"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the AMA from the APTA, Dec 2009

Monday, July 25, 2011

Lower Back Pain, the "The Doctor Effect" and Patient Self-Reported Outcomes

The Doctor Effect is also known as the Placebo Effect.

Except, as pointed out in JournalWatch's Clinical Conversations Podcast #126, Placebos and Medical Meaning, a placebo is an inert substance that has no effect on a patient.

The Placebo Effect was raised by an article in the July 14th, 2011 New England Journal of Medicine Active Albuterol or Placebo, Sham Acupuncture, or No Intervention in Asthma. The authors found that patients' self-reported breathing after sham acupucture improved while their Forced Expiratory Volume in 1 second (FEV-1) did not improve. The authors concluded that the self-report measures were therefore unreliable.

Dr. Daniel Moreman, author of Deconstructing the Placebo Effect and Finding the Meaning Response, argues that real, therapeutic effects can be measured in patients who take "inert" substances and that the patient experience (eg: feeling better) may be more important than "instrumental', or objective data, like the FEV-1.

At 11:38 min. in the podcast, Dr. Moreman (an anthropologist) directly speaks to the difficulty of lower back pain, patient self-report outcome measures and physician care.

Physical therapists should think about the Doctor Effect because of evidence that the Doctor Effect, or the process-of-care, may provide at least as large a therapeutic benefit as that provided by pharaceuticals with dangerous or deadly side effects.


  1. I don't know if I'd call something a "doctor effect" but it seems to me, after all these years working with people, the relationship and the conversation that occurs between the medical provider and the patient has an impact on the care. Our conversations can alter belief systems and expectations. Sadly, it isn't easy to predict who will change their thoughts or to what degree their thoughts will change, but that response shift does seem to affect outcomes. We know this for people with low back pain... those who have a lot of diagnostic testing and when those findings are shared and discussed with words like "herniated" and "messed up back" and "degenerated." Images are created in the patient's mind which then leads to fear.

    We know about neuroplasticity of the brain with people who have had strokes or brain injuries... well, the neuroplasticity is there with belief systems too. I know there aren't a ton of studies out there substantiating my perspective. I tend to think changes within belief systems do affect physical performance. (And I'm talking real physical performance that can be measured where what the patient says and what is measured are consistent - unlike the breathing example in your post.) I also don't think, in most cases, honest individuals are not unreliable in their self-reports. I would be more willing to wager, their self-reports are predictive in nature and would guess that in time the self-report would align itself with performance (in some cases time is needed for the physiological change to occur).

    Interesting topic.

  2. I agree, Selena, although the authors of the asthma study conclude otherwise, many providers think we can measure the placebo response - it's a real, physiological effect.

    Physical therapists can work to maximize this effect throught what Dr. Moreman calls "Medical Theater" and which I call the Process-of-Care.

    This might include small things like wearing a white coat, taking blood pressures, assessing self-report measures and setting mutually-agreed upon goals for exercise at home.


Free Tutorial

Get free stuff at BulletproofPT.com

Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.

Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.

Tim can be reached at
TimRichPT@BulletproofPT.com .

"Make Decisions like Doctors"

Copyright 2007-2010 by Tim Richardson, PT.
No reproduction without authorization.

Share PTD with your Peers!

American Physical Therapy Association

American Physical Therapy Association
Consistent with the American Physical Therapy Association Vision Statement for Physical Therapy 2020, the American Physical Therapy Association supports exclusive physical therapist ownership and operation of physical therapy services.