{"id":1577,"date":"2019-04-10T09:00:34","date_gmt":"2019-04-09T23:00:34","guid":{"rendered":"http:\/\/blog.amt.org.au\/?p=1577"},"modified":"2019-04-09T11:43:21","modified_gmt":"2019-04-09T01:43:21","slug":"why-placebo-is-lit","status":"publish","type":"post","link":"https:\/\/blog.amt.org.au\/index.php\/2019\/04\/10\/why-placebo-is-lit\/","title":{"rendered":"Why Placebo is Lit"},"content":{"rendered":"\n

By Aran Bright<\/strong><\/h2>\n\n\n\n

Holy guacamole, the topic of placebo is intense and complicated. And it is awesome!<\/p>\n\n\n\n

As massage therapists, we owe it to our clients to understand this topic as best we can. It\u2019s 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.<\/p>\n\n\n\n

Hopefully, by the end of this article you will gain an understanding of why it is probably more important to focus on the client\u2019s experience of a massage than it is to focus on what techniques you used, at least when it comes to pain reduction.<\/p>\n\n\n\n

What is Placebo?<\/strong><\/h4>\n\n\n\n

In many cases the word placebo<\/em> is associated with, \u201cdoesn\u2019t work\u201d, \u201ca sham\u201d or plain old \u201cuseless\u201d. Actually, placebo is from the Latin placere<\/em>, \u201cto please\u201d, and literally means \u201cI shall be acceptable or pleasing\u201d.<\/p>\n\n\n\n

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.<\/p>\n\n\n\n

Placebo, Non-Specific Effects and Touch-Based Analgesia<\/strong><\/h4>\n\n\n\n

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 \u2018non-specific\u2019 or \u2018contextual\u2019 effects.<\/p>\n\n\n\n

As mentioned earlier, placebo means \u201cto please\u201d, therefore it does keep things simple to consider any non-specific therapeutic approach that has a positive outcome as a placebo.<\/p>\n\n\n\n

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\u2019s 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<\/a>, Source<\/a>)<\/p>\n\n\n\n

\n\"Brussels<\/a>\n<\/div><\/figure>\n\n\n\n

What Is The Placebo Effect?<\/strong><\/h4>\n\n\n\n

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 \u2013 the <\/a>pain gate model<\/a> \u2013<\/em> 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.<\/p>\n\n\n\n

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\u2019t come in based on who they think are more important.<\/p>\n\n\n\n

In other words, the body can prioritise certain pathways (pleasant touch or nociception) depending on what it determines to be the most important.<\/p>\n\n\n\n

The other mechanisms at play here are far more complex but we will group them under the heading of \u201cemotional appraisal neurocircuitry\u201d. 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 \u201cvolume knob\u201d on pain and sensation depending on what the brain thinks is important. (Source<\/a>)<\/p>\n\n\n\n

Placebo at Work<\/strong><\/h4>\n\n\n\n

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<\/a>)<\/p>\n\n\n\n

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.<\/p>\n\n\n\n

Touch, Placebo and Mindfulness<\/strong><\/h4>\n\n\n\n

It\u2019s 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\u2019t 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?<\/p>\n\n\n\n

(Source<\/a>, Source<\/a>, Source<\/a>)<\/p>\n\n\n\n

Pleasant touch, Context and Engagement<\/strong><\/h4>\n\n\n\n

To gain the best results in terms of pain reduction, we should be focusing on three main factors:<\/p>\n\n\n\n