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Hold Times For Stretching In Manual Therapy

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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.

Articles Of The Week September 13, 2020

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In a pandemic world, stress can leave us worn down and with less energy to carry on our day-to-day lives. This article looks at the syndrome, which some of us may have once called “adrenal fatigue” and analyzes the actual mechanism at play.

Do you have Stress Bod? The surprising science of feeling awful – and what to do about it. – Ryan Maciel et al.

 

Are you still blaming a weak tranverse abdominus or multifidus muscle for your patients’ low back pain? It may be time to take a new look at better interventions.

Why We Need To Stop Blaming Tranverse Abdominus For Back Pain – Brandon Mouatt

 

We have long-since agreed that DOMS (delayed onset muscle soreness) is likely the result of microdamage to muscle fibers during exercise. However, there’s a very interesting new theory that points out possible neuropathic origins instead.

Have We Looked in the Wrong Direction for More Than 100 Years? Delayed Onset Muscle Soreness Is, in Fact, Neural Microdamage Rather Than Muscle Damage – Balazs Sonkodi et al.

 

Many of us have treated frozen shoulder in patients and can probably agree that our understanding of the condition is still thin. Here’s one more interesting piece of the puzzle regarding a factor that may predispose to the condition – that being diabetes!

Frozen shoulder and diabetes: What’s the link? – Kelly Wild

 

Putting together exercise programs can be challenging; not because we don’t know enough, but often because it’s easy to overthink it! Here’s a great article with tips that can be applied to exercise-planning for anyone from elite athletes to elderly patients.

5 Strategies to Avoid Overthinking Strength and Conditioning Programs – Eric Cressey

4 Instant Ways To Assess And Move For OA Of The Hip

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Over the past couple of weeks we’ve been discussing different ways we can help patients who are dealing with OA of the hip.

Here are some relatively simple assessments you can do, which will also be great as homecare exercises!

When looking at all of these movements/tests it is recommended that you demonstrate it once to the patient, then have them do a practice run before the actual test takes place.

Sit To Stand Test

You start this with just a chair placed with the back of it against a wall. The patient sits with feet shoulder width apart and arms crossed at the chest.

You then have them rise to a standing position, then return to seated position for as many times possible for a 30 second duration.

Doing this can help give us an idea of some activity limitations the person may have. 1

 

4 Square Step Test

The literature recommends using four canes spread out with the handles at 90°, but I didn’t have any canes, so I just used tape on the floor.

Start the person in square 1 (whichever one you dictate that is) then in a clockwise direction stepping forward into square 2, side stepping to square 3, reverse step to square 4, then side step back into square 1.

Once the person is back in square 1, you reverse the direction going counterclockwise, side step to square 4, forward step to square 3, side step to square 2, reverse step to square 1.

This is timed to see how the person can do as quickly as possible to give us an indication of how well a person can move in different directions.1

Step Test

This one is a great way to assess a persons balance.

The literature recommends a 15cm step, but I didn’t have one, so I’m just demonstrating with a platform we have at the clinic.

Have the person stand on the affected, or the test hip. With the opposite leg step up onto your elevated surface until the foot is flat on the step, then return it back down to the floor. The painful side is always the “stance” side and doesn’t move up onto the step.

See how many times the person can do this for 15 seconds.1

 

Timed Single Leg Stance

This is another one for assessing a persons balance.

Hands are placed on the hip. Testing side is the “stance” side, opposite leg is put into a flexion position so that hip is neutral.

Then time the person for a maximum of 30 seconds. The test stops if the hands come off the hips, they touch the stance leg with their hands, or the stance leg touches the non-stance leg.1

What I really like about all of these, is that while their intent is an assessment, each one of these could easily be a homecare exercise you recommend to anyone with hip issues. You can easily do any of these in your treatment room and it can give you a great indication of a patients progression or digression. As always don’t just give them this with no reasoning behind it, make it meaningful to the person, find out their goals and explain how these or any other exercise can help them attain that goal. Make it about them!

References

  1. Cibulka MT, Bloom NJ, Enseki KR, MacDonald CW, Woehrle J, McDonough CM. Hip pain and mobility deficits—hip osteoarthritis: revision 2017: clinical practice guidelines linked to the international classification of functioning, disability and health from the orthopaedic section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy. 2017 Jun;47(6):A1-37.

Articles Of The Week September 6, 2020

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As some communities look to get businesses and other activities going again, some are taking on huge efforts to sanitize and clean. However, are these efforts going to be the major thing that stops the spread of Covid-19? Interesting points made in this article.

“Hygiene Theater Is a Huge Waste of Time” – Derek Thompson

When we’re recommending homecare to one of our patients, one of the obstacles can be finding the time to actually do the homecare. This can be especially true with new parents. Now while I don’t necessarily agree with some of the comments about posture, this article does give some good advice on finding time to exercise for new moms.

“How To Focus On Fitness When You Just Don’t Have Time – Monday Workout Motivation For New Moms” – marsstarsbaby

Could something as simple as education actually alter the treatment of our patients dealing with persistent pain? While patient education is quite often one of the big recommendations when we look at the clinical guidelines of a certain pathology, this papers shows us that a simple pain education lecture to students altered how they treated patients.

“Research: Can a Pain Neuroscience Education Lecture Alter Treatment Choices for Chronic Pain?” – Adriann Louw

Don’t let the title of this one fool you, your core isn’t weak. Fortunately, this article dispels the myth of a weak core and it’s correlation to back pain.

“Your Core Is Weak” – Ellie Somers

We are pretty big advocates for movement and exercise around here but sometimes we have to acknowledge our bias and ask why? Well here are some of the reasons for and also some reasons against.

“Why Use Exercise” – Adam Meakins

 

 

Proven Ways To Increase Strength, Endurance, And Flexibility Of The Hip

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Last week we had a post all about helping patients with OA of the hip.

One of the big recommendations was doing exercises that would help with strength, endurance, and flexibility of the hip. 

Here’s a series of exercises I learned back in college (from a pretty great instructor) that I believe would help with all of those goals.

Everything You Wanted To Know About OA Of The Hip

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I wrote a post a few years back about a mistake I made helping someone who had osteoporosis in their hip and how to avoid my mistake.

We’ve also been posting lots around different hip pathologies lately.

It can be confusing, to say the least, trying to determine exactly what is going on with a patient experiencing hip pain. Coming up with what we “think” is a diagnosis, then attempting to differentiate which pathology they are experiencing if there even is one.

Then, of course, using our clinical decision making to develop a treatment plan and homecare.

But, are we really sure we’re doing the right thing for each pathology?

Well since we’ve already done posts on the SI joint and Femoroacetabular Impingement, I figured it was time to take a look at the research on Osteoarthritis and what we can do to help.

Finding A Diagnosis

Yes, I know…we’re not allowed to diagnose.

But!, that doesn’t mean we shouldn’t have some knowledge around how this is diagnosed so we can better educate our patients on what they are dealing with.

OA of the hip is usually seen in middle-aged and elderly people, most often over the age of 601, with men having a higher prevalence.

It affects the joint capsule (as well as other structures around the joint) which in turn causes some muscle weakness and limits the range of motion1, mostly with internal rotation and flexion.

When we look at the clinical guidelines around OA of the hip1 there is a list of things used in the diagnosis:

  • Moderate anterior or lateral hip pain during weight-bearing activities.
  • Morning stiffness less than one hour in duration after waking.
  • Hip internal rotation of less than 24°, or internal rotation and hip flexion 15° less than the non-painful side.
  • Increased hip pain with passive internal rotation.
  • Above the age of 50.

So if we are seeing someone and we suspect possible OA, or we are unsure of the diagnosis and their symptoms aren’t matching up to the above, this would be a good opportunity for us to refer out to get a possible differential diagnosis.1

Part of what we should assess is also what the daily function looks like for the patient sitting in front of us. What activities would they normally be doing that are being hindered because of the pain associated with this?

Also extremely important to take into account are: What are their goals? What are they hoping to get out of the treatment? What would a successful treatment look like to them?

The cited paper 1 gives four different activity tests which could be useful for you in your practice:

  • 30 Second Chair Stand Test
    • Seated on a chair, feet shoulder-width apart, arms crossed, patient stands up and repeats this as many times as possible for 30 seconds
  • 4-Square Step Test
    • Four canes placed with handles out at 90° angles to form four squares. The patient stands in square 1, steps forward with both feet into square 2, then steps right into square 3, then steps back into square 4. Sequence is then done in reverse and is timed.
  • Step Test
    • Patient steps on and off a 15cm step maintaining stance on the painful leg, both feet are placed on the step, then down to the floor on the opposite side. This is done for 15 seconds with the full number of steps counted.
  • Timed Single Leg Stance
    • The patient places hands on their hips and stands on the affected leg, with the knee of non-stance leg flexed so the foot is behind. The patient stands on 1 leg for as long as possible up to 30 seconds.
  • Six Minute Walk Test 2
    • You guessed it! Go for a walk with your patient. See how far they can go on a flat surface for 6 minutes in duration.

What I love about these assessments is how they all help to measure strength, balance, endurance, and flexibility…which are also the recommendations for exercise or homecare interventions for people with OA of the hip. So these could easily be part of homecare instructions to increase strength, balance, endurance, and flexibility and you can watch them all by clicking HERE.

In addition to these active assessments it is also important to document 1 flexion, abduction, and external rotation (FABER test) along with passive hip ROM and strength (which might be tough to do via special testing), which is where the above activities will help.

Now that you have an understanding of how individuals are diagnosed, and how we can do some assessment, it’s important to know what the research says on treatment.

The biggest recommendations are patient education, exercise, and manual therapy1.

Now, I’m not about to lecture you on the manual therapy end of things. You all have your favourite techniques and your patients come and see you because of what you do, so keep it up! When it comes to education, we aren’t so much educating patients on OA itself (we can leave that to the doctors and rheumatologists) but we can teach them some activity modifications and…you guessed it again…exercise. If the work you’re doing or if the guideline recommendations aren’t helping the patient see some improvement, this would also be a good time to refer out.

So let’s look at what the evidence says on exercise!

Exercise For Hip OA

Now it’s important to mention that weight loss is one of the main recommendations to help OA of the hip, however, counseling a patient on this is well out of our scope. Also, as Greg Lehman puts it, losing weight is really hard!

So let’s focus on what we can do (which in turn may help with a bit of weight loss), EXERCISE!

When reading over the research on this, the first statement that popped out to me was:

Pain is the dominant symptom although it is important to note that the severity of pain and the extent of changes on x-ray are not well correlated 3

This is crucially important as quite often people will get the x-ray to confirm a diagnosis and take this as an indication they shouldn’t exercise or can catastrophize over this, thinking they are so damaged exercise isn’t an option.

Pain along with joint stiffness, instability, swelling, and muscle weakness can lead to not only physical but psychological changes and impaired quality of life. 3 However, when we look at the benefits of exercise it can not only improve physical activities but can also help to improve a wide range of other functions including social, domestic, occupational, and recreation activities.

It can also help with fall risk, which is not only an immediate benefit but also a very long term benefit in preventing traumatic injuries due to fall accidents.

When looking at the type of exercise that would be most useful, it was determined that using supervised therapeutic exercise for strengthening the area is most beneficial and surprisingly (at least I was surprised) water-based exercise wasn’t as effective, nor was there as much research done in that area. Part of why this is not as effective is due to less of a load on the joint which does not correlate to walking ability or an increase in joint ROM. Also access to facilities is harder to come by compared to just being able to go for a walk outside.

However, it is suggested that for obese patients (I’m not about to make that assessment, this would be better coming from a doctor), or those who have more severe changes, aquatic exercise would probably be more beneficial until more load could be tolerated.

So, digging deeper into the research it goes back and forth as to what is more effective strengthening, or aerobic. However, the reason it seems to go back and forth is because it always comes down to what is most important, and or, more effective for the patient sitting in front of you. This way there is no “one” recommendation as far as exercise goes. To provide a good exercise recommendation is to look at what is affecting the patient more. Is it more important to strengthen the area according to the person’s daily needs? Or is aerobic exercise more important? What are the patients goals? Is going for a daily walk more important, or is being able to do a squat, climb a flight of stairs, or playing a game of tennis the top priorities.

I love these two quotes from our friend Bronnie Lennox Thompson:

Whatever the reason, tapping into that is more important than the form of the exercise.

and

Without some carryover into daily life (unless the exercise is intrinsically pleasurable), exercise is a waste of time.

Now don’t get me wrong, exercise is never a waste of time and the evidence shows us, in this case, it can assist with daily function and help with pain (it will never completely get rid of pain). However, if we aren’t making the exercise applicable to, and enjoyable for the person, the likeliness they will do it is low. We also have to take into account they will likely have some discomfort with exercise but we must educate them on how this is not correlated to the condition getting worse. If we recommend an activity and 48 hours later there is some swelling, or the pain worsens this demonstrates that we have overdone it a bit and may have to back off the homecare dosage we have given them. We must use our clinical decision making not only in our dosage but also in what’s important to the person sitting in front of us.

References

 

1. Cibulka MT, Bloom NJ, Enseki KR, MacDonald CW, Woehrle J, McDonough CM. Hip pain and mobility deficits—hip osteoarthritis: revision 2017: clinical practice guidelines linked to the international classification of functioning, disability and health from the orthopedic section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy. 2017 Jun;47(6):A1-37.
2. American College Of Rheumatology. Six Minute Walk Test. https://www.rheumatology.org/I-Am-A/Rheumatologist/Research/Clinician-Researchers/Six-Minute-Walk-Test-SMWT.[August 10, 2020]
3. Bennell KL, Hinman RS. A review of the clinical evidence for exercise in osteoarthritis of the hip and knee. Journal of Science and Medicine in Sport. 2011 Jan 1;14(1):4-9.

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