Prescription: Placebo
Recently I posted about the potential risks associated with taking Turmeric. Turmeric like many herbs, spices, supplements etc. is touted as having magical properties treating and curing dozens of different medical conditions. The literature so far, suggests the opposite, that their is likely no benefit and that there could be some risk as well. The main question that comes to mind when we talk about placebo based treatments like herbal supplements, acupuncture, chiropractic, naturopathy, homeopathy, cupping and other forms of traditional chinese medicines is what is the harm? Like if someone can take a therapy that is proven non-effective and continue to live life, what’s the harm? Why should I be evidence based? Why should I rain on your parade if you find spiritual, emotional or physical comfort in something that isn’t real? As a coach my role is primarily to educate, to teach new habits and to reinforce them, not to deceive my clients, even if the outcome is desirable. So often people chose alternative therapies that are often substantially more expensive because they provide some form of instant gratification or relief. I’m going to discuss why I believe being upfront about these therapies is important and how we unknowingly prevent people from making real change in their life by being silent.
Dr. Fine in his Article “Prescribing placebos” summaries one of the main ethical questions with going the alternative medicine route; “the failure…to engage the patient in an open, honest discussion of risks, benefits and alternatives; in other words, to seek her informed consent”. Consider the notion that if you knew that a therapy wouldn’t treat your symptoms nor it’s underlying condition, cost time and or money and could even have risks, you very likely would not take said treatment. It’s the illusion of success that allows for placebo to be somewhat effective in that individuals perception of their current reality. Like I mentioned above however, this temporary distraction often causes us to ignore underlying causes of symptoms, lifestyle factors, behaviours and real diseases that need to be addressed to offer real sustainable relief.
If we look at the case study in Dr. Fine’s article we have a woman presenting with general fatigue being prescribed Vitamin B12, the B12 won’t do anything but the patient will be satisfied for being heard and treated and will likely perceive feeling better after the injection, a sense of relief. Had the doctor said “I’m going to prescribe you something that won’t help, this injection of B12 has not been proven to treat fatigue, but let’s do it anyways so I get you out of my office and you can get on with your day, likely you’ll feel better due to the placebo effect” The patient will then be informed likely slap both hands on her head and mouth a “W-T-F”.
In this previous blog I posted I talked about Turmeric, I recently had several messages from people claiming to have started Turmeric or Curcumin recently. Most for treating inflammation, a symptom of either an injury, joint or connective tissue disfunction due to improper training or recovery, to reduce stress or to reduce blood pressure, for a list of 10 things people claim Turmeric can treat, despite evidence stating it can’t just check the last blog. In a world of high dopamine stimulation through social media, on demand TV and skip the dishes sent to your door people tend to get impatient with the human body. We get injured, strain a muscle, fall on the ice, have high stress, high BP, cholesterol diabetes, or want to lose fat and we want a solution TODAY. It’s why so many people sign up for group fitness and bootcamps and not personal training or dieticians, they want something that claims to work faster. The same goes for all the pills powders and proteins, people will consume copious amounts of nutritional supplements before they ever take a look at changing the way they eat. Skills are more important than quick fixes or we end up back where we started.
When it comes to the body we have a working self regeneration mechanism, a heal and repair mechanism that happens automatically, somehow inflammation has been painted as this evil boss we need to defeat. The reality is that the appropriate amount of inflammation is key to proper health. “When a wound swells up, turns red and hurts, it may be a sign of inflammation. Very generally speaking, inflammation is the body’s immune system’s response to an irritant.” Inflammation is a normal response to trauma within or on the body.
Here are 6 reasons trauma might not be healing and why it may seem inflammation is prolonged:
Infection
Your skin is your body’s first line of defense against infection. When the skin breaks, it allows bacteria to enter the body through an open wound. Infections in a wound can all but halt the healing process. The body fights the infection, instead of healing the wound. If a wound gets infected, you may notice redness, swelling and pain around the site, as well as puss or foul-smelling fluid. Antibiotic treatment may be used to fight the infection. We can also have auto-immune diseases, STIs and other types of long term illnesses that can flare up and contribute to slower healing and prolonged inflammation.
Poor Circulation
During the healing process, your body’s red blood cells carry new cells to the site to begin rebuilding tissue. Poor blood circulation can slow down this process, making the wound that much longer to heal. Chronic conditions, such as diabetes and obesity, can cause poor blood circulation. Exercising or elevating the wound can help improve circulation.
Poor Nutrition
The body needs an adequate supply of protein to build new tissue, as much as three times the normal daily requirement. Proper hydration is also key in helping wounds heal. Unfortunately, poor nutrition is often overlooked as a reason for wounds that won’t heal. Often we are dieting to lose weight or maybe we don’t consume enough protein, ensuring we are providing substantial material to help the inflammatory process rebuild tissue is essential to recovery.
Diabetes
Elevated blood sugar can slow down a diabetic’s blood circulation and negatively impact his immune system, putting him at a higher risk of infection. In addition, a person with diabetes can have nerve damage, so he may not feel when something is hurting, causing a wound to go unnoticed.
Excessive Swelling
Excessive swelling is caused by fluid accumulating in the skin and can impair the body’s ability to heal a wound by restricting oxygen to the skin. A variety of compression therapies can be used to remove the fluid. Once the swelling goes down, proper wound healing can begin.
Repetitive Trauma
When a person doesn’t change positions often and a wound is subject to repetitive trauma or pressure, it can lengthen or even stop the healing process due to a slow down of blood circulation. Paraplegics, spinal cord injury patients or those on bed rest are at a greater risk for repetitive trauma. Joint malformations, injuries and arthritis will be exacerbated by repetitive use, changing your behaviour and reducing load, frequency and/or intensity will be key to bring down the swelling.
Stimulants
Additionally, stimulants like caffeine and even ADHD medication are pro-inflammatory; meaning if you have pre-existing inflammation due to injury, disease or trauma, inflammation will be increased.
Looking at those 7 headlines above, remember inflammation isn’t the enemy, I really believe inflammation is the new “Free Radicals/Toxins” in 2022. People need these buzzwords for marketing and as we can see with Turmeric, Curcumin and other products, inflammation sells treatment plans. Companies brandish these buzzwords without acknowledging disease mechanisms and underlying conditions.
So why do I care?
Probably the most selfish reason I care about alternative therapies, placebo based treatments and interventions that mimic progress is that my goal as a coach/trainer/gym owner would be to promote healthy and sustainable habits, to get clients healthier with EBP — Evidence Based Practice, EBP is a process used to review, analyze, and translate the latest scientific evidence. This means the programs, supplements, and dietary interventions we prescribe to our clients are not based on anecdote alone but on the latest scientific literature, robust clinical trials and placebo controlled studies. We need to control for our internal biases as well. Just because we perceive something helps, what benefit or harm could come from suggesting someone else goes that route vs. what is proven. A great example of being misled by marketing is the idea that something can be “clinically proven” this is not to be confused with a clinical trial or scientific study. Clinically proven simply means that consumers tried the product full stop. This doesn't mean the product is ineffective however clinically proven is a marketing claim and not a proof of efficacy. Our job as coaches is to educate and inform clients, teach healthy habits and modify behaviour.
By now you should start to see the lack of benefit in so many popular trends but also see the harm in prescribing non-effective treatments to either appease clients, shut them up or give them hope. We can take a look at what I call the Waiting room phenomenon — imagine you’ve that both you and a friend are moving a fridge, one of you slips and you both tweak your back quite severely, it hurts, enough you both go to the ER. In Manitoba our wait times are 8–12 hours, but imagine you’re in any hospital and you’re both waiting in the emergency waiting area for some sort of relief. Whoever eventually gets the call first, will instantly feel a sense of relief, this will automatically translate into a reduction in pain as you’re body produces dopamine in response to moving from the waiting area to the examination room. Alternatively you’re stuck waiting longer, becoming more sore over time, stuck sitting in an uncomfortable chair with no end or relief in sight. This idea is how almost all alternative treatments are therapies work, any intervention is better than no intervention from a psychological standpoint and also a brain chemistry standpoint. Pair this notion of relief with whats called “regression to the mean”. What this means is that over time, the more data we collect the more we tend to see a trend towards the mean, basically the middle or average, this can be confused for real manipulation of the data or a real result. Another way we see regression to the mean is the idea that over time, a system will return to homeostasis. The 3 priciples before you are how therapies like acupuncture, chiropractic, reiki, cupping, continue to sell appointments, over time injuries heal, the patients just doesnt realize they would have healed without spending exorbitant amounts of money on alternative medicine. Reminder, there is no alternative to medicine. Most, not all, supplements rely on this similar notion that you either get better over time, or you have paired it with a new lifestyle change like diet and exercise. So watch for whether or not the supplement you chose has years of robust literature and substantial anecdote before taking it.
So let’s inform our clients about the risks of taking non evidence based supplements, workouts and treatments and instead promote the basics. There are no secrets and no shortcuts, eat more protein lift weight 2–5 days a week and prioritize recovery and you’ll make all the progress you seek without the potential risks, additional costs and tire spinning involved with interventions that just don't cut it.