Posted in Ella's blog posts

A placebo effect without deception

Author: Ella Ward, date published: 28/10/13

The problem of using placebo’s in sport arises when a coach’s desire to improve performance involves deception and compromises the coach-athlete relationship. A solution would be to demonstrate a placebos efficacy without deception (Benedetti et al., 2011). Recently, a study by Friedlander et al. (2010) supported the solution, concluding open-label placebos improved the symptoms in patients with Irritable Bowel Syndrome (IBS). Conversely, a study by Fitzpatrick et al. (2007) reported a decline in force production after disclosing the nature of the placebo intervention. Contrary to these two studies, the solution is sparsely investigated in the literature. Thus, a research proposal will be constructed to investigate a placebo intervention without deception. This will also provide coaches and sports scientists with a framework to optimise a placebo effect without deception.

The purpose of the proposed study is to determine whether Kinesio-tape improves circulation in the gastrocnemius muscle during cycling. The study design will be within-group. This is an improvement to Friedlander’s between-group design, where participants assigned no treatment may have been disappointed. This may have negatively influenced the results (Kaptchuk et al., 2011). Furthermore, the study will be unblinded. This is integral to its validity because it needs to reflect the circumstances where both the coach and athlete are agreeable to the placebo. However, unblinded studies have associated risks of bias (Chen et al., 2011; Kaptchuk et al., 2011).

For example, participants may change their behaviour during experimental research. This change is known as the Hawthorne Effect (Campbell et al., 2009; Rowland, 1994). Despite being difficult to overcome in a laboratory environment, measures will be taken to prevent this. For example, the cycle ergometer wattage and revolutions per minute would be maintained at constant values throughout the testing to prevent participants exercising at a higher work rate.

Another limitation is response bias, which occurs through self-reporting methods (Kaptchuk et al., 2011). An example of this occurs when participant’s who are overweight tend to over-estimate duration and intensity of exercise to “please” the experimenters (Acra et al., 1999). This bias was a limitation of Friedlander’s study because only subjective measures were collected. This inhibited researchers from discriminating between response bias or the placebo physiologically improving the condition (Kaptchuk et al., 2010). Therefore, this study will collect objective measures (Kaptchuk et al., 2011). For example, circulation will be measured by exercise physiologists using a non-invasive Laser Doppler. This method has been used in previous studies investigating KT and circulation (Docherty et al., 2012; Hashimoto & Kase, 1998). Differences between responders and non-responders will be investigated by sports psychologists. This would consist of a pre-participation questionnaire, examining the individual’s expectations, beliefs and personality traits such as Five Factor Model (McCrae & John, 1992). Each participants subjective results would be compared to their objective results.

Lastly, an unblinded study may heighten a placebo effect through the expectancy effect (Kaptchuk et al., 2011). Expectancy plays an important role in the efficacy of placebos (Benedetti et al., 2005). Friedlander’s study contained this bias due to its persuasive debriefing, which inadvertently communicated to the participants the expected results (Campbell et al., 2009; Kaptchuk et al., 2010). It is important to note that discussion of the pros and cons of treatment and shared decision making is an integral component in the coach-athlete relationship (Miller et al., 2012). Therefore, the debriefing rationale will not induce expectation, but will present multiple findings from clinical studies. For example: “one study concluded KT did not affect circulation, however another study concluded KT improved circulation when combined with low-strength exercises” (Docherty et al., 2012; Hashimoto & Kase, 1998).

The results from this study would further advance the knowledge in this field. It would also have the potential to improve performance and provide an alternate route for coaches to pursue which does not compromise the coach-athlete relationship. However overall, there is no empirical evidence supporting the efficacy of placebo’s without deception (Fitzpatrick et al., 2007). Thus, the solution would require large amounts of clinical research to match the literature that has been previously published on placebos, which may be unrealistic. The solution may also have implications to previous research, which may become invalid and meaningless when compared to overt placebo trials. The question still exists that if the research yields significant findings, will sports scientists and coaches use the results? Or will the traditional method of deception still be used due to its simplistic nature?

 

Reference list:

Acra, S. A., Buchowski, M. S., Chen, K. Y., Sun, M., & Townsend, K. M. (1999). Energy expenditure determined by self-reported physical activity is related to body fatness. Obes Res, 7(1), 23-33.

Benedetti, F., Carlino, E., & Pollo, A. (2011). Placebo mechanisms across different conditions: from the clinical setting to physical performance. Philosophical Transactions of the Royal Society B: Biological Sciences, 366(1572), 1790-1798.

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

Campbell, Cumming, Gerrig, Wilkes, & Zimbardo. (2009). Psychology and Life (Australian ed.). Australia: Pearson Education Australia.

Chen, M. H., Horsley, T., Moher, D., Morissette, K., & Tricco, A. C. (2011). Blinded versus unblinded assessments of risk of bias in studies included in a systematic review. Cochrane Database Systemic Review, 7(9).

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

Fitzpatrick, J., Kalasountas, V., & Reed, J. (2007). The effect of placebo-induced changes in expectancies on maximal force production in college students. Journal of Applied Sport Psychology, 19(1), 116-124.

Hashimoto, T., & Kase, K. (1998). Changes in the volume of the peripheral blood flow by using Kinesio Taping®. Available at www.kinesiotaping.com.

Kaptchuk, T. J., Friedlander, E., Kelley, J. M., & Kirsch, I. (2010). Placebos without deception: a randomized controlled trial in irritable bowel syndrome. PLoS One, 5(12), e15591.

Kaptchuk, T. J., Hrobjartsson, A., & Miller, F. G. (2011). Placebo effect studies are susceptible to response bias and to other types of biases. Journal of Clinical Epidemiology, 64(11), 1223-1229.

McCrae, R. R., & John, O. P. (1992). An introduction to the five-factor model and its applications. Journal of personality, 60(2), 175-215.

Miller, F. G., Brody, H., & Colloca, L. (2012). The placebo phenomenon: implications for the ethics of shared decision-making. Journal of General Internal Medicine(6), 739-742.

Rowland, T. W. (1994). On exercise physiology and the psyche. Pediatric Exercise Science, 6(2), 111-113.

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Posted in Ella's blog posts

The effect of deceit on the coach-athlete relationship

Author: Ella Ward, date published: 03/10/13

As well as being influenced by one’s psychosocial context, the efficacy of a placebo is attributed to deceitful administration (Benedetti et al., 2005; Justman, 2013). An infamous high-performance example of this is of French cyclist Richard Virenque, who attributed his success one day to a stimulant he had been injected with, however unbeknown to him, the injection contained just glucose and not the stimulant he was expecting (Vogt, 1999). As demonstrated in this example, a placebo is often administered by a third party such as a coach (Beedie, 2007). Thus, the problem arises when coach’s desire to improve performance involves deceit and compromises the coach-athlete relationship.

The coach-athlete relationship is regarded as a critical component to athlete success; with the quality of the relationship positively influencing an athlete’s self-efficacy, motivation and satisfaction (Davis et al., 2013; Jowett et al., 2012). Over the past decade there has been an abundance of conceptual frameworks developed to model this interdependent dyadic relationship; with Jowett’s (2007) model “3Cs” receiving heightened attention due to its divergence from traditional attachment theories (Davis et al., 2013). This model purports the quality of the relationship is dependent on the equilibrium of three key constructs: closeness, co-orientation and complementarity (Jowett, 2003; Jowett, 2007). However, negating anecdotal reports, there is little empirical evidence regarding the implications of deceit on the relationship (Beedie & Foad, 2009). Therefore, the next section discusses the possible implications of this, drawing upon examples from a case study by Jowett (2003) on relationships in crisis.

An athlete’s motivation has been attributed to their perception of shared closeness with the coach, thus in the event of deceit, feelings, anger, isolation, manipulation and undermining of trust may emerge, changing with how the athlete interacts with their coach and sport (Jowett, 2003).  In addition, because the efficacy of a placebo is attributed to deceit, an athlete may be misinformed about the placebo treatment or even excluded from the decision making (Brody et al., 2012; Justman, 2013). From a coaches perspective, the deception may be justified in that it improves performance, however this lack of co-orientation and incongruent expectations may result in conflict (Jowett, 2003). Higher quality relationships exhibit balanced complementarity. Contrary to this, if the athlete perceives their coach in a more powerful position, it is speculated that a placebo is more likely to be effective (Beedie, 2007). Despite the potential performance improvements, the resultant power imbalance can reverse the effectiveness of the relationship resulting in dysfunction (Davis & Jowett, 2013).

Interestingly, qualitative studies have reported individual sport athletes perceive greater relationship quality compared to team sport athletes, suggesting that overall conflict in this relationship may be more damaging (Jowett et al., 2012). Overall, the deceitful administration of a placebo is speculated to be more prevalent in high-performance sport, where athletes performance is continually being influenced and manipulated by coaches and sports scientists.  However, deceit does not only effect the coach-athlete relationship. A congruent problem is a placebo may avert people from seeking proper treatment, thus also highlighting the problem of long-term implications of delayed treatment (Clemence, 2001).

I believe the relationship shared between the coach and athlete is more powerful than any placebo effect. However, this problem is still not easily solved as coaches will continue to strive to improve performance by that fraction of a percent, possibly regardless of the implications. Therefore it is critical that research is conducted by sports psychologists and exercise scientists is aimed at demonstrating placebo effects can be achieved under circumstances in which the athlete knows it is a placebo. In the meantime, coaches need further education regarding the detrimental effects of their actions. Coaches have a ethical commitment to their athletes, therefore need to exercise full disclosure even though it may negate the efficacy of any placebo.

Reference list:

Beedie, C. J. (2007). Placebo effects in competitive sport: qualitative data. Journal of Sports Science and Medicine, 6, 21-28.

Beedie, C. J., & Foad, A. J. (2009). The placebo effect in sports performance. Sports Medicine, 39(4), 313-329.

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

Brody, H., Colloca, L., & Miller, F. G. (2012). The placebo phenomenon: implications for the ethics of Shared Decision-Making. Journal of General Internal Medicine(6), 739-742.

Clemence, M. (2001). Developing the ethics of placebos in physiotherapy. Physiotherapy, 87(11), 582-586.

Davis, L., & Jowett, S. (2013). Attachment styles within the coach-athlete dyad: preliminary investigation and assessment development. Journal of Clinical Sport Psychology, 7(2), 120-145.

Davis, L., Jowett, S., & Lafrenière, M.-A. (2013). An attachment theory perspective in the examination of relational processes associated with coach-athlete dyads. Journal of Sport & Exercise Psychology, 35, 156-167.

Jowett, S. (2003). When the” honeymoon” is over: a case study of a coach-athlete dyad in crisis. Sport Psychologist, 17(4), 444-460.

Jowett, S. (2007). Interdependence analysis and the 3 + 1Cs in the coach-athlete relationship. In S. Jowett & D. Lavallee (Eds.), Social psychology in sport (pp. 63-77). Champaign, IL: Human Kinetics.

Jowett, S., Rhind, D. J. A., & Yang, S. X. (2012). A comparison of athletes’ perceptions of the coach-athlete relationship in team and individual sports. Journal of Sport Behavior, 35(4), 433-452.

Justman, S. (2013). Deceit and transparency in placebo research. Yale Journal of Biology and Medicine, 86, 323-331.

Vogt, W. (1999). Breaking the chain: drugs and cycling, the true story. London: Random House/Yellow Jersey Press. In Beedie, C. J. (2007). Placebo effects in competitive sport: qualitative data. Journal of Sports Science and Medicine, 6, 21-28.

Posted in Ella's blog posts

Sports performance, placebo effects and kinesio-tape

Author: Ella Ward, date published: 29/08/13

Kinesio tape

Kinesio®-tape (KT) is widely used by athletes despite its unexplained performance benefits and clinical evidence of its futility (Kamper & Williams, 2013; Stedge et al., 2012). There are anecdotal reports ranging from improvements in circulation to greater strength, but researchers suggest these improvements in performance are due to a placebo effect, not from the KT itself (Stedge et al., 2012). This blog explores the issues associated with KT tape and associated limitations of research, as well as the psychological concepts of the placebo effect.

A method commonly employed by researchers to measure the efficacy of KT is the improper application of KT. For example, in a study by Ayter and colleagues in 2011, researchers used a treatment (proper application of KT) and a placebo group (sticking plaster without stretch) to assess the effect of KT on patellofemoral pain syndrome. Researchers did observe increases in pain, proprioception, balance and muscle strength with both the placebo and treatment groups (Aytar et al., 2011). However, as no control group was employed in this study, we are unable to determine whether the improvements observed were due to a placebo effect, the effect of taping alone or from the KT (Beedie, 2007). In addition, more research is needed in the field in competitive environments, rather than in a laboratory environment for KT to be accepted as therapeutic intervention in sport and performance (Beedie, 2007).

Despite the vast amount of research in the area of placebos, the phenomenon has remained largely unchallenged in the area of sport and performance (Stedge et al., 2012). In many studies, like the one above, researchers aim to investigate the efficacy of KT as a placebo assuming the outcome is a result of a placebo effect. However, if we are directly observing its effect, studies would be best served by measuring what actually causes it and explaining how and why this effect is observed in this situation, not just assuming a placebo effect has occurred. It is also important to note that care must be taken when measuring and observing the placebo effect due to psychosocial influences, as both belief and expectancy have been acknowledged as determining factors in the efficacy of placebo effects (Beedie, 2007; Benedetti et al., 2005). As these factors are not accounted for in many of the studies investigating the efficacy of KT, it may be beneficial to also conduct questionnaires and interviews in conjunction with clinical trials to generate an understanding of one’s psychosocial expectations and beliefs.

One’s belief influences the outcome in the belief of receiving a beneficial treatment (Beedie, 2007). However it is difficult to measure, quantify and determine the strength of one’s belief of its effects on athletic performance. For example, would a recreational athlete with the same belief as an elite athlete show a greater improvement in performance? And if the athlete was Usian Bolt, could he physiologically improve his performance anymore or is it at the “limit” of belief and placebo effect?

In comparison, expectancy refers to how an individual’s behaviour is influenced by the expectation of how they are meant to feel (Aktas & Baltaci, 2011). If we can elicit a placebo effect by verbally persuading someone of how they are expected to feel, it would also be of interest to examine the effect of reversing expectancy and whether this results in decrements in performance. Expectancy in KT application may also be associated with Pavlov’s theory of classical conditioning (Benedetti et al., 2005). However, the majority of studies look at the immediate effect after its application, not the effect of repeated trials on the efficacy of KT (Aytar et al., 2011; Stedge et al., 2012).

Overall, KT and the placebo effect are relevant in sport and performance, as psychologists can manipulate this intervention to enhance athletic performance; avoiding more intrusive, unethical and expensive treatment methods. However, sport practitioners and psychologists need to be confident that KT is actually beneficial for their athletes in order to recommend it as a therapeutic intervention, and convincing empirical evidence is not available yet. Therefore, practitioners need to make an informed appraisal, taking into consideration the individual’s specific psychosocial context. As it is a harmless intervention, and there potential for performance improvement, there is no harm in using Kinesio-tape.

Now after reading this, please vote on this pole:

Reference list:

Image sourced from Flickr creative commons; http://www.flickr.com/photos/zenmama/8653547400/

Aktas, G., & Baltaci, G. (2011). Does kinesiotaping increase knee muscles strength and functional performance? Isokinetics & Exercise Science, 19(3), 149-155.

Aytar, A., Ozunlu, N., Surenkok, O., Baltacı, G., Oztop, P., & Karatas, M. (2011). Initial effects of kinesio® taping in patients with patellofemoral pain syndrome: A randomized, double-blind study. Isokinetics & Exercise Science, 19(2), 135-142.

Beedie, C. J. (2007). Placebo effects in competitive sport: Qualitative data. Journal of Sports Science and Medicine, 6, 21-28.

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

Kamper, S. J., & Williams, C. M. (2013). The placebo effect: powerful, powerless or redundant? British Journal of Sports Medicine, 47(1), 6-9.

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