Are you a Merovingian?

Do you believe that non-specific effects of manual therapy can be predicted, leveraged, or manipulated?  Do you believe the context of physical therapy can be crafted in such a subtle and and predictable way as to deliver the patient from pain?  If so then you are a Merovingian (you are going to have to watch the video below).
[youtube=] “What am I talking about?” is probably your first question.  Follow me.  In the video the Merovingian, the arbiter of information, codes (i.e. creates) the dessert that the woman eats.  This dessert contains the perfect sensory stimulus to create an immensely pleasurable experience.  The Merovingian believes that he knows exactly how to create this experience.  My question, is this really any different than the therapist who describes manual therapy as a packaged method (the dessert) which creates the perfect experience to deliver the patient from pain (i.e. towards pleasure)?
Now that the hope of finding specific effects in manual therapy is waning much attention is being given to non-specific effects (1-3).  A giant leap in the right direction, IMO.  Yet, some are taking this to mean that they can specifically alter, manipulate and leverage such non-specific effects (4).  By itself this is a logically weak proposition.  For example, how does one manipulate non-specific effects, specifically? These therapists believe that they can create an environment which they can elicit the perfect response that will deliver the patient from pain.
Let’s examine this claim.  Apropos to this discussion is the nature of causality–thanks again to the Merovingian clip.  Science is a method for revealing causality from determinants.  Knowledge of causality leads to prediction, which is a form of power and enables those who wield it to make informed decisions to affect outcomes.
For the Merovingian (the therapist) to claim that they can create the perfect response to manual therapy based on non-specific effects, requires the assessment of everything that constitutes the social, contextual and cultural environment surrounding the patient-therapist encounter.  Additionally, they must make accurate judgments on all of the above.  It should be asked, is this really possible?  Given everything we know about the complexity of social networks, neural networks, and pain physiology, I would argue that it is not possible.  I am sure there are those who would disagree with me and their opinions are encouraged.
Personally, I am led to the conclusion that we cannot predict how any one patient will react to us as therapists.  What we can say is that some will probably react favorably and others may not.  The absence of prescience should prompt a search for other models, and metaphors to describe the clinical encounter–especially as it pertains to pain.  The value of treatment guides many of the reasoning models in physical therapy.    In the conservative care of pain we must move beyond treatment.  Do we have anything else that replaces it?  How does this change the construct that we apply manual therapy?  Are there models that embrace different values that may be more amenable to therapy in the absence of a Merovingian approach?
Eric Kruger @Kintegrate
Post Script: In the video above the Merovingian says, “Beneath our poised appearance we are completely out of control.” this is a nice reference to this book by Kevin Kelly which is a great intro of a different way of thinking about biology and technology.
1. Miciak, M., Gross, D. P., & Joyce, A. (2012). A review of the psychotherapeutic “common factors” model and its application in physical therapy: the need to consider general effects in physical therapy practice. Scandinavian journal of caring sciences, 26(2), 394–403. doi:10.1111/j.1471-6712.2011.00923.x
2. Bialosky, J. E., Bishop, M. D., Price, D. D., Robinson, M. E., & George, S. Z. (2009). The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Manual therapy14(5), 531-538.
3. Bialosky, J. E., Bishop, M. D., George, S. Z., & Robinson, M. E. (2011). Placebo response to manual therapy: something out of nothing?. The Journal of manual & manipulative therapy19(1), 11.
4. Benz, L. N., & Flynn, T. W. (2013). Placebo, nocebo, and expectations: leveraging positive outcomes. journal of orthopaedic & sports physical therapy,43(7), 439-441.

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  • Thanks for another thought-provoking post. I’ll be sure to read Benz et al (2013) to see what they mean about “leveraging positive outcomes.” However my first thought is that non-specific effects might be (and have been) leveraged in a predictable way regarding the physical environment the patient is treated in. The different environments patients were treated in was one of the criticisms of the Meade trial whereby differences in treatment outcome between physiotherapists (hospital) and chiropractors (private offices) could be , at last in part, attributed to the therapeutic environment (or lack of). I appreciate this is at a group level however and won’t necessarily help to predict the outcome with any one individual necessarily. Any thoughts?

    Jonathan Branney January 23, 2014 7:09 am Reply
  • I would agree with you. Many studies that demonstrate statistical causality at the group level does not equate with individual prediction. Think of it this way, knowing the ambient tempture allows for prediction of the state of water. Yet knowing the state does not predict where any one molecule will be or what it’s trajectory is. I think this is something that is lost on many clinicans and researchers as well. Even our best studies in phsyical medicine can show us general tendincies of probable trajectories (of recovery). Yet, because they are population based, they will never tell us with much certainty how any one patient will respond. Additional to this, statistical causation at a group level does not mean, determinisitic or mechanical causation at a different level. These concepts are part of the problem with believing that one can predictably leverage non-specific effects.

    ericpt February 4, 2014 3:45 pm Reply

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