Part 2: Placebo, Nocebo and Physiotherapy

Well now that the nastiness of money has been dealt with, stick with me for a brief word on placebo. There is a dearth of literature on the topic and I would invite the reader to the Resources tab for more information; there will be plenty more goodies popping up in there from time to time, so don’t be shy.

Placebo; a wonderful effect (Ref). One that all manner of professionals in the western medical world should be well aware of. It is mediated by our endogenous opioid system and is very reliant on expectations, which is obviously important in our treatment realm. A couple of brainy people used neuroimaging studies (PET and opioid selective radiotransmitter) in healthy volunteers and those who showed a large response to a placebo effect were more likely to have lower reported levels of pain (Ref). In other words, if your endogenous ‘modulating’ opioid system is highly tuned, you can experience a higher level of placebo pain relief. Another study demonstrated that with all else accounted for, the individual variance in pain came down to participants’ internal affective state during pain and the affective quality of pain (it is worth noting that this is in only 20 healthy males…. pain capacity questionable!? But then again they were Italian…) (Ref). In other words, how they felt whilst in pain and to what ‘expectation’ they attributed to the pain (Ref).  Indeed, placebo works better when you think it will work (Ref).

In the land of placebo, expectation is king.

Manual therapy and the more traditional ilk of physiotherapy have a questionable position in any (sensible) clinician’s mind surely (RefRef). Low back pain is the most burdensome condition that we will encounter as an industry. We are not alone, in physiotherapy, in the futility of our measures. It seems most primary care treatments are generally all about as useless as each other (Ref) and the relapsing-remitting course of low back pain may continue unabated whether we intervene or not (RefRef). For a young physiotherapist like me it engenders a somewhat untenable position for manual therapy; knowing that a core skill is really no better than placebo. We have popular media constantly reminding us of the power of exercise and the drawbacks of manual therapy (Ref@trustmephysiotherapist. So we evolve or die and upskill (like I have done) in other more effective areas.

But do we throw out the baby with the bathwater? And what will the APA do if everyone stops going to manual therapy courses!? More seriously, where does this leave an entire generation of new physiotherapists, who are classically trained, but all too aware of the failings of this approach? What does the tidal wave of graduates actually do with their hands!?

I would like to present an argument for the use of manual therapy born from the philosophy of ‘harnessing the placebo’. A tough muscular release can be just another way to enhance the capability of a patient’s endogenous opioid system; just like the muscle that gets bigger when you use it ie. Exercise for the placebo/pain system! They never knew they could go through that much pain and still move! I have always been of the mindset that, in the land of the placebo, physiotherapists need to let go of some professional pride and just ‘harness the placebo’. Use it for good not bad. What we are really after in the finality of things, is behaviour change, and Pavlov’s Dogs did not stop salivating overnight. Play the long game; accept that a bit of placebo in the form of hands-on may garner some trust, which might allow you to challenge your patients’ expectations and conditioned responses to pain and exercise. In fact, from my clinical experience, remaining completely hands-off may be the nocebo that we all dread. Patients are coming to us because, in large part, a series of conditioned responses in their past. Until patients stop coming to physiotherapists expecting exactly what the chiropractor does, manual therapy can be a crucial ally to be used to our advantage. Moving patients towards positive attributions of pain and reducing fear avoidance conditioning is where the profession is headed, but I’m not sure about the medical system as a whole.

The issue of overdependence, that is espoused to come from solely manual therapy and other adjuncts, may derive moreso from a system that generates a conditioned response to pain. Patients are over diagnosed and overprescribed from top down with poor language choices throughout the entire process. The RACGP guidelines on musculoskeletal disorders proves for interesting reading (Ref). And then yes, then they are probably over treated with the wildly inefficient use of manual therapy from various professions. This creates a perfect storm of endogenous opioid weaklings incapable of their own placebo, with warped belief systems, expectations and reward systems around pain.

To conclude from this month – the payment paradox and placebo – if private physiotherapy is the way forward, we may be destined for a generation of practitioners that cease to value manual therapy; this might lose the power of the placebo for the entire profession! Manual therapy can be useful to alter patients’ expectations and conditioned responses, if done in combination with good education. Use manual therapy sparingly ALWAYS with education, remember you are not treating pain, and invest in what your patient values…

Wait you already do that!? Well I guess I’ll just lay this dank beat on you then, because this has obviously been of no use . In honour of the late great… and our profession of course!

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