The most common type of nocebo effect I’ve seen in my physical therapy practice is patients reporting a decrease in muscle movement or flexibility after applying a cold pack. And only after thorough counseling do they understand the importance of cryotherapy and start to accurately report how they feel.
That’s just one example of how perception about a certain therapy can affect the outcomes. There are dozens of more examples of the nocebo effect that all healthcare professionals witness in their practices.
Nocebo response in physical therapy is real. And it can limit the effectiveness of your modalities. That’s why learning about its causes and finding ways to avoid it is necessary.
In this article, we’ll discuss what nocebo means, why it happens and what you can do about it to improve patient outcomes in physical therapy clinics. We’ll also share seven crucial tips that can help you avoid or reverse nocebo response in patients.
So grab a notebook and start taking notes so you can practically apply these tips in your treatment sessions.
What Is the Nocebo Effect in Physical Therapy Patients?
Nocebo response is a situation where a person experiences negative effects in response to something, often medication, due to a belief that the medication is harmful.
In physical therapy, patients might experience some adverse reactions after performing an exercise or after you’ve applied an intervention, for no other reason but because they believe it’s harmful. In such a case, the harmful effects experienced by the patient are called Nocebo.
Although the exercise or medication might not be dangerous itself, the harmful effects of the nocebo effect are very real.
That’s why healthcare practitioners need to take this seriously. This can affect the impact of our physical therapy interventions and, in turn, influence the outcomes.
The nocebo effect is the opposite of the placebo effect. Some have even called it the evil twin of placebo. And it’s just as powerful as a placebo if not more. That’s because negative thoughts and perspectives often tend to have a bigger influence on our minds than positive ones.[i]
The nocebo effect has been demonstrated in multiple research and case studies.
For instance, a 2015 study by Nikiphorou et al. found that almost a quarter of their trial patients discontinued their prescribed medication due to a belief about their increased side effects.[ii]
This response is mainly caused by physiological factors, media misinformation and personal beliefs. But the good news is that the nocebo effect can be reversed with appropriate therapy.
So even if your patient is dealing with side effects due to nocebo, you can help them get better by using a few techniques that we will cover in the next section.
7 Tips to Avoid the Nocebo Effect in Physical Therapy Patients
Here are seven practical techniques that you can use to prevent or reverse nocebo response in your patients:
1. Educate the Patient
The best thing you can do to remove false perceptions is effective communication. So explain your physical therapy treatment’s rationale to your patients in simple language.
If your patient’s first language is not English, then make sure that you can accurately translate the terms in the language they can understand.
Also, manage the patient’s expectations by educating them properly. Tell them about the recovery timeline and the changes to expect in the different stages of the program.
For instance, moving a joint in the painful range while exercising can sometimes trigger a painful episode for your patients. It’s completely normal to experience that. But if your patient has not been properly educated about this potential side effect, they might relate the painful episode to the exercise and never do that again.
2. Don’t Use Scary Terms
The gap between what the physical therapist says and what the patient understands can be a cause of triggering the nocebo effect.[iii]
To counter that, be cautious of the medical terms you use to explain the condition or the treatment regimen.
I’ve experienced this with one of my patients as well. She was told that the cause of her back pain was a ‘slipped disk’. She was imagining a disk that was floating outside of her spine. And so she rejected all the exercises that I prescribed her saying that these will be too risky and may cause more damage. I had to show her a 3D model of the spine to get her to understand what was happening. Luckily, we were able to get rid of her negative preconceptions and get her started on an exercise regimen.
– Dr Aamina Saeed (PT)
Your non-verbal cues are just as important here. So project confidence and present all the facts without scaring the patient. Providing balanced information is the key here. You have to focus on the positive effects of the treatment as much as – if not more – the negative attributes.
Don’t use big words or scary terms, especially while you’re elaborating on the side effects of a certain treatment. Some of these words could be herniated, bulging, loss of joint space, degenerated and so on.
3. Remove Patient’s Frustrations and Misinformation
The patient-clinician relationship plays a critical part in removing misinformation. You should welcome questions so you can assess for the nocebo effect and remove anxiety regarding your physical therapy treatments.
You need to gain the patient’s trust and build rapport. That can help them trust the treatments you prescribe and reduce the chances of a nocebo response.
You can also directly ask them if they know of any side effects that they would like to talk about. Then you can help clarify those and put things in perspective for them.
4. Get the Patient’s Buy-in
You can tackle nocebo response in physical therapy patients by making them an active part of the treatment process instead of simply prescribing certain exercises.
So while you’re working on the treatments, ask the patient if they believe a certain exercise or intervention will help them. And if possible, include that in the treatment regimen.
This can improve patient participation in physical therapy treatments. Improved patient engagement can also result in better patient satisfaction rates and lower negative effects.
5. Recognize the Warning Signs
You should be extra cautious to educate those patients who are at a higher risk of experiencing the nocebo effect.
You can identify them by having a conversation and spotting their skepticism about the exercises or the treatment regimen.
Such patients might complain too much about the exercise being painful or uncomfortable. You might also notice that the patients at risk of nocebo are non-adherent to your prescribed exercise regimen.
Be aware of the patient’s history to learn about their biases. Get an idea about their emotional state and stresses they might be going through as these can tell you about their risk for developing the nocebo response.
6. Stimulate a Placebo Effect
A great strategy to avoid nocebo response is to create an environment that stimulates a positive response to your treatment.
For example, you can provide heat or stretches to efficiently warm up the muscles before exercising.
Research suggests that these techniques might enhance joint position sense and range of motion. That can improve the psychological impact of the exercise even if you move the joint through a painful range during the treatment. [iv] , [v]
You can also advise the patient to play soothing sounds or music while exercising if they believe that it will help them. Or you can suggest that they do the treatments at the time of day when they are most energetic.
Research tells us that green light or well-lit rooms also tend to create a happy feeling which can translate to a placebo effect in patients.[vi]
7. Leverage Observational Learning
If the patient believes that the treatment you’re prescribing will hurt them, then you can show them that it won’t. Observational learning in physiotherapy is a powerful tool that you can leverage to tackle nocebo response.
You can bring the patient to a group exercise session so they can see how others are benefiting from a similar treatment regimen.
Or you can passively apply the exercises on them and show them that there isn’t as much pain or difficulty as they imagined.
You could also show patients anatomical models of the spine or knee so they can see that a bit of reduced space or instability is not a massive issue. Rather, it’s something they can fix with your help.
Why Is It Critical to Proactively Tackle Nocebo Effect in Physical Therapy?
Over-reporting of side effects, non-adherence to treatment regimens due to fear of side effects and decreased efficiency of treatments are some of the consequences of nocebo response.
All of these directly affect the outcomes of your physical therapy treatment. And if not addressed at the right time, can result in long-term problems for your patients.[vii]
Related: 10 Common Myths About Physical Therapy – Busted
In Summary
Our thoughts are powerful. Positive and negative perceptions can result in very real physiological effects that can be harmful.
The Nocebo effect presents a dilemma to most healthcare professionals. We often go back and forth when it comes to how we should tell our patients about all the facts (including potential side-effects) without risking a nocebo response.
The tips mentioned in this article are backed by medical studies and have proven to tackle nocebo. We have tried these in our practice over and over again and found them to be helpful. You should also try these out with your patients to improve their therapy outcomes and treatment adherence.
Disclaimer: This article is for informative purposes only. We provide well research and authentic information. Do not consider this as personalized health advice. Please contact a licensed doctor for medical issues and health concerns.
[i] https://www.sciencedirect.com/science/article/abs/pii/S0002934314007980
[ii] https://pubmed.ncbi.nlm.nih.gov/26549204/
[iii] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4804316/
[iv] https://www.jospt.org/doi/abs/10.2519/jospt.1984.6.2.110
[v] https://www.sciencedirect.com/science/article/abs/pii/S1466853X10000350
[vi] https://www.sciencedirect.com/science/article/abs/pii/S0304395909000906
[vii] https://www.frontiersin.org/articles/10.3389/fphar.2019.01372/full
