As I sat at the head of my treatment table this morning, looking down at my patient, I viewed their right leg in external rotation while at rest, I flashed back to my training. This patient is seeing me for sciatica-like symptoms on the right side.

My training taught that pelvic asymmetries might manifest as one leg presenting as internally rotated and the other side as externally rotated. I learned diagnostic measures in standing and supine to check for those pelvic asymmetries and treat them accordingly, both at the pelvis (wedges, pelvic balancing techniques, etc.) and the legs themselves. Often, when I applied the work based on the theories presented, my patient’s symptoms improved. Many times, their pelvic torsions and leg rotations also seemed to balance out. These changes, both in reported pain and noted postural changes, worked to validate the theories taught to me.

But today, I had a thought.

While my deconstruction of much of what I was taught in my MFR (and other) training is well known, I continue to reflect on my past’s good and bad. How do I know that my patient’s leg rotation deviations are new? How can I be confident they contribute to their pain and not just a manifestation of a life of living? Bunnell (1993) points to the “normalcy” of spinal asymmetry, with 98.4% of us having a rotational spinal curve (scoliosis/sub-scoliosis), and such spinal curves will, by association, create skeletal and postural changes up and down the body. If 98.4% of us have such changes, are 98.4% of us doomed to pain and other problems resulting from that spinal curvature?

Modality training teaches us recipes. They all do. Recipes are not causational-fact-based. MFR taught me to assess pelvic symmetry as if the pelvis is not balanced, then nothing we do will last. But other training lines teach different rules that often conflict with the rules I follow and with which I found success. My MFR training also taught that unless my patient realizes the emotion holding patterns that led to the pain/problem, they will never truly heal.

I used strategies taught to me in my MFR training to get my patient to become more aware of those past emotional holding patterns and how to help them free themselves, often “pre-training” them by posting such information on my website. I was taught that emotions are stored in restricted fascia and passed that belief onto my patients, speaking with a sense of knowing and authority. I applied these principles, and my patients felt better. The adherence to the recipe, to me at least, validated the explanatory information as it was taught to me.

Do you recognize yourself in all of the above? I’m not just speaking to MFR, as such recipes exist in nearly every manual intervention model we can use/learn. I’ve heard from clinicians that if one doesn’t spend an equal amount of time working both limbs, then the patient will somehow leave the session out of balance. I’ve heard that if the feet are not balanced/levelled, then nothing we do elsewhere will be retained. I hear from upper cervical proponents that if C1 is not put in the proper alignment with the skull, work elsewhere is useless or that if we get C1 back into place, this alone will cause the body to restore its balance. Craniosacral therapy (CST) teaches that we must restore normal movement to the spinal dural tube, change is not attainable. The recipes are nearly endless. When we use a recipe, it often works, which often causes us to believe that the recipe was the correct one and, in some cases, the best one.

Is there a “best” modality? Is one recipe superior to others? Some believe that there is. I was taught so, but what sort of external measurement is done to validate these claims? I’ve seen internal validation by many (including myself in the past). “I’ve been a therapist for 30 years, and ABC MFR is the most effective modality in the history of healthcare.” In today’s pollical climate, fact-checking has become both envied and vilified. How does one go about fact-checking a claim about the superiority of one intervention over another? That is the place of rigorous research studies. To my knowledge, there has not been a reputable study that shows one branded or unbranded manual therapy intervention superior to another.

In a recent “The Thinking Practitioner” podcast, Til Luchau and Whitney Lowe interview Mark Bishop, PT, who talks about the science behind the factors at play that make our work useful. While we like to think our outcomes are due to our mastery of finding and impacting the tissues-at-fault, much more goes into the therapeutic interaction besides any tissue-based singular selection and impacts. The full transcript from the interview is available through the above link. Such conversations are becoming more common. Though many feel that their skills and education are being diminished, what is happening is there is a better understanding of how and why we, as manual therapists, influence our patient’s problems. There is dissonance from tissue-based believers, as it seems like these newer models detract from the positive outcomes they’ve seen using the recipe of their modality. If presented in a demeaning manner, few listen. But if presented constructively, one that does not put down the hands-on work we’ve done, growth can occur.

MFR, and all other modalities and styles of intervention, are helpful. On that, we can agree. But is the efficacy due to the reasons stated in those individual seminars or lines of training? Possibly. But there are aspects that are seldom discussed in those training as they are more generic and do not seem to contribute to an individual educator’s superiority claims. All of this disagreement can get ugly, I know. Continuing education is big business, and brand-building is an essential part of a big-budget model of training. If we all started speaking the same language, and acknowledging that there are marked similarities in our shared styles, the demand for any one model may diminish.

I learned some pretty hands-on skills in my MFR training and others, and I am thankful for that. What I now find less helpful is the rationales presented in those trainings, rationales that elude external validations. I learned recipes, not science. Recipes should not be discarded, but can you take that recipe and add a layer of credible understanding and utilization of neuroscience and behavioral science to form a more cohesive, universally accepted model? OI hope so.

So, as I sight down my patient’s body, I see that that externally rotated leg may be a part of her that may never change, nor may not need to. I cannot look back in time to see if it always existed in that fashion, and I no longer see the need to “correct” that deviation. I still use the hands-on intervention style taught to me in my MFR training; I just no longer force the recipe taught there. Should we, as physical therapists, massage therapists, etc., be telling our patients that their emotional holding patterns are the reason they cannot shed their pain? I believe that it is not my place, from a professional scope of practice perspective, nor do I think that this is even a credible interpretation of existing scientific understanding. Stay in your lane, folks.

Suggestions? Give a listen to The Thinking Practitioner podcast at the link above. That could be your gateway to a deeper and more thorough understanding of how manual therapy works. Don’t let detractors sway you; we mean well. Some of us, including myself, at times, get a bit pushy, but remember, we’ve all been where you are right now. I began crossing the chasm from tissue-based beliefs to a broader human-being-based understanding of pain and impacts 15 years ago, and I am still learning and evolving. If you’d like someone to walk across the bridge with you, please feel free to let me know.

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.

• “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?