Strength is Never a Weakness: August 2015

Tuesday 18 August 2015

Lying to Make Athlete's Stronger: The Placebo Story

Lying to Make Athletes Stronger: The Placebo Story

By Andrew Richardson

Immediate Disclaimer: I never lie to my athletes, I have never used a placebo or placebos on them as it is unethical due to it not being in a lab/sports science setting under controlled conditions with participants consent to be part of a controlled study.

What if I told you there was a way to get stronger, bigger, faster, learner, jacked and tanned, or just better at anything and everything? Well there is but you may have already experienced without being told it.

There is something called a “Placebo” which you may of heard of. Not the band called Placebo (still great but wrong context for this article). A placebo can be described as “something fake which is believed by someone to make it very real”, “a substance that has a positive effect as a result of a patient’s perception that it is beneficial rather than as a result of a causative ingredient”, “an inactive substance or preparation used as a control in an experiment or test to determine the effectiveness of a medical drug”. “Something of no intrinsic remedial value that is used to appease or reassure another”.

Placebos can be used on a variety of situations and have been known to be used for a very long time. Some theorist’s believe Stonehenge in England was the first “Placebo Hospital” as people would come to see it for the stones magic healing powers. Another example of a Placebo is when a child falls and hurts their leg (small cut nothing serious) they scream for help. Mum appears she calsm the child and kisses the leg better. The child feels better even tho the mum didn’t do anything (medically speaking) to take away the pain. It was all in the head or unless mums have superpowers.

Doctors have described placebos as a mistake as we are letting our guard down to get something done. In Research particularly Sports Science it is a controversial subject. One lecturer I recall saying to a student “You want to do a study on Placebo’s Effecting Sport Performance? Hahah Good luck funding that one”.

Top Ten Facts about Placebo’s

1/ Designed to get Consumers. The Supplement Industry uses this so much.

2/ It has physical and psychological responses

3/ The Bigger the production the bigger the effect: What this means is if someone takes a white pill it has an effect, if the pill changes shape that effect is increased, then if the colour of the pill is changed, again the effect of the placebo increases. Then if someone has an injection the placebo effect is dramatically increased. Then of course if you have surgery then this is increased tenfold compared to the pill.

4/ Placebo’s can affect fertility rates: One study was trying to help women get pregnant as they were struggling to do so. 2 groups of 33 women took part one used a sugar pill the other used actual drugs. The placebo group only got 5 pregnant and the actual test group got 7 pregnant proving that the placebo was useless.

5/ Can negate the effects of drugs

6/ Price of treatment affects results: The increased price means to consumers, it costs more so it must be better where in fact it’s the same thing you are just paying for the labelling.

7/ Brand names affect results: Some sprinters feel faster in specific brands of clothing.

8/ Placebos work better than ever before: No one knows why this is the case maybe we like being told what we want to be told.

9/ If you know it’s a placebo you can still get better: Some study groups have shown this but most (including an example later on) will disprove this point.

10/ Placebo surgery is effective: This is used heavily in cartilage surgery where they take the patient to surgery and open them up but don’t do anything.

The Research

Athletes look for any product, technology, or process that might provide tem a competitive advantage. This leads some athletes to use illegal and potentially harmful drugs. Resulting in 73 documented deaths of athletes using PED’s in sport.

Counterintuitive Suggestion?

A small number of athlete’s who have failed drug tests have claimed that they did not know they had taken the drug. One athlete stated that a drug is only fully effective if the individual is aware that they have taken it

This lent some support by medical staff and was consistent with recent findings in medicine (Benedetti et al 2009). A placebo effect is a desirable outcome resulting from the belief that treatment has been received.

A Placebo Effect V Placebo Control

A neurophysiological event driven by expectation of conditioning
An experimental conditioning used to control for a range of potential confounds.

Below is an image by Dr Chris Beedie from Aberystwyth Uni where it compares experimental designs using caffeine in sports performance.

The balanced placebo is the most interesting as it has 4 different levels = 4 different sets of results as the group has been manipulated in 4 variables.

Reviews from studies (Beedie & Ford 2009, Berdiet et al 2011) indicate a moderate overall effect size for placebo studies in sport performance (n=14).

Wide Range of Interventions involving Placebos

Anabolic steroids (Ariel et al 1972 and Maganaris et al 2000)
Morphine (Benedetti et al 2007)
Carbohydrate (Clarke et al 2000, Hulson & Jeukendrup 2009)
Caffeine (Beedie et al 2006, Foal et al 2008)
Sodium Bicarbonate (McClung & Collins 2007)

How Large is the Placebo Effect on Performance?

Sustainal Varaibility
Generaly < 10% above baseline
Possible substance – response relationship (Beedie & Ford 2007, Berdiet et al 2011)
Anabolic Steroids (Ariel et al 1972 and Maganaris et al 2000)
Morphine (Benedetti et al 2007)
Carbohydrate (Clarke et al 2000)
Caffeine (Beedie et al 2006, Foal et al 2008)
Sodium Bicarbonate (McClung & Collins 2007)

Can a Placebo have a Negative Effect on Performance?

Athlete expectation predicts effect
Positive placebo effect driven by positive expectation
Negative expectation can lead to negative outcomes (Beedie et al 2006, Foal et al 2008, Beedie et al 2007, Beedie 2007, Benetti & Hopkins 2009, Duncan 2010.
Novebo Effect

Isn’t the Placebo Effect in Sport Simply the result of Increased Motivation?

Motivation is a factor yes
Increased motivation is associated with increased load
Evidence for improved performance in absence of;

1: Increased physiological load (Foad et al 2008, McClung & Collins 2007)

2: Increased perception of effort (Beedie et al 2006, Beedie et al 2007)
Same level of performance at;

1: Reduced physiological load (Foad et al 2008, McClung & Collins 2007)

2: Love Perceived Effort (Foad et al 2008, McClung & Collins 2007)

Placebo Response unlikely a stable characteristic of athlete (Beedie et al 2006, Beedie 2007)

Personality did not predict placebo responding (beedie et al 2008)
Athletes respond to placebo in one experimental trial but not another (beedie et al 2006)

Can the Placebo effect help and Athlete in Competition?

Placebo effects as laboratory phenomenon (Hopkins 1999)
Much anecdotal evidence for real world placebo effects
Hurst et al 2013, investigated the placebo effects of caffeine on a competitive 5km track time trial
Used balanced placebo design (shown earlier)
Both CP & CC associated with enhanced performance over PP & PC

Can a Placebo Enhance Performances even when the athlete knows it is a Placebo?

Athletes underperform in “open labelled” conditions (Beedie et al 2006, Foal et al 2008, Hurst et al 2013)
However positive effects of open labelled placebos in medicine recently demonstrated (Kaptchuk 2010)
Open labelled placebo “this is a placebo”. Placebos have been found to improve sports performance by up to 5% in a number of scientific studies.
Pilot study (n=12) used Cooper test
Mean improvement of 2.8%

British Cycling Head Coach Dave Brailsford sought to make up the 5% gap of which PED’s create over the drug free cyclists. This involved improving every aspect of the cycling team’s performance by 1%. It included the following;

Own team bus
Own chef to meal prep at all hotels and venues
Own bed sheets and pillows brought to each hotel to improve sleep quality
De-Humidifiers in each room to make sure the air humidity was perfect for each athlete
Bikes all custom made to fit each athlete
All bikes made lighter
All athletes changed their riding positon to create less resistance when riding
Clothing was lighter as well
Team Psychologists for each athlete to make sure they are in the correct mental state

With all these personalised improvements perhaps one can speculate a placebo effect was created as the athletes felt they would get better simply by being a part of Team Sky’s plan. They have won 3 Tour De Frances in the last 5 years so something must be working.

What do Athletes believe are the Mechanism’s of the Placebo effect in Sport?

Self report data (questionnaire & interview usually post study) (Beedie et al 2006, Foal et al 2008, Beedie et al 2007, Beedie 2007, Hurst et al 2015.
Motivation “I just felt more up for it”
Pain reduction “The pain just went away”
Emotion “I felt calmer & less tense”
Pacing “I went out harder & was able to hold it there”
Physiology “My body seemed to swtich into a different mode, it just did things more efficiently”

What are the potential Applications of Placebo Effect in Research?

Anti-Doping: education re the role of the mind in drug effects (McClung & Collins 2007).

1: previous cases (Maganaris et al 2000)

2: debrief interviews (Beedie et al 2006, Foal et al 2008, Beedie 2007)
Sport Psychology: placebo responsiveness as indicator of sub optimal status?
Research: better interpretation of findings in placebo controlled performance studies

Current Anti-Doping Research (Hurst, Foal, Coleman & Beedie )

Evaluate athletes existing Attitude Towards;

1: Drug Effectiveness

2: Drug Mechanism’s

3: Likelihood of future drug use

This feeds into the following,

Expose Athlete to Either:

1: First hand experience of placebo effect on sports performance (experience intervention) n=400

2: Educational material relating to the placebo effect on sports performance (education intervention) n=100.

This feeds into the following;

Evaluate any changes in Attitude towards;

1: Drug effectiveness

2: Drug mechanics

3: Likelihood of future drug use

Most studies use legal substances (caffeine, creatine, sodium bicarbonate)
Only 1 studies have used illegal (morphine) (Benedetti et al 2007)
Problems with both (Method & Testing)
Anti-Doping Application’s likely only relevant if placebo effects associated with drugs athletes abuse.
A definitive study of placebo & real abuse (biological) effects of an illegal performance enhancing drug is required.

Placebo Effect and Anabolic Steroids

Two studies

1/ Ariel et al (1972) “Anabolic Steroids: The Physiological Effects of Placebo’s”. Medicine & Science in Sports. Vol 4. 124-26.

In this study 15 male lifters were told the subjects who make the best progress/gains on the strength training protocol would be chosen to go on a course of anabolic steroids for 4 weeks after the 4 week protocol.

This group have the extrinsic motivation to train hard to get the drugs however, they are unaware that the steroids are actually sugar pills. (hahahah gutting for the 15 guys but all for the pursuit for good data in science)

The strength protocol was training on seated shoulder press, military press and bench press. So these 15 guys trained their asses off and after 4 weeks of training 6 of the 15 where chosen as they made the best progress averaging out 11kg over the 3 lifts. The 6 then began the “sugar pill/steroid medication”.

After the 4 week training/medicated cycle using the same training protocol as before, the results showed they gained an average of 45kg (about 100 pounds) between the three lifts. That compared to the 24 pounds total in the first 4 weeks between the lifts. Making someone believe they are on drugs, they expect to gain strength and size quickly. The human mind is a great tool in a training arsenal if used correctly.

2/ Maganaris et al (2000). “Expectancy Effects & Strength Training: Do Steroids make a difference? Sport Psychologist. Vol 14. No 3. 272-278.

11 national level powerlifters from Great Britain were all looking to get stronger through illegal means. They asked their coach if he could get them some PED’s. The coach being very smart and sly agreed to getting them the stuff, but what the athletes didn’t know was the coach had other ideas.

The coach gave all the athletes a saccharine pill or as he told the athletes “an oral steroid which is fast acting”. I can’t believe they believed him as anything orally taken usually gets destroyed by protein enzymes and stomach acid during digestion.

11 athletes took the pill they then went and immediately tested their maxes on Squat Bench and Deadlift. All improved by 4-5% on their lifts. Now National level lifters beating their PB’s by 4-5% (that’s a lot). They group kept training for another 2 weeks taking the pill and relying feeback to their coach. The reports showed they kept hitting training PB’s and volume Pb’s each session being on this “pill”.

After the 2 weeks they came in again to test, but before they did the group was split into 6 and 5. The 5 where told they weren’t on gear all along but a sugar pill. The 6 weren’t told anything but given more pills. The 6 improved again however the 5 regressed back to their old PB’s even tho they weren’t using drugs.

How I Would Use a Placebo:

Build trust with a group of clients
Tell them about a programme that is aimed at their goals
Get a list of references and exaggerate the results to make it seem it brings craxy results
Give them an incentive to train harder. Part A of the programme 20 people do and all fight for 10 secret prizes that will make them even bigger/stronger
Another motivating factor for all participants is using money. The ten who put on the most muscle get £100 per person
Those that get into the 10 spots (based on how much they gained off the programme) are given a top nutrition plan (a simple plan just labelled highly scientific with fancy words and graphs)
Now you have two groups 10 who got the nutrition plan and 10 who didn’t. Within the nutritional plan split it into 2 groups of 5. Both still receive the same nutritional plan however one is given a sugar pill labelled as a muscle gain pill which has been approved by the IOC.
From this all groups run the same training protocol and seen from the three variables who packs on the most muscle.
The placebo group with the sugar pill will probably pack on the most as they are led to believe they have been giving a muscle building drug closely followed by the nutritional plan group.

BUT…..

I couldn’t do this as it is unethical and if I did people would complain that I lied to them even tho I made them better. This feeds into the ethics of placebo trials.

An Ethical Dilemma?

To placebo or not to placebo? That is perhaps a question each coach/trainer/physio/doctor may ultimately have to answer individually.

Given the potentially placebo-inducing advertising in the sport, health & fitness industry (think sleazy advertising), should the coach consider it part of his job to influence his athlete’s perceptions of supplements. Mean if a kid came in saying he got a weight gainer all happy and excited (looking convinced it would make him into a freak) should we tell him he doesn’t need it or encourage him as it will give him the placebo effect?
Is lying to athletes morally defensive if one’s intentions are good, especially if most high level athletes are willing to be deceived if it would improve performance (Berdi et al 2014)

I personally believe placebos are linked with what can and can’t be done regarding certain tasks. If we remove all perception of what is possible and impossible form the task then is there a need for a placebo. One case is the story of Cliff Young.

Cliff Young: Sheep Farmer to Ultra Endurance Legend

Cliff Young 61 year old sheep farmer wins 1993 ultra-endurance race in Australia. This was 543.7 miles from Sydney to Melbourne.

He turned up in boots and overalls and entered the race. People looked at him to the professional youthful athletes in shock. Cliff said he could do it, all the other competitor’s laughed at him. They asked him why he thought he could do it. Cliff replied “Yes I can, you see I grew up and worked on a farm where I still do to this day. On this farm we have 2,000 acres with 2,000 sheep. I would spend 2-3 days at a time running after the sheep. It took a long time but I would always catch them”.

When the race started the pro’s quickly left Cliff. Cliff also didn’t run, he shuffled the whole way. Post race analysis of Cliff’s running mechanics/gait showed it was very energy efficient. This style of running for this event has made a lot of pro’s change their style to this one.

The pro’s knew it took 5 days to finish the race, in order to compete they decided to run 18 hours at a time then sleep 6 hours at a time. The thing was Cliff didn’t know that he just ran all through it.

Cliff literally meant he would spend 2-3 days running after his sheep. Everyone was surprised when Cliff said he was going to run it straight with no rest. By the final night he passed all the competitor’s and won the race well ahead of anyone. Set a new World Record in the process. Years later after competitor’s adopted Cliff’s outlook and style of running another day has been taken off his time.

Summary: Placebos & Drugs in the Real World

In the absence of a biological intervention

Belief that you have taken a drug might result in a therapeutic outcome
Negative expectations of the drug might result in a undesirable response

In the presence of a biological intervention

Knowledge that you have taken the drug might augment the biological effect
Ignorance of having taken the drug might offset some of the biological effect
Negative expectations of the drug might antigonise the biological effect

The human mind is very powerful if we believe something works even tho it has no significance on the outcome it will still work.

I hope you enjoyed reading this

Take care

Andrew

Andrew Richardson, Founder of Strength is Never a Weakness Blog

I have a BSc (Hons) in Applied Sport Science and a Merit in my MSc in Sport and Exercise Science and I passed my PGCE at Teesside University.

Now I will be commencing my PhD into "Investigating Sedentary Lifestyles of the Tees Valley" this October 2019.

I am employed by Teesside University Sport and WellBeing Department as a PT/Fitness Instructor.

My long term goal is to become a Sport Science and/or Sport and Exercise Lecturer. I am also keen to contribute to academia via continued research in a quest for new knowledge.

My most recent publications:

https://www.sciencedirect.com/science/article/pii/S1752928X19300216

https://www.sciencedirect.com/science/article/abs/pii/S1752928X19301076

My passion is for Sport Science which has led to additional interests incorporating Sports Psychology, Body Dysmorphia, AAS, Doping and Strength and Conditioning.

Within these respective fields, I have a passion for Strength Training, Fitness Testing, Periodisation and Tapering.

I write for numerous websites across the UK and Ireland including my own blog Strength is Never a Weakness.

I had my own business for providing training plans for teams and athletes.

I was one of the Irish National Coaches for Powerlifting, and have attained two 3rd places at the first World University Championships,

in Belarus in July 2016.Feel free to email me or call me as I am always looking for the next challenge.

Contact details below;

Facebook: Andrew Richardson (search for)

Facebook Page: @StrengthisNeveraWeakness

Twitter: @arichie17

Instagram: @arichiepowerlifting

Snapchat: @andypowerlifter

Email: a.s.richardson@tees.ac.uk

Linkedin: https://www.linkedin.com/in/andrew-richardson-b0039278

Research Gate: https://www.researchgate.net/profile/Andrew_Richardson7

Friday 14 August 2015

Dr Luke Thomas Chiropractic Series: Issue 2 Valgus Deformity and Fascia

The first in a series of articles

Valgus deformity and fascia.

In this follow up article, I will endeavour to pick up on some common squatting faults and how they could theoretically relate to certain categories of back pain seen in my clinic, hopefully taking you on a journey across some interesting material along the way. First and foremost all views are my own, however will be corroborated by research/best clinical practice where applicable, this is also not intended as a “diagnose yourself workbook” more as an intellectual exercise for PTs, Healthcare therapists and the educated athlete.

As mentioned in previous articles by Andrew squatting most certainly not solely hypertrophic exercise, squatting in my opinion spans a chasm between balance, co ordination, strength, speed and mental focus. With so many components there is A LOT that can go wrong and ultimately lead to injuries. Personally I think that the largest amount of ignorance is to be found with regard to neurological stabilization (balance) within the squat (as Andrew alluded to in his last article). We constantly train strength, speed, power, and watch videos on mental focus/motivation, yet if we have an issue we normally negate the balance/co ordination component. Ignoring this vital aspect is often a major tripping point for the intermediate lifter. Looking at the sensory homunculus (a homunculus is a physical representation of the density of sensory nerves and thus the amount of brain attributed to them) we can see an inordinate amount of receptors in the hands, the face, the tongue and then the feet. Ill hopefully touch further on this in following articles, but these are the main areas of the nervous system that are constantly sending signals to the brain in order to allow it to modify and stabilize in its environment, when we squat we should pay more attention to our feet.

Following on from that statement ill begin on the first category, and one I suffer with myself.

Valgus deformity.

Valgus deformity refers to an inwards collapsing of the knees at any point in the squat. I asked Andrew previously for his opinion on this, and very rightly he concluded a weakness/inhibition of the glutes (med) leading to a lack of external rotation of the femur. As a coach he suggested banded hypertrophy work, alteration of my stance, using my hips more (opening up my hips/taint). Some possible solutions to a very common problem in many lifters. Why did this issue arise though? As we know the body is fond of subconscious shortcuts and normally utilizes the path of least resistance without you even realizing it. The body is unfortunately only so smart; this shortcut works great in the short term, however long term leads to poor motor patterning and unsurprisingly, injury. Most evolutionary biologists will tell us this is short term compromise is a neurological adaptation evolved to get us out of sticky situation (cue being chased by a bear and stubbing your toe followed by a limping gallop) works great there and then, just not over and over again as in our training. Does that mean there is a case for a mild vaglus deformity on meet day? Possibility……

How does this relate to back pain? Just as I introduced you to some of my favourite functional categorization of the joints of the body (joint by joint approach by Mike boyle/Gray Cook), ill now introduce you to my favourite categorization of the human fascial planes.

Thomas Myers introduced “Anatomy Trains” in 2008 and it was a real game changer for manual therapists, Myers realized that since the inception of anatomy we have always used a knife to dissect the body.

We sliced the arm open to find the bicep sitting there, from physiology we then deduced that as the bicep contracts it flexes the elbow. Perfect. This is now the norm, we are still taught this in school, college and university, it completely makes sense and there isn’t much point challenging that, or is there?

What keeps us, as big fleshy sacks of meat, in one piece? We are covered in a an inordinate amount of connective tissue called fascia, this is a sheet like tissue that covers our muscles, organs, nerves, skin, etc…..

You may have even heard of from manual techniques that aim to target it (myo-fascial-release) this tissue is comprised of a matrix of collagen (a protein) which houses in it a number of cells, chemicals, proteins and water. This is all referred to as the intracellular matrix, put simply it’s the spaces in-between every cell in your body. Here is the most interesting part, for centuries we have imaged fascia to be an inert tissue, just laying in-between stuff minding its own business, until recently when in an almost epiphanic moment more and more of the fascias secret began to be unravelled.

Ill stick to the most applicable one however, otherwise this article could go on for pages. So this assumable inert fascia has been actually found to be a remarkably responsive tissue, that when stressed is able to reinforce itself, when stretched it reflexively relaxes (only at 4% stretch, at 8% it has an adverse effect showing the subtle delicate nature of the tissue) when left alone it dehydrates horribly (thixotropic nature) becoming stiff and bogged down in metabolic toxicities (part of the reason why you “stiffen up” with immobility).

Myers found that by eliminating the callus nature of the knife out of the dissection process we are left with a very different corpse, the body is wrapped in layers of fascia, layers that distribute the push and pull of daily life, and of course – squatting. These facial paths he named trains, they are predicable lines of stress that aid the action of the muscle in moving joints. No longer should we think of the bicep as an elbow flexor… yes it is the engine of the steam train providing the force, however it is the superficial arm line that provides the tracks for the engine to run on, its line of pull is far further reaching and all encompassing.

Superficial arm line:

Dissected facial lines (using a knife…..)

This paradigm shift is still slow to take hold, however its truth is infallible and as manual therapists and athletes we should be aware of these principals. Why is this relevant, well coming full circle back to the valgus collapsing in the squat, we remember Andrew proposing the glute inhibition as the principal fault, which I totally agree with. One of Myers most applicable lines for lower limb power lifting is the spiral line.

Now following this line we can see the perfect theoretical reason for valgus collapse. Glute switches off (goes slack) vastus lateralis/ITB tension increases (increased pull) knees cave (slack) fibularis near have a heart attack and lock up (severe increased pull) trying to perform the job of the far far far larger glute muscles (also leading to a transfer of weight to the medial foot – pronation which is a whole different issue).

This spiral line slings around the sacroiliac joints providing them with support and stability they need, take away the sling by inhibiting certain areas in it, and often we are left with a irritated and unstable sacroiliac joint (pain in the low back just of the centre). No matter how much physio/chiro/massage you get on that SI (sacroiliac) joint, every time you go to squat BANG its back within a couple of weeks like a stabbing toothache. Make sure you see a healthcare professional who will address all the issues, not just the obvious ones!

Thanks again to Andrew for the guest spot, until next time.

Thank You Luke for another Great Post