More than Placebo

[Karen L]

So where do I go from here? Answers Pernkopf in a particularly good mood today...


My office space is bright and as open as possible and invites playfulness and creativity but not at the expense of intelligence or compassion. My patients are greeted the same way by me or a receptionist. I want as much of the context as possible to be toward a non-threatening concept. The choice here is a clinical experience or a creative experience. I choose the later.

The first thing I want to know is if I am dealing with non-pathological pain. Patient education begins with the five questions. I am not testing or examining structure. I am listening to the patient, what is their pain story and watching to know if we have both moved through the door into the creative space. When to touch, what to touch and how to touch will become evident as the patient instinctively moves to satisfy their need state. W.E.S.S. being the confirmation of successful elicitation of self correction.

If I have understood what this thread is discussing correctly; when the operator concept matches with the expectations of the patient a meaning response and thus a placebo effect is developed in the patients brain and the output is a decrease in pain.

Some thoughts:
Ideally the contact that forms the construct is as non threatening as possible. Why not I rejected triggerpoint techniques a long time ago.
The trick is setting up the appropriate patient expectation. I didn't particularly want arthritis in my hands in the first place. My brain is a much more powerful tool to be using.

A couple of questions:
If I use tape to input lateral stretch why leave it on so long?
How is penetrance of the placebo effected, enhanced or hindered by the elaborateness of the construct?
Is there a danger that Occam's Minimalist Chainsaw has painted a plain white canvas and only we are able to see the art.

Am I understanding this thread correctly.

Karen

[Barrett Dorko]

Luck or specificity?

When mechanical deformation is at least part of the pain’s origin (easy to ascertain) we’re looking for a movement, aren’t we?

Finding the one that is sufficient to reduce the brain’s output of pain doesn’t require that we look for it or guess or get lucky. This movement would quite naturally be planned by a nervous system dedicated to our survival. We’ve all got one of those.

Survival, however, isn’t always our greatest concern in a culture more attuned to appearance and its unique definition of success. Still, the movement is there; usually hidden behind the facades of restraint, posing, posturing, compliance and fear avoidance. Given all of this, any therapist would be very lucky to find it and then describe its expression in a home program.

This is why I use ideomotion as a movement therapy for pain from mechanical deformation, also often referred to as an abnormal neurodynamic. Getting it to emerge is simply a matter of creating the right context – and that, it seems to me, requires attention and care, not luck.

If there is a specific effect to manual intervention I believe it can be found in this – not that it is always sufficient or even necessary.

[Diane]

If I use tape to input lateral stretch why leave it on so long?

A neuroscience/painscience-based hypothesis would be, until the receptors change over (72 hours). The brain has the oportunity meanwhile to practice painfree movement and neuroplasticize itself in that direction.

[nari]

Is there a danger that Occam's Minimalist Chainsaw has painted a plain white canvas and only we are able to see the art.

I think there is a risk of this happening, but perhaps most people don't use Occam's until they have a clear idea of the replacement values and tones. With digital art, the question I am asked often is: How do you know what to paint first? I puzzled over this for a while and then sensed something of an analogy emerge.
An artist doesn't wait to be told what to do nor does he/she expect it. The end result is in the brain, in a fashion, and one just works towards that, using basic principles. There are no routine or rules and the final result is usually a one-way consummatory act, but not always. Just as with patients, but it is a two-way process, and that is where PTs make it complicated.

....the methods I use reduce my reliance upon luck – they will never eliminate it entirely.

Exactly.

Nari

[Luke Rickards]

So, the act of manipulation may be found to bring about specific actions, like activation of ascending pathways, but the effect brought about may still be non-specific as it is able to be nullified with the addition of the role of expectation.

So, DNM may be found to have specific actions, like Ruffini activation, but the proposed effect brought about by the application, pain relief, could still be non-specific.

Cory,

These are the questions that research is (should be) all about. All manual therapies result in both physiological effects and psychological (psychosocial) responses. The question is, are those that are responsible for, or at least facilitate, positive outcomes the same ones that we hypothesize to do so.

You are correct in that it is possible to simply acknowledge that certain physiological responses are unavoidable following any particular technique and that the therapeutic part is really the ritual of the treatment and expectation. However, my view on this, and the point of the thread, is that if you truly believe that most of the theoretical and application details of a treatment construct are irrelevant to the outcome, why bother to make such an effort towards developing and refining them? Why not focus on priming expectation and delivering the most convincing ritual that requires the least amount of effort? We already know from Ted Kaptchuk's work that this is possible.

As Barrett points out, obtaining specific effects from many of the therapies used in our professions often relies on a degree of luck. However, I think that this is still a worthwhile pursuit, and I agree with Barret that it is possible to reduce reliance on luck with understanding. In cases where pain is mechanical in origin, it still makes sense to me to pursue some kind of input that reduces or resolves the deformation, ie a specific effect. It may not be necessary, sure, but it is very often sufficient. A really obvious example of such a specific effect is instant pain relief in a static opener position with Cx flexion on a patient who has LB and leg pain every other possible position. The patient might also find it themselves during ideomotion.

One of the exciting things for me about following the science behind what we do is that the proposed specific effects become dynamic: we can update the propositions on which we base treatment constructs as new understanding emerges. For example, we can stop proposing that the production of stretch sensations during treatment will help because the tissues are now longer, and instead see them as one of the many possible ways to initiate modulation of the sensory-discriminative dimensions of the pain experience.

[Luke Rickards]

Gandevia has already shown that skin stretching produces kinesthetic illusion in the brain. What's wrong with just going along with that? (Specific enough for you Luke?) It was worked out long ago that Ruffinis are slow-adapting, fire continuously with lateral stretch, comprise 19% of all skin receptors (see Challenge of Pain for details). I don't know how one could eliminate them with Occam's Chainsaw.

Yes, specific enough for me. I was just surprised at the suggestion it isn't important to you.

[Diane]

Ultimately what's important is getting that brain to recognize what's happening. It's the only thing in existence that will change itself. Through a placebo response.
That's what I'm saying.

[Frédéric]

I think to make tings less confusing, we should really define what we consider a placebo effect.

To me, placebo is an effect mostly related to expectation but also to every psychosocial issues that could be affected by the intervention ritual/education rather than by the intervention itself. The process of placebo is, as Diane puts it, the brain re-organising itself, changing the perceived threath level.

If we can improve this response of the brain by what we are doing and how we are doing it then, in some ways, we are specific. The application of the «tool» may not be specific but the whole package is.

[Frédéric]

Sometimes, parts of the mesodermal logic does apply, say in acute care. Where there is a need to be specific and help the patient do what will promote healing rather than hinder it.

Example : If you keep playing on a freshly sprained ankle it might heal badly. Our education toward the patient changing it's behavior is specific, not just placebo like. One could also argue that transverse friction will help the ligament get its tensile strenght quicker (there is a good article on that topic in JOSPT this month) or at least that mvts rather than immobilisation will promote a better, stronger healing. It's not about pain, of course, but specificity is present.

[Barrett Dorko]

Frederic,

I think you're on the right track. I simply remember that placebo is given to us by the patient, not received by them from the therapist.

Is that fair or incomplete?

We should face the fact that many therapy venues (part of your "whole package") are inherently threatening. Overcoming this in the midst of such an environment can be especially difficult. I've watched as my patient's recovery in my presence was massively disrupted when the maniacal laughter of a colleague or the painful crying out of another patient suddenly dominated the atmosphere. Sometimes someone will bounce a Swiss ball near my patient's head. I'm not kidding.

These things are done thoughtlessly and, when I think about it, are enabled by management devoted to productivity over all else.

[Diane]

I simply remember that placebo is given to us by the patient, not received by them from the therapist.

That's on the right track, in terms of where the placebo is coming from. The quote is more along the lines of, "A placebo response is something to be elicited from a patient, not given to them."

Frederic,

"placebo is an effect mostly related to expectation but also to every psychosocial issues that could be affected by the intervention ritual/education rather than by the intervention itself. The process of placebo is, as Diane puts it, the brain re-organising itself, changing the perceived threath level."

I agree.

[Barrett Dorko]

So, placebo is a noun and placebo response is a verb.

I think that they are often confused.

Is placebo present when the intent of the therapist is to "fool" their patient into feeling better with a method they know (or think they know) to be ineffective and/or unrelated to the origin of the patient's complaint? What does a placebo response indicate about such a situation? That the patient's crazy? Easily fooled? Faking?

Now this is getting interesting.

[Diane]

So, placebo is a noun and placebo response is a verb.

I think that they are often confused.

Is placebo present when the intent of the therapist is to "fool" their patient into feeling better with a method they know (or think they know) to be ineffective and/or unrelated to the origin of the patient's complaint? What does a placebo response indicate about such a situation? That the patient's crazy? Easily fooled? Faking?

Now this is getting interesting.

Nouns and verbs again, definitely. It would help so much if English wasn't such a screwy language in the first place.

It's extremely easy to convince peoples' "I"-illusions that they are being helped by some bogus application. It's a LOT harder to fool the nervous system itself.

I would go so far as to say, a genuine placebo response happens within the nervous system as a whole, not just at the "I"-illusion or social level.

A genuine placebo response has to involve/redirect ongoing neuroplasticity or it's not worth the powder to shoot a rat.

(Sorry for the colloquialism- it's there just for emphasis. I don't go around shooting actual rats.)

[Barrett Dorko]

Wonderful discussion Diane.

Almost certain to get us killed off - once again.

I have written in the past of therapy being defined as something enduring; something that the patient can reproduce and something that involves patient education. I have often said that it emerges from the patient, not the therapist. This is why I’ve always struggled with the word therapy attached to massage. Typically, massage contains none of this. Often, manipulation alone doesn’t have it either.

Now I can see that it might be useful to refine the definition. In the case of problems primarily of a painful nature i.e. no significant pathology that requires healing or repair, a placebo response is noted when true therapy is present. This is a profound alteration in the nervous system and could be said to be neuroplastic in nature.

Without that, the therapeutic method (placebic in nature) can't be considered enough to either lead to resolution or rise to the level of therapy as defined here.

[Frédéric]

Barrett Dorko
Is placebo present when the intent of the therapist is to "fool" their patient into feeling better with a method they know (or think they know) to be ineffective and/or unrelated to the origin of the patient's complaint? What does a placebo response indicate about such a situation? That the patient's crazy? Easily fooled? Faking?

Now this is getting interesting.

If you take the stability CPR, it says that pt w/o fear avoidance are less likely to have a positive response. So If someone as fear avoidance behavior and a PT tell them that their back is not stable, this would increase the fear issue i guess. But, if then, the PT gives a pgm for «re-stabilising» the back and educates the patient that with the exs regimen his back will become stronger and thus not unstable anymore, the said protocol might decrease the fear avoidance and elicit a positive placebo response. Yet all along the theory behind the treatment could still be completely bogus.

In a situation such as that, the placebo response is real, the pt's CNS might act differently because of the decreased threat of mvts and re-injury. Was he faking ? no just «scared» of mvts. Was he fooled ? In a way yes, cause the treatment might not do what it is proposing to do, ie. «stabilising». But on the other hand, the pt was re-assured, he now thinks his back is stronger and feels less threatened by mvts. That's positive and so, somehow, he was not really fooled. For some patient really convinced by such mesodermal logic, I think providing them with a treatment plan going along their beliefs might enhance the placebo response. That's just my assumption.