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The Power of Placebo

5/13/2015

1 Comment

 
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.
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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.

  2. Brinjikji W, Leutmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF & Jarvik JG. (2014). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2014 Nov 27.
  3. Brophy R. (2014). Arthroscopic partial meniscecomty was not better than sham surgery for medial meniscal tear. J Bone Joint Surg Am. 2014 Aug 20;96(16):1396.

  4. Graves JM, Fulton-Kehoe D, Jarvik JG & Franklin GM. (2012). Early imaging for acute low back pain: one-year health and disability outcomes among Washington State workers. Spine (Phila Pa 1976). 2012 Aug 15;37(18):1617-27.

  5. Jarvik JG, Gold LS, Comstock BA, Heagerty PJ, Rundell SD, Turner JA, Avins AL, Bauer Z, Bresnahan BW, Friedly JL, James K, Kessler L, Nedeljkovic SS, Nerenz DR, Shi X, Sullivan SD, Chan L, Schwalb JM & Deyo RA. (2015). Association of early imaging for back pain with clinical outcomes in older adults. JAMA. 2015 Mar 17;313(11):1143-53.

  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.

Like this post? For more advanced information, join the Insider Access Page now! Also, check out similar previous posts below:
Physical Therapy and Chronic Pain
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How Do You Treat Chronic Pain?
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1 Comment
Aaron
7/12/2015 01:53:17 am

Great post and agree with your points, especially that educating the patient about their pain is a delicate issue and one that needs to be proceeded with caution. I think as more PTs begin to learn about pain science, it will be a challenge to provide treatments and education in ways that do not discredit the patient's current belief system. Pain science is much more of an abstract concept than the biomechanical model and may be difficult for therapists to explain and patients to understand.

On a side note, here's an interesting article that relates to the topic in the CLBP population. http://www.ncbi.nlm.nih.gov/pubmed/?term=fuentes+therapeutic+alliance

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  • Home
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  • Special Tests
    • Cervical Spine >
      • Alar Ligament Test
      • Bakody's Sign
      • Cervical Distraction Test
      • Cervical Rotation Lateral Flexion Test
      • Craniocervical Flexion Test (CCFT)
      • Deep Neck Flexor Endurance Test
      • Posterior-Anterior Segmental Mobility
      • Segmental Mobility
      • Sharp-Purser Test
      • Spurling's Maneuver
      • Transverse Ligament Test
      • ULNT - Median
      • ULNT - Radial
      • ULNT - Ulnar
      • Vertebral Artery Test
    • Thoracic Spine >
      • Adam's Forward Bend Test
      • Passive Neck Flexion Test
      • Thoracic Compression Test
      • Thoracic Distraction Test
      • Thoracic Foraminal Closure Test
    • Lumbar Spine/Sacroiliac Joint >
      • Active Sit-Up Test
      • Alternate Gillet Test
      • Crossed Straight Leg Raise Test
      • Extensor Endurance Test
      • FABER Test
      • Fortin's Sign
      • Gaenslen Test
      • Gillet Test
      • Gower's Sign
      • Lumbar Quadrant Test
      • POSH Test
      • Posteroanterior Mobility
      • Prone Knee Bend Test
      • Prone Instability Test
      • Resisted Abduction Test
      • Sacral Clearing Test
      • Seated Forward Flexion Test
      • SIJ Compression/Distraction Test
      • Slump Test
      • Sphinx Test
      • Spine Rotators & Multifidus Test
      • Squish Test
      • Standing Forward Flexion Test
      • Straight Leg Raise Test
      • Supine to Long Sit Test
    • Shoulder >
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      • Anterior Apprehension
      • Biceps Load Test II
      • Drop Arm Sign
      • External Rotation Lag Sign
      • Hawkins-Kennedy Impingement Sign
      • Horizontal Adduction Test
      • Internal Rotation Lag Sign
      • Jobe Test
      • Ludington's Test
      • Neer Test
      • Painful Arc Sign
      • Pronated Load Test
      • Resisted Supination External Rotation Test
      • Speed's Test
      • Posterior Apprehension
      • Sulcus Sign
      • Thoracic Outlet Tests >
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        • Costoclavicular Brace
        • Hyperabduction Test
        • Roos (EAST)
      • Yergason's Test
    • Elbow >
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      • Chair Sign
      • Cozen's Test
      • Elbow Extension Test
      • Medial Epicondylalgia Test
      • Mill's Test
      • Moving Valgus Stress Test
      • Push-up Sign
      • Ulnar Nerve Compression Test
      • Valgus Stress Test
      • Varus Stress Test
    • Wrist/Hand >
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      • Carpal Compression Test
      • Finkelstein Test
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      • Long-Axis Femoral Distraction Test
      • Noble Compression Test
      • Percussion Test
      • Sign of the Buttock
      • Trendelenburg Test
    • Knee >
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      • Dial Test (Tibial Rotation Test)
      • Joint Line Tenderness
      • Lachman Test
      • McMurray Test
      • Noble Compression Test
      • Pivot-Shift Test
      • Posterior Drawer Test
      • Posterior Sag Sign
      • Quad Active Test
      • Thessaly Test
      • Valgus Stress Test
      • Varus Stress Test
    • Foot/Ankle >
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      • Calf Squeeze Test
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      • Fracture Screening Tests
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      • Test for Interdigital Neuroma
      • Windlass Test