Why Placebo is Lit
By Aran Bright
Holy guacamole, the topic of placebo is intense and complicated. And it is awesome!
As massage therapists, we owe it to our clients to understand this topic as best we can. It’s pretty clear the reason why massage is so effective has at least as much to do with the mechanisms related to the placebo effect and the nervous system as it does some of the old chestnuts, such as biomechanics.
Hopefully, by the end of this article you will gain an understanding of why it is probably more important to focus on the client’s experience of a massage than it is to focus on what techniques you used, at least when it comes to pain reduction.
What is Placebo?
In many cases the word placebo is associated with, “doesn’t work”, “a sham” or plain old “useless”. Actually, placebo is from the Latin placere, “to please”, and literally means “I shall be acceptable or pleasing”.
Medically, a placebo is an inert substance that is used to trigger a real, measurable effect; a positive effect. The good news is it may well be one of the most powerful tools open to a massage therapist in the treatment of pain. If massage therapists consider what is required for a client to have a placebo experience, we give ourselves the best chance of positive outcomes for pain reduction.
Placebo, Non-Specific Effects and Touch-Based Analgesia
Before we begin to get into how placebo works, it is important to note that massage can never really be a true placebo in one sense of the word. The medical definition implies that the placebo should have no direct effect on the subject. Touch does have measurable effects, so the more correct terms for placebo effects from massage are ‘non-specific’ or ‘contextual’ effects.
As mentioned earlier, placebo means “to please”, therefore it does keep things simple to consider any non-specific therapeutic approach that has a positive outcome as a placebo.
Touch-based analgesia (touch as a method to reduce pain) is one well researched topic associated with massage. The interesting thing about touch-based analgesia is that is does appear to be context specific. In other words, if we interpret touch as caring or therapeutic, this enhances the effectiveness of it. Also, if we focus on the sensation of touch (mindfulness), such as the warmth of someone’s hands, this also enhances the effect of touch. So here we have two different mechanisms at play: positive interpretation of touch and awareness of touch. Both mechanisms matter and they are not the same thing. (Source, Source)
What Is The Placebo Effect?
With regard to the analgesic effects that massage has in relation to pain, there are at least three mechanisms that look to be a factor. The first mechanism you are probably familiar with – the pain gate model – this theory has been around for a while and is based on touch triggering larger diameter receptors in the skin which are given priority over nociceptive (noxious) receptor signals at the spinal cord level. So by touching someone repeatedly in a pleasant way, this should reduce the amount of nociception experienced. This is the theory behind TENS and many other skin-based therapies.
One metaphor that may be useful to understand the pain gate theory is that the spinal nerve synapses to the spinal cord can act like a bouncer at a nightclub. The body has a number of nightclubs (lamina) that nerve signals can pass as they travel along the spinal cord and then to the brain. The body has a capacity to up and down regulate the signals at the spinal cord level to prioritise some pathways over the other. This is a little like a bouncer at your local nightclub choosing who can and can’t come in based on who they think are more important.
In other words, the body can prioritise certain pathways (pleasant touch or nociception) depending on what it determines to be the most important.
The other mechanisms at play here are far more complex but we will group them under the heading of “emotional appraisal neurocircuitry”. These areas of the brain include the pre-frontal cortex, the accumbens, the amygdala, the mid-brain and the somato-sensory cortex. These are the touch and emotional areas of the brain and they can control the “volume knob” on pain and sensation depending on what the brain thinks is important. (Source)
Placebo at Work
One of the best demonstrations of the placebo (or non-specific) effects in massage was a clinical trial of over 300 people with low back pain. The trial was split into three groups: relaxation massage, therapeutic (remedial) massage and usual care (GP care). What was discovered at the end of the study is that both forms of massage are better than usual care to a clinically relevant level. What was surprising is that the functional outcomes of relaxation massage outlasted remedial massage. (Source)
There is no logical way to explain the effects of the relaxation massage outperforming therapeutic/remedial massage from a direct effect. Relaxation massage by its very definition is general, whole body and gentle. What is most likely occurring is self-healing, a down regulation of pain and increase in function through the non-specific (placebo) effects of massage.
Touch, Placebo and Mindfulness
It’s possible that these three factors could well be the most important when it comes to pain reduction and massage. Touch-based analgesia has an effect on the spinal level as discussed previously, but the placebo effect and mindfulness work through higher processing levels. What is interesting is that both the placebo effect and mindfulness don’t actually reduce the amount of nociceptive signalling to the brain. Instead, they work in higher centres of the brain. So what does this mean in terms of practical application for the massage therapist?
Pleasant touch, Context and Engagement
To gain the best results in terms of pain reduction, we should be focusing on three main factors:
- Pleasant touch. It’s quite clear the activation of pleasant touch receptors in the skin is our first line of defence against nociception.
- Contextual factors. Are we creating a therapeutic experience for our clients? Do they see the process they are engaged in as a healing, therapeutic ritual? Are they engaged in the process? Are they finding the massage calming and relaxing whilst also focused on the sensation of touch? Consider for a moment some of your most admired massage gurus. What are the common things we will always tend to see? A myriad of diverse techniques that can range from fast stimulation, movement and stretching to calm, slow sustained holds. Apparently all these different methods obtain fantastic results, and I would suggest the thing they have in common is pleasant touch. Even those methods that can be painful at times are normally mixed in with something that feels amazing.
- Environment and setting. Most experts will throw complex technical language around, describing the changes and improvements you can expect to see and why this is important. And finally, the therapist is engaged. And the more excited and engaged the therapist is, the more engaged the client is. We can probably take for granted that the person who gets good results from a particular treatment will be highly engaged in that process because they love that feeling.
It is important to consider the client’s experience of a massage and how touch does not need to be complex to gain clinically worthwhile results. You do not need to bend someone like a pretzel or align anything to get better improvements in pain and function.
However, if you are working more in a functional domain, such as increasing range of motion, then biomechanical approaches and techniques are still entirely relevant.
Having a better understanding of why we need to consider the placebo effect in the management of pain can lead to better treatment outcomes.
About the Author
Aran Bright started his career as a massage therapist in 2002 after graduating from the Australian College of Natural Medicine in Queensland. In 2006, Aran completed his Diploma of Remedial Massage and, in 2007, his Bachelor of Health Science in Musculoskeletal Therapy. Aran graduated from University of Queensland with a Graduate Certificate of Sports Coaching, completed a Certificate IV in Fitness and an Advanced Diploma of Myotherapy. He currently runs his own businesses, Bright Health Training and Brisbane Workplace Massage, with his wife, Sheree.