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Placebo

So now we are going to change topic and start talking about pain. I´m a physical therapist and I treat a lot of patients and I am always surprised by how pain can be so different from one person to the other, even though they may have the same ¨injury¨. Pain is a complex thing and something I will talk more deeply about in one of my next post, but now I want to talk about how to treat pain and the placebo effect.

It´s funny how sometimes using the same technique in 2 different people, I would have different results. In some of my patients the pain would disappear and in other, the pain would just stay there. I know each patient is different and you have to treat every single one individually, but still, wouldn´t you expect to get more or less the same result? I especially remember one time when this patient came by to my clinic. He arrived 30 minutes late, so I didn´t have that much time to treat him, since my next client was already waiting. So I treated him with this new ultrasound that had just arrived to the clinic. I told him how good this ultrasound was and since I didn´t have that much time, I just gave him 5 minutes of ultrasound. After the 5 minutes of ultrasound, the patient felt great, his pain was gone, he had more movement in his shoulder than before he came in!! I couldn´t believe it, especially since the ultrasound was so new that I didn´t even know how to use it properly. I had mistakenly pressed the wrong button, and the 5 minutes that I had thought I had given him ultrasound, I had actually done nothing!!!… but the patient felt better than before, how is that possible?? Well it´s because of the effect of PLACEBO.

Placebo can be defined as an ineffective treatment that can nevertheless be consoling, but placebo effect is not restricted only to fake treatments, it also has a role in the impact of real medicine. For example, although a patient will derive benefit from taking aspirin largely due to the pill´s biochemical effects, there can also be an added bonus as a result of the patient´s confidence in the aspirin itself or confidence in the doctor who prescribes it (1). That is why sometimes the doctor´s reputation, the cost of the treatment and its novelty could all increase the placebo effect. Some known cases of placebo:

  1. In the Second World War, there was a lack of morphine at the hospitals so doctors would instead inject saline into the patient saying ¨that it was a powerful painkiller¨. The soldiers would relax immediately and show no signs of pain.(1)
  2. In the 1950´s a new technique came out that could help patients with angina. A cardiologist was not sure about this treatment, so he did a trial. Some of the patients received the new surgery with the new technique, while the other patients did not, the doctor just opened them up so the arteries were exposed, but he performed no further surgery. None of the patients knew what was happening to them, they all thought they were getting the same process. Afterwards, roughly three-quarters of the patients in both groups reported significantly benefits.(1)
  3. 117 patients with chronic low pain, divided into 4 groups. The first group received electrotherapy after limited, five minute interaction with the physical therapist, who avoided eye contact and did not openly engage the patient.The second group received the same electrotherapy with enhanced interaction, meaning the physical therapist talked to him for 30 minutes and was open and nice. The third group limited interaction while hooked to electrotherapy but the device was not connected (patients did not know this). The fourth group enhanced interaction, while hooked to electrotherapy but the device was not connected. The patients who experienced the greatest benefits were the second and fourth group!!(2)

So, as you can see, placebo can be influenced by a lot of things. In example three, just by talking to the patients and being nice and friendly, the patients experienced a better result than when the doctor gave them the real treatment but did not even look at them. It is also know for example, that a drug administered by injection has a bigger placebo effect than the same drug taken in pill form, and that taking two pills provokes a greater placebo response than taking just one. Also, green pills have the strongest placebo effect on relieving anxiety, whereas yellow pills work best for depression.

So now that you know the influence of placebo and how it can influence pain, perception and a thousand other things, do you want to know when the treatment you are receiving is placebo (fake treatment)? I mean does it really matter, as long as you, the patient, is experiencing the real benefit? I have had clients come up to me and say ¨I don´t care what you do to me, just take the pain away¨, and guess what, placebo can do that, but placebo can also be dangerous, as it could hide a serious disease.

I think it´s better to find the true therapy, something that has no doubt, something that has been scientifically proven, but however with the placebo, even test can show up to be false. So how do they really know if something works? Well, the scientifically community does trials to see if the new medicine-treatment works and this is what they do:

  1. They first do a comparison between a control group and a group receiving the treatment being tested (treatment group).
  2. There has to be a sufficiently large number of patients in each group.
  3. Random assignment of patients to each group.
  4. They administer placebo to the control group.
  5. The control group and the treatment group must have identical conditions.
  6. Blinding patients (meaning patients know as little as possible) so that they are unaware to which group they belong.
  7. Blinding doctors so that they are unaware whether they are giving a real or a placebo treatment to each patient.

This is called a randomized placebo controlled, double-blind clinical trial and it is considered to be the highest possible standard of medical testing.

OK, now that we know what placebo is and how it can affect a treatment, we must also be aware that the opposite also exist and this is called Nocebo effect. Nocebo effect is a negative reaction to harmless stimulus, the opposite of placebo. I´ll give a quick example of a nocebo effect: It has been shown that if they did an MRI (magnetic resonance imaging) on us, that about 81% (3) of us could have a disc herniation and be asymptomatic, meaning no pain. But most people think that a disc herniation is a horrible thing. Now, imagine we have back pain and we decide to go to the doctor and the doctor prescribes an MRI. In that MRI the doctor says you have a herniation (which may be producing your pain or may not be producing the pain), this information will most likely cause a very NEGATIVE effect on you and cause you to experience more pain. Instead, if the doctor explains to you that 85-95% of the people that experience back pain is non-specific (meaning they don´t know where it comes from) and that only less than 10% experiences back pain because of a herniation (4-5). And if he also says that most low back conditions have a favorable natural history, that only 5% of the patients with lower back pain will go on to have chronic lower back pain (6), and that the best thing is to try to continue with your daily activity, just maybe that would have a better effect on you.

Here is a nice video that talks about Placebo. http://crpsuk.com/2013/08/19/is-there-scientific-proof-that-we-can-heal-ourselves-lissa-rankin-talks/

So in my next post I will be talking about acupuncture. A treatment that has existed for thousand of years, there is the Yin and the Yang, it cures morning sickness, strokes, abdominal pain, whooping cough, deafness, chronic asthma, carpal tunnel, rheumatoid arthritis, insomnia, non-specific back pain, shoulder pain, period pains, whiplash……..and the list goes on. Something that can cure so much and has existed for so many years must be true, right …………or is it placebo?? Well, in my next post we will see what the scientific community has to say about that. By the way, if you get treated by acupuncture and get better every time someone sticks a needle on you, you may not want to read my next post. Until then.

Bibliography

1. Ernst E, Simon S. Trick or Treatment ? Alternative medicine on trial. Transworld Publishers.London,UK.2008

2. Medical Xpress: Physiotherapy patient interaction a key ingredient to pain reduction. University Alberta. Profesour Jorge Fuentes.

3. Kim S, Lee T, Lim Soo. Prevalence of Disc Degeneration in Asymptomatic Korean Subjects. Part 1: Lumbar Spine: Journal of Korean Neurosurgical society.2013 January; 53(1):31-38.

4.Agency for Health Care Policy and Research (AHCPR). Acute low back problems in adults. Clinical Practice Guideline Number 14. Wahington DC, US Government Printing, 1994.

5.Danish Health Technology Assessment (DIHTA). Manniche C, et al. Low back pain: Frequency Management and Prevention from an HAD Perspective, 1999.

6. Wiesel SE, Tsourmans N, Fefter HL, et al. A study of computer assisted tomography. The incidence of positive CAT scans in an asymptomatic group of patients. Spine 1984; 9: 549.

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