How important are the common factors in psychotherapy? An update

The common factors have a long history in the field of psychotherapy theory, research and practice. To understand the evidence supporting them as important therapeutic elements, the contextual model of psychotherapy is outlined. Then the evidence, primarily from meta-analyses, is presented for particular common factors, including alliance, empathy, expectations, cultural adaptation, and therapist differences. Then the evidence for four factors related to specificity, including treatment differences, specific ingredients, adherence, and competence, is presented. The evidence supports the conclusion that the common factors are important for producing the benefits of psychotherapy.

Psychobiological Mechanisms of Placebo and Nocebo Effects: Pathways to Improve Treatments and Reduce Side Effects

Placebo effects constitute a major part of treatment success in medical interventions. The nocebo effect also has a major impact, as it accounts for a significant proportion of the reported side effects for many treatments. Historically, clinical trials have aimed to reduce placebo effects; however, currently, there is interest in optimizing placebo effects to improve existing treatments and in examining ways to minimize nocebo effects to improve clinical outcome. To achieve these aims, a better understanding of the psychological and neurobiological mechanisms of the placebo and nocebo response is required. This review discusses the impact of the placebo and nocebo response in health care. We also examine the mechanisms involved in the placebo and nocebo effects, including the central mechanism of expectations. Finally, we examine ways to enhance placebo effects and reduce the impact of the nocebo response in clinical practice and suggest areas for future research.

Patients' Expectations Regarding Medical Treatment: A Critical Review of Concepts and Their Assessment

Patients’ expectations in the context of medical treatment represent a growing area of research, with accumulating evidence suggesting their influence on health outcomes across a variety of medical conditions. However, the aggregation of evidence is complicated due to an inconsistent and disintegrated application of expectation constructs and the heterogeneity of assessment strategies. Therefore, based on current expectation concepts, this critical review provides an integrated model of patients’ expectations in medical treatment. Moreover, we review existing assessment tools in the context of the integrative model of expectations and provide recommendations for improving future assessment. The integrative model includes expectations regarding treatment and patients’ treatment-related behavior. Treatment and behavior outcome expectations can relate to aspects regarding benefits and side effects and can refer to internal (e.g., symptoms) and external outcomes (e.g., reactions of others). Furthermore, timeline, structural and process expectations are important aspects with respect to medical treatment. Additionally, generalized expectations such as generalized self-efficacy or optimism have to be considered. Several instruments assessing different aspects of expectations in medical treatment can be found in the literature. However, many were developed without conceptual standardization and psychometric evaluation. Moreover, they merely assess single aspects of expectations, thus impeding the integration of evidence regarding the differential aspects of expectations. As many instruments assess treatment-specific expectations, they are not comparable between different conditions. To generate a more comprehensive understanding of expectation effects in medical treatments, we recommend that future research should apply standardized, psychometrically evaluated measures, assessing multidimensional aspects of patients’ expectations that are applicable across various medical treatments. In the future, more research is needed on the interrelation of different expectation concepts as well as on factors influencing patients’ expectations of illness and treatment. Considering the importance of patients’ expectations for health outcomes across many medical conditions, an integrated understanding and assessment of such expectations might facilitate interventions aiming to optimize patients’ expectations in order to improve health outcomes.

Does study design influence outcome? The effects of placebo control and treatment duration in antidepressant trials

BACKGROUND

Clinicians and researchers synthesize data from randomized controlled trials (RCTs) of antidepressants to make conclusions about the efficacy of medications for depression. All treatments include nonspecific factors in addition to the specific effects of drugs, and study design may influence patient outcomes via nonspecific factors. This study investigated whether placebo control and treatment duration affect the outcome in antidepressant RCTs.

METHODS

Medline and the Cochrane Database were searched to identify RCTs of antidepressants for major depression approved by the Food and Drug Administration. Included studies enrolled outpatient participants aged 18-65, lasted 6-12 weeks, compared an antidepressant to placebo or another antidepressant and were published in English after 1985. Excluded trials enrolled inpatients, pregnant women and subjects with psychosis or mania. Mixed-effects logistic regression models including study type (placebo-controlled or comparator) and study duration (6, 8 or 12 weeks) as fixed effects determined whether these factors affected response and remission rates.

RESULTS

In the 90 trials analyzed, the odds of depression response (OR = 1.79, 95% CI = 1.45-2.17, p < 0.001) and remission (OR 1.53, 95% CI = 1.11-2.11, p < 0.001) were significantly higher in comparator relative to placebo-controlled trials. Trials lasting 8 (OR = 1.37, CI = 1.14-1.64, p = 0.001) and 12 (OR = 1.52, CI = 1.12-2.07, p = 0.008) weeks had significantly greater response rates than 6-week trials without differing themselves.

CONCLUSIONS

Response and remission rates to antidepressants are significantly affected by study type and duration. Clinicians and researchers must consider the study design when interpreting and designing RCTs of antidepressant medications.

Patient expectations as predictors of outcome in patients with acute low back pain

BACKGROUND

Few studies have evaluated the association between patient expectations for recovery and clinical outcomes, and no study has evaluated whether asking patients to choose their therapy modifies such an association.

OBJECTIVE

To evaluate the association between patients' expectations and functional recovery in patients with acute low back pain (LBP), and to determine whether that association is affected by giving patients choice of therapy.

DESIGN AND PARTICIPANTS

A secondary analysis of a randomized controlled trial comparing usual care alone to usual care plus choice of chiropractic, acupuncture, or massage in 444 adults with acute LBP, lasting less than 21 days.

MEASUREMENTS AND MAIN RESULTS

Primary outcome was functional disability (Roland score) at 5 and 12 weeks. Patients' general expectations for improvement were associated with improvement in functional status (beta = 0.96, 95% CI = 0.56, 1.36). A 1-point increase in general expectations was associated with a 0.96-point improvement in Roland score. The association of expectation with outcome was 2-3 times greater in the usual care group than the choice group. However, these differences did not reach statistical significance.

CONCLUSIONS

In patients with acute LBP, higher expectations for recovery are associated with greater functional improvement. Eliciting patient expectations for improvement may be a simple way to identify patients with the highest (or lowest) likelihood of experiencing functional improvement. Incorporating questions about patient expectations in future trials may clarify the role of this important correlate of clinical outcomes.

Functional dissociation of stimulus intensity encoding and predictive coding of pain in the insula

The computational principles by which the brain creates a painful experience from nociception are still unknown. Classic theories suggest that cortical regions either reflect stimulus intensity or additive effects of intensity and expectations, respectively. By contrast, predictive coding theories provide a unified framework explaining how perception is shaped by the integration of beliefs about the world with mismatches resulting from the comparison of these beliefs against sensory input. Using functional magnetic resonance imaging during a probabilistic heat pain paradigm, we investigated which computations underlie pain perception. Skin conductance, pupil dilation, and anterior insula responses to cued pain stimuli strictly followed the response patterns hypothesized by the predictive coding model, whereas posterior insula encoded stimulus intensity. This novel functional dissociation of pain processing within the insula together with previously observed alterations in chronic pain offer a novel interpretation of aberrant pain processing as disturbed weighting of predictions and prediction errors.

Unfulfilled Expectations After Total Hip and Knee Arthroplasty Surgery: There Is a Need for Better Preoperative Patient Information and Education

BACKGROUND

The aims of this study were to assess patients' preoperative expectations of the outcome of total hip or knee arthroplasty (THA/TKA) regarding specific aspects of functioning and to determine to what extent each expectation was fulfilled after 1 year.

METHODS

This was a prospective cohort study. Preoperative expectations and their fulfillment after 1 year were measured with the Hospital for Special Surgery Hip/Knee arthroplasty Expectations Surveys. Preoperative and postoperative scores were subtracted to calculate whether expectations were unfulfilled, fulfilled, or exceeded.

RESULTS

A total of 343 THA and 322 TKA patients with complete follow-up were included. Preoperatively, >60% of patients (both THA/TKA) expected to get back to normal or have much improvement in 19 of 20 (THA) and 12 of 19 (TKA) items. Expectations were fulfilled or exceeded in >60% of patients in all 20 items for THA and 17 of 19 items for TKA. In THA, items with the largest proportions patients with unfulfilled expectations (>30%) were "improvement in walking ability: long distances" (31%), "walking stairs" (33%), and "improve ability to cut toenails" (38%). In TKA, expectations for 12 of 19 items were unfulfilled in >30% of patients, with the largest proportions seen for "being able to kneel down" (44%) and "being able to squat" (47%).

CONCLUSION

Although for most items, >60% of THA and TKA patients indicated that their expectations were met or exceeded, there was a substantial number of patients, particularly TKA patients, having unfulfilled expectations. These need more attention in preoperative patient information and education.

The Cognitive Neuroscience of Placebo Effects: Concepts, Predictions, and Physiology

Placebos have been used ubiquitously throughout the history of medicine. Expectations and associative learning processes are important psychological determinants of placebo effects, but their underlying brain mechanisms are only beginning to be understood. We examine the brain systems underlying placebo effects on pain, autonomic, and immune responses. The ventromedial prefrontal cortex (vmPFC), insula, amygdala, hypothalamus, and periaqueductal gray emerge as central brain structures underlying placebo effects. We argue that the vmPFC is a core element of a network that represents structured relationships among concepts, providing a substrate for expectations and a conception of the situation-the self in context-that is crucial for placebo effects. Such situational representations enable multidimensional predictions, or priors, that are combined with incoming sensory information to construct percepts and shape motivated behavior. They influence experience and physiology via descending pathways to physiological effector systems, including the spinal cord and other peripheral organs.

Patient expectations before arthroscopic shoulder surgery: correlation with patients' reasons for seeking treatment

BACKGROUND

Elevated expectations before orthopaedic procedures appear to correlate with inferior preoperative subjective measures. The purpose of this study was to evaluate preoperative patient expectations before arthroscopic shoulder surgery and to correlate them with preoperative subjective measures and patients' reasons for seeking treatment.

METHODS

We prospectively collected and retrospectively analyzed data from patients before elective arthroscopic shoulder surgery for a wide range of pathologic processes. Preoperative subjective data included QuickDASH scores, pain and functional components of the American Shoulder and Elbow Surgeons (ASES) score, and mental and physical components of the SF-12 score. Expectations data were collected and grouped on the basis of the reasons for seeking of medical treatment and ranked according to their relative importance.

RESULTS

The study included 313 shoulders. There were 205 men and 108 women with a mean age at surgery of 48.7 years (range, 18-78 years). Overall, the most important expectations were for the "shoulder to be back to the way it was before the problem started" and to continue participation in sporting activities. Patients who presented with the "shoulder coming out" had fewer important expectations than did those who presented for other reasons. Those patients who indicated a desire to continue participation in sports had significantly less pain (improved ASES pain scores) compared with the rest of the population.

CONCLUSIONS

Although return to sport was the most important expectation overall, the importance of other expectations varied by patients' reasons for seeking treatment. The current questionnaire may have limited use in patients with shoulder instability.

LEVEL OF EVIDENCE

Level III, cross-sectional design, epidemiology.

Learning what to expect (in visual perception)

Expectations are known to greatly affect our experience of the world. A growing theory in computational neuroscience is that perception can be successfully described using Bayesian inference models and that the brain is “Bayes-optimal” under some constraints. In this context, expectations are particularly interesting, because they can be viewed as prior beliefs in the statistical inference process. A number of questions remain unsolved, however, for example: How fast do priors change over time? Are there limits in the complexity of the priors that can be learned? How do an individual’s priors compare to the true scene statistics? Can we unlearn priors that are thought to correspond to natural scene statistics? Where and what are the neural substrate of priors? Focusing on the perception of visual motion, we here review recent studies from our laboratories and others addressing these issues. We discuss how these data on motion perception fit within the broader literature on perceptual Bayesian priors, perceptual expectations, and statistical and perceptual learning and review the possible neural basis of priors.

Self-blinding citizen science to explore psychedelic microdosing

Microdosing is the practice of regularly using low doses of psychedelic drugs. Anecdotal reports suggest that microdosing enhances well-being and cognition; however, such accounts are potentially biased by the placebo effect. This study used a 'self-blinding' citizen science initiative, where participants were given online instructions on how to incorporate placebo control into their microdosing routine without clinical supervision. The study was completed by 191 participants, making it the largest placebo-controlled trial on psychedelics to-date. All psychological outcomes improved significantly from baseline to after the 4 weeks long dose period for the microdose group; however, the placebo group also improved and no significant between-groups differences were observed. Acute (emotional state, drug intensity, mood, energy, and creativity) and post-acute (anxiety) scales showed small, but significant microdose vs. placebo differences; however, these results can be explained by participants breaking blind. The findings suggest that anecdotal benefits of microdosing can be explained by the placebo effect.

Expectations for Return to Preinjury Sport Before and After Anterior Cruciate Ligament Reconstruction

BACKGROUND

There is limited information about patient expectations regarding return to sport after anterior cruciate ligament reconstruction (ACLR). While it has generally been assumed that patients expect to return, it has also been acknowledged that expectations may change after surgery.

PURPOSE

To investigate return-to-sport expectations before and after ACLR and determine factors associated with changed expectations.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

The study sample consisted of 675 eligible patients (437 male, 238 female). Return-to-sport expectations were recorded preoperatively. Primary ACLR was performed in 595 patients (of whom 81 had a prior contralateral ACLR) and revision ACLR in 80 patients. At 12 months after surgery, the return to preinjury sport status was assessed along with patients' current sport expectations. The proportion of patients who expected to return to their preinjury level of sport was determined along with actual return rates. Logistic regression was performed to determine the factors associated with the decision to cease sport participation in patients who had expected to be able to return to their preinjury level of sport.

RESULTS

Overall, 84% of patients expected to be able to return to their preinjury level of sport. Expectations were higher for patients about to undergo their first ACLR, with 88% expecting to return, than for those about to undergo revision surgery or second primary ACLR (63% and 80% expected to return, respectively; P < .001 and P = .08, respectively). At 12 months after surgery, 24% of patients who expected to return to their preinjury level of sport had actually returned, and 15% of all patients had already decided to give up sport. In the regression models, being female ( P = .02) and having undergone previous ACLR ( P < .0001) were factors significantly associated with the decision to give up sport participation.

CONCLUSION

Patients had high expectations for returning to their preinjury level of sport at the time of undergoing initial ACLR. Expectations were lower for those who had undergone previous ACLR. Female patients and patients who had undergone previous ACLR were more likely to change their expectations and cease sport participation. These data can be used to provide patients with realistic return-to-sport expectations in the first postoperative year and highlight the challenge for patients who aim to return from multiple ACL injuries.

Transformational Teaching: Theoretical Underpinnings, Basic Principles, and Core Methods

Approaches to classroom instruction have evolved considerably over the past 50 years. This progress has been spurred by the development of several learning principles and methods of instruction, including active learning, student-centered learning, collaborative learning, experiential learning, and problem-based learning. In the present paper, we suggest that these seemingly different strategies share important underlying characteristics and can be viewed as complimentary components of a broader approach to classroom instruction called transformational teaching. Transformational teaching involves creating dynamic relationships between teachers, students, and a shared body of knowledge to promote student learning and personal growth. From this perspective, instructors are intellectual coaches who create teams of students who collaborate with each other and with their teacher to master bodies of information. Teachers assume the traditional role of facilitating students' acquisition of key course concepts, but do so while enhancing students' personal development and attitudes toward learning. They accomplish these goals by establishing a shared vision for a course, providing modeling and mastery experiences, challenging and encouraging students, personalizing attention and feedback, creating experiential lessons that transcend the boundaries of the classroom, and promoting ample opportunities for preflection and reflection. We propose that these methods are synergistically related and, when used together, maximize students' potential for intellectual and personal growth.

Patient Satisfaction and its Relation to Perceived Visit Duration With a Hand Surgeon

PURPOSE

To determine whether patient perception of time spent with a hand surgeon relates to patient satisfaction after a single new-patient office visit.

METHODS

Prior to each visit, 112 consecutive new patients predicted how much time they expected to spend with the surgeon. Following the visit, patients were asked to estimate the time spent with the surgeon, indicate whether the surgeon appeared rushed, and rate their overall satisfaction with the surgeon. Wait time and actual visit duration were measured. Patients also completed a sociodemographic survey, the Consultation and Relational Empathy Measure, the Newest Vital Sign Health Literacy test, and 3 Patient-Reported Outcomes Measurement Information System-based questionnaires: Upper Extremity Function, Pain Interference, and Depression. Multivariable logistic and linear regression models were used to determine predictors of patient satisfaction, patient-perceived surgeon rush, and high previsit expectations of visit duration.

RESULTS

Patient satisfaction was not associated with perceived visit duration but did correlate strongly with patient-rated surgeon empathy and symptoms of depression. Neither visit duration nor previsit expectations of visit length were determinants of patient-perceived surgeon rush. Only surgeon empathy was associated. Less-educated patients anticipated needing more time with the surgeon.

CONCLUSIONS

Patient satisfaction with the surgeon and with the time spent during the office visit was primarily linked to surgeon empathy rather than to visit duration or previsit expectation of visit length. Efforts to make hand surgery office visits more patient-centered should focus on improving dialogue quality, and not necessarily on making visits longer.

A meta-ethnographic synthesis of women's experience of breastfeeding

Despite considerable evidence and effort, breastfeeding duration rates in resource-rich countries such as Australia remain below World Health Organization recommendations. The literature on the experience of breastfeeding indicates that women construct and experience breastfeeding differently depending upon their own personal circumstances and the culture within which they live. Breastfeeding has also been described as a deeply personal experience, which can be associated with 'moral' decision-making. The aim of this synthesis was to better understand the social phenomenon of breastfeeding by making the hidden obvious. Using a meta-ethnographic approach, we analysed the findings from 17 qualitative studies exploring women's experience of breastfeeding. Commonly used metaphors, ideas and phrases across the national and international qualitative studies were identified. Two overarching themes emerged. Breastfeeding was described in terms of 'expectation' and 'reality', while the emotional aspects of breastfeeding were expressed in 'connected' or 'disconnected' terms. The prevalence of health professionals and public health discourses in the language women use to describe their experience, and the subsequent impact of this on maternal confidence and self-assessment of breastfeeding are discussed. This synthesis provides insight into some of the subtle ways health professionals can build maternal confidence and improve the experience of early mothering.

It's not just a knee, but a whole life: A qualitative descriptive study on patients' experiences of living with knee osteoarthritis and their expectations for knee arthroplasty

AIM

Knee arthroplasties are an increasingly common treatment for osteoarthritis (OA) and the main indication is pain. Previous research states, however, that 15-20% of the operated patients are dissatisfied and 20-30% have persistent pain after surgery. This study is aimed at describing patients' experiences of living with knee OA when scheduled for surgery and further their expectations for future life after surgery.

METHODS

We interviewed 12 patients with knee OA scheduled for arthroplasty, using semi-structured qualitative interviews. The interviews were recorded and transcribed verbatim and analyzed using qualitative thematic analysis.

FINDINGS

Three categories were formulated with an overriding theme: "It's not just a knee, but a whole life." The three categories were "Change from their earlier lives," "Coping with knee problems," and "Ultimate decision to undergo surgery." The main finding was that knee OA affects the whole body and self, ultimately affecting the patients' lives on many levels. Further findings were that knee OA was considered to be the central focus in the participants' lives, which limited their level of activity, their ability to function as desired, their quality of life, and their mental well-being. Although surgery was considered to be the only solution, the expectations regarding the outcome differed.

CONCLUSIONS

The participants were forced to change how they previously had lived their lives resulting in a feeling of loss. Thus, the experienced loss and expectations for future life must be put into the context of the individual's own personality and be taken into account when treating individuals with knee OA. The experience of living with knee OA largely varies between individuals. This mandates that patients' assessment should be considered on individual basis with regard to each patient.

Expectations of increased and decreased pain explain the effect of conditioned pain modulation in females

Objective

Chronic pain is believed to be related to a dysfunction of descending pain modulatory mechanisms. Functioning of descending pain modulation can be assessed by various methods, including conditioned pain modulation (CPM). CPM refers to the inhibition of one source of pain by a second noxious stimulus, termed the conditioning stimulus. This procedure can activate an endogenous pain inhibitory mechanism that inhibits early nociceptive processing. Chronic pain and anxiety disorders are more prevalent among females and it has been hypothesized that females react with more negative emotions towards unpleasant stimuli and this might be part of the explanation of greater pain sensitivity in females. The present study investigated whether expectations modulate the effect of conditioning stimulation on pain, subjective stress, and heart rate. In addition, we investigated whether the modulation of CPM by expectations differed between males and females.

Methods

Seventy-two subjects (including 36 women) received six noxious heat stimuli to the forearm. During three of these stimuli, a conditioning stimulus (cold-water bath) was applied to the contralateral arm in order to activate CPM. One third of the subjects were told that this would reduce pain (analgesia group), one-third that it would increase pain (hyperalgesia group), and one third received no information about its effect (no info group).

Results

Information that conditioning stimulation decreased or enhanced pain had the corresponding effect in females, but not in males. Conditioning stimulation increased stress, but not heart rate in females in the hyperalgesia group. A higher expectation of analgesia and lower stress during conditioning stimulation was associated with larger inhibitory CPM.

Conclusion

These results suggest that reduced inhibitory CPM can be due to contextually induced cognitive and emotional factors and not necessarily a dysfunction of descending inhibitory pathways.

Framing expectations in early HIV cure research

Language used to describe clinical research represents a powerful opportunity to educate volunteers. In the case of HIV cure research there is an emerging need to manage expectations by using the term 'experiment'. Cure experiments are proof-of-concept studies designed to evaluate novel paradigms to reduce persistent HIV-1 reservoirs, without any expectation of medical benefit.

Experiences of Psychotherapists With Remote Psychotherapy During the COVID-19 Pandemic: Cross-sectional Web-Based Survey Study

BACKGROUND

The current situation around the COVID-19 pandemic and the measures necessary to fight it are creating challenges for psychotherapists, who usually treat patients face-to-face with personal contact. The pandemic is accelerating the use of remote psychotherapy (ie, psychotherapy provided via telephone or the internet). However, some psychotherapists have expressed reservations regarding remote psychotherapy. As psychotherapists are the individuals who determine the frequency of use of remote psychotherapy, the potential of enabling mental health care during the COVID-19 pandemic in line with the protective measures to fight COVID-19 can be realized only if psychotherapists are willing to use remote psychotherapy.

OBJECTIVE

This study aimed to investigate the experiences of psychotherapists with remote psychotherapy in the first weeks of the COVID-19 lockdown in Austria (between March 24 and April 1, 2020).

METHODS

Austrian psychotherapists were invited to take part in a web-based survey. The therapeutic orientations of the psychotherapists (behavioral, humanistic, psychodynamic, or systemic), their rating of the comparability of remote psychotherapy (web- or telephone-based) with face-to-face psychotherapy involving personal contact, and potential discrepancies between their actual experiences and previous expectations with remote psychotherapy were assessed. Data from 1162 psychotherapists practicing before and during the COVID-19 lockdown were analyzed.

RESULTS

Psychotherapy conducted via telephone or the internet was reported to not be totally comparable to psychotherapy with personal contact (P<.001). Psychodynamic (P=.001) and humanistic (P=.005) therapists reported a higher comparability of telephone-based psychotherapy to in-person psychotherapy than behavioral therapists. Experiences with remote therapy (both web- and telephone-based) were more positive than previously expected (P<.001). Psychodynamic therapists reported more positive experiences with telephone-based psychotherapy than expected compared to behavioral (P=.03) and systemic (P=.002) therapists. In general, web-based psychotherapy was rated more positively (regarding comparability to psychotherapy with personal contact and experiences vs expectations) than telephone-based psychotherapy (P<.001); however, psychodynamic therapists reported their previous expectations to be equal to their actual experiences for both telephone- and web-based psychotherapy.

CONCLUSIONS

Psychotherapists found their experiences with remote psychotherapy (ie, web- or telephone-based psychotherapy) to be better than expected but found that this mode was not totally comparable to face-to-face psychotherapy with personal contact. Especially, behavioral therapists were found to rate telephone-based psychotherapy less favorably than therapists with other theoretical backgrounds.

Placebo analgesia: understanding the mechanisms

Expectations of pain relief drive placebo analgesia. Understanding how expectations of improvement trigger distinct biological systems to shape therapeutic analgesic outcomes has been the focus of recent pharmacologic and neuroimaging studies in the field of pain. Recent findings indicate that placebo effects can imitate the actions of real painkillers and promote the endogenous release of opioids and nonopioids in humans. Social support and observational learning also contribute to placebo analgesic effects. Distinct psychological traits can modulate expectations of analgesia, which facilitate brain pain control mechanisms involved in pain reduction. Many studies have highlighted the importance and clinical relevance of these responses. Gaining deeper understanding of these pain modulatory mechanisms has important implications for personalizing patient pain management.

The alliance in mental health care: conceptualization, evidence and clinical applications

The concept of alliance reflects the collaborative relationship between a clinician and a patient, defined as consisting of three elements: a) the agreement on the goals of treatment; b) the agreement on a task or series of tasks; c) the development of a bond. Although much of the theory and research on the alliance comes from the domain of psychotherapy, the concept is applicable to any practice involving a person seeking help and a socially sanctioned healer. An extensive research evidence suggests that the alliance (typically measured at the third or fourth session) is a robust predictor of the outcomes of various forms of psychotherapy, even when prior symptom improvement and other factors are considered. Both the clinician and the patient bring to the therapy situation different capacities to form an alliance. Factors concerning the patient include, among others, the diagnosis, attachment history and style, motivation, and needs for affiliation. However, the benefits of the alliance have been found to be mostly due to the therapist's contribution, in particular his/her facilitative interpersonal skills, including verbal fluency, communication of hope and positive expectations, persuasiveness, emotional expression; warmth, acceptance and understanding; empathy, and alliance rupture-repair responsiveness. Placebo studies have allowed to experimentally manipulate aspects of the relationship between a therapist and a patient in non-psychotherapy contexts. In these settings, two components of the relationship have emerged: an emotional one (involving being cared for and understood by the clinician) and a cognitive one (including the belief in the competence of the therapist to select and administer an effective treatment). Here we propose a model that describes three pathways through which the alliance creates benefits, named CARE (caring, attentive, real and empathic), EXPECTANCY, and SPECIFIC. Although research and clinical attention have mostly focused on the alliance between a clinician and a patient in face-to-face interactions, there is preliminary evidence concerning the alliance between patients and other clinic staff, systems of care, or the program in Internet-mediated services. These new research areas clearly require further development.

A qualitative study of changes in expectations over time among patients with chronic low back pain seeking four CAM therapies

BACKGROUND

The relationship between patient expectations about a treatment and the treatment outcomes, particularly for Complementary and Alternative Medicine (CAM) therapies, is not well understood. Using qualitative data from a larger study to develop a valid expectancy questionnaire for use with participants starting new CAM therapies, we examined how participants' expectations of treatment changed over the course of a therapy.

METHODS

We conducted semi-structured qualitative interviews with 64 participants initiating one of four CAM therapies (yoga, chiropractic, acupuncture, massage) for chronic low back pain. Participants just starting treatment were interviewed up to three times over a period of 3 months. Interviews were transcribed verbatim and analyzed using a qualitative mixed methods approach incorporating immersion/crystallization and matrix analysis for a decontexualization and recontextualization approach to understand changes in thematic emphasis over time.

RESULTS

Pre-treatment expectations consisted of conjecture about whether or not the CAM therapy could relieve pain and improve participation in meaningful activities. Expectations tended to shift over the course of treatment to be more inclusive of broader lifestyle factors, the need for long-term pain management strategies and attention to long-term quality of life and wellness. Although a shift toward greater acceptance of chronic pain and the need for strategies to keep pain from flaring was observed across participants regardless of therapy, participants varied in their assessments of whether increased awareness of the need for ongoing self-care and maintenance strategies was considered a "positive outcome". Regardless of how participants evaluated the outcome of treatment, participants from all four therapies reported increased awareness, acceptance of the chronic nature of pain, and attention to the need to take responsibility for their own health.

CONCLUSIONS

The shift in treatment expectations to greater acceptance of pain and the need for continued self-care suggests that future research should explore how CAM practitioners can capitalize on these shifts to encourage feelings of empowerment rather than disappointment surrounding realizations of the need for continued engagement with self-care.

When Does the Knee Feel Normal Again: A Cross-Sectional Study Assessing the Forgotten Joint Score in Patients After Total Knee Arthroplasty

BACKGROUND

The forgotten joint score (FJS) is a recent scoring system that assesses how natural the prosthesis feels after total joint arthroplasty. Although the FJS has been extensively applied in populations with total hip prosthetics, less is known about the patients undergoing total knee arthroplasty (TKA). The purpose of this study is to investigate the temporal relationship between TKA and the FJS.

METHODS

We evaluated 566 patients after TKA using the FJS questionnaire. Scores were calculated at the follow-up intervals of 1 (n = 79), 6 (n = 78), 12 (n = 81), 24 (n = 100), 36 (n = 76), 48 (n = 75), and 60 (n = 77) months. The scores ranged from 0-100, with a higher score indicating a more natural or "forgotten" joint.

RESULTS

Postoperative FJS averages were 39.3 ± 27.4 at 1 month, 59.4 ± 28.3 at 6 months, 72.5 ± 24.2 at 1 year, 76.4 ± 23.4 at 2 years, 75.1 ± 24.2 at 3 years, 68.6 ± 28.7 at 4 years, and 64.4 ± 29.0 at 5 years. The average score at 1 month was significantly lower than the average scores at all other intervals. The average score at 6 months was significantly lower than the average scores at 12, 24, and 36 months. The average score at 60 months was significantly lower than the average score at 24 months.

CONCLUSION

Based on the findings of this study, patients can expect marked improvement in the natural feel of the prosthesis during the first year after TKA, slight continued improvement at 2 and 3 years, and a decline after 4 years.

Predictors of patient satisfaction after reverse shoulder arthroplasty

HYPOTHESIS

The aims of this study were to determine patient satisfaction and to identify predictors of satisfaction after reverse shoulder arthroplasty (RSA). We hypothesized that the majority of patients would be satisfied after RSA and that patients with worse preoperative mental and physical health would be less satisfied.

METHODS

Satisfaction was assessed 2 years after primary RSA with domains for pain, work, activities, quality of life, and overall satisfaction. Preoperative and postoperative patient-reported factors were measured using the American Shoulder and Elbow Surgeons (ASES) shoulder score, Shoulder Activity Scale score, Short Form 12 (SF-12) mental and physical component summary scores, and visual analog scale (VAS) pain, fatigue, and general health scores. Pearson correlations were used to determine the relationship between patient-reported factors and satisfaction. Multivariate regression was performed to control for potential confounding variables.

RESULTS

A total of 161 patients were evaluated at 2 years postoperatively. Patients were "very satisfied" in an average of 3.3 of the 5 domains. Improvements in ASES, Shoulder Activity Scale, VAS pain, and SF-12 physical component summary scores were associated with higher satisfaction, with correlation coefficients ranging from 0.27 to 0.49. On multivariate analysis, patients with higher preoperative ASES scores were less satisfied after surgery (P = .005). In addition, patients with worse VAS fatigue (P = .011) and SF-12 mental (P = .034) and physical (0.011) component summary scores preoperatively had lower satisfaction.

CONCLUSION

Improvements in pain and outcome scores are associated with increased satisfaction. Patients with higher shoulder function, worse physical health, and worse mental health prior to surgery are more likely to have lower satisfaction after RSA.

Cortical encoding of melodic expectations in human temporal cortex

Humans engagement in music rests on underlying elements such as the listeners' cultural background and interest in music. These factors modulate how listeners anticipate musical events, a process inducing instantaneous neural responses as the music confronts these expectations. Measuring such neural correlates would represent a direct window into high-level brain processing. Here we recorded cortical signals as participants listened to Bach melodies. We assessed the relative contributions of acoustic versus melodic components of the music to the neural signal. Melodic features included information on pitch progressions and their tempo, which were extracted from a predictive model of musical structure based on Markov chains. We related the music to brain activity with temporal response functions demonstrating, for the first time, distinct cortical encoding of pitch and note-onset expectations during naturalistic music listening. This encoding was most pronounced at response latencies up to 350 ms, and in both planum temporale and Heschl's gyrus.