Optimising treatment expectations in chronic lower back pain through observing others: a study protocol for a randomised clinical trial

Abstract

IntroductionChronic lower back pain (CLBP) is a frequent cause of medical consultations worldwide, and it results in decreased quality of life and disability. Current treatments for CLBP are often not effective, and alternatives are urgently needed. Three promising possibilities have emerged: (1) open-label placebo treatment reduces chronic pain, (2) placebo treatment is as efficacious as opioid treatment with a high correlation between patient expectation and treatment outcome, and (3) observing positive effects in another patient can improve functional capacity. We hypothesise that treatment expectations can be positively influenced through social observation and improve treatment outcome.Methods and analysisIn our clinical trial, we will randomise patients with CLBP into five groups. Two groups receive either a 3 week course of treatment with an analgesic (ANA) (metamizole/dipyrone) or with open-label placebos (OLP). For one of each group, we will build treatment expectations through observational learning and assess its impact on the treatment. For this purpose, one group each will watch either a positive or a neutral video. The intervention groups will be compared with a control group that will not be given any medication or observational learning. Participants will be recruited via all institutions in the Hamburg metropolitan area that treat patients with CLBP. Patients are eligible for inclusion if they are at least 18 years or older, have CLBP (of at least 3 months duration), and agree to potentially receive an active ANA or an OLP. Patients with pain-related “red flags” will be excluded. The study requires 150 participants (30 participants per group) to assess the differences in the primary outcome, pain intensity. Secondary outcomes include changes in treatment expectations, anxiety, comorbid depression, stress-related neuroendocrine measures, functional and structural connectivity, functional capacity, and ANA consumption. All outcomes and treatment expectations will be measured before and after the intervention and 3 months post-intervention.Ethics and disseminationEthical approval was obtained in January 2020 from the Hamburg Medical Ethics Council (ref number PV7067). Outcomes will be disseminated through publications in peer-reviewed journals and presentations at national and international conference meetings.Trial registration numberThe approved trial protocol was registered at the German Clinical Trials Register (DRKS) and can be found at drks.de (Identifier: DRKS00024418).

No long-term effects after a 3-week open-label placebo treatment for chronic low back pain: a 3-year follow-up of a randomized controlled trial

“… 40 Ongoing research is testing whether observational learning via video demonstration may enhance nondeceptive, ie, open-label placebo efficacy in a comparable manner, offering a second feasible approach to extend short-term OLP efficacy. 41 Given that a 3-week, short-term OLP treatment in addition to TAU did not result in persistent benefits after 3 years in our sample, these mentioned approaches may advance the magnitude and longevity of OLP effects in future trials.…”

Learning pain from others: a systematic review and meta-analysis of studies on placebo hypoalgesia and nocebo hyperalgesia induced by observational learning

“…Recently, a start in this research area has been made: a protocol has been published of a study in which the effects of OL in chronic lower back pain will be assessed [55]. New knowledge generated by research in this specific population could then help to improve existing treatments as well as pain management in chronic medical conditions.…”

Musculoskeletal practitioners’ perceptions of contextual factors that may influence chronic low back pain outcomes: a modified Delphi study

“…Persistent LBP negatively impacts patients’ quality of life, activity levels, ability to work, and earning potential [ 27 ] creating deleterious personal, social, and economic consequences [ 29 – 31 ]. Existing chronic LBP (cLBP) treatments are inadequate [ 32 ], and those focusing on symptom management typically provide modest relief [ 31 , 33 , 34 ]. Consequently, multimodal cLBP management strategies incorporating the biopsychosocial perspective are required [ 32 ].…”

“…Existing chronic LBP (cLBP) treatments are inadequate [ 32 ], and those focusing on symptom management typically provide modest relief [ 31 , 33 , 34 ]. Consequently, multimodal cLBP management strategies incorporating the biopsychosocial perspective are required [ 32 ].…”

“…There is an opportunity to harness placebo effects and clinical practices which involve social and cognitive pain modulation [ 35 ] to improve treatment effectiveness for patients with cLBP [ 32 ]. Understanding MSK practitioners’ beliefs regarding the deliberate use of CFs during cLBP management may identify areas for further training and skills development.…”