Posted in Coaching

Placebos in High Performance Sport

A Placebo is something of no intrinsic remedial value that is used to appease or reassure another. There is no completely agreed upon definition of what a placebo is, and the scope of therapy can extend from an ingested agent to a physically inert external treatment. The concept of the placebo effect can extend to include
every conceivable beneficial biological, social, or human interaction that doesn’t involve some drug well-known to the pharmacopoeia. Irving Kirsch hypothesised that the self-fulfilling effects of response expectancies, in which the belief that one will feel different, leads a person to actually feel different. This effect is the placebo effect.

Despite the vast amount of research in the area of placebos, the phenomenon has remained largely unchallenged in the area of sport and performance. In high performance it is likely that there are a great number of therapies and ergogenic aids that are used with no real effect of the athlete. Instead, there is the potential for a placebo effect to occur providing a false positive for improved performance. Expectation and conditioning are among the strongest areas for explaining the placebo effect and a large component of high performance sport involves mental training of an athlete by their coaches and support staff.

The placebo effect is a psychobiological reaction attributed to numerous mechanisms including expectation of improvement and Pavlovian conditioning. These psychological reactions can have performance benefits, and when you look at high performance sport the single highest priority is performance outcome. Numerous studies have been completed where athletes falsely believe they have been administered performance enhancing agents, and obtain performance improvements over baselines and controls. These improvements may only be an increase of 1% however at top levels that can be enough to mean the difference between winning and losing. With restrictions on what agents an athlete can use and what equipment and techniques are allowed win each sport it is necessary to look at every possible option for getting the winning edge on the opposition. Some aids that can be used may only provide a placebo effect on the athlete, but this can lead to real performance outcomes.

It is shown that false belief may enhance performance. This can be achieved through a conscious decision making process as opposed to any direct somatic or psychological mechanism. To be able to determine the real benefit of a placebo however, it would be necessary to look deeper into the actual reasoning for the performance enhancements that are achieved. At the moment the only true way of determining whether there is a placebo effect in place is through performance measures and recording athlete results. If there were some neurobiological mechanism that has a physiological effect on the individual causing these changes, it would be necessary to determine what it is and then measure the impact that it has.

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Placebos and High Performance Sport

A Placebo is something of no intrinsic remedial value that is used to appease or reassure another. There is no completely agreed upon definition of what a placebo is, and the scope of therapy can extend from an ingested agent to a physically inert external treatment.7 The concept of the placebo effect can extend to include every conceivable beneficial biological, social, or human interaction that doesn’t involve some drug well-known to the pharmacopoeia.10 Irving Kirsch hypothesised that the self-fulfilling effects of response expectancies, in which the belief that one will feel different, leads a person to actually feel different. This effect is the placebo effect.8

Despite the vast amount of research in the area of placebos, the phenomenon has remained largely unchallenged in the area of sport and performance.12 In high performance it is likely that there are a great number of therapies and ergogenic aids that are used with no real effect of the athlete. Instead, there is the potential for a placebo effect to occur providing a false positive for improved performance. Expectation and conditioning are among the strongest areas for explaining the placebo effect13 and a large component of high performance sport involves mental training of an athlete by their coaches and support staff.

The placebo effect is a psychobiological reaction attributed to numerous mechanisms including expectation of improvement and Pavlovian conditioning.3,4 These psychological reactions can have performance benefits, and when you look at high performance sport the single highest priority is performance outcome. Numerous studies have been completed where athletes falsely believe they have been administered performance enhancing agents, and obtain performance improvements over baselines and controls.1,2,5,6,10,11 These improvements may only be an increase of 1% however at top levels that can be enough to mean the difference between winning and losing. With restrictions on what agents an athlete can use and what equipment and techniques are allowed win each sport it is necessary to look at every possible option for getting the winning edge on the opposition. Some aids that can be used may only provide a placebo effect on the athlete, but this can lead to real performance outcomes.

By working with sports science, psychological benefits can be enhanced for an athlete resulting in further improved results. Items such as compression garments have no proven benefit for their use, however they have shown no negative impact either, and by combining the placebo effect of using such ergogenic aids with the possibility of real physiological benefits could potentially result in an amplified boost for the athlete. Many items such as these become products that are viewed by the general population as necessary for elite athletes. It is unclear with these products if the use at high performance breeds the idea that they have a physical benefit, or if there is a physical benefit that causes the population to believe that high performance athletes need them to compete on an international stage. What is clear however is that some athletes believe that they need them to perform and as such they have a real impact on the athletes performance, whether it is through a placebo effect or physiological or neurobiological mechanism.

It is shown that false belief may enhance performance. This can be achieved through a conscious decision making process as opposed to any direct somatic or psychological mechanism.3 To be able to determine the real benefit of a placebo however, it would be necessary to look deeper into the actual reasoning for the performance enhancements that are achieved. At the moment the only true way of determining whether there is a placebo effect in place is through performance measures and recording athlete results. If there were some neurobiological mechanism that has a physiological effect on the individual causing these changes, it would be necessary to determine what it is and then measure the impact that it has.

1. Ariel, G. and Saville, W. (1972) Anabolic steroids: the physiological effects of placebos. Medicine and Science in Sport and Exercise 4, 124-126.

2. Beedie, C. J., and Foad, A. J. (2006). The effect of belief on sports performance. Invited symposium, Annual Conference of the British Association of Sport and Exercise Sciences. University of Wolverhampton.

3. Beedie, C. J. (2007). Placebo effects in competitive sport: Qualitative data. J. Sports Sci & Med, 6, 21-28.

4. Benedetti, F., Mayberg, H. S., Wager, T. D., Stohler, C. S., & Zubieta, J.-K. (2005). Neurobiological mechanisms of the placebo effect. J. Neuroscience, 25(45), 10390-10402.

5. Clark, V.R., Hopkins, W.G., Hawley, J.A., and Burke, L.M. (2000) Placebo effect of carbohydrate feeding during a 4-km cycling time trial. Medicine and Science in Sport and Exercise 32, 1642-1647

6. Foster, C., Felker, H., Porcari, J.P., Mikat, R.P. and Seebach, E. (2004) The placebo effect on exercise performance, Medicine and Science in Sport and Exercise 36, Supplement S171

7. Kamper, S.J. & Williams, C.M., (2013) The placebo effect: powerful, powerless or redundant. Br J Sports Med Vol 47 No 1, 6-9

8. Kirsch, I., (1985). Response expectancy as a determinant of experience and behaviour. American Psychologist 40 (11):1189-1202

9. Maganaris, C.N., Collins, D. and Sharp, M. (2000) Expectancy effects and strength training: do steroids make a difference? The Sport Psychologist 14, 272-278

10. Moerman, D.E. and Jonas, W.B. (2002). Deconstructing the placebo effect and finding the meaning response. Ann Intern Med. 136 (6): 471–6

11. Sonetti, D.A., Wetter, T.J. Pegelow, D.F., and Dempsey, J A. (2001) Effects of respiratory muscle training versus placebo on endurance exercise performance. Respiration Physiology 127 (2-3), 185-199.

12. Stedge, H. L., Kroskie, R. M., & Docherty, C. L. (2012). Kinesio Taping and the circulation and endurance ratio of the gastrocnemius muscle. J. Ath. Training, 47(6), 635-642.

13. Stewart-Williams S, Podd J. (2004) The placebo effect: dissolving the expectancy versus conditioning debate. Psychol Bull 130:324–40.

 

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Massage, is it all in your head?

Massage, is it all in your head? By Simon Hone

Massage, or forms of massage, have been around for many hundreds of years. Back then massage would have been used to relax and calm people and although it is still used in that manner to this day massage has become a popular recovery method for athletes competing in high level sport (Hemmings et al., 2000). Massage has large following and many positive expectations about it and how it can lead to a wide variety of benefits including a lowering of heart rate, increase of blood flow, removal of blood lactate from the muscles, increased range of motion of joints, as well as having a positive effect on the athletes mind (Hemmings et al., 2000, Hume et al., 2005, Robertson et al., 2004).

A study carried out by Hemmings et al, (2000) looked at massage as a recovery method after repeated work periods. The study was carried out on boxers with at least 2 years experience of the sport and focused on whether massage could lower blood lactate levels in the muscle after a period of work. They found that massage post exercise did nothing to help the removal of blood lactate from the muscles; in fact the group that received the massage actually had higher levels of blood lactate post exercise. However they did find that massage, as opposed to standard static recovery, showed a large perceived increase of recovery. There has also been work looking at whether a combination of active recovery, which has been shown to have a positive effect on recovery, mixed with massage as a recovery method could be highly beneficial (Martin et al., 1998). So if the massage was actually causing them to have higher blood lactate levels in the body how come they were feeling more recovered? What was at play? Placebo!

The concept of placebo is fairly simple; a stimulus which has minimal to nil proven benefits is applied or taken and then an improvement in condition or performance follows (Bialosky et al., 2011). An easy to understand example would be a doctor prescribing a “new” form of medication. The medication may be nothing different to what the patient is already taking but the pill might look different or have a slight different colour. This change, with a newly perceived outcome, may show a placebo effect (Benedetti et al., 2003, Geers et al., 2005).

The level of response observed from a placebo is reliant on several key factors; negative mood, expectation and conditioning (Bialosky et al., 2011). A person who is suffering from an injury may look into recovery methods and the placebo surrounding them. If they are willing, open minded and positive towards the treatment a faster recovery will likely be observed (Gaitan-Sierra et al., 2011, Geers et al., 2005) as opposed to someone with a negative mood or expectation about treatment where negative expectations will offer a slower recovery and poorer results (Benedetti et al., 2003).
massage
Overall massage is shown to have very few physiological benefits for the body after sports performance however the psychological benefits are not to be over-looked. Being able to appear fresher and feel like you have recovered faster is good. Massage would appear to have no negative benefits, so why not use it all the time? This notion brings into play that if you do sustain an injury during sport but it feels better after a massage could the massage be in fact masking the injury? If you do muscle tissue damage and your immediate response is, I will get a massage and it will feel better, are you actually masking the problem and possibly risking a further and worse injury?

References
Benedetti, F., Pollo, A., Lopiano, L., Lanotte, M., Vighetti, S & Rainero, I. (2003) Conscious Expectation and Unconscious Conditioning in Analgesic Motor, and Hormonal Placebo/Nocebo responses. The Journal of Neuroscience. 23 (10), 4315-4323

Bialosky, J, E., Bishop, M, D., George, S, Z & Robinson, M, E., (2011). Placebo Response to Manual Therapy: Something out of Nothing? The Journal of Manual and Manipulative Therapy. 19(1): 11–19.
Gaitan-Sierra, C & Hyland, M, E., (2011). Nonspecific Mechanism That Enhance Well-being in Health-Promoting Behaviours. Health Psychology, American Psychological Association. 30 (6), 793-796

Geers, A, L., Weiland, P, E., Kosbab, K., Landry, S, J & Helfer, S, G. (2005). Goal Activation, Expectations, and the Placebo Effect. Journal of Personality and Social Psychology. 89 (2), 143-159.

Hemmings, B., Smith, M., Graydon, J & Dyson, R. (2000). Effects of Massage on Physiological Restoration, Perceived Recovery, and Repeated Sports Performance. British Journal of Sports Medicine. 34 (2), 109-114

Hume, P, A & Kolt, G, S., (2005). The Mechanisms of Massage and Effects on Performance, Muscle Recovery and Injury Prevention. Journal of Sports Medicine. 35 (3), 235-256.

Martin, N, A., Zoeller, R, F., Robertson, R, J & Lephart, S, M. (1998). The Comparative Effects of Sports Massage, Active Recovery, and Rest in Promoting Blood Lactate Clearance after Supramaximal Leg Exercise. Journal of Athletic Training. 33 (1), 30-35.

Robertson, A., Watt, J, M & Galloway, S, D, R. Effects of Leg Massage on Recovery From High Intensity Cycling Exercise. Journal of Sports Medicine. 38 (2), 173-176.

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Conditioning a Placebo

The archetypal placebo event occurs in a medical setting. A physician gives a patient a pill that, unbeknownst to the patient, is merely a sugar pill. This is the placebo. Presently, the patient’s health improves, apparently because of the belief that the pill was a pharmacological agent, effective for the condition. This is the placebo effect (Stewart-Williams and Podd, 2004).

Although a placebo can be defined, what may be beneficial to one person may be harmful (nocebo) or have no benefit to another.

Conditioning of a placebo is when a procedure is given and produces certain results; the procedure is then substituted for something similar but should have no effect. Benedetti et al. (2003) looked at a person with Parkinson’s and a sub thalamic stimulator which increases movement speed. In the study the machine was turned off twice and then the third time was left on although the patient was told it was turned off. This should have showed that there was no change in movement speed; this was not the case, movement speed still decreased. This demonstrates a conditioned response.

In a sporting context placebos can be as simple as telling someone they are able to do something which they are attempting to do or as seen in the movie Looney Tunes where bugs bunny gives the players water and says it is a performance enhancer. Benedetti et al. (2007) demonstrated that a conditioned placebo may be affective for up to a week after the drug has stopped being administered. This raises many questions for doping during competition, if someone is able to condition themselves enough to get a benefit during the competition they will have an advantage over the competition and won’t show up any drugs in their system.

A placebo in sport doesn’t have to be a drug it may be as simple as routine or lucky clothing, which the player believes makes them play better. This belief creates a placebo effect. The reverse is also true, if a player thinks they aren’t able to perform without this “lucky clothing” or routine then they are likely to underperform without it.

Many studies have looked at the conditioning of a placebo, most are in relation to pain and being able to withstand pain as long as possible. In particular a study by Benedetti et al. 2003 who looked at the pain in response to a tourniquet. Benedetti measured his study by comparing 5 different treatment options.

Having a blind study would be the most beneficial as a comparison of multiple different aspects could be seen along with making it simple enough to impart a placebo by verbal suggestion.

There are many studies which investigate placebo and what we do understand is that some treatments can have a dampening effect on a conditioned placebo, Naloxone was seen by Pollo et al. (2011) and they concluded the endogenous opioid system was being interfered with.

The opioid system is a top-down regulatory system extending from cognitive and affective cortical brain regions to the brainstem and spinal cord dorsal horns, with the ability to negatively modulate the incoming nociceptive signals (Pollo et al. 2011).

In terms of a conditioned placebo there still has to be more research into how long the placebo effect can last, this could be especially useful for WADA (world anti-doping association) and making regulations so as to make sure everyone is on a level playing field.

If coaches are able to utilise the effect of creating a routine and getting players thinking that they can perform well the players are likely to perform better in competition. The question becomes difficult in relation to giving a substance which is to be used during the training week and a placebo in competition. If the player knows about the placebo will they still perform without or will they rely on the substance? Let alone will the player be able to trust the coach after when they find out about the placebo?  Should players be relying on substances in the first place?

Reference list

Stewart-Williams, S., & Podd, J. (2004). The Placebo Effect: Dissolving the Expectancy Versus Conditioning Debate. Psychological Bulletin. 130(2), 324-340.

Benedetti, F., Pollo, A., Lopiano L., Lanotte, M., Vighetti, S., & Rainero I. (2003). Conscious Expectation and Unconscious Conditioning in Analgesic, Motor, and Hormonal Placebo/Nocebo Responses. The Journal of Neuroscience. 23(10), 4315-4323.

Benedetti, F., Pollo, A., & Colloca, L. (2007). Opioid-Mediated Placebo Responses Boost Pain Endurance and Physical Performance: Is It Doping in Sport Competitions? The Journal of Neuroscience. 27(44), 11934-11939.

Pollo, A., Carlino, E., & Benedetti, F. (2011). Placebo Mechanisms Across Different Conditions: From the Clinical Setting to Physical Performance. Philosophical Transactions of the Royal Society B. 366, 1790-1798, doi:10.1098/rstb.2010.0381.

Benedetti, F., Mayberg, H., Wager, T., Stohler, C., Zubieta, J. (2005). Neurobiological Mechanisms of the Placebo Effect. The Journal of Neuroscience. 25(45), 10390-10402.

Deharhnais, R., Jobin, J., Cote, C., Levesque, L., Godin, G. (1993). Aerobic Exercise and the Placebo Effect: A Controlled Study. Psychosomatic Medicine. 55, 149-154.