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Both Patient and Provider Expectations Influence Treatment Effectiveness

August 26, 2020
Discussing outcomes and offering multimodal interventions can go a long way toward positive outcomes.

The success of medical treatments, particularly those for chronic pain, depend in some degree on the expectations of the patient. But the provider’s expectations and communications to the patient about those expectations matter, too.

“The data supporting the powerful influence of patient expectations are undeniable,” said Afton L. Hassett, PsyD, director of Clinical Pain Research in the Division of Pain Medicine at the University of Michigan Medical School. “To put this into context, patient expectations are the central  element of the placebo response.”

Indeed, several studies have looked at the various ways in which healthcare providers can help to manage patient expectations, such as through attentive listening and building trust or by asking how the individual patient defines “a good outcome.”1,2  Some patients say they would like to be able to kneel or squat versus being able to run, for instance.2

Recently, researchers at the German-based universities of Koblenz-Landau and Philipps-University Marburg sought to dig deeper into expectations and outcomes by asking both patients and clinicians how they felt about multimodal treatments. They specifically wanted to target psychological interventions, which they felt were often underused in pain management.3  Pain treatments, they wrote in their published study, “might not be achieving all their potential…”3

Clinicians can help manage patient expectations through attentive listening and building trust or by asking how the individual patient defines “a good outcome." (Image: iStock)

Methods

Specifically, the team designed a study to look at how the expectations of care receivers (patients) and caregivers (including psychotherapists and physicians), influenced the outcomes of chronic low back pain treatment. The results were published in the Journal of Pain Research.3

To meet inclusion criteria, caregivers had to have been practicing as either a physician, psychotherapist, or physiotherapist for longer than 1 year. Patients had to have lived with back pain of at least moderate intensity for a period greater than 6 months. Subjects who stated that they had suffered no back pain or only acute back were used as healthy controls. A total of 237 clinicians and 210 patients (85 with pain; 125 healthy controls) were enrolled.

All participants were given three vignettes of roughly 200 words each in random order describing different approaches to treating chronic low back pain: pharmacological, psychological, and multimodal. Participants were asked to rate their expectations for each approach. In addition, patients filled out questionnaires designed to assess their personal experience of pain, pain disability, and any anxiety or depression related to pain. Clinicians filled out a separate questionnaire about their professional experience and work settings.

Results

Overall, the results were not surprising:3  

  • Patients reported more disability, catastrophizing thoughts, and depressive symptoms than their healthy controls. Those who suffered from chronic low back pain had lower treatment expectations than healthy controls regardless of the pain management approach described.
  • Patients and psychotherapists expected the psychological approaches to be more effective than pharmacological treatments.
  • Psychotherapists and physicians had higher expectations for their own treatment approaches.
  • Physicians expected the pharmacological and psychological methods to be equally effective.
  • All participants (caregivers and care receivers) expected multimodal pain management to be the most effective approach.

Practical Takeaways

The university researchers concluded that clinicians should take advantage of the relationship between patient expectations and treatment outcomes by making a greater effort to use multimodal treatments.

According to Dr. Hassett, most clinicians treating patients with chronic pain agree that psychological approaches can be helpful but they sometimes reserve them for people with clear mental health disorders. She explained that “psychological approaches should not be reserved only for patients with depression, anxiety, or other psychiatric disorders. The behavioral and coping techniques taught through these therapies can help almost all patients with chronic pain.”

The study’s authors recommend other tactics as well, such as identifying circumstances in which expectations may be modified, and investigating and developing ways to use expectations to enhance routine medical care. They suggested verbal suggestions, conditioning, and mental imagery, for example.

The German team also recommended in their paper that healthcare providers convey their own positive expectations of treatment modalities offered to patients. For instance, they referenced a 2015 study published in Psychiatry Research4, which indicated that people  suffering from anxiety benefited from having a sense that their caregivers were confident and competent. However, they also cited evidence from a 2005 survey of chiropractors, osteopaths, and physiotherapists that suggested “excessive self-confidence” can in some circumstances lead providers to continue treatment despite lack of improvement.5

Overall, patient expectations should continue to be part of any treatment plan discussion and multimodal approaches including psychotherapy should be encouraged for all patients, not just those with diagnosed anxiety or depression.

Last updated on: September 2, 2020
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