What Physiotherapists Specialized in Orthopedic Manual Therapy Know About Nocebo-Related Effects and Contextual Factors: Findings From a National Survey.

Giacomo Rossettini,Marco Testa,Mattia Manoni,Andrea Turolla,Alvisa Palese,Tommaso Geri,Mattia Mirandola,Chiara Marzaro,Mirta Fiorio,Luana Colloca

doi:10.3389/fpsyg.2020.582174

Abstract

ObjectiveThe aim of this study was to investigate the knowledge of orthopedic manual therapists (OMTs) regarding context factors (CFs) capable of triggering nocebo effects during the treatment and how this knowledge is related to their socio-demographic features.DesignA cross-sectional online survey.SettingNational.Main Outcome MeasuresA 20 items questionnaire composed by open-ended and closed single-choice questions was administered to explore: (a) socio-demographic variables (10 questions); (b) the relation between different CFs and nocebo-related effects (2 questions); and (c) the knowledge of participants about nocebo-related effects and how they managed them in the clinical practice (8 questions).Participants1288 OMTs were recruited from the database of the Master in Rehabilitation of Musculoskeletal Disorders (MRDM) of the University of Genova from March to May 2019. Inclusion criteria were: (a) to possess a valid email account; (b) to understand and use as a native language the Italian; (c) to be graduated as OMTs; and (d) to be employed as physiotherapists specialized-OMTs during the survey.Results791 responses were received (61.4%); 473 of them were male (59.8%), with an average age of 31.0 ± 7.1 years. OMTs defined nocebo-related effects as the psychosocial context effects around therapy and patient with specific biological bases (72.2%). OMTs know that their clinical practice is pervaded by nocebo-related effects (42.5%), triggered by CFs. Participants communicated nocebo-related effects balancing the positive features of the therapy with the negative ones (50.9%), during the decision of the therapeutic plan (42.7%). They reported associative learning as the main mechanism involved in nocebo-related effects (28.8%). OMTs taught and trained patient’s strategies to manage nocebo-related effects (39.6%) through an evaluation and correction of patient’s anxieties, doubts and expectations (37.7%). OMTs most frequently considered themselves to have a “medium” education about nocebo-related effects (48.2%) and that their management should be taught during bachelor (78.6%).ConclusionOMTs believed that nocebo-related effects were present in their clinical practice and that they can be triggered by CFs.

Highlights

Placebo and nocebo-related effects are emerging phenomena of interest among researchers, scholars and clinicians in orthopedic manual therapy (Rossettini et al, 2018a)
While placebo-related effects have been widely inquired in orthopedic manual therapy, nocebo-related effects have been underlined as a new research field that should be investigated for several reasons (Rossettini et al, 2020)
Psychobiological explanations have been documented as the underlying mechanisms of action of contextual factors (CFs) and evoked nocebo-related effects (Colloca and Barsky, 2020) capable to exacerbate the perception of a symptom affecting the therapeutic relationship (Hansen and Zech, 2019)

Summary

Introduction

Placebo and nocebo-related effects are emerging phenomena of interest among researchers, scholars and clinicians in orthopedic manual therapy (Rossettini et al, 2018a) They represent the result of the positive (placebo) or negative (nocebo) use of contextual factors (CFs) during the administration of a therapy (Benedetti, 2013). Specific neurotransmitters (e.g., cholecystokinin and cyclooxygenase-prostaglandins activation; opioid and dopamine deactivation) have been indicated as mediators involved in CFs and triggered nocebo-related effects (Frisaldi et al, 2015). Part of these processes are the activation of neural pathways (e.g., anterior cingulate cortex, dorsolateral prefrontal cortex, periaqueductal gray, and spinal cord) (Darnall and Colloca, 2018). The negative clinical impact of CFs (e.g., patients’ expectations, beliefs) and induced nocebo-related effects on therapeutic outcomes has been highlighted at multiple healthcare levels, resulting in increased costs, work absenteeism and medicalization (Hallegraeff et al, 2012; Trinderup et al, 2018)

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