Performance enhancement with no ‘enhancement’ - the power of placebos

Can athletes and coaches utilise the power of placebo to boost performance even when they know they’re placebos?

TL;DR

Yes, placebos can improve performance even when an athlete KNOWS that they’re placebos. Of a trial group of 28 trained cyclists, 11 athletes improved their 1k TT time, 4 performed worse and 13 saw no significant change. With a mean improvement of 0.7s it’s worth experimenting with so long as you follow a similar protocol and invest some willpower into believing that what you are doing will work. If you find it doesn't work for you, all its cost you is some flour or sugar!

Introduction

Millions are spent each year by sports manufacturers and nutrition companies trying to come up with ever better products to help push athletes further and faster. A lot of what is developed is effective - some isn’t. But what if there were performance enhancers that were effectively free and were available to everyone?

‘If something’s stupid and works, then it isn’t stupid’. Maybe you’ve heard this before, but even if you haven’t, it’s still true. In this scenario, the ‘something stupid’ can be a sugar pill or capsule full of flour… placebos – items with no ability no beneficial properties but presented in a way that can trigger a positive psychological or physical response. Usually when looking for performance gains in science, placebos are used to measure the impact of making an intervention by controlling for the physical and mental impact of the intervention. This can lead to dismissal of the placebo effect as something to be reduced to a minimum. But if it’s free and well known to be able to impact performance in a beneficial way, why not maximise it? 

The only issue with a placebo is that typically they involve some level of deception. In cycling this brings up some pretty serious historical connotations – a coach coming to a rider with some ‘mystery pills’ to improve performance just screams doping, but there is an alternative. Open Placebos are a subset of placebos where the user KNOWS it's a placebo. 

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Can an open placebo still provide a performance enhancement? A study from researchers based at The University of São Paulo, Brazil endeavoured to find out. For their investigation, researchers enrolled 28 trained female cyclists to complete a 1km TT following a control session or an open-placebo intervention.

The Experiment

Participants attended the laboratory on three separate occasions. During the first visit they performed an incremental cycling test for the determination of maximal power output and VO2max. Following a 15 min rest, participants performed a familiarisation effort of the main exercise protocol, a 1-km cycling time-trial. The next two visits were for the completion of the main trials, separated by one week. The main trials were performed in a counterbalanced, randomised and crossover manner and performed at the same time of day for all individuals (between 05:00 and 12:00) to account for circadian variation in performance. Participants abstained from strenuous activity and alcohol and recorded their food intake in the 24 h period prior to the initial main trial and adopted the same dietary intake prior to the next session. Caffeine intake was prohibited on the day of the main sessions. Since all participants were involved in structured training programs, they were requested to maintain identical training routines for the weeks in which they completed the main trials. Adherence to these restrictions was confirmed verbally with the volunteers prior to their second main session.

Before the open placebo test, the athletes were all given an individual 5-min talk in which the concept of open-placebo was explained to them. The presentation was entitled “Possible benefits of open-placebo in sport” and included the following information: 

• Definition of a placebo and the placebo effect
• examples of the placebo effect in medicine and sports
• explanation of open placebo
• examples of open placebo in medicine. 

The presentation ended with three considerations for the athlete prior to taking the capsule: 

• believing is important for the placebo effect.
• however, belief in the placebo effect is not necessary as the effect may be automatic/unconscious.
• taking the pills is important to obtain an effect.

 Immediately following the individual presentation and 15 min prior to the 1-km cycling time-trial, participants ingested two red-and-white placebo capsules containing 100 mg of flour each. In the control session, no specific information was provided prior to the individuals performing the time-trial, although they remained in the company of the medic for 20 minutes to standardise each session. Athletes were strictly requested not to discuss any study details with each other between sessions to minimise any influence from teammates.

The talk was not given to athletes before the control test. 

1k TT

All trials were performed on a road bike on rollers with tracking software. Participants performed a 10 min warm-up at 100 W, followed by a 2 min rest. They then performed the 1km time-trial. Participants were instructed to complete the 1km protocol as fast as they possibly could. The gear on the bike was fixed (50 x 17) and the participants were not allowed to change it throughout the time-trial to replicate track-cycling.

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During the effort, participants only had access to distance covered and did not receive any performance information until all participants completed the study. Time to complete the time-trial and mean power output were recorded. Heart rate was monitored consistently throughout exercise. Ratings of perceived exertion were recorded following 50% and 100% of the time-trial]. blood lactate levels were taken by finger prick blood samples pre and post exercise.

Results

The open-placebo improved time-to-completion to 103.6 ± 5.0s vs. 104.4 ± 5.1s, and mean power output 244.8 ± 34.7s vs. 239.7 ± 33.2s

11 individuals improved performance following open-placebo administration(>1sec). 4 individuals showed measurable decrements in performance and the remaining 13 cyclists showed true score changes and confidence intervals within the limits of the test (±<1sec).

Demonstrating there was no influence of session order on performance, five of those who improved performed the open-placebo intervention first, while the other six performed the control session first.

Conclusion

On average, the open-placebo intervention resulted in a 0.7s improvement in 1-km time-trial performance compared with the control session. Although this difference might appear small, this improvement likely represents a meaningful and practically significant difference in performance at the elite level. Nonetheless, individual variation in response seems to be high and some athletes may even experience decreased performance.