I am afraid I don’t recognise your interpretation of the overall achievements of EBM. Massive steps forward in cancer survival rates, improved outcomes and disease control in Rheumatology, the fantastic record on vaccination all tell a different tale. Of course some therapies do not do so well – laminectomy is a good example and is being performed less in light of the evidence. In terms of CABG you seem to imply that CABG was compared to nothing when in the stuies that I am aware of it was compared to percutaneous coronary intervention – not a failure of evidence based medicine but a great example of progress in medicine and the development of equally effective but less invasive procedures. But I would be happy to see the reference source for your assertion. The “little evidence for medicine” argument is something of a fallacy . The oddest part of it is that this erroneous assertion then often leads to the beautiful idea that “therefore any old nonsense will do”. But that is a path that leads us backwards.

It is worth remembering that placebo effects are generally small, short lived and, beyond subjective outcomes, do not seem to have a strong impact on clinical results (see the Cochrane reference). Helping people to manage their symptoms better may well work via similar pathways as straightforaward placebos but it is not lying to them, selling them a story or a bottle of snake oil. As such I am comfortable with “rational hugs” but not prepared to make pretend with somebody’s symptoms.

I know in my experience that sometimes, I think, administratively we sometimes shoot ourselves in the foot. In big hospital systems, a physical therapist is just a physical therapist and there doesn’t necessarily seem to be an attitude that each therapist has strengths and weaknesses. The attitude is *all* the therapists are great. But now that I’ve been out on my own, and I have a name and an identity so to speak, for lack of a better word, something “magical” does happen when a patient requests me as a therapist by name and/or knows something about me. If it’s a physician who tells a little something about me – that’s like double “magic.” If the patient searched the net and found me and chose me, “magic” again. Honestly, no, I haven’t measured anything – so maybe I’m wrong in my thinking, but in those situations, it’s easier for me – almost like there is already a burst of trust in me.

From a purely clinical perspective, if I can understand the non-specific stuff that would be helpful – along with learning of possibilities of changing the non-specific stuff to be more suitable and receptive to physical therapy intervention. It’s almost like during my initial evaluations, I snag a lot of “physical” data, but probably a bigger more relevant chunk of information is missing – a person’s receptiveness to physical therapy… readiness for self-efficacy… belief in being able to successfully manage the situation.

I’m guessing too that there’s some confusion over codes of practice and ethics proper. Just because the APTA says something is ethical (or not) doesn’t make it so.

Like Luke I value the placebo control in research as it tests reasonable predictions about any proposed treatment modality. I would maintain that when those precitions are found false we should dump the treatment. I think this goal is somewhat distinct from investigating the effects of care. Understanding how conditioning and expectation work is key tom undersatanding the cloinical interaction but while the overall concept of “placebo” is perhaps unhelpful and covers a variety of aspects and mechanisms, the idea of placebo controls still gets my vote.

You are quite correct! This is becoming a little like the dualist body vs mind debate. We often try to see the placebo component as a discrete malignant entity that could, with a magic scalpel, be excised from the healthy active tissue beneath. In fact, in reality, the relationship is probably more one where the two are inextricably linked and not so discrete. Having said that, for the purposes of research and investigation, all the earlier comments hold. In interpreting research for clinical practice and indeed in engaging in clinical practice, however, it is worth remembering that the relationship is probably more complex than we sometimes think.