Hold Times For Stretching In Manual Therapy
I’ve been in this niche of manual therapy for nearly 3 decades.
When I entered this world, via myofascial release (MFR) training, hold-times were taught at a “minimum of 90-120 seconds”, as this was the time it was said to have taken for the fascia to begin to change from sol to gel.
But we were encouraged to stick around longer, as most patients were said to have multiple restrictions that would need to be worked through. I got quite comfortable reminding in place with hold-times often far exceeding 5-minutes.
After I left the formal MFR tribe in 2006, supposed newer advances in the understanding of fascial change moved the time frame of hold-times to 5 minutes, based on how concepts of mechanotransduction were said to influence the work we did.
That’s how science works, adaptation in models occurs as science uncovers more information.
However, did the sol-gel theory or does properties of mechanotransduction fully explain the reason why many of us stick around for really long hold-times? Is there evidence beyond the fascial science that comes into play when we linger for long time periods with our techniques and, if yes, are there additional aspects of our interactions that allow longer hold-times to have effects beyond, or rather than, that fascial science?
During the Covid shut-down, I rewrote my entire seminar curriculum, which included rebranding what I use, as a therapist, and what I teach, as an educator. As reported earlier, I moved my brand away from MFR and into Manual Therapy.
While there were and are many reasons for this move, one was the silo-like perspectives that are taken in nearly all manual therapy/massage branded modality lines of education. Each claims validations from disparate sources of evidence and science which often conflicts with the manner in which the therapy is applied. Early in my MFR career, I was struck by the vast difference in pressure application between MFR (as I learned it) and Rolfing.
MFR was slow and gentle, using long hold times that was said to be supported in the evidence. On the other hand, Rolfing used quicker strokes that were much more aggressive and it had been stated that these types of strokes were supported in their evidence. But when I went into the research citations used by each camp, there were a LOT of the same research articles. If found that odd at the time, but I knew enough to keep my mouth shut and not challenge authority.
I’ve lost touch with what sources of evidence each of these camps now uses and I suspect there have been updates all around, but even back in the early 1990s, I suspected that there were more universal (less fascial-based) explanations for how and why longer hold-times seemed to have efficacy for producing changes in fight/flight, pain, and movement problems.
Without bogging down this post too much, I came upon a study by Cerritelli (2017) titled, “Effect of Continuous Touch on Brain Functional Connectivity Is Modified by the Operator’s Tactile Attention”. To summarize the study, the researches wished to look at whether or not the clinician’s attention to the patient mattered. One might summarize this study to ask that if a clinician was distracted, would the potential therapeutic effect be less than if the clinician attended to the patient.
Therapists often use vernacular from their modality or beliefs to summarize the need for attention to the patient, but as far as I know, this was the first study of its kind to put those concepts into a research study. The study was set up with a patient being attended to at their ankle by a clinician. fMRI monitoring was made during the course of the “interaction” to determine if brain activity changed with the intervention. The clinician did nothing at the patient’s ankle except to have light pressure; no “therapy” was done of any sort. They were just asked to attend to the patient’s ankle. There were two test groups, with the only variable the state of the clinician. In one group the clinician was supplied with headphones that transmitted loud sounds, meant to distract the clinician. In the other group, the clinician had no such sounds to interfere with their attending to their patient.
The study showed that with the group being attended to by the clinician wearing the headphones (loud noises to interfere with their concentration), little change in patient brain activity was registered. But in the group where the clinician was allowed to attend to the patient without distraction, there was a decided shift in activation of brain centers toward improvements in functional connectivity.
I will leave it to you to explore the paper to read the details of this result at the full-text link here. But what I found most fascinating was that “improvements in functional connectivity” peaked at 15-minutes of hold-time (contact-time). Allowing for a sustained input, as we do in MFR-styles of engagement, may allow that added benefit of neurological input/output to maximize.
As clinicians, much of the new evidence has shown that our outcomes are not due solely to what we do with the tissues, but are a complex, multi-factorial cascade of effects from peripheral, to the brain, and back to the periphery.
Behavioral factors may play a larger less than perceived local tissue-based responses (BIalosky, 2009, 2010, 2018; Geri, 2019, Kolb, 2020). What we see as outcomes of longer hold-times embedded within the MFR culture MAY be due to mechanical properties attributed to the fascia, but we now know as well that such hold-times are absorbed by the brain of the patient, which possesses the capacity to downgrade fight or flight to rest and relax, modulate pain, and improve movement quality.
I find all of this fascinating, as it moves the bar of proof from the questionable interpretation of evidence into “fascial evidence”, toward plausible narratives, accepted by the wider scientific community, which is what we should be seeking. yes, it may reduce the importance of fascia to a level where it is simply a part of the whole and not the forgotten tissue that has been taught to many of us. Peripheral input is detected via the various receptors throughout the tissues, be it skin, fascia, muscle, joints, etc., and sent to the brain for processing.
Kolb (2020) writes about the evolution of understanding of similar concepts in his article, The evolution of manual therapy education: what are we waiting for? He reports that such information has been freely available, information that puts the effects of manual therapy not on the individual tissues, but on the whole person, though manual therapy educators continue to defy what has been known to push their beliefs onto therapists about their favored tissue-based models. I think back with sad irony at many of the concepts taught to me by my MFR educator about how medicine as a whole was stuck in outdated mindsets when, in fact, MFR education lags behind modern neuroscience. In Kolb’s words, what are we waiting for?
This sort of information does not negate the value of what we do, but may (should?) make us question the way that we frame our work. Unlike what I was taught, hold-times may matter more to our patient’s brain than to their tissues.
- Flipping the Script: Shared Decision-Making - January 17, 2022
- Are we the modality? A common denominator - September 12, 2021
- Putting Patient Preferences and Values Back In EBP - June 21, 2021