Placebo and Nocebo

[AJ Lievre]

How might this influence the way you practice (verbally, non-verbally etc).
Eric, you need to start wearing a lab coat!

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[Laura Thornton]

Thanks for sharing AJ. Great reflection paper. A few things I took away from this article:

Section 3.4.3 >> How many different kinds of touch we provide to the patient! You have never really quantify how much we do touch our patients, not just with specific manual techniques, but with assessment, guidance, demonstration, greeting, goodbyes, etc. It can have significant effects, both peripherally and centrally.

Section 3.4.1 >> “In addition in physiotherapy, the administration of an overt treatment by a mirror feedback was proposed as an effective strategy in chronic LBP (Daffada et al., 2015). Indeed, patients that looked at their back when moving during exercises reported less increase in pain and a faster resolution of their dysfunction (Wand et al., 2012; Diers et al., 2013).”

I need to do this more! I use all the time for retraining in the gym for mechanics and form, but not for placebo effect or to gain a sense of control of the movement. Even encouraging patients to use mirrors at home when performing the exercises could be beneficial. Does anyone use this strategy a lot for this?

Section 3.3 >> There are certainly some ways I can improve on my communication with patients and I admit, when times are busy at the clinic, sometimes adequacy and “this will do” attitude takes over. For instance, when I am writing home exercise programs and I’m in a rush, the sheet won’t give as many specific instructions or I won’t have time to include pictures. It definitely makes me step back and say I need to shape this up because this is the communication that you have with your patient 95% of their time when they aren’t in the clinic.

By the way, I’d be curious to see in person what slanting 90 degrees towards a patient would look like…

[Nick Law]

AJ – thanks so much for posting, a good reminder of things that influence our outcomes beyond anatomy, biomechanics, and our manual therapy skills.

Laura – I do not frequently use mirrors, and seemingly never tell people do use them at home. I think that the use of mirrors really has to be patient-specific; sometimes I feel that patients who are put in front of a mirror become incredibly and detrimentally self conscious.

“The main predictors for male patients were the therapist and treatment outcome, whereas for female patients the most important elements were organization and the communication components of care.” This certainly confirms my own experience; we do well to recognize gender based differences.

“The formulation of a diagnosis…is a form of treatment per se.” I am certainly still learning how to give a detailed diagnosis, prognosis, and comprehensive explanation of the patients condition without rambling or speaking in terms or concepts unfamiliar to the patient.

Lots of good reminders and helpers in this article – thanks again for posting.

Also – I will be requesting a skylight for our clinic….for the patients sake.

[Kristin Kelley]

Hey Nick
I use mirrors a LOT and encourage pts to also use them at home. Today I was working with a pt with LB and radiating LE pain when he was in his usual hyperlordodic posture. When we were able to do retraining with him with visual (mirror) and verbal feedback, he was able to get into a more successful posture and significantly reduce his pain during WB core contraction in functional retraining positions. He was having great difficulty initially achieving these results until I put him in front of the mirror and having him see the “before/after” positioning of his spine when he was performing exercises and activities. This patient has a really tough time with carryover between visits in performance of his HEP and thus with symptom reduction so I find with many patients this is a great tool for success. Many times I’ll take a video of a pt performing an exercise or activity correctly on their smart phone, but have found even if they have exact directions on performance of these things, without them seeing correct form will inhibit successful carryover. Many patients will tell me they don’t have a full length mirror so I then suggest they use other reflective surfaces (dark appliances, sliding glass door after dark…etc) to get feedback on general form vs having significant detail a clear mirror provides.
If you don’t think mirrors are an effective tool for these types of things in clinic or at home for the reasons you provided, what strategies are you using instead? Are you seeing success with them or are you still facing barriers with some pts?

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