““Would You Like Pain With That?” - pain, paradigms and the problem with placebo Dr Kal Fried MBBS FACSP

 PAIN & PAIN RELATED DISABILITY – (some) neuroscience …  PARADIGMS – biomodel vs biopsychosocial  PLACEBO – (& ‘NOCEBO’)ie: the ‘Mind / Body’ connection

WHY? >2000 comp case reviews  Confounders ++++ Chronic pain epidemiology ‘Pathology’ and pain ≠linear relationship Pain Rx variation in craft groups ++ with results ? < placebo The ‘failed conservative Rx’ concept Informed consent / medicolegal concerns 3 medical idioms

◦ TREAT THE PATIENT, NOT THE XRAY (INVESTIGATION) ◦ ONLY ORDER AN INVESTIGATION IF IT CHANGES MANAGEMENT.

 Is neuroplasticity in the central nervous system the missing link to our understanding of chronic musculoskeletal disorders? Pelletier et al. BMC Musculoskeletal Disorders (2015) 16:25: “Summary: Recent findings suggest that a change in model and approach is required in the rehabilitation of chronic MSD that integrate the findings of neuroplastic changes across the CNS and are targeted by rehabilitative interventions. Effects of current interventions may be mediated through peripheral and central changes but may not specifically address all underlying neuroplastic changes in the CNS potentially associated with chronic MSD”

Conclusions: For chronic MSK pain disorders, there is compelling evidence that an educational strategy addressing neurophysiology and neurobiology of pain can have a positive effect on pain, disability, catastrophization, and physical performance. Arch Phys Med Rehabil Vol 92, December

Placebo’s evil twin brother …. Medicine's inconvenient truth: the placebo and nocebo effect. Internal Medicine Journal, 44(4), Arnold, M., Finniss, D., Kerridge, I. (2014): “… we suggest that a closer examination of placebo and nocebo effects allows for the appreciation of the power of the therapeutic context on the outcome of a given therapy.” When Words Are Painful: Unraveling The Mechanisms Of The Nocebo Effect. Benedetti et al. Neuroscience 147 (2007): “… these findings underscore the important role of cognition in the therapeutic outcome, and suggest that nocebo and nocebo-related effects might represent a point of vulnerability both in the course of a disease and in the response to a therapy.”

 “VOMIT (victims of modern imaging technology) - an acronym for our times.” Richard Hayward, consultant neurosurgeon. BMJ 2003 ; 326:1273

Therapeutic Power ofEducation,Reassurance & Perspective

Equations: - Pain + scan = intervention - Pain + biomodel + nocebo = persistent pain - PAIN + PAIN LITERACY + BIOPSYCHOSOCIAL + CONFIDENT REHAB +/- INTERVENTION = OPTIMAL OUTCOME