Noxious placebos

Placebo, originally meaning “to please”, has come to mean applications which are believed not to have a known biological effect. Since these applications (“placebos”) are assumed to be “inert”, and specifically not harmful, they have been used as a standard against which planned biological manipulations (“treatments”) can be measured objectively. In this way placebos are perceived to satisfyingly demonstrate a cause and effect chain from treatment to benefit

 

However, although having no rationale, placebos themselves can produce a subjective sense of benefit. The reasons are not understood, but could include the effect of having been a centre of attention, or a mystical belief that some type of interference or intrusion into the soma must have a potential benefit. Intermediary pathways have been demonstrated with changes in dopamine and the endorphins and activation of brain areas demonstrated by imaging.

 

Although these intermediary phenomena are interesting as correlated observations, they do not advance any comprehensive explanation of the linkage between cause (application/placebo) and benefit.

 

Subjective reporting by the patient is often used to measure the benefit of treatments. In some of these cases it may not be possible to distinguish between the benefits of placebo versus planned biologically manipulation (’treatment”).

 

Let us now consider applications (“placebos”) which have no comprehensible therapeutic value but are neither inert nor benign. There are many historical examples ranging from trephination and blood-letting to purging and emeticism. Many of these “non-benign” applications persist contemporarily, such as excoriation by witch doctors, bee-sting therapy, piercings and many more. While it will have been clear to all that these treatments were harmful, with obvious damage or perturbation to the body, they must also –in the long run- have been perceived to have been beneficial to have been continues. These forms of irrational treatment must be assumed to have placebo mediated (“placebo effect”) benefit, either objectively or (more likely) subjectively.

 

Some, no doubt, have their benefit more at a societal level than at the level of the patient. By this I mean that the beneficiary is a group, rather than an individual. Procedures such as trephining could have appealed to the bystanders (as a group) as a “Don’t just stand there, do something” action, or alternatively as a protection to society by ridding one of its members of evil. (The evil will have been in the form of “spirits”, since the expectation was that the spirit was imperceptible, and therefore the release was not expected to be perceptible). Human sacrifice, judicial hanging and suicide bombing may well have been the extreme expression of a placebo producing a societal benefit.

 

Where physical damage occurs, a biological response (and perhaps a psychological response, if a distinction exists) is to be expected. Pain will produce a humeral and neurological reaction, as also would loss of body fluids or extreme temperature changes.

 

I will call these noxious placebos.

 

If one progresses to formal surgical assaults, it seems likely that such placebo effects should also exist in that domain. This would be expected to be particularly so where the motivation for surgery is more subjective than objective, and where the measurement of “success” is a subjective evaluation. In these circumstances the objective measurement of the surgical benefit might be highly distorted. [See page “Is conventional forefoot surgery proven as beneficial”]. If this is the case it will invalidate most self (patient) reporting scales of benefit.

 

I am concerned that many areas of surgery of the foot might fall into the category of noxious placebos. This is because the rationale for many surgical procedures on the forefoot is obscure. Further, a single surgical procedure might be claimed to have a benefit for a number of anatomically distinct problems [see page “Weir 2”].

I am concerned to read about the high number of complications which occur, and yet the patient (and by extension surgeon) rating of the outcome is “success”.

 

Finally, the web has many diaries of people who have undergone surgery, and suffered extreme and prolonged discomfort, sometimes multiple surgeries, and although yet to recover are already “pleased with the outcome”. One example, amongst many, is man who is “Happy with the results…so far” below…

 

Junior Member (male)   Join Date: Jun 2007 Location: New York, NY, USA Posts: 31

Re: Flat Foot Reconstruction Surgery–Share your advice & experiences please! Just a quick update from me: I saw my surgeon yesterday, the foot looks good and he’s cleared me to start physical therapy! Any advice on what I should be expecting? I’ve been pain-free for a while but I know that’s going to change as I start to put weight on it again. Basically he said that the next 2 weeks I go to therapy but don’t do anything differently at home; every week after that, I put 25% of my body weight down, so that after 4 more weeks I should be fully weight bearing. At that point I should get out of the boot and into some sneakers! Hope everyone’s doing well. lori, has your son had his consultation with the orthopaedic surgeon yet? I know it’s scarely to contemplate surgery for a child, but based on what you say about how’s it is impacting his life it does sound necessary. I am happy with the results of the surgery so far, and while many of us complain here, it does seem that most of us are really, truly glad to have had the surgery in the long run. Best wishes to your son.

Are conventional explanations about “bunions” valid?

Hello Dr Driver-Jowitt. 

Thank you for suggesting I read your brochure about finding out more about foot problems on the internet. The first hit I found on Google just gave a quick overview of the different types of bunion surgery. The first they listed was for correcting the ligaments: Repair of the Tendons and Ligaments Around the Big Toe These tissues may be too tight on one side and too loose on the other, creating an imbalance that causes the big toe to drift toward the others. Often combined with an osteotomy, this procedure shortens the loose tissues and lengthens the tight ones. http://orthoinfo.org/booklet/view_report.cfm?Thread_ID=7&topcategory=Knee

(Name withheld by request)

Thank you for the enquiry. I am familiar with this paper, issued by the American Academy of Orthopaedic Surgery and co-developed by the American Orthopaedic Foot and Ankle Society. The Academy is a prestigious organization and it is disappointing that unsupported and irrational information is projected in this document. I am not aware that there is any evidence supporting the above suppositions. The comment about “tissues being too tight and too loose” is more an effect than a cause. Much of the paper discusses tight footwear as the causative factor, and the site says:” By far the most common cause of bunions is the prolonged wearing of poorly fitting shoes”.

As demonstrated in your case, the primary deformity is not the inward veer of the toe but the protrusion of the metatarsal away from the little toe. It is not possible for a tight shoe to cause the metatarsal to protrude outwards against the shoe.

The reality is that the deformity is zigzag, with the toe veering inward (towards the little toe) and the metatarsal veering outward (away from the little toe) and towards the shoe wall.

It is also improbable that your shoes were “too tight” when your deformity developed as a school-girl. Any shoe tight enough to produce a deformity, like any deforming force anywhere in the body, would be intolerably painful long before a permanent deformity could develop.

Many “Explanations” are not more than wild unsupported conjecture, without any validity or possibility of substantiation. Consider this suggestion by a surgeon discussing his “pain free” surgery in the online edition of a national newspaper.”Female hormones also soften this tissue, which is why women are prone to bunions”. http://www.dailymail.co.uk/health/article-1051558/Pain-free-surgery-cured-bunions-just-minutes.html

If this is the case why is a “bunion” often only on one side? Why do men and pre-adolescent girls get “bunions”? They don’t have “softening hormones”. This idea is simply fantasy.

More valid than the above “explanations” is the following statement by Drs Coughlin and Jones:” The…etiology of hallux valgus deformities…is a topic of great interest for all of us, but…is no closer to being defined now than in Morton’s era.” [Thomas George Morton 1835 -1903] http://www.ejbjs.org/cgi/eletters/89/9/1887#5193

I notice that one of the corrections suggested is aimed at dividing the bone of the metatarsal (an “osteotomy“). If the deforming forces were caused by pressure from the shoe acting on the toe, what is the rationale for a surgically attack the metatarsal?

The “exostectomy” described is nonsensical to me. There is no “exostosis” (i.e. no abnormal outgrowth of bone). The prominence is the normal bone, which is made prominent by the angular deformity, as I demonstrated to you. To remove the structures as in the diagram is quite wrong: The very ligaments which prevent the angular veer, and prevent the deformity from increasing, are having their attachments to the shaft of the bones  removed, and are therefore rendered ineffective.

I am sceptical about the claim that: “Many studies have found that 85 to 90 percent of patients who undergo bunion surgery are satisfied with the results.” Notice also the contrary comment “In fact, you will have some shoe restrictions for the rest of your life.”

A more realistic and objective assessment of the outcome of “conventional” surgery for deformities of the forefoot is the following meta-analysis in the Cochrane Database Intervention for treating hallux valgus (abductovalgus) and bunions. Ferrarid, HigginsJP, Williams RL. This paper is not optimistic about the outcomes of conventional surgery as it is at present

I would like to discuss your management further when you x-rays are available.