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Explaining away treatment successes

Paul Ingraham ARCHIVEDMicroblog posts are archived and rarely updated. In contrast, most long-form articles on are updated regularly over the years (see updates page).

The benefits of many manual therapy treatments, like spinal manipulation or massage, are notoriously inconsistent and ephemeral as a general rule, and yet sometimes seem to produce amazing results. It’s difficult to explain this pattern in the world of therapy.

Most people assume that those success stories indicate that the treatment just happens to work unusually well for a certain kind of patient. And maybe that explains a few cases, thanks to a combination of luck and knowledge and skill — and that is certainly what therapists and their customers would like to believe.

And we can explain a few more treatment success stories as coincidence: recovering at the same time as a new treatment. This is not as rare as one might suppose given that people often seek care at the darkest-before-dawn point preceding natural recovery, and yet it can’t possibly explain them all, or how quickly and clearly change can follow treatment.

There’s a more likely and prosaic explanation for most success stories …

All those unreliable treatments in manual therapy are getting most of their success stories the same way: rogue waves of non-specific effects adding up to something more than the sum of their ho-hum parts. Sometimes therapy just makes a bigger impression, because everything went just so: no socially sour notes, a good belly laugh, a reassuring touch at exactly the right moment, a piece of office artwork that reminds the patient of home, a comforting story about what’s wrong that the patient could particularly relate to (but which may well be a little lost on the next patient). There are countless ways it can go well, and sometimes they really pile up. If the therapeutic interaction is the active ingredient of treatment — and there’s an extremely strong case for that — then it follows that some interactions are better than others, and some are so good that they explain most of the success stories that patients tell for years.

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