Contextual effects in musculoskeletal pain: are we overlooking essential factors?

Frontiers in Psychology, Journal Year: 2025, Volume and Issue: 16

Published: Feb. 17, 2025

The role of contextual effects in musculoskeletal pain research and clinical practice has garnered growing interest recent years (Rossettini et al., 2024). While ongoing advanced knowledge, it also sparked debate between clinicians, trialists other researchers (Saueressig 2024a;Ezzatvar 2024a;Saueressig 2024b;Ezzatvar 2024b). controversy over highlights the tension leveraging their therapeutic potential minimizing them to preserve treatment specificity (Keter 2025).Discussion Potential conflicts regarding clinicians may stem from misunderstandings four areas: (1) terms used define them, (2) relevance during placebo use, (3) value treatments, (4) statistical methods estimate effect (Figure 1).The diverse terminology scientific literature, such as "placebo effects" responses," often interchangeably or confused with effects, is a significant source misunderstanding. Contextual are linked mechanistic studies exploring biological psychosocial pathways, while responses not (Evers 2018;Cashin 2021). A "placebo" an inert substance intervention randomized controlled trials (RCTs) control for testing treatments. "Placebo responses" refer health improvements arm RCT, compared active arm. study mimics being tested without producing its benefits ideally double-blind, including socioemotional cues (contextual cues) patient-practitioner interactions elicit effects. Standard double-blind placebo-controlled lack natural history group. Thus, reflect factors like regression mean course condition, rather than neurobiological changes expectations learning, hallmarks (Carlino & Vase, 2018). Regression occurs when extreme values normalize time due random variability (Sean Natural resolution refers spontaneous improvement conditions that self-resolve, wound healing, fracture fluctuating chronic arise surrounding therapy 2024c), involving neurotransmitter release (e.g., opioids, cannabinoids, dopamine) brain regions prefrontal cortex, amygdala, periaqueductal gray (Wager Atlas, 2015). Placebo involve positive use factors, nocebo result negative application 2016). Both influence outcomes treatments injections, surgery, exercise, massage) by integrating specific components shape results patient experiences 2023). some recognize these distinctions, broader challenge complexity how understood, applied, interpreted across different contexts. This inconsistency affects design, data interpretation, communication, fuelling among researchers, differing priorities.A second misunderstanding involves consideration placebo/sham pills surgeries), although inherently lacking effect, can still symptoms through priming induced been demonstrated using open-label open-hidden paradigm. An example injections use. In one study, back patients received saline explicitly labeled placebos, alongside information on relief, addition usual care (Ashar Clinicians explained Pavlov's dogs analogy, suggesting body could respond automatically neutral stimulus-the injection. clear priming, where any observed arises injection itself but clinician's explanation, which drives modest response. CFs emerges approach, administering two ways (Benedetti 2011). open know they receiving treatment, accompanied verbal provider, activating beliefs enhance effect. hidden delivered patient's awareness, via automated means. clarifies much treatment's efficacy versus psychological components. Despite limitation immediate short-term this approach shows occur even highlighting effectiveness combines both 2011).A third belief solely itself. view partly inaccurate, clinicians-through beliefs, behavior-and patients-through history-are context, embodying elements themselves. clinicians' empathy generate caring pain. equipoise is, example, evident spinal manipulation who strongly believed showed preference increased likelihood experiencing beneficial relief 68.3 times provided (Bishop 2017). Evidence crucial clinician achieving outcomes. For adults low treated highly empathetic experienced significantly better functionality, overall quality life 12 months (Licciardone These emphasize attitudes activate influencing Empathetic encounters foster trust patient-clinician relationship, reinforcing effective communication key strong alliances (Wang 2022). Patient trigger neck expected cervical help (positive expectations) did receive it, had lower odds success (OR = 0.16; 95% CI: 0.04, 0.72) those it. Among treated, reported less disability (mean difference: -3.8; -5.9, -1.5; P .006) 2013). suggests independently impact outcomes, functioning separately direct dynamic interplay individualized combined decision-making processes, introduces additional layer complexity. examining decisions practice, physicians were more likely administer appeared responsive (Piedimonte finding physicians' choices influenced responsiveness, responsiveness turn, shaped characteristics processes.A fourth stems varying meta-analyses, along epistemological assumptions guide analyses.To accurately meta-analyses should include three-arm (RCTs). trials, group receives (specific effect), another sham "waitand-see" accounts progression (placebo response) (Cashin However, despite support literature 2024d;Hohenschurz-Schmidt 2024), impractical, particularly fields non-pharmacological rehabilitation), no-treatment raise ethical concerns possible known Delayed Treatment Design, at points, avoids enables comparisons symptom fluctuations (Mongini 2012). Alternative approaches, Proportion Attributable Effects (Zou 2016), have proposed. commonly (de Roode 2024;Ezzatvar limitations overestimate introduce bias (for details see: Saueressig 2024c). Researchers challenges measuring CFs, validity simple additive response model called into question. manipulations individual differences participants. Three distinct types identified: antagonistic, synergistic, reversal (qualitative interactions). antagonistic interaction, Conversely, synergistic model, surpasses sum either diminish treatment. cases, negate effect-for felt topical analgesic under nocebo-informed (Boussageon 2022).Despite misunderstandings, we believe there remains ground explore, premature conclude discussions We propose communities find common overcome constructive dialogue involvement organizations dedicated studying Society Interdisciplinary Studies (SIPS) numerous opportunities sharing building connections planning roundtables panels, international conferences held thus far (SIPS, communicate face managing pain, utilizing mitigate (Table 1). Additionally, everyday differs RCTs, uncontrolled unforeseen affect Consequently, careful interpretation evidence thoughtful translation findings real-world essential. Researchers, hand, scientifically robust mirrors maintaining necessary rigor. planned follow Consolidated Standards Reporting Trials (CONSORT) guidelines conducted outside laboratories, multiple applied simultaneously administration evidence-based ensure internal external (Andreau designing RCTs detail present groups, following recommendations development, implementation, reporting interventions physical, psychological, self-management therapies (CoPPS Statement) thorough balanced description (Hohenschurz-Schmidt 2023).In summary, integral unavoidable management, making inseparable practice. As scholarly evolves, our advice echoes timeless lyrics: "Accentuate positive, eliminate negative, latch affirmative" (Mercer, 1944), adopting empathy, validation, patient-centered style encounters. Meanwhile, tasked disentangling "contextual cake". perspective does serve final word hope offers step toward bridging gap research. Ultimately, fostering collaboration domains deliver meaningful • Are certain phases management taking, physical examination, administration)? Do act differently acute conditions?• presence nociceptive, nociplastic, neuropathic pain?• Does vary short, medium, long term?• subjective objective/physiological same way?• Is affected social, cultural, religious, economic geopolitical influences? How do technological advancements telehealth, digital devices, artificial intelligence) interact outcomes? impactful self-managed clinician-guided treatments?• modalities pharmacological vs. non-pharmacological)? consistently predict populations? universal applicable healthcare systems settings? stable time, evolve condition? differ early-stage advanced-stage cost-effectiveness interventions?• influences passive modalities) exercises activities)? Legend: CF, factors. A., Heymans, M.W., van Lankveld, W., Staal, J.B. (2024). exercise pain: systematic review meta-analysis. BMC Med. 22:484. doi: 10.1186/s12916-024-03679-3. Di Blasi, Z., Harkness, E., Ernst, Georgiou, Kleijnen, J. (2021). Influence context outcomes: review. Lancet. 357(9258):757-762. 10.1016/s0140-6736(00)04169-6.• Evers, A.W.M., Colloca, L., Blease, C., Annoni, M., L.Y., Benedetti, F., Bingel, U., Büchel, Carvalho, Colagiuri, B., Crum, A.J., Enck, P., Gaab, J., Geers, A.L., Howick, Jensen, K.B., Kirsch, I., Meissner, K., Napadow, V., Peerdeman, K.J., Raz, Rief, Wager, T.D., Wampold, B.E., Weimer, Wiech, Kaptchuk, T.J., Klinger, R., Kelley, J.M. ( 2018 T., Owen, P.J., Pedder, H., Tagliaferri, S., Kaczorowski, Altrichter, Richard, Miller, C.T., Donath, Belavy, D.L. (2024d). importance effects) conservative metaanalysis trials. Eur J Pain. 28:675-704. 10.1002/ejp.2222. Sean, Coulombe-Lévêque, Nadeau, Charest, A.C., Martel, Léonard, G., Tétreault, P. Counting your chickens before hatch: untreated population, beyond Pain Rep. 9:e1157. 10.1097/PR9.0000000000001157.• Sherriff, Clark, Killingback, Newell, D. (2023) Zou, Wong, Abdullah, N., Chen, X., Smith, Doherty, Zhang, W. (2016).Examination proportion attributable osteoarthritis: meta-analysis randomised Ann Rheum Dis. 75:1964Dis. 75: -1970Dis. . 10.1136Dis. /annrheumdis-2015-208387. -208387.

Language: Английский

Negative expectations and related nocebo effects in shoulder pain: a perspective for clinicians and researchers

Pain Management, Journal Year: 2025, Volume and Issue: unknown, P. 1 - 12

Published: Feb. 20, 2025

The nocebo effect, a phenomenon wherein negative expectations can worsen symptoms, is increasingly acknowledged within the context of musculoskeletal conditions. While experimental evidence has, to some extent, examined in shoulder pain, their specific relationship with effects and manifestation clinical practice remains unexplored. In this perspective, clinicians researchers are guided by first examining psychobiology neurophysiology underlying from basic science standpoint, thereby equipping robust understanding phenomenon. What considered primary potential sources individuals pain then outlined - namely, diagnostic labels, imaging special tests, medicalization normality, overtreatment. Practical strategies subsequently proposed mitigate arising these sources. Finally, research implications for advancing study people discussed. Overall, perspective provides comprehensive overview impact associated on outcomes. By identifying that may emerge everyday practice, guidance mitigating related patients offered.

Language: Английский