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Articles Of The Week October 11, 2020

October 10, 2020/in Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Jon Cain

A lot of us work with an active clientele who are looking towards prevention, not only recovery. This article discusses painful “niggles” that may be felt during activity which may be a warning signal for future injury.

The significance of painful “niggles” during exercise – Paul Ingraham

More great information showing the discrepancy of structural degeneration in relation to pain. This study, in particular, shows very minimal progression of pain in the knee during increases in cartilage-loss.

Does cartilage loss cause pain in osteoarthritis and if so, how much? – K.Bacon et al.

There’s a common belief among workers in physical jobs believe that their workday provides them sufficient physical fitness. However, there seems to be a discrepancy in the research that suggests otherwise.

While most of us aren’t likely to go into the depth of programming that this article speaks to while in clinical practice, it acts as great information on how loading varies between individuals on different days. It also has some tips for if you’ve ever encountered the problem of exercise volume being over- or under-prescribed.

What is internal load and load mangement? – Dillon Caswell

A very interesting take on internal versus external movement cueing. Again, this comes from a performance perspective but is immediately transferable to the clinical setting. A mixture of both types of cues, perhaps with a greater emphasis on the external ones, may help to create better resilience once conscious focus on movement is gone.

A Coach’s View on Internal and External Cueing – Matt Kuzdub

Let’s Stop Playing It Small Together

October 6, 2020/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Therapeutic Exercise/by Jamie Johnston

Alright, I have a confession to make.

I came to the realization a week or so ago while listening to a podcast that I’ve…well…I’ve been playing it small.

While I put out a blog post or so a week, teach some continuing education courses on first aid along with pain science and exercise, I’ve still been playing it small.

There are certain things I’m really comfortable with and other things that make me pull back and question myself, my abilities, and my thought processes. So rather than just face, those things head-on I shrink back.

This happens especially on social media.

I see some of the groups where people are asking questions, or making statements, and rather than throw my $0.02 in, I shrink, and it’s usually out of fear.

The fear I’ll get called out, fear I’m not smart enough, fear that my voice or my opinion doesn’t matter (well truly to some I know it doesn’t but that’s not the point here).

So, then a strange thing happened. I was sitting with my buddy Eric Purves telling him this as we started discussing doing a mastermind group. I looked at him and said f@#k it, I’m not playing it small, I’m putting this out there.

I opened the laptop and put it out on Facebook. To my surprise, the post got 83 reactions and 117 comments.

Also to my surprise was the response in the comments. From physio friends asking what they can do to help promote, lots of people wanting to attend, and of course a couple of negative ones. BUT, the positive far outweighed the negative.

As I pondered this I realized I’m not alone. It’s not just me that needs to stop playing it small…so does our profession, and here’s why.

Education

I will forever be a proponent of advancing our education and making it better.

As I talk to other colleagues in different parts of the world (and it happens here too) we sometimes shy away from sharing our opinions or challenging the opinions of other healthcare practitioners because our education was shorter, or not perceived to be as good a quality as theirs.

This was the way I felt for MANY years.

However, a few years ago I came to realize that if you talk to any of those other healthcare practitioners (if they’re worth their salt) they want their education to get an overhaul as well. If any of them are taking any quality continuing education courses, they soon come to realize that many of the things they were taught in college aren’t worth the textbook it was written in.

Now I’m sure there will be some who argue with me on this, but with those other professions, their education isn’t better, it’s just different. Yes, they get more recognition because they have a degree behind their name (and their associations probably lobby a lot harder) however, it’s no more evidence-based than ours (maybe even less in some cases).

In reality, we’re all fighting the same uphill battle, our entire healthcare system needs an overhaul when it comes to helping people in pain.

So if you’re trying to have a discussion with another manual therapist there’s nothing wrong with challenging their treatment narratives as long as you’re approaching it from an educated standpoint (and obviously done with some sort of decorum).

We can’t challenge and say ” your approach is wrong because I do ‘x’ treatment which works because I do it and I know it works!” However, if we can approach the topic with a statement like: “the newest research shows us that our understanding of ‘x’ isn’t what we thought it was and has since changed to …” will get us much farther into the discussion.

I realize this might be tough because there seems to be a hierarchy within our manual therapy world and for some reason, we are frequently seen as the bottom of this. But, I have to wonder, is this reality, or are we playing it small?

The reality is, our entire healthcare system needs an overhaul in education when it comes to helping people in pain, not just our education.

Time Is On Our Side…Yes, It Is!

This may be our greatest asset.

The more I come to understand the patient perspective on persistent pain (thanks to Keith Meldrum’s help) the more I realize just what a difference time with a patient makes.

I love this quote from Ken Leong from a Facebook thread, and glad I was able to use it with his permission.

Massage therapy is almost tailor-made for [the biopsychosocial] approach. The therapist has much more time than a MD to really get to know their patient or client: where they’re from, their culture, customs, what their family life is like, their history with athletics, sedentary actives, repetitive activities, their stresses, their sleep patterns, their nutrition, their living situations, who they live with and interact with daily and weekly, their commuting stress, their occasional (and therefore dangerous) heavier physical exertions, etc.

The patient or client also has time in treatment to reconnect with their mind and body, to figure out where the aches and pains came from, what are their self-perpetuating patterns are, how they can change them…

It’s like you’re tall and in front of the volleyball net, and someone sets you up for ‘the spike.

We’d be blind NOT to use all this biopsychosocial opportunity!

Ken G. Leong, RMT

If this quote doesn’t make you feel all warm and fuzzy inside for being a Massage Therapist, I don’t know what will.

Compared to every other manual therapist we have a massive opportunity to help patients simply because of the time we get to spend with them.

If we reel back to the above discussion around talking to other practitioners, how many of them spend the amount of time with their patients that we do? How many truly get to know their patients? How many understand what their patients are going through day to day?

While a few of them might, I’d say as a general rule (yes there are some outliers) they don’t get to in the same way we do.

This whole time thing isn’t just a matter of our interaction with the patient either. I’ve seen some discussions on different platforms where practitioners say things like: “I have a patient who wants a 60-minute treatment, but I only need 45min to get done what they need”.

While there’s nothing really wrong with this (as I hope the practitioner was trying to do effective treatment planning) but think about what that amount of time actually means to a patient.

This could be their time! This could be their break from the typical stresses of life. Maybe that hour is a break from being a parent, boss, caregiver, entrepreneur, or whatever other thing is causing stress in their life. That 60 minutes can make a massive difference in their weekly, or monthly (or however often you are seeing them) routine and life.

And this my friends puts us into a very valuable position in not only helping, but making a difference in our patient’s lives.

Exercise & Movement

I know, I know, you don’t think this is in your scope.

Well, in some places it is well within our scope and for others it’s questionable.

So I’d like to somewhat address where this is questionable.

From everything I’ve heard the argument is usually “it’s not in our scope to prescribe exercise, we have to refer out for that”. Every time I hear this I also notice that AROM (active range of motion) and PROM (passive range of motion) are still within scope. So, how is a patient actively moving not an exercise? If we are passively moving a part of the patient’s body while they’re on the table, how is this not exercise? If you can help a patient stretch on the table, how is this not an exercise?

We seem to think that recommending an exercise is always prescribing that you do a certain number of reps for a certain number of sets of ‘x’ movement (bench press, squat, deadlift, etc).

What if recommending exercise was simply recommending:

Go for a walk with a friend (one of the best things for low back pain).
Get on the floor and play with your kids.
Dig your hands into the garden.
Pick up your groceries.

Just get them to do something they enjoy!

Half of recommending an exercise for someone can be just giving them permission to do an activity. When they’re on your table if you can do AROM & PROM, then there’s no reason you can’t do isometric, concentric, and eccentric movements and this doesn’t require any fancy machinery or even a set of dumbells, you can simply just resist the movement while the patient performs them.

Doing this can be very effective in not only rehabbing an injury but they can also demonstrate self-efficacy, resiliency, capacity, and really isn’t that what we’re trying to do with any treatment? I hope so.

I think the bottom line here is that we have every opportunity (and probably more so than other healthcare professions) to make a massive difference to help people who are dealing with a painful experience. We need to use everything we have at our disposal to not only help our patients but to help push the profession forward. In no way am I saying everything is fine and we should stick with the status quo, we certainly need to continually push for better education to create evidence-based practice for all of us. So, I implore the profession to stop acting like me and playing it small. Let’s challenge the bad narratives regardless of who is using them and take a firm grip on the benefits we have as a profession to not only help our patients but help each other.

If you’re interested in learning more about these topics, we’ll be launching an online course about pain science and therapeutic movement soon and you can join the waitlist by clicking HERE.

Articles Of The Week October 4, 2020

October 3, 2020/in Massage, Massage Clinic, Massage Therapist, Massage Therapy/by Jon Cain

Unhealthy perfectionism can exist in ourselves as practitioners as well as clients who we are trying to guide through behavioural change. Often, these unrealistic expectations can derail progress. This article looks at models of perfectionism and provides some tools to help us modify our goals for success.

The ‘Fine Line’ in Perfectionism – Christina Pozerskis

What is blood flow restriction? Is it snake oil or does it have real benefits? Do we understand the contraindications? Now we can.

Blood flow restriction training in a nutshell – Arash Rex Maghsoodi

In our clinical community, it’s common for us to fall down the rabbit hole of believing that we need to create very complex explanations and solutions to clients’ pain. Why do we gravitate to these biases instead of the simple approaches?

Why do you hate simplicity? – Adam Meakins

At this point, we know that central sensitization has a seemingly endless list of factors that can contribute to it. This article looks at nutritional habits that may play a much larger role than previously thought in our chronic pain.

Do nutritional factors play a role in central sensitization and chronic pain? – Integrative Pain Science Institute

Our patients often complain of back pain that spikes in the morning. Here’s a rundown with some differential diagnoses as well as morning pain myths that can help you assess clients in your practice.

6 Main Causes of Morning Back Pain – Paul Ingraham

A Simple Guide To Patient Centred Exercise

September 28, 2020/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain, Therapeutic Exercise/by Ben Cormack

After ‘pain science’ and ‘biopsychosocial’ the latest buzz word on our horizon seems to be ‘patient-centered care’ or PCC for short.

Now for a buzzword, it is pretty poorly defined and we don’t really have a strict description, but I think PCC is really how we should be implementing the BioPsychoSocial (BPS) model and what the BPS model was really meant to be about rather than the more pain focused version we have today.

This blog aims to focus on how we might apply PCC in the context of an active approach to treatment but don’t be surprised if it meanders off course a bit.

Patient Or Person?

Most of the available literature in this area discusses “patient-centered care” but I much prefer “person” centered care as it turns the patient well ….into a person and a much more ‘real’ entity in a two-way relationship.

The term ‘patient’ has long been open to discussion and this is an interesting read on the subject and I picked out a couple of quotes.

“Do we need a new word for patients?”

“Patient comes from the Latin “patiens,” from “patior,” to suffer or bear. The patient, in this language, is truly passive—bearing whatever suffering is necessary and tolerating patiently the interventions of the outside expert”

“An unequal relationship between the user of healthcare services and the provider”

These are interesting perspectives that highlight the potential perspective of the ‘patient’ as a passive recipient to be told what to do and without concern for them as an individual. After all tissues and pathologies really don’t care how they are treated so why the need to worry about it?

What Actually Is PCC?

Maybe by definition, PCC is tough to define for all? What is person-centered for one may not be for another, but there do appear to be some broad themes and ideas that can be discussed.

Patient (person) centered care has previously been defined as:

“willingness to become involved in the full range of difficulties patients bring to their doctors, and not just their biomedical problems” – Stewart 1995

“the physician tries to enter the patient’s world, to see the illness through the patient’s eyes” McWhinney 1989

“Two-person medicine (rather than one person)” – Balint e al 1993

(Quotes in Mead et al 2000)

For me, a good start for PCC is not to see the therapist or technique or method or exercise as the star of the show. It’s about the PERSON that really needs our help. That does not mean fanfares, razzmatazz, and pedestals, it really means that we try to think about what THIS person in front of me needs, what is it like to walk a mile THEIR shoes?

Another very simple way to look at it is, how would YOU like to be treated?

Mead et al in “Patient-centredness: a conceptual framework and review of the empirical literature” defined 5 key aspects of a “patient-centredness”

The biopsychosocial perspective (the patient’s life)
The patient as a person
Shared power and responsibility
Therapeutic alliance
The doctor as a person (Personal qualities such as Humanness)

Wijma et al explored “Patient-centeredness in physiotherapy: What does it entail?”

They defined PCC as

“Patient centeredness in physiotherapy entails the characteristics of offering an individualized treatment, continuous communication (verbal and non-verbal), education during all aspects of treatment, working with patient-defined goals, a treatment in which the patient is supported and empowered, and a physiotherapist with patient-centered social skills, confidence, and knowledge”

What PCC Is Not

There are some criticisms of PCC that seem to centre around the idea of consumer-driven healthcare and doing ‘whatever someone wants you to do’. Maybe the idea of ‘shared decision making’, intrinsic to PCC, seems to open up this idea of consumer healthcare for some.

These discussions are often dominated by the type of treatment and the application of more passive modalities and we really need to guard against this reductionist perspective of PCC.

Rather than MAKING the decision based on someone’s preference, PCC instead really should be about people being involved in decisions, a key part of PCC, and this should reflect the best information around treatment that we have available and frank and honest conversations around the best course of action. Not simply “what treatment do you want”.

Makoul & Clayman in “An integrative model of shared decision making in medical encounters” discuss a number of steps involved with shared decision making

Define or explain the problem
Present options
Discuss the pros and cons (benefits/risks/costs)
Assess patients’ values or preferences
Discuss patient ability or self- efficacy
Provide doctor knowledge or recommendations
Check or clarify understanding
Make or explicitly defer the decision
Arrange follow-up

What Do People Really Want?

That leads us nicely into “what DO people want” and this does NOT seem to revolve around their favourite treatment type.

PCC is perhaps thinking about what healthcare can do for the end-user, the person rather than how do they fit into the broader healthcare world. What better way is there to do that than ask them : ).

The increase in qualitative research is fantastic and really helps us understand what people think, feel, and ultimately need.

This is a really interesting paper regarding a two-person perspective in back pain Listen to me, tell me’: a qualitative study of partnership in care for people with non-specific chronic low back pain

The authors here identified some key areas.

Partnership With Practitioner

“All participants expressed the need for mutual enquiry, problem-solving, negotiation and renegotiation between care-provider and care-seeker to establish mutual therapeutic goals “

‘Ask Me’

“All participants reported that engagement with their health care-provider improved if they were explicitly asked for their opinions and goals.”

‘Understand Me’

“Consideration of life circumstances and preferences was important to all participants in developing therapeutic partnerships and optimising exercise outcomes”

‘Listen To Me’

‘Explain it so I can understand’ – Valuing competent and empathetic listener

I know my own body – Participants framed the ability to ‘know your own body’ as empowering

This sentence particularly resonated with me however

“Tension existed between patients’ wanting a genuine voice in the partnership and them wanting a care-provider to give explicit diagnosis and best management instruction”

Does It Matter?

A question I often hear asked about person-centered care is does PCC actually improve ‘outcomes’? I suppose my response would be does the effect of PPC on outcomes actually matter and which outcomes are we discussing?

Although we know that contextual factors have an effect on outcomes we don’t know if PCC specifically improves the most common outcome measures, but, in my opinion it is the RIGHT way to treat other people regardless of if it changes pain, function, or whatever. Although we don’t really have much data currently, my biases say for many it would make a difference, if not to common outcome measure then to the person’s experience in healthcare (which might be an outcome measure in itself).

The Application Of PCC

Maybe we should NOT see a person-centered approach to activity/movement/exercise just about the type of exercise or the sets and reps. Instead, it’s about all those things AROUND the moving as well and I will focus mostly on these (you can retain your exercise bias : )

Starting With The End In Mind

Unless we define what recovery might look or feel like it is probably hard for anyone to know if they are actually getting there. Really the role of the therapist should be to see where someone wants to get to, where they are currently, and then help them bridge that gap.

The best place to start might be with the end in mind and this first and foremost really involves listening. Listening and understanding is, in my opinion, the real essence of PCC but many people don’t feel that this always happens in their HealthCare experiences.

This short excerpt is from the excellent “From “Non‐encounters” to autonomic agency. Conceptions of patients with low back pain about their encounters in the health care system”

Holopainen 2018

“Patients felt that they were not being heard. They felt that the encounters were expert-driven, and the HCP interrupted them and dismissed what they had to say, without listening to their wishes and opinions”

We also have to acknowledge that for some who have had pain for a long time this process of defining goals or recovery can be really tough. It’s often difficult to see outside of the pain and suffering to have a sense of what ‘life’ actually looks and feels like again.

“Patients identified the effects of pain on their lives. They reported that their circle of life had shrunk and they had given up doing things they used to enjoy” – Holopainen 2018

I try to highlight to people that they are not just moving for the sake of moving (although this can be a positive thing), we are moving to get further towards valued activities and goals that we have discussed and hopefully, this can tap into people’s intrinsic motivation.

A big problem, IMO, with goals, is that we can measure their success via their effects on more generic measures such as pain or function (certainly in research around physical therapies).

We have a wonderfully personal and specific thing, the goal, and we should actually measure the success of a goal by achieving……the goal! If that involves changes in pain then of course with a person-centered approach we have to involve pain in the goal. But we might have no changes in pain (our outcome measure) but reach a valued goal that has a huge effect on someone’s quality of life and may not always be captured by the more generic measures.

I do believe that the ‘WHY’ behind action has to be driven by the person. So much of what happens in therapy is driven by the biases of therapists about the best way to get people pain free or functioning better.

Maybe the ‘methods’ employed often fit better with the identity and values of the therapist rather than the patient?

Shared Decisions And Responsibilities

As we discussed earlier, PCC and shared decision making is not just doing what someone wants. We need to present the best available information and our professional opinion on the best course of action to properly inform decision making.

Autonomy has been shown to have an influence on exercise outcomes “Autonomy: A Missing Ingredient of a Successful Program?”. Perhaps some autonomy and choice might lead to better ‘bonding’ with exercise in rehab?

As there are a whole bunch of ways to exercise, move, and load it should be not to hard to present a number of options and allow people some choice on the best way forward. Equally, it is a therapist’s responsibility to give their opinion about the best course of action that they think will ‘fit’ the person based on the best data and a sprinkle of experience.

Laying out each other’s responsibilities in the process is an important step. I always say I am here to guide and help but you have to go and do it and believe in it for it to work. I believe we need accountability towards each other sometimes.

Planning

This for me really is true biopsychosocialism.

We are all people ‘embedded’ in the world with work, family, and social pressures. One of the best ways to implement a BPS perspective is to realize that any movement/exercise plan is not going to come at ‘no cost’ in terms of time, effort, and sacrificing something else.

People don’t just need something to do, they also need a plan to be able to do it. A destination is great but we also need a path to get there.

How many things do you never quite get around to doing because you don’t have a clear time, place, and structure to get it done?

When’s the best time to do some exercise? Before or after work. How much is OK? What should it feel like? Do they have the required information to facilitate doing it?

Another passage from “From’Non‐encounters’ to autonomic agency” highlights this.

“A lack of written instruction prevented them from doing prescribed exercises because they were unsure of what they were supposed to do”

Helping people to navigate their own individual social environments is also a beneficial way to help. We cannot often modify many ‘social’ things but we can help people understand and navigate them better. For example, how might someone access community support with getting more active? Are there free or low-cost resources that they can use? Are there support groups or family members or friends that might be able to help.

Acting as a guide rather than a healer can be really helpful for many!

Support & Motivation

Picking someone’s exercise form apart or highlighting some kind of movement dysfunction really is the opposite of PCC. It shows a complete disregard for how that might make someone else feel and how that might impact on their behaviours. But I suppose if you feel you are just dealing with a pathology then why should that matter?

We could say that view is quite the opposite of walking a mile in someone else’s shoes.

Perhaps we can think about how we might lift someone up rather than pick them apart. Think about highlighting strengths and positives. We entirely underestimate the power of motivation and optimism in healthcare in my opinion. This is a fundamental part of the role of the coach or trainer in the world of fitness but has been lost in the translation of exercise to the world of medicine.

People even say this themselves!

“patients reported that they needed someone to push them, like a personal trainer” – Holopainen 2018

Conclusion

Person-centered care is defined by the person
PCC is not just giving people what they want
People are people not just patients (passive recipients)
Think about “walking a mile in someone else’s shoes”
Think more about shared decisions (within evidence base)
Start with the end in mind, tie into valued activities
Help people navigate their ‘world’
Build people up rather than knock them down

Articles Of The Week September 20, 2020

September 19, 2020/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Uncategorized/by Jon Cain

Much of the United States, Canada, and even areas overseas are currently blanketed in forest fire smoke. Could this affect people’s pain? Here’s a study that looks at the effects of tobacco smoke on pain and rest.

Effects of smoking on patients with chronic pain: a propensity-weighted analysis on the Collaborative Health Outcomes Information Registry – James Khan et al.

Another mention to the constant fatigue that many of us are likely experiencing in these days and times. This article continues to go into depth about the varying causes of lower energy and provides more tips on how to combat it.

Why You Suffer from Constant Fatigue and How to Deal with It – Mark Pettit

We all know that pain benefits from exercise in the long term, but only some of us might be aware of the short-term analgesic effect from movement as well. An easy assumption is that this is all an endorphin effect, but are there other mechanisms at play?

Exercise Induced Analgesia –Todd Hargrove

If you’re looking through these articles, great! You’re a research-conscious practitioner. As such, it’s good to point out the occasional limitations of the research that you’re reading in order to fine-tune your perspective. This article, for instance, looks at the need to adjust our experimental groups for low back pain-clients in order to create better date.

A need of subgroups with the large group of people with (chronic) low back pain – Hester de Bandt

Research into the causes of autism are a hot topic that many of us may not want to touch, but it’s ok to look at the scientific research objectively. In particular, we stumbled upon this new relationship while researching into hypomobility syndromes.

Researchers have identified a relationship between Ehlers-Danlos Syndrome and autism – Emily L. Casanova

Hold Times For Stretching In Manual Therapy

September 15, 2020/in Massage, Massage Clinic, Massage Therapist, Massage Therapy, Myofascial Release/by Walt Fritz

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.