Placebo within osteopathy

We will try to exert self-criticism and bring the light on the subject of placebo effect within osteopathic treatments.

This article might be disturbing because it seems to reveal an important number of psychological manipulations. But if you look closer, you will see that this phenomenon exists everywhere: at school, in religions, in your local supermarket, at your doctor and of course at your osteopath! We use these techniques without realizing it, but being aware of it, allows you osteopath to increase the effect of the treatment.

The Placebo within osteopathy

It should be remembered that the patient in addition to be in pain, is in a bad mood, he is stressed, anxious to be vulnerable, does not understand what happens to him and might worry whether he will be able to work or even if he will ever recover.

This mindset parasites his ability to be positive and to improve. It is this aspect of the pain that the placebo effect will find its field of action.

The placebo effect is a psychosomatic effect. Therefore all the tricks that will increase the positivity or decrease the negativity towards the osteopath, osteopathy, and the point of view of the patient towards his own pain will have a positive effect on the patient.

We will attempt to define the main axes of the placebo effect during an osteopathic consultation.

1. The feeling towards osteopathy

• to be recommended to see a specific osteopath: the mindset of a patient to whom it is recommended to see a specific an osteopath is totally different than one who is looking for the first osteopath in the yellow pages. The first one will allow himself to wait several days for an appointment while the second will rush at the following number if the therapist is not available in the afternoon. Having followed the suggestion of his friend, the future patient is already conditioned to see a skilled osteopath and know that he will receive a good quality treatment.

• to make an appointment: this is one of the most important steps that the patient will do. He decides to be in charge of himself by coming to see an osteopath. Take such a decision shows that the patient has a "spark of desire" to get better. Because he wants to be there, the patient will generally be pro-active during treatment. The most difficult patients to treat are often patients whose appointment were booked by a third party without their full consent. They do not let themselves go and are not accommodating. They don't want to be here. They wait for only one thing, the end of treatment to tell their friend that the osteopathic treatment didn't change anything.

• the duration of treatment: the fact that treatment lasts at least 30 minutes allows the patient to be listened to, to be understood in their suffering. Just this fact allows the patients to unwind, to let go and to have time to empty their "bag".

• the cost of the consultation: The cost of the product also affects its efficiency! Some people claim that generics are not as effective, it could be because they are cheaper and thus their placebo effect is less. We interpret this as: "Generics are cheaper because they are of poorer quality" instead of "original medicines were excessively expensive". Similarly, the fact that a patient must pay for osteopathic treatment also contributes to a part of the placebo effect. Firstly because it's quite expensive (40-60 £) and secondly in France we do not usually pay for our health. It is obvious that the patient does not want to spend 40£ for nothing, so he will be into a state of mind "I want to get better." Moreover he will respect the treatment and will avoid the next few days to do anything "silly" that could "spoil" the treatment.

• to get undressed: to see the patient in his underwear is important clinically but also it has another advantage. The fact that the patient undresses makes him more suggestible. If a patient tries to establish a relationship such as "parent-child" with the osteopath, then it is very important for successful treatment for this patient not to keep his trousers for example. The fact that he is in his underwear rebalance that relationship to "adult-adult". However, if a patient is shy and force your hand into a relation "child-parent", then after the observation/examination provide a cover, or allow them to keep their trousers, they will feel more at ease and this will certainly improve the response to the osteopathic treatment.

• the principles of osteopathy: principles of osteopathy are simple and "speak" to the patient. They make sense. The patient can identify their problem as a matter of body mecanic. They self-suggest that osteopathy is the therapy that can help them.
  

2. The osteopath

• the practice: is the practice inviting? nice, clear, clean? or is it dark, obscure and looks like a summoning place for dark magic ?
  

• age: age is one factor that may work against the osteopath if he is young and be part of the factors "nocebo". If the osteopath is young and even competent, there's a good chance that the patient, even if he is getting better, will consider that an older ("more experienced") osteopath would have done better.Therefore e wil not be completely satisfied with the treatment.
  

• gender: the gender of the osteopath has an important influence on the treatment. Some women prefer to be treated by women, others by men and vice versa. The fact that the patient consults a male or female practitioner is rarely innocent. When a patient expect to be treated by a female or male practitioner and found out that it is the opposite, it can be problematic. Sometimes the unexpected happens, and this turns out to be benificial: this is called

• Cognitive Dissonance: Cognitive dissonance is a psychological concept developed by Leon Festinger in 1957 in his book "The failure of a prophecy." "Cognitive dissonance is an uncomfortable feeling caused by holding conflicting ideas simultaneously. The theory of cognitive dissonance proposes that people have a motivational drive to reduce dissonance. They do this by changing their attitudes, beliefs, and actions.^[2] Dissonance is also reduced by justifying, blaming, and denying. It is one of the most influential and extensively studied theories in social psychology".(wikipedia). The personal experience the following could be an example: one day I replaced an osteopath at the last minute and he had not had time to warn all patients. One of them was a woman who was violently raped three years previously and obviously this dreadful event was not digested. "She Might Be a little bit upset" he warned me ... When she saw me, she was obviously on the edge of canceling the appointment (perhaps the difficulty of trusting another man, a stranger, and to tell again her traumatic story) but she still accepted the treatment. We mostly worked with cranial and fascial approaches. The following week I heared that she has not felt that well for the last 3 years. Fascial treatment's effect or effect of cognitive dissonance?

• The white coat: The white coat is the dress code of the medical profession. It is a very effective barrier between the patient and the therapist. It constantly reminds the patient that he is dealing with a health practitioner. It is a very effective tool for young osteopath who need the help of a barrier. But such a barrier may also be a hindrance in the therapist-patient relationship.

• Do you have the "gift"?: Tring to show to your patients that you possess the "gift" can be a dangerous game and might be off the limits of ethics but it is a very powerful tool. The patient can be amazed and this effect makes him even more suggestible."The Gift" brings together different "extra-ordinary" abilities (magnetism, clairvoyance, radiesthesia ...). Whether it exists or not is not here the debate. But it is easy to pretend to have such a gift. It is said that some osteopaths can from a cranial hold are able to identify an old ankle injury for example. This can be done without this "gift". Here's how an unscrupulous osteopath could proceed: the patient lies on his back, then the osteopath performs a quick testing of the ankle (it takes 10sec and goes unnoticed). The osteopath locates a restriction, and then places his hands on the skull. After 3 minutes he can claim: "Ooh dear, you have a blockage in your right ankle, an old sprain maybe?". The effect is guaranteed ...

• "Cold reading":(read full facts book of cold reading Ian Rowland) is the ability to understand and "read" a person but also to make him believe we can read him/her. Using such techniques can help the therapist to subdue the patient. The patient is impressed by the "abilities" of the osteopath and this will make him more suggestible. Such techniques should be used carefully ... here are some examples:

1. when the patient describes his pain, he will often simultaneously touch the place that hurts. Without looking directly at the patient, the osteopath can see with his peripheral vision where the patient shows his pain. This information can be restored later to impress the patient, "it is the right knee that hurts you? I saw it at your gate"
2. Trying to make "hits" by asking negative questions: eg "you didn't have any headaches recently, did you?" the Osteopath is almost certain to make a "hit". If the patient answers yes then it is a "hit" and if he says no, he was not wrong!
3. the use of "Barnum statements": These statements are sentences that are true for 90% of patients but will perceive as being personal. For example: "You do have a lot of stress at the moment between work and the family, don't you?"
   

• Comparison with previous therapists: At the end of treatment it is legitimate to wonder whether if previous treatments that the patient had with other practitioners were similar to the treatment you just provided. This maneuver has two objectives: the first one is to get an idea of the approach of your colleagues and the second is to impregnate the patient with the quality of treatment that he just received.

3. Complex psychological pain patient

• the vocabulary used has an influence: in the book "predictably irrational" the author talks about an experiment conducted to evaluate the influence of words on our mood. The experiment was conducted on two groups of people, who were asked to read and memorize a lists of words. In the first group, the words were related to slow, rest, calm... In the second group, the words were synonymous of speed, stress, excitement. At the end of their memory exercise, an experimenter was discreetly timing how long it took them to travel along the corridor to the elevator. You guessed it, people in the first group took longer than the second group to reach the elevator. let' go back to a session of osteopathy: our patient is stressed, tense, on edge, it is clear that a semantic related to nervousness is to be avoided, choose a language rather quiet, sedating and a calming vocabulary.

2. subjective pain: (...). The techniques of trigger points are as effective tools to help the patient perspective the degree of pain he feels normal. These techniques mimic the pain experienced

• Subjectivity and suggestibility of an improvement: this part of the treatment takes place at the end of treatment or early treatment.

1. At the end of treatment: "Helping" the patient to feel changes in his/her body at the end of treatment is very important because it obliges the patient to recognize some efficacy of the treatment he has just received, this opens a door in accepting that some changes just happen and that it can get better in the future. Some patients, less suggestible, take care not to express their feelings.
2. At the start of second treatment: This moment is critical because the patient is not really sure what's better or not. Reevaluate the various movements or habits that were painful can give an idea of the improvement. Then ask him a percentage of improvement in order to show him the side of the "half full glass". The patient who tells you that there was no change (which is different from any temporary improvement) doesn't want to acknowledge the truth, or pays too little attention to his own body.
   

• Body language: be aware of body language and know how to read it. It shows whether the patient is receptive or not and helps to see if an action we do is perceived positively by the patient or not. Once upont the time an expert on body language began a conference in the U.S. by criticizing American mores. After a few minutes he stopped and asked his audience to stay in their body postures and to observe each other. The vast majority had their arms crossed! Crossing your arms or legs are often signs of reserve, or disagreeing. If your patient is lying on the table and hold such a posture, it is likely that it can influence negatively on their responsiveness to the osteopathic treatment. Ask them to "uncross" their legs or arms. It is important for the practitioner to "break" any body language which is in conflict with the treatment.
  

• The suggestion: the treatment can be assimilated to an induction of hypnosis. The patient is in an unusual position (lying naked in the hands of a therapist) and has run through a series of commands (get undressed, lie down, raise your leg, lie on the side ...). This makes him each time more and more suggestible at each one of your demands/commands. An experience told in "Petit traité de manipulation à l'usage des honnêtes gens" was the following: a group of students was asked to address passers for a little bit money. The result was not encouraging. Subsequently the experiment was repeated by asking them to first, ask the time and then ask for some money. They then increased massively their earnings! Acquiescence to the first suggestion makes the patient more conciliatory to the second suggestion ... During treatment it is not uncommon to repeat about 50 times, "you release, relax, let go ...." These suggestions are effective and temporarily break the state of tension and stress of the patient.

• Anchors: Suggestions are often used with anchors. It's actually a Pavlovian reflex. It combines a suggestion with a visual stimulation, touch, smell ... For example you can lightly tap the shoulder of the patient when you ask him to perform movements: like this it combines the "tapping" to respond to a command . Then involve the "tapping" to the command "relax, let go ...." Subsequently You will just have to tap the body part that you want the patient to relax. This is very effective and helps to avoid repeating the same suggestions over and over. Another powerful anchor is the power of smell. Use a cream with a pleasant smell during your treatment. The patient will associate this odor with the feeling of relaxation and being looked after. The products with camphor are a good example.

• correlations between feeling better and the osteopathic treatment: it is interesting to see how we are victims of our desire to find links between causes and effects between events that surround us. If a patient gets better after a treatment, even if it takes a week, provided that the osteopath said: "it will take several days to get better", then the patient will necessarily associate the fact that he is feeling better with the osteopathic treatment. Hasty conclusion ...

• Giving exercices and recommandations: Giving exercises or recommending to place ice pack on the pain can extend the influence of treatment. The patient is following the suggestions of his osteopath (which are effective or not), he is conditioned to be in charge of himself and to have a positive attitude. These are also firewall in case the patient does not improve: the osteopath may ask: "If you did put some ice as I recommended it, your side effects would have been much less important. " The side effects or unresolved problems are not because of the osteopath but because of the patient.

• Nutrition Recommendations: it works on the same principle as the previous examples.

• Warning: Forgetting to warn patients of side effects they might experience is a major mistake. Because knowing that they could have side effects reassure them. If side effects are felt, then the osteopath was right. He really knows his job...
  

Conclusion

If therapy only works in the field of suggestion such as hypnosis or NLP, which is the field of the placebo effect, can call them placebo therapies? of course not, because their field of expertise is suggestion.

If we consider osteopathy as a therapeutic approach strictly manual and mechanical that only treats musculoskeletal dysfonction then in this case, the placebo has a huge role in therapeutic efficacy.

But if the definition of osteopathy is considered as a holistic therapy that comprises a comprehensive care of the patient, in this case osteopathy has no placebo effect since it has expanded its fields of action with that of field of suggestion!

The more a therapist is aware of psychological variables which can influence positively the patient the less the placebo effect is important in treatment.