4 parts (click the right arrow to get to the next video)

Part I: Overcome Pain, Live Well Again (45 minutes)
Part II: Pain is like Vision (42 minutes)
Part III: Neuroplasticity (60 minutes)

Although the potential for placebo responses is a ubiquitous feature of all health care practices, placebos are usually referred to as irrelevant and unintended side-effects. It is only by subtracting the magnitude of change produced by placebo responses that the ‘real’ value of any treatment may be revealed. When ‘real’ effects are considered an impossible consequence of the intervention, the intervention is designated a sham-or a scam. However, placebo responses often result in very meaningful for changes for the patient, and since meaningful positive change is the primary motivation for seeking care, this must reconciled with the professional responsibility to provide definite therapeutic inputs.

It is now well recognised that placebo effects occur in response to the contextual components of the therapeutic encounter and the patient’s individual interpretation of these. Unless we intend to resurrect Cartesian dualism, placebo effects must be understood as arising from brain effects, i.e. processing within the central nervous system has changed in some way. Therefore, placebo is not something that is ‘administered’. It is a response that emerges from the patient.

The clinical potency of therapeutic responses dependent on the contextual components of therapy is malleable. For example, Ted Kaptchuk’s team have demonstrated that sham acupuncture is associated with significantly greater reduction in pain intensity and symptom severity than placebo pills for repetitive-use arm pain. Culture, social circumstances, personal history, individual predilections and expectations all shape the patient’s interpretation of the significance of the illness experience and that of the particular treatment process. According to Moerman and Jonas, placebo responses occur when the meaning of the illness experience has changed. They have even proposed that the placebo response may be more accurately termed the meaning response.

Meaning is enhanced via story, and the stories we tell patients about their illness and the treatment we prescribe can have a significant effect on the perception of these experiences. A classic example of this was seen in a study by Moseley et al., which demonstrated that teaching patients about the neurophysiological mechanisms responsible for their pain, particularly the tenuous relationship between pain intensity and tissue damage, resulted in immediate improvements in functional performance. The same education has been demonstrated to result in widespread alteration of brain activity characteristic of the pain experience.

Although there is no doubt that any story and subsequent treatment that is consistent with an individual’s expectations and/or is sufficiently convincing as an appropriate intervention will increase the likelihood of meaningful placebo responses, many argue that stories and accompanying treatments that are inconsistent with objective understanding of human function are unhelpful at best and dangerous at worst. Moerman and Jones write,

“by focusing on placebos, we constantly have to address the moral and ethical issues of prescribing inert treatments, of lying, and the like. It seems possible to evade the entire issue by simply avoiding placebos. One cannot, however, avoid meaning while engaging human beings.”

However, giving inert treatments is not identical to using the meaning response therapeutically. One need not give sugar pills. Providing intervention that is both consistent with objective understanding of human health and illness and seeks to enhance the significance of the therapeutic process may maximise positive outcomes without compromising ethical and moral responsibilities.

Placebo responses are not sufficiently potent to resolve all health problems. Conditions that are the most amenable to placebo responses are those associated with psychological distress and sympathetic arousal, e.g. anxiety, depression, hypertension, angina, stress-related immunosuppression, addiction, functional digestive disorders, headaches, and especially, pain. John Medina explains that psychophysical stress responses occur when a negative situation is interpreted as beyond one’s control. Positive changes in the meaning of these experiences may occur when a person:

1. receives an explanation that makes sense to them
2. feels safety in the presence of aid or the expression of care and concern
3. experiences an intervention they expect will resolve the problem as they understand it
4. gains skills and knowledge that allows control or mastery over the experience.

The following list was presented by Walach and Jonas in their paper, Placebo research: The evidence base for harnessing self-healing capacities. These methods have been demonstrated in the medical literature as effective for enhancing placebo responses:

• Use more frequent dosing (or treatment) rather than less frequent dosing (up to a limit).
• Apply therapies in therapeutic settings such as hospitals and clinics.
• Attend to the route of administration.
• Deliver therapies in a warm and caring way.
• Deliver therapies with confidence and in a credible way.
• Determine what treatment your patient believes in or not.
• Be sure you as a therapist believe in the treatment and find it credible.
• Align all beliefs congruently: patient, doctor, family, culture.
• Deliver a benign but frequent conditioned stimulus along with the effective therapy.
• Use the newest and most prominent treatment available.
• Use a well known name brand identified with success.
• Cut or stick the skin or poke into an orifice whenever it is believed important.
• Inform the patient what they can expect.
• Use a light, laser, or electronic device to deliver and track the treatment when possible.
• Incorporate reassurance, relaxation, suggestion, and anxiety reduction methods into the delivery.
• Listen and provide empathy and understanding.

and an easy one for manual therapists…

• Touch the patient.

Check out this great interview with Nicholas Humphrey on contextual therapeutic responses from an evolutionary perspective.

Dar et al.1 have recently conducted a study with aim of determining the prevalence of SIJ fusion using 3-D CT imaging. The study examined 287 consecutive patients (159 male, 128 female) referred to a hospital radiology department for a variety of abdominal complaints. The patients ranged from 22-93 years. Patients with spinal diseases, such as spondyloarthropathy and diffuse idiopathic hyperostosis (DISH), were excluded. Unfortunately, information on low back pain status was not reported. 3-D images of pelvises were obtained using a 64-slice CT scanner, and volume rendering sections of 1-2mm thickness. Multiplanar reformation was used to detect whether the fusion was intra- or extra-articular. The SIJs of each image were divided into six equal areas and the presence, side and location of fusions were recorded. Assessment was made by two radiologists who were blind to each others results and the interexaminer agreement was substantial.

SIJ fusion was found in 16.7% of subjects and was far more prevalent in males (27.7%) than females (2.3%). All fusions were extra-articular. Fusion in males was strongly correlated with age: 5.6% in the 20-39y.a. cohort, 15.85% in the 40-59y.a. cohort, 31.1% in the 60-79y.a. cohort, 46.7% in individuals aged over 80. Fusion among females was not significantly correlated with age. Fusion was present bilaterally in 11.9% of males. Diffuse fusion was present in 7.5% of males, four cases were bilateral. The superior region was involved in all male individuals manifesting the phenomenon. No fusions were isolated to the inferior part of the joint. Fusion of the females was at just above and under the arcuate line at the most anterior point of the joint.

The results of this study accord with previous skeletal and cadaver studies and demonstrate that SIJ fusion is common. Further, it is clearly an age and gender biased phenomenon. The authors suggest that manual therapists who frequently utilise manipulation techniques aimed at addressing sacroiliac articular mobility or that result in forces across the sacroiliac joint should be aware of the limited potential for compliance at this joint in older males. The risk of injury may be far greater than the potential benefits of manually applied forces during the treatment of SIJ dysfunction in this population.

1.    Dar G, Khamis S, Peleg S, Masharawi Y, Steinburg N, Peled N, Latimer B, Hershkovitz I. Sacroiliac joint fusion and the implications for manual therapy diagnosis and treatment. Manual Therapy. 2008;13:155-58.

The researchers conducted a literature search on PubMed, the Cochrane Library and on www.fasciaresearch.com. They also conducted an assessment of the rationale for the treatment within the studies. The search on PubMed resulted in 71 references, but only 23 were about manual MFR. A similar search in The Cochrane Library gave 13 hits, 5 about MFR and all of these already included in the 23 PubMed references. No futher supplements were found at www.fasciaresearch.com.

According to their results:

No studies were found with which to determine reliability of the diagnostic method. Four randomised controlled studies of the treatment were identified. Two of the efficacy studies comprised several different modalities of treatment, so that no conclusions could be drawn. In one further study, the numbers were too small to allow safe conclusions; in the other, the myofascial release treatment was inferior to an isometric contract-relax technique. Overall, no good evidence of efficacy has been shown.

The current evidence did not allow conclusions on the diagnostic criteria and methods or demonstrate any efficacy of myofascial release. Remvig et al. strongly recommended that “reliability studies be performed on diagnostic tests for myofascial dysfunction (tightness/looseness), so that efficacy studies can be performed on a more solid diagnostic foundation”.

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