Cervical manipulations are a bit harder bit can also be taught. Pretty soon it’s apparent where the power is coming from. Not the manipulation but the interaction with the practitioner. Treating oneself doesn’t work.
A GP I used to know told me that there’s only a handful of drugs that actually work, and the rest of the MIMS is filled with thousands of drugs which don’t! Would you say this is correct or was he being a bit cynical?
Here’s something I wrote for noijam along similar lines: http://noijam.com/2014/05/06/how-powerful-placebo/
Cameron
Ben
This is a great read; it’s fantastic as an osteopath to read articles that push theory and principles. I would be interested to hear your views on the this great TEDx talk by Lissa Rankin on the placebo effect https://www.youtube.com/watch?v=LWQfe__fNbs who hypothesises that the reason why it can produce physical changes is due to the patient’s own calmer state (due to the relief associated with professional help)
Secondly, how applicable would you say Benell et al’s work is to other injuries or painful representations? To say a home passive sham is no better than active rehabilitation would be contradictory to a lot of work in chronic pain such as that conducted by Lorimer Mosley who states that varied active rehabilitation is most effective for chronic pain presentations (such as hip O/A).
I’d be very interested to read your views and thank you Adam for another fantastic guest writer