Understanding the influence of placebo and nocebo in clinical practice
What is the Placebo Effect?
How do we harness the placebo effect?
- The engagement of clinical empathy in the context of disease and relief of suffering requires a specific medical interaction.
- The use of clinical empathy would require a set of interpersonal skills that depend upon active “emotional labor: by the clinician.
- Clinical empathy is a purposeful process attempting to attain specific outcomes within the clinical context that will result in the improvement of health through the engagement of psychobiological mechanisms.
The opposite side of the coin
The art of patient education
What are the ethical considerations of using the placebo effect?
What do the patients want?
“But placebos will only work if the doctor is dishonest. The question is – that if the, if it was just a common cold it will be cured in time, the body will cure itself; in that case dishonesty’s justified I think, give out placebo, by all means and then, then make them believe it. I mean you certainly don’t say that it doesn’t contain any active ingredients. You don’t tell them that…I mean I don’t think it’s immoral of the doctor to give a placebo if he’s convinced that the man has got nothing seriously wrong with him, but if he thinks that the man will be happy, then don’t tell him that it’s got no active ingredients, say here’s this, try this, you. The doctor won’t say this will cure you, all a doctor will say is try this you might get better.”
“This may make the underlying problem worse cause then the person then becomes totally dependent on the doctor giving him something that isn’t actually, is nothing more than a bit of TLC… I don’t think he really should’ve given him anything. He should tell him that he doesn’t need anything”
- Bishop FL, Aizlewood L, Adams AE. When and why placebo-prescribing is acceptable and unacceptable: a focus group study of patients’ views. PLoS One. 2014;9(7):e101822.
- Kaptchuk TJ, Friedlander E, Kelley JM, et al. Placebos without deception: a randomized controlled trial in irritable bowel syndrome. PLoS One. 2010;5(12):e15591.
- Ballou S, Kaptchuk TJ, Hirsch W, et al. Open-label versus double-blind placebo treatment in irritable bowel syndrome: study protocol for a randomized controlled trial. Trials. 2017;18(1):234.
- Carvalho C, Caetano JM, Cunha L, Rebouta P, Kaptchuk TJ, Kirsch I. Open-label placebo treatment in chronic low back pain: a randomized controlled trial. Pain. 2016;157(12):2766-2772.
- Colloca L, Pine DS, Ernst M, Miller FG, Grillon C. Vasopressin Boosts Placebo Analgesic Effects in Women: A Randomized Trial. Biol Psychiatry. 2016;79(10):794-802.
- Locher C, Frey Nascimento A, Kirsch I, Kossowsky J, Meyer A, Gaab J. Is the rationale more important than deception? A randomized controlled trial of open-label placebo analgesia. Pain. 2017;158(12):2320-2328.
- Krell HV, Leuchter AF, Morgan M, Cook IA, Abrams M. Subject expectations of treatment effectiveness and outcome of treatment with an experimental antidepressant. J Clin Psychiatry. 2004;65(9):1174-1179.
- Adler HM. Toward a biopsychosocial understanding of the patient-physician relationship: an emerging dialogue. J Gen Intern Med. 2007;22(2):280-285.
- Blasini M, Peiris N, Wright T, Colloca L. The Role of Patient-Practitioner Relationships in Placebo and Nocebo Phenomena. Int Rev Neurobiol. 2018;139:211-231.
- Blasini M, Corsi N, Klinger R, Colloca L. Nocebo and pain: An overview of the psychoneurobiological mechanisms. Pain Rep. 2017;2(2).
- Svanbergsson G, Ingvarsson T, Arnardottir RH. [MRI for diagnosis of low back pain: Usability, association with symptoms and influence on treatment]. Laeknabladid. 2017;103(1):17-22.
- Fritz JM, Brennan GP, Hunter SJ. Physical Therapy or Advanced Imaging as First Management Strategy Following a New Consultation for Low Back Pain in Primary Care: Associations with Future Health Care Utilization and Charges. Health Serv Res. 2015;50(6):1927-1940.
- Delitto A, George SZ, Van Dillen L, et al. Low back pain. J Orthop Sports Phys Ther. 2012;42(4):A1-57.
- Webster BS, Bauer AZ, Choi Y, Cifuentes M, Pransky GS. Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain. Spine (Phila Pa 1976). 2013;38(22):1939-1946.
- Clifton DR, Grooms DR, Hertel J, Onate JA. Predicting Injury: Challenges in Prospective Injury Risk Factor Identification. J Athl Train. 2016;51(8):658-661.
ABOUT THE AUTHOR
Zach has numerous research publications in peer-reviewed rehabilitation and medical journals. He has developed and taught weekend continuing education courses in the areas of plan of care development, exercise prescription, pain science, and nutrition. He has presented full education sessions at APTA NEXT conference and ACRM, PTAG, and FOTO annual conferences multiple platforms sessions and posters at CSM.
Zach is an active member of the Orthopedic and Research sections of the American Physical Therapy Association and the Physical Therapy Association of Georgia. He currently served on the APTA Science and Practice Affairs Committee and the PTAG Barney Poole Leadership Academy.