You are probably familiar with the placebo effect. Common in today’s culture referring to things that don’t actually do what they say they will, or something that is deemed fake by a portion of society that another portion may still subscribe to, like needing to foam roll prior to activity. Foam rolling is not doing what it claims, elongating tissue, or breaking up fascia, but it does result in positive outcomes depending on the level of belief that the user has.
Placebos are normally used in medical research, mainly drug research, as a way to compare the effects of drugs with active ingredients against those without active ingredients, to see if the outcomes between the two are similar or dissimilar.2 The key here is understanding that there is a relationship between the positive expectations you may have while receiving a placebo treatment and the possible positive effects that come out of that treatment. There is potential to have greater positive effects when there is a greater positive expectation.
Nocebo is the anti-placebo. The nocebo effect is a negative effect or outcome due to a negative expectation.2 A negative outcome, or nocebo effect, can be a greater perception of pain.
The idea of the nocebo and placebo effects plays into the biopsychosocial (BPS) model of pain, breaking away from the biomedical model of pain and its outdated representation of pain. The BPS model is what we use when treating patients as it takes into account not only the physical status of the person but also their expectations, beliefs, past experiences, current cultural norms and learned responses, to name a few, because all of these factors contribute to a person and their presentation. Considering all of the things just listed, we can see how positive or negative expectations can fit into this model.
Why Is It Important to Be Aware of the Nocebo Effect?
As healthcare professionals and as patients it is important to understand the nocebo effect. Evidence suggests that negative expectations can result in nocebo effects, which can make you feel pain.2 As a patient, it is important to understand that negative thinking, or being told negative things, can have a negative outcome on your road to recovery. Staying positive and seeking out a professional who will properly educate you, listen to you, and stay positive with you should be a priority.
As healthcare professionals, we can affect the outcomes and status of our patients depending on how we speak. I have had many patients who, when first working with me, feared or spoke about never getting better, living with some sort of diagnosis, re-injury, or their pain coming back. They generally quote something negative that a previous provider told them or something that they have gleaned from a friend, family member, social media, advertisements, or the news.
It is unfortunate that patients are told they are defective, whether they are symptomatic or not. This can be physically and emotionally debilitating for patients to hear, especially coming from a person of authority including the person that they went to, hoping to get some answers or help.
Viscerosymptomatic amplification, is the mechanism where information can affect a patient’s perception of symptoms.3 In other words, if negative information is provided to you, you as the patient may experience a nocebo effect. The language itself does not cause symptoms but amplifies pre-existing symptoms. The article also talks about a cycle of amplification, where patients are made aware of possible symptoms by a physician, then the patient becomes hyper-aware of their symptoms and they create a higher perception of pain or amplification of those symptoms.
We have previously discussed the myth that “Pain Equals Damage”, that patients who have seen their imaging (X-Rays, MRI’s, etc.) generally have greater disability or pain perception than those who do not see their imaging.4 Sometimes imaging can make things look “worse” than they really are. Imaging may show normal age-related levels of deterioration or structural change, where non-symptomatic patients may not have previously been aware that they had. The patient can amplify symptoms or they could even develop new behavior (like fear or avoidance of movement) that can also contribute to new symptoms or create a poor relationship with activity.
“To encounter another human is to encounter another world.”1
What we need to understand when working with one another is that we all come from different past experiences, cultures, beliefs, and situations, which can be construed as coming from other worlds. Unfortunately, many healthcare professionals are not taught in school about what language can be “dangerous” for patient outcomes, or about the new literature and changes in how we understand pain.
This nocebo effect concept creates a paradigm shift when it comes to thoughts about pain, recovery, and the connection (or lack thereof) between structure and symptoms.
At The Movement Dr., we believe it is our duty as healthcare professionals to educate our patients on their ability to recover from pain and injury. We don’t say things, like, “You have the back of an 80-year-old,” especially when there is no benefit to using statements like this. We prioritize reassurance, active treatments, and goal-driven interventions starting with what the patient/client values most.
If you have any questions about the nocebo effect or believe you may be experiencing it, get in touch with us today so we can help.
- Michael Stewart and Stephen Loftus. Sticks and Stones: The Impact of Language in Musculoskeletal Rehabilitation Journal of Orthopaedic & Sports Physical Therapy 2018 48:7, 519-522
- Colloca L. Nocebo effects can make you feel pain. Science. 2017;358(6359):44. doi:10.1126/science.aap8488
- Barsky AJ. The Iatrogenic Potential of the Physician’s Words. JAMA. 2017;318(24):2425–2426. doi:10.1001/jama.2017.16216
- Webster, Barbara S et al. “Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain.” Spine vol. 38,22 (2013): 1939-46. doi:10.1097/BRS.0b013e3182a42eb6