The Negotiation Of Pressures
- “Using a soft touch which is generally no greater than 5 grams – about the weight of a nickel – practitioners release restrictions in the soft tissues that surround the central nervous system.” (source)
- “It has been suggested that ischemic compression therapy using either 90 (seconds) low pressure up to the pain threshold or 30 s stronger pressure up to pain tolerance can create immediate pain relief and MTrP sensitivity suppression” (source)
- “In the past, it was suggested that you hold pressure the trigger point at the individuals’ pain tolerance of a 7-8/10 (10 being excruciating pain). It is now accepted that even a 7-8/10 may be to high to get a proper release, so authors and researchers suggest holding the trigger point at a level of a 5/10 until the individual experiences a decrease in symptoms, at which point you can either go deeper into the tissue (look for trigger points that are in deeper muscles) or move to another location and search for trigger points” (source)
- “Pressure during deep-tissue work must be significant but always stays just below the client’s pain threshold.” (source)
Uncertain as to how much pressure to use? Well, the above statements should straighten things out, right?
Regular readers of my blog know my take on pressures, but if you are new:
In manual therapy/massage literature, there is little, if any credible, repeatable peer-reviewed evidence to show one type of pressure being superior to another. But there is also little that shows static pressures/stretch, of the type often used in myofascial release, to be superior to dynamic/movement stretching/massage.
Sure, you will find published studies showing many different styles of pressure having positive outcomes, which mistakenly leads therapists to feel their work has been validated.
Read enough studies and you may realize that just touching may be sufficient to produce potential positive outcomes, though that is a tough sell to most therapists. Having paid my way through a very expensive MFR curriculum a few decades back, I wanted to be taught how slow, light, static engagement is superior to all other forms of manual therapy/massage. The work I was taught and still continue to use/teach was and continues to be quite effective.
But is it better than others? Probably not.
Successful therapeutic outcomes are far more complex than simply the style and amount of pressure that you use and beyond the scope of this post. So how to decide on the proper amount of pressure?
I recently had a patient in my PT manual therapy practice who had a fair amount of experience as a therapist trained in craniosacral therapy. After hearing this I fully expected the patient to request the very light pressures that are typical of that line of training. (Disclaimer: Using and sticking to using only 5 grams of pressure used to drive me crazy!!! I know the craniosacral narrative quite well and what they say happens if you use more than 5 grams, but attempting to use pressures that do not even let me rest my hand on someone drives me frickin’ crazy! Even when I was taking CST classes I cheated and used more. Things seemed to happen in a positive way no matter what sort of pressures I used, which validated my belief that the CST narrative was less than stellar. Now, with a much better understanding of pain science, indirect/contextual factors, and the potential benefit from very light stretching to the skin I can better understand why those 5 grams of pressure may work for some therapists. Back to my story.) But, instead of requesting/expecting light pressures, this patient wanted me to hammer on them, repeatedly asking for a LOT more pressure than I normally use!
Some pretty scary pressures were requested and I had to recalibrate. Understanding that patient expectation often plays a big role in outcomes I found myself in a bit of a negotiation. Even current models of Evidence-Based Practice allow that fully 1/3 of the model is based upon patient values and preferences (link).
My big take on pressures is that whatever I am doing my patient should feel that my pressures are replicating a familiar aspect of their condition. This could mean bring their pain, etc., to their awareness (NOT hurting them, just making them aware that what I am doing is familiar) or reducing the intensity of the symptom. My pressures should feel helpful to them, or at least potentially helpful. They should never leave a patient feeling that the work we are doing may not be good for them.
Logical, but not always a common approach in manual therapy/massage/myofascial release. I do not think enough therapists ask their patients for input/guidance beyond, “Are you OK with this pressure?”.
During recent sessions with this patient, I found myself trying to draw them back from the ledge a bit but equally found myself taking a look over the edge of the ledge a bit. This patient and I negotiated a pressure that they felt was potentially effective while staying within my beliefs as to what pressure was necessary. I am fairly certain that I’ve done this in the past, but never actively being aware of the negotiations that were occurring at the moment.
The concept of negotiating pressures has taken on new meaning to me. As shown at the top of this page, from statements culled from various websites, pressures are taught in somewhat predetermined ways, mostly based on the inherited narrative or a story used to support the type of therapy/modality. It may have been presented in a manner that sounded well researched and even scientific in origin, but digging deep may prove that to be false. But the pressures may have worked well for you. I must admit that my MFR training seemed to give me permission to use a variety of pressures, but words like, “Intuition” were bantered about when trying to figure out how much to use. I still maintain that light to moderate pressures are sufficient to allow awareness and help to elicit change, but now I allow myself to be a bit of a car salesman, negotiating pressures until we both agree.
How do you determine pressures? Do you think that one level of pressure is superior than others? If so, why?
- 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
I have always found that asking the client how certain pressures feel is only one part of using the proper pressure in treatment. You must also “feel” the tissues you are working on. They will tell you when to increase pressure and when to decrease pressure to achieve the maximum effectiveness from your treatment. When has achieving a state of health, wellness, and rehabilitation ever been as simple as what the “book” says.
Our experiences matter, no doubt, and these experiences guide our interventions to good effect. Tissues, however, don’t talk. We interpret what we think we are feeling, the signals that we think appropriate. Much of these experiences are also based on how we were trained and our interpretations in applying that education. Much of what we think we are feeling tend to be based on how we were trained. An MFR therapist feels fascia restrictions. A trigger point therapists feel trigger points, etc. What we think we are feeling may be less about the pathology from which framework we learned, than signals gathered over years of listening to feedback from our clients. That feedback validates that we connected with something relevant. Though you are not using the word, I’m not fond of therapists relying on what they term their “intuition” as a guiding force in therapy, as it all too often leads into more non-plausible thoughts of effect and action. I believe that those cues we use are brought forth from positive client-therapist interactions than us having a sense of what is best.
We are team of physical therapists from New York. Not commenting much around the internet but you sir Terry are right. Good conclusion! Thank you