A previous post discussing placebo and placebo effects generated a bit of interest and some discussion. One of the key players in the literature referenced was Professor Ted Kaptchuk. Professor Kaptchuk has recently published a perspective piece titled Placebo Effects in Medicine in The New England Journal of Medicine. It’s open access and definitely worth a read. A few highlights:
“Placebo effects are often considered the effects of an “inert substance,” but that characterization is misleading. In a broad sense, placebo effects are improvements in patients’ symptoms that are attributable to their participation in the therapeutic encounter, with its rituals, symbols, and interactions.”
“Moreover, recent clinical research into placebo effects has provided compelling evidence that these effects are genuine biopsychosocial phenomena that represent more than simply spontaneous remission, normal symptom fluctuations, and regression to the mean.”
“…placebo effects are not just about dummy pills: the effects of symbols and clinician interactions can dramatically enhance the effectiveness of pharmaceuticals.”
“What are the relationships among attention, gaze, touch, trust, openness, confidence, thoughtful words, and manner of speaking that can together reduce perceived discomfort, disability, and disfigurement?”
“Placebo effects are often considered unworthy and illegitimate. They are thought to be unscientific and caused by bias and prejudice. This attitude obscures a core truth of medicine: medicine’s goal is to heal, which can include cure, control of disease, and symptom relief or provision of comfort.”
“Medicine has used placebos as a methodologic tool to challenge, debunk, and discard ineffective and harmful treatments. But placebo effects are another story; they are not bogus. With proper controls for spontaneous remission and regression to the mean, placebo studies use placebos to elucidate and quantify the clinical, psychological, and biologic effects of immersion in a clinical environment”
There’s also an interview with Professor Kaptchuk that you can listen to here.
There’s an updated definition in all of this for this thing that in the past has been refereed to as the placebo effect, perhaps something along the lines of – biopsychosocial phenomena with complex neurobiological substrates, that represent improvements in patients’ symptoms that are attributable to their participation in a therapeutic encounter (or action) with its inherent ritual and symbolism, and the context dependent interaction between relationship, expectation, beliefs, values, attention, gaze, touch, trust, openness, confidence, thoughtful words, and manner of speaking.
It seems a shame to discard as ‘unworthy and illegitimate’ these powerful phenomena in the trash can labelled ‘placebo’.
Kaptchuk: “First, though placebos may provide relief, they rarely cure”.
Pain and function can be cured 100% with placebo. Us physios are doing it all the time. Pain cannot exist without physiological correlates, so this: “placebo effects do not alter the pathophysiology of diseases” is not correct either.
There’s a very important aspect of expectation which doesn’t often get mentioned. It’s power is very much dependent on the degree of expectation. If you can increase a client’s expectation by degrees, you will see a ‘dose dependent’ response in symptom improvement (1). Also, as therapist, what you’re feeling will be transferred to the patient, even without words. This is why hypnosis is by far the best tool we have available for the treatment of pain. We’ve not really explored the upper limits of expectation, but I’d suggest that it’s well within the realms of possibility to alter tissue and organ structure using the mind. It’s a logical extension of the FACT that we can alter physiology to a massive degree, given the right circumstances.
1) Lidstone SC1, Schulzer M, Dinelle K, Mak E, Sossi V, Ruth TJ, de la Fuente-Fernández R, Phillips AG, Stoessl AJ. Effects of expectation on placebo-induced dopamine release in Parkinson disease. Arch Gen Psychiatry. 2010 Aug;67(8):857-65.
I realise that shifts in awareness such as this need to go slowly to be accepted by the “old guard”, but it is clear that there is strong evidence for more than just improving the effectiveness of medications, and that once placebo/nocebo effects are better understood, then genuine healing might be more achievable, not simply a life less reliant on the right sort of medications – I say this as a person whose asthma is much, much better! When so much illness seems to be generated or exacerbated by stress, then the potential for self-improvement through learned self-calming techniques such as auto-hypnosis and relaxation training surely has enormous potential.
Suppose I do an ultrasound on a patient and tell them, “Ultrasound will help the tissues heal with heat, by increasing blood flow and nutrition to the tissue,” and this patient then feels the heat and feels encouraged by this. A patient would likely benefit from this treatment due to placebo effect. Is this okay to do? I think so. Is this an example of good physical therapy? I think probably not. While I think it is okay to use placebo effect to help benefit patient treatment, if placebo is all we have to offer, then we need to reconsider our treatment paradigm. It is important to recognize placebo as a litmus test for “bogus treatments.” If a treatment has no effect superior to placebo, it means that the treatment itself has no meaningful physiological effect. The placebo effect would be creating the physiological response. However, if we use treatments that do exhibit superior physiologic effects to placebo, and then combine some good biopsychosocial brain training then we may find a magic combination. My concern is that there are a great many PT’s who still do treatments that are poorly supported by the evidence (ahem, ultrasound), and they may choose to claim that this is good physical therapy because of reasons listed in the above post. I don’t disagree with the redefinition/renaming of the placebo effect, but I think it may be going a bit far to suggest that this is a good methodology to use for treatment. Instead our goal should be to use good treatments (which are superior to placebo), minimize nocebo, and perform pain education and provide as many SIMs as possible.
This looks like a good argument for putting ‘placebos’ into their proper place in the operator controlled treatment option hierarchy. What we assume to be the ‘placebo effect’, or as I would prefer to call it …..the ‘assisted adaptive healing process’, was already much in evidence long before any professional medical disciplines were structured, and long before any of those disciplines dared to claim credit for its possible relevance in healing. Subsequently, the whole notion of ‘placebo effect’ has been consummed into the various disciplines, as though it wouldn’t exist without their intervention. The problem there is this…..once we start to assume that ‘placebos’ are only possible within an imposed structure, we limit ourselves to only perceiving it in that light, and perhaps overlook the role of ‘assisted adaptive processes’ in the wider context, which should obviously include ‘self-induced’ placebos without any influencing external inputs. For any notion of placebo effect to be effective, it would seem that the only requirements are a self-convincing that adaptive processes will fulfill their purpose to a satisfactory outcome. Whether that self-convincing can be externally implanted, or not, is probably the real relevant question here. Whether a placebo effect can be effective by means of suggestion is probably indefinable because of the inherent assumptions required in evaluating and separating self-convincing from imposed suggestion.
If we could accept that it’s not possible for something to come from nothing ………If we could accept that a placebo application brings about a response then it can’t be nothing as the response is something………if we remember that when the patient knows they are receiving a placebo they can still experience benefit………if we could find a knew word to replace placebo such as trust, belief, hope, inspiration………..if placebo is nothing more than a synaptic response to an emotion, we accept tears when we are sad why can’t we accept physiological change when we trust? ………placebo is a treatment we just need to find a new word to replace it, to refine its application and share it with the recipient……….
Much has changed in the 43 years I’ve been in practice but the one constant has always been me. I’ve always had some success, all that has changed is my confidence through experience and my knowledge…….am I a placebo………? If so then I’ll continue to wear loud shirts to work, crack jokes at every opportunity and hug my patients when they or I need it…………move over show business…….
Isn’t using the ‘placebo’ excuse just another operator imposed understanding that there must be some intervention before any autonomic adaptive healing responses can generate their effects. Perhaps what we’re really looking at here is the fact that patient’s trust in their own adaptive responses have somehow been undermined gradually by the professions, to the point where it has become necessary to allow an externalised ‘placebo’ to claim credit for what might have occurred naturally if the patient had prior knowledge of their own healing potential. Who’s claiming credit for patients’ lack of confidence in non-medicated, or non-interventionist healing ? If there’s any re-education needed, the first lesson should be…….there will be no healing without a patient’s own autonomic responses….and that applies to all medications, all interventions, and all assumed placebos. By definition, autonomic responses don’t require a conscious ‘ switch ‘, so where does that leave ‘placebos’ in the grand scheme of things ?……an attempted power grab at a non-existing switch ?
Alternatively, given that a ‘placebo’ might just be a re-assurance to calm anxieties about healing prospects, the question that needs to be asked is this….’Does anxiety affect autonomic healing responses in a negative manner ?’ I think that it’s possible that healing anxiety might have some influence on autonomic responses, perhaps some subliminal infusion of contradictory purposes into the responses.
We are consciously capable of willfully making an injury / wound / infection worse, for example, by adding dirt to a wound, and thus negating any autonomic responses already in action. Conscious anxiety may have a similar effect of negating responses, and by calming the anxieties, the responses get a better run at completing their responsibilities. Personally, I don’t like to think that there can be be any ‘reverse’ crossovers between consciousness and the autonomic systems, i.e. that consciousness can affect autonomic functions at source, but if there were to be a question about that possibility, then ‘healing anxiety’ might be a top of the list suspect .