The Power of Placebo

Having recently completed reading Therapeutic Neuroscience Education, I have started to realize just how powerful the mind can be with our patients. With the development of modern pain science, this may indicate a need to increase our scrutiny when assessing the validity and quality of research as it becomes published. The old biomechanical model, while still relevant, is not the leading foundation we once thought it was.


For those of you not familiar with some of the recent developments in pain research, we’ll do a little review. All pain comes from the brain. No matter what the “injury” is, the pain is coming from the brain. When a threat is detected in the body, signals are sent to the brain. Depending on the level of importance, you may or may not perceive pain. This is important to recognize, because of everything that is happening in and controlled by the brain. Emotions, bodily functions, respiratory rate, control of blood flow, muscle contraction, etc., it all is controlled by the brain. This is important to understand, because the functions of one area can influence another. For example, have you ever noticed a patient’s pain was worse when they are having a bad day or depressed? The emotional aspects of the brain, when stimulated in certain ways, can make it easier for your patient to “feel pain,” simply from raising the threat level. Couple that with the lack of correlation between imaging findings and pain. Things like herniated discs, meniscal tears, bone spurs, spinal stenosis, osteoarthritis, RTC tears, etc. are just normal wear and tear. These are found in many asymptomatic individuals.

Another example includes the biopsychosocial approach. I’m sure you’ve had patients who claim “the one thing that works for me is ultrasound.” What much of the research has shown is that there is rarely any benefit to including ultrasound in treatment. But in those patients who swear by it, you may notice an improvement in their symptoms. How could this be? Is it possible the patient was convinced that they would get better, so the brain allowed the threat level to be lowered? I bring this up because of the impact a placebo can have. Studies have shown no difference between sham US and therapeutic US. No difference has been found between partial meniscectomy and sham surgery. No patient subjective reports were significantly different between those who had a successful RTC repair and those who had a re-tear. With our understanding of modern pain science, there are several ways we can interpret in these findings. One is the possibility again for the mind’s contribution. It’s possible that with the various sham treatments that because the patient thought they were getting treated, they actually felt better. Building off of this, is a placebo the same as no treatment? It doesn’t appear so. A patient’s beliefs can have significant impact on the results of an intervention, which is why it is imperative that we consider our patient’s preference in our treatment plan.


This can lead us down a path with potentially difficult decisions to make. Even though the biomechanical approach is not as significant as we once thought, should we revert back to that model in patients that are fixated on the theory? If we were to jump to an explanation of pain science right away, the patient may shut down completely to any further treatment consideration. With the impact we know the mind can have, this would be one of the worst things we could do as the patient would not even allow themselves to get better. Likely there is a middle ground to be found. A slow introduction of pain science, while touching on the patient’s existing beliefs, may help to build the trust needed to allow healing to occur. This should be considered in both the clinical and research article appraisals.

-Chris

References:

1. Borenstein DG, O’Mara JW Jr, Boden SD, Lauerman WC, Jacobson A, Platenberg C, Schellinger D & Wiesel SW. (2001). The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects: a seven-year follow-up study. J Bone Joint Surg Am. 2001 Sep;83-A(9):1306-11.
   
   
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6. Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D & Ross JS. (1994). Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994 Jul 14;331(2):69-73.
   
   
7. Nakashima H, Yukawa Y, Suda K, Yamagata M, Ueta T & Kato F. (2015). Abnormal findings on magnetic resonance images of the cervical spines in 1211 asymptomatic subjects. Spine (Phila Pa 1976). 2015 Mar 15;40(6):392-8.
   
   
8. Webster BS, Bauer AZ, Choi Y, Cifuentes M & Pransky GS. (2013). Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain. Spine (Phila Pa 1976). 2013 Oct 15;38(22):1939-46.
9. Webster BS & Cifuentes M. (2010). Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes. J Occup Environ Med. 2010 Sep;52(9):900-7.

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