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PPP Management How to help PPP patients.

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Old 22-01-2012, 02:30 AM   #1
Diane
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Default Placebo - again. (Yes.. I know..)

My head gets sore sometimes from being pulled this way then that way about what placebo is, if it's something to be avoided, shunned, ridiculed, or embraced, worked with, understood at last.

Medical research kinda depends on making it the bad guy in every case, so that the "active" ingredient in the drug, or the "efficacy" of the treatment approach, can be selected out and highlighted and taught to the next generation of whoever.

As human primate social groomers we beat ourselves up a lot for mostly failing to be able to isolate it. But really, we can't - our patients are awake, and they all have expectations. And nothing happens unless a favourable treatment context is carefully built.

Plus, the medical profession still operates under the assumption that pain is an input to the brain, not an output by the brain. This gives license to a vast array of mesodermalists who continue to not only ignore a wideangle view of pain, but insist that its "generated" by their favorite tissue, whatever it may be: joints for the orthos, fascia for the fascists, craniums and cerebral spinal fluid rhythm irregularities for the cranialists, triggerpoints for the pokers, muscles for the massagers, etc., etc. You get the drift.

So.

Meanwhile, people are hurting and are fed up. They've organized themselves into patient advocacy groups. They incorporate pain researchers right into their ranks, and invite them to speak directly to them, the pain patients, without the information having to filter all the way through the medical profession and all the human primate social grooming professions first. Which I completely support. It's called self-empowerment, or something. This is a great example: it's a free webinar next month, featuring one of Canada's finest researchers, Catherine Bushnell, organized and cosponsored by by the Canadian Institute for Relief of Pain and Disability, the Canadian Pain Coalition, and Pain BC: Out-thinking Pain:How the Mind can Control Pain.

It looks great.

So, here's something I just finished posting on Facebook on one of Paul's threads about placebo:

What if it were this simple?
Placebo = match
Distraction = dry kindling
Descending modulation = firewood
The process itself = fire
The relief at the end = the ashes.
The thing is, there has to be preparation and education (a plan to lay the fire, knowing it's been laid, knowing there is sufficient wood supply) and a therapeutic context (somewhere dry enough and out of heavy wind), and someone to start the process.

But the match. Nothing will happen without the match.
That's what I think today, about placebo, defined as expectation, in conscious people who would prefer to not have pain.

If there is not enough wood, i.e., if there is a pain syndrome that is sufficiently entrenched or genetically determined as to be beyond simple help from a manual therapist, then ... the fire might light but it will burn out pretty fast.

If I think of anything else, I'll add.
If others think of anything I missed, please add.

Link to long placebo study thread
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"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

“Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

"In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

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Last edited by Diane; 22-01-2012 at 04:06 PM. Reason: add link
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Old 22-01-2012, 04:36 AM   #2
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I've been considering what role manual contact would play, to complete the metaphor. It's not always required, but it often helps. I think I would peg it as the adding of oxygen, by fanning the fire, or blowing it gently into fuller existence.
It helps, but it can't really take the place of any of the other ingredients, which are all intrinsic to the patients.
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"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

“Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

"In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

"Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire
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Old 22-01-2012, 06:05 AM   #3
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Blogpost, Pain and Fire.

Barrett, I remember when you wrote about this a decade ago. I did not get it back then. I just got it.
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"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

“Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

"In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

"Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire
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Old 22-01-2012, 10:23 AM   #4
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Quote:
Originally Posted by Diane View Post
blowing it gently into fuller existence.
"Blowing out fire" still exists in Europe
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Old 22-01-2012, 12:59 PM   #5
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Diane, Wonderful post.

It Might Only Be Glowing is the essay to which you refer.

I didn’t write it ten years ago – it was fifteen.
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Old 22-01-2012, 03:05 PM   #6
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I guess that well-written little essay managed to squeeze it's way into some little spot and drip into my brain all these years. Drip enough fire accelerant in there and things may eventually light up, I suppose.

I remember it didn't make sense to me at the time other than metaphorically. I didn't have enough information yet about brain and pain processes for it to lay itself out. Now I do, and it does.
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"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

“Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

"In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

"Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire
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Old 22-01-2012, 03:36 PM   #7
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Diane

I didn't know much either, certainly less than you.

I let the poet lead me, and that often works. Not always. But David Whyte has never led me astray.

I've written elsewhere of ideomotion as a "controlled burn." I'll see if I can do that again.
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Old 22-01-2012, 03:43 PM   #8
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Here’s something and here’s something more.
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Old 22-01-2012, 03:58 PM   #9
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Quote:
Originally Posted by Barrett Dorko View Post
Diane

I didn't know much either, certainly less than you.

I let the poet lead me, and that often works. Not always. But David Whyte has never led me astray.

I've written elsewhere of ideomotion as a "controlled burn." I'll see if I can do that again.

I suspect ideomotion is a subset of controlled burn, but that they don't necessarily equate. In other words, using the fire-putting-out-pain metaphor, maybe ideomotion is outward expression of something the patient has to do inside his or her own brain, that might help harness their own brain parts to the task. But it isn't the actual burn itself.

I'm reading (slogging really) through this (full access BTW) paper this morning:
Dopamine, Affordance and Active Inference
(I found it posted at Facebook in one of the neuro sites/groups I've wiggled my way into. Don't remember exactly which one it was.)

Anyway, it's fascinating. Dopamine is the accelerant to everything. Whichever part of the brain gains control of the flipswitch to the dopamine dripper, will rule movement, and/OR perception. At least that's what I'm getting from it so far.
It's a 20-page paper and I'm only on page 5 so far. It's slow going, with side trips to learn what Bayesian theorem is.
From the paper page 2:
Quote:
The Bayesian perspective suggests that there are only two sorts of things that need to be inferred about the world; namely, the state of the world and uncertainty about that state.
I think that this means being stuck forever looking out (from one's own "umwelt") at "umfeld", and knowing you'll never know if it's close to being "umgebung". (From this.)
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"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

“Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

"In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

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Old 22-01-2012, 04:02 PM   #10
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Quote:
Originally Posted by Barrett Dorko View Post
Here’s something and here’s something more.
Wag Dodge. Right. I remember that. We have to create a context for our brains to WagDodgify our pain problems. As human primate social groomers we have to teach others how.
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"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

“Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

"In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

"Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

Last edited by Diane; 22-01-2012 at 05:36 PM. Reason: meaning clarification
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Old 22-01-2012, 05:33 PM   #11
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Another blogpost: Is placebo like gravity?

Quote:
So.. I'm thinking lately that manual therapy will never be able to eliminate placebo from its work. As a commenter (Natalie Shaw) pointed out today on Facebook, it's kinda like gravity. You barely notice it's there. Which made me think about the craziness of a culture demanding that you must take everything out into outer space to weigh it, so that gravity (placebo) is eliminated. How Balnibarian is that? How tooth-fairy supportive is that?

What's worse is a culture that says, OK, if you can't do that, then we accept all sorts of ideas that aren't even plausible. From Science-based Medicine blogpost by Harriet Hall,
VISCERAL MANIPULATION EMBRACED BY THE APTA



Placebo (in my own humble opinion) is a patient's attitude, readiness: it's in every awake person, every conscious human; it's there all the time, including for something as supposedly as objective as surgery (see comment by ErikMeira in the same SBM thread, Jan 20th).

Viewing it as a confound when building an evidence base for manual treatment (especially for manual treatment of live, conscious, hopeful people) is really counterproductive. I think placebo would be best framed as a match the *patient* might use to ignite his/her own recovery, regardless of treatment.

The corollary of this is that all manual therapy (regardless of kind), or maybe medical treatment too, assists, maybe blows on the flame a bit. Too much is counterproductive, might extinguish it.

Everything a patient needs for combatting nuisance pain is already right there inside their own nervous system. A good human primate social groomer will realize this (however instinctively, non-consciously); he or she will cheerfully step outside his/her own ego to help somebody build whatever fire they need to build to burn off their own pain problem.
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"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

“Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

"In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

"Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire
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Old 22-01-2012, 09:09 PM   #12
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Here is one of the Facebook threads that started my current placebo headache/headache about what it all means. This one too.
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"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

“Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

"In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

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Old 21-09-2012, 08:01 PM   #13
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Default Is TENS Just a Placebo for Chronic Pain?

Is TENS Just a Placebo for Chronic Pain? from Pain-Topics.org.

Yes, I should think so. Very much.
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"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

“Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

"In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

"Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire
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Old 21-09-2012, 10:34 PM   #14
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Probably a more effective placebo than ultrasound because the patient feels it doing 'more good' with its little buzz.

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Old 26-10-2012, 02:55 PM   #15
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http://video.google.co.uk/videoplay?...10193400691959

hadn't seen this before ---excellent ...
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Old 01-11-2012, 03:34 PM   #16
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"Placebo: Cracking the code" - 52 minutes. Excellent.

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"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

“Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

"In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

"Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire
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Old 02-11-2012, 07:01 PM   #17
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The Influence of the Therapist-Patient Relationship on Treatment Outcome in Physical Rehabilitation: A Systematic Review

In this systematic review from 2010, Amanda Hall et al discuss non-specific effects related to physical therapy treatment.

Quote:
Background The working alliance, or collaborative bond, between client and psychotherapist has been found to be related to outcome in psychotherapy.

Purpose The purpose of this study was to investigate whether the working alliance is related to outcome in physical rehabilitation settings.

Data Sources A sensitive search of 6 databases identified a total of 1,600 titles.

Study Selection Prospective studies of patients undergoing physical rehabilitation were selected for this systematic review.

Data Extraction For each included study, descriptive data regarding participants, interventions, and measures of alliance and outcome—as well as correlation data for alliance and outcomes—were extracted.

Data Synthesis Thirteen studies including patients with brain injury, musculoskeletal conditions, cardiac conditions, or multiple pathologies were retrieved. Various outcomes were measured, including pain, disability, quality of life, depression, adherence, and satisfaction with treatment. The alliance was most commonly measured with the Working Alliance Inventory, which was rated by both patient and therapist during the third or fourth treatment session. The results indicate that the alliance is positively associated with: (1) treatment adherence in patients with brain injury and patients with multiple pathologies seeking physical therapy, (2) depressive symptoms in patients with cardiac conditions and those with brain injury, (3) treatment satisfaction in patients with musculoskeletal conditions, and (4) physical function in geriatric patients and those with chronic low back pain.

Limitations Among homogenous studies, there were insufficient reported data to allow pooling of results.

Conclusions From this review, the alliance between therapist and patient appears to have a positive effect on treatment outcome in physical rehabilitation settings; however, more research is needed to determine the strength of this association.
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"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

“Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

"In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

"Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire
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Old 02-11-2012, 07:02 PM   #18
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"The relationship between patient and therapist traditionally has been viewed as an important determinant of treatment outcome and is considered central to the therapeutic process.1,2 More recently, this concept has been evaluated in research studies, where it is commonly referred to as the therapeutic alliance, helping alliance, or working alliance.3 For simplicity, this review will refer to this construct as the alliance."
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Old 02-11-2012, 07:29 PM   #19
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Hi Barrett!

Quote:
humans, if not all animals, tend toward less certain reactions to mechanical stress
I really like this.

As Mel used to remind me:

"Asymmetry of action is the rule, rather than the exception in all sports."

It amazes me how many still don't get this.
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Old 13-11-2012, 11:45 PM   #20
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Caro found the paper about the boy with the congenital skin condition that went away with hypnosis, discussed by his doctor in the video from post 16, cracking the code.

A CASE OF CONGENITAL ICTHYOSIFORM ERYTHRIODERMIA OF BROCQ TREATED BY HYPNOSIS, by AA Mason, 1952

N=1. But it's good it was written up.
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Old 22-11-2012, 07:34 AM   #21
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Default Placebo Analgesia Affects Brain Correlates of Error Processing

Placebo Analgesia Affects Brain Correlates of Error Processing.
This is open access PLoS1. They measured exteroceptive nociception. Placebo was a capsule.

Quote:
Placebo analgesia (PA) is accompanied by decreased activity in pain-related brain regions, but also by greater prefrontal cortex (PFC) activation, which has been suggested to reflect increases in top-down cognitive control and regulation of pain. Here we test whether PA is associated with altered prefrontal monitoring functions that could adjust nociceptive processing to a mismatch between expected and experienced pain. We recorded event-related potentials to response errors in a go/nogo task during placebo vs. a matched control condition. Error commission was associated with two well-described components, the error-related negativity (ERN) and the error positivity (Pe). Results show that the Pe, but not the ERN, was amplified during placebo analgesia compared to the control condition, with neural sources in the lateral and medial PFC. This Pe increase was driven by participants showing a placebo-induced change in pain tolerance, but was absent in the group of non-responders. Our results shed new light on the possible functional mechanisms underlying PA, suggesting a placebo-induced transient change in prefrontal error monitoring and control functions.
Iain McGilchrist says, in his book, page 35,
Quote:
"Imaging shows just a few peaks, where much of interest goes on elsewhere. One cannot assume that the areas that light up are those fundamentally responsible for the ‘function’ being imaged, or that areas that do not light up are not involved. And, what is more, one cannot even assume that whatever ‘peaks’ is of primary importance, since only effortful tasks tend to register - the more expert we are at something the less we will see brain activity. For example, people with higher IQs have lower cerebral metabolic rates during mentally active conditions; as do those with bigger brain size which is correlated with IQ. We have, too, to remember that the activations we visualize in the brain may actually be inhibitory in nature - inhibition may be indistinguishable from activation using current fMRI methods."
I'll have to read this slowly and over again to extract any meaning. There is a lot there to wade through though. So I except there will be something of use to extract. There is a nice reference list, at least!
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“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

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Old 24-12-2012, 06:22 PM   #22
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A nice juicy article in Harvard mag, about Ted Kaptchuk (Web that has no Weaver) and his subsequent work in placebo research. The Placebo Phenomenon

He has done quite a bit to deconstruct the phenomenon by the sound of it.
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Old 10-03-2013, 08:56 PM   #23
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Hot off the press: "Scientists Decipher the Healing Powers of Placebos"

Get your red-hot, non-specific treatment effects, right here.
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“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

"In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

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Old 11-03-2013, 01:30 AM   #24
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I can't read the whole article. Is it worthwhile or just a catchy sensationalist title?
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Old 11-03-2013, 01:34 AM   #25
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Weird - it was full print when I posted it. Sorry! I'll try to fix.
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Old 12-03-2013, 05:21 PM   #26
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The link goes to the full article again, Erik.

Here is another: "Psychiatrists, Instead of Being Embarrassed by Placebo Effect, Should Embrace It, Author Says"
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Old 14-03-2013, 08:12 PM   #27
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As a follow up.

A Harvard magazine article on Ted Kaptchuk and his latest placebo study, mentioned in the Scientific American article.

Quote:
Two weeks into Ted Kaptchuk’s first randomized clinical drug trial, nearly a third of his 270 subjects complained of awful side effects. All the patients had joined the study hoping to alleviate severe arm pain: carpal tunnel, tendinitis, chronic pain in the elbow, shoulder, wrist. In one part of the study, half the subjects received pain-reducing pills; the others were offered acupuncture treatments. And in both cases, people began to call in, saying they couldn’t get out of bed. The pills were making them sluggish, the needles caused swelling and redness; some patients’ pain ballooned to nightmarish levels. “The side effects were simply amazing,” Kaptchuk explains; curiously, they were exactly what patients had been warned their treatment might produce. But even more astounding, most of the other patients reported real relief, and those who received acupuncture felt even better than those on the anti-pain pill. These were exceptional findings: no one had ever proven that acupuncture worked better than painkillers. But Kaptchuk’s study didn’t prove it, either. The pills his team had given patients were actually made of cornstarch; the “acupuncture” needles were retractable shams that never pierced the skin. The study wasn’t aimed at comparing two treatments. It was designed to compare two fakes.
...


But researchers have found that placebo treatments—interventions with no active drug ingredients—can stimulate real physiological responses, from changes in heart rate and blood pressure to chemical activity in the brain, in cases involving pain, depression, anxiety, fatigue, and even some symptoms of Parkinson’s.
The challenge now, says Kaptchuk, is to uncover the mechanisms behind these physiological responses—what is happening in our bodies, in our brains, in the method of placebo delivery (pill or needle, for example), even in the room where placebo treatments are administered (are the physical surroundings calming? is the doctor caring or curt?). The placebo effect is actually many effects woven together—some stronger than others—and that’s what Kaptchuk hopes his “pill versus needle” study shows. The experiment, among the first to tease apart the components of placebo response, shows that the methods of placebo administration are as important as the administration itself, he explains. It’s valuable insight for any caregiver: patients’ perceptions matter, and the ways physicians frame perceptions can have significant effects on their patients’ health.
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Old 14-03-2013, 08:56 PM   #28
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This was probably covered before but I often have a time-gap between reading new information and actually realizing its implications.

Quote:
The researchers administered a placebo cream while giving people painful shocks or putting intense heat on their forearms. In one experiment, they gave subjects a warning cue, a red “get ready” sign, just before those subjects received the painful stimulus. With that signal, participants expected pain, unless the cream was applied, in which case they expected relief. That expectation of relief first activated a cognitive “executive” center of the brain called the prefrontal cortex. After that, activity in the pain response areas of the brain declined, and subjects reported relief. This temporal pattern of brain activity suggested that placebo pain relief involves an expectation signal from the prefrontal cortex that tells the midbrain to release opioids to meet the expectation of reprieve. “There is a cognitive mechanism driving the opioid system,” says Petrovic, who, in a reanalysis of his 2002 study, also pinpointed regions of the prefrontal cortex as drivers. The placebo effect seems to involve emotions, too.
That said, doesn't the placebo fit snuggly into the neuromatrix? Couldn't we also call it the neuromatrix of placebo?
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Old 16-02-2014, 11:39 PM   #29
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Default The power of the placebo effect

The power of the placebo effect

Feb 15/14, excerpt:
Quote:
Dr David Kallmes conducted a trial to see if vertebroplasty – a procedure in which patients are injected with a type of medical cement – was any more effective than a placebo.

He concluded that there was no statistically significant difference in pain relief or improvement in function between the patients who underwent the operation and those who did not.
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Old 17-02-2014, 03:15 AM   #30
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Is anyone surprised?

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Old 20-02-2014, 05:55 PM   #31
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a subject that won't go away ............

not sure if you can watch this outside uk ..........

http://www.bbc.co.uk/programmes/b03wcchn
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Old 29-03-2014, 02:03 PM   #32
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Seth Godin is sharing an ebook he has written on placebo.
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Old 29-03-2014, 06:26 PM   #33
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Quote:
Originally Posted by Diane View Post
This is a great example: it's a free webinar next month, featuring one of Canada's finest researchers, Catherine Bushnell, organized and cosponsored by by the Canadian Institute for Relief of Pain and Disability, the Canadian Pain Coalition, and Pain BC: Out-thinking Pain:How the Mind can Control Pain.

It looks great.
I just realized that this original webinar link doesn't work anymore, so I did a little googling and located it at the CIRPD Webinar Series: Chronic Pain, the Journey Forward. It is #7 on the list.
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Old 29-03-2014, 07:18 PM   #34
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Seth gives some great ideas on responsibly and ethically using placebos. The while book takes 15-20 min to read.
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