Every week or so, a patient comes into my clinic with back or shoulder pain. These patients’ MRIs are spotless, and they have been told by many doctors before me that everything looks normal — that there is no measurable source of their pain. It is my job to sit them down, look them in the eye, and tell them their pain is real.
“Your MRI is normal because the pain is coming from a misfiring of your nerves, and the MRI can’t pick that up,” I explain. Most nerve pain is not a hardware problem; it’s a software problem. This is a delicate point: too often, patients interpret it to mean that their pain is made up, or is something they can simply get over. For years, many patients have been told to ignore their pain, and the message I communicate can seem like an echo of prior bad experiences. But their pain is as real as any other. We think of pain as an alarm telling us that something is wrong, but like any alarm, it can malfunction and go off without a clear reason.
This “malfunction” occurs because nerves may become sensitive after injury and fire at lower thresholds, and this sensitivity can persist long after an injury heals. In some cases, there is no inciting injury at all. I offer my patients trigger point injections, among other treatments, to disrupt muscle spasms in painful areas. Before I administer these shots, I offer reassurance: “This is a safe procedure, and most patients experience one to two months of relief afterward,” I say. Then I clean the skin over tender areas of muscle and make small talk while I rest my hand on the patient’s shoulder. I push the needle into each spot that hurts. It is the mechanical force of the needle that has been shown to convey the relief. Nothing is injected, but many leave my office pain-free.
In medicine, ritual can be as important as remedy. In clinical trials of chronic pain, patients in both the placebo and active groups tend to improve dramatically. The relief from a placebo is on average 50–70 percent the improvement in the active group. Put another way, more than half of the pain reduction seen in trials can be attributed to the expectation of a positive response. Even surgeries, despite their hallowed aura, often fare no better than sham surgeries to treat chronic pain. In a famous study, one group of patients with back pain from spinal fractures had their fractures repaired, while the other group was simply anesthetized, opened up, and stitched back together. Afterward, people in both groups had incisions and therefore could not tell whether they had actually undergone the surgery. At follow-up appointments months later, the two groups reported similar pain levels.
Colloquially, a placebo is thought of as deception, a trick played by a doctor on their patient, and is viewed with disdain. Yet placebos in open-label studies, in which the participants know what they are taking, still heal. A placebo may be more accurately described not as a subconscious process but as a form of conditioning in which the body acts according to expectation. A patient is told a credible theory of illness and gets better when presented with a treatment, whether or not the theory is correct. One of the electrical therapies I use most in the clinic, which has helped countless people in pain, was recently shown in a randomized study to be no better than its inactive counterpart. Can I continue to offer the treatment, knowing this? Does the method by which relief is achieved matter, or is it enough that it is achieved?
“The pain isn’t just in your head,” I sometimes tell patients, “but it is in your brain.” Such a diffuse and mysterious ailment needs a cure to match. Placebos have long been regarded as a nuisance in clinical studies, the low benchmark of a treatment’s efficacy, but the term itself turns out to be a catchall name for the many mysteries of what makes up care and recovery. It may not be possible to disentangle performance, ritual, relationship, and belief from the placing of needles. Upon closer examination, the very concept of a placebo — where it starts and stops — begins to lose its meaning. So, too, does the distinction between the snake-oil quacksalver and the evidence-based academic. Doctors engage patients in a healing ritual, and patients participate in it. A great power to heal resides in each of us; it needs only to be drawn out.
