Can we please stop blaming the doctor (at least some of the time)?

If person expects that a treatment is going to have a positive effect, it greatly increases the chance of that occurring – isn’t that an amazingly wonderful and slightly mysterious phenomenon? Studies that look at these interactions in clinical situations are plentiful and it is such a  well documented phenomenon that it almost seems not worth mentioning.  But it is amazing isn’t it?

When we are talking about interventions that are directed at pain conditions, particularly chronic pain conditions, it is relatively easy to understand why a proportion of a group of people in pain, will have a positive response to even placebo conditions.     A kind researcher or clinician may have taken the time to ask a lot of questions about them and their pain, giving them the impression that they care about their story.  They may have had to review their symptoms and function over a period of time with increased scrutiny and may find that they aren’t as disabled or in as much pain as they rated themselves as being at baseline.  They may decide that “this is the one” on their pain merry-go round of interventions, and choose to get a bit more active and take a slightly more positive approach to life at the same time as the trial.  Who knows?   Fascinating stuff!

What is even more fascinating is when we see our expectations having distinctly measurable physiological consequences.  I was prompted recently to re-read this fantastic article by Alia Crumb et al from 2011, called “Mind over Milkshakes”.  In the study they took 46 subjects and got them to consume a milkshake on two separate occasions.  On one of the occasions the milkshake was presented to them as an “Indulgent” shake, and was labelled as being high fat and high calorie.  On the other occasion, it was presented as a “Sensible” shake and labelled as being healthy, low fat and low calorie. In actuality, the shakes were identical.   They took before and after blood measurements, as well as asking participants to rate how full they felt after each shake.  After consuming the indulgent shake, steep decreases in ghrelin, a hormone responsible for regulating hunger, were seen in the blood measurements and the participants rated themselves as being very satisfied or full.  However, after consuming the healthy shake, a far smaller decline in ghrelin levels was seen and subjects rated themselves as far less full.  How amazing is that? Not only do our expectations change our perceptions of body sensations such as hunger, thirst or pain, but they also change our hormonal response.

Another article that has tickled my fancy in recent times is that by Ben Darlow et al, published this year in Spine, entitled “Easy to harm, hard to heal”.  A qualitative study, they interviewed 12 subjects with acute low back pain and 11 with chronic low back pain, about their understanding of their condition.  Overwhelmingly the themes that came across were those that indicated that the subjects viewed their back as being fragile, vulnerable, unlikely to heal and at risk of further injury.  The flow on from these misconceptions meant that people believed that they needed to rest, avoid activities that they considered dangerous such as lifting, and be vigilant about their posture.  The desire for a diagnosis or label for their pain was a common theme for both acute and chronic low back pain patients, as they felt it was important for management or preventing recurrence.  People strongly believed that the pain was representing damage in their back and that avoiding bringing on that pain was therefore important – a slippery slope to loss of function, disability and misery.

It is a fantastic paper and is well worth a read.  For clinicians, these themes are not surprising – we hear these thoughts expressed about back pain on a daily basis.  We tackle these misunderstandings with reassurance and education and pave a way out of the pain spiral with active rehabilitation approaches.  It is fairly obviously that these extremely commonly held beliefs are at least partly to blame for the transition from acute to chronic pain in many patients.  It begs the question, how do we stop this before it starts?  Medical and allied health professionals are gaining greater awareness and understanding of these themes and are altering their treatment approaches.  The push to reduce reliance on passive modalities, improve our communication skills to deliver education and reassurance, and reduce the use of imaging for cases of simple low back pain is well on its way to becoming established across professional boundaries.  Yet vast numbers of patients will demand that something be “done” for their back pain, and clinicians who are well aware of these principles are often pushed into referring for imaging, owing to demanding patients with unreasonable expectations. And so begins the pain merry-go round for those patients.

The push to create awareness of these issues among healthcare professionals is an obvious place to start and needs to continue for changes to be effectively made.  This study further tells us that a great deal of the patient’s misunderstandings about their condition may have come from influences from health professionals.  However, at some point we probably need to be addressing the beliefs held by society about this common, debilitating and costly health problem, which ultimately doesn’t need to be such a burden on our healthcare and welfare systems.  Public education campaigns in other areas of healthcare where misconceptions exist, such as those associated with the over-prescription of antibiotics, or reducing higher than average back surgery rates,  have had some, albeit small, effects on changing outcomes of the patient/clinician interaction and improving desired outcomes. Perhaps it’s time we turned the conversation around from focusing on the next big cure, breakthrough or development in chronic pain treatments, and started focusing on normalising the experience of back pain.