Archives for October 2012

The Understudied Nocebo Effect

Nocebo effects are common across medicine. They appear to have profound relevance for the current epidemic of care seeking for back pain—and the tsunami of disability claims for low back pain across industrialized nations. Yet their influence has barely been studied.

From a recent Back Letter article.  Are Nocebo Effects Contributing to the International Back Pain Crisis  [Subscription necessary; if you don’t have a subscription join the ISCRS so you can get the Back Letter free as a member benefit.]


Identifying potential nocebo effects in the medical management of back pain is easy. Much of the information conveyed to patients and the general public about back pain has a nocebo aspect. Healthcare providers often create the expectation among patients and the general public that they have a serious, life-long degenerative disorder.


Even well-intended advice can be counter-productive and damaging. Throw-away lines delivered in a medical setting can stick with patients—and change the way they think, act, and work:

“You need to protect your back until the pain goes away.”

“Don’t lift anything that weighs more than five pounds.”

“I don’t think you should work with that disc herniation.”

“The vibration of driving may exacerbate your back problems. You may need to change jobs.”


Winfried Häuser and colleagues found 150,000 studies and articles that mentioned placebo effects. After stripping away placebo-controlled drug trials, they were able to identify more than 2200 studies actively addressing placebo effects. (See Häuser W et al., 2012.)

By contrast, they found only 151 publications on the topic of “nocebo.”

Of the publications on nocebo effects, only about 30 were empirical studies. The remainder were editorials, commentaries, letters to the editor, and reviews. To say this is an understudied area is an understatement.


Beware the Nocebo Effect.

Prior post on the Nocebo.


I spend the time I can spare traveling to learn from those who know things that I want to know.  At some point it can become a bit difficult to keep track of exactly where an idea came from, and this is one of those cases.  Somewhere in my travels, the book Aspire by Kevin Hall was recommended.  I wish I could properly thank someone and credit the recommendation, but it currently escapes me.  Regardless, for those who haven’t read it here’s a cliff notes version.
Communication is essential to rehab and training.  How can learning new words and understanding their meaning help you better serve the patients and athletes you work with?
Inspiration is also essential to making positive changes.  See below.
  1. Genshai (GEN-shy): It means that you should never treat another person in a manner that would make them feel small.  [Note: this includes yourself.]  Stop and reread this one.
  2. A Leader is a Pathfinder. (Lea=Path; Der=Finder).  They read the signs and clues and show others the way.  The analogy used by Kevin hall,  is of the head of a hunting party in ancient times.  The pathfinder reads small clues and guided others through constant and keen assessment.  How are your assessment skills?  Are they leading others to the correct actions?  [Also note, that Pathfinder does not imply that you do things for people, it is very much about empowering others to succeed, not fostering a state of dependence.]
  3. Namaste.  When Einstein wrote a letter to Ghandi asking what he said to people he passed on the street in a news clip he had seen, Gandhi replied “Namaste. It means I honor the place in you where the entire universe resides. I honor the place in you of light, love, truth, peace, and wisdom.”  For those of us working with others, according to Hall this concept is that “I salute the Divine within you. I salute what you do best. I salute your natural gifts. I honor your uniqueness and your specialness.”  Even more simply this is a reminder to treat each person as an individual, and to restore focus to patient or athlete centered care.  There are no cookie cutter solutions and that’s what makes each day exciting. 
  4. Passion.  ‘Passion is a sacred offering’. The origination of this word comes from Christianity and the ‘passion of christ’, referring to the willing suffering.  For you and I it means, “being willing to suffer for what you love”.  I encounter many who have given of themselves and their time, borrowed from their practices and families, endured financial challenges and hardships all in pursuit of gaining a better and deeper understanding.  These colleagues of mine are passionate about their work.  Too often I encounter folks who claim to have a passion, but fail to acknowledge the suffering and sacrifices that come along with this level of dedication.  In terms of patients looking to improve their condition or athletes who are striving for peak performance this desire must be accompanied by an understanding of the accompanied sacrifices. It’s easy to talk about making changes and improvements, but what are you willing to give to reach this goal?   Identify the goal and purpose, acknowledge the likely sacrifices.
  5. Sapere Vedere (knowing how to see).  Hall explains this as a 3D combination of hindsight, foresight, and insight.  This idea includes aspects of seeing through obstacles, avoiding myopic focus on obstacles and past failures, and letting the heart show us the vision that our eyes cannot yet see.  It is complimented by Stephen Covey’s motto of “Live life in crescendo”.  To bring this back to focusing on patients and athletes, this is acknowledge past injuries, failures, and setbacks, but not dwelling on them.  This is goal setting with many carrots, both the goals we can see in the near future and the long-term success we want to strive for.  Finally, it is the idea of creating a positive slope.  A small change in today’s treatment or training session can begin the snowball rolling down the hill.  Focus and build on each small success with the heart and mind set on the big picture.
  6. Humility.  Hall explains that this is “one of the most misundestood and misapplied words in all of language.  Humility is not being passive and submissive, nor is it distinguished by slumping shoulders, bowed heads and subservient downward glances.”  The root of the word humility is humus, meaning soil. This creates a great analogy.  When planting in soil that is hard and stubborn a seed will not grow into a great tree.  When a seed is planted within soil that is fertile (rich, moldable, and ready) the result is a massive and beautiful tree.  To grow, develop, and flourish we need humility.  Humility is about being teachable and coachable, it is being open to new ideas, remaining curious and constantly assessing if our current ideas are accurate and complete, and continuing to develop.  Are you humble in your approach to treating patients or training athletes?  Have you become beholden to a particular method?  Does that serve your long-term success?  How humble are those you work with?  Are they embracing and incorporating your teachings or are the seeds you plant sitting, ungerminated in their soil?
  7. Inspire.  “To breathe into”.   There are many sayings about air and goals.  We can stunt progress by removing air, by “Taking the wind out of my  sail” or someone can support and uplift by being, “The wind beneath your wings”.  Simply to inspire, or breathe into something, is to give hope, support and encouragement from a very fundamental place.  As respiration is a central phenomena both for existence and achieving neuromusculoskeletal rehab/training goals.  Be sure to inspire those you work with.  Give them what they need to succeed, encourage them to go farther, and provide support for them so they know that they cannot fall.
  8. Empathy.  “To be able to put oneself in another’s position, to be able to see and feel as another person does, that is the rare gift.” -Mata Amritanandamayi.  Traced to its roots, empathy means, “walking in the path of another”.  I cannot tell you how many respected friends and colleagues have told me they feel like the became better clinicians after suffering significant injuries, pain, or medical conditions.  Their experiences created empathy. For those who have not experienced these same challenges, this should serve as a reminder to assess your patients situation, not just their condition.  Where is this person (in life; mentally, physically, and emotionally)?  Where does this person want to be?  Figuring out these two points and filling this gap, is the job of the clinician or trainer.  However, along the way we must understand the attitudes, beliefs, fears, and values of the person we’re working with as they will often dictate or direct how we get to the end goal.  This is the part of the psychosocial component to the biopsychosocial approach.  There are many methods/techniques/systems that fail to adequately address this in their teaching.  Understand those you’re working with and adapt your methods to meet their situation.
  9. Coach. The origin of coach is the classic horsedrawn stagecoach.  It was a method from getting from where you are to where you want to be.  The word ‘Coach’ has been adapted to many other forms of transportation over the years, but also brought into athletic development.  There are many synonyms for ‘coach’ including: sensei, guru, lama, maestro, tutor, guide, teacher, and mentor.  According to Hall, “these words describe the same role: one who goes before and shows the way.”  A clinician or trainer is also a ‘coach’.  To be a great coach you must, know the way, communicate to show the way, and recognize potential (identify those who can get to where they need to be).  Also you must remember that “you can’t teach what you don’t know, and you can’t guide where you don’t go”.  Lead by genuine example.
  10. Ollin.  To move an act with all your heart.  This to me resembles Passion, but it has another quality of intense dedication with no turning back.  The word is pronounced ALL-in, and reminds me of Texas Hold ’em.  When you recognize an opportunity can you give it everything you have, even if it means risking complete failure?   How many of your goals do you pursue with this degree of reckless abandon?  Can you inspire Ollin, in those you work with?  Do they understand the need for this level of commitment to achieve certain goals?  Also, how often is ‘giving it all you’ve got’ reduced to a meaningless hyperbole in our athletic culture.
  11. Integrity.  Comes from the root integer, a whole number.  It refers to our words and actions being ‘whole or complete’.  It reminds me of the Four Agreements, and the quest to “be impeccable with your word”.  This is a truly rare trait as many of us have good intentions, but lack follow through.  We avoid or skew the truth as to not hurt others or step on toes.  It is easier to say what people want to hear, but this shortcut we take often impedes progress down the road.  After your assessment, do you present your findings with integrity?  Do you follow through with what your patient or client needs, as you said you would?  Are your commitments to them kept with the same passion and ollin, you expect out of them?

Hoping the ideas of Kevin Hall will breathe some renewed sense of dedication and focus to your work and for those who work with.