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Expectation and Outcome
August 14, 2010 by Dr Matthew D. Long
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Expectation and Outcome
August 14, 2010 by Dr Matthew D. Long
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Expectation and Outcome
August 14, 2010 by Dr Matthew D. Long
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As chiropractors we naturally possess confidence in the effectiveness of a spinal adjustment. Indeed, with an understanding of the neurological underpinnings of our art it is neither surprising nor unjustified that we look for scientific data to support our observations and theories. But as we dig beneath the surface of human physiology we come up against evidence that shows that our clinical successes might have just as much to do with the patient as they do with us.
I often joke with some of my patients that they "are good quality working material", and while this raises a laugh, it is closer to reality than we might think. Chiropractors intrinsically understand that their adjustments will have differing effects in each person, with the rationale given that our results are determined by the "limitations of matter" or the homeostatic capacity of the individual. However, the literature now points to another hugely important factor in determining the outcome of any treatment or intervention - patient expectation.
While we might not like to think it so, the data now suggests that a patient's expectation about the outcome of treatment is possibly the largest determinant of its success, particularly when it comes to relieving pain. But don't think that this is limited only to chiropractors. Patient expectation clouds our ability to determine efficacy of drug treatments, acupuncture and surgery too.
A paper by Tait et al in the Journal of Neurology, Neurosurgery and Psychiatry (1) demonstrated how the simple act of presenting a newly operated-upon patient with the freshly excised lumbar disc material in a jar improved outcomes in "sciatica, low back pain, leg paraesthesia, leg weakness and reduced analgesic intake compared with patients not given the disc fragments" - probably by providing "a powerful visual confirmation to the patient that the operation was technically successful." As such, the patient's expectation is that they will have no more pain.
And it's not just pain relief that varies with expectation. A study by Lidstone and colleagues (2) recently showed that Parkinson's patients will vary the amount of dopamine that they produce themselves in response to "verbal manipulation". In this case they were told that they had a particular probability (25%, 50%, 75% or 100%) of receiving an active dopamine medication rather than a placebo, when in fact they all received placebo. By setting expectations appropriately the researchers could modulate the dopamine system, which is an important part of the brain's intrinsic reward system. Interestingly, when expectation was manipulated to be lower (25% or 50%), no increase in dopamine was found, as the patient didn't think that there was much chance of reward. Similarly, if the patient was told that they had a 100% chance of receiving the active medication, the brain found no need to engage the reward system. But if a patient was told that they had a 75% chance of getting the active drug, they showed a marked increase in dopamine production on PET scans - signifying that some uncertainty was necessary. Expectation, or the promise of symptom improvement, can powerfully harness the brain's own dopamine system.
So what about chiropractic?
We know that expected effectiveness is a powerful predictor of a favourable response when treating patients with neck pain (3). Similarly patients given a negative expectation about the outcome of manipulation for lower back pain showed a significant increase in pain perception (4). We also know that the failure of disc surgery can be predicted prior to operation, based upon measuring a patient's indices of stress - higher levels of inflammatory cytokines and reduced cortisol secretion (5). Which brings us to another important feature of expectation - that it appears to modulate the immune response.
In the paper "Expectations and associations that heal: Immunomodulatory placebo effects and its neurobiology" the authors (6) suggest that, "placebo effects can benefit end-organ functioning and the overall health of the individual through positive expectations and behavioral conditioning processes" and go on to recommend that, "therapies should be designed to enhance therapeutic placebo effects and reduce nocebo effects associated with the main treatment."
I often joke with some of my patients that they "are good quality working material", and while this raises a laugh, it is closer to reality than we might think. Chiropractors intrinsically understand that their adjustments will have differing effects in each person, with the rationale given that our results are determined by the "limitations of matter" or the homeostatic capacity of the individual. However, the literature now points to another hugely important factor in determining the outcome of any treatment or intervention - patient expectation.
While we might not like to think it so, the data now suggests that a patient's expectation about the outcome of treatment is possibly the largest determinant of its success, particularly when it comes to relieving pain. But don't think that this is limited only to chiropractors. Patient expectation clouds our ability to determine efficacy of drug treatments, acupuncture and surgery too.
A paper by Tait et al in the Journal of Neurology, Neurosurgery and Psychiatry (1) demonstrated how the simple act of presenting a newly operated-upon patient with the freshly excised lumbar disc material in a jar improved outcomes in "sciatica, low back pain, leg paraesthesia, leg weakness and reduced analgesic intake compared with patients not given the disc fragments" - probably by providing "a powerful visual confirmation to the patient that the operation was technically successful." As such, the patient's expectation is that they will have no more pain.
And it's not just pain relief that varies with expectation. A study by Lidstone and colleagues (2) recently showed that Parkinson's patients will vary the amount of dopamine that they produce themselves in response to "verbal manipulation". In this case they were told that they had a particular probability (25%, 50%, 75% or 100%) of receiving an active dopamine medication rather than a placebo, when in fact they all received placebo. By setting expectations appropriately the researchers could modulate the dopamine system, which is an important part of the brain's intrinsic reward system. Interestingly, when expectation was manipulated to be lower (25% or 50%), no increase in dopamine was found, as the patient didn't think that there was much chance of reward. Similarly, if the patient was told that they had a 100% chance of receiving the active medication, the brain found no need to engage the reward system. But if a patient was told that they had a 75% chance of getting the active drug, they showed a marked increase in dopamine production on PET scans - signifying that some uncertainty was necessary. Expectation, or the promise of symptom improvement, can powerfully harness the brain's own dopamine system.
So what about chiropractic?
We know that expected effectiveness is a powerful predictor of a favourable response when treating patients with neck pain (3). Similarly patients given a negative expectation about the outcome of manipulation for lower back pain showed a significant increase in pain perception (4). We also know that the failure of disc surgery can be predicted prior to operation, based upon measuring a patient's indices of stress - higher levels of inflammatory cytokines and reduced cortisol secretion (5). Which brings us to another important feature of expectation - that it appears to modulate the immune response.
In the paper "Expectations and associations that heal: Immunomodulatory placebo effects and its neurobiology" the authors (6) suggest that, "placebo effects can benefit end-organ functioning and the overall health of the individual through positive expectations and behavioral conditioning processes" and go on to recommend that, "therapies should be designed to enhance therapeutic placebo effects and reduce nocebo effects associated with the main treatment."
There is a consensus amongst researchers that there is nothing "wrong" with using the placebo effect in clinical practice, but you do want it working for the patient, not against them.
Krummenacher (7) suggests that, "Expectations and beliefs shape reality by affecting our perception and influencing our behavior. They influence behavior by modulating the neural processes that mediate the actual sensory experience, and affect perception by directing attention to and guiding interpretation of both internal and external sensations. The role of expectations in sensory experiences is especially relevant in the context of pain processing, and research addressing the mechanisms mediating placebo analgesia have increasingly attracted scientific interest in recent years."
Clearly chiropractors treat many patients seeking pain relief. And often they achieve impressive results by the combination of their conscious, calculated and directed treatment (usually using a spinal adjustment), together with the unconscious direction they provide to patients through their confidence and belief that theirs is the right approach. In other words, they help to set their patients' expectations for treatment. And this is a very important part of appropriate and ethical patient management. Left to their own devices, some patients will undermine the best of treatment strategies if their own beliefs are negative. Not only will the analgesic effects of an adjustment be minimised, but pessimistic patients alter their motor-control strategies (the way they move) to protect themselves from further potential harm. These bad movements habits will typically predispose them to future re-injury, and in doing so, reinforce their negative preconceptions that the treatment would not work.
Moseley and colleagues (8) looked at this question of why some patients do not regain the normal fluid and variable motions of spinal movement that characterise a healthy, pain-free spine. They asked, "Why might some people not reestablish normal variability even when the pain has stopped? Relevant here is the secondary finding that nonresolvers were characterized by their beliefs about back trouble. These are the first data that link beliefs to motor variability and learning and suggest that the link may be mediated by evaluative processes, which contribute to motor variability."
They further suggested "That asymptomatic controls demonstrate a protective postural strategy when they expect their back to hurt and that recurrent back pain patients demonstrate it even when they are pain free seem consistent with that possibility."
The implications for us as clinicians are profound. If we want to maximise the potential for patient improvement then we need to ensure that we first uncover their beliefs about chiropractic and determine their expectations for treatment. You must then ensure that you can skilfully communicate what you intend to do, how this will help the patient, how long you think that it will take and how you will measure the results.
And on a lighter note, marketers have known forever that expectation can work for them or against them. Just look to the example of high-priced wine. If it costs more, it must taste better! Right?
A study in the Proceedings of the National Academy of Sciences by Plassmann et al looked at how the price of wine altered expectation and therefore taste. They proposed that, “marketing actions, such as changes in the price of a product, can affect neural representations of experienced pleasantness. We tested this hypothesis by scanning human subjects using functional MRI while they tasted wines that, contrary to reality, they believed to be different and sold at different prices. Our results show that increasing the price of a wine increases subjective reports of flavor pleasantness as well as blood-oxygen-level-dependent activity in medial orbitofrontal cortex, an area that is widely thought to encode for experienced pleasantness during experiential tasks."
In other words, when the subjects expected the taste to be superior, that's exactly what they got - it's just that their experience of quality had nothing to do with the intrinsic molecular makeup of the wine - it was mediated by price and expectation.
So it might be time to take stock of your own ‘practice experience’ from a patient’s point of view. Ask yourself, “What do my practice decor, procedures, examination, communication and treatment approaches do to maximise the expectation of a great outcome?”
Something to think about...
Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)
Krummenacher (7) suggests that, "Expectations and beliefs shape reality by affecting our perception and influencing our behavior. They influence behavior by modulating the neural processes that mediate the actual sensory experience, and affect perception by directing attention to and guiding interpretation of both internal and external sensations. The role of expectations in sensory experiences is especially relevant in the context of pain processing, and research addressing the mechanisms mediating placebo analgesia have increasingly attracted scientific interest in recent years."
Clearly chiropractors treat many patients seeking pain relief. And often they achieve impressive results by the combination of their conscious, calculated and directed treatment (usually using a spinal adjustment), together with the unconscious direction they provide to patients through their confidence and belief that theirs is the right approach. In other words, they help to set their patients' expectations for treatment. And this is a very important part of appropriate and ethical patient management. Left to their own devices, some patients will undermine the best of treatment strategies if their own beliefs are negative. Not only will the analgesic effects of an adjustment be minimised, but pessimistic patients alter their motor-control strategies (the way they move) to protect themselves from further potential harm. These bad movements habits will typically predispose them to future re-injury, and in doing so, reinforce their negative preconceptions that the treatment would not work.
Moseley and colleagues (8) looked at this question of why some patients do not regain the normal fluid and variable motions of spinal movement that characterise a healthy, pain-free spine. They asked, "Why might some people not reestablish normal variability even when the pain has stopped? Relevant here is the secondary finding that nonresolvers were characterized by their beliefs about back trouble. These are the first data that link beliefs to motor variability and learning and suggest that the link may be mediated by evaluative processes, which contribute to motor variability."
They further suggested "That asymptomatic controls demonstrate a protective postural strategy when they expect their back to hurt and that recurrent back pain patients demonstrate it even when they are pain free seem consistent with that possibility."
The implications for us as clinicians are profound. If we want to maximise the potential for patient improvement then we need to ensure that we first uncover their beliefs about chiropractic and determine their expectations for treatment. You must then ensure that you can skilfully communicate what you intend to do, how this will help the patient, how long you think that it will take and how you will measure the results.
And on a lighter note, marketers have known forever that expectation can work for them or against them. Just look to the example of high-priced wine. If it costs more, it must taste better! Right?
A study in the Proceedings of the National Academy of Sciences by Plassmann et al looked at how the price of wine altered expectation and therefore taste. They proposed that, “marketing actions, such as changes in the price of a product, can affect neural representations of experienced pleasantness. We tested this hypothesis by scanning human subjects using functional MRI while they tasted wines that, contrary to reality, they believed to be different and sold at different prices. Our results show that increasing the price of a wine increases subjective reports of flavor pleasantness as well as blood-oxygen-level-dependent activity in medial orbitofrontal cortex, an area that is widely thought to encode for experienced pleasantness during experiential tasks."
In other words, when the subjects expected the taste to be superior, that's exactly what they got - it's just that their experience of quality had nothing to do with the intrinsic molecular makeup of the wine - it was mediated by price and expectation.
So it might be time to take stock of your own ‘practice experience’ from a patient’s point of view. Ask yourself, “What do my practice decor, procedures, examination, communication and treatment approaches do to maximise the expectation of a great outcome?”
Something to think about...
Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)
References:
1. Tait MJ, Levy J, Nowell M, Pocock C, Petrik V, Bell BA, Papadopoulos MC. Improved outcome after lumbar microdiscectomy in patients shown their excised disc fragments: a prospective, double blind, randomised, controlled trial. J Neurol Neurosurg Psychiatry 2009;80:1044–1046.
2. Lidstone SC, Schulzer M, Dinelle K, Mak E, Sossi V, Ruth TJ, de la Fuente-Ferna ́ndez R, Phillips AG, Stoessl, AJ. Effects of Expectation on Placebo-Induced Dopamine Release in Parkinson Disease. Arch Gen Psychiatry. 2010 vol. 67 (8): 857-865.
3. Rubinstein SM, Knol DL, Leboeuf-Yde C, de Koekkoek TE, Pfeifle CE, van Tulder MW. Predictors of a Favorable Outcome in Patients Treated by Chiropractors for Neck Pain. SPINE. 2008 vol. 33 (13) pp. 1451-8
4. Bialosky JE, Bishop MD, Robinson ME, Barabas JA, George SZ. The influence of expectation on spinal manipulation induced hypoalgesia: An experimental study in normal subjects. BMC Musculoskeletal Disorders. 2008 vol. 9 pp. 19
5. Geiss A, Rohleder N, Kirschbaum C, Steinbach K, Bauer HW, Anton F. Predicting the failure of disc surgery by a hypofunctional HPA axis: evidence from a prospective study on patients undergoing disc surgery. PAIN. 2005 vol. 114 (1-2) pp. 104-17
6. Pacheco-López G, Engler H, Niemi MB, Schedlowski M. Expectations and associations that heal: Immunomodulatory placebo effects and its neurobiology. Brain, Behavior, and Immunity. 20 (2006) 430–446
7. Krummenacher P, Candia V, Folkers G, Schedlowski M, Schönbächler G. Prefrontal cortex modulates placebo analgesia. PAIN. 2009.
8. Moseley GL, Hodges PW. Reduced Variability of Postural Strategy Prevents Normalization of Motor Changes Induced by Back Pain: A Risk Factor for Chronic Trouble? Behavioral Neuroscience. 2006, Vol. 120, No. 2, 474–476
9. Plassmann H, O’Doherty J, Shiv B, Rangel A. Marketing actions can modulate neural representations of experienced pleasantness. Proc Nat Acad Sci. 2008. 105 (3): 1050-1054
1. Tait MJ, Levy J, Nowell M, Pocock C, Petrik V, Bell BA, Papadopoulos MC. Improved outcome after lumbar microdiscectomy in patients shown their excised disc fragments: a prospective, double blind, randomised, controlled trial. J Neurol Neurosurg Psychiatry 2009;80:1044–1046.
2. Lidstone SC, Schulzer M, Dinelle K, Mak E, Sossi V, Ruth TJ, de la Fuente-Ferna ́ndez R, Phillips AG, Stoessl, AJ. Effects of Expectation on Placebo-Induced Dopamine Release in Parkinson Disease. Arch Gen Psychiatry. 2010 vol. 67 (8): 857-865.
3. Rubinstein SM, Knol DL, Leboeuf-Yde C, de Koekkoek TE, Pfeifle CE, van Tulder MW. Predictors of a Favorable Outcome in Patients Treated by Chiropractors for Neck Pain. SPINE. 2008 vol. 33 (13) pp. 1451-8
4. Bialosky JE, Bishop MD, Robinson ME, Barabas JA, George SZ. The influence of expectation on spinal manipulation induced hypoalgesia: An experimental study in normal subjects. BMC Musculoskeletal Disorders. 2008 vol. 9 pp. 19
5. Geiss A, Rohleder N, Kirschbaum C, Steinbach K, Bauer HW, Anton F. Predicting the failure of disc surgery by a hypofunctional HPA axis: evidence from a prospective study on patients undergoing disc surgery. PAIN. 2005 vol. 114 (1-2) pp. 104-17
6. Pacheco-López G, Engler H, Niemi MB, Schedlowski M. Expectations and associations that heal: Immunomodulatory placebo effects and its neurobiology. Brain, Behavior, and Immunity. 20 (2006) 430–446
7. Krummenacher P, Candia V, Folkers G, Schedlowski M, Schönbächler G. Prefrontal cortex modulates placebo analgesia. PAIN. 2009.
8. Moseley GL, Hodges PW. Reduced Variability of Postural Strategy Prevents Normalization of Motor Changes Induced by Back Pain: A Risk Factor for Chronic Trouble? Behavioral Neuroscience. 2006, Vol. 120, No. 2, 474–476
9. Plassmann H, O’Doherty J, Shiv B, Rangel A. Marketing actions can modulate neural representations of experienced pleasantness. Proc Nat Acad Sci. 2008. 105 (3): 1050-1054