Unraveling Negative Expectations and Nocebo-Related Effects in Musculoskeletal Pain

Abstract

This Perspective adapts the ViolEx Model, a framework validated in several clinical conditions, to better understand the role of expectations in the recovery and/or maintenance of musculoskeletal (MSK) pain. Here, particular attention is given to the condition in which dysfunctional expectations are maintained despite no longer being supported by confirmatory evidence (i.e., belief—lifting the arm leads to permanent tendon damage; evidence—after the patient lifts the arm no tendon damage occurs). While the ViolEx Model suggests that cognitive immunization strategies are responsible for the maintenance of dysfunctional expectations, we suggest that such phenomenon can also be understood from a Bayesian Brain perspective, according to which the level of precision of the priors (i.e., expectations) is the determinant factor accounting for the extent of priors’ updating (i.e., we merge the two frameworks, suggesting that highly precise prior can lead to cognitive immunization responses). Importantly, this Perspective translates the theory behind these two frameworks into clinical suggestions. Precisely, it is argued that different strategies should be implemented when treating MSK pain patients, depending on the nature of their expectations (i.e., positive or negative and the level of their precision).

From sceptic to believer: Acceptability of cognitive muscular therapyTM, a new intervention for knee osteoarthritis

“…The use of visualisation and biofeedback in CMT were tools that the physiotherapists utilised to provide concrete evidence for abstract and complex information about how the body is adapting and coping with pain. Moreover, these tools allowed the physiotherapist to challenge the patient's beliefs through novel experiences rather than through verbal violation of belief, maintaining a therapeutic alliance (Rossettini et al., 2022). This process positively influenced patient engagement and physiotherapist credibility.…”

Therapeutic Alliance as Active Inference: The Role of Therapeutic Touch and Biobehavioural Synchrony in Musculoskeletal Care

“…Touch can create bio-feedback loops that help develop and learn to develop new or update less precise priors by altering the setpoint in crucial survival demands. Touch can create bio-feedback loops that help develop and learn to develop new or update less precise priors by altering the setpoint in crucial survival demands ( Rossettini et al, 2022 ). This viewpoint was initially proposed by Sterling and Eyer (1988) and has been expanding to include the integration of active inference to interception, regulation of homoeostasis and allostasis, all based on recent advances in anatomical knowledge, empirical models, and computational neuroscience ( Stephan et al, 2016 ; Fotopoulou et al, 2022 ).…”

“…The insula is a crucial region in pain processing, and developing evidence indicates that the insula encodes the magnitude of an unexpected outcome – unsigned prediction errors ( Horing and Büchel, 2022 ). Prediction errors occur in events where there is a mismatch between an expected and actual event or sensory signal ( Rossettini et al, 2022 ). Prediction errors are crucial in updating a generative model and, therefore, in driving learning ( Parr et al, 2022 ).…”

Editorial: Harnessing placebo mechanisms

“…Contextual factors (CF) are various elements deriving from a patients' interactions with practitioners and the therapeutic arena that influence disease processes and therapeutic outcomes ( 2 , 3 ). Whilst positive CF may induce placebo effects, negative CF may induce nocebo effects resulting in adverse effects ( 4 , 5 ). However, studies assessing specific CF have yielded mixed results on their contribution to placebo/nocebo effects ( 2 , 6 , 7 ).…”