I did something recently and i’m not completely sure how I feel about it. I performed an experiment on one of my children and it had some pretty alarming results – but before you call Social Services, hear me out please.
My middle child – six year old Joseph – had developed a large wart on the palm of his hand. In fact it was so large it had more in common with a limpet than a wart. What was more, it was uncomfortable, itchy and it really bothered him: this was a ‘verruca vulgaris’ in every sense.
After at least six months it hadn’t cleared up and I hatched a cunning plan: how about using a placebo ointment to see if it would get rid of this erupting wart? A nice little in-house experiment.
So I duly set about crafting a completely fictional tale about a ‘Dr. Wartz’ who would send Joseph his wart remedy. In fact – and i’m embarrassed to admit it – I got quite carried away by the project.
I sourced a lovely dark brown glass bottle and spent an age preparing a mysterious looking label, one that even Madame Maxime would have been proud of:
‘Dr Wartz’ Magic Wart Remover
Keep in ze refrigerator at all times
Apply once a day before bedtime
Your wart will vanish in four weekz
HANDLE WIZ CARE’
I filled the bottle with ultrasound gel (I know, the irony of it!) and proceeded to spin a web of deceit and illusion to my poor, unsuspecting son: how Dr Wartz had been busy helping the King of Transylvania with his warts; how expensive the gel was and how important it was that we kept the remedy cold. (I told you I got carried away).
We diligently applied the gel nightly before bedtime and within four weeks the wart had COMPLETELY AND UTTERLY VANISHED!!. Believe me when I say, this felt like a near miracle to me. It was simply incredulous to witness the wart slowly evaporate before our very eyes.
Regression to the mean? Natural history? No. Way. On. This. Earth.
Something real and physical had taken place. I’ve spent a lifetime working in healthcare and this is one of the most incredible things I have ever witnessed. My wife has filed it under ‘very strange’ and left it at that, but I can’t stop reflecting on this.
And it has got me thinking about two things: firstly, the ethics of what I had done here i.e. using placebo without consent. Secondly, whether we are really making the most of this clinical dynamite called ‘placebo’. Do we really exploit the power of placebo in our day to day clinical work?
Firstly, on the ethics of giving a placebo deceitfully.
Now, I am of the mind that our clinical work can be really tough and we face some really difficult and unsatisfying days sometimes. That’s the reality and we need all the help we can get.
I am in no way suggesting however that we use ‘the placebo effect’ as a disturbing get-out clause for the use of treatments for which there is good evidence of no effect. Not at all. Yes there are so called ‘open label studies’ where people are aware they’re receiving a placebo intervention, and they show benefit, but it is way too early to be using these studies as a reason to utilise placebo-only interventions in clinical work.
The question I am posing is: do we really push the placebo in our day to day clinical work? Think for a minute about your work. Think about Joseph’s wart. Do you really feel you are harnessing this power in your work? I think there’s a strong argument that we are not and we are at risk of overlooking the one certainty that we do have in our day to day clinical practice: the placebo effect.
Barrett et al (2006) have made practical suggestions to enhance the placebo effect in clinical practice:
- speak positively about treatments
- provide encouragement
- explore values
- create ceremony
These will in turn create positive expectations, which have been identified as key factors in the placebo response.
Testa & Rossettini (2016) also suggest being ‘optimistic’ and using ‘positive messages’ during the consultation.
As a way to access a person’s own ‘healing potential’ by influencing expectations, surely the placebo effect should be central to our work. Indeed some writers have suggested that to ignore the placebo effect is unethical because the phenomena is so well documented (Pittrof & Rubenstein 2008).
Consider the last time you gave someone exercises to carry out. Let’s say for the sake of argument it was proximal hip strengthening for anterior knee pain – something for which presently, there is evidence. Now how did you introduce the exercises to your patient? How about this:
‘I have some really effective exercises that will improve your knee pain. These exercises have been proven to help in some high quality research.’
‘Most days I have someone in this room who had a similar problem to yours – months and months of pain – and they found these exercises to be really effective.’
‘These exercises really make a difference to people who have exactly the same problem as you. In fact, you will feel the benefit immediately and every day that you carry out these exercises your problem will bother you less and less.’
‘You will be surprised how quickly you are able to do the things you love and how soon you’re back to enjoying the gym.’
Yes, I know you can almost hear the Advertising Standard Agency’s helicopter blades whirling overhead and I know they’re listening in and yes it would be a bit mad to say all of these things in one session wouldn’t it?
But do you get my gist? If a treatment has been shown to be effective already – if there is evidence for its effectiveness – push the placebo! Push it! Make it sweat buckets each and every day.
You’re NOT working in a randomised controlled trial. You’re NOT working in a laboratory.
Unleash the transformative power of the placebo and start practicing placebo-based physiotherapy.
Barrett B, Muller D, Rakel D, Rabago D, Marchand L, Scheder JC. Placebo, meaning and health. Perspect Biol Med. 2006;49:178–198.
Pittrof R, Rubenstein I. The thinking doctor’s guide to placebos. BMJ. 2008;336:1020.
Testa M, Rossettini G, Enhance placebo, avoid nocebo: how contextual factors affect physiotherapy outcomes, Manual Therapy (2016) doi:10.1016/j.math.2016.04.006