Tae Bo, Placebo & Nocebo
By John Fiadjoe, MD
Tae Bo, Placebos and Nocebos
https://pubmed.ncbi.nlm.nih.gov/20042440/
Nocebo-Induced Hyperalgesia During Local Anesthetic Injection
Dirk Varelmann, MD, DESA,* Carlo Pancaro, MD,† Eric C. Cappiello, MD,*
and William R. Camann, MD*
First, I miss Ron! I know he would be happy to know we are keeping this going. It was his final gift to pediatric anesthesiology
Many of us have heard of Tae Bo and the placebo (Latin I shall please) effect, but are you aware of the placebo effects evil cousin, the nocebo effect. Just in case you didn't know, Tae bo was a martial arts-based fad (can you say peloton) of the 1990s. The placebo effect occurs when a beneficial effect occurs after administering an inactive drug because of the recipients' belief that the drug has benefit. A nocebo effect occurs when an adverse effect occurs after taking a placebo pill due to the expectation of a negative or harmful outcome. In this randomized controlled trial, Varelmann et al. assigned healthy parturients to two statements before local anesthesia infiltration for labor epidural placement. One group was told, "You will feel a big bee sting; this is the worst part" (Nocebo condition). The other, "We are going to give you a local anesthetic that will numb the area, and you will be comfortable during the procedure" (Placebo condition). The primary outcome was a VAS pain score assessed by a blinded observer. I wasn't surprised by the results of significantly lower VAS scores in the placebo condition. What surprised me was the finding that the differences carried over to their cesarian delivery under spinal anesthesia… hmmm. Based on this study and others, I try to use pleasant, gentle language when describing procedures. Even for mask induction, I no longer say the gas smells like smelly socks or stinky farts; I say it will smell like chocolates or strawberries or anything the child finds pleasant. I am always surprised when the child reports smelling the pleasant smell! Even telling a patient about the risk of nausea and vomiting preoperatively increases their likelihood of having nausea and vomiting. Any ideas of how to get around this?
"Let's be careful out there!"
Sgt. Phil Esterhaus, Hill Street Blues
If you would like to write for PAAD, please send me an email. If you want to contribute financially, your contributions will support the Women's Empowerment and Leadership Initiative (WELI), a Society for Pediatric Anesthesia initiative to help develop future women leaders. link to follow in the next PAAD.
Words are powerful. The findings of today’s throwback study transcend obstetric anesthesia to all subspecialties, and can inform our word choice in our daily affairs.
Interesting how verbal scripts develop, replicate, and become the norm, automatic, and spill from our mouths without any thought attached. I was stung a few times in my childhood. I can still see my hand as I pulled it from a shrub holding the baseball I retrieved and numerous bees clinging to me from the hive hidden within. My 4-year-old grandson was stung by a bee over a year ago, and recalls this vividly whenever he sees a bee. I always thought it strange that one would choose this analogy for a woman experiencing severe labor pain, most fearful of receiving a needle in the back.
I have long abandoned “informing” patients about risks of PONV; it is common lay knowledge. Instead, I speak positively about measures we take to prevent it, the reasons it is unlikely to be a problem, the image of awakening in recovery feeling well, pain and nausea free. “We’ll fine tune these right away if need be.”
In this new era of protocolization, standardization, and automaticity, this study reminds us to stay awake, keep our eyes and ears open, and think as we go about doing and saying. Thank you for this timely Throwback Thursday reminder, John.