Even iets rechtzetten…

Ronald Kan, MT, MScHeliomare revalidatieSOMT

Agenda

• Evidence based clinical practice• Het bewijs• Context• Communicatie/ taal

• placebo en nocebo• Informed consent – ethische dilemma’s• Putting it all together

Evidence based clinical practice

Clinical state & circumstances

Patients’ preferences & actions

Research evidence

Clinical expertise

Haynes, 2002

Behandeleffect

Effect

Patiënt

TherapeutTherapie

Context

HET BEWIJSniet overtuigend….

Effectiviteit MT acute lage rugpijn

SMT is no more effective for acute low back pain than inert

interventions, sham SMT or as adjunct therapy. SMT also seems

to be no better than other recommended therapies. Future RCTs

should examine specific subgroups and include an economic

evaluation.

Rubinstein SM et al., Spinal manipulative therapy for acute low back pain: an update of the cochrane review. Spine (Phila Pa 1976). 2013 Feb 1;38(3):E158-77.

Effectiviteit MT chronische lage rugpijn

High-quality evidence suggests that there is no clinically relevant

difference between SMT and other interventions for reducing pain

and improving function in patients with chronic low-back pain.

Rubinstein SM et al., Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review. Spine (Phila Pa 1976). 2011 Jun;36(13):E825-46.

Effectiviteit MT bij lage rugpijn

Like previous SM for LBP systematic reviews, this review

shows a small but consistent treatment effect at least as large

as that seen in other conservative methods of care.

Goertz, C. M.,(2012). Patient-centered outcomes of high-velocity, low-amplitude spinal manipulation for low back pain: a systematic review. Journal of Electromyography and Kinesiology. 22(5), 670–691

Effectiviteit MT bij nekpijn

Thoracic spine thrust manipulation improves pain, range of

motion, and self-reported function in patients with mechanical

neck pain: a systematic review. Cross K.M. et al. JOSPT. 2011;41(9):633-42.

Cervical manipulation and mobilisation produced similar changes.

Either may provide immediate- or short-term change; no long-

term data are available. Thoracic manipulation may improve pain

and function. Gross A. et al. Manipulation or mobilization for neck pain. Cochrane

Database Syst Rev. 2010;20(1).

Manual therapies contribute usefully to the management of

nonspecific neck pain. The level of evidence is moderate for

short-term effects of upper thoracic manipulation in acute neck

pain, limited for long-term effects of neck manipulation, and

limited for all techniques and follow-up durations in chronic neck

pain.

Effectiviteit MT bij nekpijn

Vincent K. et al. Systematic review of manual therapies for nonspecific neck pain. Joint Bone Spine. 2013;80(5):508-15.

Natuurlijk beloop nek- en rugpijn

Vasseljen, O., et al. (2013). Natural course of acute neck and low back pain in the general population: the HUNT study. Pain, 154(8), 1237–1244.

Natuurlijk beloop nek- en rugpijn

Still, the course of pain was comparable to effect sizes reported in interventional studies.

Vasseljen, O., et al. (2013). Natural course of acute neck and low back pain in the general population: the HUNT study. Pain, 154(8), 1237–1244.

Externe factorenvan belang?

• Mobilisatie/ manipulatie : nee

• Forward head posture : nee

• Krachtuithoudingsvermogen DVF : ja 24,5%

Castien, R., et al.,(2013). The working mechanism of manual therapy in participants with chronic tension-type headache. JOSPT, 43(10), 693–699.

Externe variabelen

•Therapeut- en patiëntvariabelen• ideeën, verwachtingen, wensen, ervaringen

•Interactie patiënt – therapeut – context • communicatie, empathie, geruststelling

•Fysieke omgeving• professionele website, locatie, schone wc, kleur

• aard van de behandeling

• ingewikkeld, rituelen, apparatuur

Finniss, D. G., Kaptchuk, T. J., Miller, F., & Benedetti, F. (2010). Biological, clinical, and ethical advances of placebo effects. Lancet, 375(9715), 686–695.

WAAROM IS CONTEXT ZO BELANGRIJKBeïnvloeden van pijn

Neuromatrix theory of pain

Moseley, G. L., & Arntz, A. (2007). The context of a noxious stimulus affects the pain it evokes. Pain, 133(1-3), 64–71.

Moseley, G. L., Parsons, T. J., & Spence, C. (2008). Visual distortion of a limb modulates the pain and swelling evoked by movement. Current Biology : CB, 18(22), R1047–8.

Harvie, D.S., Broecker, M., Smith, R.T., Meulders, A., Madden, V.J., & Moseley, G.L. (2015). Bogus Visual Feedback Alters Onset of Movement-Evoked Pain in People With Neck Pain. Psychological Science.

PLACEBOContext en betekenisgeving: positieve verwachtingen

Lieve schat…

Sihvonen, R., et al. (2013). Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. NEJM, 369(26), 2515–2524.

Sihvonen, R., et al. (2013). Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. NEJM, 369(26), 2515–2524.

Buchbinder, R., et al. (2009). A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. NEJM, 361(6), 557–568.

Conclusions

We found no beneficial effect of vertebroplasty as

compared with a sham procedure in patients with painful

osteoporotic vertebral fractures, at 1 week or at 1, 3, or 6

months after treatment.

Buchbinder, R., et al. (2009). A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. NEJM, 361(6), 557–568.

Bialosky, J. E., et al. (2008). The influence of expectation on spinal manipulation induced hypoalgesia: An experimental study in normal subjects. BMC Musculoskeletal Disorders, 9(1), 19.

MT meer dan placebo?

Bialosky, J. E., et al. (2014). Spinal manipulative therapy-specific changes in pain sensitivity in individuals with low back pain. J Pain ,15(2), 136–148.

Events that might take place in the brain after placebo administration.

Fabrizio Benedetti et al. J. Neurosci. 2005;25:10390-10402©2005 by Society for Neuroscience

NOCEBOContext en betekenisgeving: negatieve verwachtingen

The dastardly sibling of placebo

NOCEBOContext en betekenisgeving: negatieve verwachtingen

Nocebo[ti]: 165 hits (PubMed, eerste Paasdag 2015)

Aantal studies naar placebo/ nocebo 1950 - 2011

Häuser, W., Hansen, E., & Enck, P. (2012). Nocebo phenomena in medicine: their relevance in everyday clinical practice. Deutsches Ärzteblatt International, 109(26), 459–465.

Benedetti, F., Lanotte, M., Lopiano, L., & Colloca, L. (2007). When words are painful: Unraveling the mechanisms of the nocebo effect. Neuroscience, 147(2), 260–271.

Dorsal horn

RVM ON cell OFF cell

Anxiety Acute fear

Cognitive processesLearning

Nociception

Benedetti, F., Lanotte, M., Lopiano, L., & Colloca, L. (2007). When words are painful: Unraveling the mechanisms of the nocebo effect. Neuroscience, 147(2), 260–271.

Pas op wat je zegt

Nocebo: “You are going to feel a big sting and burn in your back now, like a big bee sting; this is the worst part of the procedure.”

Placebo: “We are going to inject the local anesthetic that will numb the area where we are going to do the epidural/spinal anesthesia and you will be comfortable during the procedure.”

Varelmann, D., Pancaro, C., Cappiello, E. C., & Camann, W. R. (2010). Nocebo-Induced Hyperalgesia During Local Anesthetic Injection. Anesthesia and Analgesia, 110(3), 868–870.

Pas op wat je zegt

Varelmann, D., Pancaro, C., Cappiello, E. C., & Camann, W. R. (2010). Nocebo-Induced Hyperalgesia During Local Anesthetic Injection. Anesthesia and Analgesia, 110(3), 868–870.

Vernia, P., et al., (2010). Diagnosis of lactose intolerance and the “nocebo” effect: the role of negative expectations. Digestive and Liver, 42(9), 616–619.

Finasteride 5 mg and sexual side effects. How many of these are related to a nocebo phenomenon?

Benigne prostaat hyperplasie

Twee groepen

1. Alleen het medicijn

2. Medicijn met begeleidende tekst: "....it may cause erectile dysfunction,

decreased libido, problems of ejaculation but these are uncommon”

Mondaini, N., et al (2007). Finasteride 5 mg and sexual side effects: how many of these are related to a nocebo phenomenon? The Journal of Sexual Medicine, 4(6), 1708–1712.

Resultaten

Incidentie (%) Controle Interventie

Erectiestoornissen 9,6 30,9

Libido verlies 7,7 23,6

Ejaculatiestoornissen 5,7 16,3

Mondaini, N., et al (2007). Finasteride 5 mg and sexual side effects: how many of these are related to a nocebo phenomenon? The Journal of Sexual Medicine, 4(6), 1708–1712.

• EMLA + analgesie info

• EMLA + weinig info

• Placebo crème + analgesie info

• Placebo crème + hyperalgesie info

• EMLA + hyperalgesie info

• Geen crème (controle)

Aslaksen, P. M., Zwarg, M. L., Eilertsen, H.-I. H., Gorecka, M. M., & Bjørkedal, E. (2015). Opposite effects of the same drug. Pain, 156(1), 39–46.

Aslaksen, P. M., Zwarg, M. L., Eilertsen, H.-I. H., Gorecka, M. M., & Bjørkedal, E. (2015). Opposite effects of the same drug. Pain, 156(1), 39–46.

Bialosky, J. E., et al. (2008). The influence of expectation on spinal manipulation induced hypoalgesia: An experimental study in normal subjects. BMC Musculoskeletal Disorders, 9(1), 19.

Negatieve suggesties in het taalgebruik

• Onzekerheid versterken• Laten we een manipulatie proberen• Dit zou kunnen helpen

• Negatieve benadrukken• Dit gaat even pijn doen• De foto’s zien er niet best uit• Je hebt een hoog risico voor…• Je kan beter geen zware dingen meer tillen• Je hebt net geen hernia• Je wervelkanaal is bijzonder nauw• Je kleine rugspiertjes werken niet goed• Je hebt ook veel te zwaar werk• Het valt me nog mee hoe je functioneert met zo’n nek• Je staat ook helemaal scheef

Häuser, W., Hansen, E., & Enck, P. (2012). Nocebo phenomena in medicine: their relevance in everyday clinical practice. Deutsches Ärzteblatt International, 109(26), 459–465.

Negatieve suggesties in het taalgebruik

• Aandacht versterken• Ben je nog duizelig geweest?• Voel je je misselijk?• Zodra je pijn voelt moet je het zeggen

• Ineffectieve ontkenningen en bagatellisering• Je hoeft je geen zorgen te maken hoor• Het gaat slechts wat meer pijn doen

• Jargon gebruiken• Je gewrichten zijn geblokkeerd• Je rug is nogal instabiel• Er is sprake van slijtage

Häuser, W., Hansen, E., & Enck, P. (2012). Nocebo phenomena in medicine: their relevance in everyday clinical practice. Deutsches Ärzteblatt International, 109(26), 459–465.

Pas op wat je zegt

ResultsMost participants held biomedical beliefs about the cause of CLBP, attributing pain to structural/ anatomical vulnerability of their spine. This belief was attributed to the advice from healthcare practitioners and the results of spinal radiological imaging.

Lin, I. B., et al. (2013). Disabling chronic low back pain as an iatrogenic disorder: a qualitative study in Aboriginal Australians. BMJ Open, 3(4).

Pas op wat je zegt

ConclusionFindings are consistent with research in other populations and support that disabling CLBP may be at least partly iatrogenic. The challenge for healthcare practitioners dealing with people with low back pain from any culture is to communicate in a way that builds positive beliefs about low back pain and its future consequences, enhancing resilience to disability.

Lin, I. B., et al. (2013). Disabling chronic low back pain as an iatrogenic disorder: a qualitative study in Aboriginal Australians. BMJ Open, 3(4).

“… one is drawn to the conclusion that low back disability may well be an iatrogenic disorder in many cases.”

Hrudey, WP. Overdiagnosis and overtreatment of low back pain: Long-term effects. J Occup Rehabil.1991;1(4):303-312

Maar,… we wisten het al

Darlow, B., et al. (2013). The enduring impact of what clinicians say to people with low back pain. The Annals of Family Medicine, 11(6), 527–534.

Pas op wat je zegt

Health care professionals have a considerable and enduring influence upon the attitudes and beliefs of people with low back pain. It is important that this opportunity is used to positively influence attitudes and beliefs.

Pas op wat je zegt

Many messages from clinicians were interpreted as meaning the back needed to be protected

These messages could result in increased vigilance, worry, guilt when adherence was inadequate, or frustration when protection strategies failed.

Clinicians could also provide reassurance, which increased confidence, and advice, which positively influenced the approach to movement and activity.

Darlow, B., et al. (2013). The enduring impact of what clinicians say to people with low back pain. The Annals of Family Medicine, 11(6), 527–534.

Nocebo en informed consent

Ethische principes

• Beneficence: wel doen

• Non-maleficence: geen kwaad doen

• Autonomy disclosure

• Justice

Beauchamp, T. L., & Childress, J. F. (2009). Principles of biomedical ethics. New York: Oxford University Press.

Disclosure vs non-malificence

Patiënt volledig informeren omtrent mogelijke bij- en nawerkingen, inclusief ernstige risico’s

NOCEBO

Meer klachten

Informed consent “op maat”?

• Bijwerking• Niet noemen, bellen als er nieuwe symptomen optreden• Specifieke vs niet-specifieke bijwerkingen• Lijst geven: welke wil je weten?• Positieve invalshoek

• Patiënt kenmerken• Bekend met bijwerkingen• Symptomen al aanwezig• Angst/ depressie/ anxiety/ somatisatie

• Aandoening• Bijwerkingen op de koop toe nemen bij ernstige aandoening

• Toestemming geen informatie te geven

Informed consent “op maat”?

• Vertelen we altijd de waarheid?• Beginner• Na screening: reden verwijzen naar huisarts• Conversie stoornis: niet onmiddellijk vertellen• Number needed to treat: 10?

Effect educatie op geruststelling

Traeger, A. C., et al. (2015). Effect of Primary Care–Based Education on Reassurance in Patients With Acute Low Back Pain. JAMA Internal Medicine.

Effect educatie op geruststelling

Traeger, A. C., et al. (2015). Effect of Primary Care–Based Education on Reassurance in Patients With Acute Low Back Pain. JAMA Internal Medicine.

Samenvattend

• Effecten van MT zijn niet ondubbelzinnig positief• Effecten van MT worden mede bepaald door

externe variabelen• patiënt• therapeut• context

• Daar valt nog veel winst te behalen• Kijk naar de ‘uitstraling’ van de praktijk

Samenvattend

• Maak gebruik van het brein van de patiënt • placebo bewust toepassen• nocebo bewust vermijden

• Pas op wat je zegt!• Stel gerust!

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