The placebo effect in the motor domain is differently modulated by the external and internal focus of attention

The Role of Attention in Placebo and Nocebo Effects

BACKGROUND

Although some existing models propose that attention may be crucially implicated in placebo/nocebo effects, empirical research on this aspect remains limited and scattered.

PURPOSE

This systematic review aims to provide an inclusive overview of studies that have either directly manipulated or assessed attention within the context of placebo and nocebo procedures so to gain a synthetized picture of the role of this variable in placebo/nocebo effects. Importantly, only studies in which attention represented a mechanism or mediator of the placebo/nocebo response, and not a primary outcome, were included.

METHODS

A systematic search was conducted across multiple databases, including PubMed, Scopus, PsycINFO, Web of Science, and Embase, to identify peer-reviewed studies. These studies were subjected to methodological evaluation and eligibility criteria for inclusion.

RESULTS

We identified and classified 12 studies into three categories based on their focus: (i) those that directly assessed attention, (ii) those that directly manipulated participants' attention, and (iii) those that combined both a direct manipulation and assessment of attention. In all selected studies attention acted as a mechanism or mediator of the placebo/nocebo response, and was not considered a primary outcome of the placebo/nocebo manipulation.

CONCLUSIONS

The synthesis of the included studies reveals that the role of attention in placebo and nocebo effects is still a topic of debate, marked by variations in how attention is conceptualized and measured. Results suggest that attention has significant clinical implications, particularly in optimizing therapeutic efficacy by directing patients' focus toward signs of healing and away from indicators of illness or distress. To advance our understanding, future research should explore these attentional mechanisms, in conjunction with neurophysiological correlates.

Fire needle therapy for the treatment of cancer pain: a protocol for the systematic review and meta-analysis

Background

Cancer patients frequently suffer pain as one of their symptoms. It includes acute and chronic pain and is one of the most feared symptoms for patients. About one-third of adults actively undergoing cancer treatment suffer from pain related to their condition. Cancer pain control remains suboptimal due to a lack of assessment, knowledge, and access. Fire needle therapy, a traditional Chinese medicine, offers a potentially beneficial addition to current pain management approaches. This protocol outlines a systematic review and meta-analysis to compile evidence and examine the pain-relieving effects and safety of fire needle therapy for cancer patients.

Methods and analysis

We will systematically search China National Knowledge Infrastructure (CNKI), Wanfang Database, China Biology Medicine disc (CBM), China Science and Technology Journal Database (CSTJ or VIP), PubMed, Web of Science, Embase, Cochrane Central Registry of Controlled Trials (CENTRAL), Chinese Clinical Trial Registry (Chictr), Opengrey, Worldcat, and Scopus from inception through July 2023. Random control trials (RCTs) include all types of cancer patients (age ≥ 18 years) complaining of pain. The primary outcome will be changes in pain intensity measured by Visual Analogue Scale (VAS), Numerical Rating Scale (NRS), Neuropathic Pain Scale (NPS), or Brief Pain Inventory (BPI). Secondary outcomes include quality of life (EORTC QLQ-C30 and GCQ), performance status (KPS), times of burst pain, treatment response rate, the dose reduction of analgesic drugs, and side effects rates. Utilizing the Cochrane risk bias measurement tool: Risk of Bias 2 (RoB 2), the trials' quality will be evaluated, and meta-analysis will be performed using RevMan software (version 5.4).

Discussion

This systematic review will be the first comprehensive review of the literature to provide a meta-analysis of fire needle therapy for cancer pain, including only Random control trials (RCTs). For the sake of transparency and to avoid future duplication, the publication of this protocol offers a clear illustration of the procedures utilized in this evaluation. The results of our future studies may provide a new approach and theoretical basis for the treatment of cancer pain by medical oncology professionals.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42023418609.

Preserving the placebo effect after disclosure: A new perspective on non-deceptive placebos

The present study explores whether a particular style of placebo disclosure could serve as a tool to foster a renewed trust in one's own inherent resources and elicit a meaningful placebo effect. In a motor performance task, two placebo groups received inert transcutaneous electrical nerve stimulation (TENS) in each of four sessions along with information on its force-enhancing properties. Before the final session, one of the placebo groups was informed about the placebo, which was portrayed as a means to unleash an inherent potential. Along with force, we systematically monitored task-specific self-efficacy to test whether this variable would be differentially modulated in the two placebo groups. Compared to two control groups, placebo groups showed higher force and self-efficacy in the last session. No differences in self-efficacy were observed in the placebo groups even after revealing the placebo procedure, suggesting that the disclosure was effective in 'safeguarding' individuals' self-efficacy. These findings may have important implications, paving the way for the use of placebos that not only are ethically permissible but also support individuals' self-efficacy.

Understanding the Role of Expectancy, Anticipatory Anxiety, and Attention Bias in Nocebo Hyperalgesia: A Gaze-Contingent Attention Bias Modification Study

Nocebo effects in pain (nocebo hyperalgesia) have been thoroughly researched, and negative expectancies have been proposed as a key factor in causing nocebo hyperalgesia. However, little is known about the psychological mechanisms by which expectations exacerbate the perception of pain. A potential mechanism that has been proposed within wider pain research is pain-related attention. The aim of the present study was thus to explore whether attention bias (AB) to pain influenced nocebo hyperalgesia. One-hundred and thirty-four healthy participants were randomized in a 2 (AB training: towards vs away from pain) × 2 (nocebo condition: nocebo vs control) design. Pain-related AB was manipulated through a novel, partially gaze-contingent dot-probe task. Participants then completed either a nocebo instruction and conditioning paradigm or a matched control condition. Primary outcomes were measures of expectancy, anticipatory anxiety, and pain intensity completed during a nocebo test phase. Results showed that the AB manipulation was unsuccessful in inducing ABs either toward or away from pain. The nocebo paradigm induced significantly greater expectancy, anticipatory anxiety, and pain intensity for the nocebo groups compared to the control groups. In a posthoc analysis of participants with correctly induced ABs, AB towards pain amplified nocebo hyperalgesia, expectancy, and anticipatory anxiety relative to AB away from pain. The results are consistent with the expectancy model of nocebo effects and additionally identify anticipatory anxiety as an additional factor. Regarding AB, research is needed to develop reliable means to change attention sample-wide to corroborate the present findings. PERSPECTIVE: This article explores the role of AB, expectancy, and anticipatory anxiety in nocebo hyperalgesia. The study shows that expectancy can trigger anticipatory anxiety that exacerbates nocebo hyperalgesia. Further, successful AB training towards pain heightens nocebo hyperalgesia. These findings identify candidate psychological factors to target in minimizing nocebo hyperalgesia.

Outcomes of Patients with Lower Limb Loss after Using a Training Prosthesis: A Retrospective Case Series Study

The aim of this retrospective case series study was to investigate outcomes in patients with lower limb loss based on whether or not they used a training prosthesis (TP) during rehabilitation. The medical records of 171 consecutive patients admitted to rehabilitation hospitalization between January 2014 and December 2018 following a major amputation of the lower limb were reviewed. Patients were categorized into two groups: patients who underwent rehabilitation with a TP and patients who did not use a TP. Outcomes (i.e., discharge destination, length of stay, number of sockets required, and number of the size adaptation of each socket, as well as functional level) were compared between groups. Of the 171 patients, 126 underwent rehabilitation with a TP, and 45 patients underwent rehabilitation without any TP. In conclusion, we found that patients who used a TP had a significantly shorter hospital length of stay when compared to those who did not. This length of stay for patients with TP was not influenced by age but was lowered by a higher body mass index (BMI), tibial instead of femoral amputation, and the male gender. No association was found between the use of TP and discharge destination, functional level, number of socket modifications, and number of sockets required.

Placebo and Nocebo Effects as Bayesian-Brain Phenomena: The Overlooked Role of Likelihood and Attention

The Bayesian-brain framework applied to placebo responses and other mind-body interactions suggests that the effects on the body result from the interaction between priors, such as expectations and learning, and likelihood, such as somatosensorial information. Significant research in this area focuses on the role of the priors, but the relevance of the likelihood has been surprisingly overlooked. One way of manipulating the relevance of the likelihood is by paying attention to sensorial information. We suggest that attention can influence both precision and position (i.e., the relative distance from the priors) of the likelihood by focusing on specific components of the somatosensorial information. Two forms of attention seem particularly relevant in this framework: mindful attention and selective attention. Attention has the potential to be considered a "major player" in placebo/nocebo research, together with expectations and learning. In terms of application, relying on attentional strategies as "amplifiers" or "silencers" of sensorial information could lead to an active involvement of individuals in shaping their care process and health. In this contribution, we discuss the theoretical implications of these intuitions with the aim to provide a comprehensive framework that includes Bayesian brain, placebo/nocebo effects, and the role of attention in mind-body interactions.

Placebo effect on gait: a way to reduce the dual-task cost in older adults

The ability to perform two tasks simultaneously is essential for daily activities. In older adults, this ability is markedly reduced, as evidenced by the dual-task cost on gait. Preliminary evidences indicate that the dual-task cost can be influenced by different types of manipulations. Here, we explored the effectiveness of a new approach to reduce the dual-task cost, based on the placebo effect, a psychobiological phenomenon whereby a positive outcome follows the administration of an inert device thought to be effective. Thirty-five healthy older adults were asked to walk on a sensorized carpet (single-task condition) and to walk while counting backward (dual-task condition) in two sessions (pre-test and post-test). A placebo group, randomly selected, underwent sham transcranial direct current stimulation over the supraorbital areas between sessions, along with information about its positive effects on concentration and attention. A control group did not receive any intervention between sessions. The dual-task cost was significantly reduced in the placebo group at the post-test session compared to the pre-test for several gait parameters (Cohen's d > 1.43). At the post-test session, the dual-task cost was also lower in the placebo group than in the control group (d > 0.73). Cognitive (number of subtractions and number of errors) and subjective (perceived mental fatigability) variables remained stable across sessions. The reduced dual-task cost in the placebo group could indicate the ability to re-establish the allocation of attentional resources between tasks. These findings could contribute to the development of cognitive strategies that leverage positive expectations to boost motor control in older adults.

Association between personality traits and placebo effects: a preregistered systematic review and meta-analysis

ABSTRACT

Placebo effects are ubiquitous yet highly variable between individuals and therefore strongly affect clinical trial outcomes such as pain relief. It is unclear whether dispositional psychological traits influence responsiveness to placebo. This preregistered meta-analysis and systematic review synthesized the literature investigating the association between personality traits and placebo effects. Based on 21 studies with 798 participants, we performed formal meta-analyses for 10 different personality traits, including behavioral inhibition, fun seeking, goal-drive persistence, reward responsiveness, empathic concern, empathic fantasy, perspective-taking, personal distress, optimism, and anxiety. We did not find evidence of associations between any of these traits and magnitude of placebo effects, which was supported by equivalence tests. Furthermore, we did not find evidence for moderating factors such as placebo manipulation type (conditioning or nonconditioning) or condition (pain or nonpain). These findings challenge the notion that personality influences responsiveness to placebos and contradict its utility for identifying placebo "responders" and "nonresponders."

The placebo effect shortens movement time in goal-directed movements

The placebo effect is a powerful psychobiological phenomenon whereby a positive outcome follows the administration of an inert treatment thought to be effective. Growing evidence shows that the placebo effect extends beyond the healing context, affecting also motor performance. Here we explored the placebo effect on the control of goal-directed movement, a fundamental function in many daily activities. Twenty-four healthy volunteers performed upper-limb movements toward a target at different indexes of difficulty in two conditions: in the placebo condition, an electrical device (inert) was applied to the right forearm together with verbal information about its positive effects in improving movement precision; in the control condition, the same device was applied along with verbal information about its neutral effects on performance. Interestingly, we found shorter movement time in the placebo compared to the control condition. Moreover, subjective perception of fatigability was reduced in the placebo compared to the control condition. These findings indicate that the placebo effect can improve the execution of goal-directed movements, thus adding new evidence to the placebo effect in the motor domain. This study could inspire future applications to improve upper-limb movements or in clinical settings for patients with motor deficits.

The effect of motor and cognitive placebos on the serial reaction time task

Motor learning is a key component of human motor functions. Repeated practice is essential to gain proficiency over time but may induce fatigue. The aim of this study was to determine whether motor performance and motor learning (as assessed with the serial reaction time task, SRTT) and perceived fatigability (as assessed with subjective scales) are improved after two types of placebo interventions (motor and cognitive). A total of 90 healthy volunteers performed the SRTT with the right hand in three sessions (baseline, training and final). Before the training and the final session, one group underwent a motor-related placebo intervention in which inert electrical stimulation (TENS) was applied over the hand and accompanied by verbal suggestion that it improves movement execution (placebo-TENS). The other group underwent a cognitive-related placebo intervention in which sham transcranial direct current stimulation (tDCS) was delivered to the supraorbital area and accompanied by verbal suggestion that it increases attention (placebo-tDCS). A control group performed the same task without receiving treatment. Overall better performance on the SRTT (not ascribed to sequence-specific learning) was noted for the placebo-TENS group, which also reported less perceived fatigability at the physical level. The same was observed in a subgroup tested 24 hr later. The placebo-tDCS group reported less perceived fatigability, both at the mental and physical level. These findings indicate that motor- and cognitive-related placebo effects differently shape motor performance and perceived fatigability on a repeated motor task.

Context matters: the psychoneurobiological determinants of placebo, nocebo and context-related effects in physiotherapy

Background

Placebo and nocebo effects embody psychoneurobiological phenomena where behavioural, neurophysiological, perceptive and cognitive changes occur during the therapeutic encounter in the healthcare context. Placebo effects are produced by a positive healthcare context; while nocebo effects are consequences of negative healthcare context. Historically, placebo, nocebo and context-related effects were considered as confounding elements for clinicians and researchers. In the last two decades this attitude started to change, and the understanding of the value of these effects has increased. Despite the growing interest, the knowledge and the awareness of using the healthcare context to trigger placebo and nocebo effects is currently limited and heterogeneous among physiotherapists, reducing their translational value in the physiotherapy field.

Objectives

To introduce the placebo, nocebo and context-related effects by: (1) presenting their psychological models; (2) describing their neurophysiological mechanisms; (3) underlining their impact for the physiotherapy profession; and (4) tracing lines for future researches.

Conclusion

Several psychological mechanisms are involved in placebo, nocebo and context-related effects; including expectation, learning processes (classical conditioning and observational learning), reinforced expectations, mindset and personality traits. The neurophysiological mechanisms mainly include the endogenous opioid, the endocannabinoid and the dopaminergic systems. Neuroimaging studies have identified different brain regions involved such as the dorsolateral prefrontal cortex, the rostral anterior cingulate cortex, the periaqueductal gray and the dorsal horn of spine. From a clinical perspective, the manipulation of the healthcare context with the best evidence-based therapy represents an opportunity to trigger placebo effects and to avoid nocebo effects respecting the ethical code of conduct. From a managerial perspective, stakeholders, organizations and governments should encourage the assessment of the healthcare context aimed to improve the quality of physiotherapy services. From an educational perspective, placebo and nocebo effects are professional topics that should be integrated in the university program of health and medical professions. From a research perspective, the control of placebo, nocebo and context-related effects offers to the scientific community the chance to better measure the impact of physiotherapy on different outcomes and in different conditions through primary studies.

Microcurrent therapy in the treatment of knee osteoarthritis: could it be more than a placebo effect? A randomized controlled trial

BACKGROUND

Microcurrent therapy (MCT) is a novel electrotherapy modality with very low current-levels that may reduce pain especially in joints and muscles.

AIM

The aim of this study is to explore potential effects of MCT on pain in patients with knee osteoarthritis, to explore effects of different treatment parameters and to distinguish them from placebo-effects.

DESIGN

Randomized four arms controlled clinical trial.

SETTING

Outpatient tertiary medical care center.

POPULATION

Fifty-six patients with knee OA (Kellgren-Lawrence Score II or III, 14 male and 38 female, mean age: 71.7±7.3 years, pain intensity higher than Numeric Rating Scale [NRS] score 3 from 10).

METHODS

Patients were randomized into four groups: MCT with 100 µA (group A), MCT with 25 µA (group B), sham-treatment (group C) and a control-group without intervention. Treatment groups received 10 sessions of MCT for 30 minutes each over a period of 22 days. The primary outcome was daily pain intensity throughout the treatment period measured by a NRS from 0-10. Second outcome measurements were the Knee Osteoarthritis Outcome Score (KOOS), the SF-36 Questionnaire, the Six-Minute Walking Test and the Get-Up-and-Go Test.

RESULTS

Evening pain was reduced significantly in the verum-groups compared to sham group (Group A vs. Group C: P<0.001, Group B vs. Group C: P=0.006) and to no intervention (Group A vs. Group D: P<0.001, Group B vs. Group D: P=0.002). The difference between sham-therapy and no therapy was not significant. In the pre-post analysis of the KOOS group A improved significantly in the subscale Symptoms. Group A and B and D improved in the Activities of Daily Living subscale.

CONCLUSIONS

The results of this RCT suggest that MCT has beneficial effects on pain in patients with knee osteoarthritis that are not explained by a placebo effect. Due to the explorative, pilot character of the study, further confirmation is needed before clear recommendations can be given.

CLINICAL REHABILITATION IMPACT

More high-quality RCTs with transparent parameters should be investigated to elucidate potential effects of MCT in the field of physical medicine and rehabilitation. At the present time MCT is a treatment option that could be helpful, in particular for patients who are afraid of unpleasant sensations from electrotherapy with stronger currents.

Improved 1000-m Running Performance and Pacing Strategy With Caffeine and Placebo: A Balanced Placebo Design Study

PURPOSE

To investigate the placebo effect of caffeine on pacing strategy and performance over 1000-m running time trials using a balanced placebo design.

METHODS

Eleven well-trained male middle-distance athletes performed seven 1000-m time trials (1 familiarization, 2 baseline, and 4 experimental). Experimental trials consisted of the administration of 4 randomized treatments: informed caffeine/received caffeine, informed caffeine/received placebo, informed placebo/received caffeine, and informed placebo/received placebo. Split times were recorded at 200, 400, 600, 800, and 1000 m, and peak heart rate and rating of perceived exertion were recorded at the completion of the trial.

RESULTS

Relative to baseline, participants ran faster during informed caffeine/received caffeine (d = 0.42) and informed caffeine/received placebo (d = 0.43). These changes were associated with an increased pace during the first half of the trial. No differences were shown in pacing or performance between baseline and the informed placebo/received caffeine (d = 0.21) and informed placebo/received placebo (d = 0.10). No differences were reported between treatments for peak heart rate (η2 = .084) and rating of perceived exertion (η2 = .009).

CONCLUSIONS

The results indicate that the effect of believing to have ingested caffeine improved performance to the same magnitude as actually receiving caffeine. These improvements were associated with an increase in pace during the first half of the time trial.

The role of the dorsolateral prefrontal cortex in the motor placebo effect

The neural correlates of the placebo effect in the motor domain are still unknown. The aim of this study was to tackle the role of a frontal cortical region, the dorsolateral prefrontal cortex (dlPFC). To this end, we stimulated the cortical site corresponding to the left dlPFC with transcranial direct current stimulation (tDCS) during a placebo procedure and measured any change in the motor placebo effect in all the participants and more specifically in placebo-responders. Three different experiments were conducted in which healthy volunteers performed a force motor task with the index finger. The placebo treatment consisted of transcutaneous electrical nerve stimulation (TENS). In Experiment 1 (expectation alone), participants were only verbally suggested about the positive effects of TENS. In Experiment 2 (expectation and conditioning), participants were verbally suggested about TENS and conditioned with a surreptitious increase in a visual feedback of force. In Experiment 3 (control procedure), participants were told that TENS was inefficient. Each participant was tested in three different days with anodal, cathodal and sham tDCS over the dlPFC. Results showed that in Experiment 1 and 2 force increased after the procedure, independently of tDCS. By focusing on placebo-responders, we found that in Experiment 1 force remained stable after active tDCS, whereas it increased after inactive tDCS. These findings bring new evidence on the neural underpinnings of the motor placebo effect, by showing that independently of the polarity, active tDCS over the left dlPFC may undermine the expectation-induced enhancement of force in placebo-responders.

Positive verbal suggestion optimizes postural control

Balance is a very important function that allows maintaining a stable stance needed for many daily life activities and for preventing falls. We investigated whether balance control could be improved by a placebo procedure consisting of verbal suggestion. Thirty healthy volunteers were randomized in two groups (placebo and control) and asked to perform a single-leg stance task in which they had to stand as steadily as possible on the dominant leg. The task was repeated in three sessions (T0, T1, T2). At T1 and T2 an inert treatment was applied on the leg, by informing the placebo group that it was effective in improving balance. The control group was overtly told that treatment was inert. An accelerometer applied on participants’ leg allowed to measure body sways in different directions. Subjective parameters, like perception of stability, were also collected. Results showed that the placebo group had less body sways than the control group at T2, both in the three-dimensional space and in the anterior-posterior direction. Furthermore, the placebo group perceived to be more stable than the control group. This study represents the first evidence that placebo effect optimizes posture, with a potential translational impact in patients with postural and gait disturbances.