The Importance of Contextual Effects in Massage

 Brought to you by Brian Fulton 


Unless you have been living under a rock, you have probably heard of the biopsychosocial model as a new paradigm for understanding disease, pathology and rehabilitation. George Engel coined this term in 1977, but it has gained more traction in recent decades. Like most new concepts, it blends old ideas with new information and rebrands it under new name. As you can see by the name, there are three aspects to this assessment/treatment model- the biological, the psychological, and the social aspect. This new way of looking at the body does not discount the critical importance of biological components; in fact, biology and scientific evidence is still front and centre. However, advancements in the understanding of pain science, the evidence of poor relationships between structural issues and pain (Brinjikji, Leutmer, Comstock… et al, 2015; Suri, Boyko, Goldberg… et al, 2014; Jensen, Bran-Zawadski, Obuchowski… et al, 1994), and recognition of the importance of social and psychological context in healing and pain management have propelled us toward this more inclusive model. Like all models, it is a work in progress, and is not without its critics; however, it appears to be the best model currently available.  

One area of research that helps to inform both the psychological and social components of this model is the study of contextual (aka placebo) effects. Context is extremely important, not just in pain perception, but in all human perception. As a therapist, it is critical that you consider how contextual factors can affect clinical outcomes both in a positive and a negative manner. From a research point of view, positive effects have been labelled placebo effects, and negative effects are regarded as nocebo effects. The placebo effect has been studied extensively since the 1950s, first by default (as a standard against which to test pharmaceutical drugs), and then eventually as bona fide field unto itself. In 2011, Harvard Medical School instituted a dedicated program entitled the Program in Placebo Studies and the Therapeutic Encounter at Beth Israel Deaconess Medical Center where this phenomenon is rigorously studied.  

"There is no ‘choice’ about whether or not to ‘use’ the placebo (and nocebo) effects. Those effects are going on in every medical encounter between patient and physician. They exist whether we want them to or not; whether we are consciously exploiting them or not. The ‘choice’ is about how we go about using them: well or poorly, blindly or thoughtfully."
                                 - Dr. Howard Brody, Director of the Institute for Medical Humanities of the University of Texas *

As the above quote indicates, these effects are going in virtually all medical encounters, not just in the manual therapy professions. As a result, it is probably safe to assume that they are coming into play with each and every treatment that you deliver, and they likely continue to play a role in your client’s recovery, even after leaving your clinic. Recent systematic reviews have outlined the importance of contextual (aka placebo) factors in regards to manual therapy outcomes. Three of these papers worth perusing are ‘Enhance placebo, avoid nocebo: How contextual factors affect physiotherapy outcomes’ (Testa and Rossettini, 2016), ‘Placebo response to manual therapy: something out of nothing?’ (Bialoski. 2011), and ‘Effectiveness of manual therapies: the UK evidence report’ (Bronfort, 2010). These reports all recognize that these effects are going on during our treatments and urge practitioners to educate themselves on this topic, not only to enhance clinical outcomes, but also to avoid eliciting unwanted nocebo effects due to a lack of education on this subject. 

Improving Clinical Outcomes in your Practice

So how do you educate yourself on this matter? If you are like me, this was not a topic that was taught in massage therapy school. In addition, while research is definitely accumulating on this subject, there are not many continuing education courses available yet on this topic. There is a paucity of practical information for practitioners on this topic. It is for this reason that I decided to undertake the task of assembling current and past research on this topic and cater the information toward the manual therapy profession. The culmination of this project is a book entitled, The Placebo Effect in Manual Therapy- Improving Clinical Outcomes in your Practice. After sifting through the literature, I found that there are many contextual factors that affect clinical outcomes, but they could all be grouped into one of three categories; expectation, conditioning and meaning.  


One does not want to create unrealistic expectations for the client, but you also do not want to be the practitioner that limits your client’s hope and expectation of recovery. Studies on patient expectation suggest that it is best to err on the side of positive projection when discussing the course of recovery. We have also learned that the more powerful the symbol is, the more powerful the placebo response will typically be. This involves how you dress, behave, and manage yourself around your clients. A doctor will necessarily have more placebo power as a symbol when compared to a massage therapist, but there is a lot that you can do to improve your image with your clients. This includes everything from your competency at assessment skills, your professionalism, your confidence, and your technical competency. We also know that name brands have more symbolic power than generic brands. This would be the rationale for become certified in a modality that patients perceive as a current, effective therapy. While on this topic, it is worth mentioning that new therapies and modalities tend to have improved placebo responses when compared to older therapies. 


Another well-studied and well-established placebo theory is conditioning theory. Strong placebo responses are seen in animal models as well as human trials. Experiments have shown blood pressure modulation and immune system depression using only scents or sounds when using placebos in dogs and rats that have been exposed to classic Pavlovian conditioning. The practical application of this theory is that if your client is negatively conditioned to a modality or an approach, then you need to introduce new expectations and create new positive conditioning if you want to improve clinical outcomes. Conversely, you can attach almost any modality or protocol that your client has been positively conditioned, to a new modality or protocol, effectively piggybacking on the existing positive conditioning. There are a myriad of suggestions, permutations and combinations available to you using conditioning theory and expectation. 


Meaning is the mother of all placebo theories. This is the essence of the concept of contextual effects; in other words, what any given trigger or environmental cue can mean to your client. As you might guess, this can vary widely among clients, but there are some important concepts that have been studied, for which evidence of improved outcomes exists. The list of the concepts that I discuss and introduce in the book under the heading of meaning includes:  
• Trust
• Motivation and Desire
• The Power of Listening
• Feelings of Care and Concern  
• Establishment of a Feeling of Control
• Reducing your Patients’ Anxiety Levels
• Receiving Adequate Explanation of the Pathology
• The Narrative- How We Make Sense of the World
• Acceptance of the Mystery of Healing
• Certainty of the Patient
• Time Spent By the Practitioner
• Use of Ritual
• The Clinician’s Persona, which includes:
    • Professionalism
    • Clinician’s Belief System
    • Confidence
    • Competence
    • Attire
    • Enthusiasm of practitioner
    • Clinical/Healing Environment
    • Practitioner's Use of Humour

Each of the above headings is a chapter, or possibly even a book unto itself. Educating yourself on these many factors will make you a better practitioner, and it will help you enhance the ‘art’ of your profession, allowing you to better tune in, focus on, and empower your client; enhancing their own healing capabilities. 

Leveraging The Placebo Effect

If you are like me, you think visually.  Below is a graphic this gives you some idea of the mechanism involved. This graphic is a work in progress, and there is still much that we do not know about this phenomenon, but at least this gives you some idea of what is potentially going on. A psychosocial trigger initiates a neural process that modulates a biological pathway (via up regulation, or down-regulation), generating an effect. This effect could be subjective (such as feeling better), or it could be any number of objective outcomes.  

Understanding The Placebo Effect

Needless to say, the placebo effect is not a panacea. However, the good news for manual therapists is that this phenomenon has marked effects on pain, function and inflammation outcomes. These are areas where all manual practitioners work. Knowledge of contextual effects has tremendous potential to enhance your clinical outcomes. I should mention that knowledge and application of contextual effects in your practice is not a replacement for competency, but rather, it enhances a skillful, knowledgeable treatment.  

The next step on this journey is to educate yourself on the topic of contextual effects

Apart from books on the subject, there is a lot of professional sharing of ideas and research taking place on social media. I have found the following three groups have lots of information, discussion, files and links to research on the broader topic of the psychosocial model, as well as contextual and placebo effects as they relate to our profession.  


As well, there are also lots of excellent videos that can inform you on this topic. Here is one by Ted Kaptchuk, Professor of Medicine at Harvard Medical School, directs the Program in Placebo Studies, Healing and Therapeutic Encounter - Placebo Effects Make Good Medicine Better. 


Placebo Effect in Manual Therapy

Performing a Google search or searching past posts in the Placebo Effect in Manual Therapy Facebook group will yield more results. Needless to say, all of these topics are discussed in-depth in the book: The Placebo Effect in Manual Therapy- Improving Clinical Outcomes in your Practice

Educating yourself about contextual effects and employing these concepts in your daily practice will inevitably yield benefits for your clients, improving their health outcomes. This is what the research suggests. 

I wish you well on your journey


Meet The Author

Brian Fulton is Registered Massage Therapist practicing in Ontario, Canada. He graduated from Alexandrian Institute’s Massage Therapy program with Honours in 1999 and then went on to gain post-graduate education in Ergonomic EvaluationMyofascial ReleaseBritish Sports Therapy Soft Tissue Release.   

Brian Fulton

From 2000 until its closing in 2010, he was the staff health columnist at the Dalhousie Peer Magazine. Recently Brian completed a seven-year project examining the placebo effect’s role in the manual therapy profession. His book, ‘The Placebo Effect in Manual Therapy- Improving Clinical Outcomes in Your Practice’, published by Handspring Publishing examines the role of contextual effects in the clinical environment. In his book, he deconstructs this complex phenomenon and provides concrete, straightforward, ethical ways for you to incorporate techniques into your practice to help get your patient’s mind in the game, thereby improving therapeutic outcomes. 


Bialosky, J. E., Bishop, M. D., George, S. Z., & Robinson, M. E. (2011). Placebo response to manual therapy: Something out of nothing? Journal of Manual & Manipulative Therapy, 19(1), 11-19.

Brinjikji,W.,  Leutmer, P., Comstock B., … et al (2015).  Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36(4), 811-816.

Bronfort, G., Haas, M., Evans, R., Leiniger, B., & Triano, J. (2010). Effectiveness of manual therapies: The UK evidence report. Chiropractic & Osteopathy, 18(1), 3. 

Jensen,  M.,  Brant-Zawadski, M.,  Obuchowski, N., Modic, M., Malkasian, D.,& Ross, J. (1994) Magnetic resonance imaging of the lumbar spine in people without back pain. New England Journal of Medicine, 331(2), 69–73.

Testa, M., & Rossettini, G. (2016). Enhance placebo, avoid nocebo: How contextual factors affect physiotherapy outcomes. Manual Therapy, 24, 65-74. 

Suri, P., Boyko, E., Goldberg, J., Forsberg, C., &  Jarvik, J. (2014).  Longitudinal associations between incident lumbar spine MRI findings and chronic low back pain or radicular symptoms: retrospective analysis of data from the longitudinal assessment of imaging and disability of the back (LAIDBACK). BMC Musculoskeletal Disorders, 15,152.

Using Placebo Responses in Clinical Practice: Is there a there, there? What do we need to know? Samueli Institute, January 20, 2012: page 15

The Placebo Effect in Manual Therapy- Improving Clinical Outcomes in your Practice. Brian Fulton. Handspring Publishing. Pencaitland, U.K. 2015

The RMT Education Project
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