Current approaches to acute postoperative pain management after major abdominal surgery: a narrative review and future directions.

Poorly controlled postoperative pain is associated with increased morbidity, negatively affects quality of life and functional recovery, and is a risk factor for persistent pain and longer-term opioid use. Up to 10% of opioid-naïve patients have persistent opioid use after many types of surgeries. Opioid-related side-effects and the opioid abuse epidemic emphasise the need for alternative, opioid-minimising, multimodal analgesic strategies, including neuraxial (epidural/intrathecal) techniques, truncal nerve blocks, and lidocaine infusions. The preference for minimally invasive surgical techniques has changed anaesthetic and analgesic requirements in abdominal surgery compared with open laparotomy, leading to a decline in popularity of epidural anaesthesia and an increasing interest in intrathecal morphine and truncal nerve blocks. Limited research exists on patient quality of recovery using specific analgesic techniques after intra-abdominal surgery. Poorly controlled postoperative pain after major abdominal surgery should be a research priority as it affects patient-centred short-term and long-term outcomes (including quality of life scores, return to function measurements, disability-free survival) and has broad community health and economic implications.

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.

An Exploration of Knowledge and Attitudes of Medical Students and Rheumatologists to Placebo and Nocebo Effects: Threshold Concepts in Clinical Practice.

INTRODUCTION: Understanding placebo and nocebo responses (context/meaning effects [CMEs]) is fundamental to physician agency. Specific instruction in CMEs is often lacking in medical education. Patient-practitioner interactions may challenge medical students' understanding of biomedical causality and the nexus between this, practical ethics and professionalism across various conceptual and applied aspects of CMEs. This study compared the corpus of knowledge and phronesis related to CMEs between Australian graduate medical students and rheumatologists to gain a sophisticated understanding of this relationship to inform curriculum development. METHOD: In 2013 and 2014, the authors surveyed third-year medical students undertaking a graduate programme in an Australian medical school and Australian rheumatologists to ascertain their understanding of placebo and nocebo responses. The survey ascertained (1) the alignment of the respondents' understanding of CMEs with accepted facts and concepts; (2) opinions on the ethical status of CMEs; and (3) responses to 2 scenarios designed to explore matters of biomedical causality, practical ethics and professionalism. RESULTS: There were 88 completed surveys returned, 53 rheumatologists and 35 students. Similar proportions within each group identified CMEs, with most (n = 79/88 [89.8%]) correctly recognising a placebo (rheumatologists: 50 [94.3%], students: 29 [82.9%]) and approximately three-quarters (n = 65/88 [73.9%]) correctly recognising nocebo effects (rheumatologists: 39 [73.6%], students: 26 [74.3%]). Statistically significant differences between practitioners and students were observed in relation to the following: placebo responders and placebo responsiveness; placebos as a 'diagnostic tool'; placebos usage in clinical practice and research, and nocebo effects. CONCLUSIONS: Physicians require an awareness of CMEs and the fact that they arise from and influence the effective agency of health care professionals. Curricular emphasis is needed to permit an honest assessment of the components that influence when, how and why patient outcomes arise, and how one's agency might have neutral or negative effects but could be inclined towards positive and away from negative patient outcomes.

Magnitude, response, and psychological determinants of placebo effects in chronic low-back pain: a randomised, double-blinded, controlled trial.

INTRODUCTION: Denervation of the lumbar zygapophyseal joints by medial branch radiofrequency neurotomy has shown some benefit in treating chronic low-back pain. Before denervation, a diagnosis is made by one or more blinded injections on separate occasions to ascertain whether the relevant joints are contributing to the pain. Placebo injections have been advocated in a diagnostic regime that also includes local anaesthesia, with a decision to proceed to neurotomy based on response to local anaesthesia and not to placebo. OBJECTIVES: We investigated the magnitude of and response rate to placebo injections, and the roles of expectation, desire for pain relief, and anxiety as determinants of response to placebo. METHODS: One hundred twenty patients were randomised to receive placebo and local anaesthetic injections on alternate occasions in a double-blind manner. A smaller control group with 2 local anaesthetic injections was also used. Responses to placebo were characterised, including magnitude and frequency. RESULTS: This study demonstrated very large response to placebo injections, both response rate (78%) and magnitude (effect size d = 1.85). Expectation and anxiety were important modulators of response to placebo in this setting, with support given to expectation as a dynamic modulator of placebo responses. Large response to placebo (both in rate and magnitude) was observed when participants reported the belief that they were in the placebo arm. CONCLUSION: This study demonstrated large placebo responses in the context of injections for low-back pain and further characterised the importance of expectation and anxiety as important psychological mediators.

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.

Management of musculoskeletal pain in a compensable environment: Implementation of helpful and unhelpful Models of Care in supporting recovery and return to work.

Models of Care (MoCs) for injured workers in the compensation environment recommend adoption of biopsychosocial management approaches. Still, widespread dominance of biomedical constructs at the system, organisational and individual levels of the compensation system prevails, contributing to suboptimal management practices and outcomes for injured workers. Efforts to implement contemporary MoCs in the compensation environment show some promise in improving outcomes. Areas of promise at the organisational level, particularly in the workplace, and at the system level are discussed. Implementation of a contemporary understanding of pain biology as part of the biopsychosocial approach in the management of the person with pain and associated disability has been effective in the non-compensable environment. The implications of this for the compensable environment are explored. Resultant helpful and unhelpful perspectives and behaviours are presented as a blueprint for areas of potential change in development and implementation of MoCs in a compensable environment.

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.