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Max Zusman has a great Editorial Opinion in the Journal of Multidisciplinary Healthcare in 2013 entitled, “Belief reinforcement. one reason why costs for low back pain have not decreased”.  It is available via open source here.

There are definitely many points out of this piece that could be written about, but I like how he ends the article with a simple narrative of how a clinician could approach a patient prior to performing a manual technique.  It can be rewarding to read opinion pieces in journals as it is the only way to really write how you feel!  Otherwise the writing is more scientific.  Hence a great reason to start a blog.

Here is his exact quote,

Yes, my examination confirms that this particular area of your spine is not moving as it should.  The reason it is prevented from doing so is the presence of pain — that is a part of pain’s job, and we have already discussed the likely chemical basis for you pain.

Because you are unable to move about normally, to get you started I am going to use my hands to help your back move properly.  We are greatly assisted in this regard by the fact that when skillfully applied the treatment I use directly inhibits pain.

Pain inhibition is also useful when your own muscles begin to take over the work.  As things improve you will no longer need it. Nevertheless, I will continue to serve as your active movement guide, and general adviser, for as long as is necessary.

I really can’t disagree with this statement.  It is stated quite neutral, without any obligations to “put bones back in place” or “release muscles”.  It is scientifically accurate.

Although, I wonder if it could be jazzed up a bit more to maximize results?

Recently at the first week of AAMT Fellowship in Orthopedic Manual Therapy, Dr. Justin Dunaway gave an enlightening lecture on the biopsychosocial aspects of pain.  In particular, he spoke about the positive effect of expectation in leverage outcomes.

He quoted the 2008 Bialosky study examining the effect of subject expectation on hypoalgesia associated with SMT.  Even though the all groups demonstrated significant results in pain reduction, the negative expectation group (who would told that SMT is a form of manipulation used to treat low back pain that has unknown effects on perception of heat pain) actually had an increase in pain perception following the procedure.

In addition, he mentioned the Schenk 2013 study.  It concluded that “the deliberate employment of expectancy strengthening strategies in clinical practice offers an important opportunity to increase the therapeutic benefit for the patient”.  For all the brain therapists out there, this was the fMRI study looking at changes at the higher cortical areas.

We can’t leave out the recent Benz/Flynn 2013 study, entitled “Placebo, Nocebo, and Expectations: Leveraging Patient Outcomes”.  This is a must read.

All of us in clinical practice know that some individuals need to have more positive expectations that a treatment would work than others.  These are the ones that you may have to sway for the better, as their mindset is typically ‘glass half-empty’.  They may have already been told by a surgeon that PT is only short-term and will have to go to rehab for 4 weeks prior to receiving an MRI—in order to have surgery to fix the problem.  Whatever the story you may have heard—we all have these patients who need every bit of leveraging to maximize results.

What I am getting to is…maximize the expectation from your procedure.   You don’t have to sell it per say, but express to the patient what you normally see following the intervention.  We know we want a within-visit improvement to get between-visit results for backs and necks. An example:

I am going to perform a manual therapy technique to the area of interest.  I have had very good results with these procedures and based on everything that we have examined and spoke about with your condition so far, you should have excellent results.  Pain relief should be immediate and you should notice an improvement in how you move in the clinic today.

I am not a salesman by trade but my craft is to get people better. Maximizing expectation can be an important ingredient in that craft.

What do you add prior to your interventions?  I think Zusman’s explanation is well done, I just added a bit more expectation language to it. Do you think we should maximize expectations, or minimize the placebo that can go along with it? 


  1. I’m all for maximizing the placebo effect without the oversell. If the oversell doesn’t accomplish in the patient’s mind the degree of improvement they expected then there could be a trust issue to contend with. I would add to Zusman’s verbiage something about the threat-nonthreat dynamics at play with the pain output.

    1. Bob,
      You bring up a GREAT point about trust. We know trust is one of the inner concepts in building relationships. It has to come first! All of this falls under the Therapeutic Alliance concept.

  2. Thanks Harrison, nice post. Sounds like Dr Dunnway’s talk hit it out of the park. I particularly like how you bring together “For all the brain therapists out there, this was the fMRI study looking at changes at the higher cortical areas.” I like to think that my attempt to build on concepts like these with learning through painfree movement, seems to fit in here. Thanks for such clarity. Happy 4th!

    1. Thanks for commenting Stacy! I’ll have to check out your talk too. Sounds like we are definitely on the same page here.
      Happy 4th to you too!

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