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

If you told a patient they tested positive for upper cervical instability, would it negatively impact outcomes?

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

Not only does the patient’s mental state have little, if any influence on outcomes, but our previous review also demonstrated that pain neuroscience education (PNE) is relatively ineffective.”

— Dr. Brent Brookbush, CEO of Brookbush Institute

NEW YORK, NY, UNITED STATES, April 5, 2024 /EINPresswire.com/ — The following is quoted from the new article (and research review) by the Brookbush Institute: False Narratives, Nocebo, and Negative Expectations do NOT affect Manual Therapy Outcomes

INTRODUCTION: All peer-reviewed, published research we could locate at the time of this publication, demonstrates that nocebo, negative messaging, negative expectations, and even catastrophizing do NOT have a significant effect on manual therapy outcomes. Additionally, positive messaging and positive expectations do not have a significant effect on outcomes either. If a professional in our industry is making claims regarding the significant influence of these factors, they are not objectively reviewing all of the research available. As discussed below, the evidence demonstrates that messaging, expectations, treatment preference, stress, and catastrophizing may have an inconsistent effect on the perception of pain induced by an intervention, but no significant effect on post-treatment outcome measures.

OUR MIND IS BETTER AT PERCEPTION: The research opposes the assertion that our mental state can have a significant influence on recovery from orthopedic pain and dysfunction. Not only does the patient’s mental state have little, if any influence on outcomes, but our previously published review also demonstrated that pain neuroscience education (PNE) is ineffective when compared to other interventions. These findings suggest that our mental state and cognitive processes do not have a strong influence on recovery from orthopedic dysfunction and pain. Although explaining the role of the central nervous system (CNS) in the perception of pain is beyond the scope of this article, it is likely reasonable to suggest that the CNS has a significant role in pain perception, but almost no role in physical rehabilitation. This should make some intuitive sense to any college-educated movement professional. By what mechanism was it expected that the mind would improve or interrupt processes like inflammation, protein synthesis, cell division, connective tissue development, etc.? The mind does not initiate these processes. When considering the physiology of dysfunction, it becomes quite a logical leap to think that thoughts would supersede biological processes. Some of the claims made regarding the brain and recovery from pathology seem to imply that our mind has an almost Jedi-like “force” over healing.

SUMMARY OF RESEARCH FINDINGS: 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.



1. Gallego-Sendarrubias, G. M., Voogt, L., Arias-Buría, J. L., Bialosky, J., & Fernández-de-Las-Peñas, C. (2022). Can patient expectations modulate the short-term effects of dry needling on sensitivity outcomes in patients with mechanical neck pain? A randomized clinical trial. Pain medicine, 23(5), 965-976.

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.

5. Bishop, M. D., Bialosky, J. E., & Cleland, J. A. (2011). Patient expectations of benefit from common interventions for low back pain and effects on outcome: secondary analysis of a clinical trial of manual therapy interventions. Journal of Manual & Manipulative Therapy, 19(1), 20-25.

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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8. Stewart, M. J., Maher, C. G., Refshauge, K. M., Herbert, R. D., & Nicholas, M. K. (2008). Patient and clinician treatment preferences do not moderate the effect of exercise treatment in chronic whiplash-associated disorders. European Journal of Pain, 12(7), 879-885.

9. Donaldson, M., Learman, K., O’Halloran, B., Showalter, C., & Cook, C. (2013). The role of patients’ expectation of appropriate initial manual therapy treatment in outcomes for patients with low back pain. Journal of Manipulative and Physiological Therapeutics, 36(5), 276-283.

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.

11. Kalauokalani, D., Cherkin, D. C., Sherman, K. J., Koepsell, T. D., & Deyo, R. A. (2001). Lessons from a trial of acupuncture and massage for low back pain: patient expectations and treatment effects. Spine, 26(13), 1418–1424. https://doi.org/10.1097/00007632-200107010-00005.

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.

Brent Brookbush
Brookbush Institute
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Originally published at https://www.einpresswire.com/article/701309335/false-narratives-nocebo-and-negative-expectations-do-not-affect-manual-therapy-outcomes

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