What Should Clinicians Tell Patients about Placebo and Nocebo Effects? Practical Considerations Based on Expert Consensus.

INTRODUCTION: Clinical and laboratory studies demonstrate that placebo and nocebo effects influence various symptoms and conditions after the administration of both inert and active treatments. OBJECTIVE: There is an increasing need for up-to-date recommendations on how to inform patients about placebo and nocebo effects in clinical practice and train clinicians how to disclose this information. METHODS: Based on previous clinical recommendations concerning placebo and nocebo effects, a 3-step, invitation-only Delphi study was conducted among an interdisciplinary group of internationally recognized experts. The study consisted of open- and closed-ended survey questions followed by a final expert meeting. The surveys were subdivided into 3 parts: (1) informing patients about placebo effects, (2) informing patients about nocebo effects, and (3) training clinicians how to communicate this information to the patients. RESULTS: There was consensus that communicating general information about placebo and nocebo effects to patients (e.g., explaining their role in treatment) could be beneficial, but that such information needs to be adjusted to match the specific clinical context (e.g., condition and treatment). Experts also agreed that training clinicians to communicate about placebo and nocebo effects should be a regular and integrated part of medical education that makes use of multiple formats, including face-to-face and online modalities. CONCLUSIONS: The current 3-step Delphi study provides consensus-based recommendations and practical considerations for disclosures about placebo and nocebo effects in clinical practice. Future research is needed on how to optimally tailor information to specific clinical conditions and patients' needs, and on developing standardized disclosure training modules for clinicians.

Placebo Effects: Historical and Modern Evaluation.

The history of the placebo phenomenon is both interesting and informative. The placebo effect is a core component of health care, and if one considers a contemporary view of placebo effects, this has likely been the case for as long as records exist. An exploration of placebos and placebo effects across several centuries demonstrates many interesting facts, ranging from very early writings and experiments to the modern investigation of placebo mechanisms. A longitudinal review reveals the many challenges that have been faced, whether this is understanding what a placebo is, why it may work, and the meaning of such responses for routine clinical practice. At the core of this process are the concepts surrounding placebo, as these are imperative in the application of placebo to both routine clinical care and in the context of clinical trial design. This narrative review will look at the history of placebo, particularly key aspects over time, with a view to presenting a modern re-conceptualization of this field so as to facilitate ongoing scientific inquiry and to improve health care.

Biological, clinical, and ethical advances of placebo effects.

For many years, placebos have been defined by their inert content and their use as controls in clinical trials and treatments in clinical practice. Recent research shows that placebo effects are genuine psychobiological events attributable to the overall therapeutic context, and that these effects can be robust in both laboratory and clinical settings. There is also evidence that placebo effects can exist in clinical practice, even if no placebo is given. Further promotion and integration of laboratory and clinical research will allow advances in the ethical use of placebo mechanisms that are inherent in routine clinical care, and encourage the use of treatments that stimulate placebo effects.

Stretch exercises increase tolerance to stretch in patients with chronic musculoskeletal pain: a randomized controlled trial.

BACKGROUND: Stretch is commonly prescribed as part of physical rehabilitation in pain management programs, yet little is known about its effectiveness. OBJECTIVE: A randomized controlled trial was conducted to investigate the effects of a 3-week stretch program on muscle extensibility and stretch tolerance in patients with chronic musculoskeletal pain. DESIGN: A within-subject design was used, with one leg of each participant randomly allocated to an experimental (stretch) condition and the other leg randomly allocated to a control (no-stretch) condition. PATIENTS AND SETTING: Thirty adults with pain of musculoskeletal origin persisting for at least 3 months were recruited from patients enrolled in a multidisciplinary pain management program at a hospital in Sydney, Australia. INTERVENTION: The hamstring muscles of the experimental leg were stretched daily for 1 minute over 3 weeks; the control leg was not stretched. This intervention was embedded within a pain management program and supervised by physical therapists. MEASUREMENTS: Primary outcomes were muscle extensibility and stretch tolerance, which were reflected by passive hip flexion angles measured with standardized and nonstandardized torques, respectively. Initial measurements were taken before the first stretch on day 1, and final measurements were taken 1 to 2 days after the last stretch. A blinded assessor was used for testing. RESULTS: Stretch did not increase muscle extensibility (mean between-group difference in hip flexion was 1 degrees , 95% confidence interval=-2 degrees to 4 degrees ), but it did improve stretch tolerance (mean between-group difference in hip flexion was 8 degrees , 95% confidence interval=5 degrees to 10 degrees ). CONCLUSION: Three weeks of stretch increases tolerance to the discomfort associated with stretch but does not change muscle extensibility in patients with chronic musculoskeletal pain.

Placebo Analgesia - Understanding the Mechanisms and Implications for Clinical Practice.

There are neurobiological, cognitive and conditioning processes involved in placebo mechanismsMechanisms research has demonstrated that there is not one placebo effect, but manyPlacebo effects are an inherent element in routine clinical practiceModulation of placebo mechanisms in routine practice could provide an opportunity for improving clinical care.

A comprehensive review of the placebo effect: recent advances and current thought.

Our understanding and conceptualization of the placebo effect has shifted in emphasis from a focus on the inert content of a physical placebo agent to the overall simulation of a therapeutic intervention. Research has identified many types of placebo responses driven by different mechanisms depending on the particular context wherein the placebo is given. Some placebo responses, such as analgesia, are initiated and maintained by expectations of symptom change and changes in motivation/emotions. Placebo factors have neurobiological underpinnings and actual effects on the brain and body. They are not just response biases. Other placebo responses result from less conscious processes, such as classical conditioning in the case of immune, hormonal, and respiratory functions. The demonstration of the involvement of placebo mechanisms in clinical trials and routine clinical practice has highlighted interesting considerations for clinical trial design and opened up opportunities for ethical enhancement of these mechanisms in clinical practice.

Complex regional pain syndrome in children and adolescents.

Complex regional pain syndrome (CRPS) is a disorder characterised by pain, sensory and motor disturbances and represents a significant medical entity. This report discusses two cases of CRPS in children and adolescents, highlighting several critical issues for clinicians in the diagnosis and management of CRPS in these populations. Early diagnosis, referral and appropriate intervention are essential in decreasing pain, suffering and resorting function for children and adolescents with CRPS.