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Placebo Nocebo

I first learnt this term a few years ago and after changing my language in consults I saw significant improvements in patient recovery and outcomes.


nəˈsiːbəʊ/ noun

A detrimental effect on health produced by psychological or psychosomatic factors such as negative expectations of treatment or prognosis.

We now know through significant amounts of research that pain is a unique response to an injury or illness. It is influenced by a large number of factors and not just due to tissue ‘damage’. There are a large number of individual factors that will affect perception of pain including: beliefs, thoughts, stress levels and quality of sleep.

Doctors, physiotherapists and other healthcare providers often like to use fancy words or explanations to educate patients on a condition. Unfortunately it’s often these words that create fear or vulnerability. This leads to a negative impact on the patient’s recovery and poor outcomes.

Frequently used words and terms which can have significant negative effects are: mis-alignments, pelvic rotations, knots, unstable levels, joint degeneration, poor core stability and poor posture. This is what we call the nocebo effect.

Due to the high use of CTs and MRIs for lower back pain (a topic on its own!), a common example would be the term disc bulge. This is frequently seen on scans and blamed for the cause of non specific back pain. This well-used medical term leads many people to cease normal spinal movements and physical activity. They develop a fear of making things worse. You may have been told ‘don’t bend’ or ‘don’t slouch’ and more fearful advice. We know however that as we age it becomes almost a normal sign of ageing to have these structural changes in the spine. We could refer to it like getting grey hairs or wrinkles.

After ruling out anything sinister, patients should be reassured with positive terms. Patients should be encouraged to resume normal movements as tolerated. This gives patients more control over their pain with less fear, stress and anxiety towards the injury. When patients feel more in control of their pain outcomes improve.

If you are a practitioner – remember words and language used can be very powerful; both in a positive manner but also a negative manner. Remember the term nocebo.

Below are some phrases using positive and negative language in regards to non specific lower back pain.

1.Messages that can harm in-patients with nonspecific low back pain:

Promote beliefs about structural damage/dysfunction

  • “You have degeneration/arthritis/disc bulge/disc disease/a slipped disc”

  • “Your back is damaged”

  • “You have the back of a 70-year-old”

  • “It’s wear and tear”

Promote fear beyond acute phase

  • “You have to be careful/take it easy from now on”

  • “Your back is weak”

  • “You should avoid bending/lifting”

Promote a negative future outlook

  • “Your back wears out as you get older”

  • “This will be here for the rest of your life”

  • “I wouldn’t be surprised if you end up in a wheelchair”

Hurt equals harm

  • “Stop if you feel any pain”

  • “Let pain guide you”

2. Messages that can heal in-patients with nonspecific low back pain

Promote a biopsychosocial approach in pain

  • “Back pain does not mean your back is damaged – it means it is sensitised”

  • “Your back can be sensitised by awkward movements and postures, muscle tension, inactivity, lack of sleep, stress, worry and low mood”

  • “Most back pain is linked to minor sprains that can be very painful”

  • “Sleeping well, exercise, a healthy diet and cutting down on your smoking will help your back as well”

  • “The brain acts as an amplifier – the more you worry and think about your pain the worse it gets”

Promote resilience

  • “Your back is one of the strongest structures of the body”

  • “It’s very rare to do permanent damage to your back”

Encourage normal activity and movement

  • “Relaxed movement will help your back pain settle”

  • “Your back gets stronger with movement”

  • “Motion is lotion”

  • “Protecting your back and avoiding movement can make you worse”

Address concerns about imaging results and pains

  • “Your scan changes are normal, like grey hair”

  • “The pain does not mean you are doing damage – your back is sensitive”

Reference note:

  • PAIN MANAGEMENT TODAY 2014; 1(1): 8-13

  • PETER O’SULLIVAN DipPhysio, PGradDipMTh, PhD, FACP

  • IVAN LIN BSc(Physio), MManipTher, PhD

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