Peer Pressure and Placebo…..a match made in heaven?!

Written by Patrick Donnelly on . Posted in .

Just this morning I came across and participated in a survey on The Sports Physio’s(@AdamMeakins) twitter feed….and it got me thinking!

His survey involved one simple question. Simple, yet thought provoking:

“The reason that u should do/give a treatment that is ineffective just because if you don’t others will is…

  1. stupid
  2. smart
  3. worrying

What choice did I make and what exactly does this survey mean to me?….Well we shall get to that later

Under the realm of physiotherapy exist countless and varied treatment techniques, procedures, adjuncts and schools of thought…many having their 5 minutes of fame as the new-found fad that will revolutionise clinical practice and outcomes

With time and research we gain informed insight into what different treatment techniques are actually doing (or not doing) and which ones are consistently proving beneficial. And as we all know, clinical trials do not always marry up with what we find in our own clinical experience, perhaps due to lacking or poor quality research. That being said, evidence based research is and should be our go-to tool to validate, verify and guide our practice with critiquing of literature and experienced clinical practice providing balanced and fair influence.

How does this link in with Adams survey? Well, all too often we are faced with situations where another practitioner is utilising out-of-date techniques or treatments lacking evidence base. And despite their out-dating and lack of effectiveness….these practitioners are selling them to the public. I liken it to the car sales industry….some people just have the knack of selling…even if it is a 1990 Lada Samara 5 Door Red Petrol 1288cc.  Some practitioners may feel more capable selling e.g. hands on treatments, grade c manipulations or electrotherapy devices as they may give a “wow factor” or sense that you “are doing something” and therefore it is easier to engage the client. Others may fall into the trending trap and become the sheep following their flock regardless of what the literature or their own clinical experience tells them. Don’t get me wrong….hands on treatments, grade c manips and electrotherapy all have their own place in therapy, however it comes down to using the right technique at the right time for the right condition.

Another important point for consideration is the placebo effect.

‘A placebo is a simulated or otherwise medically ineffectual treatment for disease or other medical condition intended to deceive the recipient. Sometimes patients given a placebo will have a perceived or actual improvement in a medical condition, a phenomenon commonly called the placebo effect.’ 


For any of our clients out there, the placebo effect isn’t a con or hoax in anyway. It actually highlights the immense influence and link between our mind and body and why the two should never be treated separately…but that is a whole new blog for another day. For now, the point I am trying to make is that as clinicians we can feel pressurised to carry out or add in a treatment modality which we know the client is expecting/hoping to get, or which they received from Physio Joe Blogg’s in the past for the ‘exact same issue’ where they had been informed that this technique was ‘snapping their joint/disc/tendons/ligaments back into place’. I am sure we can all relate to a similar scenario.

Why may it be tempting to include a treatment which research and clinical experience has educated us to be ineffective? To put simply it comes down to this concept of placebo and client perception.

Despite knowing that treatment modality X will do diddley squat for the clients lateral epicondylitis or shoulder impingement, the physio may fear that by not including it the client will perceive their treatment to be inadequate compared to Physio Joe Blogg and that this perception will (and evidence proves that it can) influence their recovery. On the flipside of that, the physio may cover all bases and include the ineffective technique amongst a medley of validated techniques in the hope that the patients belief in treatment X helping their tennis elbow will in fact facilitate/speed up/amplify their recovery response giving a more positive treatment outcome. That and of course keeping face with the sheep and trending and all that!!!!!

Where do we at ABSolute.Physio stand? I opted for c) worrying. I credit myself and my clinical practice on carrying out evidence based treatments. If I were to fall into the trap of keeping face or carrying out ‘just in case’ techniques I would feed the credibility that public view gives to said treatments with the knock on effect of adding credibility to Physio Joe Blogg despite his (or her to be PC) lack of up to date and evidence guided practice.

With regards to the influence of placebo, I opt for the knowledge is power approach.

If a client came in expecting to receive treatment X and I knew it would be of absolutely no proven benefit, I would take the time to explain that to the client and help them to understand why I am taking my treatment approach. If the client understands the evidence base and clinical reasoning for their treatment, their perception should adapt with the treatment plan and therefore not hinder their recovery.

I would love to know what your thoughts are. Continuous questioning, debating and challenging our practices is how we move forward into a better profession and I commend The Sports Physio(@AdamMeakins) for triggering such discussion.

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