Archives for June 2013

Nocebo strikes again

Once again the nocebo has struck.  If I was a better web programmer, I would have some ominous and sinister background music playing as you read this.  Since I’m a novice, please play something fitting in your head as you read this.

nefariousninjaThe nocebo sneaks up on us like a nefarious ninja.  Quietly the words we hear sneak into our minds.  Scientific sounding, but often misguided labels infect our thoughts, become our fears, and disable us.  Most don’t see it coming and some don’t even know it happened, but before you know it… the damage has been done.

For those who have read this blog before you’ll recall that I have a fascination with the effects of the nocebo.  In short, the nocebo is a negative reaction to harmless stimulus, the opposite of the placebo.  Quite often in healthcare this is the idea that something is wrong.  The thought that we are broken/damaged/unstable/deranged/etc can be disabling.  Thoughts are a powerful thing and some of us are either naive to this fact or are exploiting it for personal gain.

As one of the main ethical obligations for health care providers is to ‘do no harm’ (Primum non nocere).  I will begin by stating I think planting a nocebo is harmful.   If we can agree that ideas and images can be infectious, (the current buzzword  for this is fittingly ‘viral’), then we should acknowledge that we need to carefully monitor how we communicate with our patients and athletes.

I tell this story today due to a recent case I had.  Generalities will be used to protect the innocent (& guilty) parties, but also to make the point that this could happen to just about anyone and all too often does.

Background:  A teenager reports with a chief complaint of unilateral low back pain (L2/3 level) focused an inch or so from mid-line of several weeks duration. No prior back injuries or episodes.  Back pain was of non-traumatic onset.    Intermittent symptoms are reported, but there is pain every day.  Onset is after prolonged activity, such as sitting and moreso with standing.  No extremity symptoms or nerve tension upon testing.  Full pain free ranges of motion at time of exam.

For those using your clinical acumen, you have a picture in your mind of the possibilities.  At first glance to me this appears to fall into the McKenzie classification of postural syndrome.  To put it in other terms, it’s clearly an accumulation of load or lack of endurance phenomenon.  The question is does this person have an underlying movement flaw, a lack of capacity/endurance, or just a bad habit?  What I suspected was an underlying movement/postural flaw that they couldn’t control that when repeated put straws on the camels back until it broke.  As I explained this to the patient, they looked at me as if I said something they couldn’t believe. At first, I wondered why…..

I was butting up against an existing diagnosis as they had seen another health care provider 2 days ago.

Previous diagnosis: scar tissue/adhesion of the disc based on physical exam and x-ray.  The nocebo had been planted (and was growing). If you can make sense of that diagnosis in this case, please explain it to me.  Perhaps I’ve missed something in the literature or in my clinical training.

I now understood why this was scheduled as an urgent visit and the patient thought we were going to be seeing each other frequently and for a long time.  With diligent self-management, I doubt either of these will turn out to be true.

Listen to Yoda.

As doctors, coaches, healthcare providers, or trainers we are seen as leaders to our patients, clients, and athletes.  We must respect this relationship.

Leaders can lead through love or fear.  Fear is a shortcut to loyalty and compliance, but it will always create a half-hearted bond and an oppressive relationship.  Leading from a place of trust, openness and passion requires more of us as healthcare providers, but it can also create loyalty and compliance.  Also when achieved it will foster positivity, drive, and a nurturing relationship where great things, perhaps beyond expectation can happen.  In both chronic pain patients and elite performers, I see this lead to great things.

“Men are driven by two two principal impulses, either by love or by fear.”
― Niccolò Machiavelli, The Discourses


“Since love and fear can hardly exist together, if we must choose between them, it is far safer to be feared than loved”
― Niccolò Machiavelli

Is Machiavelli correct?  Here he notes it’s safer to be feared.  He does not state that it is more productive, better in the long term, or the most ethical way, just that it is safer.

“It is best to be both feared and loved; however, if one cannot be both it is better to be feared than loved.”
― Niccolò Machiavelli, The Prince

Let’s just say, I disagree.  In the terms of healthcare providers, coaches, and fitness trainers the current state of affairs warrants us dropping the fear based, nocebo inducing model.  For an interesting discussion of this and to learn about motivation 2.0, see Drive by Daniel Pink.  The carrot and the stick have changed.

More about the nocebo…

Motivating through fear may work in the short term to get people to do something, but over the long run I believe personal pride is a much greater motivator.  It produces far better results that last for a much longer time.  -John Wooden

Stretching the marionette

Many of us, myself included, were raised in a sporting environment that emphasized stretching.  As a distance runner, I was routinely advised to stretch for 1/2 hour or more prior to running every day.  Unfortunately, many continue to repeat what they were taught and never question the status quo. There is a wealth of evidence that suggests static stretching can rob us of performance, although I do acknowledge some degree of tissue extensibility/mobility is necessary.

Liars! Changing the length of my strings makes things harder.

Those who treat runners know motor control (stability) is often an issue, particularly in the frontal and transverse planes.  Recently I saw the most under-controlled runner I’ve seen in a long time.  After an evaluation, corrective strategy, and conversation we reassessed and saw a nice improvement in symptoms and movement quality.  We discussed the future course of care and home exercise prescription and were about to part ways when…. the patient asked me what stretches he should add to the 2 exercises I just taught him.  Maybe I did the world’s worst job communicating what I thought the problem and potential solution were, but I suspect I was just up against an insurmountable preconceived notion.  Stretching is not a panacea solution.  It is also not a necessity for all activities, in particular running.  See NY Times Article: Reasons Not to Stretch.

There is also abundant evidence questioning the value and timing of static stretching.  A random selection, in no particular order:

I understand that handing out copies of the NY Times article or giving patients research citations, abstracts, or even full text articles isn’t a solution to the problem.  Further, in the current healthcare setting time and efficiency is often a key factor in clinical treatment.  So how do we effectively communicate this idea that stretching may impede performance as clearly and succinctly as possible?

Here’s one way I’ve had success.  I recommend you judge your successful communication by the change in facial expression (shocked), demeanor (surprised and curious), and the light bulb appearing above your patient/clients head.   

The way you move is coordinated in the subconscious portion of your brain.  This is done based on feedback regarding length and tension.  Changing your length and tension by stretching just before you run is like changing the length of the strings on a marionette just before the puppeteer takes the stage.  The performance will suffer.

I’m not sure why this analogy works better than all others I’ve tried, but it seems to.  Perhaps it’s the image of the clumsy puppeteer?  Maybe it’s the non-threatening nature of the analogy as it doesn’t directly compete with what so many ‘experts’ have told the athlete before?  Either way, it seems to be a way for people to grasp a complex concept that is often in opposition of their existing beliefs.


This conversation often continues into why they feel ‘tight’.  Here’s a nice recap of Professor Janda’s thoughts by Craig Liebenson, DC.