Placebo vs Nocebo

[AJ Lievre]

Placebo is not about fake treatment or smoke and mirrors. It is a valuable treatment effect we can have with our patients. Embrace it and learn how to use it.
Check out this article from this week’s NEJM issue.
Post an experience where you successfully utilized the placebo effect or got hung up on a nocebo.

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[awilson12]

Recently I had some success with placebo with a patient who was very caught up on the “slipped disc” that showed up on her MRI and was holding onto hope that PT would just push it right back into place because she didn’t want to have to get surgery. It was tempting to go full on with a patho-anatomical explanation and confront and dispel this belief. Taking a step back, though, in this situation it was more beneficial to use her beliefs that PT would be helpful and discuss all of the things we were going to do to strengthen her neck and disc. For her to hear another biomechanical explanation would have been doing her a disservice, and I think it was more successful in the end to utilize “placebo” for initial buy-in and more subtly educate over the course of multiple visits.

[pbarrettcoleman]

I still sometimes forget the gap between what words mean to us and what they mean to a patient. For instance, when I hear RTC tear, I kind of shrug it off because I know it doesn’t necessarily matter. A pt hears those words and thinks life is over.

I was working with a patient post car accident and found some hypomobilities in their lumbar. When I was working on a particular spot, I mentioned that it was stiffer than I was expecting. She held onto that thing for the rest of treatment, wondering why it was stiff, how to get it unstiff, whether she would ever be normal. I had to fight that thing the rest of the way.

[Taylor Blattenberger]

Anna,

That’s such a difficult predicament to be in. On one hand you want to convey accurate information and supply your narrative to your treatment. Although, you have the ability to turn what is usually a nocebo into a placebo for your treatment modality. Now her positive beliefs can be coupled with what you believe will be a beneficial treatment and enhance her outcomes.

What are your thoughts about the long term effects of feeding into this belief? My concern is that she connects pain with her disc being “out again” and would seek more medical treatment in the future. What did your education look like over the time and what did she make of it?

[awilson12]

Taylor-
For sure agree. I feel like situations similar to this come up on a daily basis and it is always hard to deliver a balanced message dispelling fear without challenging them too much first visit. What have you (or anyone else) found to be successful in these situations?

In this particular situation I felt that initially with the patients history and her crying the whole initial eval building some rapport and decreasing fear would go a long way to then be able to educate more thoroughly. Second visit and third visit (when she wasn’t crying the whole time) I talked about studies that showed by age 30 up to 80% of asymptomatic people have disc bulges on MRI, the misconception of a “slipped disc”, and the relationship between the severity of symptoms and her past experience and current life stressors. She seemed to respond well to this and was less obsessed with the disc being pushed back in to cure all.

Was this the best or “right” thing to do? Likely not and I’m sure there are many other ways to go about it, but throughout treatment with this specific patient this approach worked for me. What would you have done differently?

[awilson12]

P Barrett Coleman-
What was your response to those questions? Did she at some point have a better understanding and become less concerned?

[Taylor Blattenberger]

Anna,

That must have been a very challenging eval! I don’t blame you at all for taking that approach. I feel that was very well handled and I’m glad she was receptive to the education in future sessions. Definitely a great way of blending her expectations with your educational agenda as her treating therapist.

I honestly can’t say I would have done much differently. Keeping in line with the article I know I would have focused on the fact that her prognosis seemed good and that “these things get better.” I’m sure avoiding the education early also helped strengthen your alliance with her. Back to your original point, she probably didn’t need more info, she needed reassurance.

[pbarrettcoleman]

Anna:

I didn’t know it was a problem until I started talking about discharge. I started building my case by talking outloud my thoughts over a session (your ODI improved to this; you are reporting this; you are no longer reporting this and this). Then, I used this as a segue into discussing discharge planning and her readiness to take this thing on herself.

That’s when she gave me push back about the tight spot in her back. To her, this was where all of her pain was coming from, and she thought until it got “less tight,” she would never be normal. She wanted to be 100% normal, and in some ways, conceptualized this tight spot in her back as something the other reckless driver did to her.

The way I approached this was being 100% open about what I meant about this spot being tight and clarifying what that meant to me. I explained that this tight spot might have been there for years, and given her history of back pain, most likely was. I then further explained the sequela of events and how we can’t pin this on the other driver. Yes they were reckless and this really threw your for a loop, but we can’t necessarily pin anything I find with my hands on them given the time piece. Then, I discussed what does it mean to have a “tight” spot in the back and whether that is a big piece of the puzzle or not.

I did this because we had great rapport (she brought me a Sound of Music DVD and some Baklava) and felt comfortable expressing my thoughts to her. However, she didn’t accept this fully right away; I had to change my treatment style over the next 4-6 visits. I started to wean her off manual. I focused less on the spot on her back and more on movement. Overtime, she let it go, too.

It was a tough situation given the contextual factors of it being from a car accident.

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