Control and manipulation of contextual factors in musculoskeletal pain management. A valid opportunity to enhance the effectiveness of the specific therapy

Objective. To investigate the therapeutic relevance of contextual factors (CFs), placebo and nocebo responses in the management of musculoskeletal pain. Design and Method. A narrative review was performed based on an extensive literature search conducted in Medline through Pubmed without time and language limit in June 2017. The keywords adopted were: “placebo”, “nocebo”, “contextual factors”, “musculoskeletal”, “pain”. Results. 222 relevant papers were selected and used to write the review. A growing body of research ascribes to CFs a significant role as influencers of musculoskeletal pain. Indeed, CFs impact the patient’s pain through specific neurochemical process and brain circuit responsible for triggering placebo and nocebo responses. The classical conditioning, the expectancy, the anxiety reduction, the reward and psychological theories clarify the clinical effect of the CFs. CFs embody therapeutic rituals and signs constantly current in the therapeutic encounter between patients and clinicians. They are synthesizable in five dimensions: patient’s features (expectation, history, baseline characteristics); clinician’s features (behavior, belief, verbal suggestions, therapeutic touch); patient-clinician relationship features (positive therapeutic encounter, patient-centered approach, social learning); treatment features (overt therapy, posology of intervention, modality of treatment administration, promotion of treatment); healthcare setting features (environment, architecture, interior design). Conclusions. Due to their possible role on the outcome, the proactive manipulation of CFs should be taken into consideration by every clinician and incorporated in the clinical approach to musculoskeletal pain. A conscious and ethically correct integration of CFs in clinical practice is a valid opportunity to enhance the effectiveness of the specific therapy. There is a strong need of translational research on CFs to guide clinicians to a better management of pain in daily practice.