False Narratives, Nocebo, and Negative Expectations do NOT affect Manual Therapy Outcomes: Research Confirmed

Review and Commentary on Research Investigating Manual Therapy Outcomes and the Effects of Messaging, Expectations, Preferences, and Stress.

by Dr. Brent Brookbush, DPT, PT, MS, CPT, HMS, IMT

Definitions

• Placebo: A positive therapeutic outcome derived from an inert treatment.
• Nocebo: A negative therapeutic outcome, or an increase in symptoms, derived from negative expectations, messaging, or fear of treatment.
• False Narrative: A commonly held belief based on incorrect or incomplete information.

Introduction

Our Mind is Better at Perception: Considering this publication and a previous publication (Pain Neuroscience Education (PNE) is Relatively Ineffective ), the currently available research opposes the assertion that our mental state and beliefs significantly influence our recovery from orthopedic pain and dysfunction. It is likely reasonable to suggest that the central nervous system (CNS) has a significant role in the perception of pain, but almost no active role in physical recovery following orthopedic injury. For example, as this article and review demonstrate, our mental state may amplify the discomfort felt during a manual therapy technique, but that mental state cannot interrupt the physiological effects of that technique. Based on current research, it seems unlikely that any physical rehabilitation professional claiming that the brain has a significant influence on recovery from orthopedic dysfunction is familiar with the available research.

Research Summary Statement:

• The evidence demonstrates that messaging, expectations, and treatment preference may have an inconsistent effect on the perception of pain induced by a manual therapy technique (e.g. how painful an acupuncture needle feels), but no significant effect on post-treatment outcome measures (e.g. pain during motion or functional outcome measure scores). Further, stress and catastrophizing are unlikely to have a significant effect on outcomes; however, it may be advised that joint manipulations are not performed when stress/catastrophizing is high. Stress is likely to be highest during session 1 and decrease with subsequent sessions, and matching a patient's assessment findings to the best treatment option significantly improves outcomes, regardless of expectations.

Summary of Research Findings (Research Review Below):

• Messaging: Studies have investigated positive, neutral, and negative messaging, these studies did not demonstrate consistent effects from positive or negative messaging, and messaging may only exhibit occasional effects on the perception of pain during the intervention. This implies messaging has little if any influence on outcomes, including inconsistent influence on short-term subjective pain (24 hours or less), and a lack of any influence on objective post-treatment outcome measures (e.g. GRoC Scores, c- fiber mediated hypoalgesia, pain during motion, pain 7-days post-treatment).
• Expectations: Weakly and strongly held expectations do not have a significant effect on outcome measures. Further, matching a patient's assessment findings to the best treatment option significantly improves outcomes, regardless of expectations.
• Messaging and Expectations: The combination of expectations and messaging has no significant effect on outcome measures, including pain, function, disability, ischemic compression, motor performance, and hormone levels.
• Preference for Treatment Options: Patient intervention preferences do not have a significant effect on outcomes. This includes superior outcomes for more effective treatment options regardless of preference, similar outcomes for similarly effective treatment options regardless of preference, and similar outcomes for ineffective treatment options regardless of preference. The study by Kalauokalani et al. did imply a possible exception, which may result from 2 similarly effective techniques and a patient's expectations based on comparing the two techniques.
• Stress and Catastrophizing: Stress and catastrophizing are unlikely to affect outcomes, stress is likely to be highest during session 1 and decrease with subsequent sessions, and it may be advised that manipulations are not performed when stress/catastrophizing are high.

Caption: If you told a patient they tested positive for lumbar instability, would it negatively impact outcomes?

The False Narrative

The "false narrative" is discussed separately because It is not something that is investigated in the currently published research, and for good reason. It is a popular counter-argument by many contrarians on social media; however, the false narrative is little more than a clever combination of a few logical fallacies. These fallacies include a belief that outcomes are dependent on complete information, the "unsupported default position fallacy", framing a false narrative as an accusation that "begs the question", and the implication that messaging matters (which is refuted by the research review below).

• Incomplete Information: First, a lack of knowledge about how something works, and even having a false notion of how something works, does not imply that the intervention cannot be matched to an assessment and used effectively. After all, you have no idea how your phone works, but you know that it is for contacting people, and you know how to use it when you need to contact people. Whether you believe it does this by microscopic unicorns carrying your messages to your intended audience on their horns at the speed of light, or you happen to know the physics and information science involved in telecommunication, it does not matter. The messages will still get there. Austin Bradford Hill, the pioneer of the modern randomized clinical trial (RCT), noted in 1965 that knowing the “mechanism ” may aid in support of an argument for causation, but it is not necessary to imply causation, and understanding the "mechanism" is often limited by our current knowledge. Although more information is often helpful, proving causation often becomes a slippery slope argument limited by a technological barrier. For example, almost all hypotheses regarding how a therapeutic intervention works are limited by our knowledge of the resulting cellular processes in living individuals. However, what is far more relevant, is matching the level of understanding to utility, for example matching an effective technique with a reliable assessment that appropriately implies a need for that technique. The fact that knowing "how" something works is unnecessary for determining its utility results in several interesting "truths" regarding treatment:
  • You cannot dismiss a diagnosis because we lack a clear understanding of the disease.
  • You cannot dismiss a dysfunction because we lack an objective measure.
  • You cannot dismiss an assessment on the grounds of validity alone.
  • You cannot dismiss a technique because we do not know how it works.
• The "Unsupported Default Position" Fallacy: This argument starts with the false presumption that every critique of an assertion strengthens the opposing position "by default." However, this would only be true if there were only 2 possible assertions (e.g. a zero-sum game). This is rarely the case in human movement science and physical medicine, which often involves multiple potential hypotheses with a certain probability of accuracy. Regardless of which assertion was communicated first when there are many possible assertions, each assertion must be compared based on the merits of the support for that assertion. This fallacy relates to the notion of a "false narrative", because contrarians most often imply that their "narrative" is more correct because they believe they have identified a flaw in a theory regarding how an intervention works (the "false narrative). Note, that this combines both this fallacy and the incomplete information fallacy discussed above. For example, some have implied that the sacroiliac joint mobilization is ineffective because there is no evidence of change in the sacral position. This assertion is not true (for more info - Myths About Sacroiliac Joint (SIJ) Motion, Palpation, Assessment, and Treatment ); however, even if it was, it is not the only potential change that could result from mobilization and contribute to improvement in function and a reduction in pain. For example, there is evidence to show that mobilization changes joint laxity (not position), aids in correcting asymmetries in joint laxity, normalizes muscle activity, etc. Further, even if the narrative was false, research suggests that messaging, expectations, and nocebo do not have a significant influence on outcomes. In summary, every position must be supported by its own evidence, because most often multiple hypotheses exist. The "narrative" that should be adopted as "most true" should be the narrative supported by the most evidence, and regardless of which narrative is adopted, knowledge of the narrative by the patient is unlikely to affect outcomes. Unfortunately, far too often I see the opposite scenario, in which an individual condemns a technique based on the accusation of a "false narrative", replaces that "narrative" with their own completely unsupported opinion, and claims it is better for the patient.
• Begging the Question: This fallacy integrates a premise into a question or statement that has not been proven true. The classic, although somewhat tasteless example, is the question, "How long have you been beating your wife?" Although this appears to be an open-ended question, it assumes that the individual being questioned is already guilty of beating their wife. An exercise example, may be the statement “Why would everyone squat the same when everyone is structurally unique?” This assumes that everyone is structurally unique, which is also not true. Research demonstrates that variation in hip morphology happens within a small mean range (for more information, check out Squat Foot Placement: Unique Hip Anatomy and Squat Form ). An example, related to the topic of this article may be something to the effect, "What did you do during your session to control for the effects of negative messaging and nocebo?" Again, this appears to be an open-ended question, but it assumes that negative messaging and nocebo have a significant effect on outcomes (this review demonstrates that this is not true).

A Real "False Narrative" Debate (Edited for Readability)

This debate originally occurred on a Brookbush Institute social media post titled: The Long-term Efficacy of Joint Manipulation

• Contrarian Comment: How specific can you be with an intervention like manipulation… I mean you don’t actually think you're putting joints back into alignment, do you?
• Response: You are asking a leading question. Nobody suggested that we are “putting joints back into alignment”, nor do we need to demonstrate “realignment” for manipulations to have a positive effect on range of motion or pain.
• Contrarian Comment: I don’t think anyone is arguing that manipulations can have a positive impact on pain; the issue is the false narrative of “putting joints back into alignment”.
• Response: Who cares? Do you have a better narrative? Is the narrative leading to the selection of the technique when it is appropriate? Are you sure alignment isn’t an issue? Some studies demonstrate manipulation may improve the cervical lordosis angle or thoracic kyphosis angle, which has been referred to as “optimal alignment of the spine”.
• Contrarian Comment: In this context, I guess I meant how you talk to patients… I think words can have a lasting impression on patients and telling them inaccurate information like “they slip in and out of alignment at any moment” might do more harm than good.
• My Response: I’m sorry, I thought I was having a professional conversation with a colleague; in which case, I expect to be able to use the language of our profession. What I tell my patients is what is necessary to motivate them to comply with an optimal intervention plan. However, your implication is also inaccurate. Several studies show that words actually matter very little, and do not influence long-term objective outcome measures. The one exception for the influence of words may be the relatively extreme case of telling a client about the worst possible adverse effects an intervention can have, and even then the only significant effect is likely to be an increased perception of pain during the intervention, and even that effect is unreliable (less than 50% chance).

Caption: Negative messaging and patient expectation may increase the pain felt during acupuncture, but is unlikely to have a significant effect on outcomes.

Summary Statement:

• The evidence demonstrates that messaging, expectations, and treatment preference may have an inconsistent effect on the perception of pain induced by a manual therapy technique (e.g. how painful an acupuncture needle feels), but no significant effect on post-treatment outcome measures (e.g. pain during motion or functional outcome measure scores). Further, stress and catastrophizing are unlikely to have a significant effect on outcomes; however, it may be advised that joint manipulations are not performed when stress/catastrophizing is high. Stress is likely to be highest during session 1 and decrease with subsequent sessions, and matching a patient's assessment findings to the best treatment option significantly improves outcomes, regardless of expectations.

Summary of Research Findings:

• Messaging: Studies have investigated positive, neutral, and negative messaging, these studies did not demonstrate consistent effects from positive or negative messaging, and messaging may only exhibit occasional effects on the perception of pain during the intervention. This implies messaging has little if any influence on outcomes, including inconsistent influence on short-term subjective pain (24 hours or less), and a lack of any influence on objective post-treatment outcome measures (e.g. GRoC Scores, c- fiber mediated hypoalgesia, pain during motion, pain 7-days post-treatment).
• Expectations: Weakly and strongly held expectations do not have a significant effect on outcome measures. Further, matching a patient's assessment findings to the best treatment option significantly improves outcomes, regardless of expectations.
• Messaging and Expectations: The combination of expectations and messaging has no significant effect on outcome measures, including pain, function, disability, ischemic compression, motor performance, and hormone levels.
• Preference for Treatment Options: Patient intervention preferences do not have a significant effect on outcomes. This includes superior outcomes for more effective treatment options regardless of preference, similar outcomes for similarly effective treatment options regardless of preference, and similar outcomes for ineffective treatment options regardless of preference. The study by Kalauokalani et al. did imply a possible exception, which may result from 2 similarly effective techniques and a patient's expectations based on comparing the two techniques.
• Stress and Catastrophizing: Stress and catastrophizing are unlikely to affect outcomes, stress is likely to be highest during session 1 and decrease with subsequent sessions, and it may be advised that manipulations are not performed when stress/catastrophizing are high.

Research Review

Messaging

The effects of positive, neutral, and negative messaging on manual therapy outcomes have been investigated in several studies. An RCT by Gallego-Sendarrubias compared 60 patients with neck pain and/or active trigger points in the trapezius (age: 18 - 60 years) with no history of neurological symptoms, cervical radiculopathy, myelopathy, cervical trauma, systemic disease, pregnancy, psychiatric problems, or fear of needles. Participants were randomly assigned to groups receiving 1 session of dry needling or sham dry needling, after receiving positive, negative, or neutral messaging. Outcome measures were assessed immediately post-treatment, 1 day post-treatment, and 7-days post-treatment, and included patient-predicted expectations, neck pain intensity at rest and during motion, pain pressure threshold over the upper trapezius, C7 spinous process, and heel (heel was used as a baseline), and self-perceived improvement assessed with the Global Rating of Change (GRoC) score. The findings demonstrated that when compared to the sham group, the needling group exhibited significantly larger improvement in cervical pain at rest and during movement, and larger improvements in upper trapezius pain pressure threshold immediately, 1 day, and 1 week post-treatment. Further, dry needling resulted in more participants exhibiting significant changes in GRoC scores. Expectations did not significantly affect any outcome measure, except for a small but significant increase in pain pressure threshold for the dry needling group that received positive messaging, over the upper trapezius only, and only 1-day post-treatment. This isolated finding may not be clinically significant (1). An RCT by Barth et al. compared 152 patients (age: 39.54 ± 12.52 years) with chronic low back pain following acupuncture for 4 weeks, 2 sessions/week, 45 mins/session. Participants were split into groups receiving "regular" expectations briefing (told acupuncture is shown to have a small effect on CLBP), high expectation briefing (told acupuncture is shown to have a large effect on CLBP), regular adverse side effect briefing (participants given general study information), or intense adverse side effect briefing (participants given adverse side effects such as bleeding, hematoma, pain). Outcome measures included pain intensity following acupuncture treatment. The findings demonstrated that all groups exhibited significant and similar changes in pain intensity during and following acupuncture treatment. The group receiving the intense adverse side effects briefing reported a trend toward higher pain intensity (31% increase) during the technique; however, this increase did not reach statistical significance (2). An RCT by Bialosky et al. compared 60 healthy participants (age: 18 - 60 years) with no history of low back or lower extremity pain, systemic medical conditions, prescription pain medication use, surgery to the lower back, psychiatric medication use, or pregnancy. Participants were randomly assigned to groups receiving a positive message, negative message, or neutral message regarding the effects of the spinal manipulation before receiving 1 session of lumbar spine manipulation. Lumbar spine manipulation was performed 2x/side, regardless of whether a cavitation sound occurred. The positive expectation group was told that the lumbar manipulation technique "is a very effective form of manipulation used to treat low back pain and we expect it to reduce your perception of heat pain." The negative expectation group was told that the lumbar manipulation technique "is an ineffective form of manipulation used to treat low back pain and we expect it to temporarily worsen the perception of heat pain." Participants in the neutral expectation group were told that lumbar manipulation "is a form of manipulation used to treat low back pain that has unknown effects on the perception of heat pain." Outcome measures included expected and perceived pain in the lower extremity and lower back following the intervention. The findings demonstrated that positive and neutral messaging resulted in similar perceptions of pain, and despite the negative messaging having a significant effect on the intensity of perceived pain during the technique, all groups exhibited similar c-fiber-mediated hypoalgesia in the lower extremity (3). In summary, each of these studies investigated positive, neutral, and negative messaging, these studies did not demonstrate consistent effects from positive or negative messaging, and messaging only seemed to consistently affect the perception of pain during the intervention. This implies messaging has little if any influence on outcomes, including inconsistent influence on short-term subjective pain (24 hours or less), and the lack of any influence on other post-treatment outcomes (e.g. GRoC Scores, c- fiber mediated hypoalgesia, pain during motion, pain 7-days post-treatment).

Expectations

Additional studies have investigated the effects of expectations on outcomes. Mutsaers et al. compared 1195 neck pain patients (age: 44.7 ± 13.7 years) with no history of neurological disorders, neoplasms, rheumatic conditions, or referral pain. Participants were divided into 4 groups: low expectation and strongly convinced, low expectation and NOT strongly convinced, high expectation and strongly convinced, and high expectation and NOT strongly convinced. Participants were the next 5 neck patients, receiving physical therapy treatment, including manual therapy, from 272 experienced physical therapists (average experience 19.3 years). Outcome measures included the Numeric Rating Scale (NRS) for pain intensity and Neck Disability Index (NID) scores post-treatment and during 12-month follow-up. The findings demonstrated that expectation did not have a significant effect on pain intensity or NDI scores immediately post-treatment or during a 12-month follow-up (4). An RCT by Bishop et al. compared 112 men and women with low back pain (age: 18 - 60 years) with no history of nerve root compressions (including muscle weakness in the lower extremity, diminished lower extremity muscle stretch reflex, absent sensation to pinprick in lower extremity dermatome), osteoporosis, metabolic disease, rheumatoid arthritis, tumor, prolonged history of steroid use, pregnancy, or surgery to the lumbar spine. Participants were randomly assigned to 1 of 3 groups, 2 were thrust techniques, and the other was a non-thrust intervention. Additionally, patients were instructed to perform anterior and posterior pelvic tilts in a pain-free ROM during the 1st and 2nd sessions and started a strength and stabilization exercise program in the 3rd session. Participants were asked about their expectations regarding the efficacy of common rehabilitation interventions (such as aerobic exercise, manipulation, massage, medication, modalities, range of motion exercises, rest, traction, strengthening exercises, and surgery). Outcome measures included general expectations and a modified Oswestry Disability Index. The findings demonstrated exercise and manual therapy were expected to provide more benefit than rest, traction, surgery, or medication. There was no significant difference in outcomes correlated with differences in patient expectations. Further, the findings demonstrated that treating with thrust techniques is more important than matching the treatment selected to the patient's expectations (when the patient meets the criteria for good a prognosis when managed with thrust techniques based on the clinical prediction rule) (5). These studies suggest that weakly and strongly held expectations do not have a significant effect on outcome measures. Further, matching a patient's assessment findings to the best treatment option significantly improves outcomes, regardless of expectations.

Messaging and Expectations

Two additional studies investigate the combined effects of both messaging and expectations. An RCT by Riley et al. compared shoulder pain patients (age: 18 and 69 years) without a primary complaint of neck or thoracic pain, a positive cervical distraction test or Spurling's test, adhesive capsulitis, history of shoulder surgery, physiotherapy treatment or injection in the previous 3 months, contraindications to thoracic manipulation, or pregnant during the duration of the study. Participants were randomly assigned to a thoracic high-velocity low-amplitude thrust (manipulation) group or placebo manipulation group. Participants were asked about their expectations at baseline and then given positive or neutral messaging regarding the effects of the treatment. The outcome measures included the Shoulder Pain and Disability Index (SPADI) and pain intensity scores. The findings demonstrated that the effect of messaging, including a significant positive increase in expectations, resulted in no significant effect on SPADI or pain intensity scores (6). An RCT by Benedetti et al. compared 175 participants with no history of cardiovascular issues assessing pain, motor performance, and hormone release. Groups were split into 60 participants receiving ischemic compression to assess pain (pain participants), 10 Parkinson's patients receiving a motor performance task to assess motor performance (Parkinsons patients), and 95 participants receiving a hormone drug or placebo to assess hormone changes (hormone participants). Pain participants were randomly assigned to a control (no treatment for pain), saline solution (but told it was a painkiller) group, saline solution (but told it was a hyperalgesic) group, 2-day ketorolac (painkiller) with saline solution (but told it was ketorolac on the last day) group, and 2-day ketorolac (painkiller) with saline solution (but told it was hyperalgesic on the last day) group. Parkinsons patients were randomly assigned to a no-treatment (control) group, a suggestive velocity decrease group, and a suggestive velocity increase group. Hormone patients were randomly assigned to no treatment (control) group, a verbal suggestion of growth hormone increase group, a verbal suggestion of growth hormone decrease group, a verbal suggestion of cortisol decrease group, a verbal suggestion of cortisol increase group, sumatriptan plus a verbal suggestion of growth hormone increase group, sumatriptan plus a verbal suggestion of growth hormone decrease group, sumatriptan plus a verbal suggestion of cortisol decrease group, and sumatriptan plus verbal suggestion of cortisol increase group. Outcome measures included pain in the pain group, motor performance in the Parkinson's group, and growth hormone/cortisol release in the hormone group. The findings demonstrated that messaging did not affect outcomes for the pain group and Parkinsons group. Additionally, messaging did not affect the hormone participants; however, sumatriptan did have the expected effects on growth hormone and cortisol concentrations (7). These studies imply that the combination of expectations and messaging has no significant effect on outcome measures, including pain, function, disability, ischemic compression, motor performance, and hormone levels.

Preference for Treatment Options

Four studies compared outcomes following various treatments and the effect of the participant's preference for a treatment option. Stewart et al. compared 134 patients with whiplash-associated disorders (approximate average age 43 years) following advice or advice plus exercise. Based on participant treatment preferences or physiotherapist treatment preference, all participants were assigned to an advice group for 1 - 3 total sessions (average of 2.2 total sessions) or an advice plus exercise group for 1 - 12 total sessions (average of 9.9 total sessions). Outcome measures included pain intensity, Patient-Specific Functional Scale, Neck Disability Index (NDI) scores, global perceived effect, symptom bothersomeness, health-related quality of life, and work status at 6 weeks and 12 months. The findings demonstrated the advice plus exercise group exhibited greater improvements in all outcome measures regardless of the patient's or physiotherapist's treatment preferences (8). A secondary analysis of an RCT, published by Donaldson et al. compared 149 patients with low back pain. Prior to treatment participants' preferences were identified, including thrust techniques, non-thrust techniques, or no preference. All participants were randomly assigned to a thrust techniques with exercise group or a non-thrust techniques with exercise group, for 2 sessions. Outcome measures included disability, pain perception, care intensity, fear avoidance, and perception of the extent of recovery. The findings demonstrated significant and similar improvements for both groups, regardless of participant preferences, for all outcome measures (9). An RCT by Foster et al. compared 70 patients with knee osteoarthritis (average age: 65.3 years) who were given their treatment preference, and 280 patients with knee osteoarthritis (average age: 62.7 years) who were not given their treatment preference. Participants were randomly split into 3 groups; 116 participants received advice and exercise (received advice leaflet and individualized exercise program including lower limb strengthening, stretching, and balance for 6 total sessions), 117 participants received advice, exercise, and acupuncture (traditional Chinese acupuncture between 6 to 10 points from 16 commonly used locations), and 119 participants received advice, exercise, and non-penetrating acupuncture (received needles with a blunt tip between 6 to 10 points from 16 commonly used locations). Outcome measures included change in pain scores 6 and 12 months follow-up on the Western Ontario and McMaster Osteoarthritis Index (WOMAC). The findings demonstrated that neither preference groups nor treatment groups exhibited significant changes in WOMAC or treatment responses at 6 or 12 months (10). An RCT by Kalauokalani et al., compared 135 chronic low back pain patients randomly assigned to a massage group or an acupuncture group. Prior to treatment study participants were asked to describe their expectations regarding the helpfulness of each treatment on a scale of 0 to 10. The primary outcome measure was the Roland Disability Index at 10 weeks. The findings demonstrated that more of the participants with higher expectations for the treatment they received exhibited significant improvements in RDI scores. Further, patients who expected more benefit from massage than acupuncture were more likely to experience better outcomes with massage, and visa-versa. Last, general optimism about treatment, separated from a specific treatment option was not strongly associated with outcomes (11). These studies imply that patient intervention preferences do not have a significant effect on outcomes. This includes superior outcomes for more effective treatment options regardless of preference, similar outcomes for similarly effective treatment options regardless of preference, and similar outcomes for ineffective treatment options regardless of preference. The study by Kalauokalani et al. did imply a possible exception, which may result from 2 similarly effective techniques and a patient's expectations based on comparing the two techniques.

Stress and Catastrophizing

Stress and catastrophizing have also been implicated as influential variables; however, the available research does not support this conclusion. An RCT by Alonso-Perez et al. compared 39 males and 36 females (age: 29.3 ± 9.4 years) during 3 cervical spine therapy techniques. Participants were randomly assigned to a high-velocity low-amplitude (manipulation) group, a unilateral posterior-to-anterior mobilization group, or a cervical lateral glide group. Outcome measures included pain pressure threshold, hypoalgesia, pain catastrophizing, depression, anxiety, and kinesiophobia after treatment. The findings demonstrated all groups exhibited hypoalgesic effects after treatment; however, the joint mobilization group exhibited slightly larger hypoalgesic effects. Catrophizing did not have a significant effect on outcomes for most groups; however, high catastrophizing may have increased the probability of a poor outcome from manipulation (12). A double-blind, placebo-controlled RCT by Vicenzino et al. compared 11 males and 13 females (age: 17 - 35 years) with no history of neck pain or arm pain. Participants received 1 technique/day, for 3 days, in random order, including a Grade III left lateral glide mobilization of the C5/C6 segment, a placebo mobilization with no movement, and a control treatment (no contact or mobilization). Outcome measures included a stress rating scale, a stress visual analog scale, a pain intensity visual analog scale, and a modified McGill pain questionnaire. The findings demonstrated that the 3 treatments did not significantly increase pain or stress; however, perceived stress was higher on day 1 (regardless of the technique administered) when compared to day 3 (13). In summary, stress and catastrophizing are unlikely to affect outcomes, stress is likely to be highest during session 1 and decrease with subsequent sessions, and it may be advised that manipulations are not performed when stress/catastrophizing are high.

Questionable Study

This study was separated from the studies previously mentioned because the participant groups were absurdly skewed. Still, we attempted to include every peer-reviewed published study in our reviews and felt it was only appropriate to include and describe this study the same way as the previously mentioned studies. A pool of 4 RCTs by Linde et al. compared 864 patients with migraines, tension-type headaches, chronic low back pain, or osteoarthritis. The participants were randomly assigned to a waitlist control (no intervention), acupuncture group, or sham acupuncture group consisting of 1 session/week, for 12 weeks, 30 mins/session. Additionally, patients were asked prior to the intervention, and following 3 sessions whether they considered acupuncture, and their current treatment, to be effective therapy in general and what they expected from the treatment. The outcome measures for the migraine and tension-type headache group included the number of days with moderate headaches during the 4 weeks after treatment, outcome measures for the lower back pain patients included pain intensity after treatment, and outcome measures for the osteoarthritis group included Western Ontario and McMaster Osteoarthritis Index score after treatment. The findings demonstrated that significantly larger improvements in outcome measures resulted from acupuncture when compared to the sham acupuncture group, and waitlist groups. The findings also demonstrated the participants with high expectations exhibited better outcomes than patients with lower expectations after treatment and 4 weeks post-intervention; however, this result is worthy of skepticism. Nearly 90% of participants expected positive outcomes, with the majority of the remaining participants exhibiting neutral expectations. Roughly 1 % of all participants had negative expectations (14).

Bibliography

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2. Barth, J., Muff, S., Kern, A., Zieger, A., Keiser, S., Zoller, M., et al. (2021). Effect of briefing on acupuncture treatment outcome expectations, pain, and adverse side effects among patients with chronic low back pain: a randomized clinical trial. JAMA Netw. Open 4:e2121418. doi: 10.1001/jamanetworkopen.2021.21418
3. Bialosky, J. E., Bishop, M. D., Robinson, M. E., Barabas, J. A., & George, S. Z. (2008). The influence of expectation on spinal manipulation induced hypoalgesia: an experimental study in normal subjects. BMC Musculoskeletal Disorders, 9(1), 19.
4. Mutsaers, J. H., Pool-Goudzwaard, A. L., Peters, R., Koes, B. W., & Verhagen, A. P. (2020). Recovery expectations of neck pain patients do not predict treatment outcomes in manual therapy. Scientific reports, 10(1), 18518.
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6. Riley, S. P., Bialosky, J., Cote, M. P., Swanson, B. T., Tafuto, V., Sizer, P. S., & Brismée, J. M. (2015). Thoracic spinal manipulation for musculoskeletal shoulder pain: can an instructional set change patient expectation and outcome?. Manual therapy, 20(3), 469-474.
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10. Foster, N. E., Thomas, E., Hill, J. C., & Hay, E. M. (2010). The relationship between patient and practitioner expectations and preferences and clinical outcomes in a trial of exercise and acupuncture for knee osteoarthritis. European journal of pain, 14(4), 402-409.
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12. Alonso-Perez, J. L., Lopez-Lopez, A., La Touche, R., Lerma-Lara, S., Suarez, E., Rojas, J., … & Fernández-Carnero, J. (2017). Hypoalgesic effects of three different manual therapy techniques on cervical spine and psychological interaction: A randomized clinical trial. Journal of bodywork and movement therapies, 21(4), 798-803.
13. Vicenzino, B., Cartwright, T., Collins, D., & Wright, A. (1999). An investigation of stress and pain perception during manual therapy in asymptomatic subjects. European Journal of Pain, 3(1), 13-18.
14. Linde K, Witt CM, Streng A, Weidenhammer W, Wagenpfeil S, Brinkhaus B: The impact of patient expectations on outcomes in four randomized controlled trials of acupuncture in patients with chronic pain. Pain. 2007, 128: 264-271. 10.1016/j.pain.2006.12.006.

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