The silent healer: the role of communication in placebo effects

Optimizing placebo and minimizing nocebo effects through communication: e-learning and virtual reality training development

BACKGROUND

The effects of many treatments in healthcare are determined by factors other than the treatment itself. Patients' expectations and the relationship with their healthcare provider can significantly affect treatment outcomes and thereby play a major role in eliciting placebo and nocebo effects. We aim to develop and evaluate an innovative communication training, consisting of an e-learning and virtual reality (VR) training, for healthcare providers across all disciplines, to optimize placebo and minimize nocebo effects through healthcare provider-patient communication. The current paper describes the development, mid-term evaluation, optimization, and final evaluation of the communication training, conducted in The Netherlands.

METHODS

The development of both the e-learning and the VR training consisted of four phases: 1) content and technical development, 2) mid-term evaluation by healthcare providers and placebo/communication researchers, 3) optimization of the training, and 4) final evaluation by healthcare providers. To ensure the success, applicability, authenticity, and user-friendliness of the communication training, there was ongoing structural collaboration with healthcare providers as future end users, experts in the field of placebo/communication research, and educational experts in all phases.

RESULTS

Placebo/communication researchers and healthcare providers evaluated the e-learning positively (overall 7.9 on 0-10 scale) and the content was perceived as useful, accessible, and interesting. The VR training was assessed with an overall 6.9 (0-10 scale) and was evaluated as user-friendly and a safe method for practicing communication skills. Although there were some concerns regarding the authenticity of the VR training (i.e. to what extent the virtual patient reacts like a real patient), placebo and communication researchers, as well as healthcare providers, recognized the significant potential of the VR training for the future.

CONCLUSIONS

We have developed an innovative and user-friendly communication training, consisting of an e-learning and VR training (2D and 3D), that can be used to teach healthcare providers how to optimize placebo effects and minimize nocebo effects through healthcare provider-patient communication. Future studies can work on improved authenticity, translate the training into other languages and cultures, expand with additional VR cases, and measure the expected effects on providers communication skills and subsequently patient outcomes.

Enhancing Adherence and Management in Patients with Hypertension: Impact of Form and Frequency of Knowledge Intervention

BACKGROUND

The alarming rise in prevalence of hypertension warrants psychosocial methods supplementing pharmacotherapy for better management and prevention of cardiac emergencies. The objective of the study was to assess the differential impact of the form and frequency of knowledge intervention on management of primary hypertension.

MATERIALS AND METHOD

The study was conducted on 256 hypertensive patients recruited through purposive sampling at health centers in Hyderabad, India. Pretest post-test control group quasi-experimental design was adopted for the study. There were two forms of the knowledge intervention, namely 'Direct Interaction' and 'Audio-Visual'. Each form was presented in two frequencies namely 'single exposure' and 'double exposure'. The four groups were labelled as Direct Intervention Single (DIS), Direct Intervention Double (DID), Audio-Visual Single (AVS) and Audio-Visual Double (AVD). Adherence and management of hypertension were assessed at baseline and six weeks post experiment. Analysis of Covariance (ANCOVA) was applied using IBM SPSS Statistics version 20.

RESULTS

ANCOVA followed by Bonferroni Multiple Group Comparison Test revealed significant differences between the four intervention groups and control group on adherence (p<.001). In case of hypertension management significant differences were observed between Control group and DIS, DID (P<.001), Control and AVS (P<.01). Control group did not differ from AVD.

CONCLUSION

There was a positive impact of Knowledge Intervention on adherence and management of hypertension. Double exposure in audio visual form was counterproductive in hypertension management.

SEE-Diabetes, a patient-centered diabetes self-management education and support for older adults: Findings and information needs from patients' perspectives

AIMS

This study identified the information needs of people with diabetes aged 65 and older through surveys and focus groups to inform the development of a patient-centered educational decision aid for diabetes care, SEE-Diabetes (Support-Engage-Empower-Diabetes).

METHODS

We conducted survey (N = 37) and three focus groups (N = 9). The survey collected demographics, diabetes duration, insulin usage, and clinic notes accessibility through a patient portal. In focus groups, participants evaluated the Assessment and Plan section of three selected deidentified clinic notes to assess readability and helpfulness for diabetes care.

RESULTS

The mean age of participants was 66 (24-82, SD = 12), and 22 were female (60%). The mean diabetes duration was 20.9 years (1-63, SD=15). Most participants (80%) read their clinical notes via patient portal. In the focus groups, the readability of clinic notes was noted as a primary concern because of medical abbreviations and poor formatting. Participants found the helpfulness of clinic notes was negatively impacted by vague or insufficient self-care information.

CONCLUSIONS

We found the high use of patient portal for reading clinic notes, which offers a use case opportunity for the proposed SEE-Diabetes educational aid. Feedback about the readability and helpfulness of clinic notes will be considered during the design process.

What is the value of simulated patient assessment in structured clinical examinations of undergraduate students, and how should it be used?

INTRODUCTION

The aim of this study was to explore correlations between clinical assessor and simulated patient (SP) scores drawn from summative Integrated Structured Clinical Examination (ISCE) and inform the best use of SP scores in future assessments.

MATERIALS AND METHODS

This retrospective study explores summative clinical assessor and formative SP numeric scores drawn from summative ISCE assessments spanning three academic years (2017-18 to 2019-20). Analyses were carried out using R 3.5.1 (R Core Team, 2018), with the stats package.

RESULTS

The sample consisted of 169 final-year BDS students across the three cohorts and included 95 females (56.2%) and 74 males (43.8%). Data from eight substations where SPs were included, were explored. Kendall's Tau, a non-parametric correlation, was used to investigate the relationships between the assessor and SP scores. Clinical assessor scores were out of a total of 20 points across various assessed domains within each substation. The formative SP assessment was out of 10 points with the same five affective domains related to communication included in each substation. Overall, the assessor and patient substation scores were not correlated (τ = 0.04, p = .272) indicating that communication skills alone, as assessed by patients, do not correlate with more holistic performance across other domains. There was significant positive correlation for two of the eight substations with the other substations showing very little correlation.

CONCLUSION

This study shows that assessment of student performance by SPs does not show a correlation with examiner scores and may provide additional information relating to affective skills of students. Notwithstanding the limitations of this study, the findings underscore the need to investigate further the value of involvement of SPs in clinical assessments to explore if scores by SPs can be used to enhance the validity of assessments if used summatively.

Positive Treatment Expectations Shape Perceived Medication Efficacy in a Translational Placebo Paradigm for the Gut-Brain Axis

Placebo research has established the pivotal role of treatment expectations in shaping symptom experience and patient-reported treatment outcomes. Perceived treatment efficacy constitutes a relevant yet understudied aspect, especially in the context of the gut-brain axis with visceral pain as key symptom. Using a clinically relevant experimental model of visceral pain, we elucidated effects of pre-treatment expectations on post-treatment perceived treatment efficacy as an indicator of treatment satisfaction in a translational placebo intervention. We implemented positive suggestions regarding intravenous treatment with a spasmolytic drug (in reality saline), herein applied in combination with two series of individually calibrated rectal distensions in healthy volunteers. The first series used distension pressures inducing pain (pain phase). In the second series, pressures were surreptitiously reduced, modeling pain relief (pain relief phase). Using visual analog scales (VAS), expected and perceived treatment efficacy were assessed, along with perceived pain intensity. Manipulation checks supported that the induction of positive pre-treatment expectations and the modeling of pain relief were successful. Generalized Linear Models (GLM) were implemented to assess the role of inter-individual variability in positive pre-treatment expectations in perceived treatment efficacy and pain perception. GLM indicated no association between pre-treatment expectations and perceived treatment efficacy or perceived pain for the pain phase. For the relief phase, pre-treatment expectations (p = 0.024) as well as efficacy ratings assessed after the preceding pain phase (p < 0.001) were significantly associated with treatment efficacy assessed after the relief phase, together explaining 54% of the variance in perceived treatment efficacy. The association between pre-treatment expectations and perceived pain approached significance (p = 0.057) in the relief phase. Our data from an experimental translational placebo intervention in visceral pain support that reported post-treatment medication efficacy is shaped by pre-treatment expectations. The observation that individuals with higher positive expectations reported less pain and higher treatment satisfaction after pain relief may provide first evidence that perceived symptom improvement may facilitate treatment satisfaction. The immediate experience of symptoms within a given psychosocial treatment context may dynamically change perceptions about treatment, with implications for treatment satisfaction, compliance and adherence of patients with conditions of the gut-brain axis.

Effect of Briefing on Acupuncture Treatment Outcome Expectations, Pain, and Adverse Side Effects Among Patients With Chronic Low Back Pain: A Randomized Clinical Trial

IMPORTANCE

In observational studies, patients' treatment outcome expectations have been associated with better outcomes (ie, a placebo response), whereas concerns about adverse side effects have been associated with an in increase in the negative effects of treatments (ie, a nocebo response). Some randomized trials have suggested that communication from clinicians could affect the treatment outcomes by changing patients' expectations.

OBJECTIVE

To investigate whether treatment outcome expectations and reported adverse side effects could be affected by different briefing contents before a minimal acupuncture treatment in patients with chronic low back pain (CLBP).

DESIGN, SETTING, AND PARTICIPANTS

This randomized single-blinded clinical trial was conducted among patients with CLBP at 1 outpatient clinic in Switzerland who had a pain intensity of at least 4 on a numeric rating scale from 0 to 10. Different recruitment channels were used to enroll patients. Data were collected from May 2016 to December 2017 and were analyzed from June to November 2018.

INTERVENTIONS

Patients were randomized to receive either a regular expectation briefing or a high expectation briefing (effectiveness) and either a regular adverse side effect briefing or an intense adverse side effect briefing (adverse side effect) in a 2 × 2 factorial design. The intervention (briefing sessions and written materials) was standardized and delivered before the acupuncture treatment, with additional booster informative emails provided during the 4-week, 8-session acupuncture course.

MAIN OUTCOMES AND MEASURES

The primary end point was the patients' expectations regarding the effectiveness of the acupuncture treatment (Expectation for Treatment Scale [ETS]) after the briefing and the subsequent pain intensity (numeric rating scale). The primary end point for the adverse side effect briefing was the adverse side effect score at the end of the acupuncture treatment, derived from session-by-session assessments of adverse side effects.

RESULTS

A total of 152 patients with CLBP (mean [SD] age, 39.54 [12.52] years; 100 [65.8%] women) were included. The estimated group difference (regular vs high) for the ETS was -0.16 (95% CI -0.81 to 0.50, P = .64), indicating no evidence for a difference between intervention groups. There was also no evidence for a difference in pain intensity at the end of the acupuncture treatment between the groups with different expectation briefings. The adverse side effects score in the group with the intense adverse side effect briefing were estimated to be 1.31 times higher (95% CI, 0.94 to 1.82; P = .11) than after a regular adverse side effect briefing, but the finding was not statistically significant.

CONCLUSIONS AND RELEVANCE

In this study, suggestions regarding treatment benefits (placebo) and adverse side effects (nocebo) did not affect treatment expectations or adverse side effects. Information regarding adverse side effects might require more research to understand nocebo responses.

TRIAL REGISTRATION

German Clinical Trials Register Identifier: DRKS00010191.

Harnessing Placebo Effects in Primary Care: Using the Person-Based Approach to Develop an Online Intervention to Enhance Practitioners' Communication of Clinical Empathy and Realistic Optimism During Consultations

Background: Empathic communication and positive messages are important components of "placebo" effects and can improve patient outcomes, including pain. Communicating empathy and optimism to patients within consultations may also enhance the effects of verum, i.e., non-placebo, treatments. This is particularly relevant for osteoarthritis, which is common, costly and difficult to manage. Digital interventions can be effective tools for changing practitioner behavior. This paper describes the systematic planning, development and optimization of an online intervention-"Empathico"-to help primary healthcare practitioners enhance their communication of clinical empathy and realistic optimism during consultations. Methods: The Person-Based Approach to intervention development was used. This entailed integrating insights from placebo and behavior change theory and evidence, and conducting primary and secondary qualitative research. Systematic literature reviews identified barriers, facilitators, and promising methods for enhancing clinical empathy and realistic optimism. Qualitative studies explored practitioners' and patients' perspectives, initially on the communication of clinical empathy and realistic optimism and subsequently on different iterations of the Empathico intervention. Insights from the literature reviews, qualitative studies and public contributor input were integrated into a logic model, behavioral analysis and principles that guided intervention development and optimization. Results: The Empathico intervention comprises 7 sections: Introduction, Empathy, Optimism, Application of Empathico for Osteoarthritis, Reflection on my Consultations, Setting Goals and Further Resources. Iterative refinement of Empathico, using feedback from patients and practitioners, resulted in highly positive feedback and helped to (1) contextualize evidence-based recommendations from placebo studies within the complexities of primary healthcare consultations and (2) ensure the intervention addressed practitioners' and patients' concerns and priorities. Conclusions: We have developed an evidence-based, theoretically-grounded intervention that should enable practitioners to better harness placebo effects of communication in consultations. The extensive use of qualitative research throughout the development and optimization process ensured that Empathico is highly acceptable and meaningful to practitioners. This means that practitioners are more likely to engage with Empathico and make changes to enhance their communication of clinical empathy and realistic optimism in clinical practice. Empathico is now ready to be evaluated in a large-scale randomized trial to explore its impact on patient outcomes.

Parkinson's disease: Content analysis of patient online discussion forums. A prospective observational study using Netnography

OBJECTIVES

To assess the users' characteristics, discussion contents, and the atmosphere of virtual peer communities.

METHODS

A qualitative, prospective study was conducted using the Netnography method. The most popular, publicly accessible French discussion forums were investigated. The web users' quotes were collected from May to October 2018. Data analysis triangulation was performed by two researchers using the NVivo 12® software.

RESULTS

The users discussed their experience with Parkinson's disease (PD) in a warm atmosphere. 23 discussion threads were analysed: 302 messages posted by 70 users (70% were females; the average illness duration was 6 years); 115 encoded nodes were created. Five user profiles appeared: leader, follower, expert, mixed, and undetermined. Common preoccupations were a lack of time and listening from the physicians' side. Three themes emerged: managing symptoms, living with PD, and sharing illness experiences. Users sought actively for a cure to limit or stop disease evolution, using alternative and complementary therapies to optimize their daily condition.

CONCLUSIONS

Online forums foster person's informal learnings about coping with PD. Healthcare professionals can use these learnings to optimize person-centred support.

PRACTICE IMPLICATIONS

During consultations, healthcare professionals should invite persons to discuss their online activity, informal learnings, beliefs and expectations towards therapeutic strategies.

Explaining placebo effects in an online survey study: Does 'Pavlov' ring a bell?

OBJECTIVES

Despite the increasing knowledge about placebo effects and their beneficial impact on treatment outcomes, strategies that explicitly employ these mechanisms remain scarce. To benefit from placebo effects, it is important to gain better understanding in how individuals want to be informed about placebo effects (for example about the underlying mechanisms that steer placebo effects). The main aim of this study was to investigate placebo information strategies in a general population sample by assessing current placebo knowledge, preferences for different placebo explanations (built around well-known mechanisms involved in placebo effects), and attitudes and acceptability towards the use of placebo effects in treatment.

DESIGN

Online survey.

SETTING

Leiden, The Netherlands.

PARTICIPANTS

444 participants (377 completers), aged 16-78 years.

MAIN OUTCOME MEASURES

Current placebo knowledge, placebo explanation preferences, and placebo attitudes and acceptability.

RESULTS

Participants scored high on current placebo knowledge (correct answers: M = 81.15%, SD = 12.75). Comparisons of 8 different placebo explanations revealed that participants preferred explanations based on brain mechanisms and positive expectations more than all other explanations (F(7, 368) = 3.618, p = .001). Furthermore, attitudes and acceptability for placebos in treatment varied for the type of the condition (i.e. more acceptant for psychological complaints) and participants indicated that physicians do not always have to be honest while making use of placebo effects for therapeutic benefit.

CONCLUSION

Our results brought forth new evidence in placebo information strategies, and indicated that explanations based on brain mechanisms and positive expectations were most preferred. These results can be insightful to construct placebo information strategies for both clinical context and research practices.

Pre-consultation information about one's physician can affect trust and treatment outcome expectations

OBJECTIVE

Information about physicians' skills is increasingly available on the internet and consulted by patients. The impact of such information on patient expectations is largely unknown. The aim of the present study was to investigate whether information about the competence and empathic skills of a physician may impact pre-consultation trust and treatment outcome expectations in mild and severe medical conditions.

METHODS

In this experimental web-based study, participants (n = 237) read vignettes describing competence and empathic skills (low versus high) of a fictive physician who would surgically remove a mole or melanoma (low versus high severity) following a 2 × 2 × 2 between-subjects design. Participants rated trust in the physician and treatment outcome expectations.

RESULTS

High competence and empathy raised trust in the physician, regardless of condition severity. High competence and high empathy both also increased expected surgery success, while only high competence reduced expected side effects.

CONCLUSION

Pre-consultation information highlighting a physician's competence and/or empathy may lead to higher trust in that physician, higher expected surgery success, and lower expected side effects.

PRACTICE IMPLICATIONS

Physicians and hospital staff should be aware of the effects of written information available and might, for example, provide profiles on hospital websites emphasizing healthcare providers' competence and empathy.

The ethical dilemma of placebo use in clinical practice

The clinical use of placebo that involves some ethical issues has led to much controversy. From the standpoint of both supporters and opponents, this article discusses this topic from three ethical principles such as beneficence, justice, and autonomy and also gives the recommendations. Finally, the moral dilemma caused by the different views between nurses and doctors in clinical practice is discussed.

Pharmacists' responses to cues and concerns of polypharmacy patients during clinical medication reviews-A video observation study

OBJECTIVE

The research questions of this study are 1) How do pharmacists respond to negative emotions of patients during a clinical medication review (CMR)? 2) How do patients express negative emotions during a CMR? 3) Who (pharmacist or patient) initiates a negative emotion to be discussed during a CMR?

METHODS

We used video-recordings to observe 132 CMR interviews of 49 pharmacists. Videos were coded with the Verona coding definitions on emotional sequences(-provider responses) (VR-CoDES(-P)).

RESULTS

In total 2538 negative emotions were identified, mainly expressed as cues (95.0 %). Often cues were expressed as verbal hints to hidden concerns (33.2 %) or were related to cognitive or physical causes (28.3 %).Three-quarters of the negative emotions were elicited by patients. 2670 pharmacists' responses were coded. The most common response was non-explicit providing space (77.6 %) and the least common response was explicit reducing space (5.8 %).

CONCLUSION

Pharmacists are mainly non-explicitly providing space in their responses. While this hinders their ability to capture patients' problems it also may enable patients to initiate topics.

PRACTICE IMPLICATIONS

Pharmacists are able to respond to patients' negative emotions. Training should focus on developing pharmacist's skills to be more explicit in their responses to get more in-depth knowledge of patients' problems.

The Trials and Tribulations of Selecting Comparison Groups in Randomized Trials of Nonpharmacological Complementary and Integrative Health Interventions

Editor's Note: For over two decades, JACM Editorial Board member Karen Sherman, PhD has been among the most respected clinical trialists in complementary and integrative health research. The epidemiologist and Senior Researcher at Kaiser Permanente Washington Health Research Institute has focused on pain conditions and has led or been part of teams exploring the roles of such therapies as yoga, acupuncture, mind-body and manual therapies. In this Invited Commentary, Sherman shares wisdom gleaned from the process: trial designs, principles for selecting controls, benefits and liabilities of placebo and sham controls, attention controls, usual care controls, and more. She also discusses the effects of comparison groups on sample sizes, comparison groups for mechanistic studies, and other comparison groups' considerations. This commentary should prove a useful primer wherever research methods in complementary and integrative health are taught. We are pleased to offer it here through JACM. -John Weeks, Editor-in-Chief, JACM (johnweeks-integrator.com).

Relationships Between Context, Process, and Outcome Indicators to Assess Quality of Physiotherapy Care in Patients with Whiplash-Associated Disorders: Applying Donabedian's Model of Care

BACKGROUND

Quality indicators (QIs) are measurable elements of practice performance and may relate to context, process, outcome and structure. A valid set of QIs have been developed, reflecting the clinical reasoning used in primary care physiotherapy for patients with whiplash-associated disorders (WAD). Donabedian's model postulates relationships between the constructs of quality of care, acting in a virtuous circle.

AIM

To explore the relative strengths of the relationships between context, process, and outcome indicators in the assessment of primary care physiotherapy in patients with WAD.

MATERIALS AND METHODS

Data on WAD patients (N=810) were collected over a period of 16 years in primary care physiotherapy practices by means of patients records. This routinely collected dataset (RCD-WAD) was classified in context, process, and outcome variables and analyzed retrospectively. Clinically relevant variables were selected based on expert consensus. Associations were expressed, using zero-order, as Spearman rank correlation coefficients (criterion: rs >0.25 [minimum: fair]; α-value = 0.05).

RESULTS

In round 1, 62 of 85 (72.9%) variables were selected by an expert panel as relevant for clinical reasoning; in round 2, 34 of 62 (54.8%) (context variables 9 of 18 [50.0%]; process variables 18 of 34 [52.9]; outcome variables 8 of 10 [90.0%]) as highly relevant. Associations between the selected context and process variables ranged from 0.27 to 0.53 (p≤0.00), between selected context and outcome variables from 0.26 to 0.55 (p≤0.00), and between selected process and outcome variables from 0.29 to 0.59 (p≤0.00). Moderate associations (rs >0.50; p≤0.00) were found between "pain coping" and "fear avoidance" as process variables, and "pain intensity" and "functioning" as outcome variables.

CONCLUSION

The identified associations between selected context, process, and outcome variables were fair to moderate. Ongoing work may clarify some of these associations and provide guidance to physiotherapists on how best to improve the quality of clinical reasoning in terms of relationships between context, process, and outcome in the management of patients with WAD.

How are medication related problems managed in primary care? An exploratory study in patients with diabetes and primary care providers

BACKGROUND

Medication self-management is important for patients who are controlling diabetes. Achieving medication self-management goals, may depend on treatment complexity and patients' capacities such as health literacy, knowledge and attitude.

OBJECTIVES

The aims of this study were to explore how patients with diabetes self-manage their medications, how patients seek support when experiencing problems and how primary healthcare providers identify patients' medication related problems and provide support.

METHODS

Semi-structured interviews were conducted among patients with diabetes receiving primary care and with their primary healthcare providers - GPs, nurses, pharmacists and technicians - between January and June 2017. A purposive sampling strategy was used to identify and select participants. An interview guide based on the Cycle of Complexity model was developed. Interviews were audiotaped and transcribed verbatim. Transcripts were coded with a combination of deductive and inductive codes. A thematic analysis was performed to identify categories and themes in the data. Findings were compared with the Cycle of Complexity model.

RESULTS

Twelve patients and 27 healthcare providers were included in the study. From the transcripts 95 codes, 6 categories and 2 major themes were extracted. Patients used practical solutions and gaining knowledge to manage their medication. Their problems were often related to stress and concerns about using medications. A trusted relationship with the healthcare provider was essential for patients to share problems and ask for support. Informal support was sought from family and peer-patients. Healthcare providers perceive problem identification as challenging. They relied on patients coming forward, computer notifications, clinical parameters and gut-feeling. Healthcare providers were able to offer appropriate support if a medication management problem was known.

CONCLUSION

Patients are confident of finding their way to manage their medications. However, sharing problems with healthcare providers requires a trusted relationship. This is acknowledged by both patients and healthcare providers.

Effects of Covertly Measured Home Exercise Adherence on Patient Outcomes Among Older Adults With Chronic Knee Pain

BACKGROUND

Assessment of home exercise adherence and the degree to which adherence influences changes in patient outcomes is limited by the use of self-reported measures.

OBJECTIVES

To determine the relationship between adherence to a home strengthening program, covertly measured by accelerometers in ankle cuff weights, and changes in self-reported pain, physical function, and knee extensor strength among people with chronic knee pain.

METHODS

This is a secondary analysis of data from a clinical measurement study in 54 adults, aged 45 years or older, with chronic knee pain who completed a 12-week, home-based quadriceps-strengthening program. A triaxial accelerometer was concealed in the ankle cuff weight used for exercises to assess exercise adherence. Associations between exercise adherence and changes in pain and function (measured using the Western Ontario and McMaster Universities Osteoarthritis Index) and peak isometric knee extensor strength were examined using mixed-effects and linear regression models and fractional polynomials.

RESULTS

Exercise adherence declined from a median of 90% (interquartile range, 70%-100%) in weeks 0 to 2 to 65% (interquartile range, 25%-90%) in weeks 10 to 12. Significant improvements were observed in knee pain (mean change, -3.2 units; 95% confidence interval [CI]: -2.4, -3.9 units), function (mean change, -10.1 units; 95% CI: -7.8, -12.4 units), and knee extensor strength (mean change, 0.34 Nm/kg; 95% CI: 0.26, 0.42 Nm/kg) across the group over the same period. Exercise adherence was not associated with changes in pain, function, and knee extensor strength over 2-week periods or over the entire 12 weeks.

CONCLUSION

Covertly measured adherence to a home strengthening program was not associated with changes in patient outcomes. These findings challenge the notion that greater exercise adherence leads to greater improvement in patient outcomes during a short-term intervention. J Orthop Sports Phys Ther 2019;49(7):548-556. doi:10.2519/jospt.2019.8843.

Placebo and nocebo response magnitude on temporomandibular disorder-related pain: A systematic review and meta-analysis

OBJECTIVES

The aim of this systematic review (SR) was to answer the following question: "In adult patients with temporomandibular disorder (TMD)-related pain, what is the placebo or nocebo effect of different therapies?"

METHODS

A SR was performed with randomised clinical placebo-controlled trials on diagnosed painful TMD studies from five main databases and from three grey literature. Studies included must have sample older than 18 years, with painful TMD, which diagnosis was done by Research Diagnostic Criteria (RDC/TMD) or Diagnostic Criteria (DC/TMD).

RESULTS

Out of 770 articles obtained, 42 met the inclusion criteria for qualitative and 26 for quantitative analysis. Meta-analysis indicated mean variation on pain intensity for placebo therapy was higher on laser acupuncture with 45.5 mm point reduction, followed by avocado soya bean extract with 36 mm and amitriptyline 25 mg with 25.2 mm. Laser showed a 29% of placebo effect, as well medicine with 19% and other therapies with 26%. Possible nocebo effect of 8% pain increase was found for intra-articular injection of Ultracain.

CONCLUSIONS

Based on the available data, the placebo response could play a major effect on TMD pain management and may be responsible from 10% to 75% of pain relief. Laser acupuncture, avocado soya bean and amitriptyline promoted the higher placebo effect. Possible nocebo effect was found only for Ultracain injection with 8%.

CLINICAL RELEVANCE

Clinicians could apply such evidence to optimise pain management and judgement about treatment efficacy, and researches may find it useful when designing their investigations.

The Use of Expectancy and Empathy When Communicating With Patients With Advanced Breast Cancer; an Observational Study of Clinician-Patient Consultations

Background: Information provision about prognosis, treatments, and side-effects is important in advanced cancer, yet also associated with impaired patient well-being. To counter potential detrimental effects, communication strategies based on placebo and nocebo effect mechanisms might be promising to apply in daily practice. This study aimed to provide more insight into how often and how oncologists use expectancy and empathy expressions in consultations with patients with advanced breast cancer. Methods: Forty-five consultations between oncologists and patients were audiotaped. To determine how often expectancy and empathy expressions were used, a coding scheme was created. Most consultations (n = 33) were coded and discussed by two coders, and the remaining 13 were coded by one coder. To determine how expectancy and empathy expressions were used, principles of inductive content analysis were followed. Results: Discussed evaluation (i.e., scan) results were good (n = 26,58%) or uncertain (n = 12,27%) and less often bad (n = 7,15%). Uncertain expectations about prognosis, treatment outcomes, and side effects occurred in 13, 38, and 27 consultations (29%, 85%, and 56%), followed by negative expectations in 8, 26, and 28 consultations (18%, 58%, and 62%) and positive expectations in 6, 34, and 17 consultations (13%, 76%, and 38%). When oncologists provided expectancy expressions, they tapped into three different dimensions: relational, personal, and explicit. Positive expectations emphasized the doctor-patient relationship, while negative expectations focused on the severity of the illness, and uncertainty was characterized by a balance between (potential) negative outcomes and hope. Observed generic or specific empathy expressions were regularly provided, most frequently understanding (n = 29,64% of consultations), respecting (n = 17,38%), supporting (n = 16,36%), and exploring (n = 16,36%). A lack of empathy occurred less often and contained, among others, not responding to patients' emotional concerns (n = 13,27% of consultations), interrupting (n = 7,16%), and an absence of understanding (n = 4,9%). Conclusion: In consultations with mainly positive or uncertain medical outcomes, oncologists predominantly made use of uncertain expectations (hope for the best, prepare for the worst) and used several empathic behaviors. Replication studies, e.g., in these and other medical situations, are needed. Follow-up studies should test the effect of specific communication strategies on patient outcomes, to counter potential negative effects of information provision. Studies should focus on uncertain situations. Ultimately, specific placebo and nocebo effect-inspired communication strategies can be harnessed in clinical care to improve patient outcomes.

Semi-Individualized Homeopathy Add-On Versus Usual Care Only for Premenstrual Disorders: A Randomized, Controlled Feasibility Study

OBJECTIVES

Premenstrual syndrome and premenstrual dysphoric disorder (PMS/PMDD) bother a substantial number of women. Homeopathy seems a promising treatment, but it needs investigation using reliable study designs. The feasibility of organizing an international randomized pragmatic trial on a homeopathic add-on treatment (usual care [UC] + HT) compared with UC alone was evaluated.

DESIGN

A multicenter, randomized, controlled pragmatic trial with parallel groups.

SETTINGS/LOCATION

The study was organized in general and private homeopathic practices in the Netherlands and Sweden and in an outpatient university clinic in Germany.

SUBJECTS

Women diagnosed as having PMS/PMDD, based on prospective daily rating by the daily record of severity of problems (DRSP) during a period of 2 months, were included and randomized.

INTERVENTIONS

Women were to receive UC + HT or UC for 4 months. Homeopathic medicine selection was according to a previously tested prognostic questionnaire and electronic algorithm. Usual care was as provided by the women's general practitioner according to their preferences.

OUTCOME MEASURES

Before and after treatment, the women completed diaries (DRSP), the measure yourself concerns and well-being, and other questionnaires. Intention-to-treat (ITT) and per protocol (PP) analyses were performed.

RESULTS

In Germany, the study could not proceed because of legal limitations. In Sweden, recruitment proved extremely difficult. In the Netherlands and Sweden, 60 women were randomized (UC + HT: 28; UC: 32), data of 47/46 women were analyzed (ITT/PP). After 4 months, relative mean change of DRSP scores in the UC + HT group was significantly better than in the UC group (p = 0.03).

CONCLUSIONS

With respect to recruitment and different legal status, it does not seem feasible to perform a larger, international, pragmatic randomized trial on (semi-)individualized homeopathy for PMS/PMDD. Since the added value of HT compared with UC was demonstrated by significant differences in symptom score changes, further studies are warranted.

The Application of Persuasion Theory to Placebo Effects

Placebo effects, or positive outcomes resulting from expectations about a treatment, are powerful components of modern medical care. In this chapter, we suggest that our understanding of placebo effects may benefit from more explicitly connecting this phenomenon to the existing empirical psychological literature on persuasion. Persuasion typically involves an attempt to bring about a change in beliefs or attitudes as a result of providing information on a topic. We begin by providing a brief overview of the psychological literature on placebo effects. We then point to connections between this literature and research on persuasive communication. Although some links have been made, these initial connections have predominantly relied on classic theories of persuasion rather than on more contemporary and comprehensive models. Next, we describe a modern theory of persuasion that may facilitate the study of placebo effects and analyze two issues pertinent to the literature on placebo effects from the lens of this model. Specifically, we consider how and when characteristics of a practitioner (e.g., variables such as perceptions of a practitioner's confidence or competence) can influence the magnitude of placebo effects, and how modern persuasion theory can help in understanding the durability of placebo effects over time. We conclude that examining placebo effects as an outcome of persuasive communication would be a fruitful line of future research.

Examining the effects of enhanced provider-patient communication on postoperative tonsillectomy pain: protocol of a randomised controlled trial performed by nurses in daily clinical care

INTRODUCTION

Placebo effects (true biopsychological effects not attributable to the active ingredients of medical technical interventions) can be attributed to several mechanisms, such as expectancy manipulation and empathy manipulation elicited by a provider's communication. So far, effects have primarily been shown in laboratory settings. The aim of this study is to determine the separate and combined effects of expectancy manipulation and empathy manipulation during preoperative and postoperative tonsillectomy analgesia care on clinical adult patients' outcomes.

METHODS AND ANALYSIS

Using a two-by-two randomised controlled trial, 128 adult tonsillectomy patients will be randomly assigned to one out of four conditions differing in the level of expectancy manipulation (standard vs enhanced) and empathy manipulation (standard vs enhanced). Day care ward nurses are trained to deliver the intervention, while patients are treated via the standard analgesia protocol and hospital routines. The primary outcome, perceived pain, is measured via hospital routine by a Numeric Rating Scale, and additional prehospitalisation, perihospitalisation and posthospitalisation questionnaires are completed (until day 3, ie, 2 days after the operation). The manipulation is checked using audio recordings of nurse-patient interactions.

ETHICS AND DISSEMINATION

Although communication is manipulated, the manipulations do not cross norms or values of acceptable behaviour. Standard medical care is provided. The ethical committee of the UMC Utrecht and the local OLVG hospital committee approved the study. Results will be published via (inter)national peer-reviewed journals and a lay publication.

TRIAL REGISTRATION NUMBER

NTR5994; Pre-results.

Specifying the effects of physician's communication on patients' outcomes: A randomised controlled trial

OBJECTIVE

To experimentally test the effects of physician's affect-oriented communication and inducing expectations on outcomes in patients with menstrual pain.

METHODS

Using a 2×2 RCT design, four videotaped simulated medical consultations were used, depicting a physician and a patient with menstrual pain. In the videos, two elements of physician's communication were manipulated: (1) affect-oriented communication (positive: warm, emphatic; versus negative: cold, formal), and (2) outcome expectation induction (positive versus uncertain). Participants (293 women with menstrual pain), acting as analogue patients, viewed one of the four videos. Pre- and post video participants' outcomes (anxiety, mood, self-efficacy, outcome expectations, and satisfaction) were assessed.

RESULTS

Positive affect-oriented communication reduced anxiety (p<0.001), negative mood (p=0.001), and increased satisfaction (p<0.001) compared to negative affect-oriented communication. Positive expectations increased feelings of self-efficacy (p<0.001) and outcome expectancies (p<0.001), compared to uncertain expectations, but did not reduce anxiety. The combination of positive affect-oriented communication and a positive expectation reduced anxiety (p=0.02), increased outcome expectancies (p=0.01) and satisfaction (p=0.001).

CONCLUSION

Being empathic and inducing positive expectations have distinct and combined effects, demonstrating that both are needed to influence patients' outcomes for the best.

PRACTICE IMPLICATIONS

Continued medical training is needed to harness placebo-effects of medical communication into practice.

What techniques might be used to harness placebo effects in non-malignant pain? A literature review and survey to develop a taxonomy

OBJECTIVES

Placebo effects can be clinically meaningful but are seldom fully exploited in clinical practice. This review aimed to facilitate translational research by producing a taxonomy of techniques that could augment placebo analgesia in clinical practice.

DESIGN

Literature review and survey.

METHODS

We systematically analysed methods which could plausibly be used to elicit placebo effects in 169 clinical and laboratory-based studies involving non-malignant pain, drawn from seven systematic reviews. In a validation exercise, we surveyed 33 leading placebo researchers (mean 12 years’ research experience, SD 9.8), who were asked to comment on and add to the draft taxonomy derived from the literature.

RESULTS

The final taxonomy defines 30 procedures that may contribute to placebo effects in clinical and experimental research, proposes 60 possible clinical applications and classifies procedures into five domains: the patient’s characteristics and belief (5 procedures and 11 clinical applications), the practitioner’s characteristics and beliefs (2 procedures and 4 clinical applications), the healthcare setting (8 procedures and 13 clinical applications), treatment characteristics (8 procedures and 14 clinical applications) and the patientâ€"practitioner interaction (7 procedures and 18 clinical applications).

CONCLUSION

The taxonomy provides a preliminary and novel tool with potential to guide translational research aiming to harness placebo effects for patient benefit in practice.

Chinese phytotherapy to reduce stress, anxiety and improve quality of life: randomized controlled trial

OBJECTIVE

To evaluate the effect of Chinese phytotherapyto reduce stress levels, anxiety and improve quality of life.

METHOD

double-blind randomized controlled trial with 89 volunteers divided into three groups: control (no intervention), Placebo and Phytotherapy. The study was conducted in 2015 with healthy adults treated at the Integrated and Eastern Therapy Institute,in Sao Paulo, Brazil. Participants were evaluated at baseline and after three weeks with the Stress Symptoms List (SSL), Anxiety Inventory-Trait and State and SF12v2 for quality of life. Intervention groups received a placebo or Gan May Zao formula (GMDZ)flaskwith 50 ml.

RESULTS

According to ANOVA, there were significant differences (p = 0.025) after treatment of stress (SSL2). And the difference was between control and Phytotherapy groups, according to the Tukey post hoc (p = 0.022). There were no differences in the levels of state-anxiety and physical and mental domains in the SF12v2.

CONCLUSION

The GMDZ formula reduced stress levels, but more studies are needed with greater sample, with reassessment of dosage and a longer period of treatment to confirm and extend the results. Brazilian Registry of Clinical Trials: RBR-28s4hz.

OBJETIVO

Avaliar o efeito da fitoterapia chinesa na redução de níveis de estresse, ansiedade e melhoria de qualidade de vida.

MÉTODO

Ensaio clínico randomizado duplo-cego, com 89 voluntários divididos em três grupos: Controle (sem intervenção), Placebo e Fitoterapia. Foi realizado em 2015, com adultos saudáveis atendidos no Instituto de Terapia Integrada e Oriental, São Paulo. Foram avaliados no baseline e, após 3 semanas,pela Lista de Sintomas de Stress (LSS), Inventário de Ansiedade-Traço e Estado e o SF12v2 de qualidade de vida. Os grupos de intervenção receberam um frasco de 50 ml de placebo ou da fórmula Gan Mai Da Zao (GMDZ).

RESULTADOS

Segundo ANOVA, houve diferença (p=0,025) no pós-tratamento de estresse (LSS2). E a diferença foi entre os grupos Controle e Fitoterapia, de acordo com o post hocde Tukey (p=0,022). Não houve diferenças nos níveis de ansiedade-estado e domínio físico e mental do SF12v2.

CONCLUSÃO

A fórmula GMDZ reduziu os níveis de estresse, mas são necessários mais estudos com amostra significativa, com reavaliação da posologia e um período maior de tratamento para confirmar e ampliar os resultados. Registro Brasileiro de Ensaios Clínicos: RBR-28s4hz.

Effects of subtle cognitive manipulations on placebo analgesia - An implicit priming study

Background

Expectancy is widely accepted as a key contributor to placebo effects. However, it is not known whether non‐conscious expectancies achieved through semantic priming may contribute to placebo analgesia. In this study, we investigated if an implicit priming procedure, where participants were unaware of the intended priming influence, affected placebo analgesia.

Methods

In a double‐blind experiment, healthy participants (n = 36) were randomized to different implicit priming types; one aimed at increasing positive expectations and one neutral control condition. First, pain calibration (thermal) and a credibility demonstration of the placebo analgesic device were performed. In a second step, an independent experimenter administered the priming task; Scrambled Sentence Test. Then, pain sensitivity was assessed while telling participants that the analgesic device was either turned on (placebo) or turned off (baseline). Pain responses were recorded on a 0–100 Numeric Response Scale.

Results

Overall, there was a significant placebo effect (p < 0.001), however, the priming conditions (positive/neutral) did not lead to differences in placebo outcome. Prior experience of pain relief (during initial pain testing) correlated significantly with placebo analgesia (p < 0.001) and explained 34% of placebo variance. Trait neuroticism correlated positively with placebo analgesia (p < 0.05) and explained 21% of placebo variance.

Conclusions

Priming is one of many ways to influence behaviour, and non‐conscious activation of positive expectations could theoretically affect placebo analgesia. Yet, we found no SST priming effect on placebo analgesia. Instead, our data point to the significance of prior experience of pain relief, trait neuroticism and social interaction with the treating clinician.

Significance

Our findings challenge the role of semantic priming as a behavioural modifier that may shape expectations of pain relief, and affect placebo analgesia.

Expectations predict chronic pain treatment outcomes

Accumulating evidence suggests an association between patient pretreatment expectations and numerous health outcomes. However, it remains unclear if and how expectations relate to outcomes after treatments in multidisciplinary pain programs. The present study aims at investigating the predictive association between expectations and clinical outcomes in a large database of chronic pain patients. In this observational cohort study, participants were 2272 patients treated in one of 3 university-affiliated multidisciplinary pain treatment centers. All patients received personalized care, including medical, psychological, and/or physical interventions. Patient expectations regarding pain relief and improvements in quality of life and functioning were measured before the first visit to the pain centers and served as predictor variables. Changes in pain intensity, depressive symptoms, pain interference, and tendency to catastrophize, as well as satisfaction with pain treatment and global impressions of change at 6-month follow-up, were considered as treatment outcomes. Structural equation modeling analyses showed significant positive relationships between expectations and most clinical outcomes, and this association was largely mediated by patients' global impressions of change. Similar patterns of relationships between variables were also observed in various subgroups of patients based on sex, age, pain duration, and pain classification. Such results emphasize the relevance of patient expectations as a determinant of outcomes in multimodal pain treatment programs. Furthermore, the results suggest that superior clinical outcomes are observed in individuals who expect high positive outcomes as a result of treatment.

Psychiatrists' Attitudes Toward Non-Pharmacologic Factors Within the Context of Antidepressant Pharmacotherapy

OBJECTIVE

Recent meta-analyses of antidepressant clinical trials have suggested that up to 82 % of response can be attributed to non-medication-related factors. The present study examines psychiatrists' attitudes regarding non-pharmacologic factors within the context of antidepressant pharmacotherapy.

METHODS

A web-based, 20-question cross-sectional survey was distributed to 101 staff psychiatrists and 48 post-graduate trainees in psychiatry at an academic hospital in Boston, MA. Demographics, practice characteristics, beliefs about non-pharmacologic factors affecting prescribing practices, perceived response and remission rates, and opinions about the need for further investigations in the psychopharmacology process were assessed.

RESULTS

Overall completion rate was 53 %. The final sample included 79 responses. The medians for clinician-perceived response rates (54 %) and remission rates (33 %) were in agreement with published rates. The reported median of the what portion of clinical outcomes is believed to be due to placebo effects (26 %) was numerically lower than suggested by literature. The contribution of the active ingredients of medications was perceived to be significantly higher than the contribution of patient characteristics and clinician characteristics. A longer time since graduation from medical school was significantly associated with higher belief in the effect of the active ingredients of antidepressant medications and with less perceived importance of placebo effects.

CONCLUSION

These findings suggest a discrepancy between empirical evidence and psychiatrists' beliefs on the impact of placebo effects on clinical outcomes. Educating antidepressant prescribers about the evidence based on psychosocial mediators of placebo effects' contribution to outcome may represent a promising strategy for improving clinical outcomes.

Is linking research, teaching and practice in communication in health care the way forward?

This paper is based on the keynote lecture given at the ICCH conference in New Orleans in October 2015. With as background the observation that even though research and teaching of communication have been receiving attention for some time now, patients still encounter many problems when they visit clinicians because of health problems, it subsequently touches upon research on integration of communication with correct medical content, person centered communication and the role of placebo on outcomes. For teaching it emphasizes methods working best to teach clinical communication skills and lead to behavior changes in professionals: experiential teaching methods but taking care of a balance with cognitive methods. It then discusses the challenge of transfer to clinical practice and what is needed to overcome these challenges: learning from reflecting on undesired outcomes in clinical practice, feedback from clinicians who are open to communication and support learners with effective feedback in that specific context. It adds suggestions about where linking more between research, teaching and clinical practice could help moving communication in health care forward and builds the case for involving policymakers and members of hospital boards to help manage the necessary climate change in clinical settings.

Automated Video Analysis of Non-verbal Communication in a Medical Setting

Non-verbal communication plays a significant role in establishing good rapport between physicians and patients and may influence aspects of patient health outcomes. It is therefore important to analyze non-verbal communication in medical settings. Current approaches to measure non-verbal interactions in medicine employ coding by human raters. Such tools are labor intensive and hence limit the scale of possible studies. Here, we present an automated video analysis tool for non-verbal interactions in a medical setting. We test the tool using videos of subjects that interact with an actor portraying a doctor. The actor interviews the subjects performing one of two scripted scenarios of interviewing the subjects: in one scenario the actor showed minimal engagement with the subject. The second scenario included active listening by the doctor and attentiveness to the subject. We analyze the cross correlation in total kinetic energy of the two people in the dyad, and also characterize the frequency spectrum of their motion. We find large differences in interpersonal motion synchrony and entrainment between the two performance scenarios. The active listening scenario shows more synchrony and more symmetric followership than the other scenario. Moreover, the active listening scenario shows more high-frequency motion termed jitter that has been recently suggested to be a marker of followership. The present approach may be useful for analyzing physician-patient interactions in terms of synchrony and dominance in a range of medical settings.

More Than Needles: The Importance of Explanations and Self-Care Advice in Treating Primary Dysmenorrhea with Acupuncture

Background. Primary dysmenorrhea is a common gynaecological condition. Traditional Chinese medicine (TCM) acupuncturists commonly treat primary dysmenorrhea and dispense specific self-care advice for this condition. The impact of self-care advice on primary dysmenorrhea is unknown. Methods. 19 TCM acupuncture practitioners from New Zealand or Australia and 12 New Zealand women who had recently undergone acupuncture treatment for primary dysmenorrhea as part of a randomised controlled trial participated in this qualitative, pragmatic study. Focus groups and semistructured interviews were used to collect data. These were recorded, transcribed, and analysed using thematic analysis. Results. The overarching theme was that an acupuncture treatment consisted of “more than needles” for both practitioners and participants. Practitioners and participants both discussed the partnership they engaged in during treatment, based on openness and trust. Women felt that the TCM self-care advice was related to positive outcomes for their dysmenorrhea and increased their feelings of control over their menstrual symptoms. Conclusions. Most of the women in this study found improved symptom control and reduced pain. A contributing factor for these improvements may be an increased internal health locus of control and an increase in self-efficacy resulting from the self-care advice given during the clinical trial.

The Psychological Dimensions of Placebo-Studies

Abstract. The placebo effect involves a complex network of psychological variables that are often disregarded by studies enquiring into this effect. It is hence little surprising that these psychological variables confound study outcomes and that experiments investigating the placebo effect often yield radically different results. The current article identifies three categories of psychological and methodological factors that are not systematically considered in placebo research: psychological confounds (Hawthorne effects and demand effects); methodological and data-analysis issues; and clinicians’ expectancy effects. These factors are not necessarily to be seen as mere artifacts, however, because they may constitute favorable components of the placebo effect. A set of benchmark criteria is therefore proposed to allow researchers to capitalize on these components during placebo research rather than have their results confounded by them; and to allow for a more reliable interpretation of study outcomes.

Overlap and Differences Between Patient and Provider Expectations for Treatment Outcomes: The Case of Acupuncture

Our study aimed to identify patient-provider clusters with different patterns of expectations for treatment outcomes. All patients (n = 885) received acupuncture treatment from physicians for their migraine, headache, osteoarthritis, or chronic low back pain. We identified 6 robust patient-provider expectation clusters (PPECs; interclassification reliability >.89) showing differences between patients and providers in their expected treatment responses (eg, unrealistic optimists, optimistic doubters). For example, the optimistic doubters had high expectations for their treatment outcomes but were skeptical of the benefits of acupuncture in general. The providers expected good improvements for these patients. These 6 PPECs differed in their clinical characteristics and in the associated treatment responses. For example, unrealistic optimists showed the weakest treatment benefits after 6 months; other PPECs and clinical patterns are also presented in the report. Our study suggests that comparing the expectations of patients and providers is a valuable approach to identify groups of patients with greater responsiveness and those with limited treatment benefits.

PERSPECTIVE

Patients and providers of acupuncture might vary in their expectation of the treatment effect and in clinical practice the overlap of expectations of patients and providers should be considered as important in initial consultations.

Nocebo responses to high-voltage power lines: Evidence from a prospective field study

BACKGROUND

Experimental studies suggest that nocebo responses might occur after exposure to equipment emitting electromagnetic fields such as high voltage power lines (HVPLs) or mobile phone base stations.

OBJECTIVES

The present study investigates to what extent health responses to a new HVPL can be explained by beliefs of residents regarding the health effects of HVPLs.

METHODS

We used a quasi-experimental prospective field study design with two pretests during the construction of a new HVPL, and two posttests after it has been put into operation. Residents living near (0-300 m, n=229; 300-500 m, n=489) and farther away (500-2000 m, n=536) filled out questionnaires about their health and their beliefs about the negative health effects of power lines. Longitudinal mediation models were applied to investigate to what extent these beliefs could explain a change in reported symptoms after the new line was put into operation.

RESULTS

Significant (p<.01) indirect effects were found for proximity on the increase in reported cognitive (R(2)=0.41) and somatic (R(2)=0.79) symptoms after the power line was put into operation through an increase in the belief that power lines causes health effects. The direct effects of proximity on an increase in reported symptoms were not significant.

CONCLUSIONS

Our findings suggest that increases in reported health complaints after a new HVPL has been put into operation can be explained by nocebo mechanisms. Future field studies are needed to know whether our findings extend to other environmental health issues in a community.

Exploring physiotherapists' personality traits that may influence treatment outcome in patients with chronic diseases: a cohort study

Background

During treatment of patients with Chronic Diseases (CD) the therapist-patient interaction is often intense, and the strategies used during treatment require physiotherapists to assume a coaching role. Uncovering therapist factors that explain inter-therapist variation might provide tools to improve treatment outcome and to train future therapists. The purpose of this study was to explore the so-called ‘therapist-effect’, by looking at the influence of intrinsic therapist factors, specifically personality traits, on treatment outcome in patients with CD.

Methods

A cohort study was performed using data from the NIVEL Primary Care Database (NPCD) in 2011–2012 and an additional questionnaire. Patients with CD (n = 393) treated by Dutch physiotherapists working in outpatient practices (n = 39) were included. Patient and treatment outcome variables were extracted from NPCD. The course of complaint was measured using the Numeric Rating Scale. Therapist variables were measured using a questionnaire consisting of demographics and the Big Five traits: Extraversion, Neuroticism, Agreeableness, Conscientiousness and Openness to experiences. Data were analysed using multilevel linear regression.

Results

Only Neuroticism was found to be significant (Neuroticism F = 0.71, P = 0.01; therapist gender F = 0.72, P = 0.03; life events F = −0.54, P = 0.09; patient gender F = −0.43, P = 0.10; patient age F = 0.01, P = 0.27). Subgroup analyses of 180 patients with Osteoarthritis and 30 therapists showed similar results.

Conclusions

There are indications that patients with CD who are treated by therapists who tend to be calmer, more relaxed, secure and resilient have a greater reduction in severity of complaints compared to patients treated by therapists who show less of these traits. Being a male therapist and having experienced life events influence outcome positively. However, more extensive research is needed to validate the current findings.

Exploring residents' communication learning process in the workplace: a five-phase model

Context

Competency-based education is a resurgent paradigm in professional medical education. However, more specific knowledge is needed about the learning process of such competencies, since they consist of complex skills. We chose to focus on the competency of skilled communication and want to further explore its learning process, since it is regarded as a main competency in medical education.

Objective

This study aims to explore in more detail the learning process that residents in general practice go through during workplace-based learning in order to become skilled communicators.

Methods

A qualitative study was conducted in which twelve GP residents were observed during their regular consultations, and were interviewed in-depth afterwards.

Results

Analysis of the data resulted in the construction of five phases and two overall conditions to describe the development towards becoming a skilled communicator: Confrontation with (un)desired behaviour or clinical outcomes was the first phase. Becoming conscious of one’s own behaviour and changing the underlying frame of reference formed the second phase. The third phase consisted of the search for alternative behaviour. In the fourth phase, personalization of the alternative behaviour had to occur, this was perceived as difficult and required much time. Finally, the fifth phase concerned full internalization of the new behaviour, which by then had become an integrated part of the residents’ clinical repertoire. Safety and cognitive & emotional space were labelled as overall conditions influencing this learning process.

Conclusions

Knowledge and awareness of these five phases can be used to adjust medical working and learning environments in such a way that development of skilled medical communication can come to full fruition and its benefits are more fully reaped.

Exploring the effect of space and place on response to exercise therapy for knee and hip pain--a protocol for a double-blind randomised controlled clinical trial: the CONEX trial

INTRODUCTION

Context effects are described as effects of a given treatment, not directly caused by the treatment itself, but rather caused by the context in which treatment is delivered. Exercise is a recommended core treatment in clinical guidelines for musculoskeletal disorders. Although moderately effective overall, variation is seen in size of response to exercise across randomised controlled trial (RCT) studies. Part of this variation may be related to the fact that exercise interventions are performed in different physical environments, which may affect participants differently. The study aims to investigate the effect of exercising in a contextually enhanced physical environment for 8 weeks in people with knee or hip pain.

METHODS AND ANALYSIS

The study is a double-blind RCT. Eligible participants are 35 years or older with persisting knee and/or hip pain for 3 months. Participants are randomised to one of three groups: (1) exercise in a contextually enhanced environment, (2) exercise in a standard environment and (3) waiting list. The contextually enhanced environment is located in a newly built facility, has large windows providing abundant daylight and overlooks a recreational park. The standard environment is in a basement, has artificial lighting and is marked by years of use; that is, resembling many clinical environments. The primary outcome is the participant's global perceived effect rated on a seven-point Likert scale after 8 weeks exercise. Patient-reported and objective secondary outcomes are included.

ETHICS AND DISSEMINATION

The Regional Scientific Ethical Committee for Southern Denmark has approved the study. Study findings will be disseminated in peer-reviewed publications and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT02043613.

How can placebo effects best be applied in clinical practice? A narrative review

Placebo effects are documented in a number of clinical and experimental studies. It is possible to benefit from placebo effects in clinical practice by using them as effects additive to those of documented and effective treatments. The purpose of this paper is to discuss how doctors and other health workers may benefit from placebo effects within an ethical framework. A narrative review of the literature relating to placebo effects in clinical practice was performed. We searched PubMed and selected textbooks on placebo effects for articles and book chapters relating to placebo effects in clinical practice. By drawing on placebo effects, doctors may access patients' self-healing potentials. In practice, doctors may best benefit from placebo effects by influencing the patient's expectations through communication. An important principle is to give the patient information stating that a particular treatment is effective, as long as this is based on realistic optimism. A patient-centered style involving elements such as developing trust and respect, exploring the patient's values, speaking positively about treatments, and providing reassurance and encouragement might aid in activating placebo effects. The total effect of a documented treatment will partly depend on how well the placebo effects have been activated. Thus, placebo effects can be understood as a form of supplemental treatment.

Chiropractor interaction and treatment equivalence in a pilot randomized controlled trial: an observational analysis of clinical encounter video-recordings

Background

Chiropractic care is a complex health intervention composed of both treatment effects and non-specific, or placebo, effects. While doctor-patient interactions are a component of the non-specific effects of chiropractic, these effects are not evaluated in most clinical trials. This study aimed to: 1) develop an instrument to assess practitioner-patient interactions; 2) determine the equivalence of a chiropractor’s verbal interactions and treatment delivery for participants allocated to active or sham chiropractic groups; and 3) describe the perceptions of a treatment-masked evaluator and study participants regarding treatment group assignment.

Methods

We conducted an observational analysis of digital video-recordings derived from study visits conducted during a pilot randomized trial of conservative therapies for temporomandibular pain. A theory-based, iterative process developed the 13-item Chiropractor Interaction and Treatment Equivalence Instrument. A trained evaluator masked to treatment assignment coded video-recordings of clinical encounters between one chiropractor and multiple visits of 26 participants allocated to active or sham chiropractic treatment groups. Non-parametric statistics were calculated.

Results

The trial ran from January 2010 to October 2011. We analyzed 111 complete video-recordings (54 active, 57 sham). Chiropractor interactions differed between the treatment groups in 7 categories. Active participants received more interactions with clinical information (8 vs. 4) or explanations (3.5 vs. 1) than sham participants within the therapeutic domain. Active participants received more directions (63 vs. 58) and adjusting instrument thrusts (41.5 vs. 23) in the procedural domain and more optimistic (2.5 vs. 0) or neutral (7.5 vs. 5) outcome statements in the treatment effectiveness domain. Active participants recorded longer visit durations (13.5 vs. 10 minutes). The evaluator correctly identified 61% of active care video-recordings as active treatments but categorized only 31% of the sham treatments correctly. Following the first treatment, 82% of active and 11% of sham participants correctly identified their treatment group. At 2-months, 93% of active and 42% of sham participants correctly identified their group assignment.

Conclusions

Our findings show the feasibility of evaluating doctor-patient interactions in chiropractic clinical trials using video-recordings and standardized instrumentation. Clinical trial design and clinician training protocols should improve and assess the equivalence of doctor-patient interactions between treatment groups.

Trial registration

This trial was registered in ClinicalTrials.gov as NCT01021306 on 24 November 2009.