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Maximising placebo


Imagine this scenario. Your child is running down the hall, trips and lands headfirst.

Now consider these two different responses.

I saw you trip and fall. It will be alright. Let me kiss it better.


Oh my God! You banged your head. You could have killed yourself! 

We all know these contrasting approaches would produce different reactions in the child. The first reaction is an example of placebo and the second could be described as the opposite effect, nocebo.

However, you may not appreciate the physical and chemical changes occurring during these events.

A common misconception about placebo is that it is merely a non-specific, psychological effect occurring in the suggestible person. Yet incredible research over the last two decades has transformed our understanding of these placebo phenomena.

Professor Fabrizio Benedetti is a pre-eminent placebo researcher and his work has demonstrated the specificity in various placebo effects. For example, if someone is given opioids for three days (conditioning), and then on the fourth day given a placebo, the brain will produce its own opiates from its own ‘drug cabinet’. These endogenous opioids will use the same pathway as the conditioning opiates.

Yet if someone is conditioned with cannabinoids (a different class of drugs – one example is cannabis) and then given a placebo, the brain will produce its own cannabinoids and light up that pathway. The same placebo effect specificity is seen with aspirin conditioning, some immune suppressants, some hormones and many other drug systems. Even in Parkinson’s disease, if patients are conditioned, sham electrical brain stimulation will create a 200% increase in dopamine, and motor function will markedly improve, albeit temporarily.

Basically, once the body has learnt a response, it is capable of mediating that same response solely through the power of expectation and ritual (pill, injection, procedure etc.).

These are conscious placebo effects, as the power of expectation is crucial. Interestingly, if someone is given an active drug through hidden administration, its effect may be greatly diminished compared to the patient who is aware of and expecting drug administration.

There are also examples of unconscious placebo effects. For example, if someone takes a round, white pill and knows it is a placebo there may be physiological effects occurring in various drug pathways, regardless of the person not expecting any effect. In this case, the ritual alone is enough to trigger chemical mediators.

In fact, the more complex the ritual, the greater the placebo effect. Surgery has been described as the ultimate placebo due to its elaborate machinations. White coats, important surgeons, anaesthesia, and sharp knives. Sham knee meniscal surgery trials (anaesthesia and incision only) have produced superior outcomes to the actual meniscal surgery.

Studies have also shown more expensive, brand name medication to be more effective than cheaper, generic versions (for example, Nurofen versus ibuprofen). Here, marketing complicates the ritual and expectation picture. The other day I bought a brand name, specifically due to this! It’s madness!

Health care practitioners must juggle placing ethics and honesty first and yet attempt to not completely demolish placebo effects.

As Fabrizio Benedetti says, “Our words alone move a lot of molecules around in the patient’s brain.” Next time my kid falls, I’m going to maximise the placebo by using the most effective child placebo: kissing it better!

Further reading:

Cure: the science of mind over body. Jo Marchant – Very accessible and entertaining.

Placebo effects. Fabrizio Benedetti – More clinical, in-depth look into the science of placebo.

Frequently Asked Questions

Osteopaths are primary healthcare providers which means that no referral is necessary. If your treatment is being covered by WorkSafe, TAC or DVA, you will require a referral to ensure that your costs are covered.

We are able to treat WorkSafe, TAC, EPC and DVA patients, however you will require a referral from your GP. For TAC and WorkSafe patients we will also require your claim number and date of injury.

We are covered by private health funds via extras cover. Exact details will vary depending on the individual fund and level of cover. We do have a Hicaps machine which enables you to claim health fund payments on the spot.

For medicare rebates you must qualify for an EPC plan. You will need to discuss this with your GP, and a referral is necessary.

Yes, please bring in any X-ray, CT or MRI scan results you may have. If you have a report for these scans, make sure you bring this along as well.

During your first consultation your osteopath will ask questions about your problem and symptoms. They may also ask questions about your medical history, any medications you are taking or other factors that may not appear to be directly related to your problem. If your medical condition changes during the course of your osteopathic treatment, you should tell your osteopath.

Your osteopath may ask about any recent X-rays, scans or test results that you may have.

Depending on the area of your body requiring treatment, your osteopath may ask you to undress to your underwear. It’s important that you feel comfortable, so you may want to wear loose pants or bring a pair of shorts to change into.

Next, your osteopath will conduct a full osteopathic examination and if necessary, clinical tests. This may involve diagnostic, orthopaedic or neurological tests, postural assessments and activities or exercises, which will help determine how best to manage your condition.

The examination may include passive and active movements, such as the osteopath lifting your arms or legs. As part of the examination, you may also be asked to bend over or stand in your underwear. Be sure to wear comfortable, flexible and appropriate underwear.

As osteopathy takes a holistic approach to treatment, your practitioner may look at other parts of your body, as well as the area that is troubling you. For example, if you have a sore knee, your osteopath may also look at your ankle, pelvis and back.

Your osteopath may also provide education and advice to help you manage your condition between treatments. This may include giving you exercises to do at home or work.

Osteopathy is a form of manual therapy, so hands-on treatment may include massage, stretching, repetitive movements, mobilisation and/or manipulation. Most osteopathic treatment is gentle and should not cause undue discomfort. If your injuries do require hands-on treatment of painful and tender areas, your osteopath will exercise care to make you as comfortable as possible.

Some people experience mild soreness for a day or two after treatment, similar to that felt after mild exercise. If this soreness persists or increases significantly, call your osteopath to discuss your concerns.

Your initial consultation may last up to one hour. This will enable your osteopath to take a thorough history, examine and treat you. Follow-up treatments are usually shorter. Depending on your condition, they can take 30-40 minutes.

Generally you would expect to see some changes in your symptoms after one or two visits; however, some long-term or chronic conditions may require a longer course or more frequent treatment. If you have any concerns, your osteopath will be happy to discuss these with you.

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