Tijdens @NVMT-Nl symposium 2015

2. Even iets rechtzetten…
Ronald Kan, MT, MSc
Heliomare revalidatie
SOMT

3. Agenda
• Evidence based clinical practice
• Het bewijs
• Context
• Communicatie/ taal
• placebo en nocebo
• Informed consent – ethische dilemma’s
• Putting it all together

4. Evidence based clinical practice
Clinical state &
circumstances
Patients’
preferences
& actions
Research evidence
Clinical expertise
Haynes, 2002

5. Behandeleffect
Effect
Patiënt
TherapeutTherapie
Context

6. HET BEWIJS
niet overtuigend….

7. 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.

8. 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.

9. 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

10. 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).

11. 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.

12. 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.

13. 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.

14. Externe factoren
van 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.

16. 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.

17. WAAROM IS CONTEXT ZO BELANGRIJK
Beïnvloeden van pijn

18. Neuromatrix theory of pain

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

20. 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.

21. 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.

22. PLACEBO
Context en betekenisgeving: positieve verwachtingen

23. Lieve schat…

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

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

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

29. 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.

30. 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.

31. 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.

32. 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

33. NOCEBO
Context en betekenisgeving: negatieve verwachtingen
The dastardly sibling of placebo

34. NOCEBO
Context en betekenisgeving: negatieve verwachtingen
Nocebo[ti]: 165 hits
(PubMed, eerste Paasdag 2015)

35. 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.

36. 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.

37. Dorsal horn
RVM ON cell OFF cell
Anxiety Acute fear
Cognitive processes
Learning
Nociception

38. 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.

41. 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.

42. 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.

43. 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.

44. 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.

45. 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.

46. • 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.

47. 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.

48. 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.

49. 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.

50. 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.

51. Pas op wat je zegt
Results
Most 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).

52. Pas op wat je zegt
Conclusion
Findings 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).

53. “… 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

54. 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.

55. 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.

56. Nocebo en informed consent

57. 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.

58. Disclosure vs non-malificence
Patiënt volledig informeren omtrent mogelijke
bij- en nawerkingen, inclusief ernstige risico’s
NOCEBO
Meer klachten

59. 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

60. 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?

61. 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.

62. 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.

63. 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

64. Samenvattend
• Maak gebruik van het brein van de patiënt
• placebo bewust toepassen
• nocebo bewust vermijden
• Pas op wat je zegt!
• Stel gerust!

65. DANK VOOR UW AANDACHT
Iets rechtgezet?