The powerful nocebo effect
Everyone has heard of the placebo effect, our ability to produce a powerful healing response triggered by the belief that a treatment will be good for us. Our brain can reduce pain or other symptoms depending on how much we believe in a treatment or how much we believe that we can improve our symptoms. This phenomenon is well known and has been widely written about, but have you heard of the nocebo effect?
The nocebo effect is the opposite of the placebo effect, it’s our ability to activate a response that can cause pain or other symptoms depending on whether we think something is dangerous or will do us harm. If we believe that something dangerous has happened to us or that there is something wrong, even if there isn’t, it can lead to symptoms. I’m going to describe two examples of when this has happened, both of which are case studies written up in medical journals:
The first one is a 29 year old builder, who jumped down off a step and landed on an upturned 15cm nail, which went straight through his boot. He was taken to A+E were it was reported that the slightest movement of the nail caused extreme pain so he had to be sedated with fentanyl and midazolam. The nail was then removed from the boot and the boot removed from his foot and when the boot was removed, the doctors found the nail had actually gone between his toes and not through his foot. His pain improved almost immediately once he realised there was no damage to his foot (Fisher et al., 1995).
The second is a 26 year old American man who was enrolled in a medical trial that was testing anti-depressants. After an argument with his girlfriend he took an overdose of the pills he was taking in the trial. After arriving at hospital he collapsed with low blood pressure and needed intravenous fluids to maintain his blood pressure. The doctors at the hospital contacted the trial to see what medication the man had taken. They found out that he actually been in the placebo group and after he was told this his symptoms disappeared in 15 minutes. (Reeves et al., 2007).
In the case of the builder the protective part of his brain thought that his foot had been damaged and therefore caused intense pain to protect the foot even though there wasn’t any damage. In the second case the man who ingested the medication believed the pills were going to cause an adverse effect and so he felt the effects he anticipated. These are both examples of how our beliefs or our perceptions can influence the symptoms we feel, making symptoms worse and causing pain.
In both cases their symptoms settled down very quickly once they realised there was nothing wrong, but what would happen if we continued to believe there was something wrong? It could mean that we continue to experience pain even when there is no damage.
I see this happen a lot with people who have had MRI scans on their lower back and have been told they have a prolapsed disc causing the pain. Often their belief from that point onward is that their back is in some way weak and not structurally sound. This gives the message to their nervous system that the back needs protecting and this can lead to them experiencing on-going pain to protect the back. It is the same with people who have had x-rays on their knees and told that they have osteoarthritis and in many other instances.
The belief that an area of the body isn’t structurally sound leads people to think that it is harmful to do activity and they begin to adapt their lives to avoid certain movements or to avoid the pain. This in turn means they become de-conditioned and the body doesn’t get the movement it requires. A viscous circle is then created, which further enhances the pain or means people experience pain for longer.
I feel this is one of the major reasons why treatments don’t work, because if we don’t address the belief that something is wrong, then the brain will continue to produce the pain, despite having treatment.
That’s why addressing someone’s beliefs about their pain is one of the first things I do. If someone thinks that something is damaged when it isn’t, then we need to change that to help improve the pain. I often give people different techniques to help to do this. Two of the techniques I use most often are positive affirmations about the affected area of the body and visualising the area of the body being strong and healthy rather than being weak. By changing how we think about the affected part of the body it helps to remove the nocebo and takes away the need for the protective pain response, thereby giving people more confidence to begin being active again.
Fisher JP, Hassan DT, O’Connor N (1995) Minerva. BMJ 310: 70.
Reeves, R.R., Ladner, M.E., Hart, R.H & Burke, R.S. (2007) Nocebo effects with antidepressant clinical drug trial placebos. General Hospital Psychiatry Vol 29 (3) pp 275-277
May 8, 2019
A different approach to lower back pain
Last year I posted a couple of blogs on lower back pain and the papers that had been published on lower back pain in the Lancet. If you haven’t read these papers I would advise you to do so. They were a global study and highlighted a lot of the misconceptions about lower back pain. They also highlighted some of the challenges to improving back care. Here is the link to the papers on the Lancet website: https://www.thelancet.com/series/low-back-pain
For me these papers were important because they represented a shift in the way we approach lower back pain. A shift away from the biomedical model to a biopsychosocial approach. A model where we take into account what is happening in someone’s life and their beliefs about pain and not just focus on finding a damaged structure in someone’s back and treating that. For the majority of people with lower back pain there is no structural cause for the pain. Studies have shown that prolapsed discs and facet joint arthritis are as common in people without pain as they are in people with pain. In some cases there are more serious causes of back pain, but these are rare and most people have what’s known as non-specific lower back pain.
The Lancet papers highlighted that a lot of treatment that focused on the structure in someone’s back, like supports, injections and some surgery aren’t very effective. They also highlighted that MRI scans and x-rays are not always necessary as they can often make people more anxious about their back if something is found, even if it is unrelated. The studies report that medical intervention can make people’s pain worse over the long term if it is purely focused on a structural problem or if things aren’t explained properly.
These are some of the reasons why I set up the Bristol Pain Relief Centre. I felt there needed to be a different way of approaching lower back pain. Over the years I have seen many people with chronic lower back pain who are afraid to move or do activities they previously did for fear of damaging their back. They may have had an MRI scan or an x-ray and have been told that there was a disc bulge causing their pain or some wear and tear or they may have been told that there was something out of alignment. Either way they thought there was something wrong with their back and began to protect it. This belief that something is damaged makes the pain worse as our nervous systems become more protective of our backs and the amount of activity you do becomes less and less.
I’ve also seen people who have developed a fear of the pain itself. People become afraid to move because the pain may come on. This also leads them to adapt their lives and become less active. The important thing to note is that pain does not always mean damage. Pain is an alarm system that can be triggered by our brains and central nervous system in response to a perceived threat. But often it is the perception of threat that causes the pain rather than a threat itself. Helping people to understand this can be very useful. By knowing that they are not going to damage themselves it helps build confidence to move again, which in turn helps switch off the protective pain mechanism.
When treating people with long term lower back pain there are also other factors to take into account. Emotional factors past and present can play a significant role in how our nervous systems respond. It can make our nervous system become hyper-responsive to information. Meaning something that shouldn’t cause pain now does. This pattern can become stronger over a period of time and unknowingly people can be doing things that reinforce this pattern, creating a viscous cycle. Our beliefs about the causes of pain can influence the pain we experience.
This was highlighted in the lancet papers that we need to recognise that social and economic factors, as well as personal and cultural beliefs are all associated with someone’s back pain. If we don’t recognise this going forwards it may lead to back pain becoming even more of a global problem.
This is why over the years I have shifted from focusing on back pain as structural problem and focused more on the person. Pain is often a physiological response triggered by physical, emotional and cognitive factors and not just a structural problem. I have found it very useful to shift away from pain as purely a physical problem and treat the person, not just the area they have pain. I’ve seen many people with long term pain recover, by looking at their pain from a different perspective. It’s not always easy to do, particularly when someone has become afraid to move, but it is possible.
If you want to find out more about this different way of working, then why not give me a call on: 07976 926347 or send me an email to firstname.lastname@example.org. We can book in a free 30 telephone consultation, where I can explain the approach in more detail.
February 20, 2019
The Importance of Spending Time in Nature
There are certain things that are just good for you, you can’t really argue with it, they just have a positive effect on your health. Things like regular exercise, a healthy diet, laughing and spending time with friends all just have a positive influence on us. The other thing I would add to this list is spending time outdoors in the natural environment. Whether this is going for a walk in a forest, hiking up a mountain, or just spending a bit of time in your garden, it naturally has a positive impact on you and your health.
The problem is that nowadays a lot of us live in cities and we rarely see green space. We spend a lot more time indoors, on computers and not moving and if we do go outside we are bombarded by artificial stimulus and noise. Having a lot of other people around, as well as traffic and higher levels of noise can overwhelm our nervous system.
In contrast in the countryside there is less stimulation and the noises you hear are not mechanical and harsh. They are softer sounds such as the wind blowing, trees rustling and birds singing. There are less people around and there is less stimulation, so it gives us and our nervous systems a chance to relax and switch off. Looking at green and brown colours is more calming than looking at concrete and neon.
The positive influence of spending time in nature has been backed up by studies showing it has significant benefits for our health and well-being. Researchers at the University of Derby (Richardson et al., 2016) along with the Wildlife Trust created a campaign to get people to engage more with nature over a 30 day period, it was called ‘30 days wild’. The campaign provided ideas about how to spend time in Nature and gave guidance on activities people could get involved in. These things could be very small such as taking the time to watch a butterfly or smelling a flower. They found that by doing this people reported a significant improvement in their happiness, their connectedness to nature and pro-nature behaviour, after the 30 days trial.
Other studies report that having green spaces in cities and regular contact with the natural environment has a positive influence on our mental and physical well-being (Hartig et al., 2014, Maller et al., 2006) and could make people more resilient when dealing with stress. Researchers in Brighton (Gould van Praag et al., 2017) found that just listening to natural sounds and images had a relaxing effect on our nervous system compared to artificial sounds and images. They found there was a shift towards parasympathetic activation and alterations in the default mode network in the brain, during the natural sounds compared to artificial stimulus. The default mode network area of the brain that has been associated with day dreaming and non-task focused activity and the parasympathic nervous system is involved with rest and relaxation, in contrast to the sympathetic nervous system, which is involved with fight or flight responses.
Overall, there are huge benefits from having regular contact with nature. If you find that you are too busy to set time aside to do this, that’s probably when you need it the most. Why not have a look at the 30 days wild trial to find some simple tips about connecting with nature. It might make it easier to fit it into your day.
Gould van Praag, C.D., Garfinkel, S.N., Sparasci, O., Mees, A., Philippides, A.O., Ware, M., Ottaviani, C. & Critchley, H.D. (2017) Mind-Wandering and alterations to default mode network connectivity when listening to naturalistic versus artificial sounds. Scientific Reports 7:45273 DOI: 10.1038/srep45273
Hartig, T., Mitchell, R., de Vries, S. & Frumkin, H. (2014) Nature and Health. Annu Rev Public Health 35: 207-228. doi: 10.1146/annurev-publhealth-032013-182443. Epub 2014 Jan 2.
Maller, C., Townsend, M., Pryor, A., Brown, P. & St Leger, L. (2006) Healthy nature healthy people: ‘contact with nature’ as an upstream health promotion intervention for populations. Health Promotion Int. Mar;21(1):45-54. Epub 2005 Dec 22.
Richardson, M., Cormack, A., McRobert, L. & Underhill, R (2016) 30 Days Wild: Development and Evaluation of a Large-scale Nature Engagement Campaign to Improve Well-Being. PloS ONE 11(2): e0149777. doi.org/10.1371/journal.pone.0149777
December 6, 2018
Lower Back Pain – The latest evidence – Part 2
Following on from my previous blog on the papers published early this year in the medical journal the Lancet, this second blog looks at some of the other important messages from this key research. If you haven’t already read these papers then here is a link to the Lancet’s website where you can find them: https://www.thelancet.com/series/low-back-pain
One of the other and most significant messages that came out of these research papers was:
‘For nearly all people with low back pain, it is not possible to identify a specific nociceptive cause’ Hartvigsen et al (2018)
What this means is that for most people suffering with lower back pain, we don’t know the structural cause of the pain. This may sound crazy, but for the majority of people, doctors and other healthcare professionals are not able to diagnose the structural cause of their lower back pain. If you’re reading this and you have lower back pain you may have been told, that your pain is due to a structural change such as a slipped or bulging disc or it is due to degenerative changes in your spine. Although you may have been told this, these are not the cause of the pain. The reason why these aren’t the cause of the pain is because these structural changes occur naturally in everyone, even people who are pain free. Numerous MRI studies have now been conducted on thousands of people who don’t have lower back pain. What they have found is that a high percentage of these people had bulging discs, disc extrusions and osteoarthritis in their facet joints, but they were pain free and leading an active life. So if structural changes are the cause of pain, surely these people should be in pain as well?
Two examples of these studies are:
Matsumoto et al (2013) found that MRI scans showed degenerative changes [including protrusions, compressions and stenosis] in both the lumbar (lower back) and cervical spine (neck) in 78.7% of the asymptomatic volunteers. In another study, lumbar MRI of asymptomatic volunteers (age 14–82, mean age 46) showed 60% had bulges, 45% had protrusions, 31% had extrusions, 76% had annular fissures, 76% had nuclear degeneration (Kim et al., 2013). There are more studies that I have included on my website, you can follow this link to see their conclusions: http://bristolpainreliefcentre.co.uk/are-you-in-pain/useful-information/
One of the other conclusions of the Lancet papers was that we are doing far too many MRI scans of people’s lower backs and that by doing unnecessary scans it can make people’s pain worse. This is because when people find out they have a prolapsed disc or narrowing of their disc space, they naturally become more protective of their back. This can increase the protective pain response and also means people start to do less, which isn’t good. A study comparing people who had an MRI scan shortly after the onset of their back pain compared to people who didn’t have one, found the ones who did have an MRI scan had their back pain for a longer period of time (Webster et al., 2013).
There are some cases when further investigation is definitely warranted. In these cases it is to rule out serious spinal pathology including vertebral fractures, Axial spondyloarthritis, Malignancy, Infections and Cauda Equina (Hartvigsen et al., 2018). If you have one of these conditions then you will more than likely be experiencing symptoms that a physiotherapist or doctor would recognise as needing further investigation. So it’s always good to checked by your GP if you are unsure of whether you need a scan or not, but remember, if your GP thinks you don’t, it’s not just because they are trying to save money, it’s because it is unnecessary and may actually make things worse.
If you read part 1 of this blog, I explain how it is more likely that the pain is being caused by what is happening in our lives, the emotional impact this has on us and how we adapt because of it. This leads to physiological responses, such as your muscles tightening up in your back, an enhanced pain response in your central nervous system, as well as adaptive changes in the neuro-endocrine and immune system. Although at this stage I can’t say for sure, back pain is more likely due to a combination of physiological responses, triggered by life events, rather than a structural problem with your back.
The good news is that these changes are not permanent and most back pain settles on its own, without the need for medication, injections or surgery. If you have back pain have a think about what has been going on in life recently, has been there been anything that has had an emotional impact or anything thing that has caused you to change your normal routine? If so, try to get back into your usual routine and stay active, it’s better to keep moving than to rest. Using some stress management techniques such as meditation and therapeutic writing may also be helpful.
Kim et al (2013)Prevalence of disc degeneration in asymptomatic Korean subjects. Part 1: lumbar spine. Journal of the Korean Neurosurgical Society (PMID: 23440899)
Matsumoto et al (2013)Tandem age-related lumbar and cervical intervertebral disc changes in asymptomatic subjects. European Spine Journal (PMID: 22990606), 2013, 708–13.
Webster et al (2013) Iatrogenic Consequences of Early Magnetic Resonance Imaging in Acute, Work-Related, Disabling Low Back Pain Spine (Phila Pa 1976). 2013 Oct 15; 38(22): 1939–1946
July 10, 2018
Lower back pain – The latest evidence – Part 1
Recently, there has been a lot of coverage in the mainstream media about three research articles on lower back pain, that were published in the medical journal The Lancet. These studies can be found on the Lancet’s website: https://www.thelancet.com/series/low-back-pain. In my opinion the research represents a significant shift in the way we treat lower back pain. Moving away from focusing on treating the structures in the lower back, such as joints and discs, to a more holistic approach. The main message portrayed in the press was that treatments regularly used for lower back pain, such as injections and surgery, are often ineffective and potentially harmful. Important to know for someone suffering with lower back pain, as you want to know how good a treatment option will be and whether it could cause you harm, but alongside this there was also lots of other good information about lower back pain that didn’t get picked up on. So I am going to highlight the other information that I think is relevant over a series of blogs.
The first paper published in the Lancet is titled: What is low back pain and why we need to pay attention (Hartvigson et al., 2018), and one of the key messages I took from this paper was:
‘Lower back pain is a symptom and not a disease’
The article explains that in the majority of people there is no nociceptive cause for lower back pain, this means there is often no known structural cause for their back pain (I will go into this in more detail in my next blog). If in most people there is no known structural cause of their pain and lower back pain is a symptom, what is it a symptom of? In the article it reports that the cause of lower back pain is related to a combination of psychological, social and biophysical factors, but what does all that mean?
In my experience after treating thousands of people with acute lower back pain, the onset of pain is a symptom of what is going on in someone’s life, rather than they have damaged their back. It is related to the circumstances they find themselves in and the emotional impact this is having on them. It is very rare that people with lower back pain have done something physical, to have damaged their back. Our lower backs are very robust and it takes a lot to damage them. Instead what I have noticed, is that there has often been a change in circumstances prior to the onset of pain. This change in circumstances usually has an emotional impact, it may also have a physical impact and it takes them out of their usual routine. By doing this it means that they lose their coping strategies and it means that the situation becomes stressful. I’ll use an example of a typical (but made up) presentation of a patient with lower back pain to explain this:
‘A 55 year old gentleman comes to see me with lower back pain, which started a week earlier. There was no physical reason for this pain, he hadn’t lifted anything heavy or over worked himself at the gym, it had just come on one morning. The pain is very intense and limiting his movement, but there is nothing concerning and he is generally healthy. After questioning him further it turns out that he has a quarterly target to meet at work and he is behind, meaning he is working longer hours than usual. He also has a sick mother who lives in a different city, two hours away, who he visits most weekends. He has a wife and two children, who he is not seeing as much and is finding it difficult to take his children to their various clubs. He usually attends the gym twice a week, but hasn’t been able to find the time.’
The circumstances this man finds himself in are having a large emotional strain on him. He is under more pressure at work than usual and working longer hours. His mother being sick is also having an emotional impact on him and he is having to drive to see her at weekends, sitting in Friday traffic. He has his normal duties to attend to, but is finding it difficult and he is not getting as much downtime as usual. He misses seeing his wife and children as much and may feel guilty that he isn’t helping out as much as he normally would do. He is also sitting for longer periods, which is not good for our metabolism and general health. The combination of these events is having a psychological and physiological impact on him, which means he is under a lot more stress than usual. At some point something needs to change and if it doesn’t people often experience pain. It’s your body’s way of telling you to slow down, or get some help. There are physiological responses that lead to this, which I will also explain in a later blog.
For most people an acute episode of lower back pain will usually settle within a month or so. Usually because the pain has the desired effect and it makes someone change what they are doing, or get some sort of support. Sometimes it can develop into chronic (long-term) lower back pain. In my experience this is because we haven’t acknowledged what else is going on in someone’s life when the pain began, we have focused on the structure of someone’s back, even when the research shows that most of the time there is no known structural cause for lower back pain. Maybe, by being more aware of the psychosocial factors in someone’s pain, we can be more affective at preventing lower back pain and stopping long term problems?
If you are suffering with lower back pain or know someone suffering with lower back pain, my advice would be, rather than look for a physical reason for the pain, think about what is going on in your life at present or in the recent past, or if you have chronic pain think back to when the pain started. Has there, or was there a change in your circumstances that lead to there being more stress then usual? What was the emotional impact of this? Has it taken you out of your usual routine? By acknowledging this and then giving yourself more time out, it may help to reduce the pain and allow you to get back to normal more quickly.