Ref Physical Therapy and non-specific effects.

[Diane]

Let's get serious about this. A very nice breadcrumb trail exists, right in our own profession, and I want to fan it.

Check out the following:

1. Amanda M. Hall*, Paulo H. Ferreira, Christopher G. Maher, Jane Latimer and Manuela L. Ferreira; The Influence of the Therapist-Patient Relationship on Treatment Outcome in Physical Rehabilitation: A Systematic Review. Physical Therapy August 2010 vol. 90 no. 8 1099-1110 Full access.

2. Maxi Miciak BScPT (PhD Student)**, Douglas P. Gross PhD (Associate Professor), Anthony Joyce PhD (Professor); A review of the psychotherapeutic ‘common factors’ model and its application in physical therapy: the need to consider general effects in physical therapy practice. Scandinavian Journal of Caring Sciences Volume 26, Issue 2, pages 394–403, June 2012

This article explores the common factors model of psychotherapeutic intervention and discusses its relevance for physical therapy practice. The model provides an explanation for why the effects associated with specific technical approaches only minimally explain successful psychotherapy clinical outcomes. It postulates that factors common across diverse interventions (i.e. ‘nonspecific’ mechanisms) are responsible for a larger component of treatment efficacy. We outline the applicability of the common factors model to physical therapy and provide supportive evidence from evaluation and prognostic research on interventions for conditions seen in musculoskeletal physical therapy practice. The relevancy and consequences of applying the common factors model to physical therapy practice and research are discussed. The continued advance and evolution of the physical therapy profession requires creative and comprehensive analysis of all factors impacting clinical effectiveness. Additional research is needed to more clearly delineate the common factors that are operational in physical therapy practice and to measure their relative impact on clinical outcomes.

3. Gebhard B, Relevance of Common Factors in Physical Therapy: A Qualitative Analysis, a poster presentation.

References from the poster presentation:

Frank J D, Frank J B. Persuasion and healing: A comparative study of psychotherapy. Baltimore, MD: Johns Hopkins
University; 1991 (3rd ed.).
Gibbs G R. Analyzing qualitative Data. Sage Publications, London, UK, 2007 (1st ed.).
Grencavage L, Norcross J C. Where Are the Commonalities Among the Therapeutic Common Factors? Professional Psychology: Research and Practice 1990; 21: 372-378.
*Hall A M, Ferreira P H, Maher C G, Latimer J, Ferreira M L. The Influence of the Therapist-Patient Relationship on Treatment Outcome in Physical Rehabilitation: A Systematic Review. Physical Therapy 2010; 90: 1099-1110.
Mayring P. Qualitative Inhaltsanalyse, Beltz, Weinheim, 2010 (11st ed.).
**Miciak M, Gross D P, Joyce A A. Review of the psychotherapeutic ‘common factors’ model and its application in physical
therapy: the need to consider general effects in physical therapy practice. Scan J Caring Sci 2011; doi: 10.1111/j.1471-
6712.2011.00923.x.

[Diane]

I blogged about Miciak, recently: Deep versus shallow models of treatment
She saw the post and came by to make a comment.

[proud]

Diane,

The longer I practice (15 years of uninterupted clinical care ONLY...as in no administrative side bars), the more patients I see (average 15 per day)...the more convinced I am that the profession is going to have to wrap it's head around these issues.

We have to work within these realities not avoid them.

Frankly, I think it's the way forward and I feel good quality Phyiotherapy care (better than the current out-dated biomechanical model) exists within these realities.

[Diane]

I agree, proud. It's what happens anyway. All the science points right at this. All the inconclusive, poor inter-rater reliability testing, all the pain science, everything. I would like the profession to catch up to the reality, reframe itself just a bit. To itself, at least. To the students that enter it. "We help people. We help their nervous systems. Here's how."

[Diane]

Here is a nice little news item about exercise and knee osteoarthritis. Factors impacting benefit of exercise in knee OA identified.

It discusses this paper: Associations for change in physical and psychological factors and treatment response following exercise in knee osteoarthritis: An exploratory study

The researchers found that, after adjustment, the only two factors that were significantly associated with treatment response were
1. change in self-reported knee instability
2. fear of physical activity

[Mark Hollis]

I like the weekends. I come here. I see new papers. I go to work on Monday with a little skip in my step. Thank you

[Simon Thakur]

Me too. Thumbs up!

[Frédéric]

Yup, it's like a gas station for the mind!

[PCollinsDPT]

Originally Posted by Frédéric

Yup, it's like a gas station for the mind!

I'd like to agree, but sometimes I feel like that gas station is further and further away!

[Diane]

Hi PCollinsDPT, welcome to SS. Check out the Welcome forum, start a thread there to introduce yourself.

[Diane]

The Therapeutic Alliance Between Clinicians and Patients Predicts Outcome in Chronic Low Back Pain

Abstract

Background The impact of the relationship (therapeutic alliance) between patients and physical therapists on treatment outcome in the rehabilitation of chronic low back pain (LBP) has not been previously investigated.

Objective To investigate whether the therapeutic alliance between physical therapists and chronic LBP patients predicts clinical outcomes.

Design Retrospective observational study nested within a randomized controlled trial.

Methods 182 patients with chronic LBP who volunteered for a randomized controlled trial that compared the efficacy of exercises and spinal manipulative therapy rated their alliance with physical therapists by completing the Working Alliance Inventory at the second treatment session. The primary outcomes of function, global perceived effect of treatment, pain, and disability were assessed before and after 8 weeks of treatment. Linear regression models were used to investigate if the alliance was a predictor of outcome or moderated the effect of treatment.

Results The therapeutic alliance was consistently a predictor of outcome for all the measures of treatment outcome. The therapeutic alliance moderated the effect of treatment on global perceived effect for two of three treatment contrasts (general exercise vs motor control exercise, spinal manipulative therapy vs motor control exercise). There was no treatment effect modification when outcome was measured with function, pain and disability measures.

Limitations Therapeutic alliance was measured at the second treatment session and it is likely to bias the interaction during initial stages of treatment. Data analysis was restricted to primary outcomes at 8 weeks.

Conclusions Positive therapeutic alliance ratings between physical therapists and patients are associated with improvements of outcomes in LBP. Future research should investigate the factors explaining this relationship and the impact of training interventions aimed at optimizing the alliance.

LINK

[Ken Shearer]

Who would have known my deep-seeded love of psychology would help me as much as it does.

Honestly I didn't when I began to pursue this career path. I find there is a constant (but lessening) battle of my natural instincts and those "things" that we're pounded into my head for years.

I much rather perform instincts.

[Diane]

This maybe should go into a different thread, but, considering that PTs are going to be licensed to do injecting, maybe here is fine: Expensive Arthritis Treatment No Better Than Steroid Therapy

A randomized, double-blind clinical trial by researchers at Hospital for Special Surgery has revealed that corticosteroids are more effective than the more expensive treatment, hylan G-F 20 (Synvisc One, Genzyme Biosurgery), in providing pain relief to patients with thumb arthritis. The study also showed that both of these commonly used treatments provided clinically meaningful pain relief, but so did a placebo injection.

[Diane]

I'm putting this link to the video about sham knee surgery into this thread.

[Diane]

Here is a write-up about the study.

[Diane]

Here is the actual study. A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee, sent to me on Twitter by painfreeindia.

[Diane]

This looks good: Patient-centered interviewing is associated with decreased responses to painful stimuli: An initial fMRI study

File under, "Yeah... we could have predicted that.."

Abstract
Objective
To identify the functional magnetic resonance imaging (fMRI) changes associated with a patient-centered interview (PCI) and a positive provider–patient relationship (PPR).

Methods
Nine female patients participated, five randomly selected to undergo a replicable, evidence-based PCI, the other four receiving standard clinician-centered interviews (CCI). To verify that PCI differed from CCI, we rated the interviews and administered a patient satisfaction with the provider–patient relationship (PPR) questionnaire. Patients were then scanned as they received painful stimulation while viewing pictures of the interviewing doctor and control images (unknown doctor).

Results
Interview ratings and questionnaire results confirmed that PCIs and CCIs were performed as planned and PCIs led to a much more positive PPR. We found significantly reduced pain-related neural activation in the left anterior insula region in the PCI group when the interviewing doctor's picture was shown.

Conclusion
This study identifies an association between a PCI that produced a positive PPR and reduced pain-related neural responses in the anterior insula. This is an initial step in understanding the neural underpinnings of a PCI.

Practice implications
If confirmed, our results indicate one neurobiological underpinning of an effective PCI, providing an additional scientific rationale for its use clinically.

[Diane]

Check this out: Empathy Soothes Patients’ Pain, from Pain-Topics.org

[Diane]

What a great interview: Dr. Abraham Verghese (nice Irish-sounding accent) at Stanford explains why he sees physical examination of a patient as a ritual, why he thinks that's exactly how a patient experiences it.
He steps back and looks at medical interaction as an anthropologist would - i.e., way more objectively.

[Diane]

Small excerpt from this fabulous 8 minute interview:

... the lesson I’ve learned from hanging around with my anthropology colleagues here at Stanford is that rituals are all about transformation. A ritual signals the crossing of a threshold. We baptize to signal crossing of a threshold, we marry to signal our departure from a lifetime of solitude, loneliness and misery to one of eternal bliss.

So crossing a threshold is why we have a ritual. And I would say, that the act of one individual coming to another, and telling them things they wouldn’t tell their rabbi or their preacher... and then incredibly, disrobing and allowing touch.. I would say that signals a ritual of incredible importance.

[Frédéric]

Dr Verghese has so interesting things to say, so true. Just like his moving Ted talk, this interview highlights how I see my role and practice now.

One observation. Medical exams are generally more rare or spread apart in time than a typical PT encounter, where the initial assessment is usually followed by numerous treatments/follow ups. I think this sort of changes the ritual's power after sometime. I actually wonder after how long does the ritual looses most of its power. I think we have a window of opportunity to «make this transformation» after which, the ritual becomes somewhat diluted and then the «enchantement» kind of stops.

And some patients are more easily enchanted than others.

[Diane]

I agree.

[advantage1]

Great video Diane. A couple of points I found interesting in the interview were regarding garb. For the doctor he mentions that they wear a ceremonial garb that is a part of the experience of the ritual. What is our ceremonial garb? We don't have a universal garb that identifies us and I wonder if that takes from the experience. Finally, I found it interesting when he mentioned the patient removing their garb which in some cases is a uniform (i.e. police officer, military member etc.) In my experience depending on the person, they can have a hard time with not being in uniform. For example, a high ranking soldier cannot easily adjust to having no rank and becoming a patient. I find in these cases their is a sense of control that they must relinquish yet can't. I wonder if others have expereinced this?

[Diane]

I would say, our PT ceremonial garb is less about what we're wearing (although polo shirts are quite popular, guys at least..)
..and more about the Can-Do attitude we are encouraged to cultivate, even though we are not taught anything even remotely understandable in terms of an explanatory model for what we do and think we can do. In fact if that attitude isn't kept visible, we are flunked out of PT school, some of us. (Which nearly happened to me, 40-odd years ago, although it didn't, quite.)

Other things: PTs in hospitals at least, like to wear stethoscopes..
PTs carry stuff around - pens, things for patients to squeeze, whatever.

But the biggest bunch of ritual equipment is not portable - it's the big bright coloured mess of exercise equipment and play tools and theraband and balls, etc., kept in plain sight in the departments, along with the machines that ping and beep. It's the cold treatment tables, with changes of sheets if we're lucky, and curtains that zip around them to make a not-very private "stall". What secrets could you possibly have that the world shouldn't know about? What sort of gossip going on next door should you not be interested in following? What? You want private time with a therapist? Well, you'll have to go down the street and pay big bucks out of your pocket to that odd-ball therapist who only sees people one at a time and insists on rooms with doors that close, and no drafts, and no noise, and lights that can be lowered. Sheesh. She's weird.

[proud]

Originally Posted by Diane

..and more about the Can-Do attitude we are encouraged to cultivate,

HA! I must say Diane, you really have your finger on the pulse of "Physiotherapy". I am always amazed at how low PT's will stoop to ensure they maintain this "can-do attitude". I have witnessed PT's completly de-professionalize themselves to hold onto this.

I suspect it contributes to why PT's within hospital settings who bargain for contracts end up the lowest paid health professionals....

We almost refuse to see ourselves as professionals. I think most PT's know they are living a lie (in terms of having an explanatory model they can defend) that they recognize....they would struggle to prove to anyone that they indeed are professionals...

Thus the need to appease everyone with that "can-do attitude"

And yes...the bells and whistles are the PT's ceremonial garb.

If you don't use IFC or ultrasound, gouge someone with a metal instrument, use theraband or some other "strength" device and suddenly you're the weirdo....

[Curious One]

Originally Posted by Diane

Well, you'll have to go down the street and pay big bucks out of your pocket to that odd-ball therapist who only sees people one at a time and insists on rooms with doors that close, and no drafts, and no noise, and lights that can be lowered. Sheesh. She's weird.

I may not have my pulse on everything PT, but I am certainly open to hearing more of everyone's experiences. One thing is for sure, I can certainly step right up with you on this statement.

Many times a colleague (DC) who doesn't know how I run my office learns that I have all the same as you described above, with the main thing being the lowered lights, they look at me as if I've gone batty. *ha*

Somehow, it's nice to know I'm not the only one dealing with this attitude amongst peers.

[Diane]

There is nothing I hate more, CO, than being horizontal on a table of some kind, be it at a gym or in someone's office being examined, and having bright lights overhead. There is no need for them, especially during manual therapy.

I also have a treatment table with a warmer in it. Call me crazy. I used it to full effect today, with a new patient who is stressed out because she has Crohn's disease (in remission at the moment), in the course of being treated became addicted to prescribed painkillers, is withdrawing from them, also has a new baby, had to go on disability from a teaching job, has a bunch of new neck, headache and shoulder pain because she's got financial stress and is working in a restaurant. Oh, and she's always cold. The lights were turned down low while we mopped up her pain perception of headache, neck pain etc. Worked very well in fact, reducing noxious input, turning nociception to yesiception..

[Diane]

Here is another link, posted by Carol on FB, A Touch Of Sense by Abraham Varghese from 2009.

[nari]

What health professionals wear is probably a sort of cultural thing.
Here, wearing a tie for guys would be unthinkable and laughable; the reason being that we have to feel comfortable, not threaten patients with formal clothes (docs are different!) and get physical.

Women used to wear polo shirts emblazoned with our physio symbol, but now they wear standard street clothes.
Stethoscopes are standard for the wards but not anywhere else.

A ritual is always something that alarms me - it smacks of stereotyping, so I always avoided saying the same words in greeting a patient by changing when and how I said them. I often didn't mention my name because it is unusual and they often forgot it anyway; it came later.

Oh and the toys!! The obligatory theraband, the modality request, hot packs, cold packs and zillions of standardised exercises to strengthen something or the other, the exercycle, the ship's wheel for painful shoulders........

Nari

[Diane]

advantage1 wrote:

I found it interesting when he mentioned the patient removing their garb which in some cases is a uniform (i.e. police officer, military member etc.) In my experience depending on the person, they can have a hard time with not being in uniform. For example, a high ranking soldier cannot easily adjust to having no rank and becoming a patient. I find in these cases their is a sense of control that they must relinquish yet can't. I wonder if others have expereinced this?

I haven't had any problem with people not being willing to take their clothes off, usually. I drape people very well, provide gowns etc. Haven't had to treat any soldiers. They may well be more attached to their clothing. Maybe Jason would know more about that.

[Kyle Ridgeway]

Other things: PTs in hospitals at least, like to wear stethoscopes

Totally off topic, but I am all for this. PT's in hospitals (at least in the US) need to be listening to breath sounds more, so I am OK with this. The ones who wear them, use them (in my experience). I don't think this a problem at all.

[Kyle Ridgeway]

Although I am sure they are some who wear them because they feel important or professional when doing so.

[Kyle Ridgeway]

The Therapeutic Alliance Between Clinicians and Patients Predicts Outcome in Chronic Low Back Pain

Background The impact of the relationship (therapeutic alliance) between patients and physical therapists on treatment outcome in the rehabilitation of chronic low back pain (LBP) has not been previously investigated.

Objective To investigate whether the therapeutic alliance between physical therapists and chronic LBP patients predicts clinical outcomes.

Design Retrospective observational study nested within a randomized controlled trial.

Methods 182 patients with chronic LBP who volunteered for a randomized controlled trial that compared the efficacy of exercises and spinal manipulative therapy rated their alliance with physical therapists by completing the Working Alliance Inventory at the second treatment session. The primary outcomes of function, global perceived effect of treatment, pain, and disability were assessed before and after 8 weeks of treatment. Linear regression models were used to investigate if the alliance was a predictor of outcome or moderated the effect of treatment.

Results The therapeutic alliance was consistently a predictor of outcome for all the measures of treatment outcome. The therapeutic alliance moderated the effect of treatment on global perceived effect for two of three treatment contrasts (general exercise vs motor control exercise, spinal manipulative therapy vs motor control exercise). There was no treatment effect modification when outcome was measured with function, pain and disability measures.

Limitations Therapeutic alliance was measured at the second treatment session and it is likely to bias the interaction during initial stages of treatment. Data analysis was restricted to primary outcomes at 8 weeks.

Conclusions Positive therapeutic alliance ratings between physical therapists and patients are associated with improvements of outcomes in LBP. Future research should investigate the factors explaining this relationship and the impact of training interventions aimed at optimizing the alliance.

My bold.

[Kyle Ridgeway]

The Therapeutic Alliance Between Clinicians and Patients Predicts Outcome in Chronic Low Back Pain

Abstract
Background The impact of the relationship (therapeutic alliance) between patients and physical therapists on treatment outcome in the rehabilitation of chronic low back pain (LBP) has not been previously investigated.

Objective To investigate whether the therapeutic alliance between physical therapists and chronic LBP patients predicts clinical outcomes.

Design Retrospective observational study nested within a randomized controlled trial.

Methods 182 patients with chronic LBP who volunteered for a randomized controlled trial that compared the efficacy of exercises and spinal manipulative therapy rated their alliance with physical therapists by completing the Working Alliance Inventory at the second treatment session. The primary outcomes of function, global perceived effect of treatment, pain, and disability were assessed before and after 8 weeks of treatment. Linear regression models were used to investigate if the alliance was a predictor of outcome or moderated the effect of treatment.

Results The therapeutic alliance was consistently a predictor of outcome for all the measures of treatment outcome. The therapeutic alliance moderated the effect of treatment on global perceived effect for two of three treatment contrasts (general exercise vs motor control exercise, spinal manipulative therapy vs motor control exercise). There was no treatment effect modification when outcome was measured with function, pain and disability measures.

Limitations Therapeutic alliance was measured at the second treatment session and it is likely to bias the interaction during initial stages of treatment. Data analysis was restricted to primary outcomes at 8 weeks.

Conclusions Positive therapeutic alliance ratings between physical therapists and patients are associated with improvements of outcomes in LBP. Future research should investigate the factors explaining this relationship and the impact of training interventions aimed at optimizing the alliance.

[TexasOrtho]

This is an area I in which I struggle and appreciate Dianes ideas greatly. We have worked on keeping treatment tables more warm and I'm less likely to treat my patients in supine and prone.

That being said, old habits and rituals are difficult to break. I'm slowly evolving but its progress.

[advantage1]

Diane,

To clarify my point regarding removing clothes, I didn't mean that soldiers have a hard time removing their clotihing. What I meant was there are some people who wear uniforms and have an occupation that gives them authoity that can't allow themselves to be in a position of being a patient. In the interview he discusses how the removal of clothing and the doctor placing their hands on the patient is a large part of the ritual. However, someone such as a CEO or General cannot allow themselves to easily let go and turn off their authoratative pesona. I know I've treated high ranking military members who squirm and resist having someone question them and advise them what to do.

[Diane]

For sure, no argument from me, really.. If you follow KevinMD.com, a group blog by doctors who are trying to change the rituals the medical profession and the system that has evolved to contain it, enact, like robots, you'll find some great stories. One (from there, I'm pretty sure, don't have time to hunt it down just now) involved a medical director who had a nasty experience as a patient. He turned up at a board meeting wearing nothing but a hospital gown flapping open at the back, and successfully shocked everyone present into softening up toward his ideas about treating patients with more dignity and respect. Great use of clothing (inverse "ceremonial garb") to make people aware of ritual, I thought.

[Milehigh]

I work in a busy outpatient enviroment in a hospital, with stalls, and you are likely to hear everything from children screaming, telephone's going off, multiple languages being spoken through interpreters, dogs barking--it can be literally a zoo at my work.

I am working to push for change, noise reduction curtians etc. Doing what I can.

One thing that just came to me was this. Over on this thread What do you want to become? There is plenty of discussion re: distraction and the manipulation of attention. I think these lessons are crtical about how we can shape the context despite being in a less ideal enviroment.

What I try to do at my work, is mostly shield the pt. I try to find the most quite space to work in I can, I dim lights when I can, cover the pt.s eyes, and I try to keep their attention focused on me and on themselves. Generally this works most times.

I watch people's eyes to see where they go. Today, I caught my patient glancing at the curtain where it opens and realzied that it had inadvertenly opened a little bit. I immediatley closed it. Probably a small thing yet this kind of mind reading is imperative to the patient/therapist relationship.

I wish my work permitted me to be as werid as wanted to be. Right now it is just the price I pay to treat the kind of pt.s I want to treat.

Is their any threads, journal articles, or other resources that discuss design esthetics i.e. geometery of space and its effect on the mind? I am really interested in this. I think it is very related. I watched this show Urbanized, within it they talked about how European squares (mostly) all were designed around specific dimensions. These dimensions allowed the person in the square to frame their enviroment so they could see everything around them. That when a space got to big, like many modern (North American) squares, people stopped accessing them because of a natural percived threat due to our visual systems inability to frame the entire picture and therefore be at esthetic ease.

I think this is essentially what feng shui is sans the mumbo jumbo. I would love to know if anyone has any other insights on this with specific relation to health care.

Eric



Eric

[Elanchaim]

I purchased this book a few years back and enjoyed a few chapters, before leaving at my in laws house. It discusses how physical space impacts healing.

http://www.amazon.com/Healing-Spaces.../dp/0674057481

[keithp]

Eric,
There is a thread titled The Perfect Clinic that may be what you are looking for...I would link it but am on a tablet and it is a bit laborious. Sorry.

Respectfully,
Keith

[Diane]

From this thread: Physiotherapists' knowledge, attitudes, and intolerance of uncertainty influence decision making in low back pain.

Abstract
BACKGROUND:
Low back pain (LBP) remains a common health problem that is characterized by ambiguity and can progress to chronic disability. In recent years researchers have started to focus on understanding whether and how the attitudes and beliefs of the health care providers influence the management and the outcome of LBP.
OBJECTIVES:
The purpose of this study was to characterize Quebec physiotherapists' (PTs') knowledge, attitudes, and beliefs about LBP and their intolerance of uncertainty (IU) to determine whether and how these characteristics predict judgments of assessment and treatment recommendations.
METHODS:
A total of 108 PTs from Quebec, Canada completed the Pain Attitudes and Beliefs Scale for Physiotherapists, the Fear of Pain Questionnaire, and the Intolerance of Uncertainty Scale. Participants also read 2 vignettes that described patients with LBP and reported their assessment and treatment recommendations.
RESULTS:
Only 13 PTs (12%) were able to identify clinical practice guidelines for LBP. In addition, PTs did not generally agree with recommendations to return to work or activity. A biomedical orientation was a significant predictor of clinical judgments of spinal pathology and was associated with an increased sense of IU. In contrast, a behavioral approach better predicted treatment recommendations for return-to-work or activity. Finally, the association between IU and treatment decisions was mediated by treatment orientation.
DISCUSSION:
Health care practitioners play a significant role in the management of LBP. Research on the process of knowledge translation, clinical decision making, and dealing with uncertainty to avoid aggravating LBP disability is clearly warranted.

[PatrickL]

To clarify my point regarding removing clothes, I didn't mean that soldiers have a hard time removing their clotihing. What I meant was there are some people who wear uniforms and have an occupation that gives them authoity that can't allow themselves to be in a position of being a patient. In the interview he discusses how the removal of clothing and the doctor placing their hands on the patient is a large part of the ritual. However, someone such as a CEO or General cannot allow themselves to easily let go and turn off their authoratative pesona. I know I've treated high ranking military members who squirm and resist having someone question them and advise them what to do.

on the flipside, ive read stories about S&M (by no means a hobby of mine) that state that very often the masochist is a high powered business man. These people are in positions of power and authority 24/7. Some gain a sense relaxation/pleasure from being relieved of their position of power and assuming a student/learner role.

im sure ive observed this from the bigwigs that come to our clinic (minus leather straps and whips)

[Milehigh]

This assuredly belongs here: The Placebo Phenomenon

Ted Kaptchuk’s first randomized clinical drug trial, nearly a third of his 270 subjects complained of awful side effects. All the patients had joined the study hoping to alleviate severe arm pain: carpal tunnel, tendinitis, chronic pain in the elbow, shoulder, wrist. In one part of the study, half the subjects received pain-reducing pills; the others were offered acupuncture treatments. And in both cases, people began to call in, saying they couldn’t get out of bed. The pills were making them sluggish, the needles caused swelling and redness; some patients’ pain ballooned to nightmarish levels. “The side effects were simply amazing,” Kaptchuk explains; curiously, they were exactly what patients had been warned their treatment might produce. But even more astounding, most of the other patients reported real relief, and those who received acupuncture felt even better than those on the anti-pain pill. These were exceptional findings: no one had ever proven that acupuncture worked better than painkillers. But Kaptchuk’s study didn’t prove it, either. The pills his team had given patients were actually made of cornstarch; the “acupuncture” needles were retractable shams that never pierced the skin. The study wasn’t aimed at comparing two treatments. It was designed to compare two fakes.

The experiment split 262 adults with IBS into three groups: a no-treatment control group, told they were on a waiting list for treatment; a second group who received sham acupuncture without much interaction with the practitioner; and a third group who received sham acupuncture with great attention lavished upon them—at least 20 minutes of what Kaptchuk describes as “very schmaltzy” care (“I’m so glad to meet you”; “I know how difficult this is for you”; “This treatment has excellent results”). Practitioners were also required to touch the hands or shoulders of members of the third group and spend at least 20 seconds lost in thoughtful silence.

The results were not surprising: the patients who experienced the greatest relief were those who received the most care. But in an age of rushed doctor’s visits and packed waiting rooms, it was the first study to show a “dose-dependent response” for a placebo: the more care people got—even if it was fake—the better they tended to fare.

For years, doctor-patient interactions were lumped into a generic “placebo response”: a sum of such variables as patients’ reporting bias (a conscious or unconscious desire to please the researchers); patients simply responding to doctors’ attention; the different methods of placebo delivery; and symptoms subsiding without treatment—the inevitable trajectory of most chronic ailments. “There was simply no way to quantify the ritual of medicine,” says Phillips of the doctor-patient interaction. And the ritual, he adds, is the one finding from placebo research that doctors can apply to their practice immediately.

The question ultimately inspired a pilot study, published by the peer-reviewed science and medicine journal PLOS ONE in 2010, that yielded his most famous findings to date. His team again compared two groups of IBS sufferers. One group received no treatment. The other patients were told they’d be taking fake, inert drugs (delivered in bottles labeled “placebo pills”) and told also that placebos often have healing effects.

The study’s results shocked the investigators themselves: even patients who knew they were taking placebos described real improvement, reporting twice as much symptom relief as the no-treatment group. That’s a difference so significant, says Kaptchuk, it’s comparable to the improvement seen in trials for the best real IBS drugs.

“We’d hoped for measurable objective changes in breathing; what we got instead was a more precise diagram of placebo effects and how clearly the ritual of medicine makes people more comfortable.”

[Patrick Septon]

Originally Posted by Diane

This looks good: Patient-centered interviewing is associated with decreased responses to painful stimuli: An initial fMRI study

File under, "Yeah... we could have predicted that.."

Diane, I was unable to get access to the full text of this article (even after registering on the website). Is there any way you know of to get this? Or, if not, maybe you can help me out with my question: I'd love to know the specifics of exactly how the patient-centered interview differed from the clinician-centered interview.

[caro]

The Perfect Clinic thread.

[Diane]

Originally Posted by Patrick Septon

Diane, I was unable to get access to the full text of this article (even after registering on the website). Is there any way you know of to get this? Or, if not, maybe you can help me out with my question: I'd love to know the specifics of exactly how the patient-centered interview differed from the clinician-centered interview.

Here you are.

[Patrick Septon]

In light of what I'm learning about placebo effects and rituals, I'm having a hard time knowing where to draw the line between giving the patient a realistic expectation and flat-out lying to them.

The experiment split 262 adults with IBS into three groups: a no-treatment control group, told they were on a waiting list for treatment; a second group who received sham acupuncture without much interaction with the practitioner; and a third group who received sham acupuncture with great attention lavished upon them—at least 20 minutes of what Kaptchuk describes as “very schmaltzy” care (“I’m so glad to meet you”; “I know how difficult this is for you”; “This treatment has excellent results”). Practitioners were also required to touch the hands or shoulders of members of the third group and spend at least 20 seconds lost in thoughtful silence.
The results were not surprising: the patients who experienced the greatest relief were those who received the most care. But in an age of rushed doctor’s visits and packed waiting rooms, it was the first study to show a “dose-dependent response” for a placebo: the more care people got—even if it was fake—the better they tended to fare.

The part that struck me about the above quote is the practicioner telling the patient, "this treatment has excellent results," when the practicioner knows that it is a "sham" treatment. Now, obviously this works (combined with all of the attention lavished upon the patients in the third group), and it was necessary for the study - but in a real treatment setting, it's not exactly honest. Is it ethical to give the patient unrealistic expectations? Then again, as long as I say that the treatment has excellent results, maybe it automatically will. Plus, if I truly am certain that my treatment, whatever it may be, is going to help the patient, then I'm not really lying. But I, personally, am never actually certain about that sort of thing.

I've never really felt confident in any of the mechanical-based exercise or manual therapies that I've learned. I used to think that this was because I wasn't good enough at the technique, or I didn't understand the rationale thoroughly enough. I'm only now coming to realize that I understand the rationale just fine, it just doesn't make sense to me. I think my lack of confidence has probably shown through to patients (I'm not a very good actor), and that obviously isn't ideal. But even now that I'm starting to use more interactive treatment techniques, I feel like I can't truly be "confident" that my treatments will "work" until I've seen the results over an extended period of time. Until then, am I supposed to pretend? Later, if the treatment hasn't helped, how do I explain my confidence to the patient?

One group received no treatment. The other patients were told they’d be taking fake, inert drugs (delivered in bottles labeled “placebo pills”) and told also that placebos often have healing effects.
The study’s results shocked the investigators themselves: even patients who knew they were taking placebos described real improvement, reporting twice as much symptom relief as the no-treatment group.

Do I just come right out and tell the patient, "it doesn't really matter what I do to you"? According to the evidence, this seems more honest. I would think that letting them in on that secret would spoil the ritual, but according to the above study, maybe not.

When I talk to other PTs I know, most of the time they sound very confident in their methods and, according to them, get great results. I feel like I'm not as confident as other PTs - but I keep coming back to "Doubt is not a pleasant mental state, but certainty is a ridiculous one."

I guess what I'm asking is: Is it ethical to bend the truth? How far? Is it risky to be too honest? Is it right for therapists to be actors? This is an issue that has been bothering me for a while. I'd appreciate any thoughts on the matter.

[Diane]

The placebo effect is present in every medical intervention

The concept of the self being an autonomous being is a deeply held belief in western civilisation, but we affect each other all the time....Those who had been given the cream (the control group had nothing) showed "placebo effect patterns" in the prefrontal cortex. This part of the brain activates when anticipating pain relief and triggers a reduction of activity in pain-sensing areas of the brain. Wager suggests that this interplay within the prefrontal cortex may also trigger a release of pain-relieving opioids in the midbrain.

[Diane]

97 percent of UK doctors have given placebos to patients at least once

[Frédéric]

Avoiding to tell some facts while concentrating on others is not a lie!