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  • Writer's pictureDaniel Rockman

Dealing with pain - How contextual factors can reduce your pain

When receiving treatment, for example, a physio examining your lower back pain, there is far more going on behind the scenes to influence the result of the treatment than just whether they choose to massage or dry needle. That is to say, what clinical method they use to treat you matters far less than you might think.

In fact, up to 75% of the result can be attributed to a completely separate variable,,,


I don't want to come off as a conspiracy theorist so let me link the peer-reviewed article that I have been reading which explains what I'm talking about: Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain

Not a super catchy name for a title but it's the content that matters anyway.

This study looks specifically at the contextual factors affecting musculoskeletal therapy but the effect is present in other fields as well. What we're talking about here is the way in which the therapy is delivered or the factors that make up the context of the treatment.

So if your favourite doc who works a second job as a clown tells you of your treatment options with full confidence and a smile on his face, you are more likely to experience a better result.

If your doctor's office consists of the cheapest looking equipment you could imagine and what looks like a fake, online doctorate certificate on the wall, you are less likely to have a positive outcome.

This is true even if the doctors give the exact same clinical treatment.

The reason for this comes down to a well known effect in studies called the placebo effect and its lesser known little brother, the nocebo effect.

A placebo effect is when a positive effect is felt due to psychological reasons as opposed to the actual treatment.

A nocebo effect is the opposite, when a negative effect is felt due to psychological reasons and not the actual treatment.

These placebo and nocebo effects come in to play regardless of if you want them there thanks to the contextual factors surrounding the treatment.

Contextual factors are complex and can be internal, external or


Some examples of contextual factors are:

  • patient’s expectation

  • patient's history

  • baseline characteristics

  • clinician’s behavior

  • clinician's beliefs

  • verbal suggestions

  • therapeutic touch

  • a positive therapeutic experience

  • a negative therapeutic experience

  • social learning

  • dosage of intervention

  • how treatment is administered

  • marketing of treatment

  • the health care setting.

All of these contextual factors will contribute to triggering placebo or nocebo effects in the outcome of the treatment. Therefore, these factors are very important parts of the treatment process and should be mindfully managed by both the patient and the clinician.

Patients' biggest contextual factors were their history of treatment and expectations of treatment.

If you've had a negative experience with a certain treatment, you are more likely to have another negative experience and vice versa.

If you have high expectations in your treatment it will show better results, so go to a doctor you can trust!

As a health care provider, the architecture and interior design can have an effect on patients. Providing adequate furnishing, colours, artwork, light, outside views, temperature, soothing sounds and music all have positive impacts on patient’s pain.

In terms of the clinician, they found that active listening, extra time spent with the patient, more face-to-face visit, warmth, attention, care, encouragement and support significantly reduced pain more than the same therapy performed with neutral therapeutic interaction.

Who knew that doctors being friendly is a genuine way of healing?!

Does this mean we shouldn't worry about the actual treatment if so much of the effect comes from context?

Of course the actual treatment still matters. There are physiological changes that can't be reproduced through sheer positive vibes alone. If you are receiving the wrong treatment, your outcome will undoubtedly be worse than if you were receiving the correct treatment. Especially in the physiotherapy field, there are multiple methods for treating the same injury, and in an ideal world, the most suitable method should be used ALONGSIDE positive contextual factors to create the best possible outcome for the patient.

In addition, the study found that long-term patients had a reduced placebo effect, so it appears the benefits of the positive contextual factors gradually wear off and a physiological fix should be found.

Does this actually change anything biologically? Yes! The pain processing pathways in the brain are noticeably less active with a placebo-induced reduction in pain. I'll spare you the extra long neurobiological words (hypothalamus was one of the more understandable words in the article...), just know that your psychology will change your biology.

The main thing I'm taking away from this article is that health is holistic. Treatment for any pain shouldn't just be administering a method, but includes the whole process of seeking help.

Small things can significantly alter your outcome and, therefore, you should be aware of as many contextual factors as you can be. You should try to use your internal contextual factors, your clinic's external factors and your clinician's relational factors to your advantage in order to minimise your pain.

I guess it really is worth finding a GP, physio or osteo that you bond with, and can entrust to create an environment filled with positive contextual factors to get the most out of your treatment. If you can utilise these contextual factors in your favour, it is scientifically proven to be a better outcome for you.

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