Rossettini Clinical relevance of contextual factors as triggers of placebo and nocebo

[Baderjosh]

edit: article link Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain | BMC Musculoskeletal Disorders | Full Text

This article brought up a few interesting ideas and thoughts. For those who work within an interdisciplinary setting as rehab providers, I am curious as to what everyone’s thoughts are on the ethics of leveraging the placebo effect.

Of course, from an ethical perspective, it is important to give the patient a thorough explanation on the research and underlying scientific principles behind any treatment they may be receiving. However, this brings up an interesting situation.

For example, say a patient’s physician recommends a corticosteroid injection at the site of a degenerative disc for non-specific low back pain. Per the article, we know that “in general, the higher the invasiveness of the treatment (e.g. acupuncture, dry needling, injection, surgery), the better is the reduction of pain [via the placebo effect]” (page 6 2nd column of the article). If the patient has made up their mind on getting the corticosteroid injection, but asks you the rehab provider what your thoughts are about it, what do you think is the “right thing to do?”

In my opinion, it is always necessary to be candid and upfront with a patient to aid in developing their autonomy and decision making process. However, is this potentially mitigating the powerful effect of the placebo analgesia they may receive from the injection? Worse yet, would this be noceboing them by creating negative expectations about the treatment based on your thoughts, the person which you have likely built up a therapeutic alliance with and they trust?

Note I am using the corticosteroid injection as an example, but this can potentially apply to any passive modality (e.g. acupuncture, cupping, massage, etc.)

Thanks so much for creating this forum and reading list!

[kelleyhenry]

I agree that we should give a thorough explanation of the research and scientific principles but many practitioners think they are doing this but are giving patients bad or outdated information.

I have the same battle with harnessing the placebo effect for passive therapies. I have a high level athlete who does his own research and asks questions so I give him honest and straightforward answers. He still wants the work done but he questions whether or not I should just set the expectation that the treatment will work. If I do that, I’m not sure how that makes me different than a snake oil salesman. It’s always a fine line to walk because we aren’t just dealing with inert bodies but entire humans with brains, past experiences, expectation etc.

[JHG]

You bring up an interesting dilemma.

If you are working in an environment where various providers are working under the same roof, then I would suggest that this paper first be circulated among all clinicians with the opportunity for discussion and perhaps this may help align everyone’s practice philosophy moving forward.

If this is an issue you have to deal with in real-time with a patient, this can be tricky if you are unfamiliar with another provider’s practice philosophy or their knowledge of this information as you risk causing friction by way of broken telephone via the patient (i.e. “Baderjosh told me this injection is like a sugar pill, and I already have diabetes…”) I’m not saying that you would say that to the patient, but patients have a way of distorting the message in their own words between providers.

Also, if you are sharing care of this patient with another provider but they work out of a different location, this can further complicate matters if the two of you do not communicate your plan of care to one another.

My approach would be to briefly and succinctly explain the mechanism and benefits of exercise with respect to pain management and then compare this to the mechanism of the corticosteroid injection and explain that sometimes it works and sometimes it doesn’t.

I think an important factor to consider is the reaction that most people will have when they learn new information that violates their preexisting beliefs for the first time. The natural response is to typically reject this information. This applies to both health care providers and consumers. I think a flexible approach might yield more favourable results in the long-term than a hard-lined stance, especially if the other provider is unaware of this information.

[Baderjosh]

@kelleyhenry

I agree that we should give a thorough explanation of the research and scientific principles but many practitioners think they are doing this but are giving patients bad or outdated information.

I have the same battle with harnessing the placebo effect for passive therapies. I have a high level athlete who does his own research and asks questions so I give him honest and straightforward answers. He still wants the work done but he questions whether or not I should just set the expectation that the treatment will work. If I do that, I’m not sure how that makes me different than a snake oil salesman. It’s always a fine line to walk because we aren’t just dealing with inert bodies but entire humans with brains, past experiences, expectation etc.

I could not agree more. In setting the expectation that the treatment will work, based on the literature the provider may actually improve the outcomes that the patient would experience. However, it does create the internal dilemma that it “does not feel right” within the provider. You are absolutely right that you must take into account the entire human experience when making these decisions. Which of course, is a hard thing to do if you have not built a strong alliance with them at that given time.

@JHG

You bring up an interesting dilemma.

My approach would be to briefly and succinctly explain the mechanism and benefits of exercise with respect to pain management and then compare this to the mechanism of the corticosteroid injection and explain that sometimes it works and sometimes it doesn’t.

I think an important factor to consider is the reaction that most people will have when they learn new information that violates their preexisting beliefs for the first time. The natural response is to typically reject this information. This applies to both health care providers and consumers. I think a flexible approach might yield more favourable results in the long-term than a hard-lined stance, especially if the other provider is unaware of this information.

I like your approach of comparing the benefits of exercise to the alternative treatments. And I definitely agree that taking a hard-lined stance can create more problems than it solves. Approaching each interaction with fellow colleagues with an open mind tends to break down barriers, while going on the offensive can build them back up, even if you perceive it as being constructive by providing evidence to support your position.

[Lactateislove]

I’ve had a situation where a lady who came to an exercise class I said she had just signed the papers to have a knee arthroscopy performed and wanted to know my opinion on the surgery as a student physical therapist. I reluctantly told her the evidence says it results in no better outcomes than sham surgery. She was frustrated with my response, especially since her orthropaedic specialist doctor and physical therapist recommended the surgery.

After asking another physical therapist about this situation they said I did the right thing by saying “the evidence says” to make it less opinionated. However it’ll be interesting next year when I’m qualified to figure out how i’ll handle these situations when I a doctor or more experienced clinician recommends treatment against current evidence. i guess this paper will be handy to have on hand.

[kelleyhenry]

Article about placebo in Time magazine People Are Now Taking Placebo Pills to Treat Themselves | TIME

[kelleyhenry]

Placebo and CAM in sports https://bjsm.bmj.com/content/52/13/817