More good questions.
If a procedure that is not supported by research, but does not appear to have significant risks, has a positive effect on a patient, is it worthwhile?
Define “worthwhile”? Worthwhile to who? From the perspective of the medical system, an intervention with reasonable quality data showing it does not tend to provide benefit likely represents a low-value intervention that wastes resources.
But from the perspective of a patient who does has a positive effect (via whatever mechanism), it may be perceived as worthwhile, depending on their preferences and values in the context of the proposed treatment. (IOW, how much benefit are they getting versus how “big of a deal” is the procedure - is it surgery, with its associated risks? An injection? A pill?)
Would informing the patient that research shows no effect be a nocebo issue?
I suppose that’s one way to think about it. Though I tend to think of it more that it has the potential to nullify a placebo effect. So-called “open-label placebo” trials where the patients are told they’re receiving a placebo that has no effects … tend to show no effect.
Summarizing, our patient has pain in right upper hamstring lower glute region. Diagnostic block on right side lumbar facet joints appeared to help. Subsequent cortisone injection at SI joint appeared to help. Pain has gone from occasionally “seeing stars” to frequently sore or achy.
Doctor now proposes a diagnostic block on the left side to see what happens, saying that her experience shows it can provide further improvement. If pain returns, she would do a second diagnostic block on the right side. If this helps, she would try radiofrequency denervation. The doctor says that there is no substantial risk from these procedures.
Yes, I am quite familiar with this and see it offered/done fairly regularly.
As an additional data point, another patient we met in the waiting room has periodic radiofrequency denervations and reports substantial relief.
Take a look at this article: Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain - PMC as well as the included figures; in particular, this one: https://www.ncbi.nlm.nih.gov/pmc/art…1/figure/Fig3/
What you have experienced is one of the known “contextual factors” that can influence expectations, and thus outcomes.
Consider the alternative situation, where you ran into our own Sean Herbison in the waiting room. He underwent this exact procedure for his chronic back pain and did not receive benefit. What impression would that leave on you or the patient in the waiting room, going in for your consultation? I am not trying to “nocebo” you here – just trying to make you think a bit more.
If something appears to work and has no significant risks, why not proceed with it? I suppose it might reinforce a biomechanical model of pain.
Correct. Which then reinforces dependence.
Again, as I mentioned last time – I am not suggesting to you whether or not you should pursue the intervention. I can present the data from controlled studies that can more accurately tell us the effects of the intervention itself, versus those of the various and complex contextual factors that come into play when treating persistent pain. Should you choose to get the intervention done, I certainly hope it helps.