Massage & Bodywork

MAY | JUNE 2019

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102 m a s s a g e & b o d y w o r k m a y / j u n e 2 0 1 9 client expectations influence the outcomes of manual therapy, and his thoughts on placebo mechanisms (a favorite topic of my own: see "Are You a Placebo," Massage & Bodywork, July/August 2018, page 80). Bishop says that placebo has a "branding problem" because "people think placebo is nothing; a sugar pill. Placebo mechanisms, however, are far from nothing," since the mechanisms behind placebo responses are physical, hormonal, endocrine, and neurotransmitter changes in the body. Bishop emphasized that placebo effects are always present in our treatments, whether we consciously use them or not. "We always provide care within a context," Bishop says. "I've never walked into a black room, in a dark spandex suit, to treat someone lying on a table who's blindfolded, with earplugs, and asleep." But it was his findings on client and practitioner expectations I found most interesting: • In a 400-person comparative study of spinal manipulation versus spinal mobilization effectiveness for back pain, therapeutic touch (or TT, in which therapists simply "place their hands on or near their patient's body with the intention to help or heal" 3 ) was used as sham treatment (i.e., as a placebo comparison, intended to reveal the direct effects of the spinal methods). In a surprise to the researchers, at the end of the six-year study, TT was the most desired treatment by the participants, and the treatment they most expected to help their pain. 4 • In another comparative study, massage therapy was the neck pain treatment that study participants most expected would help (Image 3). 5 • In studies of cervical, shoulder, and lumbar complaints, patients' general expectation of recovery has been repeatedly found to be the strongest predictor of recovery; stronger than the therapeutic method used, practitioner experience, or other factors. 6 Given this, Bishop says, our skills at building an alliance and keeping clients engaged are probably more important to pain recovery than any particular method or therapy. • And perhaps most importantly, Bishop's research showed that method does matter, but on the providers' (rather than clients') side: when practitioners had a strong preference for a particular treatment, that treatment had better results, no matter what that treatment was. 7 IS PAIN SCIENCE PASSÉ? This was the fifth San Diego Pain Summit, and with 111 participants in attendance, this summit was a bit smaller than in previous years. Does this dip in size mean that interest in pain science is waning? There are signs elsewhere that perhaps the initial gush of enthusiasm about biopsychosocial approaches might be fading. In the manual therapy blogs and podcasts I follow, "pain" is much less frequently a topic than it was just a couple years ago; and on one (formerly?) pain-science–friendly podcast, the hosts audibly snickered when "pain science" was mentioned among the list of trendy topics that are no longer in the fore. 8 Or could it be that biopsychosocial perspectives on pain have by now percolated deeply enough into our field that they are no longer quite so radical or new? No idea stays on the cutting edge indefinitely; at some point, a novel view either fades away or becomes part of the mainstream. Though some would argue that pain science hasn't penetrated deeply enough into massage and bodywork yet, its influence on our field is well-established and maturing. After all, these ideas have been around for some time now. Many physical therapists trace pain science ideas to David Butler's neurodynamic work in the 1990s; or MTs, to Diane Jacob's Dermoneuromodulating approach, which she developed in the last decade. But biopsychosocial concepts have parallels in earlier concepts of body- mind holism, including Feldenkrais's work from the 1970s, and many other early influences on massage and bodywork. Here at, it's been about six years since we offered our first pain-science–focused course ("Chronic Pain," also available in ABMP's online member library at, and it's not an exaggeration to say our entire in-person curriculum has been accordingly revised in the years since. We are not alone in this: several of my esteemed continuing education colleagues (such as Erik Dalton, Walt Fritz, Whitney Lowe, Ruth Werner, and others) have also incorporated pain PT and researcher Mark Bishop, PhD, on the influence of patients' and practitioners' expectations on therapeutic outcomes. Chart: Study participants' expectations of neck pain benefit from common interventions for "this episode of neck pain," ranked by level of agreement (blue bar) with "I believe [the intervention] will significantly help improve this episode of my neck pain." From the left (most agreement): Massage; Manipulation; Strengthening; ROM; Aerobic; Traction; Rest; Modalities; Medication; Surgery (least agreement). Image courtesy; chart slide courtesy Dr. Bishop, used by permission. 3

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