Sensory Approach to Manual Therapy
The Placebo Paradox: Unveiling the Mind-Body Connection in Pain Management
Unlock the mysterious efficacy of placebos and their role in pain management as we host neuroscience professor and esteemed author Serge Marchand. Together, we unravel the power of patient-practitioner interactions, where empathy and positive reinforcement can significantly alter a patient's pain experience. Listen to how even the most seasoned professionals must navigate the fine line between science and empathy, and how this dance can redefine healing approaches across healthcare.
This episode isn't just about the sugar pill effect; it's an expedition into the heart of expectation and its profound impact on treatment success. Serge Marchand gifts us with insights from his latest research, sharing personal stories that illustrate the interplay between the psychological and physical realms of pain. We tackle the controversial pendulum swing in pain neuroeducation, revealing the importance of balancing biomechanics with psychological factors in pain perception. We also probe into the ethical conundrums that arise when deploying placebos, emphasizing the delicate balance required to maintain patient trust while maximizing treatment efficacy.
Wrap up your understanding of the placebo's role in therapy with a discussion on the brain-body nexus and its implications for manual therapy. We consider how even non-efficacious treatments can sometimes yield surprising benefits, and ponder the potential of emerging research techniques like hypnosis and transcranial stimulation. The episode culminates with a forward-looking anticipation of future discussions, promising to shed even more light on the enigmatic workings of the nervous system. Join us for a journey that is as much about the science of healing as it is about the healing power of belief.
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Unlock the mysterious efficacy of placebos and their role in pain management as we host neuroscience professor and esteemed author Serge Marchand. Together, we unravel the power of patient-practitioner interactions, where empathy and positive reinforcement can significantly alter a patient's pain experience. Listen to how even the most seasoned professionals must navigate the fine line between science and empathy, and how this dance can redefine healing approaches across healthcare.
This episode isn't just about the sugar pill effect; it's an expedition into the heart of expectation and its profound impact on treatment success. Serge Marchand gifts us with insights from his latest research, sharing personal stories that illustrate the interplay between the psychological and physical realms of pain. We tackle the controversial pendulum swing in pain neuroeducation, revealing the importance of balancing biomechanics with psychological factors in pain perception. We also probe into the ethical conundrums that arise when deploying placebos, emphasizing the delicate balance required to maintain patient trust while maximizing treatment efficacy.
Wrap up your understanding of the placebo's role in therapy with a discussion on the brain-body nexus and its implications for manual therapy. We consider how even non-efficacious treatments can sometimes yield surprising benefits, and ponder the potential of emerging research techniques like hypnosis and transcranial stimulation. The episode culminates with a forward-looking anticipation of future discussions, promising to shed even more light on the enigmatic workings of the nervous system. Join us for a journey that is as much about the science of healing as it is about the healing power of belief.
Start for FREE
Disclaimer: This post contains affiliate links. If you make a purchase, I may receive a commission at no extra cost to you.
Hello everybody and welcome again to another Sensory Approach to Manual Therapy podcast. Today, I am here with Selj Mel Shah, who is a professor at the University of Sherbrooke, where I live. He is also the author of a really great book called the Pain Phenomenon, which was originally published in 2012 with the IASP, which a lot of you will be familiar with, and he just informed me that the newest version of that book is going to be coming out in May 2024. So if you are interested in it, I recommend getting that new one. And Salj is a specialist in neurosciences. He has a PhD in neurological sciences and he has spent the majority of his career really focusing on the ideas of pain and concepts around that, and we're going to talk a little bit about pain, but really I want to talk to him about placebos, which is a subject that he's been getting interested in over the last couple of years. That interests me a lot. So welcome, selj. Thanks for being here.
Speaker 2:Thank you. Thank you, thanks for the invitation. I think placebo is a very interesting subject.
Speaker 1:I'm excited. Before we get into placebos, I wanted to ask you why neuroscience, why pain studies? I mean, of all the things to study in the human body, I mean, I am fascinated with pain. A lot of my followers are Most of my followers are clinicians, and so the pain study is interesting to us.
Speaker 2:But I'm always interested in knowing why scientists like this subject I start my um, you know I start university, uh, studying in psychology and I was working with young people having some, you know, social troubles and different things in psychoeducation and during my courses, my first years, uh, one course was called psychophysiology and psychophysiology was, in fact, you know, the brain and how your behavior are related to different parts of your brain and everything. And for me that was a really game changer. I mean I started at that moment to say, ok, I'm going to finish my baccalaureate but after that I will go study neuroscience. I mean it's too exciting, no-transcript. I mean it was a domain I wanted to study. Then I started at the beginning. At the first year I was at university, I started to collaborate on Project in Pain and you know I just dedicated the rest of my life working on that.
Speaker 1:That's great and you touch on a subject that I've brought up in many of my podcasts and to a lot of my students when I teach around the globe, and the idea that we treat in isolation, the idea that you know just the problem being presented to us, just the diagnostic box, is the problem. You know there's a large amount of the population that, as clinicians, who are moving away from the idea that we we treat in isolation and that understanding their, the client history, but understanding the evidence around, just the injury typically, but understanding their psychological state, their motivation to get better, you know these things become so much more important. But it also it leaves at least my group of listeners as massage therapists. It leaves us in a large conundrum, which is stay within your lane scope of practice. You know we're not allowed delving into the psychology. We're not allowed delving, we're allowed listening, but we're not allowed giving advice.
Speaker 1:Scenario where you might observably, as a clinician, understand a lot of the mechanisms of discomfort, but you can only isolate your treatment to a limited number of them. So, as a scientist, how have you found that interconnectedness when it comes to treatment? Has it been in working in teams or has it been finding that isolating tends to help people more. Where do you find that balance?
Speaker 2:I think it's a very interesting question, a very complex one, but very interesting question. First of all, I don't believe in using one approach only for every patient. Clearly, I mean, you know and you know and we all know it's not working. But and I understand at the same time that there is some legal aspect of it also you don't want to to play being a doctor, you don't want to play being a psychologist, but you don't have to. You don't have to. You can touch all that at different points and you can. You know and in fact you don't have the choice.
Speaker 2:For example, if you are an MD or a physical therapist or any profession, you talk with the patient and at the moment you talk to the patient and especially in your approach, if you touch the patient you know massage, for example you touch the person. When you touch someone, there is a contact. There's a physical contact, but there is also an emotional contact with the person and I think this is part of the treatment. I will give you a very simple example. You go to the doctor and you have you know you don't feel good, I mean something is happening, and you have this. You know you hike someplace and you know you think it's dangerous, you think it's terrible, it's a terrible thing happening. You think it's a cancer, you think it's something terrible.
Speaker 2:And then you get the diagnosis from the doctor, who says no, no, no, no, I'm sure it's not that, I'm sure it's just this or that. And you start to feel better. And it's not because the pain is gone. It's because the way your brain is interacting with this pain is different, and it's the same, the susceptive signal. And that's why, every time I see a doctor who says to a patient, for example I'm going to give you this pill. You've been sick for 10 years. I know you have this chronic pain for a long time. Then don't expect too much. You know we'll try it, the pain catastrophizing.
Speaker 2:I mean this is terrible. This is the worst way to approach a patient, I think. But it happens all the time and unfortunately this doctor won't to be honest. I mean, it's not because they're bad, it's because they want to be honest.
Speaker 1:But honesty in this way is not helping the patient yeah, what you're describing is really interesting because, like, I'm about to teach a class in calgary in june for the canadian massage conference, and the class one of the virtual classes I'm doing, is called the integration of evidence-based medicine and patient-centered care. And it's that tricky balance of being able to prevent, to present evidence in a way that's honest as a clinician, without creating pain catastrophizing, without diminishing the client's values and belief system around their discomfort, where we're still saying, okay, we want you to get better, but we, we want you to understand how serious it is, but we also want you to understand that there's hope, um, and, and that's such a tricky thing because even in scenarios and in cases where hope, you know, terminal, terminal and this is, you know, stage four cancer, things like that even in those scenarios the research really shows us that hope it's not going to help them get better, but it is going to increase quality of life, you know, while they're doing their palliative care. And so it's that that tricky balance. And it leads perfectly into the idea of placebo, because so much of the conversation around placebos is currently right now, there's this big dilemma in medicine of do we allow placebos to be, do we understand that they are effective enough, powerful enough and influential enough to be considered an intervention, or do we move away from that idea, knowing that if we were to use?
Speaker 1:You know the ethical dilemma of if you're using placebos intervention, are you scanning people out of money and time and health? And yet in the research, I think the historical way we looked at placebos is that a placebo is a negative side effect. In research we don't want the placebo to beat out the intervention and it's always seen that. It's not seen that the intervention is bad, it's seen that it's too bad. They had a placebo positive outcome and the mentality now that I think you and I spoke about at lunch a couple months ago was that the effects of placebos are becoming powerful enough that should we not consider that as part of our care? Powerful enough that? Should we not consider that as part of our care? And I wanted to get your understanding of that a little bit more and where we're going with that, because I know there's two camps of thought on that idea.
Speaker 2:Yeah, I mean it's a very interesting topic and a little complex, but at the same time not this complex when you think about it. The best way to think about it is to say that there is a placebo effect in any intervention we do. You know, it's not just possible to not have a placebo for different reasons. For example, patients have expectations and you may try to change and you can play with them. I mean this is clear. But at the same time they come with. You can play with them. I mean this is clear, but at the same time they come with expectation. They have conditioning.
Speaker 2:I mean, for example, let's say that the last time I went for a massage I felt better after that. Then I'm conditioned, or worse. I went to a massage and for some reason it was worse. I mean my pain increased. Then I will have expectation about it. Then expectation and belief are two things that are driving placebo effect. Then to get a placebo, we don't have to use a placebo. We can use any approach we want and there will be a placebo linked to it.
Speaker 2:What we would like to do is to decrease the nocebo effect and increase the placebo effect. I mean that's mainly what we need to work on. Let's take the example of I'm receiving a new treatment. It's a pharmacological treatment and the doctor knows that for this treatment I will have some side effects and the side effects are going to be nausea, going to be dry mouth and you know a lot of those things. And let's say that I'm a little hypochondriac and you know any side effects for me will be terrible. And there's two ways to see that. You can say to the patient you know, if you say there's going to be some side effects, you know that this patient is going to get them.
Speaker 1:They're going to experience them.
Speaker 2:Are you, you know, are you, are you going to not tell them? I mean this is unethical. I mean you have to tell them. Something can happen. Then there is different way. I will just give you a little trick. For example, you can say to the patient you may possibly have this and that it's possible. It happened. It doesn't happen every time, but it happened. If it happens, it's a very good sign that this drug is working for you, and it may stay there for a couple of days, but after that you will get the good effect and the bad effect will go down. And you know, if you present it this way, I will almost be happy to have it, because I will know that the drug is working for me.
Speaker 1:The Japanese actually have a word for this and we use it in shiatsu massage and I know physios and physical therapists have used it. I know acupuncturists use it and it's called menken and it means their translation is in order to get better, you got to get a little bit worse. No-transcript it is, and old kids medicine used to be exactly like that and we were using that also, the I.
Speaker 2:I have done a project for low back pain years ago, 20-something years, maybe 30 years ago, and it was called a low back school. I think it was Sweden who started this type of intervention, but anyway, you see it a lot now. What you do is you have a group of patients who are suffering of low back pain or any other type of chronic pain and you teach them different things that they can do in their life to reduce their pain. And the concept is not complex but at the same time it's extremely powerful, because you see other patients in pain like you and you see one who go a little better than you and you say, okay, then it's possible. And you see a patient that is worse than you and you say, okay, I'm not this bad, you know this kind of thing.
Speaker 2:Then the group effect is very important and I remember the psychologist telling us we're going to tell them to do some exercise and for sure, at the beginning it's going to be worse, it's going to be more painful because they will start to do exercise again. For some of them they haven't moved for years because they're suffering. Then we told them okay, you're going to do this and that. Then we told them okay, you're going to do this and that and, uh, and. And then we teach them.
Speaker 2:We told them if your back ache, it's because you're starting to heal, I mean because you're doing the exercise in the good way. But if it's too much, it's bad, if it's zero, it's because nothing is happening. And then you know, you have this kind of window where they know that it's going to be a little more painful, not too much, because too much is because it's dangerous. You can, you know, you can have some problem. Then I remember a patient coming back to the school, you know, the next week it was once a week and saying you know, I've done my exercise and it's a little more painful than I know it's working, you know, like being happy.
Speaker 1:Happy that they're having the symptom of feeling.
Speaker 2:You probably have experienced exactly the same. You go to the gym or you do some bicycle or you run or whatever, and you have reduced the deal during winter. And it's spring and you start again and you come back home and the next day you're aching but you say, oh, I know, my muscles are working.
Speaker 1:Now I know I think the term we use is a. It's a, it's a feel-good pain. It hurts so good. It hurts so good exactly.
Speaker 2:But at the same time, if you take the same pain, the same intensity, same deception signal, and you haven't done exercise and you're, you're, you think that you may have developed a disease or whatever, the same intensity will be perceived as terrible. Then we can see that real pain. Because you know, when we talk about the psychology of pain, patients think that we are talking about the fact that you don't have a real pain. You have a pain in your head, you think you're in pain and we're going to help you and this is terrible. I don't want anyone to tell me that. But if you can understand that any type of pain, even cancer pain or, as you said, you know, terminal pain, is a real pain, but we know that psychological aspect can reduce it or increase it, then it's a different. You know it's a different story. Then you're, you know you want to play the game with the person.
Speaker 1:Yeah, you're speaking to the a lot of pain neuroeducation and there's been a really interesting move in the past I've only seen it this year, but I think it's maybe about a year or so old where there's a lot of thought process around moving away from pain education and I think I think it went to an extreme, like people got really excited about pain neuroeducation and they kind of threw structure and biomechanics out as like this no, that stuff's not real. And there were a lot of great studies that showed that the effects of like posture and pain they're just not as correlated as we had previously thought. But it kind of went too far in the other direction where they said, well, no, it just doesn't exist. It's like no, there are. There are scenarios where, like, guess what, when you break a bone, your structure is affected and you have pain. It's not just your perceived threat. In that level, you actually have a physical stimulus that is significant enough to induce threat, and so it's. It just seems like the pain neurotication went too far in one direction where it threw out the baby with the bath water and now it's trying to come back together.
Speaker 1:And so, speaking of this stuff a little bit here around like the effects of placebos in every intervention. You know like from what you wear in your session. I think in your podcast, passion Science, you talk about placebos and for my listeners, if you speak French or understand French, I highly recommend listening to his podcast. You talk about the effect of, like the doctor and the language and you use the faith healers of old where they were, might, you know, might be doing a ceremony where they hold a bone and they have a necklace on and they have a special garment and they're speaking in tongues and stuff like that. And then you do the equivalent to referencing current doctors who are wearing a white lab coat and they have their necklace, their stethoscope and they speak in Latin. So it's a different language and that kind of correlates to that placebo effect and it made me think about it.
Speaker 1:As a clinician, you know like, I wear professional clothing, I wear button up shirts, I wear slacks, I don't wear jeans, I don't wear yoga pants on. I have a more professional look and I've encouraged a lot of my students in classes to to move away from the comfort look and to move into the look. I'm presenting a profession and industry as a professional and I've always thought of it just as, oh, it makes me feel comfortable. But now I realize I'm obviously playing into this unsaid placebo effect of having medical charts on my wall, of having athletes on my wall, the visual of coming in and that integration. But it makes me wonder that part is placebo and it creates expectation. What about when we move into the idea of open label placebo?
Speaker 2:I mean this is really interesting. I mean, I know the people who started their project on open placebo years ago from Harvard, dr Kapchak, and you know a group of people and some people you know think it's not true. I mean, you know, just like any other research, some people say we tried it, it's not working. My opinion on that it's clear it's working. For example, if you have someone coming and saying I will give you my placebo, and I know it's a placebo and I use it. You know, I know, you remember anyone you have digestive problem for me, this, that that cure anything. You know, because when I was young and my mother will give me that, saying oh, you know you're going to feel better after that. And I know, I mean I know physiologically, I know it's not doing. You know, when I have a headache I take it and I feel better.
Speaker 1:And for people not in Quebec it would be the equivalent to Pepto-Bismol.
Speaker 2:Exactly.
Speaker 2:It would be the equivalent of that. Then what my impression is and I think it's based on some science also you know, we're conditioned. For example, if you take two pills, two white pills, in your hand, and you have a glass of water and you swallow the pills you've done that before with real treatment and you got an effect then you're conditioned to have a response to that. Then, even if you tell me, oh, those are not real pills, but my brain sees two little pills, like every time I have a glass of water. It's exactly the same. You know the same environment, the same gesture and everything. I swallow them, then I start to have the effect and I will just trigger this placebo effect. And that's why open placebo is probably working.
Speaker 2:And there is a few studies, even one that have been published very recently, that I just look at the title and rapidly and they said that it was very strong, it was strong enough. Then they recommend to no longer use any placebo deceptive placebo because this says open placebo is as strong. Then my impression is every time we do something for our health or anything else, most probably, but let's talk about health and pain or whatever there is this part of psychological aspect that we have expectation about, that. We've been, you know, we had experience with, and it just triggered on and what is really, really fascinating about it and this is the research that have been done in the last 20, 25 years is to show that, physiologically, the response you have is extremely close to the real treatment. For example, if you use an anti-histaminic or if you use an opioid, you can block them by using the antagonist, and the placebo effect is close to the real effect.
Speaker 1:I think that was from Benedetti's paper right Exactly real effect. I think that was from beneditti's paper, right exactly where there's uh they, they inject morphine to try to create the endorphin response with the placebo, and then they use non-anti-inflammatories to essentially block off the morphine effect. And yet we still have the endorphin response, even though the chemicals have essentially negated each other out exactly.
Speaker 2:It's not exactly that, but it's close to that. What they've done is they trigger a placebo effect using a anopioids, morphine, for example. Okay, then they give morphine one day, morphine the other day, morphine another day, and then a placebo, and they see that you know, it was just saline, it was injection then. Then they saw a response, a very strong response.
Speaker 1:Similar to the morphine responses.
Speaker 2:Exactly Similar to not exactly the same, but you know comparable and then they give naloxone. Naloxone is an antagonist to morphine and they totally blocked the effect. But in the same group, they started a new placebo effect using ketorolac. Ketorolac is an anti-inflammatory that you can inject, and they give Ketorolac, ketorolac, ketorolac, and then they have the placebo effect. And then they give Naloxone, the anti-opioids, and they didn't block the effect.
Speaker 2:Then it's like the body is able to produce a placebo effect, that kind of mimic, the drug you give and will not react to the same antagonist, then physiologically it's not one response, because everyone was convinced that, oh, placebo is opioidergic, is endogenous opioids. But it's not only that. I mean there is other, also neurotransmitters, for example.
Speaker 1:We know that endocannabinoids, for example, are are triggered by placebo effect it's really interesting because it makes, it leads us down this really interesting conversation of if the placebo is not triggered by a single effect, okay. Well then there's the visual, there's the auditory. You know, being a massage therapist, like people come in, I mainly focus on therapeutics. So I don't have spa music on, my lights are usually knocked in. It's more of a therapeutic environment. They see my, you know, they see my papers on the wall, they see the anatomy charts, they see photos of Olympic athletes. They have a certain opinion. But then also the way I speak to them. I use scientific language, I don't dumb it down for them. I talk about neurotransmitter, we talk about allostasis and allostatic load and we get into that. And so it leads me to a question which has kind of been something I've been hovering around for the past couple of years, which is not just around the idea of placebo that's one component to it but when it comes to both, threat, injury, disease, all these kinds of things we've always known that disease can come from a multitude of resources, from, you know, disease, all these kinds of things. We've always known that disease can come from a multitude of resources, from what you eat, what you drink, what you smoke, to how active you are, to your genetics, to hereditary, like. There's this whole slew.
Speaker 1:And yet again, like we said earlier on in this podcast, when it comes to treatment, people hyper fixate on a single modality. You know, this is the only thing you can do for X. This is the only thing you can do for this injury, this type of treatment. And it's made me wonder more and more, like if what they hear, not only through the music but through what I say, matters, well then, shouldn't I change what I say, change what they see? If how I touch them matters, shouldn't I use more pressure in some scenarios than less than others?
Speaker 1:And people will say, oh, this is a given, but conceptually, when it comes to care, this is not what we're taught in school. Even in massage school we're taught. For low back pain, here's your protocol, treatment. And more and more the insurance companies are actually asking for protocols. If you have IT band syndrome, you work TFL, you work lute, medius and maximus, you enforce the quadriceps and the hamstrings and you work on stretching, rolling or working on the IT band, which you can't do. But that's your protocol that you're given to get these insurance payments, essentially. And so, even though we know disease or injury or stress can come from a multitude of resources, our treatments tend to be hyperfixated on a single component and to me it's always seemed very aftermined and backwards when it seems that a multitude of care can have this impact for recovery.
Speaker 2:My impression is, even if you don't want to, you're working with all that all the time. For example, let's say that I'm patient and after that I see the way you're talking and what you're explaining made sense to me. It sounds scientific. Then that's another thing. I look at the way you're dressed, the way you. You know you're confident, you seem to know what you're doing. That's another good thing for me. But if I'm another patient, I would like some music around. I would like to have a scent of whatever and everything like that. But if you try that with me, it may sound too bizarre for me. Then, you see, the problem is expectation and you can ask, for example, you know it will be easy, for I can easily think about a situation where you say this is the kind of therapy we're using. In some cases we also do a massage of the neck or whatever, just to relax. We don't think that this is where it's working, but in some cases it seems to help. Do you prefer that we concentrate on your low back pain, your leg pain or whatever? Or you would like also that, because we think that in some cases you know it's a general aspect Some people prefer to have some music, because you know they don't want me to talk, they just want to relax and everything. And some other don't. You know it's possible to ask. Maybe I will say I don't know and I will let you choose. It may happen a lot. But in some cases they may say oh, you know what Music for me will be good, because I will be too tense, because you know I need. You know someone is touching me Normally it's just my husband, my wife. Then you know you have different situation and I think it's important to ask. Another thing is I don't know if it's possible for you to have someone else do it, because it's easier, but you can do it also yourself.
Speaker 2:You can ask the patient what is your expectation about this treatment? Do you think it will reduce your pain From how much? And if someone tells you oh, you know, I tried a lot of things and you know I'm not sure, and blah, blah, blah, you're in trouble. In fact, you want good expectation, then you have to work on the expectation. For example, if someone says something like that, you can go and say I understand and it's okay. I mean we're going to try. But honestly I think it's going to be more than that because I've seen patients like you. Then you can raise my expectation and this is a good thing and it's not a gizmo way of working, it's really, when you think about it, it's because I can block. You know that we've done a project where we told the patient, this is going to augment your pain. It was supposed to reduce it and it really augmented the pain. I mean, it didn't reduce it a lot. Then you can block psychologically a good effect.
Speaker 1:It's similar to using that idea that the nocebo can be phrased in a way where you're causing a positive, feel-good response. Here it's by creating that expectation and I do that with a lot of my clients and I know I teach a lot of my students to do it. It's a concept that comes from behavior neuroscience, which is client expectation will lead to predictable result, and so essentially I tell them you know, you should feel this way for two days and then you should feel good for this many days by the end of our whatever time together, however many sessions it is. What would your ideal level of recovery be? Would it be back to an Olympic level athlete? Is it back to just running around the lake? You know what it is, and if they can hit that, then they're supposed to journal. They have to take notes, um, and when they take their notes, they're being able to trace their either progress or regression, uh, and then, as they take those notes, they're able to say, yeah, this was a successful treatment or not, and and and move on from there, um.
Speaker 1:So one of the things that I wanted to ask you about with that is there was a study that came out quite recently called the effectiveness of placebo interventions with patients with non-specific low back pain. It was a meta analysis and a systematic review, and one of the things that it really talked about in there a lot was how placebos seem to be statistically significant and yet not clinically relevant. And when I put up this blog post I had a couple of my subscribers ask me questions about how can something be statistically significant but not clinically relevant? And I informed them that in this paper they had set the criteria of clinical relevance at 20% effectiveness and the placebo was only 14% effective, and they kind of understood that. But the thing that to me was striking in this paper was that the short-term effects for placebo were greater than the interventions, but that the medium and long-term effects were less effective, that they probably just regressed back to the mean for that recovery process.
Speaker 1:So for me, what I took away from that is that in the short-term effect, if I can use placebos, what it would do is give my clients confidence of movement, quality of life, laughter and joy, and we know laughter has an effect on pain and things like this. So I always took this to be as well. If a, if a placebo short or medium term and long-term has no effect, then who cares? But you know what Short term it seems to have a really big effect where, if they're feeling good, like you had said in that paper, where the delay onset muscle soreness it hurts so good, well then won't they be more active, which could lead to further progression.
Speaker 2:I agree with that. I mean a lot of papers published, you know, years and years ago came out with this idea that the placebo effect is especially strong for a short-term effect. But there is a lot of papers showing that there is a long-term effect also. We don't know if the long-term effect is related only to the placebo, because the problem is, when you have a short-term effect, you change things. Let's say, for example, I receive a treatment that is fully placebo.
Speaker 2:I received the pills that have nothing in it, no other treatment, and you tell me oh, you know what for your low back pain. This is incredible. You'll see, it's a new drug, you're going to be very good. Then I take them and I tell you six months later my God, it changed my life. I feel so good now I started to do exercise, I'm running again. I was never running since the last three, four years and blah, blah, I may have changed the way I'm living and now I feel better. It's not just, you know, the pill, just give me the willing to do something.
Speaker 2:Then we never know if it's the placebo effect that have a long-term effect or if the fact that I have a good effect at the beginning. You know. Just I changed the way I'm moving the change, I'm thinking a lot of those things, but either way it's a good thing. I mean in this case, as you said, I mean I totally agree with you. If you have the effect of your treatment plus the placebo effect, it may help you to start to have a long-term effect from your treatment.
Speaker 2:And it's true for any type of treatment pharmacological, non-pharmacological, it's exactly the same. The problem is, let's say that I have a good effect of the treatment and I have a placebo over that, and after a couple of days both are reduced a little. Because it could happen Sometimes. You know, when you do some trigger points, for example, wow, I feel so good. But the next time, you know, yes, the effect is there, but not as much as the first time I may have expected. If my expectation is like that and it reduces like that, I will feel bad. Then that's another thing also about expectation. A good trick that we use in the low back school I was talking about was to change the importance of how good you feel, you know change the importance of being pain free, exactly.
Speaker 2:For example, we told the patient okay, you're going to do the this program with us. We're going to ask you to do some movement, to do some exercise. We're going to ask you to do meditation. We're going to ask you a lot of things, but in exchange to that, we're going to give you a pain reduction. What will be the smallest reduction that you will think is good enough to do 12 weeks of everything. We're going to ask you that we described and the patient said oh, my God, you know, 50% will be, will be okay. I said okay, then what you're telling me is 40% means nothing. I said no, no, I never said that. I mean, you know I've been suffering for 10 years. I said okay, then 40% is good defining our, defining our predictive.
Speaker 2:Yeah, defining their predictable terms we reduce it as as low as 10, because you know, playing with that and people said, oh, you know, I'd be suffering all the time if you reduce my pain by 10 and we say we want to beat that, we want to go to close to one percent, one hundred%, but let's start. And then you change expectation, then you know that if I have 10% pain reduction it's a demonstration that it's working, something is happening, I'm going in the good path, I'm going in the nice way. And this is so important because we realize that if you don't do that, the patient come to see you with a frozen shoulder, for example, and they say I cannot move my hand. You know I cannot raise my hand higher than that. And then they go here and you say, and how do you feel? I say yeah, but the other one is going there. You know it's not working.
Speaker 1:We get that so often as clinicians.
Speaker 2:And the expectation is a very important thing, you can have success or non-success with the same results, depending on the expectation.
Speaker 1:I talk about that a lot with my students and my mentees and I say you know, the time will come in and I'll talk about their pain and then they'll start feeling better and then they'll go run, they'll go do an activity that they've been avoiding because of their pain and then they'll go. Well, I was active but, look, I'm still in pain. It's like, yeah, but is your pain diminished but your activity level has increased? That's a success. You're not pain-free but you are on the way to success and that's an important detail. When it comes to exercise Like we do that a lot, we talk about in my classes as well the importance of, when doing exercise, recovery.
Speaker 1:We avoid two things sharp pain and a grimace, but we don't avoid discomfort. It's going to be tense, it's going to be tight, it's going to be a stretch, it's going to ache. You just avoid dangerous pain. You know threat pain, kinds of things like that. Exactly, totally, totally. So when I attended the Neuro Show back in November you talked about, which, for those who don't know what it is, if ever you're in the Sherbrooke area, it's this really cool thing. I really enjoyed the Neuro show. I'll be going back and bringing my wife this year where they take a couple of research papers and they turn them into pieces of theater and the good news about that is that you'll never really forget the theater. So I remember those research papers quite well, those research papers quite well, and one of the ones that actually wasn't part of the theater but that you had talked about, that for me really stands out, was the temperature in the feet. One, can you, can you tell us about that?
Speaker 2:one Cause to me it's a little trick I use when I every time I give a talk and there is a placebo effect. You know I want to talk about, because one thing that is really important, about the placebo, and you'll see that you will feel the same. Let's say that I ask you do you believe that placebo can happen? It's a real thing, and you know we will both say yes, absolutely, we believe that placebo exists. Okay, good, then there is two things that can happen.
Speaker 2:You have a subject who come to see you and they say, oh, you know what? I have this terrible pain, but what I'm using is this little bracelet with the wood of whatever from. You know the cross or whatever. You know the wood from something, a tree, and then now my back feels quite better. Then you totally know it's a placebo. You can have two reactions. You can have one reaction saying okay, then it's a psychological effect and it's a real effect and they feel better. Or you can say you know this patient was not suffering at all. I mean, it's just, you know, use any gizmo and they feel better. Any gizmo and they feel better. Unfortunately, a lot of of of caregivers will have the uh, the second way of thinking. You know they will think okay, if you feel better with that, it's because you need no treatment.
Speaker 1:I mean you have and that's taking away from, that's taking away from the patient centered care about exactly, but it moves us ethically away from evidence medicine exactly, exactly then.
Speaker 2:Then there's two ways to react to that. The first way to say I don't, because if they ask you, do you think it's working, you can say I have no proof of that. My wife do that. My wife is a general family doctor and she said I have no proof of that, but if you feel better with it and it's not costly, please use it. You know, and I will try to give you a pill also or whatever, but please use it Then. This is the first thing. The second thing is okay, we both believe in placebo. And then we have a health problem and we receive a treatment and after the treatment we say, oh, my God, thank you, because it was terrible. And the doctor said, oh, by the way, I give you a placebo. We will feel extremely offensed, you know. You will say my god, I trust you and you give me a placebo. And even we will feel bad of feeling better with a placebo. Like you know, like my, I was tricked and psychologically I responded. Then you see it say it's a very complex thing.
Speaker 2:Then everybody believe in, especially people who are you know, who knows about health and read a little around. Everyone will say, yeah, I know placebo is real but I'm not a placebo responder, then it's a funny thing, but it's the way it is and I'm sure I'm a placebo responder and I have no problem with that. I mean because I know it's a real effect, I know it's the way it is and I'm sure I'm a placebo responder and I have no problem with that. I mean because I know it's a real effect, I know it's my brain see something and react.
Speaker 2:A good example of that that you can use with your patient, if you know, or your student, is visual illusion. You know those visual illusion where you have a straight line but you put some circle and you see the line. And even if you know, if you say to the people you know the line is straight, you know it's clear, oh, the two lines are exactly the same length. But look, if we do this, one seems shorter. Do you still see it shorter? They will say yes, I still.
Speaker 2:But you know it's not true, I know, but I still say this is a placebo effect. You know it's not a placebo effect in this case, but you know the parallel is close enough to say, okay, it's a bizarre effect, but it worked. Then. That's why, when we talk about placebo and placebo response and using placebo. It's a thin line between being dishonest and still being honest and using it. But there is a way to still being honest and using it and we can tell the patient. We can say to the patient we're going to do that, we know this part is the treatment, this other part there is other things that are working around and we know, we've seen it and it's true. I mean, it's not you.
Speaker 1:I mean, it's not, you know, I think we, I think we get into the realm of the god complex in the medical industry when it comes to the unknown and we go, well, instead of using the simple term. You know, like I have a friend who's a scientist who works with molecular metals and water retainment fields and things like that, and she was talking to me about research when I was getting into it. This would have been about 15 years ago or so and she said you know, we don't say that gravity exists. We say we have no proof that gravity doesn't exist, even though to most humans we would say no, gravity is real, right. And so it's one of those things where it made me think.
Speaker 1:When it comes to medicine, instead of saying, you know, like your wife, you know, saying I don't have any evidence that shows it doesn't work, but if it makes you feel better, go with it. That's true patient centered care. Most, most clinicians would want to feel smarter, for whatever reason, like ego, power, ethical dilemmas, whatever reason they have by saying no, we know that that's not true. X, y, z, and it really gets into that thing that god complex of.
Speaker 1:As clinicians, are we all powerful in the room, do we have the answers to every condition being presented in front of us, and it's obviously very arrogant to assume that we would in any case, um, so so I guess leading my next question, which would be um, what are some of the more unique placebo experiences, both as a scientist, but also maybe just as a researcher reading or a lecturer? What are some more unique placebo stories you've had? Not not me, I mean, it could be a personal story, but also just be something you've read about, because I know the foot one for me is amazing one and I use it all the time in my classes. But I'd be interested in hearing some of your more unique stories around placebos. Yeah, and I use it all the time in my classes, but I'd be interested in hearing some of your more unique stories around placebos.
Speaker 2:Yeah, and I will finish with the foot things and I will come back to that. I mean, the way I'm using it is. You know that if you think about any part of your body, especially your foot, for example, and if I tell you, okay, now think about your two foot and realize that they are a little hot in your shoes, if you do that, you will realize. You say yeah, even a little humid. If I, you know, I move my toes around, I can feel that my foot are hot or cold or and, and then if I push you to think that one of your foot is warmer than the other one, and and I use a trick, like I say it's the left one because it's the heart and whatever you know the reason Then you start to think about it and what will happen is, if you concentrate on a part of your body, you will have a vasodilatation and it will become a little harder.
Speaker 2:I mean, it's almost nothing, but if you put some thermode in it, you will have a little difference. And then you will have a feedback saying, yeah, absolutely, it's true. And then it will be a little warmer and you will say, yeah, you see, it's true, and this is a good demonstration of you know, a psychological effect on physiological response. Then I use this trick when I give a conference on placebo and I say raise your hand if your left foot is warmer or the right one, and everyone or you know a lot of people raise their hand and I say no, it's not true. I mean I was just tricking you. And it's funny because you know they react. But at the same time they laugh and they say OK, and then it's a good demonstration. We all are placebo responders, both of us.
Speaker 1:And I think it's interesting too, because the way you phrase it matters and I think that's really what I try to get across to a lot of my students and my followers is how you communicate your thoughts to your clients makes a difference. So if I say to my clients or my students I say which of your feet is warmer, they'll make a choice. If I say, are your feet the same temperature? They won't choose and they'll say no, they're the same. But if I say which is warmer, so if my clients come in and I say, comparatively to our last session, do you feel better? Yeah, they'll make a comparative analysis. But if I say you know, how are you feeling overall? They might still say I'm just as much pain as I used to have. Or how do you feel compared to the other body part? Oh, I still. I'm still in pain in my shoulder compared to my healthy shoulder. But if I say compared to day one, where is it? You know there's a really good analysis and I really think it matters how you say it.
Speaker 2:I like your example and I think also, let's say that you have a low back pain and you're doing a massage on the back. You can even say something like which part of your back right now feel, the better. You know where the treatments start to work more than other places. Then you push me to think about a place that is better than the other. Then I say, oh, now the upper part is better, I need a little more. Okay, then we're going to concentrate on that. Then you convince me that something is starting and people may say, oh, this is terrible. No, it's not. I mean for sure. If you're using this trick to do something that you know already is not working and you're fooling the patient by taking their money and doing whatever you want, I mean this is terrible. But if you're doing something that you know that physiologically should work and you help it to work better, this is just perfect and the example you give from doctors.
Speaker 2:I have a story that happened a couple of months ago. A colleague of mine, a patient, was saying I'm taking this medication and it was something you know, not dangerous at all and it made me feel better. And she saw a specialist and the specialist they said no, this is, this is completely stupid, this is not helping you at all, and you know. And she came back to her doctor and said you know, he told me that it's not true. And she said oh, this is the way you think, but I'm not sure you know, even if it's a speciality, and you know this is it's. You know, I don't see the point of proving to a patient that the fact that they're using their little bracelet is not good. I don't see the point. I see the point of saying there is no science. I can tell you that why it's working. I mean, I don't have anything on that, but if it's good for you, continue to use it. I mean, that's the you know, it's really. The importance is to show them that you're not telling them that there is some magic in the air and you use it. But there is a good science and in some cases we don't have the science behind it. But if it's good, perfect, you know, and the good example I have.
Speaker 2:Okay, I will give you a couple of the first time I was really in a situation. It was not with the placebo, it was a nocebo, and it was totally an accident. I was a master degree student and I was doing some electrophysiology and with very old equipment, the equipment of the time, and you know we had electrodes everywhere, you know, plugged in different machines. One machine was to give electrical shock, to have a reflex and a susceptive reflex, and the other one were on the head to record EEG, yeah, electroencephalography, and also EMG and different things. Then it was extremely complex and there was a lot of machine and everything and I was a young, you know young student and I remember with one of the subject I had a knob and you know it was a terrible way to do that.
Speaker 2:But in front of the subject I was, you know, turning the knob to give it an electrical shock. And I told the student tell me when it's painful, you know when you start to feel it and what's painful. And I started to turn and I said to myself, oh my God, it's a tough guy because you know, normally I don't go this. And he said oh. He said oh, yeah, ok, I can feel it, I can feel this, ok. And he said, oh my God, it's really a bad. Ok, I'm sorry. Then I just stopped and I said what's happening?
Speaker 1:here, so awesome.
Speaker 2:And I was really feeling, you know, I didn't know what to do. Then I plugged them and I said, ok, maybe it will be different. Now I changed the type of simulation and he said, oh yeah, it's totally different. And I said, and then I asked him, I said, and the first simulation, he said it's really bizarre. I didn't feel really the electrical shock, but it was terrible. You know, it was kind of inside the stimulation or whatever. Then that wasn't the SIBO effect. I mean, he was seeing me with all you know. He was probably nervous seeing all the wires and turning the knob, but then for this guy it was a dangerous situation.
Speaker 1:It makes me think of the old theory. Know that it's like the pain is in the brain, like he saw an environmental context that made him believe it was significant enough. And I've always had and I know a lot of clinicians and I know you and I've talked about this where it's really hard as a clinician to walk away happy with somebody saying I've been told the pain is in my brain, because I always look at them and go, yeah, but your brain is in your body, like you cannot separate the two. It's that like the pain's in your brain and your brain's in your body, like you are going to experience a symptom for real, whether it's psychosomatic or not. You know, like the pain has a manifestation somewhere in the sensory system and which is?
Speaker 1:You know, which is why I named my podcast, the sensory portion, manual therapy, because the sensory system becomes such an important component to our care. That's always been kind of overlooked and, yeah, it becomes something that's so, so powerful when we're, when we're looking at. Just, I love that story about the placebo. I think that's. I think that's fantastic.
Speaker 2:Another story, that is with a placebo. There was a project where we use two injection. In both cases it was saline, it was a placebo, but in one occasion we said to the patient it was a very strong analgesic to see. The reason for this project was to test the effect on both clinical pain it was low back pain at the time and experimental pain in the same subject. The reason for that? That? There was a lot of paper on the. You know, on the science magazine there was a lot of publication on the fact that placebo seems to work better for clinical pain because you expect a good effect. You know you really. You know you have a desire of being better For experimental pain. You know it's going to stop. I mean, you know, you know you're not tortured. You know, you know that the person who's giving you the experimental pain can stop anytime. If you tell them, then we've done that and it was working. I mean, and we found exactly the same but in the same subject. Experimental pain was reduced, but clinical pain was more reduced than experimental pain. It was nice.
Speaker 2:But I remember one patient coming back to the lab a couple of days later. I don't remember why, but he came back to the lab and said you know, I've been suffering of this low back pain for 10 years and now, my God, I'm a new man. You know I'm taking the stairs, you know it changed my life and we had to tell them it was a placebo, because you know it was. You know, the ethic committee told us at the end because we cannot tell them at the beginning but at the end we have to tell them that both stimulation, both treatment were placebo. Then it was very, you know, I was feeling bad because I said my God, the guy is better, the guy is feeling good and everything.
Speaker 2:Then I sat with them and I started to explain all the neurophysiological aspect of placebo and everything. And I told him I said you know, when you have a good placebo effect, it's because you're powerful, it's because you have a very powerful brain. You know, if you were not, if you didn't have a powerful brain, you will never be able to trigger something this powerful. And I told the guy I have good papers to show you that it's a real effect. It's not. And he was extremely happy. Then I said you see, you receive no treatment, but your brain cure you. I mean, it's incredible. I mean see, you are among the few that have such an important effect.
Speaker 1:How you know how amazing, how amazing would it really be if we were that powerful, right like exactly so you know, we read books as a kid about wizards and magic and blah blah, lord of, like I'm a fantasy buff, so like lord of the rings and all this kind of thing, and I was like man. If only healing powers truly were that magical, how awesome would that be. Um, you brought up an interesting point earlier on, um, and it was like talking about the effectiveness of placebo and you, you know, like it's just always a good thing, we're all going to be susceptible to just use it. But I think that's an important distinction and I want to get your thoughts on this because, as a clinician, I don't care why you get better. I care, you get better, absolutely you get better. So if it's the placebo, if it's my elbow, if it's the cupping, if it's the tools, if it's that you walked into my room, if it's that you paid me money, you got better treatment. Success check done. You'll refer your clients to your friends.
Speaker 1:To me, I'm happy as a researcher. Is it the same when it comes to a placebo? Because, yes, it's a good. So that's the question is, you know, because research is moving away from the idea that placebos are necessarily a bound thing, but where is placebos placed in research in the future. As a clinician I don't care. As the reason you got it's good to be able to understand that. I can replicate it, use it on another client in the future, but in research it's, it's not so good to have that theory around placebos.
Speaker 2:Yes, as it's not so good to have that theory around placebos. Yes, as a researcher it's totally different, because even if we see a patient, he feels really good and goes home and say we're really happy for the patient. But as a scientist, we want to understand and there is a lot of people around the world doing research on placebo. I think of Luana Koloka, for example, who was a student of Benedetti and now she's the champion on placebo research in the world and I discussed that with her and she said it's really funny because she's a you know, middle-aged or young investigator. And she told me one day she said you know, I was afraid that after five, 10 years of research I will have to change my field because you know a placebo. And she said I can't believe everything we discover, and we discover every more. You know even more every day because now we have some new equipment. For example, we can look at what's happening in the brain in real time. We can see neurotransmitters activation and everything that. What it gives us is, if we understand better what is placebo, we can probably work in a way to increase it, even pharmacologically. For example, we know that we can block some placebo by using antagonists. But we know also that we can block the nociceptive effect Not nociceptive but nocebo. We can block the nocebo effect also pharmacologically. Then if we can use different drugs, I saw recently a paper I reviewed a paper on hypnosis.
Speaker 2:You know that hypnosis is also working quite well to decrease pain and also to work on other physiological effects. But the problem is you are a good subject to hypnosis or not? And it seems to be a trait. Then you cannot just say you know, I'm going to change from very bad to a very good. But there is a new study showing that you can do some transcranial stimulation and increase your trait hypnotizability. Then placebo is probably the same, the psychological aspect of pain control, for example.
Speaker 2:We want to increase it. We don't want to lie to the patient. We want to tell them the truth about it and we want to give a real physiological treatment. For example, when when the patient told me you know, the doctor says it's all in my head and it seems to be in a negative way, I say yeah, but tell them that if you take a hammer and you stab their hand it's going to be in their head also. But ask them if you can do it again and again and they will say no, you know, it's really important to understand that when we say it's in your head, it doesn't mean that nothing is happening in your hand, you know, or your foot. It means that what you're thinking can increase what's happening in your foot or your hand, or it can decrease it. Then this is a very I think when you're teaching to your students, I'm sure you're talking about that, but you're really doing something in the physiology on the body and that's important.
Speaker 2:Yes, but at the same time, you know that you can do all the work you want. And if you say at the same time, I'm not sure it's going to work, and the patients say, yeah, I don't have very good expectation, you know that you're going to decrease the effect and exactly I mean this is not good and this is the way of thinking about placebo.
Speaker 2:Placebo is not a panacea, you know it's, it's like anything. I mean you're not going to do miracle with placebo, like you're not going to do miracle with any drugs, especially for chronic pain. But if you put all that together, those physical treatment, pharmacology, psychological aspect, then you can help a patient enough that they will be able after that to go and fly by its own.
Speaker 1:I've been a massage therapist now this will be 20 years this year and the more I do this, the more I have this theory of throwing my kitchen sink at the clients which is why hold anything back.
Speaker 1:I have a good enough understanding of why people tend to be in pain when it comes to threat perception and their ability to accommodate stressors, and where they're at and why pain is present in their life. It may not be structural. It might be for whatever reason emotional, spiritual, mental but when it comes to recovery it's like why not assume that a placebo is going to have a percentage of an effect on them, but it may not be the percentage that overpowers their ability to be nociceptive and have negative responses. I know that the way I talk to them will have a percentage. It on its own is probably not enough to overcome their pain. I know that my physiological touch is going to have an effect. My physiological touch is going to have an effect. Individually, each one of these components is likely not going to be powerful enough to overcome my client's chronic discomfort, but as a totality of it it is.
Speaker 1:And who am I to assume, as a therapist, that I know which of those is the most important? Because every client is different. One might come in and they need something different. So my theory now is becoming more and more is just throw the kitchen sink at your client. You give them everything and something will stick, and let's hope that what sticks is the thing that makes them feel better, and the next time they come in it might be a completely different thing that makes them feel better. It might be the exercise now, it might be the vocabulary, it might be that they're more open-minded to it because they has it contextually. That had a positive response, so I love that. So, then, my last question for you is going to be where do you think placebo fits into manual therapy, or even clinical therapy, not just manual therapy? You know doctors across the board. Where do you think it fits in moving into the future?
Speaker 2:My impression is we understand more and more also that there is a social context of placebo. For example, let's say that there is a new drug coming on the market you see it or you hear about it, you know from the Internet or whatever and you say, oh, wow, this is probably the drug I need for my problem, you know. Then we know that the placebo effect is going to be very high. Let's say that you have a group of patients who start to say that I went for a manual therapy and since I received that, I have this neck pain that is terrible. And then say that to another patient, another patient. You may have a bunch of patients who will develop neck pain after a leg massage, for example. Then you see this contextual effect or this group effect or this you know, especially today, that we communicate on the Internet with everyone can be very positive, can be extremely negative also at the same time. This is a field that we have to understand A lot, and lot of therapists and I'm sure you were aware of that the patient will come and say, oh, I saw on the internet that my problem is related to this and that, and it's really hard to change that, even if you think about it and you say I can't see why in this case he will have the disease that he's naming, because he saw that on TikTok and it's really hard to change, then I think this is one field where we have to understand a little better. How can we work with that, how can we work positively with that and also how can we deconstruct all the negative around that on that, the other part for me that is really important is to be able to teach to any therapist, any type of therapist, that placebo is a friend. And but after I've said that I want you to do your work the way you learn it, I want to be sure that you don't say, okay, then I can go around and dance and clap my hand and I can ask people to pay me money. No, this is not okay. I mean, I want you to do something that you learn, that have science behind it and you know that when you do that, you're doing something on the muscle. You're doing something with your pill. If you're a doctor, you're doing something with your knife. If you're a surgeon, you know what you're doing and you had placebo to that. And I think this is a complex thing because the person who's fooling the patient and taking their money and say, yeah, but they feel better. Ask them. They feel better. Yeah, but that's not okay. That's not okay. This is stealing. This is really going and taking the money of people. That's not okay. This is stealing. This is really going and taking the money of people.
Speaker 2:And I think this is one part of the. You know all the education we have to do around placebo and placebo have to think about that and it's a complex process. You know it's easy to say like that, but just thinking about it, thinking about the fact that there is a new drug on the market and everyone says, wow, this is marvelous. And we know it's not marvelous, it's good, you know it's good, like other drugs for different problems, but it's not the magic pill. It will just slow down over time. Then we have to think about all that and after that, from a neuroscientist point of view, continue to understand what's happening. You know, neurophysiologically, every time you have a placebo response. This is amazing and we're not. You know. We understand part of it, but there is still place to look.
Speaker 1:I love it. I love it. Well, I'm so grateful. I'm so grateful that you joined us today. I love the conversation. I'm going to walk away with a lot of thoughts and a lot to reflect on and, uh, I'm really, I'm really excited about it and, uh, thank you so much for joining us.
Speaker 2:It was a pleasure.
Speaker 1:Thank you for having me and uh, and let's keep in touch with that yes, of course, I know that I was speaking with guillaume, who's going to be on my podcast in a couple weeks, and we're going to talk about a lot of really interesting stuff with the sympathetic, parasympathetic nervous system, so hopefully that'll that'll move forward, but yeah, so I just want to say thank you again and I hope you have a great day.
