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This article about placebo is about how placebo allegedly works even when people know that it’s a placebo — placebo without deception. This is based on a well-known 2010 study of placebo for irritable bowel syndrome. The article is about that researcher’s plans to study open-label placebos for cancer next. And that’s really all the article has to offer: it’s basically a press release for the research sequel to the original placebo-hyping blockbuster. There is no new research, yet. It was just an advertisement for the idea.
I don’t like the idea.
Ironically, Kaptchuk’s 2010 evidence of placebo without deception was itself deceptive (or at least disingenuous), because patients were still given a clear reason to have faith in what they were given. In this way, the 2010 study was well-crafted to produce a placebo effect, just by raising expectations with a different kind of deception. And Kaptchuk will do the same with the next study, with completely predictable results. And it will be a big deal, mark my words… because cancer. And because everyone loves the “power” of placebo!
I explain the problem with the 2010 study in more detail in my placebo article.
“Efficacy” is how well a treatment works in ideal circumstances, such as in a carefully contrived scientic test. Unfortunately, real life is rarely ideal! (You may have noticed.) “Effectiveness” is how well the same thing works in typical clinical settings and patients’ lives. Which is what matters to most patients.
A classic example of efficacy versus effectiveness is strong calorie restriction for losing weight: anyone who substantially restricts calorie intake over long periods will lose weight, but it’s a serious error to assume that it’s just a matter of discipline. Low calorie diets are so difficult to sustain for so many reasons, many of them out of our control, that most people will gain back any weight they do manage to lose. They are efficacious, but also notoriously ineffective.
A recent editorial in the British Journal of Sports Medicine explains that exercise (in a physical therapy context) is well-known to be efficacious, but may not be effective. That is, it works well when tested in the lab, but not so much for real patients. Again, effectiveness is what matters to patients! If effectiveness is low, only a few lucky and/or disciplined people can realistically expect to benefit.
For example, I recently shared a perfect example of this problem: Ylinen et al found fairly good evidence that strengthening is probably efficacious for many people with chronic neck pain… but maybe only if they stick to it for as long as a year. That takes a lot of discipline, and many people will fail at it. (And some will fail even if they stick to it, because not all cases respond to strengthening.) So even if it does work in a scientific test, can we say “it works”? It’s ambiguous.
I think there’s a large gray zone here: some exercise therapies are much more difficult and impractical than others. When they are truly efficacious, they are an opportunity for determined patients with frustrating chronic pain: an intervention that might really work, but onlyif you’re up to a substantial challenge! Many people aren’t…but you can be some will be. And for those patients only, “it works.”
See Kenny Venere’s more detailed discussion of effectiveness and efficacy.
I love it when The Onion does health stuff: “Area Man's Knee Making Weird Sound.”
COLORADO SPRINGS, CO—Noting that it began happening just a few days ago, local 31-year-old Anthony Forster told reporters Monday that his left knee has been making a really strange sound lately. “It’s like a little clicking noise—can you hear it?” said Forster, as he repeatedly flexed his knee back and forth in an effort to demonstrate the unusual sound. “You have to get really close and listen for it. It usually happens when I bend my knee all the way back and—there, did you hear that? It was doing it worse before, but you can still hear it.” At press time, sources confirmed a small blood clot just above Forster’s knee had broken loose and was traveling through his bloodstream to his brain, where it is expected to cause a massive stroke, killing him instantly.
Nice touch with the hypochrondiac flourish at the end.
The evidence we have for longer term training is nothing but good news: lasting improvements in strength, pain, and disability. It still hasn’t been replicated, but it’s excellent preliminary data. For more information, see Ylinen et al, or a much more detailed new discussion in my neck pain book.
(By the way, this is yet another in a series of many updates about exercise efficacy. They just keep happening.)
The good news is that the prognosis for most painful problems is good without any help. In fact, as things get better, you can usually count on getting better faster. You can’t rush it, but healing speeds up on its own. I recently rewrote and modernized my article on this topic:
Impossible mission? I set out to summarize basic tips about over-the-counter pain medications as concisely as possible — a blurb I can re-use in many places on PainScience.com. It has to be brief and readable and yet hit all the highlights that most people need to understand, most of the time. And of course it has to be safe and accurate advice, with a certain amount of legal paranoia. For instance, I’d like to be able to say that combining different types of OTC analgesics is quite safe, because I think it is, but I’m not absolutely sure and I would have to be. So it’s a very tricky paragraph to write. Here’s the result (so far, revised once after some reader suggestions):
Over-the-counter (OTC) pain medications are fairly safe and work in different ways, so do experiment cautiously. There are four kinds: acetominophen/paracetamol (Tylenol, Panadol), plus three non-steroidal anti-inflammatories (NSAIDs): aspirin (Bayer, Bufferin), ibuprofen (Advil, Motrin), and naproxen (Aleve, Naprosyn). Don’t take any of them chronically — risks go up over time, and they can even backfire and cause pain (rebound headaches). So respect dosage limits, especially for acetominophen, which hurts livers, and beware the hidden dosages in cold meds. NSAIDs are safer, but they irritate the gut, even taken with food, and especially with booze. Voltaren® Gel is an ointment NSAID, and great for treating superficial pain with minimal dosing.
And I’d really like to include this, but I just can’t make it fit into 140 words!
Athletes, please don’t take “Vitamin I” to prevent soreness — it doesn’t work!
There’s a widespread assumption about stress, based on all kinds of educating guessing and some hard data (e.g. McBeth et al): we assume that harsh stress has biological consequences which in turn drives up the risk of chronic pain later.
That’s a chain of reasoning with three links: stress > biological consequences > pain. A > B > C. It seems strong.
But here’s an eyebrow-raiser of a new study that “could not confirm” those connections: Generaal et al, 2015. The researchers looked for and failed to confirm “that dysregulated biological stress systems increase the risk of developing chronic multisite musculoskeletal pain.”
And yet they did confirm that “adverse life events” are a risk factor for pain. A causes C (or at least one follows the other). But the B-for-biology middleman may not be required.
If those results are reproducible, it implies that severe stresses might ultimately lead to chronic pain without any obvious biological effects — no endocrine system “burnout” (which is a real thing in itself, see Kakiashvili et al). In other words, the connection might be entirely psychological. For instance, adverse life events may dial up the sensitivity of the brain’s threat-o-meter, which is plausible.
Or the study might have gotten it wrong, of course. Stress might have biological effects these researchers didn’t examine (for instance, functional connectivity in the brain is altered with stress and predicts chronification of pain — hat tip to Tony Ingram for this suggestion).
So many citations are utter bollocks if you take the time to look. I encounter all the time as I work, but recently the phrase “better citation needed” popped into my head. So I doodled this up for my article Bogus Citations:
[better citation needed]
Not a big deal on a small screen, but nice and big and bold in a larger window, like an image of text but quicker to load. It’s just text styled with CSS, very simple, but with one nifty new trick I learned: it uses viewport percentage units so that the font-size scales with the size of the window it’s in. I have wanted this “simple” text-styling effect countless times over the years. Where have you been all my life, VPUs?!
Massage therapists and others who do “energy work” tend to be contemptuous of those who don’t. (This is a sign of their spiritual sophistication, I assume.) Laura Allen, massage therapist, author of Excuse Me, Exactly How Does That Work? Hocus Pocus In Holistic Healthcare:
There are some strange ideas floating around out there about massage therapists who stick to the practice of massage without throwing in energy work. I laugh with my clients. I grieve with my clients. I empathize or sympathize with whatever emotional time they might be going through and at times comfort them. Leaving energy work out of my practice does not mean I am some kind of uncaring robot just going through the physical motions. But that seems to be the general characterization a lot of people make about us.
I have often encountered this attitude towards energy atheism, as though my inability to see human interactions through a spiritual lens is stunted and pitiable. I think it’s actually the other way around. It’s far more rewarding to try to understand why life actually feels the way it does, rather than chalking it all up to unknown and unknowable forces.
There is infinite room in psychology and biology for profound, meaningful shared experiences. It isn’t necessary or helpful to attribute strange and interesting sensations to poorly defined “energy.” Actually, it’s a cop-out, a failure of imagination and knowledge, a grossly oversimplified reckoning of the amazing richness of human nature.
These thoughts originally came up in a Facebook discussion. I refined them and baked them into my article about Therapeutic Touch is Silly.
A reader asked me that. It’s not actually quite as outrageous as it looks. It’s really just a whole-body TENS machine treatment (mild electrical stimulation of tissue). But it does reek rather amusingly of “What could possibly go wrong?” And, medically speaking, it’s waaaay out in left field, and unlikely to be good for anything. If nothing else, it was doomed to extinction by economics: the high cost of the infrastructure and equipment to deliver such treatments is way out of proportion to the slim hope of any significant benefit.
Plus, can you imagine the lawsuits it would generate today?