Physiotherapy Pain Association Symposium: Placebo -nocebo 10th March 2001 Derby

Over 100 delegates from all parts of the UK descended on Derby City General Hospital for the Physiotherapy Pain Association Symposium on 10th March 2001. The title of the day was Placebo - Nocebo.

Dr Nigel Lawes, Lecturer in Neurosciences from the University of East London, started the morning session by posing the question- 'Placebo effect - does it exist, does it matter? He went on to provide evidence that the placebo effect is measurable and has powerful physiological consequences. Nigel promoted Physiotherapists as the 'best deliverers' of the placebo effect and really emphasised our role in it's effectiveness and the need to understand it in the correct context. Traditionally 'woolly' issues like being optimistic, motivated, convincing, and developing a good rapport with patients are all part of facilitating positive recovery responses and as such need just as much attention as our basic, more 'physically' orientated skills.

Following Nigel, Clinical Psychologist Dr Mitch Noon reinforced this concept describing and discussing the nature and power of a positive 'therapeutic alliance'- the patient/therapist relationship. He emphasised such things as the value of joint agreement on expectation/goals of treatment as powerful influences on outcome.

Delegates were challenged by Caroline Hafner, MCSP to consider communication of information to patients. Caroline has carried out a study on patients with chronic pain asking about their understanding of the cause of the pain based on what they had been told by health professionals. Misconceptions, anxieties and altered behaviour were common with many patients anticipating disability and increasing dysfunction. A powerful message is that what health professionals say to patients may actually prevent the recovery of physical confidence and maintain pain and disability.

Penny Mortimer, MCSP, presented the question, 'Investigations - do they help or hinder?' The poor correlation of symptoms with test results was discussed. It was explained that some patients will not be satisfied until tests are carried out whilst others will not accept test results as valid. These issues may be powerful barriers to patients adopting helpful recovery pathways. Penny is currently carrying out research on this subject, results pending.

Louis Gifford, MCSP, delivered the final presentation looking at why the placebo might have evolved. He showed how animals respond to injury and described various types of recovery behaviour in social animals. He outlined how injury produces an acute stress response that for purposes of survival diverts resources away from healing physiology, putting it on hold. Healing physiology was not facilitated until the animal perceived that it was 'safe' and resources could be directed towards recovery rather than survival. He explained the therapists' role in creating a 'safe', secure, reassured state that liberates the body from the acute stress response to heal and repair itself.

A very well informed audience supplied many pertinent questions for the lively end of the day question/answer session.

Louis Gifford had introduced the symposium with the question 'Am I just a tall, skinny placebo?' The conclusion drawn from this day seems to be an affirmative. …The placebo is something that must be grasped in a positive way as it has such a positive impact on patients' pain, recovery and lifestyle, so don't knock it, but recognise the power available and utilise to the patient's advantage.
For those who missed the day, the positive feedback from all the delegates means that it may well be repeated in the future but all the speakers are contributing chapters to the new Topical Issues in Pain 3 book , due for publication Autumn 2001. (details from CNS Press 01326 312156 email info@cnspress.co.uk).

Grace Smith
Derby City General Hospital