Monthly Archives: November 2015

Can we please stop blaming the doctor (at least some of the time)?

If person expects that a treatment is going to have a positive effect, it greatly increases the chance of that occurring – isn’t that an amazingly wonderful and slightly mysterious phenomenon? Studies that look at these interactions in clinical situations are plentiful and it is such a  well documented phenomenon that it almost seems not worth mentioning.  But it is amazing isn’t it?

When we are talking about interventions that are directed at pain conditions, particularly chronic pain conditions, it is relatively easy to understand why a proportion of a group of people in pain, will have a positive response to even placebo conditions.     A kind researcher or clinician may have taken the time to ask a lot of questions about them and their pain, giving them the impression that they care about their story.  They may have had to review their symptoms and function over a period of time with increased scrutiny and may find that they aren’t as disabled or in as much pain as they rated themselves as being at baseline.  They may decide that “this is the one” on their pain merry-go round of interventions, and choose to get a bit more active and take a slightly more positive approach to life at the same time as the trial.  Who knows?   Fascinating stuff!

What is even more fascinating is when we see our expectations having distinctly measurable physiological consequences.  I was prompted recently to re-read this fantastic article by Alia Crumb et al from 2011, called “Mind over Milkshakes”.  In the study they took 46 subjects and got them to consume a milkshake on two separate occasions.  On one of the occasions the milkshake was presented to them as an “Indulgent” shake, and was labelled as being high fat and high calorie.  On the other occasion, it was presented as a “Sensible” shake and labelled as being healthy, low fat and low calorie. In actuality, the shakes were identical.   They took before and after blood measurements, as well as asking participants to rate how full they felt after each shake.  After consuming the indulgent shake, steep decreases in ghrelin, a hormone responsible for regulating hunger, were seen in the blood measurements and the participants rated themselves as being very satisfied or full.  However, after consuming the healthy shake, a far smaller decline in ghrelin levels was seen and subjects rated themselves as far less full.  How amazing is that? Not only do our expectations change our perceptions of body sensations such as hunger, thirst or pain, but they also change our hormonal response.

Another article that has tickled my fancy in recent times is that by Ben Darlow et al, published this year in Spine, entitled “Easy to harm, hard to heal”.  A qualitative study, they interviewed 12 subjects with acute low back pain and 11 with chronic low back pain, about their understanding of their condition.  Overwhelmingly the themes that came across were those that indicated that the subjects viewed their back as being fragile, vulnerable, unlikely to heal and at risk of further injury.  The flow on from these misconceptions meant that people believed that they needed to rest, avoid activities that they considered dangerous such as lifting, and be vigilant about their posture.  The desire for a diagnosis or label for their pain was a common theme for both acute and chronic low back pain patients, as they felt it was important for management or preventing recurrence.  People strongly believed that the pain was representing damage in their back and that avoiding bringing on that pain was therefore important – a slippery slope to loss of function, disability and misery.

It is a fantastic paper and is well worth a read.  For clinicians, these themes are not surprising – we hear these thoughts expressed about back pain on a daily basis.  We tackle these misunderstandings with reassurance and education and pave a way out of the pain spiral with active rehabilitation approaches.  It is fairly obviously that these extremely commonly held beliefs are at least partly to blame for the transition from acute to chronic pain in many patients.  It begs the question, how do we stop this before it starts?  Medical and allied health professionals are gaining greater awareness and understanding of these themes and are altering their treatment approaches.  The push to reduce reliance on passive modalities, improve our communication skills to deliver education and reassurance, and reduce the use of imaging for cases of simple low back pain is well on its way to becoming established across professional boundaries.  Yet vast numbers of patients will demand that something be “done” for their back pain, and clinicians who are well aware of these principles are often pushed into referring for imaging, owing to demanding patients with unreasonable expectations. And so begins the pain merry-go round for those patients.

The push to create awareness of these issues among healthcare professionals is an obvious place to start and needs to continue for changes to be effectively made.  This study further tells us that a great deal of the patient’s misunderstandings about their condition may have come from influences from health professionals.  However, at some point we probably need to be addressing the beliefs held by society about this common, debilitating and costly health problem, which ultimately doesn’t need to be such a burden on our healthcare and welfare systems.  Public education campaigns in other areas of healthcare where misconceptions exist, such as those associated with the over-prescription of antibiotics, or reducing higher than average back surgery rates,  have had some, albeit small, effects on changing outcomes of the patient/clinician interaction and improving desired outcomes. Perhaps it’s time we turned the conversation around from focusing on the next big cure, breakthrough or development in chronic pain treatments, and started focusing on normalising the experience of back pain.


Guest Post: Carey Wheeler : What a Balinese taxi driver taught me about pain science…

By Carey Wheeler

A couple of years ago I was on a holiday with my family in Bali. On one of the days we went for a trip to the Bali Zoo and we asked our taxi driver if we could take the long way there by seeing some of the surrounding sights and sounds. Religion plays a very large role in daily life for the Balinese, and being the inquisitive type that I am, I was interested in learning about the different rituals and beliefs of this vibrant culture.

One thing of particular interest was how so many religions all got along so well in such a small part of the country. The metaphor that the driver used was perhaps the most succinct and intelligent answer I could ever imagine. Conveniently, it can also be used as a metaphor for physical therapy and pain science.

As we navigated the narrow streets of the outskirts of Seminyak, his story went something like this: “The Balinese people are very welcoming. We are very humble and understanding. For us, God is like this van. If you look at the van from that side (motioning to the left), all you can see is what you see from that side. If you look from the front, that’s all you see. Look from the top and the van looks different again. But you are always looking at the same van. The Balinese people understand this. We understand that even though we may be looking at religion from different angles, we are all celebrating God in our own way.” Wow!


This is not the first time that physical therapy has been likened to religion. The secular, isolated and reductionist models that pervade and divide the manual and exercise therapy worlds see us bickering between manipulative and non-manipulative therapies, between hands-off exercise based therapies and hands-on therapies. There is constant back and forth between the fascia fanatics and trigger pointers, the craniosacral pulsers and lymphatic drainers. The question has been asked before and needs to be asked again: How can they all be right?

When we are faced with a question like this, Occam’s Razor usually cuts to the point pretty well; “the simplest answer is usually correct”. The only way that all of these approaches can be correct is if the mechanisms by which they propose to have their effect are the same. Therefore the posturing, postulating and bickering is unnecessary and frivolous. The specifics and the details of each branch of physical and manual therapy are no longer contentious. We are all looking at the same van from a slightly different angle. Like the Balinese, we can actually all get along in this small world of ours. So rather than argue about what we can see from where we stand, we need to discuss what it is that we are actually looking at.

In physical therapies, the engine, chassis and interior of our van are built from the non-specific effects of what we do. Formerly known as the placebo effect, the non-specific effects of physical therapies include aspects such as expectation, conditioning, descending inhibition and, in some cases, diffuse noxious inhibitory control (1). All of these very real and very interactive mechanisms of physical therapy are at play with everything that we do. The likelihood of us finding more and more relevant non-specific effects is far greater than us chancing upon the elusive specific effects we have been searching so long for. Rather than debate which modality provides the strongest specific effect to a certain tissue we should discuss how we can maximise the role that the non-specific effects play in our interaction with our patients and clients.

The caveat here is that when we have enough evidence to show that a modality or an approach holds no clinical benefit beyond the non-specific effects,  we need to seriously consider the ethics of continuing to use that modality (i.e stop looking at the van from that angle). The retort, and one that I acknowledge is very valid, is that when interacting with patients it is the magnitude to which we can influence the non-specific effects of an intervention that will ultimately determine the effectiveness of that intervention (2). This means that we have to acknowledge the role of the patient’s beliefs and expectations in their outcomes, but to not let patient beliefs dictate an implausible or non-evidence based approach.

However, if we can all agree that the immediate and short term outcomes that our patient’s see are based largely on the non-specific effects of our interventions then we can also agree that it is what happens outside of the clinic that is most important to long term outcomes. Long term structural, psychological and social or behavioural change doesn’t occur in a single session or with two sessions per week for six weeks. We need to stop the bickering over beliefs, shake hands, and acknowledge that we all have the potential to have an effect on pain in the short term. Then we can sit down together and help each other to ask better questions.

What biopsychosocial factors have led this person to be here today? What can I do to give this patient the power they need to make the changes that are necessary for long term change? How can I best communicate this information to this patient to make sure they understand what it is we are actually trying to change? Who else in their circle of influence needs to understand this so they can be the best support for this patient? The questions go on and on but they are infinitely more meaningful than asking from what angle does the van look the best!

1) Bialosky.JE, Bishop.MD, George.SZ, Robinson.ME, 2011, Journal of Manual and Manipulative Therapy, ‘Placebo response to manual therapy: something out of nothing?’, Vol.19, Iss.1, pp.11-19

2) Kalauokalani. D, Cherkin. DC, Sherman. KJ, Koepsell.TD, Deyo.RA, 2001, Spine, ‘Lessons from a trial of acupuncture and massage for low back pain: patient expectations and treatment effects’, Vol.26, Iss.13, pp.1418-1424



Carey Wheeler is a Clinical Myotherapist (BHSc) and has been in private practice for 5 years. He lives and works in Geelong, Australia.   Carey’s clinical approach has always been movement based with a strong focus towards active therapy which developed from a background in strength and conditioning as a personal trainer. One of his main practice goals is to help patients bridge the gap between rehab and training.