Science-based Theatrics in Physical Therapy????

Placebo and non-specific effects of physical therapy intervention have been popular topics in the recently in physical therapy discussions and research(1-3).  Due to this clinicians now are realizing that a positive outcome is much more than the specific biomechanics or mechanical effects of the intervention being delivered.  For some this seems to have created a bit of a threat to long-held beliefs that it is all about the mechanics or mechanical effects of interventions.  If we gaze across the physical therapy continuing education landscape there continues to be a focus around interventions and the technical side of our craft.  Needling, tissue scraping, manipulation, among other interventions continue to be promoted as the next tool we all must have in our toolboxes.

I had an epiphany of sorts in clinical practice a few years ago.  In my nomadic travels in physical therapy I have had the opportunity to work in multiple settings with many different clinicians.  The interesting thing I realized is that, for the most part, all of these clinicians had happy patients who sang their praises and reported improvement in their conditions.   The part that took me some time to figure out was how they all had happy patients when they all practiced so differently and often at times in ways that directly opposed or conflicted with other successful clinicians.



The above picture is and adaption of a graph taken from Explain Pain(4) by David Butler and Lorimer Moseley.  Pain is much more than the dichotomy it is proposed to be here but this picture serves us well to discuss the progression of pain and time.  We see the blue line as traditional tissue injury and healing which we are all taught in school.  Patients ideally travel this line smoothly and, as healing proceeds, pain nicely follows suit and all ends well.  This is the black and white world that is described to us in our education.  It is here where often we have nociceptive-dominant pain that is from a true “tissue issue” that responds beautifully to peripheral tissue-based treatment.  There is a place for peripheral mechanical treatment, but we must also recognize that the clinic it is not the black and white world we would like it to be.

The gray represents what many of us live with in the clinic each day.  Tissue healing time frames have often long since passed and we are left with a huge gray area.  It is in this gray part of the this graph where huge variability exists in our treatments, their proposed effects, the patient response to intervention,  and the narratives we use to describe the our treatments to our patients.  I have had the privilege of working with very experienced master clinicians in my career.  There is no doubt they were masterful in the technical side of their care, but often they had very different interventions that at times opposed or conflicted with the thoughts and applications of other clinicians.  The one common denominator I have seen in these clinicians is the mastery of therapeutic alliance or the clinical encounter.  The belief and confidence they were able to instill in their patients regardless of background theory was impressive.

Of course there are times when specific mechanical directed treatment is necessary.   There are times when tissues are injured and mechanical strategies to un-load and then strategically re-load the tissue are appropriate.  It is in the gray are that our mastery of the clinical encounter becomes vital when often here there are yellow flags and psychobiologic factors that are often reinforcing a patient’s pain state and behaviors.  Even when tissue healing has passed, peripherally-based treatments have the capabilities of generating change from a top-down mode of effect.  An interesting study(5) looked at the effect of performance style of the physician on a patient’s pain threshold and tolerance from a cold pressor test before and after application of a placebo cream.  Patients were divided into two groups.  A trained actor acted as the physician and he presented the cream in either a way that emulated standard doctor-patient encounter (scenario A) and this was compared the other group where attentiveness, strong suggestion, and elements common to ritual healing were employed (scenario B).  It was found that the patients in scenario B had a significant increase in their pain threshold.  The authors concluded that structured manipulation of physician’s verbal and non-verbal performance in ways that were designed to maximize rapport and faith in treatment resulted in a significant beneficial effect on the size of the response to placebo analgesia.

Daniel Moerman, a expert in the field of medical anthropology,  has made the recommendation that we replace the term “placebo effects” with “meaning response”(6).  In a paper discussing this he states that the inert treatments themselves are not responsible for the benefits we see from them but something else:

That is to say, the “active” ingredient responsible for the placebo effect does not lie in the placebo itself, but rather in the meaning—the cultural salience—patients project onto it.

We can manipulate the meaning a patient ascribes to our treatments in many ways.  Subtle things such as the way we dress, our confidence, our virtuoso skill, the warm healing environment that we provide, and the confident explanatory models we use (whether scientifically valid or not) are just some examples of the ways we manipulate this.   Clinicians who are looking at the patient experience are ahead of the game here as they recognize that a positive outcome is not only about them and their skill but the context they create around the treatments they deliver.  The context and meaning we create starts from the moment a front-desk worker answers the call from a new patient looking to schedule an appointment  and ends the when the patient is warmly told to have a great day by other support staff on their way back to their car.

Edzard Ernst, a vocal critic of alternative medicine, had the following quote in his blog(7) regarding this study and another study on placebo response.

“Good clinicians have probably always been good ‘performers’. Alternative practitioners tend to be excellent ‘performers’, and I am sure their success is mainly due to this ability. I see little reason why conventional practitioners should not (re-)learn the skills that once upon a time were called ‘good bed-side manners’. Maximizing the placebo effect in this way might maximize the benefit patients experience – and for that we do not require the placebo-therapies of alternative medicine.”

The issue arises when we become performers who use theatrics that use narratives that science has not supported.  Will we use narratives of joints out of alignment or place, subtle fascial restrictions we are detecting with our hands, subtle mobility restrictions we are detecting with our hands, disruptions of cerebrospinal fluid flow,  cranial bone movement issues, or whatever narrative we choose that science has failed to support? Maybe instead we can choose an alternative path and to embrace science rather than fight it.   Sure it may challenge our long held beliefs, but should it be about us or the patient?


May this all not show us the the most powerful clinical tool we own in practice?  Could a set of empathetic listening ears and expectation/belief-generating educating mouths be the tools that are most important in our toolbox.  It seems the human body is designed to heal and the narratives that create fear of the body and proposed pathoanatomy or faults steal the confidence and belief a patient has in this innate healing potential.  We cannot forget that expertly performed technique and skillful handling of a patient in pain remains important, but maybe the never-ending quest for more complex technique is the result of trying to fit complex pain problems into mechanical/technical treatment paradigms.   It is time we stop treating all patients like they are machines where we can identify the “faulty part” and correct, fix, or re-align it.  A patient just knowing that they are going to be okay can be the most important treatment they receive.

We need to change the narrative around the suffering human in pain who we perform in front of each day.  Instead of narratives of jelly leaking out of the jelly donut (that still is used too often today) why not instead choose narratives that embrace the human body’s capacity to heal, it’s robust nature, neuroplascticity, and give the patient a narrative that generates self-efficacy and self-confidence.  Narratives of joints being out or fascia being tight will remain a great business model as it will have patients running to us any time they experience a pain or ache  But again I ask, is it about us or the patient?

  1. Bialosky J, Bishop MD, George SZ. Placebo response to manual therapy: something out of nothing? J Man Manip Ther. 2011;19(1):11-19.

  2. Bishop MD, Mintken PE, Bialosky JE, Cleland JA. Patient expectations of benefit from interventions for neck pain and resulting influence on outcomes. J Orthop Sports Phys Ther. 2013;43(7):457-465.

  3. Bialosky JE, Bishop MD, Cleland JA. Individual expectation: an overlooked, but pertinent, factor in the treatment of individuals experiencing musculoskeletal pain. Phys Ther. 2010;90(9):1345-1355.

  4. Butler DS, Moseley GL, Sunyata. Explain Pain. Adelaide: Noigroup Publications; 2003
  5. Czerniak E, Biegon A, Ziv A, et al. Manipulating the Placebo Response in Experimental Pain by Altering Doctor’s Performance Style. Front Psychol. 2016;7:874.
  6. Moerman DE, Harrington A. Making space for the placebo effect in pain medicine. Seminars in Pain Medicine. 2005;3(1):2-6.




Mark Kargela is the founder of Modern Pain Care and serves as faculty.  He is a graduate of Grand Valley State University in 2003 where he received his masters degree. He later received his transitional DPT along with a manual therapy certification (MTC) from the University of St. Augustine. Dr. Kargela is credentialed in Mechanical Diagnosis and Therapy (cert-MDT) and is board certified in orthopedic physical therapy.  Dr. Kargela has also been involved in the Michigan Physical Therapy Association in delegate and district treasurer roles along with serving as adjunct faculty at Grand Valley State University. He is a graduate of the Evidence in Motion’s (EIM) Orthopedic Manual Physical Therapy fellowship program in 2012. He has served as faculty in Evidence In Motion’s Fellowship teaching pain science and clinical reasoning curriculum.  Currently, Dr. Kargela serves as a manuscript reviewer for the Journal of Manual and Manipulative Therapy.    Dr. Kargela also is adjunct faculty at Franklin Pierce University and regularly lectures to Phoenix area physical therapy programs.


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Mark Kargela

Mark has been practicing physical therapy since 2003. He spent the his career pursuing expertise in manual therapy treatments. When he recognized that manual therapy had limited success in chronic pain he began intense study of pain neuroscience and advanced training. He practices in Glendale, Arizona where he is a Clinical Assistant Professor and runs Midwestern University's Physical Therapy Institute. He also teaches nationally for Modern Pain Care and lectures across the country on spine care and persistent pain.

  • Mark Kargela Derek Little says:

    Great article Mark! Can you please subscribe me to your email?

    • Mark Kargela Mark Kargela says:

      Sure Derek. There should be a pop-up that comes up for subscriptions but it obviously is not working. I’ll add you and get on fixing it. Thanks for reading!

  • Mark Kargela Kjartan says:

    Great article ? ?? Can you add me to the subscribers list? Tried to but it would not let me ? Kind regards Kjartan

  • Mark Kargela Graham Yates says:

    Hi Mark
    I have been in (manual therapy)practice for 17 years and have just come to this conclusion independently, through both reading research on the alliance but also through practice and my confidence in what I say and do (even though most physical aspects have small effect sizes). It comes from the understanding of modern pain neuroscience, which actually gives you confidence when dealing with people with marked pain, that education, good listening skills, clever use of metaphors and stories can create great changes before the power of touch is even introduced. Touch is indeed powerful, but I think can be a nocebo when unwanted or perceived as threatening. Also I have been trying to introduce “magic” into the treatments, This is shakier ground as it leaves the evidence behind, but as evolutionary biologist Nicholas Humphrey shows, placebo healing in our ancestry will have been bought about by a shaman giving “permission” to heal, when healing may have been subconsciously delayed by the individual due to the metabolic expense of mounting a neurohumeroimmune response in times of limited resources.As psychotherapy researcher Scott Miller states we have to look at what spiritual healers do and learn from them.Appealing to the spiritual(for both the religious and atheist) I believe is a vastly unexplored area of manual medicine, but one I think could significantly improve outcomes. It’s just finding a way to do it without appearing as a”snake oil” practitioner.

  • Mark Kargela Joe Willis says:

    I agree with most of what you’ve said. But I would disagree with a statement in the conclusion, “jelly donut”, because, as you stated earlier, combining tissue injury interventions with biopsychosocial interventions, leads to better outcomes. The “jelly donut” is a novel way to explain annular injury and nucleus migration, and serves to educate the patient on the tissue injury. But, to your point, it’s best not to stop with that anatomical/tissue based nugget. The “donut” statement can easily be followed up with a calm, reassuring statement, “but the disc can heal and pain can resolve, and this is how we do it….” We go on to then explain pain does not mean injury, etc. Thoughts?

    • Mark Kargela Mark Kargela says:

      Is it necessary to speculate on an annular injury? I think we are making a large leap in our diagnostic abilities. I also think keeping things broad and possibly instead using strain/sprain is less threatening to a patient. Bringing out a spine model and pointing to something that is injured, when we cannot be sure unless an MRI has confirmed, to me opens us up to the possibility the patient will further develop maladaptive beliefs and behaviors around their condition. I think putting that jelly donut story into a patient’s conception of the problem does not instill confidence in movement. For the right patient this story may be fine, but I think it’s a narrative that increases the risk of moving the patient in the wrong direction as far as beliefs and behaviors

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