Induction of nocebo and placebo effects on itch and pain by verbal suggestions

(Van Laarhoven et al., 2011)

Aims: To study verbally induced nocebo and placebo effects on itch and pain.

Methods: 105 healthy female subjects were randomly assigned to one of 4 groups: (Itch nocebo n=36 vs Control n=20 or Pain nocebo n=33 vs Control n=16). In itch / pain nocebo groups patients were told a verbal suggestion stating that 95% of healthy people will experience Itch / pain and in control groups a neutral suggestion stating only 5% may experience Itch, 5% pain otherwise nothing. All groups tested for mechanical stimuli (Von Frey), electrical stimuli, ionophoresis of Histamine. Then all nocebo group undertook another ionophoresis stimuli. With either placebo suggestion of reduction of itch / pain or control with suggestion of same gel and that everyone feels itch or pain but not the other according to the group. All group rated pain and itch on VAS scales before and every 30 seconds during test, and after.

Results: Subjects who received verbal suggestions to induce high pain expectations reported significantly more pain than subjects who received verbal suggestions inducing low pain expectations. Subjects who received verbal suggestions inducing high itch expectations experienced significantly higher levels of itch evoked by the somatosensory stimuli than subjects who received verbal suggestions inducing low itch expectations. The nocebo effects induced by verbal suggestions appeared to be stronger for itch than for pain.

Itch levels decreased to a greater extent when suggestions of itch reduction were given than when suggestions of pain reduction were given, while the decrease in itch was not significantly different when it was suggested that itch would be reduced in comparison to neutral suggestions and same for pain.

Limitations: Only women, from one university of Netherlands, small sample. Part 2 habituation of histamine effect possible. Lab setting can be a cofounding factor. Lack control group with no expectations at all. Healthy subjects only. Small effect: MIDC not reached, low levels of itch / pain in general.

In practice: Itch and pain can be induced by only giving verbal suggestions. The perception of different ambiguous stimuli can be influenced by negative suggestions, in such a way that negative expectations can adversely influence the intensity of itch or pain experienced.

Van Laarhoven, A. I. M., Vogelaar, M. L., Wilder-Smith, O. H., Van Riel, P. L. C. M., Van De Kerkhof, P. C. M., Kraaimaat, F. W., & Evers, A. W. M. (2011). Induction of nocebo and placebo effects on itch and pain by verbal suggestions. Pain, 152(7), 1486–1494.

Reliability, validity and diagnostic accuracy of palpation of the sciatic, tibial and common peroneal nerves in the exam of LB related leg pain.

(Walsh & Hall, 2009)

Aim: The aim of this study was to determine the reliability, validity and diagnostic accuracy of manual palpation of the sciatic, tibial and common peroneal nerves in the examination of low-back related leg pain.

Methods: 45 subjects. Palpation compared to SLR + Slump. Inclusion: presence of unilateral low-back related leg pain, 18 to 70yo, English speaking. Exclusion: signs of serious pathology, history of spinal surgery or neurological disease, unable to tolerate testing process.

Palpation at the sciatic nerve at the midway point of a line from ischial tuberosity to the greater trochanter of the femur; the tibial nerve where it bisects the popliteal fossa at the mid-point of the popliteal crease; and the common peroneal nerve where it passes behind the head of fibula to wind around the neck of fibula. Bilateral simultaneous palpation. Positive if pain or discomfort on one leg or more on one leg if bilaterally. Following palpation: PPT measured at same spots. 3 measures 10 s rest, asymptomatic leg then symptomatic, mean of 3 measures taken. Proximal to distal. 2nd blinded examiner did Slump and SLR. For each test, reproduction of presenting symptoms, which was made worse by dorsiflexion, was recorded as a positive finding. Positive if +ve Slump AND +ve SLR. First 20 subjects did the exact same procedure with a 3rd examiner to measure inter tester reliability.

Results: Reliability: Substantial agreement was found for all palpation tests. K=0,7-0,8. PPT reliability demonstrated excellent inter-tester reliability.

Validity: There were no significant differences in PPTs between sides at any of the nerves in subjects who were negative on manual palpation. In subjects who were positive on manual palpation, mean PPTs were significantly lower on the symptomatic side compared to the asymptomatic side for each of the nerves

Limitations: Small sample from Australia, SLR and Slump non gold standard.

In Practice: This study provides support for the use of nerve palpation in clinical examination, with evidence of excellent reliability and diagnostic accuracy as well as validity of manual palpation for three lower limb nerve sites.

Walsh, J., & Hall, T. (2009). Reliability, validity and diagnostic accuracy of palpation of the sciatic, tibial and common peroneal nerves in the examination of low back related leg pain. Manual Therapy, 14(6), 623–629.

Patellofemoral Pain

(Willy et al., 2019)

Aims: Guidelines on PFP

Methods: Review of literature & experts’ consensus.

Limitations: May be bias in experts’ opinion. Broad topic. Expert consensus

In Practice:

Diagnosis: The presence of retro-patellar or peri-patellar pain, (2) reproduction of retro-patellar or peri-patellar pain with squatting, stair climbing, prolonged sitting, or other functional activities loading the PFJ in a flexed position, and (3) exclusion of all other conditions that may cause anterior knee pain.

Assessment: Clinicians should use the Anterior Knee Pain Scale (AKPS), the patellofemoral pain and osteoarthritis sub-scale of the Knee injury and Osteoarthritis Outcome Score (KOOS-PF), or the (VAS) for activity, for worst pain, for usual pain, or the numeric pain-rating scale (NPRS) to measure pain.

Treatment: Should include exercise therapy with combined hip- and knee-targeted exercises to reduce pain and improve patient-reported outcomes and functional performance in the short, medium, and long term.

Clinicians may use tailored patellar taping in combination with exercise therapy to assist in immediate pain reduction, and to enhance outcomes of exercise therapy in the short term (4 weeks).

Clinicians should prescribe prefabricated foot orthoses for patients with greater than normal pronation to reduce pain, but only in the short term (up to 6 weeks).

Willy, R. W., Hoglund, L. T., Barton, C. J., Bolgla, L. A., Scalzitti, D. A., Logerstedt, D. S., … Torburn, L. (2019). Patellofemoral Pain. Journal of Orthopaedic & Sports Physical Therapy, 49(9), CPG1–CPG95.

Great learning opportunities :

This post is a simple list of all resources I currently use to learn. (I will try to update it frequently).

I wanted to list them all in one place and make them accessible to everyone seeking for sources of information.

You will find here different types of learning inputs according to the learning experience you want to try:

  • hearing with podcasts
  • reading with blogs, websites, infographics …
  • watching with videos …

I am amazed how accessible knowledge is ! Almost everything you want to learn is taught in different styles, depth, duration, and format. So I hope you will discover helpful links below:

Have a nice learning journey !

Podcasts (English):

Physiotherapy centred:—The-current-state-of-Self-management-emseu7


Philosophy centred:



Podcasts (French) :



Websites (English):



Websites (French):




Validity of clinical small-fiber sensory testing to detect small-fiber degeneration

(Ridehalgh, Sandy-Hindmarch, & Schmid, 2018)

Aims: To examine the validity of clinical tests to assess small nerve fibers degeneration using Carpal Tunnel Syndrome (CST) as a model neuropathy.

Methods: Prospective cross-sectional. Presence of CTS was assessed with skin biopsies. 85 patients with CTS were evaluated with Neurotip and Quantitative sensory testing (T°). A subgroup of 51 CTS was tested with toothpick and coins.

Results: None of the test in isolation has sufficient validity in isolation. However, reduced pinprick has LR+3,94 and Sp=0,88 and can help rule in small fiber degeneration (not toothpick). Negative cold and warm with coin has LR-0,14, Se=0,98 and can help rule out small fibers degeneration. More severe easier to rule in, less severe more difficult to rule out.

Issues: Tested only on upper arm and may be different in ≠ areas of body less innervated. Excluded other small nerve neuropathies, or other issues that may be present in clinical practice. + and – LR are weak, the study shows which is the best indicator but among relatively weak tools. Use of control may inflate Sp and LR+.

Practice: Use pinprick test first, if positive then we can rule in pathology. If negative, cold warm coin detection is needed to rule out small-fiber degeneration. Just clinical suspicion: Gold standard in needed to confirm diagnosis.

Ridehalgh, C., Sandy-Hindmarch, O. P., & Schmid, A. B. (2018). Validity of Clinical Small–Fiber Sensory Testing to Detect Small–Nerve Fiber Degeneration. Journal of Orthopaedic & Sports Physical Therapy, 48(10), 767–774.

Movement control tests of the LBP; evaluation of the difference between P with LBP and healthy controls

(Luomajoki, Kool, de Bruin, & Airaksinen, 2008)

Aims: To determine whether the number of positive tests out of six active MC tests was different in patients LBP VS healthy controls + if ≠ according to the duration of LBP.

Methods: Case control study, Non blinded, 108 P and 102 controls, consecutive Germans, LBP (excluded radiculopathy), 12 ratters. 3 trials, oral explanation + if needed demonstration. 6 Motor control tests performed (Luomajoki tests) in the same order. Statistical analysis.

Results: Comparable groups, 2,21 (P) vs 0,75 (C) positive tests. Statistical difference, large effect size. There was a significant difference between acute and chronic, as well as between subacute and chronic but not between acute and subacute patient groups. The more chronic the more +ve tests.

Limitations: Case control no search of cofounding factors? Small clinical difference. Results not shown (which test + wich – on the 6). No blinding + subjective diag.

In Practice: There may be a difference, in the number of MC tests in LBP patients and the more chronic the more positive tests. MC evaluation through Luomajoki tests may be of use in LBP patients. Although tests have not been studied for validity, and the effect of MC treatment strategies have not been proven effective.

Luomajoki, H., Kool, J., de Bruin, E. D., & Airaksinen, O. (2008). Movement control tests of the low back; evaluation of the difference between patients with low back pain and healthy controls. BMC Musculoskeletal Disorders, 9(1), 170.

Creep and hysteresis / preconditioning : Load displacement time characteristics of the spine under PA mob

(Lee & Evans, 1992)

Aims: Among others, to evaluate the effects of cyclic and sustained PA loadings, and on loading rate on PA mobility.

Method: N = 28, 18 – 23 yo, 50/50 male/female. Assessed mobility of L3-L5 (max 150N), three cyclic loadings on L4 (150N) and sustained loading on L4 (100N in two min). Displacements measured with transducers on level above and below. Pad put under applicator to minimize discomfort. Pad preloaded.

Results: No gender difference in spinal mobility. PA mobility together varied significantly between spinal levels, L5 most mobile, then L4 and L3. Cyclic and sustained load induced progressively more displacements. For sustained, most displacement seen in the first 30 seconds (69%) creep. For cyclic two first loading cycles showed more displacement (hysteresis / preconditioning). Slow rate of loading produced more displacement. However, effects of creep and preconditioning are temporary.

Limitations: Error of the measured displacement because of soft tissue compression. We do not know the actual vertebral displacement.

Lee, R., & Evans, J. (1992). Load-displacement-time characteristics of the spine under posteroanterior mobilisation. Australian Journal of Physiotherapy, 38(2), 115–123.

Massage for LBP

(Furlan, Giraldo, Baskwill, Irvin, & Imamura, 2015)

Aims: To assess the effects of massage therapy for people with non-specific LBP.

Methods: RCTs, LBP, Inactive (supposed to be ineffective) or active modalities. Outcomes measures = pain and functional status, < or > to 6months. Secondary outcome = overall improvement, patient satisfaction, quality of life and work-related status. Cochrane methodology. Total patients 3096.

Results: Adverse events: No other that increase in pain in 5 to 25% of patients.

-Massage vs inactive controls for acute LBP: It is unclear whether or not massage is more effective than inactive controls for pain and function at short-term follow-up.

-Massage vs inactive controls for sub-acute and chronic LBP: It is unclear whether or not massage is better than inactive controls for pain and function in the long term.

-Massage vs active controls for acute LBP: unknown.

-Massage vs active controls for sub-acute and chronic LBP: It is unclear whether or not massage is more effective than active controls for pain and function in the short-term follow-up and for pain and function in the long-term.

Low to very low quality of evidence.

Limitations: Allocation, blinding, incomplete data, selective reporting, funding not reported,

In Practice: We have very little confidence that massage is an effective treatment for LBP. For acute LBP, massage improved pain but not function when compared to inactive controls in the short-term follow-up. For sub-acute and chronic LBP, massage improved pain and function outcomes in the short-term but not in the long-term follow-up when it was compared to inactive controls. Compared with active controls, massage improved pain in the short and long- term follow-ups, but it did not improve function at any follow-up. There were only minor adverse effects with massage. The benefits of massage for patients with acute, sub-acute and chronic non-specific LBP were found mostly in the short-term follow-up period (up to six months after randomization) for pain outcomes.

Furlan, A. D., Giraldo, M., Baskwill, A., Irvin, E., & Imamura, M. (2015). Massage for low-back pain. Cochrane Database of Systematic Reviews, 2017(12).

Runners with PFP have altered biomechanics which targeted interventions can modify

(Neal, Barton, Gallie, O’Halloran, & Morrissey, 2016)

Aims: To synthesise prospective, observational and intervention studies that measure clinical and biomechanical outcomes in symptomatic running populations.

Methods: SR, 2 independent reviewers, 28 studies, PeDro scale for quality.

Results: Very limited prospective evidence indicates that increased peak hip adduction is a risk factor for PFP development in female runners; in addition to limited evidence that running retraining changes both symptoms and function via a likely kinematic mechanism of reduced peak hip adduction. This is supported by moderate evidence from cross-sectional research in mixed sex cohorts, with a correlation also identified between PFP during running and increased peak hip adduction, internal rotation and contralateral pelvic drop. Further prospective research is needed to clarify if these relationships are of a causal or associative nature. Limited evidence also indicates that proximal strengthening exercise changes both symptoms and function at short-term follow up, but currently potential biomechanical mechanisms are unclear.

Limitations: In some studies: insufficient data, methodological issues, representativeness of sample, reliability of outcome measure, only 1 HQ and 2MQ, short term 3 months only …

In Practice: Running pattern may be influencing PFP and evaluating and addressing these may help some patients (especially in female group).

Neal, B. S., Barton, C. J., Gallie, R., O’Halloran, P., & Morrissey, D. (2016). Runners with patellofemoral pain have altered biomechanics which targeted interventions can modify: A systematic review and meta-analysis. Gait and Posture, 45, 69–82.

No difference in quantitative MRI in PFP cartilage composition between patients with PFP and healthy controls

(Van Der Heijden et al., 2015)

Aims: To investigate differences in patellofemoral cartilage composition between patients with PFP and healthy control sub- jects using quantitative MRI

Methods: Cross-sectional case-control study, PFP group symptom duration from 2 months to 2 years, 14 to 40 yo. 64 patients and 70 controls.

Results: No significant differences were found in relaxation times of patellar and femoral cartilage between patients and control subjects within the adolescent and adult sub-groups.

Limitations: Small number, some did not do all MRI tests. Diagnostic criteria incomplete. Differences in controls needed adjustment. Selected population.

In practice: Cartilage composition seems not to differ between patients with PFP and asymptomatic controls.

Van Der Heijden, R. A., Oei, E. H. G., Bron, E. E., Van Tiel, J., Van Veldhoven, P. L. J., Klein, S., … Van Middelkoop, M. (2015). No Difference on Quantitative Magnetic Resonance Imaging in Patellofemoral Cartilage Composition between Patients with Patellofemoral Pain and Healthy Controls. American Journal of Sports Medicine, 44(5), 1172–1178.