In April of 2016, I had the pleasure to meet Brian Fulton, RMT, who was a co-presenter at the Registered Massage Therapists’ Association of British Columbia’s Biennial Conference, “Manual Therapy: an Interdisciplinary Approach to the Science and Practice”. His talk involved the understanding of the placebo effect in manual therapy and since that time I have been intrigued by the concepts presented in his talk and in his book, “The Placebo Effect in Manual Therapy”. Conversations since that time affirmed that he and I shared much interest and skepticism regarding the published and inherited narratives surrounding much of manual therapy. Brian agreed to participate in an interview for this blog and also to respond to questions that readers might have.

Walt: Hi Brian, Thanks for agreeing to answer some of my questions. Would you share a bit about yourself?

Brian: Thanks for inviting me! I am a Registered Massage Therapist and have been practicing in Ontario, Canada since 1999. I began writing, both as a personal interest, and as a way of promoting the profession of massage therapy in 2000 when an opportunity arose for me to be the staff health columnist for a local magazine. Since that time I have found myself writing quite a bit on various health topics that interest me. This book was a great outlet for that writing urge, and it allowed me to explore a topic in depth that held great curiosity for me, but about which I knew very little.    

Walt: What drove you to have interest in this topic?

Brian: It has always seemed to me that many manual therapy professionals and gurus seem to be quite certain that their method or their approach is THE way to treat many issues, or to treat specific issues. However, I always found it odd that vastly different approaches often seemed to be able to generate positive therapeutic outcomes for a given pathology. For example with tendonitis, various electrotherapies are employed (even as stand-alone modalities), NSAIDs are used, hydrotherapy is used, subtle manual therapies, stretching, and not-so-subtle therapies (friction technique) all claim to have positive clinical outcomes, and each modality has its own narrative/explanation for the mechanism of action. As manual practitioners, we have all witnessed this phenomenon, and it begs the question, what caused the healing to happen? Is there some commonality in all of these treatments? Is there another active agent at play? My sense was that psychosocial factors might be coming into play and accounting for at least part of the healing. Study of the placebo effect is looks specifically at the contributions of those psychosocial factors. Furthermore, while many books have been written on this subject, almost all are theoretical.

So, in 2007, I undertook the project of writing a book that could put this theory into practice, and I wrote it with a specific audience in mind– manual practitioners. It took years to complete, since it was written in my spare time, and it took another full year to publish. When I began the project, people looked at this subject suspiciously, for a whole host of reasons. My vindication has been that now the biopsychosocial approach is very much in vogue, especially in pain science. This is no longer a fringe idea; it has gone mainstream. This is also evidenced by the creation of the Program in Placebo Studies and the Therapeutic Encounter (PiPS) in 2011 at Harvard University. Its stated purpose is “to bring together researchers who are examining the placebo response and the impact of medical ritual, the patient-physician relationship and the power of hope, trust, persuasion, compassion and empathic witnessing in the healing process. PiPS research is multi-disciplinary and extremely inclusive spanning molecular biology, neuroscience and clinical care, as well as interdisciplinary, ranging from the basic sciences to psychology to the history of medicine.”

Walt: Why do you feel it is important for manual therapists to understand the placebo effect?

Brian: One of the most important reasons for therapists to get a basic understanding of this information is that the placebo effect is a bona fide phenomenon, and it is ‘in play’ during every medical encounter, whether we think so or not. Just like global warming, our belief is not required for the very real effects to manifest. Positive effects are termed ‘placebo effects’, and negative effects are known as ‘nocebo effects’.   So, by not understanding the principles involved in this phenomenon, not only are you failing to optimize the effects of your manual therapy, but you are also at risk of undermining your efforts, thereby doing a disservice to your client.

Psychosocial factors play an important role in the therapeutic encounter, and as you read manual therapy research, you will see terms such as non-specific effects, contextual factors, psychosocial factors, and placebo effects. Having looked at this topic in depth, I would say that the differences in these terms are simply semantics. I would say that ‘psychosocial factors’ is actually the correct umbrella term. However I used the term Placebo Effect in the book, because there is over sixty years of research available on this phenomenon. As a Medical Subject Heading[i] it yields far more research on this phenomenon than any other term. Think of classic image of blind men describing different parts of an elephant.

Walt: Would you mind sharing a few passages from the book?

Brian: From the preface:

“If you think that this topic is not terribly important because your patients are responding only to your treatment modality and not a placebo effect, then I suggest you look at the 2011 peer-reviewed paper published by The Journal of Manual and Manipulative Therapy entitled Placebo response to manual therapy: something out of nothing? In it, the authors look at 94 different research papers on manual therapy and on the placebo effect and draw some relevant inferences about the placebo effect in manual therapy. Some of the papers that they look at clearly suggest that what you and I think may be happening isn’t exactly what is happening. The evidence points to a strong placebo component in what we do in our professions. The authors state, “We suggest that manual therapists conceptualize placebo not only as a comparative intervention, but also as a potential active mechanism to partially account for treatment effects associated with manual therapy. We are not suggesting manual therapists include known sham or ineffective interventions in their clinical practice, but take steps to maximize placebo responses to reduce pain.” [ii] The evidence-based model is not affecting many practitioners mindsets quite as quickly as it was assumed it might. This is happening for many reasons, but certainly one reason is that many of us in this field operate from instinct and our own practice logic. We are not easily swayed by one study that says our model is incorrect. However when multiple studies say the same thing, it is definitely time to change our ways and adopt the new paradigm.

Another review of evidence is a paper published in 2010 entitled Effectiveness of manual therapies: the UK evidence report. In this report the authors looked at 49 recent relevant systematic reviews, 16 evidence-based clinical guidelines, plus an additional 46 random controlled trials (RCT) that had not yet been included in systematic reviews and guidelines. The authors looked at 26 categories of conditions containing RCT evidence for the use of manual therapy: 13 musculoskeletal conditions, four types of chronic headache and nine non-musculoskeletal conditions. This report, published in Chiropractic and Manual Therapies (the official journal of the Chiropractic & Osteopathic College of Australasia, the European Academy of Chiropractic and The Royal College of Chiropractors) recognizes the important role that manual therapy plays in treating a wide variety of ailments, but even in this report the authors state, “Additionally, there is substantial evidence to show that the ritual of the patient practitioner interaction has a therapeutic effect in itself separate from any specific effects of the treatment applied. This phenomenon is termed contextual effects. The contextual or, as it is often called, non-specific effect of the therapeutic encounter can be quite different depending on the type of provider, the explanation or diagnosis given, the provider’s enthusiasm, and the patient’s expectations”[iii]. “

Here is another excerpt from the book. It is from an early chapter which introduces the reader to the placebo phenomenon.

“There are many interesting phenomenon surrounding the placebo effect in respect to what enhances and suppresses the actual response to the placebo pill or treatment. The following effects have been documented in research studies. They are not all laid in stone, as there has been some variability in the findings, but the trends indicate the following:

• The effects of a placebo increase if the pill is physically larger, and yet smaller than normal sized pills also appear to have a more powerful effect. [iv]
• Warmer-coloured pills work better as stimulants, while cool-colored pills work better as depressants.[v]
• The effects will increase if the placebo is taken with increased frequency (conditioning theory).[vi]
• Increased frequency of visits to the attending health professional increase the effectiveness of the placebo (conditioning theory).[vii]
• Being told that a placebo will decrease pain will decrease most people’s experience of pain, and yet being told that that same placebo makes pain worse will increase most people’s experience of pain. (The nocebo effect)[viii]
• A placebo can be viewed as a symbol. The more significant the symbol, the more powerful the effect is likely to be. Surgery is at the high end of that scale. The scale looks something like this:
  • capsules beat out tablets[ix]
  • injections beat out drugs administered orally[x]
  • injections that sting work better than injections that do not sting[xi]
  • medical treatment machines beat out injections[xii]
  • sham surgery is considered the most powerful placebo[xiii]
• New or novel treatments (or drugs) often beat out older ones.[xiv]
• The severity of pain being treated influences the placebo response. With increased pain there is increased placebo response.[xv]. A 2001 review found that invasive, uncomfortable, sophisticated or painful interventions tended to enhance the placebo effect.[xvi]
• A placebo administered by a doctor is more potent than a placebo administered by a clerk. Even less effective is a placebo send via postal delivery.[xvii]
• Brand name placebos work better than generic placebos.[xviii]
• More expensive placebos tend to be more powerful than discounted ones.[xix]
• It is well-established that people who adhere to their drug schedules experience better outcomes. It is the same with placebos. The better that people adhere to their placebo drug schedule, the better their outcome. This was even shown in patient mortality figures.[xx]
• People have actually experienced withdrawal symptoms after long-term use of placebos.[xxi]
• Placebos have been shown to be geographically and culturally sensitive to placebo treatments.[xxii]”

Walt: The concept of the narrative has become a bit of an obsession with me on many levels.  We have discussed a bit of this in the past, namely my issue with certain aspects of the research on the placebo effect. You speak to the importance of the narrative, both to the patient but also to the therapists. If I am understanding you correctly, the apparent strength of the narrative can have effect on the outcome of the therapeutic intervention, no matter how accurate or inaccurate the therapist’s narrative might be. This is a bit troubling to me, as it sounds as if as long as the therapist sounds knowledgeable and tells a good story, the chances of improved outcomes go up. This makes sense, to some degree, as if a patient is given information that sounds plausible they have trust in the therapist’s knowledge and abilities. But if the story is bogus but told with certainty and an adequate sprinkling of science-like phrases, the placebo effect can be just as strong. Is this correct?

Brian: I appreciate your concerns, and there is no doubt that there are aspects of this phenomenon that can be exploited by a therapist of weaker moral character, but this could be said about almost any technique or modality. This is one of the reasons that we have regulatory colleges overseeing therapists to see that they are in compliance, acting ethically and professionally. Another driver keeping therapists from generating false narratives is the continuing education requirements from our regulatory colleges (in Canada) that oblige all practitioners to stay up to date with current knowledge. Much of what I was taught in school surrounding explanation of trigger points, Epsom salt use, stretching to prevent injury, massage flushing toxins, (and on and on) is no longer accurate. If I do not stay up to date as a health professional, then I continue to spread misinformation. So I would say that professionalism, ethics and regulation all help to prevent a therapist from knowingly generating a false narrative. Furthermore, if you look at the totality of the factors I examined in the book, professionalism and trust are also on that list, as well as narrative. If you create a false narrative, but then your client visits another health professional who explains to them that the explanations that you gave are not up-to-date and have now been disproven, you will have then lost the trust of your client. In reading my book or listening to my seminars you will recall that ‘trust’ is something harp on regularly as a theme that runs through all aspects of the therapeutic relationship and the placebo phenomenon.  

It is also important to keep in mind that ‘narrative’ is only one factor of many that surround this phenomenon. In the book I examine and write about the following other factors as well:

• Conditioning
• Expectancy
• Motivation and Desire
• Trust
• The Power of Listening
• Feelings of Care and Concern
• Establishment of a Feeling of Control
• Reducing your Patients’ Anxiety Levels
• Receiving Adequate Explanation of the Pathology
• Acceptance of the Mystery of Healing
• Certainty of the Patient
• Time Spent By the Practitioner
• Use of Ritual
• The Clinician’s Persona
  • Professionalism
  • Clinician’s Belief System
  • Confidence
  • Competence
  • Attire
  • Enthusiasm of practitioner
• Clinical/Healing Environment
• Practitioner’s Use of Humour

Walt: Also, the concept of how a patient’s narrative having great meaning has become more evident from listening to you and others speak. But, if a patient’s narrative is very inaccurate it can be conflicting with a patient’s understanding of pain. Is there a “best way” to deal with honoring a patient’s narrative to maximize benefit? Is there a time when re-education into newer understanding/narrative are best applied?

Brian: This is a very good question Walt. Certainly we need to meet our patients where they are, and speak to them in terms that they understand. So, there is no doubt that our explanations will take on a different manner depending upon their education, their cognitive abilities, their culture, and their own system of beliefs. As for the patient’s own narrative, I see no reason not to re-educate them toward a current understanding of pain science, healing, rehabilitation etc. There may be some situations where you might not want to disrupt their narrative, but I think that this would have to be examined on a case-by-case basis. The aspect of narrative that I deal with in the book is essentially whether the patient’s narrative is ‘working for them’. In other words, if their narrative leaves them feeling disempowered, unhappy, depressed, hopeless etc., then this would be evidence that their narrative is not working for them. Modern pain science has some hope and explanations for people feeling like they are powerless or not improving. We are not psychotherapists, and there will be times when we will want to refer out for issues beyond our scope of practice, but there are many things that I believe we can do to educate the patient and give them real (not false) hope. In this way, we are helping them to rewrite their own inner narrative to one of greater empowerment.

Walt: Brian, thanks so much for being a part of this discussion. I mention you and your book in each of my seminars as I feel the information you share is crucial to our understanding the nature of the therapeutic relationship.  I want to share with readers your website and contact information: www.fultonmassagetherapy.com. You can find Brian’s book, “The Placebo Effect in Manual Therapy” through Amazon.

If you have questions, please add them below.

For now,

Walt Fritz, PT

Foundations in Myofascial Release Seminars

References: The full reference list can be downloaded here.

[i] U.S. National Library of Medicine’s Medical Subject Headings MeSH®

[ii] Bialosky, 2011

[iii] Bronfort, 2010

[iv] Buckalew 1981, Thompson, 2005: 41

[v] de Craen, 1996

[vi] de Craen, 1999

[vii] Thompson, 2005: 40

[viii] Thompson, 2005: 71-82

[ix] Hussain, 1970

[x] Grenfell, 1961

[xi] Ernst, 2001: 17-30

[xii] Kaptchuk, 2000

[xiii] Kirsh, 2010: 111

[xiv] Shapiro: in Harrington 2000: 22

[xv] Levine, 1979

[xvi]Ernst, 2001: 17-30

[xvii] Thompson, 2005: 40

[xviii] Branthwaite 1981

[xix] Waber 2008

[xx] Simpson 2006

[xxi] Ockene, 2005

[xxii] Moerman, 1983

Author: Walt Fritz