Link Between Positive Clinician‐Conveyed Expectations of Treatment Effect and Pain Reduction in Knee Osteoarthritis, Mediated by Patient Self‐Efficacy

Abstract

Objective A prior knee osteoarthritis (OA) trial found that provider conveyed expectations for treatment success were associated with pain improvement. We hypothesized this relationship was mediated by patient self-efficacy since expectations of improvement may enhance one’s ability to control health behaviors, and therefore health. Our aim was to examine whether self-efficacy was a mediator of the relationship observed in this trial. Methods A secondary analysis of a three arm (traditional acupuncture, sham acupuncture, and wait list) trial for knee OA was conducted. Those in the acupuncture groups were equally randomized to acupuncturists trained to communicate a high or neutral expectation of treatment success (e.g. used language conveying high or unclear likelihood that acupuncture would reduce knee pain). A modified Arthritis Self-Efficacy Questionnaire and the Western Ontario McMasters (WOMAC) pain subscale were administered. Linear regression analyses were used to examine whether patient self-efficacy mediated the relationship between provider communication style and knee pain at 3 months. Results High expectation provider communication was associated with patient self-efficacy, β coefficient of 0.14 (95%CI: 0.01, 0.28). Self-efficacy was associated with WOMAC pain, β coefficient of −9.29 (95%CI: −11.11, −7.47), while controlling for the provider communication style. The indirect effect a*b of −1.36 for high versus neutral expectation, (bootstrap 95% CI: −2.80, −0.15, does not include 0), supports that patient self-efficacy mediates the relationship between provider-communicated expectations of treatment effects and knee pain. Conclusion Our findings suggest that clinician-conveyed expectations can enhance the benefit of treatments targeting knee OA symptoms, mediated by improved patient self-efficacy.

The Influence of Verbal Suggestion on Post-Needling Soreness and Pain Processing after Dry Needling Treatment: An Experimental Study

“…Those findings, together with the fact that in previous studies have found effects of verbal suggestions, varied depending on the route of administration of the therapy, with larger effects in cases involving invasive treatments versus non-invasive treatments [ 43 , 44 ], which could partly explain why, in our study, no differences were observed between the different types of suggestions, since neither tapping, being a painful technique and on the other hand being an invasive therapy, could activate endogenous modulation systems. In contrast, other studies in patients with osteoarthritis who received verbal suggestions associated with acupuncture treatment, but applied to acupuncture points other than those necessary to produce an effect, produced a greater improvement in patients than the group who received a neutral suggestion [ 45 ] which was maintained for 3 months. Even a recent narrative review found that positive verbal suggestions have favorable effects on osteoarthritis pain and low back pain [ 46 ].…”

How Do Nonsurgical Interventions Improve Pain and Physical Function in People With Osteoarthritis? A Scoping Review of Mediation Analysis Studies

“…The search strategy identified 22,402 studies, of which 164 full texts were screened to determine eligibility (Figure 2). Nine Three studies assessed the mediational role of self-efficacy (22,27,29), 2 studies assessed the mediational role of body weight (21,24), and single studies assessed the mediational role of knee muscle perfusion (25), knee extensor strength (26), the external knee adduction moment (28), inflammatory biomarkers (23), knee pain (27), physical activity (27), dietary intake (27) and pain beliefs (24). One study reported on the mediational effect of cardiovascular fitness on WOMAC summary score (21); however data specific to pain and physical function were not retrievable.…”

Direct and mediated effects of treatment context on low back pain outcome: a prospective cohort study

“…The current study extends understanding of the mechanisms through which contextual factors may impact patient health outcomes. Earlier studies have investigated pathways among smaller numbers of contextual variables and suggested, for example, that self-efficacy mediates the impact on osteoarthritis pain of practitioners communicating positive expectancies, 35 affective aspects of the therapeutic relationship may shape Open access patient expectancies in chronic pain, 70 and expectancies might impact pain via reduced catastrophising in chronic back pain. 33 The current results further suggest contextual factors reduce back-related disability in part by enhancing patient self-efficacy for coping with pain, reducing the perceived threat of pain and reducing psychosocial distress.…”

“…Such components include: positive and empathetic patient–practitioner relationships and a strong patient–practitioner alliance 4–10 (patient–practitioner relationship); patients’ outcome expectancies and perceived treatment credibility 9 11–16 (patient beliefs); musculoskeletal practitioners’ beliefs about pain 17–22 and outcome expectancies 23 (practitioner beliefs); good organisational environments (eg, collegiality) 24 , the physical–sensory environment (eg, music) 25 and the healthcare sector 26–28 (environment), although evidence of effects of healthcare sector on patient outcomes is mainly qualitative. Contextual components might impact patient outcomes via (1) behavioural pathways (eg, improved self-management), 29 30 but see also Haanstra et al who found that adherence accounted for only a small proportion of the relationship between expectancies and pain outcomes, 31 (2) psychosocial pathways (eg, reconceptualising pain as less threatening 32–34 ; increased self-efficacy 35 36 ) and/or (3) neurophysiological pathways. 37–41 The focus in this study was on psychosocial pathways; more details on how these were hypothesised to operate are provided in our published protocol.…”