by Giacomo Rossettini – PhD, PT

‘I definitely feel less pain in my back after the manipulation’. ‘My shoulder has better mobility after the massage’. Phrases such as these, uttered daily by patients in rehabilitative settings, lead clinicians to think that their hands-on treatments are so powerful that they are sometimes miraculous. Although the literature supports a short- to medium-term benefit of hands-on techniques in managing musculoskeletal pain,1 if we ask why they work, we are often surprised by the justifications proposed by the clinical and scientific community. Indeed, in addition to biomechanical and neurophysiological explanations,2 the international literature has recently suggested Contextual factors (CFs) as mechanisms for understanding the clinical functioning of hands-on techniques, regardless of what they are (e.g., joint mobilizations, joint manipulations, soft tissue or neurodynamic techniques).3

In detail, CFs are “components of all therapeutic encounters and may constitute the entirety of the perceived effects of the intervention itself or be additive to effects of interventions such as pharmacological and nonpharmacological treatments. CFs are perceived cues that affect both the patient and practitioner and can arise from previous experiences and immediate dynamics within the encounter, or a combination of both. CFs fall into broad categories that can include patient characteristics, practitioner characteristics, treatment characteristics, characteristics of the dynamic between the patient and practitioner and characteristics of the setting within which the encounter is being delivered. CFs can be complexly interwoven in the patients and practitioners experience so as to influence what patients and practitioners expect the outcome of the encounter to be. Through such conscious and unconscious expectations, involving a range of specific neurological pathways, CFs can directly influence (both positively and negatively) symptoms and characteristics associated with the presenting condition. The proportion of clinical effects observed associated with CFs can vary from large to small depending on the characteristics of the patient, practitioner, condition and intervention”.4

To better understand the mechanisms of action of CFs and their relevance for manual therapy, we must think of a clinical scenario that we may frequently encounter in our hospitals or outpatient clinics; for example, when treating a patient with non-specific musculoskeletal pain such as temporomandibular pain. When patients receive any hands-on technique directed at the temporomandibular joint, their sensory systems are simultaneously influenced by the treatment specificity and CFs.5 Specifically, while evaluating the arthrokinematic joint play, the sense of smell is stimulated by the aroma of the sanitary disinfectant in the environment. In contrast, the sense of taste is triggered by the clinician’s latex taste of the glove. Sight is activated by the sight of the skeleton and the treatment table in the rehabilitation setting, touch is by the rituality of the intra-buccal procedure and technique, and hearing is stimulated by the clinician’s words that reassure the symptom reduction and positive prognosis of the disorder.

As presented in the example above, CFs offer stimuli which are constantly encoded by patients’ brains, which interpret them, and evaluate their meaning based on patients’ previous positive or negative experiences, expectations, and preferences.6 This process of interpretation in the clinic results in a direct influence on therapeutic outcomes. In agreement, if CFs are interpreted positively, they may improve symptoms, whereas if they are analyzed negatively, the clinical scenario may worsen.6 In particular, among the various outcomes, it is the subjective ones (e.g., pain, disability and satisfaction), which describe the dimension of the patient’s illness, that CFs more influence than the objective ones (e.g., biomarkers, cytokine level), which analyze the dimension of disease.7 As clinicians, we observe daily how important the patient’s perception and experience of care are for motivating him/her during the rehabilitation process.

What should give us further pause for thought is that while patients with musculoskeletal pain ethically and favorably view the adoption of CFs in addition to evidence-based treatments,8 as clinicians, we do not always feel confident and prepared to consciously use and integrate them into our clinical reasoning and decision-making process.9

Since CFs always exist and cannot be eliminated – whether we want to or not – the choice of how to apply them during the hands-on technique is our responsibility and must emerge through adequate training developed at multiple levels of the educational continuum (e.g., from bachelor to continuing professional development).10

Thus, in manual therapy, rather than asking whether one “technique”/”school” is better than another (e.g., articular vs fascial vs muscular) or fueling debates on which “approach” is more successful (e.g., hand-on Vs hands-off) by continuing to wage war against each other, we might start to think about how we can tailor CFs during the administration of each treatment. With this in mind, we could start from the elements that unite us rather than those that distance us, recognizing the relevance of CFs for our patients and the profession. If this does not represent a point of arrival, at least it is an excellent opportunity to start a constructive discussion.

REFERENCES

  1. Lin I, Wiles L, Waller R, Goucke R, Nagree Y, Gibberd M, Straker L, Maher CG, O’Sullivan PPB. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020 Jan;54(2):79-86. doi: 10.1136/bjsports-2018-099878.
  2. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. 2009 Oct;14(5):531-8. doi: 10.1016/j.math.2008.09.001.
  3. Bialosky JE, Beneciuk JM, Bishop MD, Coronado RA, Penza CW, Simon CB, George SZ. Unraveling the Mechanisms of Manual Therapy: Modeling an Approach. J Orthop Sports Phys Ther. 2018 Jan;48(1):8-18. doi: 10.2519/jospt.2018.7476.
  4. Cook CE, Bailliard A, Bent JA, Bialosky JE, Carlino E, Colloca L, Esteves JE, Newell D, Palese A, Reed WR, Vilardaga JP, Rossettini G. An international consensus definition for contextual factors: findings from a nominal group technique. Front Psychol. 2023 Jul 3;14:1178560. doi: 10.3389/fpsyg.2023.1178560
  5. Testa M, Rossettini G. Enhance placebo, avoid nocebo: How contextual factors affect physiotherapy outcomes. Man Ther. 2016 Aug;24:65-74. doi: 10.1016/j.math.2016.04.006.
  6. Rossettini G, Campaci F, Bialosky J, Huysmans E, Vase L, Carlino E. The Biology of Placebo and Nocebo Effects on Experimental and Chronic Pain: State of the Art. J Clin Med. 2023 Jun 18;12(12):4113. doi: 10.3390/jcm12124113.
  7. Rossettini G, Carlino E, Testa M. Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain. BMC Musculoskelet Disord. 2018 Jan 22;19(1):27. doi: 10.1186/s12891-018-1943-8.
  8. Rossettini G, Palese A, Geri T, Mirandola M, Tortella F, Testa M. The Knowledge of Contextual Factors as Triggers of Placebo and Nocebo Effects in Patients With Musculoskeletal Pain: Findings From a National Survey. Front Psychiatry. 2019 Jul 4;10:478. doi: 10.3389/fpsyt.2019.00478
  9. Rossettini G, Palese A, Geri T, Fiorio M, Colloca L, Testa M. Physical therapists’ perspectives on using contextual factors in clinical practice: Findings from an Italian national survey. PLoS One. 2018 Nov 30;13(11):e0208159. doi: 10.1371/journal.pone.0208159.
  10. Rossettini G, Camerone EM, Carlino E, Benedetti F, Testa M. Context matters: the psychoneurobiological determinants of placebo, nocebo and context-related effects in physiotherapy. Arch Physiother. 2020 Jun 11;10:11. doi: 10.1186/s40945-020-00082-y.