Did you know that volleyball players can jump higher after they visualize themselves flying? Or that individuals with hand arthritis who imagine playing the piano have a reduction in pain?
This month, I had the opportunity to attend and present my work at my first psychology conference, the Society for Interdisciplinary Placebos Studies Conference, in Duisburg, Germany. As an engineer and biomechanist by training, I was nervous to venture into a world where I felt like a total newbie. Fortunately, the community warmly welcomed me, and through inspiring conversations and talks, I gained valuable new insights. Beyond fascinating anecdotes (like the ones above), I'd like to share some key takeaways and how placebos relate to and should be more deeply considered in engineering and biomechanics.
The power of placebos: pain, performance, and interventions
One of the topics I found most captivating was the implications of the placebo effect for clinical trials, pain management, and even athletic performance. Contrary to common belief, the placebo effect is not just about tricking the mind. It has real and measurable effects on our bodies.
Regarding clinical trials, the placebo effect becomes particularly intriguing in the context of pain. For instance, Dr. Luana Colloca showed that while genetics play a role in predicting pain outcomes of clinical trials, manipulating expectations has an even greater impact. In other exciting research, Professor Nanna Finnerup shared that hormonal changes during different menstrual cycle phases can also affect pain thresholds and expectations. For example, women in the mid-follicular phase have a similar pain threshold to men. However, In the luteal phase, average pain expectations increase and pain thresholds decrease. Further, neurobiology research by Professor A Vania Apkarian demonstrated that pain is not solely determined by nociception but is influenced by a range of factors, including personality traits and brain properties. Understanding these factors is crucial for designing effective interventions and evaluating treatment outcomes.
In terms of performance, Dr.Phillip Hurst discussed the role of the psyche in the effectiveness of performance-enhancing substances, including a study where he found similar improvements in running speed between caffeine and caffeine placebo. He also highlighted that emotional responses play a crucial role in placebos of sports contexts and how emotional regulation occurs through various situations, including listening to music, imagery, self-talk, breathing, and drugs.
The importance of patient-physician (and researcher) interactions
A simultaneous hyperscan neuroimaging study by Professor Vitaly Napadow revealed that the brain responses of patients and practitioners overlap during acupuncture treatment. This connection increases with social interaction beforehand and decreases with practitioner burnout. Additionally, while usually seen as a mandatory process of a study, the informed consent process can even impact participant expectations. In fact, Professor Yvonne Nestoriuc, showed through a randomized controlled trial that patients receiving an “optimized” informed consent had improved positive treatment expectations compared to those who received a typical informed consent.
While many studies highlighted patient-physician interactions, the participant-researcher interaction can be viewed similarly. How we interact with participants before and during studies, the language of participant consent, and the instructions given all play a role in shaping participant expectations and experience, which (as learned above) can dramatically affect both psychological and physiological outcomes. We should be mindful of these effects, whether we want to leverage these effects to support the efficacy of treatments or mitigate differences between study arms, and include details of these interactions as part of the research design.
"Maybe we don’t need to administer placebos, but give effective drugs and [improve] expectations." – Fabrizio Benedetti
Placebos beyond the horizon
With these insights, how do we mindfully design studies to consider the placebo effect? A critical aspect of this is the importance of the control group. To this point, Dr. David Hohenschurz-Schmidt, presented new guidelines on how control group interventions are designed, conducted, and reported. More details can be found in their manuscript soon-to-be in BMJ, but some key points resonated with me. First, we can standardize the language of risks and benefits, the duration and number of study visits, and the questions and structured checklists to detail outcomes and adverse events. Second, they recommend that researchers include measures that capture participants' treatment expectations. Thus, after participant consent, initial participant-research interactions, and communication of the study details, but before the treatment itself, we can determine whether expectations were consistent across groups and evaluate the role of expectations in mediating treatment outcomes.
Overall, it was emphasized that placebos are particularly beneficial for diseases without effective treatments, such as osteoarthritis. But is it ethical to deceive patients, telling them they are receiving treatment when they are receiving a sugar pill (or another treatment-specific placebo)? An alternative strategy to harness placebo effects is using open-label prescribed placebos, or "honest placebos." In this case, the patient is informed of research on the power of placebos and given the option to try a prescribed placebo treatment. Some studies found promising results of using open-label placebos, while others were unclear. In alignment with the organized debate on open-label placebo, there is still much work to do in this area. But another promising construct to ethically and effectively target and harness the benefits of placebos is our mindset.
Looking toward the future, Professor Alia Crum explored the impact of mindsets, social effects, and the creation of reality on the placebo response. Her work demonstrates how mindsets can influence health outcomes in a range of domains both within and beyond medicine via affective, attentional, behavioral, and physiological mechanisms. In practice, uncertain contexts, such as the early stages of treatment, are critical points to influence mindsets. Presentations by former members of the Stanford Mind & Body Lab, Drs. Lauren Heathcote, Lauren Howe, Kari Liebowitz, and Octavia Zahrt, (and myself!) shared the positive effects of changing mindset on a range of topics from immune response to physical activity and osteoarthritis.
Resonating this sentiment of leveraging the power of the mind to improve treatment effectiveness, Professor Fabrizio Benedetti proposed, “Maybe we don’t need to administer placebos, but give effective drugs and [improve] expectations.”
The dance of biomechanics and psychology
Placebos are not limited to the realm of psychology. In fact, the intersection of biomechanics and placebos offers a promising avenue for future research. By examining the role of placebos in pain, performance, and interventions, we can gain new insights into optimizing human movement and improving biomechanical engineering solutions.
Every interaction with a study participant, every survey we give or instructions we share, even simple details, affects that participant, and thus the overall study, in some way. While appearing small or subtle, these details matter. Fortunately, we can become mindful of these nuances and optimize them for more rigorous trials and effective intervention. In my experience, the best way to do this is to directly collaborate with psychologists and seek their expertise and advice. However, even if this isn’t possible, the awareness of these details can make a difference.
Lastly, biomechanists have some work to do regarding presentation puns. Perhaps psychology content is riper for jokes, but with the new artificial intelligence chatbots available to assist, we no longer have an excuse to not drop a creative pun here or there (see section title). However, I will not disclose which dance floor was more poppin’ when it came to the conference gala.
Attending the psychology conference was an eye-opening experience for me, as it provided a fresh perspective on the power of placebos in shaping our perceptions and experiences. I left with a renewed appreciation for the intricacies of psychology and its relevance to engineering and biomechanics. So if an opportunity arises to attend a conference in psychology or another area you may not feel an “expert” in, I highly recommend seizing the opportunity and keeping an open mind to interdisciplinary perspectives and applications.
Additional notes
The work I presented, The effect of changing mindsets on pain and physical activity levels in individuals with knee osteoarthritis, was on an ongoing clinical trial to test a digital mindset intervention for individuals with knee osteoarthritis. This work is an extension of a previous study uncovering the relationship between exercise mindsets and physical activity levels in the knee osteoarthritis population.
The anecdotes provided at the beginning of this post were from informal conversations about ongoing work. While not yet published, these anecdotes highlight the incredible power of our minds and the potential for placebo effects to enhance various aspects of the human experience.
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