Side-effect expectations are associated with disability, physical fitness, and somatic symptoms 3 months after post-COVID... 2024 Salzmann et al

[Andy]

Full title: Side-effect expectations are associated with disability, physical fitness, and somatic symptoms 3 months after post-COVID neurological inpatient rehabilitation

Highlights

• Post-COVID-19 condition is asscociated with long-term health issues.
  
  
• A biopsychosocial approach seems necessary to enhance treatment of post-COVID.
  
  
• We examined the impact of expectations on post-COVID neurological rehab outcomes.
  
  
• Side-effect expectations predicted illness-related disability and patients‘fitness.
  
  
• Managing patient expectations is crucial for optimal rehab outcomes.

Abstract

Introduction
The COVID-19 pandemic, caused by SARS-CoV-2, has led to long-term health issues known as post-COVID-19 condition, including fatigue and cognitive disruptions. Despite its recognition as a public health concern, the efficacy of therapeutic interventions, especially in neurological rehabilitation, remains unclear. This study examines how treatment expectations are associated with psychological and physical outcomes in post-COVID-19 condition neurological rehabilitation.

Methods
In an observational cohort study 61 patients with confirmed post-COVID-19 condition were included. Baseline (T0) data on treatment and side effect expectations were collected, before participants underwent a 4–6 week multidisciplinary rehabilitation program. Primary outcome was illness-related disability (Pain Disability Index). Secondary outcomes included depressive symptoms (PHQ-9), anxiety levels (GAD-7), functional status (PCFS), fatigue (CFS), and physical fitness (6MWT). Regression models analyzed the associations of baseline expectations with outcomes at the end of rehabilitation (T1) and three months post-rehabilitation (T2).

Results
After adjusting for multiple testing, higher baseline side-effect expectations were associated with greater illness-related disability (β = 0.42, p = 0.007), reduced physical fitness (β = − 0.24, p = 0.04), and more somatic symptoms (β = 0.33, p = 0.006) at follow-up (T2). Positive treatment expectations were associated with poorer functional status (β = 0.35, p = 0.011) at T2.

Conclusion
This study highlights the associations of side-effect expectations with post-COVID-19 condition rehabilitation outcomes. Higher side-effect expectations were associated to poorer outcomes, indicating a nocebo effect. Surprisingly, positive expectations were linked to worse outcomes, possibly due to unrealistic optimism. Managing patient expectations realistically and addressing side-effect concerns seems crucial for optimizing rehabilitation outcomes.

Open access, https://www.sciencedirect.com/science/article/pii/S0022399924003143

 

[forestglip]

Patients participated in a 4–6 week multidisciplinary rehabilitation program tailored to their specific neurological symptoms. The program components included physical therapy, cognitive rehabilitation exercises, and psychosocial support based on initial comprehensive evaluations by an interdisciplinary team comprising neurologists, psychologists, psychiatrists, and physical therapists.

Higher side-effect expectations at baseline were moderately associated with greater illness-related disability (PDI: β = 0.42, p = 0.007), reduced physical fitness (six-minute walking test: β = − 0.24, p = 0.04), and more perceived somatic symptoms (PHQ-15: β = 0.33, p = 0.006) at follow-up (T2).

Patients with higher side-effect expectations tended to have poorer outcomes, aligning with the nocebo effect [8,9,11], where anticipation of adverse effects exacerbates symptoms and hinders recovery. The results are also in line with studies underscoring the importance of expectations and beliefs showing that the belief in having been infected was associated with more persistent somatic symptoms after COVID than having a laboratory-confirmed infection [24,25].

One reason for the findings in our study could be that patients who expect side-effects may experience heightened anxiety and stress as well as more symptoms [8,12]. Additionally, these patients might be less likely to fully engage in their rehabilitation program due to fear of exacerbating side-effects, thereby reducing the effectiveness of the treatment.

I don't see them suggest that maybe the reason the patients with higher side effect expectations did worse was because they know their bodies. All the interventions require some degree of physical and/or mental exertion. If they have experienced PEM in the past, surely they'll be more likely to both expect the interventions to cause them some degree of harm, as well as be correct.

They did say this about more "realistic" expectations, though I'm not quite sure what they are suggesting:

However, in this case, patients with prior unsuccessful rehabilitation attempts might have developed more realistic or even pessimistic expectations, which paradoxically helped them engage more effectively with the treatment.

Not really sure what to make of the other association:

More positive treatment expectations at baseline were moderately associated with a poorer functional status (PCFS: β = 0.35, p = 0.011) at follow-up (T2). All other other associations were not statistically significant after adjusting for multiple testing.

Interestingly, this study also found that positive treatment expectations were associated with a worse functional status. This result is in contrast with much of the existing literature [8,9,11], which generally finds that positive expectations enhance treatment effects (ie, recovery in a rehabilitation context) and negative expectations hinder it [10]. One possible explanation for this unexpected finding is that the positive expectations of patients in this study might have been overly optimistic or unrealistic. When patients have overly high expectations, the gap between these expectations and actual outcomes can cause expectation violations [27], leading to disappointment and reduced motivation, which could negatively impact recovery.

 

[rvallee]

Good grief this is dumb. Zero attempt at making sense of the world out there. They're completely dominated by their own thoughts.

 

[RedFox]

The authors of this paper simply don't understand the nature of long Covid or chronic illness in general. People expect certain outcomes from therapy because they know their bodies.

 

[bobbler]

Uggggh

I wonder how well they checked for whether there was maybe a bigger confounding factor that was causal to both expectations and outcome

I find this new propaganda so scary as it’s stopping the disabled from expressing their limits . It really is hysterical women / wimpy disabled people not pushing hard enough so keeping themselves disabled crap this expectation effect nonsense trope

And as @forestglip points out there was a negative correlation where the most enthusiastic ended up with the worst function

and they tried to twist that!

here’s why it makes no sense

you should only use functional measures to see if it works

expectation isn’t why this fails!

not suggest the opposite conclusion - I’m gobsmacked at the cheek

Clearly their sales pitch was not accurate ie fibbed about what it could do outcome wise

maybe the message is that they need to stop claiming that and any funding they get based on it until they improve what they do to be something that does work functionally and long term by doing proper research ??

 

[Hutan]

Incredible

The people who expected to get worse with the BPS treatment got worse.
The people who expected to get better with BPS treatment got worse.
Conclusion: 'Managing patient expectations is crucial for optimal rehab outcomes." (e.g. lower the bar for "success")

Look at the title, focused on the 'wrong thinking' of the patients. It should have been 'Current approaches to curing Long Covid aren't working'. But no, the deluded thinking continues.

A German study. Perhaps that satirist who did the good item on ME/CFS lately would be interested to get a copy of the paper.

 

[bobbler]

Incredible

The people who expected to get worse with the BPS treatment got worse.
The people who expected to get better with BPS treatment got worse.
Conclusion: 'Managing patient expectations is crucial for optimal rehab outcomes." (e.g. lower the bar for "success")

Look at the title, focused on the 'wrong thinking' of the patients. It should have been 'Current approaches to curing Long Covid aren't working'. But no, the deluded thinking continues.

A German study. Perhaps that satirist who did the good item on ME/CFS lately would be interested to get a copy of the paper.

If it wasn't for a small sample size then this is one of those papers to add to one of those threads for 'debunking the orthodoxy'

because it proves that whatever expectation they had that wasn't what made the difference

ie they proved their 'null'?

Worse, as well as expectations having nothing to do with it, the message is that their treatment doesn't help, so they should be using that as useful information to either report that and let someone else take over who is a different dept with soemthing to offer and pass on those results so they don't try the same things - not suggesting they need to try some third way on the spiel and mind-bending they wrap the treatment up in

then suggested in their own recommendations that what they needed to work on was expectations. Which to me

 

[Hutan]

Worth noting the people involved. They all should be embarrassed.

Journal of Psychosomatic Research

Stefan Salzmann ab; Mirko Herrman c; Markus Henning c; Lisa Schwertner c; Frank Euteneuer d; Lara Goldau a; Celine Bahr a; Christoph Berwanger c; Winfried Rief a
a Clinical Psychology and Psychotherapy, Philipps University Marburg, Marburg, Germany
b Medical Psychology, Health and Medical University Erfurt, Erfurt, Germany
c Hardtwaldklinik I Werner Wicker GmbH & Co. KG, Hospital for Neurology – Psychiatry/Psychotherapy With Psychosomatic and Trauma Therapy, Bad Zwesten, Germany
d Clinical Psychology and Psychotherapy, Department of Psychology, Medical School Berlin, Berlin, Germany


Funding sources
The study was funded by by the Professional Association for Health Services and Welfare (Berufsgenossenschaft für Gesundheitsdienst und Wohlfahrtspflege), Würzburg. The funder had no influence over the study design, data collection, analysis, interpretation, or manuscript preparation. The study was also inspired by the DFG CRC 289 on Treatment Expectations (Deutsche Forschungsgemeinschaft DFG, German Research Foundation: project-ID 422744262–TRR 289).

Declaration of competing interest
SS reports research funding (no personal honoraria) from the German Research Foundation and the German Heart Foundation/German Foundation of Heart Research. WR declares to have received honoraria from Boehringer Ingelheim for workshops on Post Covid, and royalties from book publishers. All other authors report to have no conflicts of interest to declare.

 

[SNT Gatchaman]

This is inane. Again with the Goldilocks mentality. Only we the very clever therapists can get this fixed with RightThink (apologies Orwell).

 

[Hutan]

This observational cohort study was conducted at the Hardtwaldklinik I Werner Wicker GmbH & Co. KG, Hospital for neurology – psychiatry/psychotherapy with psychosomatic and trauma therapy, Bad Zwesten, Germany, focusing on neurological rehabilitation for patients suffering from post-COVID-19 condition. A total of 64 patients were included in the study. The inclusion criteria included adults with a confirmed COVID-19 diagnosis, persistent neurological symptoms lasting more than 12 weeks post-acute infection, aligning with the definition of post-COVID-19 condition.

We aimed to recruit a sample size of 120 patients, based on the assumption that 10 patients could be enrolled per month over a 12-month recruitment period; however, due to the high effort involved in conducting the study, only 64 patients could be recruited in the allotted time frame. From these 64 patients, three had to be excluded because of missing data (2) and retracted informed consent (1), resulting in a final sample of 61 patients.

They struggled to get the planned cohort - which suggests word is getting around. As well as the three patients excluded or who withdrew, there is missing data in lots of the measures. There is missing data for six patients' baseline 6 minute walking data.

The analyses were adjusted for age, sex, and baseline severity of symptoms before including all three baseline expectations. We included baseline scores of each outcome (e.g., PDI at the start of rehabilitation) in our model to control for initial status and better isolate the association of patients' expectations with clinical outcomes. Although outcomes were measured at multiple time points (T0, T1, and T2), we did not use a repeated measures design. Instead, we conducted separate analyses for the end of rehabilitation (T1) and three months post-rehabilitation (T2). Baseline scores, sex, and age served as covariates to account for individual differences at the start of rehabilitation and enhance the precision of our estimates.

Always a bit worrying when the data is fiddled with, especially by people who clearly expect and want a certain outcome and especially when there is missing data too. Possibly okay, just flagging.

Mean positive treatment expectations were on average 6.22 (on a scale from 0 to 10), while negative treatment expectations were low with a mean of 0.82, and side-effect expectations were slightly higher but still low with 1.63 (scale 0–10). Patients spent an average of 32 days in inpatient rehabilitation.

Not surprisingly, their cohort was hopeful of a good outcome and did not expect much in the way of side effects. That's a lot of 'inpatient rehabilitation'. If you can't convert someone into thinking they are cured in over a month of residential care, maybe, just maybe, they have a condition that isn't amenable to being fixed by thinking differently.

 

[Hutan]

The Results section is terrible. There is no raw data given, the outcomes are all hidden behind models supposedly calculating outcomes with regression equations based on baseline data. Totally opaque.

Sex is a variable in the equations, and I don't think they even tell us which is higher, male or female.

It is important to consider that this sample might be unique since most patients had undergone previous rehabilitations that were not fully successful, as indicated by their continued need for rehabilitation.

Although we assessed several symptoms such as anxiety and depression using questionnaires, we did not systematically record the specific dosage and treatment each patient received for specific symptoms during the rehabilitation program. This limits our ability to interpret the impact of these treatments on the observed associations.

I don't really have words to convey how useless and misleading I think this piece of research is, and how unprofessional it is of the journal editors to allow the paper to have been published.

 

[Sean]

I don't see them suggest that maybe the reason the patients with higher side effect expectations did worse was because they know their bodies. All the interventions require some degree of physical and/or mental exertion. If they have experienced PEM in the past, surely they'll be more likely to both expect the interventions to cause them some degree of harm, as well as be correct.

+1

The people who expected to get worse with the BPS treatment got worse.
The people who expected to get better with BPS treatment got worse.
Conclusion: 'Managing patient expectations is crucial for optimal rehab outcomes." (e.g. lower the bar for "success")

It's ridiculous, isn't it.

The actual outcomes seem to make no difference at all to their 'reasoning', the explanation/conclusion they come up with is always 'more BPS'.

 

[SNT Gatchaman]

as indicated by their continued need for rehabilitation

It's not the patients that need rehabilitation.

 

[Andy]

how unprofessional it is of the journal editors to allow the paper to have been published

The journal being the Journal of Psychosomatic Research. The advisory board of the journal includes such 'champions' of good science as Per Fink, Judith Rosmalen, Michael Sharpe, and Jon Stone....

 

[Kiristar]

This is so disturbing. There's such an obvious answer to the accusatory title and for that to be ignored.

 

[Joan Crawford]

"Positive treatment expectations were associated with poorer functional status (β = 0.35, p = 0.011) at T2."

Doesn't this completely undermine their arguments?

 

[Joan Crawford]

"Managing patient expectations is crucial for optimal rehab outcomes."

What about the expectations of the clinicians and researchers? Where for goodness sake is the reflection on what the heck they have actually set out to do, and what data they received.

If twiddling about with pt outcomes by managing these is all you've got in the clinic then, please stop, go home and pass the patients on to someone with a grasp of reality, science and some hope of making objective improvements in patients' functioning.

Stop blaming the patients for poor outcomes that they don't like. Sick. Disturbing

 

[V.R.T.]

Chilling. But this obliviousness is the reaction I got telling a doctor how much sicker GET made me. He shrugged it off and recommend...more GET.

These people honestly live in their own fantasy world and the scientific community is enabling them. A whole discipline full of naked emperors strutting about talking nonsense to each other.

 

[rvallee]

It is important to consider that this sample might be unique since most patients had undergone previous rehabilitations that were not fully successful, as indicated by their continued need for rehabilitation.

So. Rehabilitation didn't work. Therefore they need more rehabilitation. And it still didn't work. Therefore they need even more rehabilitation.

You could get smarter reasoning out of brain damage. Not out of people who suffered brain damage but the actual damaged brain itself.

Any random group of willing teenagers would do better than this. Literally any random group. They don't even need lots of resources. They just need to care and not be mindlessly biased. There is clearly something wrong with medical training that you so consistently get worse outcomes out of experts than from a random process.

Hell, there is no way that any current ranked LLM wouldn't do better than this in every single way. Statistically, LLMs have outperformed this at least for a year. So before this study even started, it was already far dumber than even several open source LLMs out there.

Fantasy universe indeed. With zero overlap with actual reality.

 

[NelliePledge]

In all seriousness As it is German research team I really hope someone is going to flag it up to the late night comedian guy