THE PLACEBO EFFECT AND ITS ROLE IN MASSAGE
Be careful! Words can damage…
By Boris Prilutsky
Previously, I already wrote about my consulting work in the research settings. While I am performing a massage procedure, scientists use recording equipment, and lab tests and they are trying to develop medications, to replicate outcome of massage. The principal investigator, who is a neurologist, Ph.D., the professor of neurology at the local medical school in LA, is a very powerful person in scientific circles. Sometimes during conferences, I do not feel comfortable when he is asking my opinion. Seriously speaking, sometimes I even do not feel comfortable at all. I’m the only one who is a massage therapist in this assembly; the rest are scientists, PhDs or students working on their Ph.D. programs.
I’m not trying to show off. This is just to explain why when three weeks ago he called me and said:” if you don’t mind, approximately in 40 minutes I will bring a patient, who exhibits a very difficult case of migraine attack” I said, “Of course!”
In 40 minutes at the conference room, there were eight people, two representatives from each team. The principal investigator requested them to present at my initial evaluation. A few minutes later, he brought a 56 years old woman, a movie star. Obviously, she was suffering: she was very anxious and shaking. In such cases, I ask to briefly present a history and describe symptoms in details. Then I do palpations, assessments of a range of motion, etc. During the last 45 days, nonstop, she suffered from high-intensity pressure headaches and couldn’t sleep.
In the beginning, the prescribed medications could somehow control the intensity of pain even though temporarily. Then during the last week, the pain became unbearable. The primary care physician did all tests, including MRI. All of them turned out perfect. The neurologist performed EEG and other neurological tests. All were good. The neurologist diagnosed her, with a migraine, whatever it means. Because the prescribed medications stopped working, the primary care physician requested the second opinion from a topnotch neurologist.
Not to be confused, the principal investigator was the 3rd opinion. He didn’t damage her and immediately decided that I have to see her. Straight from his office, he brought her to the research facility. I wasn’t there for the second opinion visit and didn’t know the content of the doctor-patient conversation. However, according to her, when she asked about the prognosis, the answer was that it was possible that she will have to live with these headaches all her life, including the possibility of ending up in coma and death.
She said:” Boris, the doctor believes that you will know the answer to when I will die.” I said:” Ma’am, I am a massage therapist, with me people talking about life and not death.” Everyone, including her, started laughing. As she was sitting, I examined the range of motion in her neck. It was terribly limited. Preliminary I could palpate significant tension in fascia and muscles, at the neck and upper back area. Examination/palpation of TMJ muscles/fascia suggested significant buildups of tension. When somebody suffers from severe headaches, very anxious etc., I always first perform Manchurian acupressure for tension headaches. In a direct translation from Chinese, it is head pressure headaches. We interpret it as tension headaches. No matter what is the cause of a headache, fifteen minutes seven positions acupressure session immediately reduces the intensity of a headache. For example, when I am treating fibromyalgia patients, who are also emotionally exhausted, I always start with Manchurian acupressure. It works miraculously. In such cases, the mechanism of placebo almost always gets activated, contributing to the energy boost and the sense of ” light at the end of the tunnel.” It has always been a game changer.
As I was expecting, it worked with this actress miraculously. After fifteen minutes of acupressure, I asked her to report if intensity or a headache changed and whether she’s experiencing a change in her condition. She offered us a bit drama play and said: “…my goodness Boris, I don’t feel a headache.” I responded: “Ma’am your reaction to the first acupressure procedure, is excellent and encouraging. We have a chance to help you to get rid of headaches, to stabilize your condition, and bring you back to life. Then I asked her to lay on the table, addressed tension within fascia and muscles, and trigger points. Spend time also to address TMJ musculature. It takes additional 30 minutes. Then I assessed her range of motion, and we all were pleasantly surprised witnessing significant ROM improvement, including at TMJ motion. In total, so far I have performed six treatment on her. Almost no episodes of high-intensity headaches, not less importantly, she is slipping in average seven hours each night. I am planning to provide additional 9 to 10 treatments, to sustain the results.
After the treatment was completed, the principal investigator said: “The results it is obvious. What do you think about this difficult phenomenon?” I answered:” It was the obvious case of tension headaches and not a migraine. The treatment addressed the buildups of tension. By addressing the causes of these headaches, we achieved results.”
When the lady left the facility, we talked a bit more. I asked whether the neurologist who provided the second opinion was the board certified idiot, or somehow things got complicated. The principal investigator told us, that second opinion neurologist, was a very knowledgeable and experienced physician, and that somehow things got out of control. One of the fellows, who is a neurologist, participating in a Ph.D. program, told me:”Boris, it was a great therapeutic joke, when you said”:’ Ma’am, I am a massage therapist, with me people talking about life; not about death.’ She laughed, and I got a good feeling about the further treatment he said.
I said:”Doctor it wasn’t a joke. I meant what I said.”
This Ph.D. student said:” you are a lucky person, sir, to believe so much in power of your occupation.“ He got my traditional answer:” In my opinion, there is a big difference between believing and knowing, Doctor. Thank God I know about the power of massage, as most of the massage therapists do.”
Currently, I am working on the article for Journal of Massage Science. Most likely, the title of this article will be “PLACEBO EFFECT AND ITS ROLE IN MASSAGE THERAPY.” In general, I will discuss the mechanisms of placebo as well as nocebo. In many ways, our approach and views on psychologically triggered placebo are different from the classic approach of the medical society. Today I presented the case when nocebo practically destroyed the patient. In fact, she could possibly die.
Thank God, it didn’t happen. One can say, “come on Boris, she wouldn’t die.” I disagree. There are enough documented cases when psychologically triggered nocebo led patients to death. But this is not the point. The even difficult case of nocebo, couldn’t sustain and resist powerful stimulation by massage.
- On August 8th, 2018, at world massage Festival in Las Vegas,
I will teach, Manchurian acupressure for tension headaches”
8 Credit Hours
Manchurian Acupressure for tension headaches is a modern name of this method. Direct translation sounds like “For head pressure reduction”. It is sequence compressions of different points on the face, head, neck, and rib cage. This class is primarily hands-on training. In most cases, after 15 minutes of appropriate applications, the intensity of headaches is rapidly reduced or eliminated. Very effective in cases of a tension headache, but also helping in different cases of headaches including migraine headaches.
For more details please click here http://worldmassagefestival.com/2018/prilutsky.html
Looking forward to seeing you in my class.
Twenty Years Later
This article was first published in Science of Massage Institute online Magazine
It is the time to go back to the roots
Below, I am including a link to the article that was published in “Massage today” in 2005.
The title of the article was: Should Massage Therapists Use the Term “Medical” Massage
2005 was the time when massage therapy community started its division. I’m not the smartest guy on the block, but I know that when some professionals in a professional field start proclaiming superiority over other professionals, it’s dividing the house, and the divided house cannot sustain itself.
Before 2000, as a massage community, we did much better, in comparisons to 2005. As they say: “The proof is in the pudding” – in 2000 public’s out-of-pocket expenditure on massage procedures was $6 billion, while in 2005 it was $3,5 billion.
How did this division start? Already since 2000, some people started proclaiming themselves “advanced massage therapists.” This was done to charge clients more money, or just to feel “the superior”. After all, whom would you rather be inclined to pay a higher fee for a session a “regular” therapist or to “advanced” one?
In attempts to accentuate their uniqueness, these people started to coin different alternative names for massage techniques they performed. Little by little, we as a field started losing the unity in professional representation. The public and the medical community started to get confused whom to hire. As a result, our entire field lost its trust in the eyes of the public and the medical community. As the public has become confused about massage therapy profession, massage schools started to enroll fewer students, and of course, the membership in trade association was decreased. As I mentioned above this resulted in public out-of-pocket expenditure on massage procedures dropped from $6 billion to 3,500 billion.
Surely, the field is evolving and new methodology could be developed. However, for the sake of the benefit of the entire massage field, the naming conventions should be kept under the umbrella of massage field.
How could this be done elegantly? Let me bring forward the example of Medical Massage. On the record, I was the first who introduced the term Medical Massage in America. Twenty-three years ago, I produced my first instructional VHS. A few years later, Dr.RossTurchaninov published the great Medical Massage Textbook. Many American therapists, loved this name, and adopted the term Medical Massage in their practice, even though their implied meaning was different than the meaning Dr, Turchaninov and I attributed to this term.
Both of us were trained to perform medical massage protocols based on the segment reflex massage concept, as it was proposed by the Soviet physician professor Anatoli Sherback. Since in Russia this type of massage was primarily used in the medical setting, it was a common knowledge that medical massage is based on the concept of“segment-reflex massage.” Therefore, should this be in Russian setting, such voluntarist appropriation of the term Medical Massage could have raised some eyebrows and become the issue of a conflict?
To me, this slight inconsistency didn’t make any difference, since any massage therapy is about results. If using a certain method, one could deliver sustainable results and feels comfortable calling this method Medical Massage, so be it. As long as collectively, we called ourselves massage therapists, as an industry, we’d continue to do well.The public and the healthcare professionals knew us as massage therapists and knew that we delivered results.
The influx of alternative names was only one side of the problem that infected the industry. The other side was the initiative to increase the number of study hours to become the member of the professional association.
Before 2000, a person could become a member of trade association if he or she went through massage program. Somewhere between 2000 and 2005, the rules were changed and now a person could become a member of association only after going through 500 hours. To me, this approach seemed erroneous and in 2005 I wrote an article about it for Massage Today. After sending it to massage today, I also gave it for a review to my American friend, a student of mine (at the time he was a retired MBA from Columbia University, majoring in Political Economy).
Having read my article, he told me:” Boris, this article will not be published because you speak out against the powerful special interest groups.” When I asked him to explain, he told me that trade associations demand 500 hrs. of training, while Title IV schools teach 720-hrs programs, to be qualified for federal financial aid. Thus, because of my proposal, they will be deprived of the large sums of money. In my article, I proposed that 200 hours is sufficient length program to teach a massage therapist to perform a full body medical stress management massage.
I couldn’t agree with my friend and said:” Quite the contrary, what I proposed was to everyone’s benefit, including the interest of trade association and title IV schools, it was the interest of the entire massage therapy fields.”At that time, I used to run massage school approved by the state of California. My program contained around 760 hours of training: the basic obligatory program and optional CE programs. Today the new owners converted my school to title IV, and run the same 760 hours program, but obligatory for all the students. Because of the formalistic approach to the issue, the enrollment in professional massage association was falling, but neither professional association nor massage schools were doing anything about it.
These problems were corroding the massage industry like an infection. At the time, I felt that if the situation would not be corrected, it will continue destroying the field as we as a field would lose the professional identification. My friend said that most likely I was correct. “However, mark my words, if accidentally your article will be published, you will become the enemy of the state.”
” It will never happen,” I replied as I was confident that my proposal will stop dividing the community, which was to everybody’s benefit.
As it turned out, the article did get published. However, one of the editors, the nice lady by the name of Rebecca, was immediately fired. My friend was positive that she was fired because she accepted my article. I still don’t know what was the true reason. Yet what I know is that 13 years later, the entire massage therapy industry is in a much worse shape, and is divided.
From my experiences, I can conclude that there is no superior methodology of treatment. Rather there are great massage therapists, and there are those that are not as good. There are therapists that deliver great results, and those whose results are not as good.Regardless of how much one knows and how good her/his hands-on performances are, there is always a huge room for improvement in your professional skill. The sky is the limit.
I strongly believe that now it the time to come back to the roots, the way it was 24 years ago, when our professional field was called massage therapy fields, and all of us used to be proud to be a massage therapist. At that time, many of my students used to make more than $100,000 a year. The massage therapy field was collectively delivering a massive good outcome, and therefore the entire field got the recognition by the public, which spent $6 billion out-of-pocket on the helpful massage therapy procedures.
Here is the link to the 2005 article.
It looks like, the forecast given in this article, was indeed correct.Yet I am not stricken by joy because that as today the conditions within our industry are far from being great.
With technological developments of testing equipment, we are getting a more scientific explanation on what we are doing.
From the author.
During my career as an educator, I always used to repeat to my students: ”we are teaching you the science-based massage therapy. You will be trained how to perform massage techniques, appropriate sequences of massage techniques specifically designed for different massage protocols. We will teach you scientific concepts, including the physiological effect of massage on the human body, pathophysiology of disorders that you will treat, and the skill to control the amount of pressure you should apply when addressing abnormalities. When it comes to learning, try to understand the material to the deepest level possible rather than just memorizing it. The only thing we cannot teach you is a sense of touch. The sense of touch is what makes a difference between a good and a great therapist. During training, we will do our best to help you develop a sense of touch.”
I always used to finish this type of a conversation by saying: ”Please remember that when it comes to the development of a sense of touch and your abilities to deliver results, the sky is the limit. This is an ongoing process. I spent many years in the field and yet I continue constantly developing and improving my personal sense of touch.”
Years ago, in the end of the class, two lady-friends from Inglewood CA used to joke with me:” Boris, you are so smart and experienced, and yet you cannot define what sense of touch is. The class started laughing, and joining them I said: ”It looks like I’m not smart enough to define what sense of touch is.” The class was dismissed, and little by little the students started walking out from the classroom. Suddenly from nowhere, I have asked the class to be seated and announced: “Guys, I have the definition of what sense of touch is. The sense of touch, is your ability to understand, the physiological effect of massage, pathophysiology, etc., to the point, that you will see with your hands, what eyes cannot see.”
I never in my life, wrote an article, like the one I’m offering you today. I strongly believe that if one to carefully study this article, it would help you to develop the sense of touch to even greater degree.
Best wishes and good luck
With technological developments of testing equipment, we are getting a more scientific explanation on what we are doing.
Those who have been massage therapy practitioner for a long time, sometimes witness clients’ emotional releases. Clients might cry, shake, demonstrate painless muscle constriction, complain about a sensation of cold with the room temperature of 75°. Some report crying after the treatment.
Usually, these releases happen when we apply kneading techniques on specific areas of the body. We call these areas “bookmarks” of emotional memories. These emotional memories are stored somewhere is in the brain.
While a student, I was told, that everyone, even the clients who are not crying out, releases this emotional garbage. When treating cases of anxieties, depressions, chronic pain, phantom pains, it is extremely important to clean up this emotional garbage, because when it’s stored somewhere in the brain at a subconscious level, it’s constantly poisoning well-being of patients, not allowing them to progress in a healing process.
Today, Melzlack‘s neuromatrix theory of pain and anxiety explains much more about the phenomenon of central sensitization of pain, emotions, etc. When we spend 50% of a procedure time on kneading, the human body reacts to original stimuli with multiple positive changes in functions of organs and systems. Therefore, during numerous repeated treatments, we achieve an approximate balance of sympathetic and parasympathetic activities. Please read a short explanation of the physiological effect of massage on the human body.
As far as I know, back in the nineteen seventies, our professors, MDs, and PhDs used to teach us that unless emotional garbage will be cleaned, it would be practically impossible to get to the desired balance of autonomic activities. This blog is a clarification of what Bookmarks are. I was told, it became clear from treatment room experiences that by creating an action potential, somehow, from the areas of somatic bookmarks, we stimulate and awaken reactions – emotional releases. No one even suspected, that nociceptors would be triggered, and stimulate emotional release.
On a side note, I always have been amazed and admired writings of Dr.RossTurchaninov. Practically any piece of writing he created, is good enough to be used as a study material in schools. In this article, inspired by his narrative style, I will try to create simple “schooling” article on this subject.
Please try reading this article carefully (the link is below), paying a special attention at what I proposed in my article four years ago: “Nociception can also cause generalized autonomic responses before or without reaching consciousness to cause pallor, diaphoresis, tachycardia, hypertension, lightheadedness, nausea and fainting. as you can see it is a very complicated physiology and pathophysiology.
Let’s continue the lesson.
Please careful read, my blog below.
Now, please, read the article below. Actually, I have to thank James Westmoreland for it, who referred me to Eric Delton’s site, where he posted the link below.
I’m quoting from the article. “The reason we can say this stimulus is painful, it’s hurting me, is because there’s a signal from our arm reaching the spinal cord, and then from the spinal cord to the brain,” Colloca told Seeker.
Dear friends, please pay attention, nocebo triggered/activated/released pain impulse. This was recorded by fMRI scans. Of course, before this equipment was developed, we all, including myself, believed that nocebo is a purely psychological phenomenon/brain generated pain.
As you understood from my previous explanation, the central sensitization of pain, and the central generation of pain and anxieties, was known much before professor Melzack proposed NMT of pain and anxieties. This great neuroscientist only formulated this as a scientific theory.
Let’s discuss functions of nociceptors.
Peripheral receptors cannot generate pain, emotional responses, hot or cold sensation, etc., but can only generate impulses. Of course, when impulses reach the brain, the brain generates pain, hot or cold sensation, etc.
We shall ascertain that the intensity of pain that one experiences, depends proportionally on the intensity/ frequency of pain impulse. For example, if one will cut a finger superficially, pain receptors will generate a certain low-grade intensity/frequency pain impulse. When it reaches the brain, we do feel pain but not an intense one. When a finger cut is deep, causing a significant wound, the more significant amount of pain receptors would be involved, which will generate high-intensity/frequency pain impulses, and when they reache the brain, the brain generates high-intensity pain. This is a general principle.
Interestingly, researchers used a special equipment in this study that recorded nocebo triggered pain and pain were not generated in the brain unless the brain received pain impulse. Goodness! Is it conceivable that nocebo activates pain receptors/nociceptors to generate pain impulse? Personally, prior to this study, I would be convinced, that nocebo effect is a pure brain generated phenomena.
It is appropriate to make a following statement.
We know, that the brain can generate pain on its own. When it’s happening, why would the brain send any impulses to peripheral receptors, or even to spinal cord? Besides, in cases of phantom leg pain, there is no leg, therefore cannot be nociceptors.
On the other hand, these researchers obviously recorded nosebo/psychological factor activated nociceptors. As a matter of fact, in this case harmful logical stimuli haven’t been involved. Obviously, psychological factor triggered generation of pain by brain, and only then its impulse was released and activated nociceptors. There must be a reason for that and, I suspect, that this reason is making people instinctively massage a painful spot, release action potentials, to stimulate centers. Later I will provide a more extended explanation on what I have said above.
Now let’s come back to what I have published four years ago.
“Nociception can also cause generalized autonomic responses before or without reaching consciousness to cause pallor, diaphoresis, tachycardia, hypertension, lightheadedness, nausea and fainting.
Was it pure psychological, brain generated phenomena? I doubted it.
It has been recorded that nocebo activates pain receptors/nociceptors, which in turn generating pain impulse.
These findings, just add an additional support to a scientific explanation for what we do as massage therapists.
There is no doubt in my mind that bookmarks containing nociceptors, encoded to stimulate centers containing emotional memories. When massage stimulates nociceptors, they release action potentials/specifically encoded impulses, which trigger the release of traumatic memories, stimulate centers in the brain, and promote emotional releases.
Can this nociceptor carry any memory? Of course not. These bookmarks connected to these emotional memories in the brain, and when we mobilize skin, fascia, and muscles, we release action potentials within mechanoreceptors, including nociceptors. Massage of these bookmarked areas generates a huge amount of therapeutic impulses, flow of therapeutic action potentials, and this is what stimulates emotional releases, as well as other multiple positive changes in functions of organs and systems.
Massage of emotional memories’ bookmarks, seemingly prompts nociceptors to generate impulses of therapeutic frequencies and intensity. These action potentials, stimulate access to emotional memory in the brain and trigger release of damaging to well-being emotions.
Let’s refer to the physiological effect of massage, which was researched by Dr.Sirazini in 1937 and is accepted and clinically proved today as the scientific fact. Action potentials released from mechanoreceptors stimulate central nervous system and trigger multiple positive changes in functions of organs and systems. What I didn’t know until this study came out, is that nocebo, supposedly purely psychological factor, also triggers pain receptors/nociceptors, releasing pain impulse. Thus, the current state of my understanding, is that emotional releases that we trigger because of massage, is a result of action potentials released from nociceptors.
What I knew, was that we cannot release nociceptive action potentials, until painful stimuli are applied to a patient’s body. It could be caused by either vigorous pressure, or tissue injury, or hot or cold sensation that would come to contact with the body, including the hot or cold environment. Now I am positive that by providing massage we can release action potentials within nociceptors, without harmful stimuli etc.
One might wonder, why this is such a big deal? Do we witness the phenomena of emotional releases for many decades? I would agree with this comment, because from a clinical perspective, for most of us, the important evidence is an evidence of results. Still, in my opinion, for us, this is an important discovery.
In a frame of established facts of medical physiology, we can speculate on processes, which are not yet established by scientific experiments. Especially if these speculations, are supported by clinical outcomes.
For example, in the aforementioned study, using a special equipment researchers recorded nocebo effect triggered pain; pain that wasn’t generated by the brain without receiving pain impulse.
Why would it be wrong to conclude that nociception can also cause generalized autonomic responses before or without reaching consciousness? Thus, pallor, diaphoresis, tachycardia, hypertension, lightheadedness, nausea and fainting are the result of nociceptive impulse, which reaches emotional storages and causes a negative unpleasant clinical reaction.
Why cannot we conclude, that by performing kneading techniques, paced as 70 movements per minutes, we generate a massive release of therapeutic action potentials, including those from nociceptors? Then, by reaching emotional storages, we trigger therapeutic effect of emotional releases.
Quantity, quality, and the intensity of stimulation equals reaction. Nociception generates a sympathetic reaction. A short time, aggressive nociceptive impulses, cause diaphoresis, tachycardia, hypertension, lightheadedness, nausea, and fainting. Therefore, while creating a massive therapeutic release of nociceptive action potentials, we, in fact, treat mentioned above disorders. We know that massage therapy is a very powerful methodology of treatment, in cases of diaphoresis, tachycardia, hypertension, lightheadedness, and nausea. This is a clinical effect. Why cannot we conclude, that in addition to reporting pain, nociceptors, hot and cold sensation can trigger sympathetic reaction/panic attack, at the time when we engaging them, deforming nociceptors, reaching the level of adaptation, therefore successfully treating anxieties?
I will try to reach out to patients who suffer from hypochondria, and I think massage therapy will work. The importance of this conclusions I’m discussing in my summary below.
The great Neuromatrix theory of pain and anxieties, astonishing recording by fMRI scans: ”nocebo triggered/activated/released pain impulse”… did it change the way we practice massage? Not really, not the way we perform hands-on protocols. It just offers us an additional explanation, understanding, and a scientific support – adds validity to what we do. In my opinion, these findings, make our hands-on performances, better and more meaningful. It is boosting our therapists’ energetic status. Our occupation is unique as we use our hands during treatment, which makes the energetic connections much stronger than those spun by any other healthcare profession.
Now, for a better understanding of what I said above, I would like to offer you some extra curriculum LOL work. Read this article.
Please let me know if my article was a good study material. Also, as you understood, my narrative regarding the relation between centers, nociceptors within bookmarks, release of nociceptive action potential due to massage stimulation is my own conjecture.
If you will be able to find a disconnect in my presentation, please do not hesitate to post a rebuttal. It’s important for me, as it’s important for each of us if we are to advance. Looking forward to good discussion.