The Pain Relieving Power of Positive Cues

How does manual therapy and passive care provide pain relief?

This is the million dollar question for pain relief based therapies.  And positive cues are the million dollar answer.  This is the very reason why we currently have hundreds of different named pain-resolution techniques and systems. We have seen explanations ranging from “auras” and “energy” to “trigger points,” “tight muscles” and “fascial adhesions” to “movement preferences” and “movement dysfunctions.” So many different explanations. Some of these explanations agree with each other and actually overlap. Some don’t. Some completely contradict each other. And yet here’s the catch. They all work; they work well enough anyway. They all seem to work to the same degree of success (which, even for the most evidence-based approaches, is admittedly not a high degree once we consider chronic low back pain.)

They all must have SOMETHING in common with one another. If they all work at about the same rate of success than they all must have some unseen, ethereal connection. As it turns out, that one thing is healing conferred to the patient as a result of the optimistic cues communicated throughout the appointment, the confident and professional affect of the provider and the attentive relationship between provider and patient. In short a patient experience that is enjoyable, seen to be helpful toward a solution or both is the therapy.


This is not the placebo effect. More on this later, but I am not talking about the placebo effect. Stay with me.

The science of this is that our brains are powerful prediction machines. The clinical value of therapy is provided by the interaction of these optimistic and helpful cues and the “prediction” that is created by the brain after being fed these cues. This is a fascinating story by itself. I am going to cover this with videos, further blog posts and an upcoming e-book which I am currently working on. For the sake of brevity, I’ll simply repeat that this is not the placebo effect. More interestingly, the very real benefits of pain-based therapy are provided through the way that positive cues will influence the “prediction” and provide a more pleasant experience.


And this unexpected truth is common to all of the expensive techniques… The “secret” ones, the popular ones, the ones that the NBA team and the quarterback and your Uncle Tommy with ‘the knee thing that one year’ all had success with.  The same can be said of very charismatic, well-reputed practitioners.  Practitioners who have a totally unique style, practitioners with “really good hands” or “a gift” or any other built-in positive context generator.  The method of choice is not the common denominator; instead it is healing, therapeutic confidence demonstrated by a competent, confident provider with a proven system.  The common denominator is the positive context of the intervention or environment.   

And understanding this is crucially important to resolving low back pain-related disability.  Because services and products merely serves as the catalysts which allow you to heal by your own power.  In fact, the most high-quality science has demonstrated that whatever tool, technique or therapy choice your care provider uses to guide you through your lower back pain isn’t actually all that important.  Very different treatment approaches all seem to have the same degree of success when we look at them with large enough and powerful enough studies.  

Furthermore, despite the fact that many of these techniques demonstrate some degree of clinical effectiveness the explanations for HOW they are supposed to work tend to lack strong evidence.  So look, I don’t want to be the James Randi of pain care and start an internet sparring match with every copyrighted therapy system out there.  But trying to explain the effects of care from a biomedical model hasn’t been very accurate whereas understanding the predictive processing, which we have earlier touched upon, has filled those knowledge gaps.  


So let’s think about those cues again. Let’s think about the relationship with a trusted pain care-provider. The message to the person with pain is essentially “I have the right tool.”  The tool is usually bundled with a built-in explanation as to why this is the best tool for the job. Usually it has something to do with biomechanics or with muscle anatomy.  The tool, the explanation, the relationship between provider and patient (hopefully built on some level of trust) all serve as the cues and create the confidence that tell your brain and body “here is the solution!”  When all of these things come together a powerful thing happens with regards to that predictive process I mentioned. Your body is able to create the resources necessary to make a positive impact on your pain experience.  


Once again its time for me to repeat myself. This is not the placebo effect.  This is not a “fake” treatment or an empty treatment “tricking” anyone into realizing that “there was never any pain in the first place.”  I am referring to very meaningful, very positive provider-patient exchanges.  This. Is. Not. The. Placebo. Effect.  Its most CERTAINLY NOT an indication that your pain was somehow not real. This idea is completely irrelevant to the very true fact that your pain experience is meaningful and it is self-evidently real pain simply by the fact that you feel it at all.  

This is also not new-agey, feel good life coaching and it has nothing to do with The Secret.  I’m not simply trying to coin some kitschy, fridge magnet quote like “if your head feels good your body will follow.”  No, this is a neurobiological process at play just like when a physical therapist builds up the load capacity of a post-op knee or a pain management physician prescribes muscle relaxers in order to provide relief.  I am talking about the way in which the therapeutic alliance between provider and patient positively influences those fundamental brain processes that allow you to exist within and interact with the outside world.  

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