The Nocebo Effect - Why Belief In A Treatment Is Vital

We all know what the placebo effect is. It's the very real-world phenomenon of the body responding positively to an otherwise ineffective treatment or stimulus caused by the belief that there will be a positive outcome. The placebo effect is, in reality, a large reason for many success stories in the therapeutic world, believe it or not. In fact, some modalities actually rely on a patient's belief that it will decrease their pain.

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BUT.. did you ever stop to consider the opposite effect being a possibility as well?

The "nocebo" effect is classified as when a negative expectation results in a negative outcome, whether it's to do with movement, nutrition, a clinical treatment, or virtually anything else. Truly, it's the other far-side of the spectrum from the placebo.

This ties directly in with my past topics about how language selection and expectations of pain can propagate and cause more pain. Like I've said before, mental state has a huge effect on driving the body's outputs, whether it be pain, inflammation, or more.

This being said, the nocebo has a massive influence on the effectiveness of a therapy treatment. If a client does not believe in a certain type of treatment or modality or they think that it will cause them harm, then it absolutely can interfere with the treatment outcome!

For this reason, I do my best to thoroughly educate my clients in exactly what kind of processes are occurring in their body before, during, and after any treatment I provide in order to help them understand the targeted effect and increase the probability of success.

If a client simply doesn't believe in a modality at all, then that's ok! Therapists work for the client, not the other way around, and the client does not HAVE to subscribe to every philosophy. However, in absence of that belief, gears need to be switched with either a new approach or a new therapist, otherwise we're charging that client continually for treatments with no outcome. And that's where responsibility on the clinician's side comes in.

The brain is a funny thing, but it's the boss. We gotta work with it.

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More Pain, More...Pain?

A lot of you reading this may subscribe to - and possibly live by - the "more pain, more gain" rule. The harder you workout and the more sore you get, the more strength and size you gain. The harder you run through the burn, the faster you become. Transferring this train of thought to the rehab realm: the harder you dig in there, the better you'll recover.

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Whether it's through traditional massage, Graston, cupping, active release, or some other form of modality, does a higher intensity of the treatment correspond to increased recovery? In other words, does a more painful session somehow equate to less pain once a client leaves? (Even if the client can "take it"?)

Well, let's consider the reasons why people may believe that "going harder" results in an increased benefit. For instance, when it comes to tight muscles, scar tissue, adhesions, and the like, the common believe is that these modalities are physically breaking down those restrictions. Unfortunately, as I've pointed out in the past, massage does not break down muscle or scar tissue. Rather, these treatments are providing a new sensation to the nervous system in order to allow the tissue to relax and release its tone in the region.

That being said, given that this effect is nervous system-driven, more or less pressure may sometimes be required. Pain tolerance, while not all in your head, can dictate how much of an effect you experience from treatment. With that in mind, however, it can mean that a highly-sensitive person can get the exact same result from a very light massage as a very highly pain-tolerant individual with a more aggressive session of active release.

With all of this being the case, I can't say that I'm very comfortable with trying to give anyone a "harder" session of soft-tissue work than they can take. Some discomfort is to be expected, of course, but if I'm causing excruciating pain, I don't see how that can result in the pain relief that I'm striving to achieve. In fact, the intensity of these treatments might actually work to increase pain-sensitivity, acting in the exact opposite direction of what the goal is!

Does this diminish the usefulness of therapists, however? Of course not. It's still my job to be able to gauge each individual's reaction to different sensations and deliver an effective treatment that remains within their tolerance. When it comes to modality application, just call me a Conservative.

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What Can Speed Bone Healing?

I've been fortunate to never have had experienced a bone fracture in my own life. (I figure that I'll probably get hit by a car in the week following this blog post.) I understand how much fractures are a drag, though. Not being able to do anything except immobilize it and let time heal it enough to start doing any rehab.

A topic that's starting to pop up, however, is if there are modalities which can increase the rate of bone healing and accelerate the recovery process. Well, I decided to surf through the research and see what I could dig up.

Exercise

Let's start with the modality that I'm clearly the most focused on. It's common that weight bearing and physical activity will increase the rate of healthy bone formation in healthy populations and those with osteoporosis. But can early exercise while a fracture is still in its healing phase be beneficial?

Unfortunately, there's not a whole lot of research that I could find on exercise, although it's clear that weight-bearing is a definite factor in increase bone formation. Research does suggest that regular contraction of the muscle around the injured bone may decrease the rate of bone loss, but it's not conclusive.

With this information, the only safe advice to give would be that weight-bearing (standing and walking on a fractured leg, for instance) is beneficial to the healing process, but only under the clearance and supervision by a professional when the bone is stable enough for each progression.

Massage

This will be a short and sweet entry. After a scan of journal databases, I found no research directly on the stimulation of soft tissue over the site of a fracture. Being that a fracture is a widely-taught contraindication of massage, we can only assume that manual therapy is off-limits when it comes to bone healing.

Ultrasound

Here's where we can get interesting!

I found one fantastic journal review that compiled everything nicely for us. It cited multiple studies that found a positive effect of specific ultrasound signals on the rate of bone healing. Even when it came to applying the modality to smokers, who are known to have decreased rates of fracture and tissue healing, ultrasound was able to counteract the effect.

It seems that, despite my recent post about why ultrasound probably does nothing for you, that there is probably some use for it after all.

Electrotherapy

The findings here were interesting, as I was taught in college that electrotherapy such as IFC (interferential current) could accelerate the bone healing process. However, this is another modality that does not seem to have much research behind it, What I was able to find was little more than a suggestion that electrotherapy may help prevent complications of fracture non-unions. On the other hand, one newer study seemed to find that IFC made no difference in bone healing times.

Laser

Laser is a newer therapy on the block. With it emerging more recently, there's been a bit more hype to research it.

The research, so far, has been positive when it comes to the effect of laser on the acceleration of bone healing. However, it's important to note that most of the studies to this date have been done on rabbits and rats. Nonetheless, bones are bones, and this find is still a promising one. I'll be careful about getting too excited until I see a bit more evidence, though.


In short, there's still some research to be done before we can say anything for sure. At this time, it's safe to say that weight-bearing to stimulate bone growth using mechanical stress is the best advice to accelerate fracture healing, although ultrasound shows a lot of promise as well. Massage is a no-go, electricity probably has little effect, and we should probably wait on more results about laser.

Regardless, make sure to do your rehab once the cast comes off.