Editorial Br J Sports Med: first published as 10.1136/bjsports-2017-097747 on 19 July 2017. Downloaded from

Such connections between brain physi- ‘Caution, this treatment is a placebo. ology and mechanistic evidence are being used as an argument for CAM. We have It might work, but it might not’: why been researching the placebo effect in sport for some time (14 years in the case emerging mechanistic evidence for of the first author). While it is not unusual to be invited to speak at scientific confer- placebo effects does not legitimise ences or to media on one’s area of exper- tise, we now receive as many invitations to speak on the issue of CAM, and an equal complementary and alternative volume of traffic from proponents and/or practitioners of CAM, at times congratu- medicines in sport lating us for ‘legitimizing’ their product or treatment. 1 2 3 4 Chris Beedie, Greg Whyte, Andrew M Lane, Emma Cohen, We strongly contest this position, and John Raglin,5 Phil Hurst,1 Damian Coleman,1 Abby Foad1 propose five challenges to the idea that placebo mechanisms legitimise the use of CAM by clinicians in sports medicine/ Complementary and alternative medicines CAM is widely used in sport, often by sports physiotherapy: (CAM) are treatments for which either elite athletes. One example is Michael 1. Variability: Placebo responding is evidence is lacking, or for which evidence Phelps’ use of ‘cupping’ during the 2016 variable, both between and within suggests no effect over a placebo treatment. Olympics. Evidence for the effective- athletes.6 Furthermore, most research http://bjsm.bmj.com/ When a non-evidence-based treatment is ness of CAM in sport has been reported papers report acute placebo effects, used alongside conventional medicine, it is in some work, but more studies have and little is known about their stability considered ‘complementary’. When a non- reported CAM outcomes as no better over time. evidence-based treatment is used instead of than placebo. The link between CAM and 2. Negative placebo effects: The conventional medicine, it is considered the placebo effect has been made explicit effect, a negative response related to ‘alternative’. Many forms of CAM have by health agencies1 and scientists.2 As a negative expectations, is well docu- 6 origins and/or a history of use beyond consequence, where credible causal mech- mented. Rather than assuming that on September 30, 2021 by guest. Protected copyright. evidence-based medicine. Further, many anisms for apparent therapeutic effects are a CAM treatment will either result in CAM treatments are based on principles absent, placebo effects are often assumed. a positive effect or no effect, practi- and/or evidence that are not recognised by The placebo effect was historically tioners must consider the possibility the majority of independent scientists. considered a non-specific phenomenon, that administration of a placebo treat- When a person uses CAM and experiences but recent studies indicate numerous ment can exert a negative effect. an improvement in symptoms, this may be discrete placebo effects operating via 3. Failure to adopt a more effective treat- due to the placebo effect.1 dopamine,3 opioid4 and cannabinoid5 ment: Athletes are often eager to neurotransmission. For example, placebo accept at face value treatments that 1School of Human and Life Sciences, Canterbury Christ analgesia following preconditioning might expedite their return to play.7 Church University, Canterbury, Kent, UK 2 with morphine is blocked by the antago- Consequently, patients of practitioners Research Institute for Sport and Exercise Sciences, nist , but analgesia conditioned who administer CAM may be denied Liverpool John Moores University, Liverpool, UK 3Institute of Sport, University of Wolverhampton, using a non- was naloxone or choose to forego potentially more 8 Walsall, UK insensitive. Likewise, the cannabinoid effective evidence-based treatments. 4Institute of Cognitive and Evolutionary Anthropology, receptor antagonist rimonabant had no In sport, this might range from an University of Oxford, Oxford, Oxfordshire, UK effect on opioid-induced placebo anal- athlete not eating sufficient fresh fruit 5School of Public Health, Indiana University, Bloomington, Indiana, USA gesia following preconditioning with because she is receiving sufficient morphine, but antagonised placebo anal- vitamin C through supplements, to Correspondence to Dr Chris Beedie, School of gesia following preconditioning with the choosing CAM as opposed to conven- Human and Life Sciences, Canterbury Christ Church University, N Holmes Rd, Canterbury, Kent CT1 1QU, non-opioid non-steroidal anti-inflamma- tional medicine to treat injury or UK; chris.​ ​beedie@canterbury.​ ​ac.uk​ tory drug, ketorolac. illness.

Beedie C, et al. Br J Sports Med July 2018 Vol 52 No 13 817 Editorial Br J Sports Med: first published as 10.1136/bjsports-2017-097747 on 19 July 2017. Downloaded from

4. Ethics of deception: In light of the non-specific effects as a basis for prescrip- cited and the use is non-commercial. See: http://​ challenges of points 1 and 2, it is argu- tion. If a practitioner seeks to use a treat- creativecommons.org/​ ​licenses/by-​ ​nc/4.​ ​0/ ably unethical to knowingly advocate ment in order to capitalise on the placebo © Article author(s) (or their employer(s) unless CAM while also assuming the likely component of that treatment, they should otherwise stated in the text of the article) 2018. All mechanism of effect is the placebo. do so methodically.9 rights reserved. No commercial use is permitted unless otherwise expressly granted. We acknowledge emerging evidence In sports medicine the outcome is often that open label administration of more important than the mechanism. placebos can be effective. However, Scientific research on placebo mechanisms even in such cases, the administration has yielded fascinating insights suggesting To cite Beedie C, Whyte G, Lane AM, et al. of placebos may ultimately be counter- the potential and mechanisms of Br J Sports Med 2018;52:817–818. productive. There are serious ethical -based treatments. We anticipate that Received 3 March 2017 challenges around deception, risk and when applied systematically, such research Revised 20 April 2017 harm to patients. findings enable sports medicine practi- Accepted 7 June 2017 Published Online First 19 July 2017 5. Identification of ‘headroom’ tioners to deliver all treatments—CAM mechanisms: The capacity to respond and conventional—more effectively. But Br J Sports Med 2018;52:817–818. doi:10.1136/bjsports-2017-097747 to a placebo is evidence of headroom such use of the placebo component of a 6 or reserve capacity. Headroom treatment does not legitimise CAM per se; References is likely amenable to legitimate while it might be going too far to suggest 1 The placebo effect and complementary and alternative treatments, both physiological and that many CAM treatments should be medicine: national Health Service, 2016. http://www.​ psychological. Practitioners should labelled with the statement ‘Caution: This nhs.uk/​ ​Livewell/complementary-​ ​alternative-medicine/​ ​ strive to identify and capitalise on treatment is a placebo, it may work, but Pages/placebo-​ ​effect.aspx.​ 2 Kaptchuk TJ, Miller FG. Viewpoint: what is the best headroom through legitimate, ethical, it may not, it might even be counter-pro- and most ethical model for the relationship between controllable and stable treatments (eg, ductive,’ we argue this is most certainly mainstream and : opposition, optimal nutrition, systematic recovery the that practitioners should keep integration, or pluralism? Acad Med 2005;80:286–90. and psychological skills training). in mind. 3 Benedetti F, Frisaldi E, Carlino E, et al. Teaching neurons to respond to placebos. J Physiol 2016;594:5647–60. CAM can be effective, but can also be 4 Benedetti F, Carlino E, Piedimonte A. Increasing ineffective or even harmful. Evidence is Contributors All authors contributed equally to the uncertainty in CNS clinical trials: the role of placebo, vague in both respects, but practitioners writing of the manuscript. nocebo, and Hawthorne effects. Lancet Neurol and athletes using CAM do not always Competing interests None declared 2016;15:736–47. recognise this. We acknowledge the Provenance and peer review Not commissioned; 5 Benedetti F, Thoen W, Blanchard C, et al. as a externally peer reviewed. reward: changing the meaning of pain from negative to distinction between lack of evidence for positive co-activates opioid and cannabinoid systems. an effect, and evidence for the lack of an Pain 2013;154:361–7. effect. In relation to the former, sports 6 Beedie CJ, Foad AJ. The placebo effect in medicine researchers should seek to use sports performance: a brief review. Sports Med robust, reliable and, where necessary, 2009;39:313–29. 7 Franklyn-Miller A, Etherington J, McCrory P. Sports and innovative methods to establish the effi- exercise medicine--specialists or snake oil salesmen? Br http://bjsm.bmj.com/ cacy and mechanisms of CAM treatments. Open Access This is an Open Access article distributed J Sports Med 2011;45:83–4. In relation to the latter, sports medicine in accordance with the Creative Commons Attribution 8 Smith K, Ernst E, Colquhoun D, et al. (CAM): Ethical and practitioners should regard non-evi- Non Commercial (CC BY-NC 4.0) license, which permits Policy Issues. 2016;30:60–2. others to distribute, remix, adapt, build upon this work 9 Beedie C, Foad A, Hurst P. Capitalizing on the Placebo dence-based treatments with caution, non-commercially, and license their derivative works on Component of Treatments. Curr Sports Med Rep and resist the temptation to rely on different terms, provided the original work is properly 2015;14:284–7. on September 30, 2021 by guest. Protected copyright.

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