Using a biopsychosocial approach means – we need to understand the impact of contextual effects

Using a biopsychosocial approach means – we need to understand the impact of contextual effects

Contextual effects are everything that happens around a treatment that could influence its impact. They could also be called non-specific effects, because their impact isn’t specific to the treatment nor is it due to the specific impact on the body the treatment has.

These are incredibly important to consider because systematic reviews identify that their impact could explain up to 60-75% of the treatment outcome!

While this may seem crazy, it does make sense.

Imagine you’re going to adjust someone’s neck. If you appear nervous, make the adjustment and yell ‘oh no’, it is likely that the patient is going to have a negative outcome from the experience regardless of whether you did a good adjustment or not.

The same can be said for telling someone that they’ve got bone-on-bone degeneration and that they’ll never be pain-free again without surgery. Is that patient going to experience a good outcome from conservative therapy? Probably not, simply because we’ve told them already it would be a waste of time.

Where I think many people go wrong interpreting contextual effects is the idea that contextual or non-specific effects are things that directly impact the tissue. Like setting someone’s expectation about their recovery miraculously helps their shoulder.

The issue here is behaviour. The guy you yelled ‘oh no’ to may experience a bad outcome not because of the adjustment but because he spent the rest of the week with his neck immobilised worried you snapped something. The patient with bone-on-bone degeneration requires surgery in the end because everytime they experienced pain they associated it with bone scraping on each other and they refused to move the knee until it was replaced.

These are prime examples of nocebo effects! So what should we do? Enhance placebo effect and avoid nocebo.

Thinking about what we do and say that could influence a patient towards a better outcome, such as listening and reflecting, building trust, providing treatments that help the patient feel more control of their health.

It also means avoiding things that could negatively impact the outcome, like nasty medical jargon and unhelpful pain narratives

Alex Murray Podiatrist

Alex Murray is a Podiatrist working in private practice and the founder of website Making Sense in Podiatry. He's passionate about helping other clinicians make sense of evidence and clinical practice with a core philosophy of exploring the complexity of human beings, embracing the uncertainty of clinical practice, and avoiding overly reductionist thinking. In addition to his undergraduate degree from La Trobe, he also holds a Post Graduate Diploma in Sports and Exercise Medicine from the University of Otago. He has experience with both national and international athletes and has recently transitioned to focusing primarily on helping the general population and local athletes manage their pain and achieve their goals.

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