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      The influence of clinical equipoise and patient preferences on outcomes of conservative manual interventions for spinal pain: an experimental study

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          Expected pain relief from treatment is associated with positive clinical outcomes in patients with musculoskeletal pain. Less studied is the influence on outcomes related to the preference of patients and providers for a specific treatment.


          We sought to determine how provider and patient preferences for a manual therapy intervention influenced outcomes in individuals with acutely induced low back pain (LBP).

          Participants and methods

          Pain-free participants were randomly assigned to one of two manual therapies (joint biased [JB] or constant touch [CT]) 48 hours after completing an exercise protocol to induce LBP. Expectations for pain relief and preferences for treatment were collected at baseline, prior to randomization. Pain relief was assessed using a 100 mm visual analog scale. All study procedures were conducted in a private testing laboratory at the University of Florida campus.


          Sixty participants were included in this study. After controlling for preintervention pain intensity, the multivariate model included only preintervention pain ( B=0.12, p=0.07) and provider preference ( B=3.05, p<0.0001) and explained 35.8% of the variance in postintervention pain. When determining whether a participant met his or her expected pain relief, receiving an intervention from a provider with a strong preference for that intervention increased the odds of meeting a participant’s expected pain relief 68.3 times ( p=0.013) compared to receiving any intervention from a provider with no preference. Receiving JB intervention from any provider increased the odds of meeting expected relief 29.7 times ( p=0.023). The effect of a participant receiving an intervention they preferred was retained in the model but did not meet the criteria for a significant contribution.


          Our primary findings were that participant and provider preferences for treatment positively influence pain outcomes in individuals with acutely induced LBP, and joint-biased interventions resulted in a greater chance of meeting participants’ expected outcomes. This is contrary to our hypothesis that the interaction of receiving an intervention for which a participant had a preference would result in the best outcome.

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          Most cited references 23

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          The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model.

          Prior studies suggest manual therapy (MT) as effective in the treatment of musculoskeletal pain; however, the mechanisms through which MT exerts its effects are not established. In this paper we present a comprehensive model to direct future studies in MT. This model provides visualization of potential individual mechanisms of MT that the current literature suggests as pertinent and provides a framework for the consideration of the potential interaction between these individual mechanisms. Specifically, this model suggests that a mechanical force from MT initiates a cascade of neurophysiological responses from the peripheral and central nervous system which are then responsible for the clinical outcomes. This model provides clear direction so that future studies may provide appropriate methodology to account for multiple potential pertinent mechanisms.
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            Response expectancies in placebo analgesia and their clinical relevance.

            Response expectancies have been proposed as the major determinant of placebo effects. Here we report that different expectations produce different analgesic effects which in turn can be harnessed in clinical practice. Thoracotomized patients were treated with buprenorphine on request for 3 consecutive days, together with a basal intravenous infusion of saline solution. However, the symbolic meaning of this basal infusion was changed in three different groups of patients. The first group was told nothing about any analgesic effect (natural history). The second group was told that the basal infusion was either a powerful painkiller or a placebo (classic double-blind administration). The third group was told that the basal infusion was a potent painkiller (deceptive administration). Therefore, whereas the analgesic treatment was exactly the same in the three groups, the verbal instructions about the basal infusion differed. The placebo effect of the saline basal infusion was measured by recording the doses of buprenorphine requested over the three-days treatment. We found that the double-blind group showed a reduction of buprenorphine requests compared to the natural history group. However, this reduction was even larger in the deceptive administration group. Overall, after 3 days of placebo infusion, the first group received 11.55 mg of buprenorphine, the second group 9.15 mg, and the third group 7.65 mg. Despite these dose differences, analgesia was the same in the three groups. These results indicate that different verbal instructions about certain and uncertain expectations of analgesia produce different placebo analgesic effects, which in turn trigger a dramatic change of behaviour leading to a significant reduction of opioid intake.
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              How important are back pain beliefs and expectations for satisfactory recovery from back pain?

              In this article, we provide an evidence-based review of pain beliefs and their influence on pain perception and response to treatment. We examine the nature of pain perception and the role of cognitive and emotional processes in the interpretation of pain signals, giving meaning to pain and shaping our response to it. We highlight three types of beliefs that have a particularly strong influence: fear-avoidance beliefs, pain self-efficacy beliefs and catastrophising. We examine the influence of beliefs, preferences and expectations on seeking consultation, interventions and treatment outcome from the perspective both of the patient and the health-care practitioner. We then adopt a broader societal perspective, considering secondary prevention and campaigns, which have attempted to change beliefs at a population level. The article concludes with a summary of the key messages for clinical management of patients presenting with painful conditions and suggestions for further research. Copyright 2010. Published by Elsevier Ltd.

                Author and article information

                J Pain Res
                J Pain Res
                Journal of Pain Research
                Journal of Pain Research
                Dove Medical Press
                26 April 2017
                : 10
                : 965-972
                [1 ]Department of Physical Therapy, University of Florida
                [2 ]Center for Pain Research and Behavioral Health
                [3 ]Brooks-PHHP Research Collaboration, Gainesville, FL, USA
                Author notes
                Correspondence: Mark D Bishop, Department of Physical Therapy, University of Florida, PO Box 1000154 HSC, Gainesville, FL 32610, USA, Tel +1 352 273 6112, Email bish@ 123456ufl.edu
                © 2017 Bishop et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Original Research

                Anesthesiology & Pain management

                equipoise, expectations, manual therapy, acute pain


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