The Nocebo Effect

By Douglas Nelson
[Table Lessons]

Ms. K. was an elegant woman in her late 70s. Her many years of dance training were evident in the way she carried herself. When I asked her how I might be of help, her reply was very clear.
“I have been diagnosed with severe degenerative arthritis of my spine and my right hip. I don’t know how much you can do for arthritic degeneration, but I would be happy with any small improvement.”
“I assume this has been coming on gradually, getting progressively worse?” I asked.
“No,” she replied, looking at me as though I had gotten it all wrong. “This started December 20, right before Christmas. It was a stressful time.”
“And before that?” I inquired.
“Not bad, except for being a little stiff in the morning. After the holidays, I went to see my doctor and he took X-rays. The diagnosis was degenerative arthritis in my lumbar spine and right hip. He said there isn’t really anything to do for the back and that the hip isn’t bad enough to do a replacement.”
“Show me where your back is hurting,” I said. Ms. K. stood and pointed to her low back and sacral area, and stated that the pain was bilateral.
While Ms. K. was standing, I palpated her erector spinae in the lumbar area. I took her hand and placed her finger on the muscle. “What do you feel?” I asked.
“I feel my spine.”
“Actually, that’s a muscle,” I replied. She looked at me in disbelief. “It feels hard because it is working like crazy, but this muscle should be fairly relaxed while you are standing.” I placed her fingers over the muscle again and began altering her body’s position, bringing her spine over the gravitational line.
“Oh my goodness, I just felt it soften.”
“Exactly,” I replied. “By altering your position, you let the bones in your spine bear your weight instead of the muscles, allowing the muscles to relax. Can you feel the difference? Lean forward and feel the muscle contract again. Now, bring your weight back again and feel the muscle relax.”
“That’s wonderful,” she exclaimed, staring at me in amazement. “I can practice this at home, too, correct?”
“Yes, you can,” I said. “Could you lie on your right side on my table? Let’s examine your muscles in that position.”
With Ms. K. lying on her side, I began to palpate her multifidi and erector spinae. While several areas were quite sensitive, it wasn’t until I touched the multifidi attachments at about S2 that she reacted strongly.
“Goodness, that is tender,” Ms. K. exclaimed. “No wonder I hurt.”
I had Ms. K. lie on her left side and we went through the same procedure with her right multifidi and erector spinae. The areas of tenderness were quite similar bilaterally.
I then turned my attention to her hip, taking it gently through a range of motion in all planes. I was stunned at her movement capability—it was far better than I expected. My face must have looked perplexed.
“Is everything OK?” Ms. K. asked.
“Better than OK,” I replied. “Your hip has much more movement than I expected, given your diagnosis.”
“That’s nice to hear, but both doctors said the hip is very arthritic. I am afraid that I won’t be able to sustain the active lifestyle that my husband and I have always enjoyed.”
“Wait, both doctors?” I asked.
“Yes, a doctor at Mayo Clinic also said that I would likely be using a cane in less than five years. It is quite depressing to have that to look forward to.”
“When was that?” I asked.
“1999,” she replied nonchalantly. I stared at her in disbelief. It took a moment for her to realize what she had just said. I had to respond.
“I’d like to make three points, if I may. First, it would be extremely unusual for anyone over 70 to not show degenerative changes in the spine. Second, it isn’t a given that arthritis is the cause of your back pain. Since your pain started exactly on December 20, what do you suppose your spine looked like on December 19? Third, the prediction that you would be using a cane in five years was 15 years ago.”
Ms. K.’s expression changed as she processed the meaning of my words. “Maybe the X-ray looks worse than it actually is?” she wondered aloud.
In Ms. K.’s case, and in many others, seeing was believing. Being told what to expect by two doctors and an X-ray had colored her interpretation of her aches, pains, and physical problems.
Words and images have powerful effects, both positive (placebo) and negative (nocebo). X-rays don’t always tell the whole story—there isn’t always a direct relationship between what is seen and the pain a person is experiencing.
Ms. K. improved greatly after two sessions, showing that degenerative changes could not account for all of her pain. Much of that improvement was probably due to a change in her perception of the meaning of her pain.

Douglas Nelson is the founder and principal instructor for Precision Neuromuscular Therapy Seminars and president of the 16-therapist clinic BodyWork Associates in Champaign, Illinois. His clinic, seminars, and research endeavors explore the science behind this work. Visit, or email him at

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