Editor’s Note: Til Luchau and Whitney Lowe recently spoke with manual therapist, physiotherapist, and researcher Mark Bishop about his fascinating research into how clients’ expectations influence treatment results. His research shows that clients who think treatment will help often benefit far more than those who don’t expect much relief. Key excerpts from their longer conversation (which took place on Whitney and Til’s The Thinking Practitioner podcast) have been edited here for clarity and context.

Til Luchau: Mark, you are a physiotherapist with more than 30 years of clinical and research experience in the rehabilitation of musculoskeletal pain disorders. Your impressive bio says your work has “focused on the mechanisms underpinning the effectiveness of conservative interventions for pain, especially in manual therapy and exercise.”¹

I met you at the San Diego Pain Summit in 2019, where you said some pretty interesting things about client expectations, treatment choices, and treatment results.

Mark Bishop: Yes, the thing that fascinated me clinically was that there were people I was not able to help. This motivated me to start studying manual therapies, which techniques I should use for which people, and when I should apply those.

Mental or Physical?

MB: We had the good fortune to collaborate with a group of clinical and health psychologists. At that time, I had a very dualistic view that there were psychological factors and [separate] neurophysiological factors. It was a psychologist who really encouraged us to think a little bit differently. He said that if you thought anything, part of your brain depolarized, so that had to be neurophysiology. That did get us thinking!

TL: You’re saying that the thought itself is a neurophysiological, that is physical, phenomenon.

MB: Absolutely. If something is happening in the cortex, that’s as neurophysiological as anything that we were measuring as far as nerve function or reflexes.

TL: You’re describing a shift from being focused on the body to including what was happening in the brain.

MB: Yes, but what we were actually interested in is what the person was telling us about pain. For example, in the context of expectation, if I talk about an expectation that something bad might happen, maybe this treatment will hurt, the gain in the system gets elevated because of anxiety or fear and you’re more likely to tell me that it hurts. Now, if I give you that stimulus again at a different time and your anxiety about it has gone down, your response will likely be different, even though the stimulus did not change.

TL: So, my brain gets predisposed by my expectations. If I think it’s going to hurt, I’m more likely to experience or report that as pain.

MB: Yes, and the opposite is true. If you’re expecting something to be good, you’re more likely to report either less pain or to benefit from it. People can have expectations to benefit from the treatment in general, and more specific expectations of the technique that you’re about to apply. Each of those expectations can influence what people are thinking about what is happening to them.

Let’s say Til comes in with neck pain. He’s expecting the clinic to look a certain way. That meets his expectations. He’s generally expecting benefit from treatment for his neck. Then, he receives a technique that he has high expectations is going to help him. Chances are that he is going to report feeling better than someone who comes to see the provider and they don’t like the place or the provider. They’re not expecting much from treatment, and then I do an intervention that is not what they expect to help them. Even if it’s the same intervention for the same condition, they often report worse outcomes, compared to the person with high expectations.

Whitney Lowe: In one of your papers, you said this made you consider these neurological and psychological factors to be far more prominent than we may have originally thought, in terms of beneficial physical outcomes.² Is that correct?

MB: It is, which made us think we’d all gone through the rigorous training to master our particular area of manual therapy, but since it turns out that different providers are treating the same condition differently and yet getting similar outcomes, there has to be something else that is contributing to the outcomes. So, we were looking at what might explain how we can have so many varied approaches with similar outcomes for the same conditions.

Some of our work suggests that the expectation someone has before we start is a stronger predictor of what they’ll tell you six months later, than which treatment they actually received.³

TL: What the client or patient thinks about you, your practice, or your techniques—even before they come to you—has a stronger correlation to how they’re doing six months later than the treatment you actually did.

MB: Yes. We asked people before they started treatment about their general expectation on full recovery. The people who said, before we did anything, that they would be completely recovered in six months were the ones who had the largest change in outcome.

WL: So, the people who said they expected to recover had the largest change in outcome?

MB: Yes sir. That’s a very general expectation. That has nothing to do with what we actually did. That [has] everything to do with what you think before you even get treatment.

There are some great examples of context and expectations in the placebo literature with people in a hospital in pain, randomized to two groups.⁴ One group has a health professional walk up in a white coat. The person in the bed can see the injection going into the IV bag. And you get a great response after the injection. When you give the same injection from behind the screen, so the person doesn’t know when it’s administered, in some drugs used for pain you actually eliminate the effectiveness. So, the effectiveness of that particular medication was all context.

TL: That makes me think about practitioners whose focus may be general self-care, relaxation, and stress relief, rather than pain per se. Do you see any reason these effects wouldn’t apply there as well?

MB: They do apply. In fact, in exercise studies, expectation of benefit predicts performance improvement. Your ability to run faster is influenced by your confidence in the training program and your expectation that you will run faster. People with high expectations report lower exertion than people who don’t expect it to help.

It’s that old adage about if your head’s not in the game, you are not putting in the effort. So, as with exercise, if I go to see you expecting benefit in the forms of relaxation or stress relief, I will experience more relaxation and stress relief.

In an upcoming excerpt of their conversation, Til and Whitney talk with Dr. Bishop about ways practitioners can put these ideas to use, about managing client expectations during a pandemic, and more. Thanks to Alexandra Hammer for superlative editing and improvements to the original transcription.

Notes

1. Mark D. Bishop, PT, PhD, FAPTA, is a faculty member in the Department of Physical Therapy, with affiliations in the Center for Pain Research and Behavioral Health, and the Pain Research and Intervention Center of Excellence, at the University of Florida.

2. Mark D. Bishop et al., “Patient Expectations of Benefit from Interventions for Neck Pain and Resulting Influence on Outcomes,” Journal of Orthopaedic and Sports Physical Therapy 43, no. 7 (July 2013): 457–65, https://doi.org/10.2519/jospt.2013.4492.

3. Mark D. Bishop et al., “Patient Expectations of Benefit from Interventions for Neck Pain and Resulting Influence on Outcomes.”

4. Martina Amanzio et al., “Response Variability to Analgesics: A Role for Non-Specific Activation of Endogenous Opioids,” Pain 90, no. 3 (February 2001): 205-15, https://doi.org/10.1016/s0304-3959(00)00486-3.