Placebo control

I’ve always found it unsettling how research performed in the lab does not accurately mirror the patient visit experience. Many researchers only study the treatment (ie. lumbar adjustment effectiveness for low back pain), while in actuality the visit experience is multidimentional and different in every office.

In real life, the treatment intervention is about 10 per cent of the entire visit as it gets mixed in with all the other ingredients that make up a patient visit. Things like how the patient is engaged by clinic staff, how they are engaged by the doctor, followed by the assessment method the chiropractor uses, ancillary pre-adjustment modalities, the post adjustment re-assessment, and instructional advice given prior to leaving the office – these are all vital factors and just some of the things that influence the patients’ physiology and their response to treatment. My point is, how treatments are traditionally researched may not be transferable to reality.

In addition to that, there are some chiropractors who are what I call ‘outliers’ – those who are simply better than other DCs and are able to attain uncommonly good results. This has never been or likely can never be researched – but that doesn’t mean it’s not true.

Placebo control
Although placebo is traditionally considered an inert intervention, the pain research literature suggests that placebo is an active hypoalgesic agent.

Bishop et al, in the Journal of Manual and Manipulative Therapy in 2011, concluded that the mechanisms through which manual therapy inhibits musculoskeletal pain are likely multifaceted and related to the interaction between the intervention, the patient, the practitioner and the environment.

Fuentes et al in Physical Therapy (2014) studied the effect of the therapeutic alliance between the patient and clinician by using four groups: no treatment, sham treatment, treatment with no clinician-patient interaction, and treatment with enhanced clinician-patient interaction. In the last group the therapeutic interaction was enhanced through verbal behaviors, including active listening, tone of voice, nonverbal behaviors and empathy. Fuentes concluded that the context in which physical therapy interventions are offered has the potential to dramatically improve therapeutic effects when enhancing their interaction with patients suffering from chronic low back pain.

The interviews
I interviewed two well-known lecturers on the topic, who are also full-time clinicians from Portugal in the treatment of musculoskeletal pain using medicine, acupuncture and soft tissue release.

I asked them how they classify these outlier chiropractors. “We can’t measure such subjective variables. These outliers should be more carefully studied because the expectation a patient has toward our interaction with him/her will create a positive or negative expectation and not a full placebo effect. We must control all the controllable variables so that we can offer the most positive experience to the patient, and also help us treat them better and faster and with less or no side effects,” said Dr. Hugo Silva Pinto, medical doctor and sports medicine specialist.

Dr. António Encarnação, medical doctor and physical medicine and rehabilitation specialist, agreed: “When you visit someone who is considered a specialist in a given subject… your expectation will be higher, so you will be in a situation where your dorso-lateral pre-frontal cortex and other brain areas related to placebo effect will be more active. So, a well-regarded expert will be in a position where the techniques that he will use will have a higher impact in the function of the brain structures implied in the effect of treatment. If the doctor is confident that the technique he is using will help the patient, it will translate into a greater effect – that has been confirmed experimentally.”

placebo in practice
Pinto says the build-up to the appointment can be constructed with information from family and friends, neighbours and internet forums.

Encarnação says expectation, social learning and prior experiences are all significant aspects that do have an impact on outcome of any therapeutic technique. He added patients are influenced just by being in the waiting room talking to other patients, the conditions of the treatment room – lighting, temperature, sound, scent, a comfortable treatment table. These are all clinically helpful, but they are aspects that are very difficult to replicate in a study.

In 14 years I presided over 98,000 clinical visits and 32,666 hours of patient interaction. Things like making eye contact, repeating the patient’s words, and asking for clarifications during the patient history go a long way to prime the patient to respond to your treatments. We need to embrace and control more of our clinical environment – how we speak to the patient – and learn from those better than us so we can consistently produce quality clinical results.

Dr. Anthony Lombardi, DC, is consultant to athletes in the NFL, CFL and NHL, and founder of the Hamilton Back Clinic in Hamilton, Ont. He teaches his fundamental EXSTORE Assessment System and conducts practice-building workshops to health professionals. Visit exstore.ca for information.