Three Reasons It Matters Why A Treatment Works

Why exactly does someone feel better after a massage? Or acupuncture? Or foam rolling? Or a chiropractic adjustment, or wearing K-tape, or doing mobility drills, or a hamstring stretch?

There are some good answers to these questions, and the interesting thing I’d like to point out in this post is that quite often, the therapist doesn’t know them. Or even care about them! Or maybe the therapist has heard the good answers, but prefers alternative bad answers that are far less plausible given the current state of relevant science.

Speaking of bad explanations: Foam rolling probably doesn’t work by breaking adhesions or melting fascia. Chiropractic manipulation doesn’t put joints that are “out” back “in.” Deep tissue massage doesn’t get rid of toxins or “muscle knots.” Acupuncture doesn’t access special points or meridians – putting the needles in random places works just as well. Some sham surgeries work just as well the real thing. Motor control exercises often work to reduce pain even though motor control hasn’t changed.

None of this means that the above treatments can’t work to make someone feel better. It just means they don’t work in the manner advertised. And no this doesn’t mean that everything is just placebo (that’s a confusing word without a clear meaning.)

In general, it seems that therapists have a strong bias towards the idea they are fixing “issues in the tissues.” And they tend to ignore issues in the more complex systems in the body – nervous, immune, autonomic – which are very sensitive to even minor inputs and have a great influence over how we move and feel. Maybe this is because these systems are less visible, or tangible, or just not what practitioners learned about when they were in school.

I was trained as a Rolfer and taught that Rolfing works by changing fascia. So when people got up from the table and said they felt taller, or looser, or had less pain, this was because their fascia had somehow changed for the better.

After doing some research about the deformability of fascia in response to manual pressure, I decided this was not a good explanation for our observations. A better explanation would involve the nervous system, which is constantly adjusting muscle tension, movement patterns, perception, and pain sensitivity in response to new sensory information, including the highly novel sensory information caused by bodywork.

Of course, it’s kind of a bummer to learn that a central premise of your education is incorrect. But the good news is that this doesn’t mean people can’t be helped with your treatment. That is a completely separate issue. So my attitude was – OK, it’s not about the fascia, but that doesn’t mean I can’t help people.

But for many Rolfers, it just has to be about the fascia. And for chiros, it has to be about the subluxation, and for Reiki practitioners, it has to be about energy, and for others, it needs to be about posture, or core strength, or muscle imbalances, or movement patterns.

And of course, many others will say: “I don’t care how the treatment works, I just know that it works does so who cares why?”

Here’s three reasons why it’s important to know why your treatment works.

1. If You Know How Something Works, You Can Make It Work Better

This should be obvious. If you know where the target is, it’s easier to hit the bullseye.

Let’s assume that stretching or massage works to create better range of motion by getting the muscles to relax. (Reasonable enough, right? And supported by research!)

But if you think that it works by forcefully breaking adhesions or physically lengthening tissues you might lose focus on whether your clients are staying relaxed.

When I work on someone I always ask “how does that feel?” Here’s a common response from clients who think it’s all about the fascia: “Don’t worry about me, I have a very high pain tolerance, just do what you have to do.”

And I will think to myself: “Well, I need to know how you feel because that is one of the main targets for this work.” But if my target was breaking up fascia or muscle knots then indeed I wouldn’t care how they felt. And I wouldn’t do as good of a job.

2. Unintended Consequences

Imagine someone with neck pain goes to the chiropractor, is told their neck is “out”, gets cracked to put it back “in”, and then immediately feels much better. What’s the harm if they think that pain relief came from some form of realignment?

Maybe in the short term, there is no harm, but false beliefs have a mischievous way of eventually causing problems in the long term.

Let’s say the neck pain comes back. The client thinks her neck must be “out” again so she needs another crack. So she overlooks other potential solutions like exercise, rest, or gentle movement. If the neck pain continues, she might eventually develop the pathological belief that her neck is fragile and unstable. This can have a nocebo effect – creating further pain and avoidance of healthy movement.

I have seen many clients with similar misconceptions, and this has cost them significant time, money, anxiety, and confusion.

And I’m not just talking about the clients of chiropractors.

I have seen yoga people who are always stretching; Pilates people always stabilizing; corrective exercisers looking for microscopic muscle imbalances; joint mobility fans perpetually mobilizing, as if their joints need a constant bath in synovial fluid, or will start knitting themselves together with some sort of fascial “fuzz” after just a few minutes of stasis. Rust never sleeps!

All these pathological behaviours ultimately stem from false beliefs about why certain therapies have worked for them in the past. These beliefs cluster around the idea that they have corrected “issues in the tissues” as opposed to temporarily adjusting the sensitivity of the nervous system.

The bottom line is that false beliefs, no matter how small, are like viruses – they multiply, get passed to others, mutate to form superbugs, and can eventually cause disease. Don’t spread them, people!

3. The Truth Matters

The truth has inherent value, even when its practical application is not immediately obvious. Knowledge is always powerful – for you, your clients, and the whole community.

We don’t yet know exactly why people have chronic pain and the best ways to treat it.

Even though that knowledge hasn’t been created yet, that doesn’t mean it’s useless to learn more. Every step away from misinformation and confusion is a step in the direction of the truth.

Let’s face it. The truth is good and ignorance sucks. Here’s some quotes from smart people to prove it.

“All evils are caused by lack of knowledge.”

–David Deustch

“I think it’s much more interesting to live not knowing than to have answers which might be wrong.”

— Richard Feynman

“It ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so.”

— Mark Twain

“The truth will set you free, but first it will piss you off.”

–Joe Klaas

Many thanks to my readers and members of my social media community who are thinkers, skeptics, and unafraid to follow where the evidence leads.

Todd Hargrove

Todd Hargrove is a Certified Feldenkrais Practitioner and a Certified Rolfer living and practicing in Seattle. He became interested in movement and pain twenty years ago, when as a lawyer, he was trying to treat his own chronic pain and win more squash matches. He got some great results, and eventually changed careers to help others make similar improvements. In 2008 he started writing a blog at bettermovement.org to share knowledge with a wider audience. His writing seeks to explain why pain science and neuroscience is relevant to manual and exercise therapists. He recently published a book called “A Guide to Better Movement: The Science and Practice of Moving with More Skill and Less Pain”.