The power and value of placebo and nocebo in painful osteoarthritis

Abstract

This paper reviews some recent advances in our understanding of the effects of sham or dummy interventions on pain and other symptoms in osteoarthritis (OA), and outlines two new approaches to the investigation of placebo and nocebo effects. We argue that the placebo effect provides us with a valuable way of investigating the nature of conditions like OA. For example, by examining which symptoms, biochemical markers or imaging features do or do not respond to placebo, we might learn more about the relationships between pathology and symptoms in OA. Placebo and nocebo effects are positive or negative outcomes resulting from the human interactions and contexts in which healthcare consultations take place. Subtle changes in behaviours and the environments in which consultations take place can have major effects on pain and other symptoms being experienced by people with OA. Nocebo effects are particularly powerful, leading to many health-care professionals (HCPs) causing unintended harm to their clients. Based on our own research, we conclude that beneficial outcomes are most likely to occur when both the (HCP) and the client feel safe and relaxed, and when the experiences of the client are validated by the (HCP). These findings have important implications for clinical practice. We believe that research in this field needs to be 'trans-disciplinary', escaping from the constraints of the purely biomedical, deterministic, positivist paradigm of most medical research. We provide the example of our own work which combines performance studies and scholarship, with psychology and medicine.

Pharmaceutical-grade Chondroitin sulfate is as effective as celecoxib and superior to placebo in symptomatic knee osteoarthritis: the ChONdroitin versus CElecoxib versus Placebo Trial (CONCEPT)

“…This is not surprising as a substantial placebo effect was previously reported in trials assessing drugs in OA 29 30. However, both active groups (CS and celecoxib) provided a significantly greater reduction in pain (VAS) and a better improvement in function (LI) than the placebo, after 6 months and 3 months, respectively.…”

Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain

“…pain neuroscience education) commonly applied in clinical practice [ 35 – 37 ]. Third, CFs serve as additional tools for the interpretation of the clinical picture and guide clinicians in managing the complexity behind the patient’s musculoskeletal pain [ 38 ]. Taking into consideration CFs as active influencer of the therapeutic outcomes, can help to explain some unexpected outcomes and variability of symptoms experience [ 39 ].…”

The role of placebo effects in immune-related conditions: mechanisms and clinical considerations

“…To elaborate, patients in a study with irritable bowel syndrome (although not a typical inflammatory disease, inflammatory processes have been linked to the pathophysiology of this disease) showed that when a physician adapted a more empathic communication style (the 'augmented' condition, focusing their communication style on warmth and confidence) relief rates increased from 44% to 62%, demonstrating the importance of a validating contextual cue in the generation of the placebo effect [37]. In contrast, invalidating contextual cues, for example when a health practitioner gives no or nonunderstanding feedback, may lead to high levels of arousal and can have detrimental consequences for the development of nocebo effects, again underlining the importance of the patient-doctor interaction [38]. Additionally, by openly administering placebo treatments and educating patients about the importance of treatment expectations (open-label studies), it was demonstrated that placebo's can still cause adequate relief [39].…”