I am a current student of physical therapy and before I say anything else, I just wanted to thank you for the content that you put out. One of my friends in class steered me in your direction and my perspectives on fitness, pain and rehabilitation have shifted dramatically ever since. I have read many of your articles on topics related to therapy, so I am generally familiar with your perspectives on different modalities, many of which come to the conclusion that the research suggests they are nothing more than placebo. With that being said, I am struggling with a thought experiment. If I was to create an imaginary patient that wasn’t progressing no matter what interventions a therapist provided, be it exercise, pain education, etc., does a situation exist where you would deem it appropriate to potentially use a modality that the research suggests is a placebo?
Essentially, if all other options have been exhausted, is it ethical to do nothing and allow the patient to continue with their symptoms rather than employ a technique that is not definitively supported by research but may be beneficial via placebo?
I know you didn’t ask for my view (I’m not part of the BBM team) but I’m not opposed to sending patients out of the clinic without doing anything besides education.
The vast majority of conditions entering the clinic aren’t diseases but mere MSK predicaments (look up Nortin Hadler). When I talk to the patient about their condition, I let them know one of their options is do to nothing at all. Time and regression to the mean may be as effective as what I do in the clinic. It cost zero dollars and has no negative side effects. Sometimes “treating” a patient carries with it harms: cost, time, transportation, time away from work and family. These are not discussed in school or many course/conferences but are in fact “harms” we must factor in.
@agacek4 - I think your thought experiment is actually operating from a false premise. There are a few definitions that’ll likely need clarification to have this conversation effectively but placebo in of itself is thought of as an inert substance but is capable of having contextual effects based on environment, delivery, setting expectations, conditioning, etc, which has many questioning utilizing the phrase placebo given it’s the other factors having effect rather than the inert substance (which by definition can’t have an effect).
The point being - if we think we aren’t already capitalizing on contextual effects via consultation, education, setting expectations, etc - then we would be wrong.
The ethical dilemma becomes when we knowingly use interventions no better than placebo given these build false-beliefs and conditioned responses unnecessarily to a “substance” lacking efficacy. This would be where it can be argued we are doing more harm than good long-term. Recall - efficacy trails (Randomized Controlled Trials in healthcare) demonstrate an intervention works or is better than placebo in ideal situations (often not clinical practice) and effective interventions appear to “work” under realistic (clinical) situations. Plenty of interventions appear to work (effective) but completely lack efficacy. Choosing to utilize these interventions is questionable given we know they aren’t actually doing anything. This is way I take the stance of minimal effective dose for interventions - meaning, having conversations, setting expectations, and educating can and does capitalize on the above effects while minimizing the chance I rob the person of their self-efficacy (something we know to be quite important, most especially when examining the discussion of persistent pain).
Hopefully this provides some guidance on the topic. Happy to discuss.