The nocebo effects of communication   March 21st, 2016

I once was told by a former colleague that I would most definitely get back pain if I didn’t stop slumping in my L1 vertebra. Of course today I am still ‘slumping in my L1 vertebra’ and no, I don’t believe that it will ever cause me back pain. Because science says so (Christensen et al. 2008). One could argue whether or not she was able to tell that I was slumping at all or if the location she mentioned (L1) can be distinguished, etc. However, that is not the point I’m trying to make. Telling someone that they are ‘slumping in their L1’ and ‘it will cause you back problems in the long run’ can have a huge nocebo effect for a patient, not only in the present but also in the future.

Nocebo effects, the counterpart of placebo effects, are adverse events based on negative expectations. It is recognized that nocebo effects can occur during routine treatments and can be produced by, for instance, verbal communication and past treatment experiences (Finniss et al. 2010). Nocebo effects are a direct result of the psychosocial context or therapeutic environment on a patient’s mind, brain, and body (Colloca et al. 2012). It has been shown that nocebo effects trigger the activation of cholecystokinin, that, in turn, facilitates pain transmission. Furthermore, brain-imaging studies have found higher activation of the pain neuromatrix.

As a down to earth physiotherapist with knowledge of pain, I instantly knew that my colleague was wrong about ‘slumping in your L1 will cause you back pain’ and therefore I did not worry. However, patients do worry, especially when such information is delivered from healthcare professionals that they trust. As science tells us, negative verbal information can convert non-nociceptive stimulation into the experience of pain (Colloca et al. 2008), even to the same level as painful stimuli. So for patients, not posture, but the nocebo of the ‘advice’ can indeed cause or increase their back pain! This might, for instance, also play a role in the transition from acute pain into chronic pain. Importantly, the effects of nocebo-communication can be long-lasting (Rodriguez-Raecke et al. 2010) and bias further treatment.

Patients, especially those with chronic pain, often have heard numerous of ‘diagnoses’ for their pain and therefore likely have heard some form of nocebo. Can you imagine how frightening it must be to be told: ‘your muscles are too long for your joints’, ‘your disc slips’, ‘your back is weak, so you should not bend this way’, etc. and how that influences the nocebo hyperalgesic response by activating the pain neuromatrix and endocrine system? (Colloca et al. 2007)

Furthermore, how will this affect patients’ further treatment?
As physiotherapists we try to do utmost for our patients. Not only because it’s ethical, but also because we care for our patients and our profession. No physiotherapist wants to be a ‘nocebo effect’ or say something that is a nocebo effect. So therefore, we should be aware of any ‘nocebo-talk’ we might say to our patients, of our perceptions and behavior. We should challenge the things we are taught and change it into placebo effects.

Amarins Wijma

2016  Pain in Motion

References and further reading:

Christensen et al. Spinal curves and health: a systematic critical review of the epidemiological literature dealing with associations between sagittal spinal curves and health. J Manipulative Physiol Ther. 2008 Nov-Dec;31(9):690-714.

Finniss DG, Kaptchuk TJ, Miller F, Benedetti F. Biological, clinical, and ethical advances of placebo effects. Lancet. 2010; 375(9715):686-695.

Colloca L, Finniss D. Nocebo Effects, Patient-Clinician Communication, and Therapeutic Outcomes. JAMA - 2012; 307(6):567-568

Colloca L, Sigaudo M, Benedetti F. The role of learning in nocebo and placebo

effects. Pain. 2008;136(1-2):211-218

Rodriguez-Raecke R, Doganci B, Breimhorst M, et al. Insular cortex activity is associated with effects of negative expectation on nociceptive long-term habituation. J Neurosci. 2010;30(34):11363-11368

Colloca L, Benedetti F. Nocebo hyperalgesia: how anxiety is turned into pain. Curr Opin Anaesthesiol. 2007 Oct;20(5):435-9.

Benson H., The nocebo effect: history and physiology. Prev Med. 1997 Sep-Oct;26(5 Pt 1):612-5.

Benedetti F, Lanotte M, Lopiano L, Colloca L. When words are painful: unraveling the mechanisms of the nocebo effect. Neuroscience. 2007 Jun 29;147(2):260-71.