PSYCHOLOGY AND PHYSICAL THERAPY

Dr Chris Beedie, Phd and James Hopker, BSc.

IMPLICATIONS FOR THERAPISTS The problems faced by a physical therapist attempting to review the literature on the placebo effect to improve her or his prac- tice, are compounded by what seems like a vast array of diverse effects of varying magnitudes. In part one we focused on the placebo effect in relation to one of the key components of physical therapy - pain reduction. In a recently published theory of the placebo effect, Dylan Evans (1) argues that the placebo effect results from the function of the immune system, specifically the acute phase. This phase is responsible for such phenomena as initial pain and inflammation, (he also suggests that several mild psychological disorders such as anxiety may be placebo respon- sive via the same pathways). Evans pro- poses that the placebo effect functions by limiting the action of the acute phase response (which he sees as almost a ‘quick and dirty’ response), allowing the more effective acquired immune response to function and therefore promote healing. The root of Evans’ compelling argument is that the placebo effect will not function in any situation that is beyond the capac- ity of the immune system. Evans, in fact, supports this argument by calling into question some of the grander claims made on behalf of the placebo effect, such as a placebo-induced cure of cancer. If Evans is correct and the placebo effect is limit- ed to pain and inflammation, how can it be utilised by physical therapists?

PAIN AND INFLAMMATION IN PHYSICAL THERAPY Musculoskeletal pain and loss of function due to inflammation are commonly pre- sented complaints by athletes following injury. Most acute injuries are charac- terised by bleeding immediately following the injury. In a moderate to severe mus- cular injury, a haematoma may form with swelling evident within minutes of the occurrence. Cellular injury results in altered tissue metabolism, liberation of material such as leukocytes and other phagocytic cells, and exudates that initi- ate the inflammatory process. If this is left untreated a significant haematoma will be visible within minutes. This inflammatory phase may continue for 48- 72 hours following the injury and is cru-

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In part one of this article (sportEX dynamics issue 4), we reviewed some of the literature relating to the placebo effect, especially in relation to pain and inflam- mation. The placebo effect is a favourable outcome arising from a patient’s belief that they have received a beneficial treatment even though they haven’t. In part two below, we suggest how the placebo effect may be used to enhance or augment existing therapies.

cial to the entire healing process. Therefore the goal of early stage treat- ment is to limit internal bleeding, swelling and subsequent pain as much as possible in order to improve conditions for subsequent treatment and healing of the injury. High levels of swelling may result in a delay in the initiation of the fibroblastic repair phase and laying down of new tissue due to the amount of cellu- lar debris to be removed. However, if this response does not accomplish what it is supposed to, or if it does not subside, normal healing cannot take place. Therefore, management of pain and

influenced by a variety of biopsychosocial factors such as beliefs, the patient- practitioner relationship, the treatment

inflammation should be designed to enhance the healing process within the time frame required for this part of the process. Pain and inflammation have a fundamental impact on the athlete, over and above the injury itself, because they limit participation, which in itself can lead to problems such as de-training, reduced confidence and loss of

identity.

The management of pain and inflamma- tion is complex and usually consists of several forms of therapy being used con- currently. Typically physical therapy approaches such as ice, electrophysical agents, manual techniques, and interven- tions to change pain-provoking movement patterns, are methods of choice. Patients are also given pharmacological agents such as anti-inflammatory drugs (eg. ibuprofen) to help reduce swelling and pain and therefore promote healing.

IMPLICATIONS FOR PRACTICE From the evidence presented in part 1 it is clear that therapeutic outcomes can be

setting and the client’s confidence in the treatment and therapist. It might be argued that placebo effects are most evident when the patient is anxious (see end of article) or in pain from their injury. The therapist is perceived to have exper- tise and effective technology at her/his disposal, and the patient and therapist believe the treatment will work, and produce positive outcomes on patient

health. Perhaps most importantly, thera- pists need to accept that what they may feel as unimportant factors in the delivery

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