Placebo... Nocebo... Placebo... Nocebo

Growing evidence suggests patient psychosocial factors matter.  A few variables we definitely know about - the effects of depression or the effects of fear and anxiety for someone with low back pain.  I'd extrapolate that data and assume a score indicating low confidence on the Activity-specific Balance Confidence Scale would suggest someone has a fear of falling and that fear could be limiting function.  Why do we care about these psychosocial factors?  Obviously these factors are relevant in our treatment interventions and are even becoming relevant in predicting outcomes of our interventions.

I just recently read a couple of articles about two concepts at opposite ends of a spectrum.  On one end, there is nocebo.  The concept of nocebo really isn't something that just happens in randomized controlled drug trials.  Physical therapists deal with nocebo every day.  It seems to me nocebo is the self-prophetization of patients. Think about it using diagnostic testing as a focus.  The actual action of having a diagnostic procedure is not a bad thing, really, it's just a procedure.  The result of the procedure is a report.  The report is just a factual summary of findings.  It's what happens next that creates issues.  The not knowing; the fabrication of a "story" that happens in a patient's brain; the interpretation of that "story"; the perception of how that "story" affects the patient's life... and then the behavioral choices - consciously or subconsciously that will happen because of perceptions.  The patient just does this - it just happens.  Sometimes though, medical professionals through their actions and communications can solidify the "story."  You may not know it, but as a physical therapist, you spend quite a bit of time unraveling nocebo and altering perceptions and brain "stories." 

The other end of the spectrum is placebo.  Physical therapists should harness this concept and use it to the fullest.  I'd be interested in seeing the full text of the linked study.  What we communicate and how we communicate is highly relevant and important.  The linked study definitely suggests physiological change could really occur in the spinal cord with manual intervention.  (Physical therapy research has hinted and theorized this, but this is the first study I've seen that does give some verification to what has been proposed.)  I'm willing to bet if a different study was performed with a physical therapist performing a manual intervention there would be two equally important variables.  Obviously, the manual intervention is one component, but the other component would be the prior communication setting up a patient's expectations and perceptions. 

My thoughts:  If you hang your hat only on the placebo and don't use your window of opportunity to immediately move the patient forward to a slightly higher, active level, you've lost that power of placebo.  If you aren't aware of nocebo, the amount of change and progress will be limited.

I believe the art of what we do is the nocebo-placebo teeter-totter.  Do you notice that teeter-totter?

~Selena

photo via Flickr by lilmsmrtas