Is your massage a placebo? (Part 2)

Some note worthy links:
Seven alternatives to evidence-based medicine (this is satire, folks)
I highly recommend the "Why Science?" series here.


In the first part of this blog, I explained the origin of, and the need to understand, the placebo in medicine.  I left off with this question: how does one know if massage is a placebo or a valid physical treatment?

Before the inclusion of the Scientific Method, it is safe to assume that tradition was the foundation of clinical reasoning.  The handing down of wisdom from master to student was the best paradigm we had. Much of that wisdom was based in faulty models of how disease, health, and the human body function.  This tradition leads to very poor critical thinking, it even has its own recognized logical fallacy: The Appeal to Tradition.

Finding this appeal doesn't require much work when discussing any form of massage or manual therapy.  Modalities almost universally originate from one charismatic master, and are then carried onward by his/her followers with little room for questioning.  This origin story usually has a sequel when the best students of that master become "apologists" for their respective school and begin to make subtle changes to keep the method alive.  Here is one example of many: Chiropractic Medicine

Massage is deeply rooted in this old paradigm, it is a part of nearly every cultural tradition.  In arguing with other massage therapists (something I often find myself doing) one of the first statements they will make is, "Massage has been around for thousands of years."  This is meant as a blanket defense against all criticism; a tactic used to defend many forms of alternative medicine.  It is meant to demand respect without giving an answer to any of the difficult questions.

That line of thought is helpful in one very substantial way, if other CAM therapies use that same appeal they could be used in designing tests for massage.  In fact, acupuncture is often tested right along-side massage. The results are fascinating for these studies, mostly because they often conflict and show a wide variety of results.  The highest level of evidence you can find on acupuncture indicates that is sometimes works better than a "sham" treatment, and even that is contended for good reasons.  Poking people with needles (sometimes with heat or vibration or electricity added) is a very large sensation, which will effect how the brain reports pain. 

It's important to note here that not all placebos are created equally.  As Dr. Harriet Hall put it:

We not only know placebos “work,” we know there is a hierarchy of effectiveness:

• Placebo surgery works better than placebo injections
• Placebo injections work better than placebo pills
• Sham acupuncture treatment works better than a placebo pill
• Capsules work better than tablets
• Big pills work better than small
• The more doses a day, the better
• The more expensive, the better
• The color of the pill makes a difference
• Telling the patient, “This will relieve your pain” works better than saying “This might help.”

Here is the rest of that very enlightening article. 

You'll notice that spending time engaging one on one with a person while physically applying pressure isn't on that list.  Again, how does one fake interpersonal contact?  It has also been shown that patient expectations influence the results.

Massage research is very poorly executed, and very poorly standardized.  Researchers have to define what they mean by "massage" before engaging in a study.  The method of precise measurement of time, amount of pressure, style, direction of force, purposed model, and practitioner expertise must be worked out before the trial even begins.  That is why so many reviews are inconclusive:

"No recommendations for practice can be made at this time because the effectiveness of massage for neck pain remains uncertain."

"It is concluded that too few trials of massage therapy exist for a reliable evaluation of its efficacy."

To further complicate matters this systematic review, recommends "acupuncture massage."

Variables need to be removed and each individual claim needs to be looked at case-by-base.

 This brings me to another huge stumbling block in answering the placebo question: if we can't figure out how to test massage in an objective way, how will we ever know if it is doing anything?  A common complaint (made mostly by practitioners who disagree with a particular study) is that the scientific method eliminates the effects by eliminating the variables.  This, of course, is a way to reject any study that wasn't done with you as the practitioner, within your own clinic, with your clients, without any change to your exact methodology, and necessarily reported by you; because the presence of skepticism may skew the results.  In other words, it is completely bogus.

Real science is messy, but it is self-correcting: for example:  The Cortisol Question.  Each claim made by massage advocates will need to be rigorously tested before the placebo question can be answered.  Massage is beneficial, and it employs many plausible mechanisms that could reasonably affect a patient.  That said, it can't claim to treat or cure anything without at least preliminary research results to fall back on.  Which it has for many of the previously mentioned conditions:

1. headaches
2. heart-rate variability and mood
3. neck pain
4. osteoarthritis of the knee 
5. pain, mood status, relaxation, and sleep in cancer patients
6. anxiety and depression

This list could go on and on, as massage gets tested and found plausible regularly.  It is important to remember, all of this needs more research.  Science and massage have just started hanging out in some of the same circles, they are far from friends. Also, all these questions could be asked several new ways, and of several different types of massage.

There is much more to explore on this topic.