The legitimacy of placebo treatments in clinical practice: evidence and ethics

Effects of an open-label placebo on visual attention directed to food high in sugar, appetite, and desire for sweet taste

BACKGROUND

Interventions with deceptive placebos can reduce visual attention directed to high-calorie sweets. Open-label placebos (OLPs), which avoid the ethical concerns associated with deception, have shown promise in various fields. This is the first study to test the effects of OLPs on appetite, desire for sweet taste and visual attention for high-sugar foods.

METHODS

In this preregistered laboratory study, fifty-three females (mean age = 22.8 years) were presented with image pairs depicting food high vs. low in sugar as well as non-food items. The image presentation was conducted once with and without an OLP. Different indicators of visual attention (total fixation duration, number of fixations, first fixation location), general appetite and the desire to eat the depicted food items were assessed. Moreover, participants tasted and evaluated a sucrose solution to determine their desire for the sweet taste.

RESULTS

The OLP decreased general appetite (p = .005, ηp2 = .09) and the desire to taste the sucrose solution again (p = .036, d = .30). The intervention did not affect visual attention: both conditions (with/without OLP) were characterized by a longer total fixation duration and a higher number of fixations for images with low-sugar food compared to high-sugar food when presented alongside images of non-food.

CONCLUSION

The OLP did not reduce visual attention toward images of high-sugar food, and OLP effects were only observed in self-report measures. Future research should elaborate on how the efficacy of OLPs can be improved or whether deception is necessary to decrease visual attention via placebos.

Preserving the placebo effect after disclosure: A new perspective on non-deceptive placebos

The present study explores whether a particular style of placebo disclosure could serve as a tool to foster a renewed trust in one's own inherent resources and elicit a meaningful placebo effect. In a motor performance task, two placebo groups received inert transcutaneous electrical nerve stimulation (TENS) in each of four sessions along with information on its force-enhancing properties. Before the final session, one of the placebo groups was informed about the placebo, which was portrayed as a means to unleash an inherent potential. Along with force, we systematically monitored task-specific self-efficacy to test whether this variable would be differentially modulated in the two placebo groups. Compared to two control groups, placebo groups showed higher force and self-efficacy in the last session. No differences in self-efficacy were observed in the placebo groups even after revealing the placebo procedure, suggesting that the disclosure was effective in 'safeguarding' individuals' self-efficacy. These findings may have important implications, paving the way for the use of placebos that not only are ethically permissible but also support individuals' self-efficacy.

Working with patients' treatment expectations - what we can learn from homeopathy

The usual homeopathic remedy, "globules," does not contain any pharmacologically active ingredient. However, many patients and practitioners report beneficial effects of homeopathic treatment on various health outcomes. Experimental and clinical research of the last two decades analyzing the underlying mechanisms of the placebo effect could explain this phenomenon, with patients' treatment expectations as the predominant mechanism. Treatment expectations can be optimized through various factors, such as prior information, communication, and treatment context. This narrative review analyses how homeopathy successfully utilizes these factors. Subsequently, it is discussed what evidence-based medicine could learn from homeopathic practice to optimize treatment expectations (e.g., using an empathic, patient-centered communication style, deliberately selecting objects in practice rooms, or using clear treatment rituals and salient contextual stimuli) and thereby treatment effectiveness. Homeopathic remedy does not work beyond the placebo effect but is recommended or prescribed as an active treatment by those who believe in it. Thus, practitioners need to understand the manner in which homeopathy (as an example of inert treatment) works and are advised to reintegrate its underlying effective placebo mechanisms into evidence-based medicine. This promises to increase treatment efficacy, tolerability, satisfaction, and compliance with evidence-based treatments, and addresses the desires patients are trying to satisfy in homeopathy in an ethical, fully informed way that is grounded in evidence-based medicine.

The Placebo Effect in Exercise and Mental Health Research

This chapter describes the placebo effect in the context of physical activity and mental health. Following a brief historical overview, definitions for placebos, placebo effects, and related terminology are discussed. Next, three major methodological challenges posed from studying the placebo effect in the context of exercise are described. Additionally, the role of a primary psychological mechanism of placebo and nocebo effects - expectations - will be summarized through the lens of key terminology. Findings from relevant chronic and acute exercise studies that have measured or manipulated exercise-associated expectations will be presented. The chapter concludes with recommendations for controlling or quantifying the placebo effect in exercise and mental health research and its implications in clinical practice.

Acupuncture for Japanese Katakori (Chronic Neck Pain): A Randomized Placebo-Controlled Double-Blind Study

Background and Objectives: Although acupuncture is listed as a beneficial treatment for neck/shoulder stiffness, which has increased with the spread of information technology, to date, evidence of its efficacy under double-blind conditions has not been shown. This study aimed to assess whether acupuncture treatment with superficial skin piercing is superior to placebo treatment. Materials and Methods: A randomized, double-blind (practitioner-patient) placebo-controlled trial was performed at a single center with four arms (ISRCTN76896018). Four hundred patients with essential neck/shoulder stiffness were randomly assigned to penetrating needle treatment (acupuncture ritual and skin penetration), skin-touch needle treatment (acupuncture ritual and skin touch), no-touch needle treatment (acupuncture ritual alone), and no-treatment control. Each of the six acupuncturists applied a needle to each of the four acupoints in the neck/shoulder of 50 patients. Results: Each of the three treatments significantly (p = 0.01) improved neck/shoulder stiffness compared with the no-treatment control immediately and 24 h after treatment. There was a significant improvement in penetrating needle treatment over no-touch needle treatment 24 h later. However, there was no significant difference between the penetrating and skin-touch and skin-touch vs. no-touch. Conclusions: All treatments that received the ritual of acupuncture were better than the no-treatment control. Only genuine acupuncture involves the specific effects of needle insertion into the body. The acupuncture ritual had a significant impact on the subjective improvement of neck/shoulder stiffness; however, improvement with ritual alone versions of placebo acupuncture was not maintained as with superficial skin piercing. Our study provides important evidence of acupuncture efficacy and information regarding inert no-touch placebo control in acupuncture research.

The role of positive information provision in open-label placebo effects

Open label placebos (OLPs) appear generally efficacious among clinical samples, but the empirical evidence regarding their use in non-clinical and sub-clinical samples, as well as when administered independent of a convincing rationale, is mixed. Healthy participants (N = 102) were randomised to either a 6-day course of OLP pills with information provision (OLP-plus: N = 35), without information provision (OLP-only: N = 35), or no-treatment control group (N = 32). OLP pills were described as enhancing physical (symptoms and sleep) and psychological (positive and negative emotional) well-being. Well-being was assessed at baseline and on Day 6. Expectancies and adherence were measured. OLP administration interacted with baseline well-being. The OLP-plus group demonstrated increased well-being on all outcomes other than positive emotions, but only when they reported decreased baseline well-being. OLP-only and control groups did not differ. The OLP-plus group demonstrated elevated expectancies, that mediated the OLP effect on physical symptoms relative to control, but only when well-being was lower than average at baseline (i.e. moderated-mediation). Results demonstrate the importance of information provided with OLPs. The moderating effect of baseline outcomes may reconcile inconsistent results regarding clinical and non-clinical samples. Accounting for baseline symptoms in non-clinical and sub-clinical samples is likely to enhance our understanding of when OLPs are effective.

The impact of pharmaceutical form and simulated side effects in an open-label-placebo RCT for improving psychological distress in highly stressed students

Open-label placebo (OLP) may be utilized to reduce psychological distress. Yet, potential contextual effects have not been explored. We investigated the impact of pharmaceutical form and the simulation of side effects in a parallel group RCT (DRKS00030987). A sample of 177 highly stressed university students at risk of depression were randomly assigned by computer generated tables to a 1-week intervention with active or passive OLP nasal spray or passive OLP capsule or a no-treatment control group. After the intervention, groups differed significantly in depressive symptoms but not regarding other outcomes of psychological distress (stress, anxiety, sleep quality, somatization), well-being or treatment expectation. OLP groups benefitted significantly more compared to the no-treatment control group (d = .40), OLP nasal spray groups significantly more than the OLP capsule group (d = .40) and the active OLP group significantly more than the passive OLP groups (d = .42). Interestingly, before intervention, most participants, regardless of group assignment, believed that the OLP capsule would be most beneficial. The effectiveness of OLP treatments seems to be highly influenced by the symptom focus conveyed by the OLP rationale. Moreover, pharmaceutical form and simulation of side effects may modulate efficacy, while explicit treatment expectation seems to play a minor role.

Open-label placebos-a systematic review and meta-analysis of experimental studies with non-clinical samples

The use of open-label placebos (OLPs) has shown to be effective in clinical trials. We conducted a systematic review and meta-analysis to examine whether OLPs are effective in experimental studies with non-clinical populations. We searched five databases on April 15, 2021. We conducted separate analyses for self-reported and objective outcomes and examined whether the level of suggestiveness of the instructions influenced the efficacy of OLPs. Of the 3573 identified records, 20 studies comprising 1201 participants were included, of which 17 studies were eligible for meta-analysis. The studies investigated the effect of OLPs on well-being, pain, stress, arousal, wound healing, sadness, itchiness, test anxiety, and physiological recovery. We found a significant effect of OLPs for self-reported outcomes (k = 13; standardized mean difference (SMD) = 0.43; 95% CI = 0.28, 0.58; I2 = 7.2%), but not for objective outcomes (k = 8; SMD =  - 0.02; 95% CI =  - 0.25, 0.21; I2 = 43.6%). The level of suggestiveness of the instructions influenced the efficacy of OLPs for objective outcomes (p = 0.02), but not for self-reported outcomes. The risk of bias was moderate for most studies, and the overall quality of the evidence was rated low to very low. In conclusion, OLPs appear to be effective when examined in experimental studies. However, further research is needed to better understand the mechanisms underlying OLPs.

A digital application and augmented physician rounds reduce postoperative pain and opioid consumption after primary total knee replacement (TKR): a randomized clinical trial

BACKGROUND

Severe postoperative pain not only is a considerable burden for patients but also leads to overprescription of opioids, resulting in considerable health concerns. The remarkable development of new technologies in the health care system provides novel treatment opportunities in this area and could exploit the additional placebo effect, provide added value for patients, and at the same time support hospital staff. We aimed to test the pain- and opioid intake-reducing effects of enhanced postoperative pain management by boosting pain medication by using a technical application and/or augmented physician rounds.

METHODS

In a four-arm, randomized clinical trial, 96 patients (24 patients per group) scheduled for a total knee replacement (TKR) were randomized into four groups for four postoperative days: an "application" group (APP) with information via an iPad-based application; a "doctor" group (DOC) with augmented physician rounds; a combination group (APP+DOC), which received both interventions; and a "treatment as usual" group (TAU) as a baseline with no additional intervention besides the standard care which consists of standardized medication, regular physician rounds, and physiotherapy. Postoperative pain and opioid requirements pre- and postoperatively until hospital discharge were recorded.

RESULTS

The difference between post- and preoperative pain was significantly different between the groups (P=.02, partial η2=.10). APP+DOC experienced greater postoperative pain relief than DOC (mean: 2.3 vs. 0.7, 95% CI: 0.08-3.09; P=.04) and TAU (mean 2.3 vs. 0.1; 95% CI: 0.69-3.71; P=.005), respectively, the difference compared to APP (mean 2.3 vs. 1.7; 95% CI -1.98-1.76) was not significant. Opioid consumption differed significantly between groups (P=.01, partial η2=.12). APP+DOC (72.9 mg) and DOC (75.4 mg) consumed less oxycodone than APP (83.3 mg) and TAU (87.9 mg; 95% CI: 2.9-22.1; P=.003). APP+DOC consumed significantly less oxycodone than DOC (d=0.2-0.4). There were no significant group differences in NSAID and Morphine sulfate consumption. Patients in APP+DOC were more satisfied with their treatment than patients in TAU (P=.03, partial η2=.09).

CONCLUSIONS

The combination of an innovative digital app, which implements open drug administration and augmented physician rounds that support the doctor-patient relationship can significantly improve postoperative pain management.

TRIAL REGISTRATION

The protocol was approved by the local ethics committee of the ethical commission of the German Psychological Society (Deutsche Gesellschaft für Psychologie; DGPs). The study was registered at DRKS.de (identifier: DRKS00009554).

Community Reintegration After Rehabilitation for Hip Fracture: A Systematic Review and Meta-analysis

OBJECTIVE

To investigate the effect of rehabilitation on the physical, social, and psychological dimensions of community reintegration after hip fracture.

DATA SOURCES

Electronic databases Embase, EMCare, MEDLINE, PsycINFO, Cumulative Index to Nursing and Allied Health, and SPORTDiscus were searched from the earliest date available to second June 2021.

STUDY SELECTION

Searching identified 1844 potentially relevant articles. Twenty randomized controlled trials evaluating physical retraining, cognitive retraining, and model of care interventions on physical, social and psychological aspects of community reintegration for 3075 adults after hip fracture were included.

DATA EXTRACTION

Data were extracted using predetermined templates for participant characteristics, intervention type and setting, and outcomes related to community reintegration. Methodological quality was assessed using the Physiotherapy Evidence Database scale, and the Grading of Recommendations, Assessment, Development, and Evaluations approach was applied to each meta-analysis.

DATA SYNTHESIS

Post intervention data were pooled to calculate risk ratios (RRs), mean differences, standardized mean differences, and 95% confidence intervals (CIs) using inverse variance methods and a random-effects model. Compared with usual care or no rehabilitation, there was moderate-quality evidence to suggest that physical retraining interventions improved outdoor mobility (RR, 1.45; 95% CI, 1.09-1.91; I2=0%) and moderate-quality evidence to suggest that physical retraining improved Nottingham Extended Activities of Daily Living Scale scores (physical and social reintegration) by a mean 3.5 units (95% CI, 0.99-6.01; I2=0%). Meta-analyses showed no significant effect for cognitive retraining and model of care interventions on any dimension of community reintegration.

CONCLUSIONS

Preliminary evidence suggests that physical rehabilitation after hip fracture improves physical and social aspects of community reintegration. The effect of psychological and home-based interventions on community reintegration is currently unclear. Further research is needed to determine the effect of rehabilitation on community reintegration, using interventions and measures that encompass all dimensions of community reintegration.

Open-Label Placebo Administration Decreases Pain in Elderly Patients With Symptomatic Knee Osteoarthritis - A Randomized Controlled Trial

Background

Recent studies indicate that the administration of open-label placebos (OLP) can improve symptoms in various medical conditions. The primary aim of this 3-week randomized controlled trial was to examine the effects of OLP treatments on pain, functional disability, and mobility in patients with arthritic knee pain.

Methods

Sixty patients (55% females; mean age, 66.9 ± 9.7 SD years) were randomized to one of two OLP treatments (n = 41) or no treatment (NT; n = 19). OLP treatments were accompanied by the verbal suggestion "to decrease pain" (OLP-pain, n = 20) or "to improve mood" (OLP-mood, n = 21). Pain and mood levels were monitored on 11-point Numeric Rating Scales (NRSs) in a patient diary, and global clinical improvement (CGI-I) was assessed at the end of the study. At baseline and after 21 days, patients filled in validated questionnaires to assess symptoms and functional disability of the knee (WOMAC), mental and physical quality of life (SF-36), state anxiety (STAI-state), perceived stress (PSQ-20), and self-efficacy (GSE). In addition, knee mobility (neutral zero-method), heart rate variability (HRV), and diurnal cortisol levels were evaluated before and after treatment.

Results

Evaluation of daily pain ratings indicated significant pain decrease in the OLP groups compared to NT (p = 0.013, d = 0.64), with no difference between the OLP-pain and the OLP-mood groups (p = 0.856, d = 0.05). OLP treatment also improved WOMAC pain (p = 0.036, d = 0.55), again with no difference between the two OLP groups (p = 0.65, d = 0.17). WOMAC function and stiffness, knee mobility, stress, state anxiety, quality of life, and self-efficacy did not change differently between groups.

Conclusion

OLP treatment improved knee pain in elderly patients with symptomatic knee osteoarthritis (OA), while functional disability and mobility of the knee did not change. The content of the verbal suggestion was of minor importance. OLP administration may be considered as supportive analgesic treatment in elderly patients with symptomatic knee OA.

Trial Registration

German Clinical Trials Register (https://www.drks.de/), DRKS00015191 (retrospectively registered).

Even when you know it is a placebo, you experience less sadness: First evidence from an experimental open-label placebo investigation

BACKGROUND

Recent studies demonstrate substantial effects of deceptive placebo on experimentally induced sadness, even on autonomic activity. Whether deception is necessary, remains to be elucidated. We investigated the effect of an open-label placebo (OLP) treatment, i.e. an openly administered placebo delivered with a convincing rationale for its sadness-protecting effect.

METHODS

Eighty-four healthy females were randomized to an OLP group or a no-treatment control group. All participants received the same detailed information about the OLP effect, only the OLP group received an OLP nasal spray. Before and after the OLP intervention, participants underwent a sad mood induction procedure combining self-deprecating statements (Velten's method) and sad music. Sadness was assessed by the Positive and Negative Affect Schedule (PANAS-X). Autonomic activity was measured continuously.

RESULTS

Participants in the OLP group reported a significantly attenuated increase in sadness upon mood induction and less sadness after induction compared to the control group (d = 0.79). Regardless of intervention, heart rate decreased during mood inductions with a more pronounced deceleration in the second mood induction.

LIMITATIONS

Generalizability is limited due to the selective sample and the reliance on an experimentally controlled mood induction.

CONCLUSION

OLP treatment had a beneficial effect on perceived sadness, at least at the subjective level. Hence, deception may not necessarily be required for placebos to modulate experienced sad mood. Investigating the beneficial effects of OLP in (sub-)clinical samples would seem a promising and required next step towards a clinical use of placebo-associated positive treatment expectations.

Attitudes Toward a Pre-authorized Concealed Opioid Taper: A Qualitative Analysis of Patient and Clinician Perspectives

Standard opioid tapers tend to be associated with increased patient anxiety and higher pain ratings. Pre-authorized concealed opioid reductions may minimize expectations such as fear of increased pain due to the reduction of opioids and, prolong analgesic benefits in experimental settings. We recently observed that patients and clinicians are open to concealed opioid tapering. However, little is known about the "why" behind their attitudes. Based on this lack of data, we analyzed qualitative responses to survey questions on patients' and clinicians' acceptance of a concealed opioid reduction for chronic pain. Seventy-four patients with a history of high dose opioid therapy and 49 clinicians completed a web-based questionnaire with open-ended questions examining responses to two hypothetical clinical trials comparing a concealed opioid reduction pre-authorized by patients vs. standard tapering. We used content analysis based on qualitative descriptive methodology to analyze comments from the patients and clinicians. Five themes were identified: informed consent; anxiety; safety; support; and ignorance is bliss, or not. These themes highlight the overall positive attitudes toward concealed opioid tapers. Our findings reinforce the importance of patient-centered care and are expected to inform the design of clinical trials from both the patient and clinician perspective. This qualitative study presents patients' and clinicians' attitudes toward hypothetical scenarios for a trial of pre-authorized reduction of opioids. The findings indicate positive attitudes and the relevance of engaging patients with effective decision-making processes.

Lay perspectives of the open-label placebo rationale: a qualitative study of participants in an experimental trial

OBJECTIVES

To analyse participants' concepts about the open-label placebo (OLP) effect; to explore their views about the discussion points that are applied in conventional OLP trials and to examine their experiences of taking part in an OLP trial.

DESIGN

A qualitative study using thematic analysis of semistructured interviews that were nested within a randomised controlled trial investigating experimental OLP analgesia (registered at ClinicalTrials.gov: NCT02578420).

PARTICIPANTS

30 healthy adults who took part in the randomised controlled trial.

RESULTS

Participants mostly conceptualised placebo as something that is inert and requires deception in order to be effective. Interviewees used a broad definition of placebos, going beyond a conventional notion of sugar pills. In contrast to the conventional OLP rationale, participants seldom emphasised classical conditioning as a mechanism of placebo effects, stressing a variety of other well-established components through which placebos might be therapeutic, whereas the conventional OLP disclosures state that 'a positive attitude helps but is not necessary', participants in our study applied other attitudes, such as 'it's worth a try'. When asked about their experiences during the trial, the majority emphasised that the concept of OLP was completely novel to them. Participants were rather sceptical about the efficacy of the intervention.

CONCLUSION

Integrating lay perspectives into the scientific rationale of OLP treatments might enhance the plausibility and credibility of the rationale in ethical treatments.

TRIAL REGISTRATION NUMBER

NCT02578420.

The effectiveness of high-intensity laser therapy in the treatment of post-stroke patients with hemiplegic shoulder pain: a prospective randomized controlled study

To evaluate clinical and ultrasonographic efficacy of high-intensity laser therapy (HILT) in patients with hemiplegic shoulder pain (HSP) accompanied by partial thickness rotator cuff tear (PTRCT). The study was designed as a prospective, randomized, controlled trial. Patients with HSP accompanied by PTRCT (n = 44) were randomly assigned to HILT and control groups. Both groups were treated with a multidisciplinary stroke rehabilitation and a therapeutic exercise program to the affected shoulder supervised by physiotherapists. In addition, HILT group received 3 sessions of the intervention per week for 3 weeks. Primary outcome measure was visual analogue scale (VAS) for pain. Secondary outcome measures were range of motion (ROM) of the shoulder joint, Shoulder Pain and Disability Index (SPADI), Brunnstrom Recovery Stage (BRS), Modified Ashworth Scale (MAS), Nottingham Health Profile (NHP), Functional Independence Measure (FIM), and ultrasonographic PTRCT size. Participants were assessed at pre- and post-treatment. A total of 41 patients completed the study. A statistically significant improvement was observed in VAS, ROM, FIM, SPADI, NHP, and PTRCT parameters in HILT group at post-treatment compared to pre-treatment (all P < 0.05). However, control group indicated significant improvement only in VAS, ROM, and SPADI parameters (all P < 0.05). When differences in clinical parameters at pre- and post-treatment assessment were compared between two groups, change in VAS, FIM, BRS, SPADI, NHP, and PTRCT in HILT group was significantly better than control group (all P < 0.05). HILT combined with therapeutic exercise seems to be clinically and ultrasonographically more effective in the treatment of patients with HSP accompanied by PTRCT than therapeutic exercise alone in the short term. Further studies are needed with long-term follow-up. CinicalTrials.gov Identifier: NCT04669405.

Effects of open-label placebos in clinical trials: a systematic review and meta-analysis

Open-label placebos (OLPs) are placebos without deception in the sense that patients know that they are receiving a placebo. The objective of our study is to systematically review and analyze the effect of OLPs in comparison to no treatment in clinical trials. A systematic literature search was carried out in February 2020. Randomized controlled trials of any medical condition or mental disorder comparing OLPs to no treatment were included. Data extraction and risk of bias rating were independently assessed. 1246 records were screened and thirteen studies were included into the systematic review. Eleven trials were eligible for meta-analysis. These trials assessed effects of OLPs on back pain, cancer-related fatigue, attention deficit hyperactivity disorder, allergic rhinitis, major depression, irritable bowel syndrome and menopausal hot flushes. Risk of bias was moderate among all studies. We found a significant overall effect (standardized mean difference = 0.72, 95% Cl 0.39–1.05, p < 0.0001, I² = 76%) of OLP. Thus, OLPs appear to be a promising treatment in different conditions but the respective research is in its infancy. More research is needed, especially with respect to different medical and mental disorders and instructions accompanying the OLP administration as well as the role of expectations and mindsets.

More than consent for ethical open-label placebo research

Recent studies have explored the effectiveness of open-label placebos (OLPs) for a variety of conditions, including chronic pain, cancer-related fatigue and irritable bowel syndrome. OLPs are thought to sidestep traditional ethical worries about placebos because they do not involve deception: with an OLP, patients or subjects are told outright that they are not given an active substance. As deception is framed as the primary hurdle to ethical placebo use, the door is ostensibly opened to ethical studies of OLPs. In this article, I suggest that even though OLPs seemingly do not involve deception, there are other ethical considerations in their clinical investigation and subsequent use. Research ethics often focusses on informed consent-of which, deception and honesty are a piece-as a means to justify research practices with human subjects. Yet, it is but one of the ethical considerations that should be taken into account. With research into placebo effects in particular, I argue that the history of clinical placebo use grounds special considerations for OLP research that go beyond respect for the autonomy of individual patients through informed consent and encompass structural concerns about the type of patient for whom a placebo has historically been thought appropriate.

[Placebo effects in pain therapy]

In the past few decades, research on pain and placebo analgesia has gained importance both scientifically and clinically. In this article, the current findings and focus of research as well as the significance of placebo research for assessing the effectiveness of pain medication are illustrated. The underlying mechanisms of placebo analgesia not only have implications for theoretical models but also offer clinically relevant guidelines for everyday interventions in pain treatment. However, many placebo phenomena are not fully understood and have to be investigated further in order to exploit the full potential of placebo effects. Interindividual differences and their inclusion in treatment will play a major role in this aspect.

Placebo effects in pain

Placebo effects influence symptom perceptions and treatment outcomes. Placebo effects can be explored in laboratory settings controlling for natural history and expectations. Such a mechanistic approach to neurological disorders has been implemented in the domain of chronic clinical pain and other neurological disorders. This article therefore focuses on definitions and historical notes related to placebo effects and mechanisms of placebo effects in chronic pain. Knowledge on mechanisms of placebo effects could inform current clinical practice for the treatment of neurological disorders by focusing on patients (and providers) expectations for outcome optimization.

From substance to process: A meta-ethnographic review of how healthcare professionals and patients understand placebos and their effects in primary care

Research suggests that a 'placebo' can improve conditions common in primary care including pain, depression and irritable bowel syndrome. However, disagreement persists over the definition and clinical relevance of placebo treatments. We conducted a meta-ethnographic, mixed-research systematic review to explore how healthcare professionals and patients understand placebos and their effects in primary care. We conducted systematic literature searches of five databases - augmented by reference chaining, key author searches and expert opinion - related to views on placebos, placebo effects and placebo use in primary care. From a total of 34 eligible quantitative, qualitative and mixed-methods articles reporting findings from 28 studies, 21 were related to healthcare professionals' views, 11 were related to patients' views and two were related to both groups. In the studies under review, healthcare professionals reported using placebos at markedly different frequencies. This was highly influenced by how placebos were defined in the studies. Both healthcare professionals and patients predominantly defined placebos as material substances such as 'inert' pills, despite this definition being inconsistent with current scientific thinking. However, healthcare professionals also, but less prevalently, defined placebos in a different way: as contextual processes. This better concurs with modern placebo definitions, which focus on context, ritual, meaning and enactivism. However, given the enduring ubiquity of substance definitions, for both healthcare professionals and patients, we question the practical, clinical validity of stretching the term 'placebo' towards its modern iteration. To produce 'placebo effects', therefore, primary healthcare professionals may be better off abandoning placebo terminology altogether.

Neuroenhancement for sale: assessing the website claims of neurofeedback providers in the United States

Although electroencephalographic (EEG) neurofeedback is a technique that has been in existence for many decades, it has remained controversial, largely due to questions about efficacy. Yet neurofeedback is being widely offered to the public, often at great expense. To date, however, there has not been empirical data on which providers are utilizing neurofeedback, what they are offering it for, and how they are advertising the technique. The present study aimed to fill that gap by systematically analyzing the websites of neurofeedback practitioners in the United States. To that end, we obtained data from four directories of neurofeedback providers, extracting practitioner names, geographical locations, professional training, and website URLs. Only websites offering neurofeedback services (N=371) were included in the next step, wherein two coders independently coded the websites based on a codebook developed from preliminary analyses. We found that nearly all websites (97.0%) contained claims about at least one clinical indication, most commonly anxiety, ADHD/ADD, and depression; however, only 36.0% of providers had either a medical degree (MD) or a doctoral-level degree in psychology. The majority of websites advertised neurofeedback for cognitive (90.0%) or performance (67.9%) enhancement, and roughly three-quarters utilized language related to complementary and alternative medicine (CAM). In sum, there is a considerable divergence between the scientific literature on neurofeedback and the marketing of neurofeedback services to the general public, raising concerns regarding the misrepresentation of services and misleading advertising claims.

State of the art: What have the pain sciences brought to physiotherapy?

Background

Pain is the most common reason for patients to seek help from a health care professional. In the past few decades, research has yielded gains in the Pain Sciences - multiple fields of scientific research that, when integrated, help to clarify what causes and influences human pain.

Objectives

In this article, we discuss the key areas in which the Pain Sciences have shifted the physiotherapy profession.

Method

A narrative review of the Pain Sciences literature was conducted. The review analyses how the Pain Sciences have influenced physiotherapy in several categories: assessment; clinical reasoning; treatment; research rigor and building the profile of the profession.

Results

Scientific research on pain has largely converged in support of three ‘game-changing’ concepts that have shifted the physiotherapy profession’s understanding and treatment of pain: (1) pain is not a signal originating from bodily tissues, (2) pain is not an accurate measure of tissue damage and (3) the plasticity of the nervous system means the nervous system itself is a viable target of treatment. These three concepts have influenced physiotherapy assessment and treatment approaches, and research design to consider pain mechanisms using patient-centred models.

Conclusion

The Pain Sciences have shifted physiotherapists’ assessment and treatment approaches and shifted the status of the physiotherapy profession. Ultimately the Pain Sciences have embedded interdisciplinary teams and expanded physiotherapy practice.

Clinical implications

We believe that the pain sciences should be embedded in undergraduate and postgraduate education and training of physiotherapists (including the three key concepts regarding pain) to benefit physiotherapists and their patients.

Can an Open-Label Placebo Be as Effective as a Deceptive Placebo? Methodological Considerations of a Study Protocol

Background: Placebo has been studied for many years and is ever-present in healthcare. In clinical practice, its use is limited by ethical issues raised by the deception entailed by its administration. Objective: To investigate whether, when given detailed information about pain and underlying placebo mechanisms, subjects will have a response similar to that of those subjected to a procedure in which they receive a conventional placebo treatment. Methods: The study is designed as a non-inferiority randomized, parallel with a nested crossover trial. In addition, 126 subjects without any known pathology will be included. They will be randomized into two groups. Each subject will undergo three Cold Pressor Tests (CPT): calibration, condition of interest (deceptive placebo or educated placebo), and control. Our main judgment criterion will be the comparison in pain intensity experienced on the visual analog scale between the two CPTs with placebo conditions. Results: This study will allow us to rule on the non-inferiority of an "educated" placebo compared to a deceptive placebo in the context of an acute painful stimulation. It is another step towards the understanding of open-label placebo and its use in clinical practice. Conclusions: This study has been approved by the ethics committee in France (2017-A01643-50) and registered on ClinicalTrials.gov (NCT03934138).

Deceptive but not open label placebos attenuate motion-induced nausea

OBJECTIVE

Nausea is a common complaint, known to respond to the placebo effect. Existing research has employed deception when administering placebos for nausea, limiting therapeutic translation on ethical grounds. We therefore examined the potential of non-deceptive open-label placebos (OLPs) to reduce nausea.

METHODS

Galvanic Vestibular Stimulation (GVS) and Virtual Reality (VR) were employed to model nausea in healthy volunteers across two experiments. In both experiments nausea was elicited with and without sham treatment (peppermint vapor and brain stimulation, respectively). In Exp. 1, participants (n = 61) were randomized to deceptive placebo, semi-open placebo, fully-open placebo, or control. In Exp. 2, participants (n = 93) were randomized to deceptive placebo, semi-open placebo, or control.

RESULTS

Exp. 1 found limited evidence for a placebo effect (F(1, 56) = 1.15, p = .29, η_p² =0.02), even following deceptive treatment (F(1, 56) = 1.92, p = .17, η_p²=0.03). In Exp. 2, deceptive placebo reduced nausea relative to control (F(1, 89) = 6.91, p = .010, η_p²=0.07) and OLP (F(1, 89) = 5.47, p = .022, η_p²=0.06). Pooled Bayesian analysis across experiments provided strong evidence that deceptive placebos reduce nausea relative to control (BF₁₀ = 30.91) and anecdotal evidence for the benefit of deceptive treatment over non-deceptive (BF₁₀ = 2.46) and no benefit of OLP over control (BF₁₀ = 0.63).

CONCLUSIONS

No positive evidence for OLP effects in nausea were observed. However, a deceptive effect in VR was observed. These findings raise questions regarding the efficacy of open-label intervention in nausea.

Impacts of low-energy extracorporeal shockwave therapy on pain, pruritus, and health-related quality of life in patients with burn: A randomized placebo-controlled study

BACKGROUND

The management of post-burn pain and pruritus remain a potent challenge because of their bad effects on health-related quality of life (HRQOL). The main purpose of this study was to evaluate the impacts of low-energy extracorporeal shockwave therapy (low-energy ESWT) in the management of pain, pruritus, and HRQOL in patients with burn.

METHODS

Forty-five adult patients with burn, their age ranged from 18 to 55 years, were included in the study, they randomly assigned into 22 patients in the study group (low-energy ESWT) and 23 patients in the placebo group. The study group received low-energy ESWT (0.05-0.20mJ/mm², a frequency of 4Hz with total shocks from 1000 to 2000 shocks) once per week for 4 successive weeks, while the placebo group received ESWT without energy. Both groups received traditional physical therapy program of selective different exercises (respiratory, range of motion, endurance, strengthening, balance, mobilization, stretching, and gait training) 3days per week for 4 weeks. Numerical Rating Scale (NRS) for pain and for pruritus, Pressure Pain Threshold (PPT), 12-Item Pruritus Severity Scale (12-PSS), and Burn Specific Health Scale-Brief (BSHS-B) were measured before and after treatment procedures in both groups.

RESULTS

NRS were decreased significantly in the study group than in the placebo group (P<0.05). PPT, 12-PSS, and BSHS-B scores were improved more significantly in the study group than in the placebo group (P<0.05) while body image and burn associated issues were improved at the same level in both groups (P>0.05).

CONCLUSION

The findings suggest that low-energy ESWT with traditional regular physical therapy may relive post-burn pain and pruritus, and improve HRQOL, particularly in adult patients with burn.

Long-Term Effect of Pulsed Nd:YAG Laser in the Treatment of Patients with Rotator Cuff Tendinopathy: A Randomized Controlled Trial

OBJECTIVE

The purpose of the present study was to investigate the long-term effect of pulsed Nd:YAG laser on the treatment of rotator cuff tendinopathy.

METHODS

Sixty patients with rotator cuff tendinopathy participated and completed the study. The mean age was 50.2 ± 3.6 years. Participants were randomly assigned to one of two groups: the control group and the treatment group. Both groups were treated with an exercise program, in addition to the pulsed Nd:YAG laser received by the treatment group and the "sham" laser received by the control group, both for three sessions per week for 4 weeks. Outcome measures included pain, assessed by the visual analog scale, and range of motion (ROM), assessed using a traditional goniometer, while the shoulder pain and disability index were used to evaluate the functional recovery of the shoulder joint. Evaluation was carried out before treatment, immediately after treatment, 3 months posttreatment, and 6 months posttreatment. Statistical analyses were used to investigate the effect of interventions and to compare the study groups' pretreatment, posttreatment, and at follow-up points. The significance level was set to p < 0.05.

RESULTS

Pain was significantly decreased after treatment and at follow-up points, while ROM and shoulder functions were significantly improved after treatment and at follow-up intervals in both groups. The improvement was more significant in the treatment group than in the control group posttreatment and at follow-up intervals.

CONCLUSIONS

Pulsed Nd:YAG laser combined with an exercise program seems to be more effective in the treatment of patients with rotator cuff tendinopathy than a sham laser with exercises.

A discursive exploration of public perspectives on placebos and their effects

There is increasing evidence that placebos could be effective in clinical practice. However, knowledge of public perspectives on placebos is underdeveloped. We conducted a discourse analysis of internet comments on news articles related to placebos, aiming to improve this knowledge for clinicians and researchers. We developed two discursive constructs of the placebo. The dominant construct of the 'placebo pill' informs a paradoxical understanding of placebos that closes down treatment. The less-prevalent counter-discursive construct of the 'treatment process' frames placebos as potentially viable within modern evidence-based medicine. We discuss the opportunities and challenges of this alternative understanding of placebos.

Functional Movement Disorders and Placebo: A Brief Review of the Placebo Effect in Movement Disorders and Ethical Considerations for Placebo Therapy

Background

Functional movement disorders are common and disabling neurologic conditions. Patients with functional neurologic disorders represent a large proportion of neurology clinic referrals, and limited availability of subspecialty care creates a considerable burden for the healthcare system. These conditions are currently treated with a combination of physical therapy and cognitive behavioral therapy, with variable success.

Methods

We searched the Medline database for studies on the epidemiology and physiology of functional movement disorders, as well as those on the placebo effect in movement disorders. We reviewed and summarized the literature on these topics and explored ethical issues concerning the administration of placebos to patients with functional movement disorders.

Results

Studies of placebos, particularly in patients with movement disorders, have shown that these "inert" agents can provide demonstrable neurophysiologic benefits, even in open-label studies. Physician surveys have shown that many administer placebos for diagnostic and therapeutic purposes, although there are ethical concerns about this practice. We used a principle-based approach and reviewed ethical arguments for (justice and beneficence) and against (non-maleficence and autonomy) the use of placebos in functional movement disorders. In this context, we argue for the importance of the therapeutic alliance in preserving patient autonomy while exploring the potential benefits of placebo therapy.

Conclusions

An ethical argument is presented in support of nondeceptive clinical placebo use for the treatment of functional movement disorders. Patient and clinician attitudes regarding the use of placebos should be investigated before placebo-therapy trials are conducted.

Placebo acceptability in chronic pain patients: More dependent on application mode and resulting condition than on individual factors

Introduction

Placebo effects can be very effective in certain pain conditions, but their use is still highly controversial. Several studies show that patients would accept a placebo treatment under certain circumstances, particularly when they are informed prior to the treatment or when there are no effective treatment alternatives. This study examines the question, which factors influence the degree of acceptability of a hypothetical placebo application.

Methods

Patients filled in a questionnaire dealing with placebo applications. Moreover general data, diagnosis, duration of pain, pain ratings and anxiety/depression/stress scores, sleep disorders and opioid intake were collected from the patients` charts. 129 patients (44 men / 85 women, mean age 51.5 years, 18.0–80.9 years) entered the study. All patients had chronic pain syndromes and were treated in an universitary academic interdisciplinary pain center. Mean duration of pain was 14.7 years.

Results

The study did not show significant differences in placebo acceptability among patients with different pain diagnoses or accompanying psychological diagnoses or disorders. Hidden placebo application was considered much more unacceptable for the patients than the enhanced placebo or the open placebo application. An improved condition was associated with less feeling of deception, more trust and less negative mood than an unchanged or worsened condition.

Conclusion

Acceptance of placebo as pain therapy is much more dependent on the way of application (hidden or open) or on the resulting condition (improved, unchanged or worsened) than on factors inherent in the individual patients.

How often do general practitioners use placebos and non-specific interventions? Systematic review and meta-analysis of surveys

Background

In a systematic review and meta-analysis we summarize the available evidence on how frequently general practitioners/family physicians (GPs) use pure placebos (e.g., placebo pills) and non-specific therapies (sometimes referred to as impure placebos; e.g., antibiotics for common cold).

Methods

We searched Medline, PubMed and SCOPUS up to July 2018 to identify cross-sectional quantitative surveys among GPs. Outcomes of primary interest were the percentages of GPs having used any placebo, pure placebos or non-specific therapies at least once in their career, at least once in the last year, at least monthly or at least weekly. Outcomes were described as proportions and pooled with random-effects meta-analysis.

Results

Of 674 publications, 16 studies from 13 countries with a total of 2.981 participating GPs (range 27 to 783) met the inclusion criteria. The percentage of GPs having used any form of placebo at least once in their career ranged from 29% to 97%, in the last year at least once from 46% to 95%, at least monthly from 15% to 89%, and at least weekly from 1% to 75%. The use of non-specific therapies by far outnumbered the use of pure placebo. For example, the proportion of GPs using pure placebos at least monthly varied between 2% and 15% compared to 53% and 89% for non-specific therapies; use at least weekly varied between 1% and 3% for pure placebos and between 16% and 75% for non-specific therapies. Besides eliciting placebos effects, many other reasons related to patient expectations, demands and medical problems were reported as reasons for applying placebo interventions.

Conclusion

High prevalence estimates of placebo use among GPs are mainly driven by the frequent use of non-specific therapies; pure placebos are used rarely. The interpretation of our quantitative findings is complicated by the diversity of definitions and survey methods.

Clinical Use of Placebo Effects in Patients With Pain Disorders

The analgesic placebo effect is well documented by numerous studies. Many important influencing factors, however, are yet to be discovered. In the arena of placebo effects and clinical implications, expectancies play a central role. Expectancies are shaped by processes of classical and social learning as well as verbal instructions and are strongly related to emotional factors. Expectancies trigger a cascade of endogenous opioids and non-opioids, which alter the experience of pain. For clinical application it is important to know, that placebo research yields ethical possibilities to use placebo effects without deception and without using placebos. Since placebo effects contribute to responses to active analgesics, it is feasible to enhance patients' benefits from pain treatments by increasing the additional placebo effect. There are several possibilities to use the placebo effects via shaping and adapting information about analgesic medication and via associating medication intake with a positive context. A positive patient-clinician communication atmosphere is very important to generate clinically meaningful placebo effects in pain medicine.

Super Pill is Less Effective than an Ordinary Mint in Altering Subjective Psychological Feeling States within a Few Minutes

Expectations shape human behavior. Initial drug use might be associated with information-based expectations. In this study, we presumed that changes in affect and perceived physical wellbeing will be stronger after receiving an active placebo (Tic Tac mint; n = 40), than a pure placebo (inert pill; n = 40) given as a mood-enhancing "super pill." After baseline measures, participants completed a treatment-expectancy scale, ingested the mint/super pill, and attended to the effects over 3-minutes. Subsequently, they completed again the psychological tests. Expectancy scores were positive and did not differ between the groups. The pure placebo group increased in physical wellbeing but less than the active placebo group, which also showed an increase in positive affect. Negative affect decreased in both groups. The Tic Tac produced greater affective changes than the pure placebo. Since these are new findings on the ultra-short placebo effects on affect, the results might have relevance for drug-use studies.

Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain

Placebo and nocebo effects are embodied psycho-neurobiological responses capable of modulating pain and producing changes at different neurobiological, body at perceptual and cognitive levels. These modifications are triggered by different contextual factors (CFs) presented in the therapeutic encounter between patient and healthcare providers, such as healing rituals and signs. The CFs directly impact on the quality of the therapeutic outcome: a positive context, that is a context characterized by the presence of positive CFs, can reduce pain by producing placebo effects, while a negative context, characterized by the presence of negative CFs, can aggravate pain by creating nocebo effects. Despite the increasing interest about this topic; the detailed study of CFs as triggers of placebo and nocebo effects is still lacked in the management of musculoskeletal pain.

Increasing evidence suggest a relevant role of CFs in musculoskeletal pain management. CFs are a complex sets of internal, external or relational elements encompassing: patient’s expectation, history, baseline characteristics; clinician’s behavior, belief, verbal suggestions and therapeutic touch; positive therapeutic encounter, patient-centered approach and social learning; overt therapy, posology of intervention, modality of treatment administration; marketing features of treatment and health care setting. Different explanatory models such as classical conditioning and expectancy can explain how CFs trigger placebo and nocebo effects. CFs act through specific neural networks and neurotransmitters that were described as mediators of placebo and nocebo effects.

Available findings suggest a relevant clinical role and impact of CFs. They should be integrated in the clinical reasoning to increase the number of treatment solutions, boosts their efficacy and improve the quality of the decision-making. From a clinical perspective, the mindful manipulation of CFs represents a useful opportunity to enrich a well-established therapy in therapeutic setting within the ethical border. From a translational perspective, there is a strong need of research studies on CFs close to routine and real-world clinical practice in order to underline the uncertainty of therapy action and help clinicians to implement knowledge in daily practice.

Clinical guidelines for low back pain: A critical review of consensus and inconsistencies across three major guidelines

Given the scale and cost of the low back pain problem, it is imperative that healthcare professionals involved in the care of people with low back pain have access to up-to-date, evidence-based information to assist them in treatment decision-making. Clinical guidelines exist to promote the consistent best practice, to reduce unwarranted variation and to reduce the use of low-value interventions in patient care. Recent decades have witnessed the publication of a number of such guidelines. In this narrative review, we consider three selected international interdisciplinary guidelines for the management of low back pain. Guideline development methods, consistent recommendations and inconsistencies between these guidelines are critically discussed.

Applications and limitations of behaviorally conditioned immunopharmacological responses

The importance of placebo responses for the treatment of various medical conditions has increasingly been recognized, whereas knowledge and systematic application in clinical settings are still sparse. One possible application for placebo responses in pharmacotherapy is given by learning paradigms, such as behaviorally conditioned immunosuppression, aiming at drug dose reduction while maintaining therapeutic efficacy of drug treatment. In an established learning paradigm of conditioned taste aversion/avoidance (CTA) in both, rats and humans, respectively, a novel-tasting drinking solution (conditioned stimulus, CS) is paired with an injection of the immunosuppressive drug cyclosporine A (CsA) as unconditioned stimulus (US). The conditioned response, evoked by re-presenting the CS alone at a later time, is reflected by avoidance behavior of consuming the solution (conditioned taste aversion; CTA) and a diminished interleukin (IL)-2 and interferon (IFN)-γ cytokine production as well as mRNA expression of rat splenic T cells or human peripheral T lymphocytes, closely mimicking the immunosuppressive effects of CsA. However, due to unreinforced CS-re-exposure conditioned responses progressively decreases over time (extinction), reflecting a considerable challenge for potential clinical applications of this learned immunosuppression. The present article discusses and critically reviews actual approaches, applications but also limitations of learning paradigms in immune pharmacotherapy.

Drug versus placebo randomized controlled trials in neonates: A review of ClinicalTrials.gov registry

BACKGROUND

Despite specific initiatives and identified needs, most neonatal drugs are still used off-label, with variable dosage administrations and schedules. In high risk preterm and term neonates, drug evaluation is challenging and randomized controlled trials (RCT) are difficult to conduct and even more is the use of a placebo, required in the absence of a reference validated drug to be used as comparator.

METHODS

We analyzed the complete ClinicalTrials.gov registry 1) to describe neonatal RCT involving a placebo, 2) to report on the medical context and ethical aspects of placebo use.

RESULTS

Placebo versus drug RCT (n = 146), either prevention trials (n = 57, 39%) or therapeutic interventions (n = 89, 61%), represent more than a third of neonatal trials registered in the National Institute of Health clinical trial database (USA) since 1999. They mainly concerned preterm infants, evaluating complications of prematurity. Most trials were conducted in the USA, were single centered, and funded by non-profit organizations. For the three top drug trials evaluating steroids (n = 13, 9.6%), erythropoietin (EPO, n = 10, 6.8%) and nitric oxide (NO, n = 9, 6.2%), the objectives of the trial and follow-up were analyzed in more details.

CONCLUSION

Although a matter of debate, the use of placebo should be promoted in neonates to evaluate a potential new treatment, in the absence of reference drug. Analysis of the trials evaluating steroids showed that long-term follow-up of exposed patients, although required by international guidelines, is frequently missing and should be planned to collect additional information and optimize drug evaluation in these high-risk patients.

Contextually Aided Recovery (CARe): a scientific theory for innate healing

BACKGROUND

The chiropractic profession emerged when scientific explanations for causes of health and disease were still in infancy and the co-existence of notions such as innate healing and vitalism were perhaps admissible within such a historical context. Notwithstanding, within the scientific culture of the 21^st Century all healthcare paradigms require evidential support which in regard these early concepts are in large part, absent. Nevertheless, a large body of emerging scientific evidence supports the existence of innate healing phenomena that may explain a plethora of clinical outcomes observed during chiropractic care. However, in contrast to the notion that removing the putative subluxation constitutes the mechanism by which this healing is initiated, the evidentially supported explanation is one that invokes the impact of contextual factors inherent in the skilful care and authority of the healthcare provider. This perspective is presented here as the scientific model of Contextually Aided Recovery (CARe).

MAIN BODY

This paper contends that;Contextual effects are powerful and desirable and are triggered by contextual factors present in all therapeutic encounters including those encountered in chiropractic practice.These factors can elicit large clinical effects with substantive evidence supporting pain, immune and motor modulation.The compartmentalisation of specific and non-specific effects is a biologically and scientifically false dichotomy, erroneously invoked to de-legitimise treatment approaches that expertly construct contextual healing scenarios.The use of factors to construct contextual healing scenarios that maximise positive (placebo) and minimize negative (nocebo) effects is a skilful clinical art within the multimodal approach that describes modern chiropractic care and should be presented and defended as a legitimate component of orthodox healthcare Clinical improvement during chiropractic care, beyond any biologically specific treatment effects of manipulation and other modalities, may be largely understood considering contextual factors as described by a Contextually Aided Recovery (CARe) model.