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Incorporating Placebos into Mainstream Medicine

Alternative medicine by definition is medicine that has not been shown to work any better than placebo. Patients think they are helped by alternative medicine. Placebos, by definition, do “please” patients. We would all like to please our patients, but we don’t want to lie to them. Is there a compromise? Is there a way we can ethically elicit the same placebo response that alternative theorists elicit by telling their patients fairy tales about qi, subluxations, or the memory of water?

Psychiatrist Morgan Levy has written a book entitled Placebo Medicine. It’s available free online. In it, he makes an intriguing case for incorporating the best alternative medicine placebo treatments into mainstream medicine.

In a light, entertaining style, he covers the placebo effect, suggestibility, and the foibles of the human thought processes that allow us to believe a treatment works when it doesn’t.

“Thinking like a human” is not a logical way to think but it is not a stupid way to think either. You could say that our thinking is intelligently illogical. Millions of years of evolution did not result in humans that think like a computer. It is precisely because we think in an intelligently illogical way that our predecessors were able to survive… [by acting on quick assumptions rather than waiting for comprehensive, definitive data]… We have evolved to survive, not to play chess.

He offers evidence from scientific studies indicating that belief in a treatment and the power of suggestion can have actual physiologic consequences such as production of endorphins or changes on brain imaging studies. He spices his narrative with colorful stories, including anecdotes from his own sex life and an impassioned plea (tongue in cheek?) for everyone to drink coffee for its proven benefits.

He gives examples (10 each) of three groups of treatments that elicit the placebo effect:

• Herbs and spices, (Bach’s flower remedies, Gingko, Echinacea, etc.)
• Misused therapies (chelation, colonic irrigation, fish oil, etc.)
• Totally fake treatments (acupuncture, homeopathy, ear candles, etc.)

He explains that some of these treatments do have real therapeutic effects, but they are being marketed for claims that are not the same as those real effects, or the real effects are too mild to support the claims.

“Placebo” is commonly thought of as a synonym for “ineffective” but it actually describes a therapeutic phenomenon that is very real and can be quite effective.
The mechanism of action involves the way we think about therapy rather than any actual effect of the therapy.

What if we told a patient:

I’m sending you to a Placebo Medicine specialist who will administer magnetic therapy. This therapy will have no real physiologic effect. However, if you carefully follow the direction of the magno-therapist and fully buy into what he or she is saying, then your brain will produce endorphins that will relieve the pain in your elbow.

This might work even better if we used Levy’s suggested term “Non-Pharmacological Intervention” or NPI instead of using the word “placebo.”

We could select patients by testing with suggestibility and psychosomatic instruments. We could tell the patient that he is fortunate because “Considering your scores on these scales you have a high probability of responding well to NPI treatments.”

What if scientific medicine were to co-opt the CAM movement? We could take these treatments out of the hands of the less ethical practitioners and outright scam artists and place it in the hands of those who are more likely to be altruistic. The truly altruistic practitioners could work within official guidelines. The charlatans would no longer be able to paint conventional medicine as the enemy. Family doctors would get to use placebos again. It would be a win-win situation.

If an acupuncturist is willing to use sham acupuncture and they don’t mind the patient being fully informed and they don’t cost too much, then I would gladly make referrals… I think that I could select an appropriate patient, perhaps one of my more somatic individuals, and educate them about the placebo effect. I would tell them how it can facilitate the brain to produce naturally occurring endorphins. I would refer patients for chronic idiopathic pain or for nausea and I would encourage them to fully buy into the story that the acupuncturist tells. I would say that the more they are able to do this the better it will work. Finally, I would follow the patient up afterwards.

I’m not entirely convinced, but I wonder if Dr. Levy might just be on to something. What do you think?

Posted in: Acupuncture, Book & movie reviews, Medical Ethics

Leave a Comment (53) ↓

53 thoughts on “Incorporating Placebos into Mainstream Medicine

  1. twaza says:

    The placebo effect (but not placebos) should be routinely and consciously exploited in mainstream medicine.

    Placebos as described in this post are inherently deceitful because the rely on unjustifiable claims of efficacy and mechanisms.

    Scientific medicine has to be truthful because telling lies denies patients their autonomy and impedes scientific progress.

    What scientific medicine should be doing is to learn what makes placebos work, and how this can be incorporated ethically and effectively into everyday clinical practice.

    At the core of the placebo effect is belief and hope that the intervention will be effective, and trust in the clinician. With due attention to the patient’s needs, values, and understanding, there is no reason why the clinical encounter could not be seen as an opportunity to foster the patient’s trust in the clinician, and to ensure that they have realistic hopes for the eventual outcome.

  2. No.

    I wouldn’t trust this guy further than I could throw him.

    If you use an obfuscating term like “non-pharmacologic intervention” instead of “placebo” or “fairy-tale” in order to prevent the patient from fully grasping what you mean by “no real physiologic effect,” then you cannot turn around and declare that the patient is “fully informed.”

    There are a lot of other reasons this is a Very Bad Idea (twaza got many of them) but if someone is telling me that a patient he has deliberately lied to is fully informed, then I stop listening to him right there. And I get angry.

  3. weing says:

    Thanks for the link. Damn, I feel stupid. I also thought the word came from ship high in transit.

  4. apgaylard says:

    David Colquhoun has elaborated on a couple of the dilemmas that need addressing if this sort of placebo medicine is to be ethically exploited. I think the comments above address the “lying dilemma” but the “training dilemma” is also interesting. Are the trainers to lie to their students? Or, if True Believers are used as trainers, howare their students to be taught to use the therapy appropriately. The CAM world is replete with examples of therapies being used well outside anything approaching an evidence base – Chiropractic is the obvious example du jour.

  5. Todd W. says:

    The big question is, how can the placebo effect be used ethically? I’m not certain Levy’s approach is necessarily good, as it would give a veneer of legitimacy to CAM treatments that they just do not deserve. I don’t see it deterring scam artists from peddling their quackery.

    There is a place, though, for using placebo as a treatment, particularly for psychosomatic illness and subjective symptoms, like pain. I’ve often wondered whether a company could market a sugar pill, giving it some drug-sounding name, like Placebex. The package insert would indicate that it has no pharmacological effect and that its indications are limited to psychosomatic illnesses and those where the illness is mild, self-limiting, for which no pharmaceutical works and when the patient demands to receive a pill. Like when someone has a viral infection and they demand antibiotics.

    Just a thought.

  6. wb4 says:

    In response to the commenters who have expressed disapproval of doctors lying to patients, this post is not suggesting that they do so. The idea is that a doctor first explains the placebo effect to the patient, and that the therapy he is about to recommend works only because of the placebo effect. The patient is fully informed. The doctor wouldn’t say, “I’m referring you to an acupuncturist because your chi is blocked.” He’d say, “I’m referring you to an acupuncturist because I think you would respond well to a placebo.”

  7. LovleAnjel says:

    I also have objections to lying to a patient about a treatment, or giving them something that doesn’t work for the problem they have. (In college, the health center gave me antibiotics for a sinus infection, and my ‘real’ doctor back home told me most cases are viral and he wouldn’t have prescribed them…I got very angry with the health center for wasting my money and screwing with my intestinal flora for no reason.)

    Is it ethical to lie to a patient because they’ll ‘feel better’?

    Is it ethical to make them pay for sugar pills?

    A better idea, would be for physicians to foster a more personal relationship with their patients. This is what a lot of CAM practitioners have over real medicine. I have had docs who saw me for ten minutes and had no idea who I was, and others who asked questions about my life, then noted the answers in my file so that the next time they saw me, they could ask me how grad school was going. I don’t expect them to know who I am or remember things about me off the top of their heads, but the fact that they made an effort made a huge difference in how I felt.

  8. Dan Warren says:

    This is a challenging and sensitive topic that I encounter every day as a pain medicine specialist. There are a few pitfalls that I would caution:

    The mere concept of intentionally deceiving a patient about the nature of the care provided damages the cooperative relationship between the physician and patient. It moves the physician into a paternalistic and condescending role that most cultures (and the AMA) consider inappropriate.

    There is also the ethical dilemma of what to charge for such a treatment. There is a suggestion that the more expensive the placebo is, the more effective patients report it to be (link below).
    http://www.ncbi.nlm.nih.gov/pubmed/18319411?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

    There are similar suggestions (I will find links later for a guest submission) that the more invasive a treatment is, the more profound the placebo effect, with surgery being more effective than injections, more so than pills…

    If I want to produce the “best placebo response” for my patients, should I charge a huge fee for invasive sham treatments in effort to treat their idiopathic complaints? I think not.

    I would also contend that when physicians endorse “placebo treatments” (such as acupuncture for argument sake) in effort to provide placebo response for a patient with no other reasonable therapeutic options, this becomes a passive endorsement of the dirty hippie acupuncturist in the strip mall that does not believe in germ theory (thank you Mark Crislip!!) and puts patients at truly undue risk.

    Thus, I do not “use placebos for therapeutic effect” in my practice. More to follow (if I can scrape up the time…)

  9. Harriet Hall says:

    In “Snake Oil Science” R. Barker Bausell made a suggestion similar to Levy’s. After totally demolishing all the “evidence” for CAM, he says a patient might get a placebo response from it and could choose a relatively innocuous CAM treatment and try to believe they will feel better.

    Neither Levy nor Bausell nor I believe it is acceptable to lie to patients.

  10. Ido says:

    I don’t think being informed would work, at least not for me. As a kid my mum used to give me homeopathic remedies and they seemed to work. Coughs, for examples, became less severe. Now that I know better I took a few homeopathic remedies when my mum asked me because I didn’t want to argue. Unlike my childhood memories, this just didn’t work. I can say that it seems to happen every time

    This is obviously anecdotal, and I’m not trying to defend it as being more than that. But I can safely claim that at least for me, being informed of the inefficacy of a homeopathy changed my body’s response to it. Not that I presume to know too much about the placebo effect, but it seems predictable to me.

    I think there might be a way to make an informed patient to susceptible to placebo treatment, but honestly it seems quite difficult. You practically tell someone a treatment has only a psychological effect, and then rely on their own self-deception capability. I personally find it difficult to delude myself like that. I just hope I’m not mischaracterizing what Levy says, but if I am correct, doctors would have to be artists of rhetoric to be able to pull this off.

  11. Jojo says:

    As a patient, I would say that doctors need to be very careful about how they use the placebo effect. I agree that it is a valid medical treatment and that there are people who can benefit from it, but there is significant damage that can be done if a patient does not feel that their doctor is being honest with them. Dr. Levy’s suggestion of “Non-Pharmacological Intervention” seems very deceptive to me. When I see that phrase, I think of treatments such as surgery, physical therapy, immobilizing broken bones, and shocking kidney stones. Buy lumping things like massage therapy and ear candling in with procedures that do have therapeutic value beyond placebo, you either raise the sham treatments to the level of EBM or you reduce EMB to the level of sham treatments. The necessity of blurring the truth for the placebo effect to work is likely to also blur the patient’s trust in their doctor’s ability to present honest medical advice. With the amount of quality medical information on the internet I think the risk of a patient discovering that Dr. Levy’s “Non-Pharmacological Intervention” are no more effective placebo is very high, and that trust will be lost in many of those situations.

    I understand that many doctors encounter patients that could really benefit from the placebo effect, especially for conditions that involve hard to treat pain. It must be very frustrating to know that you may be able to offer them help by recommending CAM for it’s placebo effect. But I wonder, like LovleAnjel, if some of those problems could be solved through better relationships with patients in an honest manner, than through deceiving them into thinking something is more than what it is.

    (That comes off sounding accusatory towards doctors, when I don’t intend it to. I recognize that most doctors would prefer to be able to spend more time with their patients and are just as frustrated by the limitations placed on them by the current economic model of the medical industry as the patients are.)

  12. kausikdatta says:

    Ms. Hall, you (or Levy or Bausell) may not personally believe that it is acceptable to lie to patients. But in advocating placebo as ‘therapy’, a physician is clearly lying by implication – don’t you think? I take the words you quoted:

    What if we told a patient:

    I’m sending you to a Placebo Medicine specialist who will administer magnetic therapy. This therapy will have no real physiologic effect. However, if you carefully follow the direction of the magno-therapist and fully buy into what he or she is saying, then your brain will produce endorphins that will relieve the pain in your elbow.

    This might work even better if we used Levy’s suggested term “Non-Pharmacological Intervention” or NPI instead of using the word “placebo.”

    For most patients, particularly those that are accustomed to consider the doctor to be a in position of authority and superior knowledge (it is not an uncommon patient position), would hear this:
    “I’m sending you to a Placebo Medicine specialist … you carefully follow the direction of the magneto-therapist … your brain will produce endorphins that will relieve the pain in your elbow.”

    Do you disagree that this is a very plausible scenario?

    As twaza and Allison and other early commenters have correctly pointed out, science-based medicine has to be truthful – and that includes truth by association, too. Is there any evidence whatsoever that magneto-therapy (or homeopathy or fairy pixie dust) induces endorphin or enkephalin secretion, and that it leads to cessation of pain? If yes, then science-based medicine ought to try figuring out exactly what it is that causes this effect, and that factor should be incorporated into modern medicine.

    Case in point, this is the way modern psychiatric medicines work. More and more somatic components of psychological disorders, and neuro-psychiatric components of somatic disorders are being identified and investigated, and so are pharmacological agents that target particular neurochemicals for fine tuning. Why not in physiologic medicine? If auto-endorphins are to be the panacea, then we should have well-researched, mechanism-elucidated, safety-assessed therapeutic agents that act as agonists for such endorphins.

    That is the only way to ensure that patients are not left at the mercies of snake-oil salesmen.

  13. rmgw says:

    “We could take these treatments out of the hands of the less ethical practitioners and outright scam artists and place it in the hands of those who are more likely to be altruistic.”

    Oh really? “We” being? behaving like this, how could “we” tell who is “less ethical”? – or is a distinction being drawn between “outright scam artists” and some other kind of scam artists?
    as for working out “who (is) more likely to be altruistic……….”

    This has to be a hoax.
    Rita

  14. Sam says:

    Whatever one thinks of CAM it does seem to be catching on:

    Integrative medicine: Mainstream Physicians Give Alternatives a Try:
    http://www.missoulian.com/articles/2009/07/26/livingwell/lw04.txt

    “Many mainstream physicians continue to be skeptical of alternative therapies, saying their efficacy has not been proven and their successes may be nothing more than variations of the placebo effect. But increasing numbers of institutions, including Johns Hopkins Hospital and the R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center, have established integrative medicine units that bring together conventional and alternative approaches to care.”

  15. James Fox says:

    The Santa myth doesn’t seem to do most children much harm and there are significant financial benefits to St. Nick’s ongoing exploitation of the young and gullible. Most parents happily engage in this myth expecting some joy for their children. HOWEVER in my opinion it would be unethical and egregious for a practicing physician to engage in this same charade despite informing the patient (there is no Santa) of the known total lack of real efficacy for the recommended treatment. And any pediatrician engaging in this type of psycho slight of hand should lose their license to practice. A bad idea that could open the door to regular abuse and lining the pockets of true believers in wooCAM.

  16. mckenzievmd says:

    I still don’t see how one can take advantage of the non-specific therapeutic effects of belief and expectancy without lying, at least by implication. Obfuscatory terms like “NPI” are only usefl because they obscure the fact that the therapy has only the value the patient’s belief gives it, and if we were truly clear about that with the patient it wouldn’t work any more.

    And, of course, for those of us struggling to bring reasonable standards of EBM and SBM to veterinary medicine, this approach would only make our job more difficult. Belief and expectancy placebos are not effective in non-human animals (though classical conditioning and some other non-specific therapeutic effects may apply), but they certainly affect our clients. So how do we explain why they got NPI therapy from their physician but it isn’t appropriate for their pet because it doesn’t actually do anything itself, it just tricks their mind into doing something? :-)

    Brennen McKenzie, MA, VMD
    http://www.skeptvet.com
    http://skeptvet.com/Blog

  17. trrll says:

    A recent survey of Chicago-area physicians found that about half had used a placebo in clinical practice http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=17994270

    It is very much a grey area. I’d say that any time a physician prescribes a drug that they do not rationally believe will have a beneficial pharmacological effect, they are engaging in placebo medicine. A lot of “take two aspirins and call me in the morning” probably falls into this category.

    It is worth noting that the efficacy of placebos for treatment of conditions other than pain is itself controversial.

    But in this discussion, people do seem to be assuming facts not in evidence. For instance, how important to the placebo effect is lying to the patient? Here is an anecdote:

    When I have blood drawn, even a few milliliters, I become faint, and my skin becomes pale and clammy. This is clearly a psychosomatic reaction; it doesn’t happen if I don’t watch. It is quite specific to a blood draw–a severe bleeding cut does not elicit this reaction, nor does watching a physician cut into me with a scalpel. I am fully aware that there is no rational physiological basis for this reaction, and it does not bother me consciously in the least to see my blood drawn; the reaction seems to come out of the blue. Even more oddly, on one occasion I had a medical tech “catch” the reaction from me, and have to leave the room. It seems to me that this qualifies as a type of “nocebo” response, and it is quite independent of my knowledge that having blood drawn will not hurt me. That being the case, I have some doubts as to what extent a physician’s being honest about a placebo will diminish the effect.

    And of course, there are various ways of being honest. For example, a physician might say, “I see no scientific explanation for the efficacy of this treatment, and I believe it is likely a placebo, but some patients with your symptoms say that it works for them.”

    I do think that there is another ethical concern, which is cost–it seems to me that there is an ethical issue associated with charging a patient for a treatment that you do not genuinely believe to be effective.

  18. Calli Arcale says:

    Allison Cummings:

    If you use an obfuscating term like “non-pharmacologic intervention” instead of “placebo” or “fairy-tale” in order to prevent the patient from fully grasping what you mean by “no real physiologic effect,” then you cannot turn around and declare that the patient is “fully informed.”

    Very well said. I think you’ve hit the nail on the head. He suggests replacing “placebo” with “non-pharmacologic intervention” but this is just obfuscation, and obfuscation is a form of deliberate deception. The *intent* is to prevent the patient from being fully informed (and realizing that it’s a sham treatment), ergo, you do not have informed consent.

    I understand the temptation to give someone a sugar pill sometimes. My grandfather, when he was in practice, did in fact do this, and spiced it up by warning patients that the “drug” could cause nausea, but it would be worth it if it alleviated their symptoms. As a teenager, I thought that was awfully clever of him. As an adult, I’m deeply disappointed. Essentially, he was deciding that some of his patients were hypochondriacs, and gave them a placebo to get them out of his hair. Not good, on many levels.

  19. Tim Kreider says:

    This is a fascinating question to me, and I haven’t yet figured out precisely how I feel about it. Great comments.

    The hard question I ask myself is “is this any different from what the integrative medicine proponents want?” The only big difference I see is in the personal belief of the physician making the acupuncture referral. I’m sure responsible IM docs often give disclaimers about “no scientific explanation/evidence” for acupuncture or whatever.

    Anyone know of a trial comparing “nothing for you” to “take this inert sugar pill for 1 week” for pain or cold or such? Even if honesty precludes the conscious expectation part of placebo, maybe we could still exploit conditioning etc for some small benefit.

  20. weing says:

    And don’t forget, the more expensive the placebo, the better it works.

  21. epersonae says:

    At least he’s not suggesting killer bees….

    An angry crowd has gathered outside the Hibbert Medical Clinic…

    Crowd: We need a cure! We need a cure!
    Hibbert: Ho ho ho. Why, the only cure is bedrest.
    Anything I give you would be a placebo.
    Woman: [frantic] Where can we get these placebos?

    The crowd overturn a truck in search of placebos, but alas the only
    thing inside is a crate of killer bees.

    Marge in Chains

    I actually don’t know how I feel about this…mostly, I can see it from both directions simultaneously. In taking antidepressants, sometimes I wonder how much of my experience is placebo, and yet I find as long as I’m able to function better, I don’t much care.

  22. ... says:

    Hmm. If patients find out, then it wouldn’t be effective as a placebo anymore. And patients wouldn’t like the idea of being prescribed a placebo. And allowing them to foster belief in something proven to be wrong is just unethical.

  23. twaza says:

    Levy makes some extraordinary assertions. For example, in the section on echinacea for preventing and treating the common cold he contrasts an RCT published in the New England Journal of Medicine in 2005 with a systematic review and meta-analysis published in the Lancet in 2007. The RCT and the meta-analysis came to opposite conclusions. Levy says:

    ” Lancet is usually a fairly reasonable medical journal but they tend to suspend critical thinking a bit when it comes to integrative therapies. The study they reported was ridiculous. They took 14 studies that used very different measures and combined the data in a meta-analysis. They got an answer that showed a benefit way beyond what any of the individual studies had shown. Under the best of circumstances a meta-analysis is a tricky procedure but when the studies involved use totally different methods then a meta-analysis is a statistically inappropriate technique.

    The Lancet would never have allowed such a study if the issue was a new drug to prevent stroke or heart disease. Why would they let this study slip by?

    Money. (You were warned that Dr. Levy has no tact.)

    Did I tell you that the non-traditional medical industry is a trillion dollar per year industry? Oh, Lancet would never be influenced by that…yeah, right.

    This industry makes its money by doing fake marketing studies on compounds that regular medicine discarded as not likely to be effective. I would even go out on a limb and suggest that the 2007 meta-analysis was intentionally fabricated. The well done double blind placebo controlled study in 2005 probably cut into their profits. The industry needed to fight back. Rather than doing a real study that might not produce the desired results they did an inappropriate meta-analysis.”

    This is the biggest strawman I have ever seen, and it fails.

    The Lancet, being run by humans, makes mistakes from time to time, for example publishing the fabricated link between autism and the MMR vaccine. In the MMR case, the Lancet was taken in by the authors. I have not seen it suggested anywhere that it was influenced by money. And, it has published papers that would not make big pharma happy.

    If the article was fabricated, it was done by a group with impeccable credentials. I quote from their website:

    “The Agency for Healthcare Research and Quality (AHRQ) has designated 14 Evidence-based Practice Centers (EPCs) throughout North America. The University of Connecticut (UCONN) and Hartford Hospital (HH) were jointly selected as an EPC in July of 2007. ”

    For more, visit http://pharmacy.uconn.edu/index.php?option=com_content&task=view&id=483&Itemid=774

    The one substantive criticsm Levy makes of the meta-analysis is that “They took 14 studies that used very different measures and combined the data in a meta-analysis.”

    He doesn’t mention it, but a Cochrane systematic review on echiacea and the common cold published a year earlier set (a priori) criteria for combining studies. Because no studies met all 4 criteria, they did not do a meta-analysis.

    However, there is a case to be made for combining studies with different methods – as long as they aren’t too different. A fruit salad works well with apples and pears and peaches, but would be spoiled by garlic and onions (HT Steve Simon). A famous (or notorious, depending on your taste in fruit salads) Cochrane systematic review on the placebo effect did combine studies with very different methods. (It concluded that the placebo is powerless!)

    Levy tries to be funny, but fails.

    He tries a classic bait and switch trick: “trust me, I am a hard-nosed sceptic; when you’re hooked I will sell you something really phony (like a placebo), and you will be truly pleased”. I hope no-one falls for this cheap trick

  24. “Non-Pharmacological Intervention” is clearly an attempt to deceive and a violation of the spirit of informed consent.

    How strong is the placebo response when the subject knows (or believes) they are receiving the placebo and fully understand what that means? I ask this because I don’t know if there’s an ethical way to use placebos in medical practice without being clearly honest about it.

    I don’t think I’ve seen anyone bring up the Frankenstein’s monster issue this raises. (Don’t create a monster you can’t control) It’s one of the points that comes up when someone asks what’s the harm in CAM in general. The idea that faith in the CAM treatment will result in a displacement or deferral of scientifically validated treatments for future medical needs. Once the patient trusts in the effectiveness of an alternative treatment, there is the likely potential for the patient to seek out that treatment for future issue rather than consulting with an MD.

    Frankly that whole thing smacks me of trying to catch a tiger by the tail, and someone’s going to get eaten by the tiger. Sending patients for placebo CAM treatments, no matter how clearly you explain that is nothing but placebo, is just going to foster belief in the genuine effectiveness of the particular CAM modality; I believe that this is inevitable. It’s unintentionally going to become the intelligent design of medicine: a backdoor for CAM to enter the world of mainstream medicine.

    Here’s your headline now, “Western Medicine Finally Concedes: CAM Works!” That’s exactly how the Alties are going to spin it: Allopathic medicine has finally found away to save face while conceding defeat in the war against CAM & Integrative Medicine; commence opening the floodgates.

  25. Peter Lipson says:

    Deception aside, the placebo EFFECT is not a TREATMENT. It is an artifact, something you see when you observe any patient for anything. We are probably “using” the placebo effect already, every time we sit down across from a patient, put down our pen, and converse.

    There’s nothing here to exploit.

  26. tommyhj says:

    I have several points.

    1:
    Lots of practitioners are using the placebo effect as active treatment already. One third (or so they say) of the practitioners in my country (Denmark) offers acupuncture to their patients. In Germany many practitioners offers homoeopathic remedies. This is happening right now, so the discussion is not about “if we should”, but more “if we should stop our colleges”. The answer is naturally, yes we should (stop them), as other commenters have elaborated.

    2:
    The placebo effect is an inherent effect in almost all treatment, where conscious patients grade the severity of symptoms, under influence of suggestibility, belief in treatment, subconscious bias, natural history of the disease, state of mind, stress levels, etc. In that way we use the effect to our advantage every time a patient claims a treatment has worked. Some of it was evidence based treatment and physiology, some of it was trust, belief and placebo. The aspirin scenario is a classic in that respect.

    Sometimes we even see the opposite of placebo effect. When a treatment actually works, but for other reasons the patient is angry with the system, stressed, drugged etc, and he will perceive his condition to be worsening. Those are the patients that we loose to CAM.

    3:
    It is possible to harvest some of the benefits of the placebo effect without lying to the patient. This is called cognitive therapy. The chronic pain patient can learn to live with the pain given some cognitive tools to relax and accept that life is what it is. In stead of magic, we can tell patients that half of the treatment of chronic conditions is the way the patient perceives the disease. We can tell them that they have a choice: You can learn not to be bothered by your irritable bowel syndrome, and then you don’t have it. Or you could spend a lot of money and convince yourself that you must feel better or else the money was a waste – your choice. Perception is key, and maybe we can learn our most difficult patient to perceive their illness differently, instead of sending them to the chiropractor or acupuncturist.

    4: (off topic)
    Basic science should include some basic philosophy in school, so people know that anecdotes isn’t evidence, “the chineese did it for millennia” isn’t an argument, and that the last thing aunt Emma tried before she got better wasn’t the necessarily the cure (I always find lost things the last place I look too). I mean, ignorance is no. 1 preventable cause of death by CAM. :)

  27. antipodean says:

    I would be horrified if a treating physician was knowingly prescribing placebos. Furthermore, treating ‘suggestible’ or less educated patients with placebos whilst fully disclosing the fact they will have a placebo is also highly unethical. Either you are exploiting their trust in you, their lack of education in this area or you are calling them idiots. You are still attempting to dupe them. How does this separate you, as a so called evidence-based practitioner, from a typical sCAM practitioner?

    tommyhj. Cognitive behavioural therapy is not a type of placebo. I agree that some of it’s mechanism may have concepts attached that might appear placebo-like but it’s effects for numerous conditions are far superior to typical placebo effects

    Non-Pharmaceutical Intervention (NPI). This is a totally naive label. Surgery, device-based treatments (implantable or non-implantable), physiotherapy, excercise, diet, light therapy etc etc. All legitimate evidence-based treatments for various conditions that are not pharmaceutical and are also not placebos. The NPI label is just another method for lying to patients.

    I completely agree with Peter:

    “the placebo EFFECT is not a TREATMENT. It is an artifact, something you see when you observe any patient for anything.”

    It’s simply a matter of good manners. A little bit of respect and genuine concern for those who come to you for help might go a long way further in the long run than referral to a scam artist, good intentioned or not.

  28. pmoran says:

    Brave of you to address this, Harriet.

    Recent studies suggest that without much agonizing about anything, many doctors do use dubious treatments, presumably knowing that they are probably placebos.

    How much deception is involved? I suspect that any deception is likely to be mutual, part of that unspoken collusion that exists between a good doctor and his patient towards getting well again (“Well, will we try that? A lot of people think it can help.” ).

    I cannot see any change occurring in the policy of any medical body regarding the use of placebos. The main importance of the subject is that it should force us to examine some basic assumptions.

    Some that come to mind are:

    - that CAM cannot, and does not “work” in any respect. (All we can say is that the methods don’t work, or are unlikely to work, better than a comparable placebo)

    - That there is a clear divide between treatments that “work” and those that don’t (this can hang upon a mere few per cent better performance over placebo in RCTs. Sometimes the answer — regarding any intrinsic activity– is not clear even after dozens of studies or later studies necessitate a change of mind. It is often in the end a matter of probability. )

    - That conventional medicine has satisfactory answers for most medical problems (the upsurge of CAM and the very consideration of the use of placebos proves not — there would be no need for either if there were 100% effective and entirely safe EBM treatments for everything. Is CAM is largely a manifestation of present-day medicine’s limitations? ).

    - That it is irrational and merely indicative of a poor grasp of science when people turn to CAM. (It need not entail much thought at all to try out a treatment, when in distress and nothing else is helping).

    - That better science education will help answer the CAM “problem” (to the extent that it is a soluble problem the key thing is probably where people are prepared to invest their trust. Building trust may need to start from having a very clear-sighted understanding of the terrain.)

  29. The Blind Watchmaker says:

    This is the preferred treatment of the HMO’s I deal with. The saying goes… you can’t get somethin’ for nothin’. Well, maybe you can, a little.

  30. Harriet Hall says:

    Lots of thoughtful comments. I have done some more thinking and I have gone back to a position I have stated before:

    I would not recommend CAM to a patient or refer to a CAM provider.
    If the patient asked for information about CAM, I would explain that there is no scientific evidence to support it.
    If the patient expressed an interest in trying CAM, I would tell him that there was no scientific evidence to support it but I would acknowledge that some people have thought it helped them. I would tell them I had no objection to their trying it, and I might mention that even if they just had a placebo response, they might feel better, which would be a good thing. I would show interest and ask them to return to me for followup and tell me how the CAM treatment went.

  31. pmoore says:

    I’ve recently become “re-immersed” in Science; after a 10 year accidental foray into an IT career I’m now a 1st year Science student with lofty aspiration to studying medicine, so this is my disclaimer for anything silly I’m about to say… I’m a beginner!

    My understanding of the Placebos and the Placebo effect is that a placebo is like a sugar pill or something else where someone believes they are getting real medicine but it has no pharmacological effect. The Placebo effect is when a patient receives some sort of therapeutic benefit from unknowingly receiving a placebo, believing it is a real medical treatment.

    So I had a couple of questions:

    1. Is there a requirement for a patient to be completely unaware that they are receiving a placebo, so they really believe they are receiving real medicine, for it to have a positive effect. Or if someone is given a sugar pill for a headache and is fully informed it is a sugar pill, is there a possibility of any benefit? Perhaps a shorter question is, does fully informing a patient reduce the likelihood of a placebo effect?

    2. Is the placebo effect a real benefit? Is it a cure or a temporary psychological relief?

    3. If the placebo effect is really down to someone believing they are receiving real medicine, so “I think I’m getting medicine so I get better” does real medicine not provide the same psychological benefits? So if someone is receiving medication for pain, is there a need to also refer them to an acupuncturist or similar? Will it provide any additional benefit beyond their belief that their real medicine is helping them?

    Anyhoo… thanks for reading, sorry if they are silly questions, but maybe someone can set straight my confusion or satisfy my curiosity :)

    Thanks!

  32. halincoh says:

    In grad school, a million years ago, I was one of the first to make a connection between enkephalins, endorphins, and the placebo effect. Unfortunately, others beat me to the publishing race. Ever since then I have been a fan of this specific aspect of the placebo. As a primary care the physician , I continue to remain a fan. I AM a placebo effect. But … I must always be better than JUST a placebo effect. My treatments must be better. The therapeutic world , in general, should not dismiss the effect, and, those who are more suggestive than others for instance, may respond better to this mileu than others. Embrace it within a clinically/scientifically proven treatment plan. But never, ever settle for it.

  33. Tsuken says:

    I agree with what Peter Lipson said above about placebo effect vs a placebo: they’re not necessarily, nor always, the same thing. I’ve certainly wondered about the placebo effect being perhaps part of the explanation for why I’ve seen the same treatment produce consistently good results prescribed by a colleague, and not when used in the same doses, in the same disorders, by others (including me).

    Conversely, I make a conscious effort to engage my patients in their treatment, and make it clear that (and why) I expect they will have positive results … which if you want to you can certainly call using the placebo effect – but in addition to a real treatment.

    Kausikdatta, I’m not sure what you mean by

    Case in point, this is the way modern psychiatric medicines work.

    It reads (to me) as though you’re suggesting that psychiatric medication works without physiological basis – though I accept (and hope) that I could be wrong. While we don’t have the physiology of psychiatric illness “sorted” at this point, there are clear physiological bases for these illnesses and their treatment.

    As a last point, I’d like personally to emphasise that Dr Levy does not appear to me representative of psychiatrists as a group (being one myself). The overly chatty and superficial tone, coupled with what appears to me a knee-jerk diagnosis(es) in the very first section (re: Dr Lorraine Day) without any justification in the text, and lack of boundaries involved in blazoning personal sexual anecdotes on the Web (I’ll believe Harriet’s report of these, as I don’t intend reading much further) greatly diminish his appearance of professional credibility in my eyes.

    Given that we (a) can’t point to the “Bipolar gene”, or the “schizophrenia virus” or suchlike, and that we are dealing with – and trying to study – the totality of very complex organisms called humans, with all the “vagaries” of our conscious and unconscious minds, we need to be *at least* as scientifically rigourous as our colleagues in other branches of medicine. He appears to have fallen for a particular notion and is running with it (I think) too far: more than evidence, logic, or professionalism can carry it.

  34. shawmutt says:

    The problem I see is not in the placebo effect itself, but the billions made by scam artists who sell the placebo effect in its many forms of sCAM.

  35. Steve S says:

    I had an interesting encounter with an integrative medicine practitioner yesterday. She was talking about accupuncture and its use in her practice to my residences, particularly my new interns. She talked about the history of it, left half; theories of it working including endorphins, and then got into fractils, chaos theory and kurelin (I don’t know if I spelled that right) photography as some how being related to and proving it. She also said accupuncture is part of the new energy medicine movement. Also about the organizations of such. She also talked about using nuclear medicine to track the meridians and some histology specimens. She then showed a bunch of studies she said support it, most were small samples up to maybe a dozen as most subjects. She also talked about it working in horses, etc. It was getting close to the end of her talk and I couldn’t stand it any more. I corrected her history. Pointed out that hitting your thumb with a hammer will release endorphins. I questioned the existence of the meridens and explained to my residents that china didn’t allow dissections and they made up the meridans and the number some how equals the number of days in a year. I talked about the good literature of placebo in vet medicine. She then said said I was a skeptic, like it was a dirty word. Then she said it is a difference in philosophy. I told her we are not discussing transcendentalism v existensialism, we are discussing science and science here in the US is the same as science anywhere else in the world. Then my partner took to some questions and tried a gentler mode of questioning. He said I was getting a little hard on her. She then got couple hours to talk to the interns without me, I had to see real patients. One of my interns afterwards said that she lost all credibility with him after she told him to ask the next back patient what his or her favorite color is. And she said it would be blue. I was happy that at least one of my interns saw through the veil. But the medical school I work at has also gotten a grant to start a integrative medicine curriculum with this junk. What is one to do?

  36. Steve S says:

    Oh as to this discussion one important point. My partner asked the intergrative “physician” why she does it. Her response was not based on studies, but based on her experience of what she believed worked for patients. She also said her patients come to her for what they believed worked. She also said they believe as she does that it has preventative aspects also.

  37. Tsuken says:

    @Steve S: well done. Exhausting though – and sadly with no impact I’m sure, on the “integrative medicine practitioner”

    … what are we practising? Disintegrative medicine? ;-)

  38. tommyhj says:

    Every aspiring medical professional ought to read this post and its comments. Praise to Harriet for bringing up such a touchy subject!

    The approach that Harriet outlines in her last comment is indeed what I see as the best compromise when dealing with patients who considers CAM treatment. It shows respect, humility, trust and secures follow-up.

  39. Calli Arcale says:

    Steve S:

    She talked about the history of it, left half; theories of it working including endorphins, and then got into fractils, chaos theory and kurelin (I don’t know if I spelled that right) photography as some how being related to and proving it.

    Oh my. That would be Kirlian Photography. The technique involves putting the subject into direct physical contact with a piece of photographic film put on top of an electrified plate. Basically, an electrical corona is created, which the film then records. Kirlian didn’t originate the concept, but he did give it new notoriety by suggesting that it provided a means of viewing a person’s aura, and by using color film (not previously available). The woo-woo community snapped it up, especially as it suggested that people might have different color auras, which would apparently mean something. It validated their pre-existing notions, so it became fashionable. It’s not so big nowdays, but obviously some adherents still exist.

  40. alison says:

    As a non-expert (a scientist but not a medical one) I too would be interested in some responses to pmoore’s comments above. And to this one: if it’s necessary to believe for the placebo effect to work, how does that account for the many anecdotes on the lines of ‘I was a complete sceptic until I tried it, but then I was convinced’. Is that because a confident and charismatic practitioner can exert an overwhelmingly powerful effect, or could it be that the sceptic wasn’t really that sceptical in the first place? Or do the CAM folks make up these testimonials? Just wondering about a really fascinating subject.

  41. Harriet Hall says:

    It is not necessary to believe for the placebo response to occur. This is well documented in the literature. After patients in blinded studies are told they only got placebo, they frequently want to keep using it. And people can disbelieve on one level and believe on another. And there is a strong confounder: the varying natural course of illness and regression to the mean assure that some people will improve anyway. There are all kinds of other confounders like the patient’s wanting to please the provider and not wanting to admit they have wasted their money. There is an excellent article on why bogus treatments seem to work at http://www.quackwatch.com/01QuackeryRelatedTopics/altbelief.html

  42. kausikdatta says:

    Tsuken:

    It reads (to me) as though you’re suggesting that psychiatric medication works without physiological basis – though I accept (and hope) that I could be wrong.

    Pardon my incomprehensible sentence construction, Tsuken. But I am rather relieved to say that in this case, you are wrong.

    Whew!

    I meant quite the opposite. Modern psychiatric medication absolutely relies more and more on the underlying physiological – organic, if you will – basis. I quote from my original post -

    More and more somatic components of psychological disorders, and neuro-psychiatric components of somatic disorders are being identified and investigated, and so are pharmacological agents that target particular neurochemicals for fine tuning.

    Most psychiatric medicines that are in use today have solid empirical base; their mechanisms of action, and what they specifically can or cannot do, are well-researched and understood.

    My lament is that the flim-flam, pretentious CAM purports to work on same or similar principles – without providing a shred of evidence. Many of the so-called modern practitioners of CAM facilely talk about how various forms of CAM releases endorphins, the panacea of all illnesses, but when it comes to actual, consistently demonstrable evidence, they have zilch, zippo, nada. Many of them consciously omit to mention that effects of CAM observed in placebo-controlled studies were not any better than the placebos.

    Already ordinary lay-people buy into this scam for various reasons. Responsible physicians should not consciously send more of their patients in that direction (which was the original idea in Harriet’s discussion of Levy’s concept).

  43. Jon Newman says:

    Suppose someone developed a clinical prediction rule for people that will benefit from the use of a placebo. Likely predictors would include:

    –an absence of relevant/detectable pathology including “red flags”
    –recent onset or recent exacerbation of symptoms
    –lack of psychological findings associated with poorer outcomes

    People testing positive on the clinical prediction rule could be provided with a placebo as part of an overall treatment plan. The practitioner can feel good because there will be evidence to support its use and need not to lie to the patient.

    Of course there will have to be a CPR developed for each placebo even if the main predictors will probably be the same.

    The only point where deception has a chance of creeping in is if the patient asks how/why the treatment works. Here is where I think many (most?) alt. med. providers go wrong.

    I disagree with those that suggest that placebo therapy has “no real physiological effects” as clearly there are such effects or there would be no such thing as a placebo response making this whole discussion moot. Also, pharmaceutical companies would no longer have to demonstrate their drugs work better than a placebo. Perhaps it would be closer to the truth to argue that there are no relevant and direct context-independent effects.

    Regardless, I think a more involved narrative is necessary in these circumstances. Just saying, “it’s placebo”, does not accomplish the task of actually informing the patient as such an approach assumes the patient has a deep understanding of placebo effect and all that that entails. Similarly, I would not tell someone “that’s your plasma cascade system” and move on when discussing their experience of recently sprained ankle. I suppose it takes time that many practitioners just don’t have.

  44. pmoran says:

    ” 2. Is the placebo effect a real benefit? Is it a cure or a temporary psychological relief?”

    Its psychologically mediated; the level of benefit is the big question.

    Unfortunately the available evidence is consistent with a range of answers which are themselves very context dependent. For example there is virtually no evidence that cancer responds to make-believe treatments, but cancer symptoms might be helped, at least for a while.

    I am concerned that we skeptics should not assume that we know the answer, in our eagerness to cut all ground from under CAM. That is inconsistent with normal scientific caution.

    But I am prepared to test my view of the evidence out, if others disagree.

  45. Dan Warren says:

    Steve S: (and all academic faculty)

    The idea that this “physician” had access to the interns for such a pitch is appalling. I applaud you for sticking your neck out to counter the nonsense.

    I would like to encourage all the academic physicians reading this blog to take a stand for science based medicine by influencing the curriculum in your respective institutions.

    My state professional society (anesthesiology) had received requests for lecture presentation on acupuncture in anesthesia and pain medicine. Rather than letting the local woo master “integrative medicine” specialist shill the same story unfettered, I presented with her in a pro-con type format. I certainly did not “convert the true believers”, but probably un-shrugged some shruggies and strengthened the resolve of skeptics.

    For those who have the opportunity, presenting concepts in such a format reduces the accusations that alt med is being stomped out of the curriculum in a monopolistic effort, but prevents utter nonsense from being fed to training physicians without retort. This type of effort could lead to further critical thinking education for residents and medical students. This placebo discussion would be ripe for a problem-based learning module…

  46. kausikdatta says:

    Jon:

    I disagree with those that suggest that placebo therapy has “no real physiological effects” as clearly there are such effects or there would be no such thing as a placebo response making this whole discussion moot. Also, pharmaceutical companies would no longer have to demonstrate their drugs work better than a placebo.

    I must object to this oxymoronic term, “Placebo Therapy”. If it is placebo, it is not therapy – and vice versa.

    The placebo response (e.g. amelioration of symptoms without actual pharmacological intervention) occurs by random chance, as a result of concatenation of non-targeted events, or by means of unidentified processes within the physiological system that are not directly relevant to the pharmacological agent being tested in comparison.

    Therefore, the placebo response may vary greatly between individuals, and may not be reproducible even under identical conditions. That is why when therapeutic agents are investigated and tested, their effects/efficacies must be demonstrable as better than (not same as) the effects of the placebo – so that events occurring by random chance can be appropriately controlled for.

    A simple, if parallel, example. In mouse studies, often phosphate-buffered saline (PBS) is used as a vehicle for delivery of infectious agents or drugs or any other agent; therefore, in the control group, just plain PBS is delivered without the agent. It has been shown that delivery of plain PBS can per se raise the levels – albeit minimally – of certain cytokines and chemokines in the system (which in normal physiology regulate the immune responses). Therefore, in order to demonstrate the effect of the infectious agent or the drug, the test group must have significant changes in the levels of those cytokines or chemokines. Only then, one has a basis for arguing about the effect of the introduced agent.

    The same argument goes for placebo effect also. The mechanisms are unknown, and therefore, the responses are not controllable. If scientific studies can unearth what exactly happens when a placebo is given, it would not remain ‘placebo’ any more; rather, the principle would be incorporated into a therapeutic modality.

    As long as the parameters of a placebo response (read, ‘CAM’) are not elucidated, CAM remains firmly entrenched in the realm of pseudo-science – fit only for scamming the gullible.

  47. Jon Newman says:

    kausikdatta–

    I find myself in agreement with much of your post. Regarding “placebo therapy”: I used that term based on the this portion of the quote in the opening post.

    “I’m sending you to a Placebo Medicine specialist who will administer magnetic therapy. This therapy will have no real physiologic effect.”

    I thought it reasonable to generalize “this therapy” to “placebo therapy” since a placebo was the referent of “this therapy.” Maybe the confusion highlights the benefit of using the term “non-pharmacological intervention” except that many placebos are, at least nominally, pharmacologic.

    “The same argument goes for placebo effect also. The mechanisms are unknown, and therefore, the responses are not controllable.”

    I’d say that the mechanisms aren’t completely accounted for rather than “unknown.” There is quite a bit known about the response to placebo.

  48. daedalus2u says:

    I have a blog post where I talk about my understanding of the physiology behind the placebo effect.

    http://daedalus2u.blogspot.com/2007/04/placebo-and-nocebo-effects.html

    I see it as the normal neurologic regulation of the allocation of metabolic resources (especially ATP) between different metabolic tasks according to priority. These priorities change over time, so the allocation of resources must change also. Optimizing resource allocation over time allows greater resources to be devoted to reproduction and not used as “overhead”. For example under conditions of “fight or flight”, ATP is held in reserve for allocation to immediate consumption such as for running from a bear. ATP held in reserve cannot be used for tasks such as healing or reproduction. When the bear is escaped from, then those resources can be allocated back to longer term uses such as healing and reproduction. That allocation is mediate through processes which include what is known as the placebo effect. I see the placebo effect as the neurogenic reallocation of metabolic resources away from a “fight or flight” state to a state where healing can happen. Essentially all placebos are “stress relievers” of a certain type. “Stress” is a very complex state, so there must be equally complex physiological pathways to get out of that state of stress.

    I would characterize a “placebo therapy” as any treatment which produced therapeutic effect not mediated through chemical or physical effects, i.e. pharmacology or surgery. Treatments mediated through communication (such as psychotherapy) are (according to my definition) placebos.

    The healing that placebos accomplish is “real” healing. Healing is a very complex physiological process under extremely complex physiological control. A simple treatment cannot produce complex results. The complexity of the healing process is already inherent in the organism that is healing. A placebo simply facilitates switching the organism into a state where healing is upregulated.

    I appreciate that when many people use the term “placebo” they include imaginary and delusional results. That is not how I am using the term. I limit the term “placebo effects” to actual physiological effects triggered by non-chemical and non-physical treatments. If there are no effects, there is no placebo effect.

  49. trrll says:

    One point of confusion is that the “placebo effect” can mean more than one thing.

    It is not uncommon in clinical trials to observe improvement, sometimes substantial, in the group randomized to placebo. There are multiple factors that can cause this:

    1. Natural course of illness/Regression toward the mean: Many conditions get better on their own, and even conditions that do not improve over time often fluctuate. Since people are more likely to seek medical care when they are having a “bad time,” there is a good chance that they will improve in the future even if nothing is done.

    2. Optimism: A physician would like to believe that what he is doing is benefiting the patient, and may be predisposed to see improvement where there is none. Similarly, an optimistic patient may perceive improvement in symptoms when there is none.

    3. Power of suggestion: The expectation of a benefit on the part of the patient may cause the patient to feel better, presumably as a consequence of changes in neural activity and/or release of physiological mediators (e.g. endorphins) that improve the patient’s condition or reduce the patient’s awareness of symptoms.

    Of these three, only the third could potentially be turned to therapeutic ends; the first two are artifacts with no benefit to the patient. It is rare that experiments are designed to distinguish among these, and ethical constraints related to informed consent often limit the ability to design such experiments. As a result, the existence of a placebo effect of the third kind remains controversial; the evidence is strongest with respect to pain. If there is such an effect, it is unclear to what extent that it is influenced by the patient’s belief in the therapy. It could be a type of conditioned response, for example.

    As for the anecdotes, “I was a complete sceptic until I tried it, but then I was convinced,” most people are unaware of the magnitude of confirmation bias. If one’s symptoms seem to improve after a “treatment,” due to random fluctuation of symptoms (factor 1), this can cause one to be convinced of the validity of the treatment. Some people are constantly trying one alternative therapy after another. For such people, it is virtually inevitable that they will occasionally feel better after a treatment. They think they are finding the treatments that “work for them,” when it is actually nothing more than random chance.

  50. Diane Jacobs says:

    Even though I do realize what a pesky confounder placebo response is for medical and pharmacological investigation and research, as a manual therapist/human primate social groomer I’d like to stick up for it, if I may (after all, it isn’t going to go away any time soon).

    I really do think it requires some detailed understanding and ethical handling instead.

    If it were not for placebo response, manual treatment for ordinary mechanical, non-medical, non-pathological pain would probably have no success whatsoever. As it is, mostly thanks to placebo response, it is possible to treat mechanical pain in a science-based manner, quite effectively, by drawing on neuroscience, explaining brain and pain mechanisms to patients, then treating them with hands-on methods and/or just with education. Imagine. :)

    People/patients do need to have an explanation to keep their cognitive-evaluative brain parts distracted, busy, and hopeful, give the chemistry in there an opportunity to change a bit, do some downregulating, provide a window of opportunity sufficient such that with just small added manual kinesthetic stimuli, the sensory-discriminative parts can do some short-term neuroplasticizing. Judicious movement homework done over a three-day period until receptors have all had a chance to turn over, become less sensitive, does the real job. Convincing people, both kinesthetically and cognitively, that this is even possible, I see as my job, the real job of PT.

    References:
    1. Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain.
    G Lorimer Moseley
    Eur J Pain
    Feb 2004 (Vol. 8, Issue 1, Pages 39-45)

    2. Widespread brain activity during an abdominal task markedly reduced after pain physiology education: fMRI evaluation of a single patient with chronic low back pain.
    G Lorimer Moseley
    Aust J Physiother
    2005 (Vol. 51, Issue 1, Pages 49-52)
    MEDLINE | Related Records

    3. A randomized controlled trial of intensive neurophysiology education in chronic low back pain.
    G Lorimer Moseley, Michael K Nicholas, Paul W Hodges
    Clin J Pain
    (Vol. 20, Issue 5, Pages 324-30)

    Diane

  51. Diane Jacobs says:

    It seems to me part of the problem facing the medical profession/every health profession, is how to weed out invasive, expensive, wasteful procedures based primarily (and inadvertently) on a way outdated Cartesian idea of pain, and are subsequently recognized/updated as placeboic, only.

    A related problem is, how can we all stop the proliferation of more procedures like these developing? I submit that every health care profession could use some “rehab,” which would include heavy exposure to updated pain science.

    E.g., I imagine most everyone has seen Studies Question Using Cement for Spine Injuries (Denise Grady).
    My favorite bit from her news article is:

    “How could the treatment group and the controls get the same pain relief? One possibility is the placebo effect: people felt better because they believed they had received an effective treatment. Studies have found that pain is especially susceptible to placebos.”

    . (my bold)

    It seems to me that it would be cheaper in the long term to help people learn to harness their own placebo response, instead; help patients learn to downregulate their own pain. It seems to me this could lead to far fewer anxious people with pain bothering medical physicians and surgeons.

    On another related topic, John Medina’s (molecular biologist) blogpost,
    The Biological Threat of Stress: From the Jungle to Wall Street” is a very good read. It states that stress can take a toll on brains, but that the difference between “good” stress, which enhances learning, and “bad” stress, which interferes, is a sense of personal control:

    “The more out of control you feel over some bad thing coming at you, the more likely you are to experience the type of stress that can hurt you.”

    Stress (perhaps related to imagining some lethal disease could be causing their pain) affects patients’ pain perception. Returning a locus of control to patients may adequately reduce stress. Teaching them that pain is a brain output, that the brain is a threat detector which can upregulate or downregulate pain perception, can provide them with information that is science-based and can help them get through episodes of recurring mechanical pain which is not based on any pathology, but rather is related simply to their own daily physical behaviour patterns.

    Diane Jacobs

  52. digaman says:

    I talk about researchers who are investigating potential therapeutic uses for the placebo response in my article in the new issue of Wired magazine, “The Placebo Problem.” I also note the fact that the act of taking an active drug can also trigger a placebo response, boosting the effect of the drug itself. It was Henry Beecher who pointed this out, while advocating the adoption of placebo-controlled RCTs as the gold standard of medicine in the mid-20th century.

    http://www.wired.com/medtech/drugs/magazine/17-09/ff_placebo_effect

    (Yes, I’m aware of Peter Lipson’s post and am participating in the thread at White Coat Underground: http://scienceblogs.com/whitecoatunderground/2009/09/placebo_is_not_what_you_think.php.)

    Great discussion here.

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