A good friend of noi, he generated a lot of interest with a previous post and recently sent us another very interesting piece
A recent story on 60 minutes piqued my interest and sent me searching the internet for more information on a drug called Etanercept.
The video below shows the treatment of a woman who has suffered 9 months of reasonably severe back and leg pain (I have no reason to doubt her story). In desperation, she attends a specialist medical clinic where she is injected with Etanercept and her pain disappears in 5 minutes. Have a look. There’s many similar videos on Youtube.
Impressive. How does this happen?
Blockbuster drugs only come along once in a blue moon, so the odds that Etanercept is a blockbuster in the making are extremely small (possible, but small). In fact a 2012 independent trial found Etanercept not even as effective as placebo in the treatment of sciatica. Given this, we can make a safe bet that this patient’s outcome represents a very rapid and powerful placebo response.
Many factors are assisting a placebo response:
-Etanercept is expensive
-Etanercept is not widely available (exclusive clinic setting, off label use)
-Etanercept is injected
-The procedure is being filmed (very powerful)
-Lots of suggestive language, build up, white coat etc.
-Last but by no means least, Flavor Flav in the background holding the clock!
Mr Flav with his trademark clock
It works out very well for the patient, which is great. No one could complain about the outcome, and I’m not suggesting any impropriety on behalf of the doctor or the clinic. I think the cost is around $1000 from what I can find on the net. That’s not too bad considering she has avoided the inconvenience and trauma of surgery.
We’ve all seen patients like this. It’s very easy to automatically expect that such a case might take weeks to recover. What about if we change our expectations? As clinicians, how can we go about regularly creating miracles like the one seen in the video? Can we comfortably entertain the notion that such rapid and powerful outcomes are even possible? What tricks can we use to ‘power up’ suggestion? Can such outcomes be achieved in 30, 15, 5 minute consultations? How far can we push the boundaries?
I believe each and everyone of us has the ability to “perform miracles”…….. How many times did my sons crash to the ground and scream with pain only to experience “total relief” by the administration of an “ice cream” preferably chocolate ……… However my research is flawed as I never asked after the pain levels after administration………better maybe, however not to take their attention back to the past……
Thanks for the post, Cameron. Very powerful and practical story. Makes me think of the number of times that, after an extended history taking and thorough examination, patients have expressed feeling much better shortly after I tell them “it’s not a heart attack…rotator cuff tear… cancer…etc”. Hail to the Drug Cabinet in the Brain.
The questions you post have the inlaid assumption that the miracle is maintained after the video ends. Have you ever listened to a patient describe PT when they think a therapist is not present? The intersection of social conformity and placebo is a messy one. We have known about the unreliability and inaccuracy of verbal reports for some time. (Nisbett & Wilson, 1977). What happens in 8 weeks when the miracle wears off? What happens when the social and contextual reinforcements of the expression return this time without the confidence of the wizard behind the curtain?
For every reward their is an equal risk. I believe the more we promise by enhancing a prediction of relief (read expectation) the more we risk if the reward does occur. This is not solely the temporary monetary loss of treating therapist but systemic trust in physical therapy and medicine in general.
Social and contextual cues exert powerful effects on the therapeutic relationship but the term placebo is applied when a construct of treatment is applied to the person. If we drop the use of this construct the nature of placebo becomes much less interesting. All we are left with is the residual social and contextual factors that forecast relief.
Therefore, instead of cranking up the placebo to 11 maybe we should just try to forecast relief in the ways that jive the best with the patient’s cognitive and affective processing sans the smoke and mirrors. As an aside, it truly amazes me how many therapists daftly label threat as something internal to the body (a misalignment, OA, poor muscle control) and indirectly forecast a poor prognosis. The only time it is not advisable to forecast relief is if there is an emergency.
Nisbett, R., & Wilson, T. (1977). Telling more than we can know: Verbal reports on mental processes. Psychological Review, (3). Retrieved from http://psycnet.apa.org/journals/rev/84/3/231/
Fair point Eric. I can report that the clinic’s own uncontrolled studies have shown that improvements following injection were maintained*. “…Mean VAS intensity of pain, sensory disturbance, and weakness were significantly reduced… at 20 min, 1 day, 1 week, 2 weeks, and 1 month with a p < 0.0001 at each time interval". Surely 1 month is adequate.
Also, David has some studies which I'm hoping he will post here which relate specifically to how well the placebo response can last into the future.
So if it's the case that the skillful use of smoke and mirrors will affect great and lasting improvements for the patient, would you still be against using it?
I take your point about the risk of failure, and how a patient might react to being given "false hope". This is such an important point. The way around this is to avoid using words to convey the confidence.
Since a large percentage of communication is non-verbal (perhaps 60% or more), the most effective way to convey confidence is through tone of voice, body langauge, gestures and general behaviour. When I use verbal suggestion, I make every effort to remain congruent with my inner experience. If I say “this will take 2 days to recover” but cannot convince myself of this, such incongruence will only create mistrust.
The placebo phenomenon suggests that rather than there being an objective truth ‘out there’, truth may in fact bend to our concept of what is possible. If so, we need to train our minds to be able to entertain great expectations, and express that expectation congruently
Hi Wesley. Hail indeed!
Juicy topic – it raises its head every now and then and then we kind of forget it. I have grappled with it for years, it is difficult to define, I get confused by the mass of often conflicting research, discussions with Pinot Noir help a little. Am I alone here? A few thoughts”. My simple conceptualisation of placebo revolve around “healthy brainpower” and of course the effect has to be emergent or collective ie a spectrum of inputs contribute to it. The thought of placebo always makes me think of the wonderful quote – I think it was Howard Spiro the gastroenterologist in his first placebo based book saying something like “I got sick of looking up patient’s bums for pains that belonged in the brain”.
Placebo can last a long time, though it’s not often reported. In studies, those on placebo interventions often do OK (and have less side effects) – two years for example in studies (Nickel JC et al CMAJ 1996: 155: 1251) on drug interventions for prostate enlargement – the placebo group even had better urine flow http://www.ncbi.nlm.nih.gov/pubmed/8911291
But forgetting thestudies for a moment – if a person with a problem visited your clinic 6 years ago and the therapeutic process went well, enhanced by your good looking and caring receptionist, plus the new paintjob for the clinic walls and up to date news magazines representing your political persuasions in the waiting room, then that essential “place of safety neurosignature” could last forever. The patient could feel better just making an appointment.
Eric raises the critical point though – when the magic goes, what is next i.e. when the interactive power fades, the secretary gets grumpy, the paint peels and “Harpers” is replaced by “Who” magazine, where to?” . Those skilled in chronic pain treatment will know the scenario well – the patient who may come after their favourite practitioner doesn’t seem to be getting the results any more. The brain is out of puff and its hard to progress. It is interesting that the key elements to maintained placebo are that the relationship between patient and clinician has to remain reciprocally healthy (Benson H, Friedman R (1996) AnnRev Med 47:193) These authors call it “remembered wellness” suggesting the term replace placebo.
There is danger here of course and I fear for the patient Cameron introduced us to. Somehow the answer is to gradually hand over the placebo effects to the patient rather than having the clinician as primary source. Back to my Pinot.
Thanks for the posts
I agree with the notion that placebo is an emergent phenomenon. The most powerful contributing factors in the development of chronic pain seem to be related to anxiety and self esteem. For example, ttp://www.ncbi.nlm.nih.gov/pubmed/8747252 I’m not sure if I should make such a sweeping statement, but clinically it seems true to say that only stressed people get aches and pains. The more stress the more it hurts and for longer.
Whilst I like the idea of giving the power back to the patient, I can’t do this easily in the clinical setting. I can’t say to someone with chronic back pain “Hey, if you fixed your relationship/work/family/money problems your back pain would disappear”, even though it’s probably the most honest thing I could say to him. Who am I to tell him to get his life together?! All I can say is “you know stress can cause this problem to be maintained”, and show him some more detailed explanations if he is open to the “pain as output” model. But then what? His relationship/work issues are still problematic. If he had the inclination, insight or energy to fix these, he probably would have done so already. Another problem I see with the education approach is that the patient actually understands the explanations and says “ok it’s caused by stress, therefore I don’t need to come to a physio… good bye”. If the patient doesn’t return, I lose my chance to apply person-centered (Rogerian) techniques which are by far the most powerful techniques I’ve ever used.