COLUMN BUSINESS TALK Placebo effect I Why evidence-based practice is not always practical BY ANTHONY LOMBARDI and related to the interaction between the intervention, the patient, the practi-tioner and the environment. Fuentes et al in Physical Therapy (2014) studied the effect of the thera-peutic alliance between the patient and clinician by using four groups: no treat-ment, sham treatment, treatment with no clinician-patient interaction, and treatment with enhanced clinician-pa-tient interaction. In the last group the therapeutic interaction was enhanced through verbal behaviors, including active listening, tone of voice, nonverbal behaviors and empathy. Fuentes con-cluded that the context in which physi-cal therapy interventions are offered has the potential to dramatically improve therapeutic effects when enhancing their interaction with patients suffering from chronic low back pain. doctor and physical medicine and reha-bilitation specialist, agreed: “When you visit someone who is considered a spe-cialist in a given subject... your expecta-tion 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.” ’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. lum-bar 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 ingre-dients 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 instruc-tional 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 treat-ments are traditionally researched may not be transferable to reality. In addition to that, there are some chiropractors who are what I call ‘outli-ers’ – those who are simply better than other DCs and are able to attain un-commonly good results. This has never been or likely can never be researched – but that doesn’t mean it’s not true. PLACEBO IN PRACTICE THE INTERVIEWS PLACEBO CONTROL Although placebo is traditionally con-sidered 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, con-cluded that the mechanisms through which manual therapy inhibits muscu-loskeletal pain are likely multifaceted I interviewed two well-known lecturers on the topic, who are also full-time cli-nicians 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 meas-ure such subjective variables. These outliers should be more carefully stud-ied because the expectation a patient has toward our interaction with him/her will create a positive or negative expec-tation and not a full placebo effect. We must control all the controllable varia-bles so that we can offer the most posi-tive 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 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. www.canadianchiropractor.ca Pinto says the build-up to the appoint-ment can be constructed with informa-tion from family and friends, neighbours and internet forums. Encarnação says expectation, social learning and prior experiences are all significant aspects that do have an im-pact on outcome of any therapeutic technique. He added patients are influ-enced just by being in the waiting room talking to other patients, the conditions of the treatment room – lighting, tem-perature, 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 pa-tient 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 environ-ment – how we speak to the patient – and learn from those better than us so we can consistently produce quality clinical results. July/August 2016 Canadian Chiropractor 11
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