My take on why manual therapy "works", part 8.
OLDER POSTS IN THIS SERIES
The last statement in the SomaSimple post is:
"Non-specific effects is the term used when the word "placebo effect" is too contentious."
That was meant to be a bit tongue-in-cheek.. but when I use this slide from Benedetti, I do cross out the word "placebo" and substitute, "Non-medical, non-surgical, non-pharmaceutical non-specific effects follow processing of YES-ciception".
A big piece of this is avoiding nocebo. Why? Because nocebo makes the brain produce cholecystokinin or CCK. So what, you might ask. Well, consider this: CCK antagonizes the effect of endogenous opioids and thereby reduces the effect we want, i.e., descending inhibition of a favourable kind down the spinal cord of the patient we are treating from nuclei in and around and through the periaqueductal grey or PAG, a deep deep part of the critter brain.
How does nocebo do that? It messes with rostral centres which are busy trying to gauge threat, inside a neuromatrix which has many opinions based on prior experience and learning.
We have no idea what the neurotags might be in any given patient. However, the more we can stay away from words like torn or frayed or degenerated or even tissue, when we talk to patients, the better, as Adriaan Louw pointed out in his excellent blogpost.
About placebo response then, or non-specific effects if you prefer, or just learning a new idea which can change the brain over time, in an old blogpost I compared placebo to a match to be lit for anything to be able to happen in terms of eliciting descending modulation of a favourable kind, to kill that other fire that is pain. Not that a bunch of other stuff doesn't need to be there too.. fuel, a place to burn it safely, maybe someone on the outside who will help the flame come to life then stay alive long enough to do some good. Nocebo is like putting matches under the tap first. Trying to strike them while standing in the shower.
Just the idea that someone else thinks the situation isn't hopeless is usually enough to encourage hope. Hope can light the match quite well, provided the match is kept nice and dry, and provided the patient is taught about caring for their own matches.
This concludes the series on "My take on why manual therapy "works""
1. The Placebo and Nocebo Effect: How the Therapist’s Words Act on the Patient’s Brain. Fabrizio Benedetti, writing for Karger Gazette.
2. Every Chronic Pain Patient Has a Brain - Adriaan Louw, OPTP blog, April 2014
3. Pain and fire - HumanAntiGravitySuit blogpost, Jan 21 2012