Anyone who has watched any sport in the last few years will be aware of Kinesio Tape (KT). It’s the coloured tape that athletes wear to recover from/prevent injury. I really noticed it in the 2012 Olympics, when it seemed that every second athlete had some on, and it is still extremely prevalent.
Manufacturers of the tape claim it can alleviate pain, reduce inflammation, relax muscles, enhance performance, and help with rehabilitation as well as supporting muscles during a sporting event. Furthermore, it can be used for hundreds of common injuries such as lower back pain, knee pain, shin splints, carpal tunnel syndrome, and tennis elbow, just to name a few. And all of this for as little as £8 per roll.Any product that claims to have such wide-ranging benefits deserves some scrutiny. So what evidence is there for KT effectiveness? Well, surprisingly little. In the last three decades there have been nearly 100 papers published regarding KT. In 2014, Australian scientists reviewed that literature and published their findings in the Journal of Physiotherapy. The paper was entitled: “Current evidence does not support the use of Kinesio Taping in clinical practice: a systematic review”, and the title says it all. They reported that “Kinesio Taping was no better than sham taping/placebo”. Furthermore, in studies that did show an effect of KT, the scientists found that either the effect was tiny and probably not clinically significant, or that the trials were of low quality.A second review in 2013 concluded that “there currently exists insufficient evidence to support the use of KT over other modalities in clinical practice”. It is pretty clear that KT does nothing that ordinary tape doesn’t do.So it’s no better than standard taping; but what does standard taping do? Again, the literature is pretty mixed on this. There is some evidence that taping an injured muscle may help it perform better, just like a brace. It is also thought to offer slight pain relief by structurally supporting a joint, however, a brace is more effective. There is also some evidence that it can improve proprioception (the awareness of where a limb is in space without looking), but this is disputed. Ultimately, taping can help with an injured joint or muscle, albeit in a minor way.So given that using gaffer tape works just as well as KT, why is it that sportspeople spend the extra money on expensive KT? Marketing is the obvious answer. In both the 2008 and 2012 Olympics, Kinesio Holding Co. donated huge amounts of tape to the US Olympic Committee. American beach volleyball player Kerri Walsh embraced the product and the company saw a 300% rise in sales in the immediate aftermath.
Selling to athletes makes perfect sense really. They are well known to be a superstitious group of people, and those superstitions can help them perform better. Michael Jordan played every single game of his career in the same pair of shorts from the University of North Carolina. Serena Williams never changes her socks during a tournament. In the arena of elite sport, small margins can be the difference between winning and losing, so the placebo effect of a particular ritual can be decisive.Ultimately, Kinesio Taping is just the latest in a long list of products that sports people have embraced because they thought it gave them the edge (who remembers those white strips that people used to put on their noses to make it easier to breathe?). Ironically, although these products themselves do nothing, the belief that they do may have a minor effect. Unlike other pseudoscience I have written about, this isn’t a particularly harmful one. So if someone wants to spend their hard-earned cash on magic tape, who am I to object?!
Alternative medicine as a placebo
I recently wrote a post about the decision by NICE to no longer recommend acupuncture for lower back pain. This decision was made because, like most alternative medicine, acupuncture hasn’t been shown to work any better than a placebo. However, plenty of people use and get benefit from such treatments. This raises an interesting question: is there a place for complementary and alternative medicine (as a placebo) in the clinic?
The ethics of prescribing placebos is a complicated topic. People are perfectly entitled to use alternative medicine, and if they get a benefit, that’s obviously good. However, whether a doctor should prescribe alternative medicine is a different matter.As I have previously written, most complementary and alternative medicine works purely on the placebo effect. People argue that alternative medicine should be allowed to be prescribed, because if the placebo effect helps someone, then that justifies its use. Indeed, here in Glasgow we have an NHS funded “homeopathic hospital”, and if it helps people, why should we stop that?Unfortunately it’s not that simple. If a doctor prescribes such a therapy, it has the effect of offering a medical credibility to the therapy that doesn’t work. This may not sound like a big problem, but it is. There are many examples of people eschewing mainstream medicine for “natural” alternatives and herbal remedies.A court in Canada, for example, recently convicted the parents of a child who died from meningitis after they consulted a naturopath rather than a medical professional. The naturopath recommended the parents give ecinachia to their dying child. This isn’t an isolated case; it’s worth visiting the What’s the Harm website to see the toll that belief in pseudoscience can have.The reality is that if a doctor prescribes acupuncture for pain, then a patient is more likely to believe the plethora of false claims that an acupuncturist may make (including it being effective against diabetes, heart attacks, cancer and even ebola). This in turn increases the risk of patients postponing or declining evidence-based conventional treatment when it is needed. It was recently shown that women who were using certain alternative therapies were less likely to start chemo for their breast cancer. Regardless of whether someone benefits from the placebo effect given by an alternative therapy, it is simply not ethical to legitimise it as a practice. Furthermore, it is perfectly possible to give a placebo that does not come with the added nonsense, which brings me on to my next point.In 2008, the American Federal Trade Commission made a ruling on the use of the Q-Ray Ionised Bracelet in medicine. The makers argued that they could claim it was a cure for chronic pain because, like acupuncture and other alternative medicine, it exhibited the placebo effect. In his ruling on the case, the judge said the following:
“Like a sugar pill, it alleviates symptoms even though there is no apparent medical reason. Since the placebo effect can be obtained from sugar pills, charging $200 for a device that is represented as a miracle cure but works no better than a dummy pill is a form of fraud.”
When we can get the same or similar effects from a far cheaper placebo, then a doctor prescribing alternative medicine is ripping off their patient or the NHS. With already stretched resources, it is scandalous that the NHS pays £1.33 million per year to the Glasgow Homeopathic Hospital. People spend a huge amount of money on alternative medicine (it’s a $34 billion industry in the US), a product that doesn’t work, and is also completely unregulated.The unregulated nature of the industry is something that people are generally unaware of. Numerous studies have shown that alternative remedies regularly contain contaminants like toxic metals, pharmaceuticals, insects, rodents, parasites, fungi, pesticides and other fillers. These contaminants have led to serious illness is many cases, and several deaths. Prof. Edzard Ernst (former Chair in Complementary Medicine at the University of Exeter) has written extensively about this topic and is a good place to look for more information.The placebo effect has a significant role to play in health care. It can undoubtedly improve subjective symptoms in a number of contexts. However, while any effect alternative medicine has can be explained by placebo, the industry claims that it does much more than that. Couple this with the unregulated nature of the products and the expense involved, and it is clear that alternative medicine should never be given legitimacy by the mainstream medical community. I’ll leave you with this quote from Tim Minchin:
"By definition", I begin"Alternative Medicine", I continue"Has either not been proved to work,Or been proved not to work.Do you know what they call "alternative medicine"That's been proved to work?Medicine."
https://www.youtube.com/watch?v=HhGuXCuDb1U
The placebo effect
The recent decision by NICE to no longer recommend acupuncture for lower back pain got me thinking about the placebo effect. It is a bizarre phenomenon: any treatment (regardless of whether it is a real treatment or not) will improve symptoms in some people simply because the recipient believes that it will work. So if we give someone a placebo (a sugar pill for example) and tell them that it can work for their illness, a proportion of patients will feel better. There are so many interesting things about the placebo effect it’s difficult to know where to start.The more the placebo, the bigger the effectTake this observation: if we give someone sugar pills as a placebo, then they might see improvement in their symptoms. However, if we give them four sugar pills instead of two, then we will see a bigger improvement. And if a placebo injection is used, then this is more effective again.It matters what a placebo looks likeSugar pills with a brand name stamped on them will have a stronger placebo effect than those that don’t. Researchers have also found that sugar pills with a $2.50 price tag ease pain much more effectively than identical pills with a10 cents tag. We actually see the same effect with wine; people rate a wine highly if they think it is more expensive.You don’t necessarily have to deceive peopleBizarrely, there is still a placebo effect even when the patients know they are getting a placebo. When researchers told people who were on a trial for an irritable bowel syndrome that they were receiving “placebo pills made of an inert substance”, they found that patients still experienced a reduction in symptom severity, even though they knew they were on a placebo. In another study, researchers gave patients a fake pain-relieving gel for 4 days, and then told them the truth, that it was it was actually just dyed vaseline. However, the pain relieving effect still persisted after this, suggesting that conditioning is part of this effect.The placebo effect is getting stronger with timeResearchers analysing 20 years of clinical trials for pain have noticed a weird pattern: the placebo effect has been increasing over that time (but only in the US). Several explanations for this have been suggested, including that patients are getting more attention and encouragement now compared to the past, so their overall experience in the trial is better. It has also been pointed out that over this time pharmaceutical companies have turned to private companies to run their trials. As these companies are paid to recruit more people, they may inadvertently include less ill patients on the trial in order to boost numbers. This has been shown to result in an apparent treatment effect in patients, contributing to the placebo effect.There is a placebo effect on animalsThis is a really confusing one: animals experience the placebo effect! If this effect is driven by the expectation that the treatment will work, how do we explain that? More about that below.Placebos can cause side effectsWhen patients are aware of the side effects of a treatment, they can also experience these while on placebo. For example, if a patient has previously taken opioid pain relief (one related to opium, such as morphine, codeine or vicodin), which can result in respiratory depression, they are then more likely to experience the same symptoms when on a placebo. Furthermore, if someone has been on hormone replacement therapy (HRT) placebo and this is then discontinued, they can experience the same withdrawal symptoms as someone who has actually been on HRT.And placebos aren’t just a medical thingThe placebo effect exists in other areas of life too. After drinking placebo vodka, people’s IQ drops and they have impaired judgement. This is demonstrated with predictably funny results in a video of a non-alcoholic keg party that you can find here.The above examples all point to the fact that while the placebo itself is an inert substance, it can still result in real physiological effects through suggestion, expectation and other mental processes.We really don’t have a good grasp on how the placebo effect works. We know that it usually affects subjective symptoms like pain, depression, hot flushes, and insomnia, but that it very rarely improves the underlying disease mechanisms. Survival from serious forms of cancer has little observable placebo effect for example. However, we do know that it is made up of a mix of different biological and psychological factors.First and most obvious of these is that mood and belief can have a significant effect on subjective symptoms, both through our perception of those symptoms, but also through real biological mechanisms. When studying the placebo effect in pain research, scientists found that a drug called naloxone, which inhibits opioids, could also inhibit the placebo effect, suggesting that placebo and opioid pain relief share a common mechanism. Other scientists then used brain imaging to suggest that placebo and opioid pain relief both seem to work via the same pathways in the brain, showing that for pain relief at least, part of the placebo effect is caused by a real biological mechanism.Such biological mechanisms are also at play in systems where mood really matters. The placebo effect can lower the release of stress hormones (through altering someone’s mood) and as such can have an effect on the heart and the immune system. The influence of a placebo in this context is mild, but almost certainly real.These biological explanations are in the minority however; it is thought that most of the placebo effect is as a result of cognitive biases that we are all prone to. Before I get into that however, I will point out that, placebo or not, if someone feels better after taking something, then it may have legitimate use in medicine. I won’t address this issue here, but will in my next post on this blog. The use of alternative medicine falls into this category, and is an interesting topic.Back to the placebo effect; the most common cognitive bias that falls into this category is called regression to the mean. The many so-called “cures” for the common cold (echinacea, hot lemon, etc.) are a great example of this. We can show that these none of these remedies have any effect above the placebo. However, when people get better they credit whatever treatment they have taken for this natural improvement in their symptoms. Often, by the time someone starts their herbal remedy (or whatever they decide to go with) their body has already dealt with the illness and they are on the mend. It is very natural for us to see cause and effect where there is none, but most improvements like this are as a result of the placebo effect, specifically regression to the mean.The animal placebo effect mentioned above can be explained by another bias we are prone to called the caregivers effect. This occurs because animals cannot directly report their subjective symptoms, so people have to observe the animals and decide whether they are responding to the therapy. Often, the humans will perceive improvement even when objective measures show none.In human trials, other biases occur. People taking a treatment want to get better and want the time and money they have invested to be worthwhile, so when they are asked to rate their symptoms, they tend to over-estimate their improvement. This is known as reporting bias, and also affects scientists, who want their treatments to work and will tend to over-estimate the positive effect in their trial.It is also known that simply being in a clinical trial can contribute to the placebo effect. Participants tend to take better care of themselves than normal, and also get more medical attention than people not in trials. This causes improvements in people on the trial, not because of any biologically “real” placebo effect, but simply because they are part of the trial. This is known as the clinical trial effect.The placebo effect is an incredibly fascinating thing. It shines a light on how much we do not understand about our bodies, but also on how much tricks of the mind can affect our perception of ourselves. I began this article by talking about acupuncture, but the role of the placebo effect in alternative medicine is not one I will address in this post. However, I will tackle this, and the question of whether it is ethical to prescribe a placebo, in my next piece on this topic.
