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Ruth Werner BCTMB considers the nature of the placebo effect

Ruth Werner BCTMB, past president of the Massage Therapy Foundation and foreword writer for Brian Fulton’s well received book The Placebo Effect in Manual Therapy considers the value of Brian’s thesis in her foreword to the book. We are delighted to share it here and give you a taste of the book itself.

Ruth Werner

Ruth Werner

‘We already know that touch feels good; why ask why?

I once had a chiropractor who came very highly recommended. His understanding of the principles of his science was flawless. But he treated me dismissively, he seldom made eye contact, and when a neck adjustment sent an electric jolt down my arm and I flinched, he shrugged and said, ‘Well, chiropractic isn’t for everybody’. Here was someone who understood his technique perfectly, but his ability to convey his skill into a positive outcome was impaired by his inability to make a useful personal connection. (I promptly fired him, and found someone else.)

The use of touch to promote well-being is as ancient as the first caress a mother ever gave to her baby, but the field of touch research is still in its early days. We continue to struggle with questions such as if manual therapies work, and for whom, in what circumstances, under what conditions and done by what level of professional. Then come questions of how well manual therapies compare with other interventions for effectiveness, safety, and cost. Dosing studies attempt to define the sweet spot where manual therapies find their peak usefulness, balanced
with pragmatic considerations like cost and convenience.

All these inquiries can be framed as yes-or-no questions to help develop our knowledge of how to get the best from manual therapy, as we understand it.

But the research examined here by Brian Fulton goes beyond yes-or-no questions. It takes a brave researcher to undertake the question not of if, but of how touch affects function. We see that it appears to improve our sense of well-being and ability to cope with everyday life stressors – but how? We see that people with anxiety disorders and depression report improved symptoms when they receive welcomed touch, but why? In the best of all possible worlds the answers to these questions allow us to hone our skills so that we can achieve positive outcomes on purpose instead of by accident. To the frustration of some traditional scientists, it can be difficult to untangle how much of a positive outcome is due to the skin-to-skin intervention, and how much is due to the subjective and complex interactions that happen between a practitioner and a patient. And ultimately, the solution is not one or the other; it is both.

In this book the author has focused on a phenomenon that is sometimes considered to be statistical ‘noise’ that comes up between a research question and its results – the placebo effect. He has made a compelling argument that this noise can be as interesting and elucidating as any typical result. In the world of manual therapies, as in any relationship that relies heavily on a level of trust and positive expectations between practitioners and their patients, that relationship itself turns out to be as important for the patient as any exchange of skills or advice. In other words, if we like our clinician, and we know that s/he has our best interest at heart, and we expect his or her work to be effective, then – voila! We are more likely to have a positive outcome than if we didn’t have that sense of warmth and unconditional positive regard that is the basis of the therapeutic relationship. This leads to the larger question: how can we harness that power?

So, yes, it’s important to know what happens in a session of manual therapy, from the molecular changes in the tissues up through lines of force that stretch fascia or stimulate nerve endings. But at an even more fundamental level, understanding how to maximize the power of a good therapeutic relationship is just as vital, much more subtle, and usually under-addressed. Most manual therapists are not taught to embrace the power of the therapeutic relationship, and to use it to its fullest. This book will help to fill some of that vacuum, and I look forward to seeing how it influences new generations of hands-on health care providers.

Ruth Werner
Waldport, OR, USA