Placebo? If It Works, It Works!
It feels like we’re thinking too hard!
There’s been a lot of back-and-forth amongst clinicians about what is and isn’t an effective treatment; of course, based in & on the available evidence.
And, of course, it’s important to be evidence-based in our approach, but at what cost?
When the goal is to ease our patients’ pains, improve their health, & better their lives; how much does the latest meta-analysis or cohort study really matter?
Manual therapy is one that’s heavily debated amongst clinicians. It’s also, very much, a “people dealing with people” approach to treatment. Some clinicians swear by it & implement a manual technique into every session. Others write it off as a placebo; they swear manual techniques are a waste of time & avoid them like the plague! Funny enough, both sides have formed their opinions based off of the available literature!
From an evidence-based perspective, It’s impossible to say which side is right in this situation.
From a “people dealing with people” perspective, there’s a very clear and obvious winner.
I was working with a patient a couple of months ago that had come in for some pretty serious hip pain. An older gentleman with a full history of medical ailments, surgeries, accidents, and incidents; so, as you’d imagine, I wasn’t the first physical therapist he’d seen. Luckily, we hit it off pretty quickly – he loved to talk sports, give advice, and tell stories & of course, I’m very appreciative of all of those things. One thing he’d said to me really stood out, and it relates to this discussion…
We were doing our hip mobilizations – the ones with the big, long Mulligan belt that’ll quickly turn your treatment into a huge production – when the patient says,
“I was talking to my buddy about you the other day… ‘There’s a new PT at the clinic up here – pretty good too! He’s not like the guys at the other place. Doesn’t just sit on his laptop and drink coffee while I do all the exercises I could be doing at home!’”
Of course, I was appreciative of that as well! Those are the types of comments that really make me feel like I’m doing the right thing – like I’m making a genuine impact on someone’s life!
None of our patients are driving out to the clinic just to get the bare minimum human interaction and do the same old, boring exercises!
That should be common sense!
Which brings us back to the topic at hand: why would we avoid placebo interventions if our patients respond well to them?! At the very least, wouldn’t the occasional placebo technique be beneficial for patient buy-in?
If we’re basing our approach solely off of what our patients think & believe, there’s plenty of evidence suggesting that we should be doing manual therapy. According to a 2023 review by Thomas et. al, most patients with lower back pain believe that manual therapy is effective in treating their pain & prefer it to other lower back pain treatments! And why wouldn’t they? Manual therapy, at the very least, is something to look forward to – it’s an experience.
You can call it a placebo effect, but to write it off for that alone is insane! It’s still an intervention with an effect. It offers at least some benefit!
Carvalho et. al put together a study in which subjects knowingly took placebo pills with no active ingredients for treatment of their lower back pain while also receiving education regarding the potential power of the placebo effect. When compared to a control group that didn’t take the pill, the placebo group reported significantly less pain & symptoms!
“There was a clinically significant 30% reduction in both usual and maximum pain in the placebo group compared to reductions of 9% and 16% in usual and maximum pain, respectively, in the continued usual treatment group.”
What we’re finding is that if our patients expect a treatment to work, it’ll probably work!
“Our meta-analysis of the subset of studies in which expectations were measured demonstrated that verbal suggestion indeed induced expectations of pain relief, and the study authors showed that these expectations predicted effects on actually experienced pain.”
To hit the point home, in the spirit of creating a meaningful & worthwhile experience it can’t be overstated how much our patients value the skilled touch of a trained clinician. Especially now – post-pandemic!
We’re going through an epidemic of loneliness & isolation, and that loneliness has been shown to be both harmful & debilitating!
“In sum, lonelier people experienced more concurrent pain, depression, and fatigue and greater increases in the pain, depression, and fatigue symptom cluster from one year to the next...”
Even the smallest interactions have the potential to be overwhelmingly impactful! Imagine how impactful a back rub could be for someone who hasn’t left their house in days! Even if that’s not your style, the very least you could do is to show a genuine interest in your patients’ recovery!
The evidence doesn’t say that manual therapy is the be-all, end-all for patient outcomes, but it does say if your patient believes in it, then it’ll work! It’s really that simple!
So, it’s about time we simplified our approach!
The occasional placebo is likely to do more good than bad!
Our patients know what works for them; the literature & our expertise should only be used to lead us in the right direction!
Works Cited & Further Reading
Thomas, M., Thomson, O. P., Kolubinski, D. C., & Stewart-Lord, A. (2023). The attitudes and beliefs about manual therapy held by patients experiencing low back pain: a scoping review. Musculoskeletal science & practice, 65, 102752. https://doi.org/10.1016/j.msksp.2023.102752
Carvalho, C., Caetano, J. M., Cunha, L., Rebouta, P., Kaptchuk, T. J., & Kirsch, I. (2016). Open-label placebo treatment in chronic low back pain: a randomized controlled trial. Pain, 157(12), 2766–2772. https://doi.org/10.1097/j.pain.0000000000000700
Peerdeman, K. J., van Laarhoven, A. I. M., Keij, S. M., Vase, L., Rovers, M. M., Peters, M. L., & Evers, A. W. M. (2016). Relieving patients' pain with expectation interventions: a meta-analysis. Pain, 157(6), 1179–1191. https://doi.org/10.1097/j.pain.0000000000000540
Jaremka, L. M., Andridge, R. R., Fagundes, C. P., Alfano, C. M., Povoski, S. P., Lipari, A. M., Agnese, D. M., Arnold, M. W., Farrar, W. B., Yee, L. D., Carson, W. E., 3rd, Bekaii-Saab, T., Martin, E. W., Jr, Schmidt, C. R., & Kiecolt-Glaser, J. K. (2014). Pain, depression, and fatigue: loneliness as a longitudinal risk factor. Health psychology : official journal of the Division of Health Psychology, American Psychological Association, 33(9), 948–957. https://doi.org/10.1037/a0034012
