On this episode we just basically rant about several things in our industry with our buddy from the UK Tristen Attenborough
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The longer I exist in the world of manual therapy, the more I see little difference between styles of work or modalities. Despite claims of unique access to single tissues or pathologies, all manual therapy is performed in remarkably similar ways. What are the underlying qualities of each of the dozens (or hundreds) of seemingly unique brands of manual therapy that link their positive outcomes? I believe it to be the therapeutic relationship rather than the way one treats or the tissues one thinks they are accessing.
What thinks you?
Despite claims of tissue or pathology specificity, in the end, we are touching people. Can a specific style of stretch or input bias our ability to single out a specific tissue, structure, or supposed pathology to the exclusion of others?
Reflexology makes claims to access specific points in the foot reflecting on the general health and well-being, but can one remove from the interaction that the clinician is actively listening to the patient’s complaints or concerns and attending to those needs? Myofascial release claims domain over impacting restricted fascia by using long, slow, static holds throughout the body, but can one have certainty that is it fascia alone they are impacting and not muscle or, even forbid, skin? Massage typically uses a muscle-centric model to explain both the problem and the solution. Still, does using lotion and gliding on the skin assure us that muscles are the primary target?
Typically a messy argument ensues when such thoughts are posted to social media, as the tribalism of each modality or style of work creates angst among its many users. Having been indoctrinated to the mysteries of fascia and the lack of education on the part of physicians and others in healthcare on its importance, I can well relate to such tribalistic actions. But what is it that links the various manual therapy interventions that we all use?
Diane Jacobs and Jason Silvernail (1) wrote a paper many years back comparing the traditional way clinicians act in their roles. They viewed these traditional roles as one of the operator, where the clinician calls all of the shots, and the patient acts in a passive role. They compare this concept with a preferred alternative, viewing the clinician in the role of the interactor. Through this role, the clinician adopts a role that allows and requires decisions to be shared by both parties, allowing the patient’s values and expectations to be better represented. This view, and the views of many others (2-5), is moving the bar of manual therapy’s effects from clinician-driven tissue-based perspectives into interactional effects from a successful therapeutic relationship.
As I read therapists defend their modality or style of interaction regarding manual therapy, I was struck by the thought that instead of the modality being what is done to the tissues, the modality may be the clinician themself.
Few follow the rigid, pre-ordained protocols or historical narratives of any given modality without personalizing it to meet their way of treating or thinking or combining it with other styles. While therapists tend to see themselves as blending one modality to another as the situation demands, are they not in the role of creator, providing unique experiences to each individual patient? They are, hopefully, crafting the experience to meet the needs of the patient in an N of 1 fashion. Even when I thought myself an MFR purist I seldom sought out for my patient to unwind (though MFR training insists that such movement or emotional expressions come only from the patient; the clinician is simply the facilitator), seeing it as probably out of the scope of practice of a physical therapist as well as not representing what I was comfortable expecting of my patients. Sure, some clinicians are applying a routine to the patient that varies little from one patient to the next, but few would be accused of robotically applying exactly the same procure to each person. We personalize every session. Are we applying a modality? That would depend on how you define the term, and it is a very loosely defined term under the best of circumstances.
Instead of seeing ourselves as a follower of a model or educator, might it not be more accurate to see ourselves as the provider of a unique service? Our training, education, and experiences all form who we are, but we allow ourselves to be branded under the label of one person’s line or brand…and we do it quite willingly? Enthusiasm for a certain work can cause us to take on that branding. We are told that it is good for business, as it allows the public to find you, that special someone, in a sea of mediocre clinicians (sale-pitches like this are common in the continuing education field!). There is nothing wrong with this, but mightn’t it be better advertising to promote ourselves, instead of the person who taught us? The same positive impacts can be seen from seeing a professional who promotes causative ideas relating to dehydration, gluten intolerance, sugar overload, insufficient protein/fat in the diet, lack of vitamins, etc. Somehow, people are helped by all of these interventions and beliefs. Does that person just so happen to find their way to the expert who specializes in the exact thing that is deficient or problematic in your tissues, or are there aspects of relationship-building that can be credited with at least some of the positive impacts?
What is the common denominator that makes all of us successful, that allows us to help patients no matter what intervention we use? I see much of this fall to the therapeutic relationship that we build with the patient. As an observer on this ride of ours through life, I’ve made it a hobby to observe how clinicians treat, how they engage patients, how they speak to them, and how they include (or not include) the patient in the decision-making process. Like it or not, there are remarkable similarities to what all of us do. While binds us together?
The therapeutic relationship is complex. We see ourselves as the giver of knowledge and techniques. Our patients see us in a similar light and hope that we are the person who knows exactly what to do to help them. Often they switch clinicians regularly, as when one doesn’t help them, they assume that there must be someone else who can. Often they the past clinicians as not having the special training or knowledge that the next one will when it is possible it was that the past therapist didn’t have the right ability to form a successful relationship like the next one does.
These are fuzzy concepts and ones that are easy to pick apart. Picking apart is often what we do when our beliefs are challenged, and I am guessing that I have seriously challenged some core beliefs in readers. I mean no disrespect to what you’ve learned and experienced, as those experiences are strong glue that binds us to our beliefs. I might ask you to reflect on how it is that we all find ways of helping others when what we do and believe is so vastly different? Are there common denominators? Might we, and the relationships we build, be the modality?
There is many a narrative that needs to change in our profession. One such narrative is the theory of “myofascial slings” and in this Facebook post it helps us understand why this theory isn’t really useful for us.
Can Myofascial Slings Transmit Stretch From One Body Part To Another? – Raphael Bender
I remember a teacher in college telling me that some people will come in for treatment just to experience human touch. This has perhaps never been more important than during this pandemic where people have been isolated and lack the normal human touch they are used to.
Touch Deprivation Post-Covid: A “Tsunami Of Need” For Massage – Doug Nelson
Trigger points (TrPs) are a common source of discussion and debate on social media and even though most of us were taught about trigger points in school, the research has long been updated. We need to pay attention to that.
A Trigger Point Review – Eric Purves
One of the other articles we cited talked about interception, this article refers to this as: “your brain’s perception of your body’s state, transmitted from receptors on all your internal organs.” This plays some interesting roles in both physical and mental health.
Interoception: The Hidden Sense That Shapes Wellbeing – David Robson
We really like analogies around here, so this one really resonated. When we look at someone dealing with pain we have to be careful around causation. There are too many factors that contribute to a pain experience to narrow it down to just one thing.
Understanding Causation, A Coffee Mug Analogy – Modern Pain Care
Well, it was early in my career, and I think it’s safe to say I fell for it hook, line, and sinker.
I think it was my third continuing education course, and I was entranced by the idea of saving my hands and using these cool-looking tools. I figured I could really dig in and go deeper in treatments without beating my hands up. I’d also stand out as different from all the other therapists I knew around me because I would be offering something “different”.
So, I jumped in with two feet and headed to Vancouver for the weekend. I believe the course was $500 plus at the end I would invest another $3000 into those cool looking tools.
I heard some pretty fanciful explanations as to what I would be capable of doing with this new modality, “breaking down scar tissue” and “bringing more inflammation to areas to cause healing.”
While it all didn’t make total sense to me, I went with it.
The following week people came into the clinic, looked at the tools and said, “what’s with the torture implements”?
Some people loved them; others hated them.
When I took this course, one of the main things they taught was how going in with these tools and digging in really deep would bring inflammation to the area to promote tissue healing.
This was the purpose (or the reason) why the skin looked all red and bruised post-treatment.
Some other proposed mechanisms (1) would be causing greater flexibility compared to doing manual therapy without the tools as they would “reach deeper tissues” to have a more significant effect. Other proposed changes would include improvements in joint range of motion, increased stretch tolerance, and decreasing muscle stiffness by inhibiting muscle activity by modulating the nervous system.
So this study (1) looked at how IASTM would influence these proposed mechanisms on ankle dorsiflexion. What they found was quite interesting:
Throughout this paper, there was no mention of contextual factors or other things that contribute to successful clinical outcomes, especially since this was done on healthy people.
Another study (2) compared the effects between a massage roller stick and IASTM on hamstring range of motion and found that neither one was better than the other. Both helped increase ROM after a 3.5-minute treatment, but one was not better than the other.
However, a significant point in the study is how the massage sticks are probably better for home use and is perhaps a lot more cost-effective for the practitioner; they also pointed out how clinician preference plays a vital role on which to use.
What about if we compare IASTM to other therapies like spinal manipulation (typical of a chiropractic adjustment)? Well, one study (3) looked at the difference between SMT (spinal manipulation), IASTM, and placebo and found no difference in outcomes when helping with thoracic pain. However, it is essential to remember there is a lot of placebo involved in treatments.
In most of the studies, patients received over four weeks of treatment and more than eight treatment sessions. Also, the most successful ones were combined with exercise. In fact, they were more successful when combined with a home exercise program, so give good homecare! (3)
Important to take into account (4) that one IASTM company has a guideline protocol of doing:
If we handled every treatment like this, we would have good outcomes with just about any soft tissue treatment (except for the ice, unless a patient really likes that).
Most research (4) doesn’t use IASTM as a stand-alone intervention; it is always combined with other things to show a positive outcome. However, since most of the case reports reflect more of a subjective outcome, it’s essential to consider this if you’re deciding to put this modality to use.
Fortunately, the studies also show it is better to move away from the theory of causing increased inflammation with skin redness (ecchymosis, petechiae) due to the potential of iatrogenic tissue damage.
Some research(5) was done in a laboratory setting on rabbits to study the effectiveness of IASTM. They put a surgical injection into the Achilles tendon to induce tendinopathy. Then, after allowing three weeks to heal, they used IASTM on the tendon.
The results showed that the cross-sectional area of the tendon was larger on the treated tendon than the untreated one. They also found changes in elasticity and viscosity, but not to the point of being statistically significant.
While the study proposes that the larger cross-sectional area could mean a stronger tendon, they leave something significant out.
They went in and caused damage to the area with a surgical incision. This would naturally signal the body to send healing properties to the site to help with this. However, the rabbits were also allowed to move freely in their cage between treatments, and they were only comparing their results to “conservative” treatments.
The most recent research shows us that the best thing for a tendon injury is to load the tissue with movement. Yet, they disregard the contribution of the rabbit’s activities and that loading the tissue is not part of “conservative treatment”.
Also, none of this has been performed on humans, so it’s hard to say how it would affect our Achilles tendon until this human research is done.
As we have seen over the past year and a half (with a pandemic going on), there has been increased awareness of disinfecting our treatment rooms and clinic space for both patient and therapist safety.
Well, there’s an issue with this modality in this regard too.
Since there is no best practice guideline in place (4), the therapist’s responsibility is to make sure these tools are properly disinfected after each use.
While this can be tricky in a clinical setting, IASTM is very popular with therapists involved in sport.
The recommendations in a clinical setting look something like this(4):
This is recommended after every patient. If the tool were to contact any bodily fluid (blood, mucous, etc.), we would be required to use a high-level disinfectant as they use with surgical instruments.
This is obviously a hygiene issue, so the new recommendation is (4):
So in addition to all of the sanitization procedures, we now have to do in our clinic space, with the extra time this would take, could we accomplish it effectively between patients?
Also, if you’re a sports therapist working in the field, is this really practical? I think it would be difficult.
Another hygiene issue is using a lubricant. When I took the course, we were given a small container filled with something resembling coconut oil. The direction was to take the tool, use the tip and dig out some of the lotion/oil. Then put a small dab on your hand for more use; however, there were still times you would dip the same tool back into the lubricant.
The new recommendation would be to use a tongue depressor (easily discarded) to scoop the lubricant, then put the amount needed for treatment into a paper cup or another disposable container.
When it all comes down to it, IASTM is like any other modality. The original narrative needs to change. However, one difference is the importance of discussing the potential consequence of its use (because of petechiae). This is important because, like any other modality, if we aren’t giving patients the most up-to-date information and narrative, we aren’t actually getting proper consent. I still use my tools once in a while because I have some patients who love how it feels and request it. If I decide to use them on another person (because there is still some things I can do with them I can’t do with my hands), then there is a good conversation with them about what I’m doing, explaining why, and letting them know it’s okay to withdraw their consent if they don’t like it. All in all, if you want to learn IASTM, then by all means take the course and use it, just make sure your patients are properly informed when you do.
I posted something earlier this week about other practitioners questioning what you are doing in practice (specifically to movement). Naturally, this post was a good reminder that we don’t know what is going on in another person’s practice. More specifically we don’t know what’s going on with the person in front of that practitioner and why they’re recommending certain things to their patient. Contextual factors play a large role in what we do, even when it comes to recommending exercise.
What Is Wrong With 3 Sets Of 10 Reps – Marcus Blumensaat
We know how important communication is with our patients so it’s really interesting to see when new research learns new things about this in the brain. After years of research, neuroscientists have discovered a new pathway in the human brain that processes the sounds of language. While we will still need to work on our communication skills, it’s interesting to see how the brain processes this.
Sounds And Words Are Processed Separately And Simultaneously In The Brain – Cell Press
We quite often identify with the techniques we use as therapists. Quite often we hear therapists talking about what they are “doing to a patient”, where a therapist is an ‘operator’. However, this takes the person on your table out of the equation making them a passive recipient. Since we know there are more factors to a successful treatment than just a passive technique, we need to move past the ‘operator’ thinking.
Therapist As Operator Or Interactor? Moving Beyond The Technique – Diane Jacobs & Jason Silvernail
Ever use dad jokes as part of your communication with your patients? Turns out this might be a way to help build a better therapeutic alliance with your patients!
Shop Talk: Therapeutic Alliance – Sheila Schindler-Ivens
I was reading something the other day about how important it is to make tough decisions in life vs. easy decisions and their outcomes. For instance, when working on your business, the easy decision is to sleep in, the tough decision is to get up and get to work. While this post is talking about fitness, the point behind it still rings true; “Easy decisions, tough life. Tough decisions, easy life.”
The Paradox Of Tough Decisions – Eric Bach