Are we the modality? A common denominator

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?

References

  1. Jacobs, D. F., & Silvernail, J. L. (2011). Therapist as operator or interactor? Moving beyond the technique. The Journal of manual & manipulative therapy, 19(2), 120–121. https://doi.org/10.1179/106698111X12998437860794
  2. Bialosky, J. E., Beneciuk, J. M., Bishop, M. D., Coronado, R. A., Penza, C. W., Simon, C. B., & George, S. Z. (2018). Unraveling the Mechanisms of Manual Therapy: Modeling an Approach. The Journal of orthopaedic and sports physical therapy, 48(1), 8–18. https://doi.org/10.2519/jospt.2018.7476
  3. Geri, T., Viceconti, A., Minacci, M., Testa, M., & Rossettini, G. (2019). Manual therapy: Exploiting the role of human touch. Musculoskeletal science & practice, 44, 102044. https://doi.org/10.1016/j.msksp.2019.07.008
  4. Bishop, M. D., Torres-Cueco, R., Gay, C. W., Lluch-Girbés, E., Beneciuk, J. M., & Bialosky, J. E. (2015). What effect can manual therapy have on a patient’s pain experience?. Pain management, 5(6), 455–464. https://doi.org/10.2217/pmt.15.39
  5. Anjum, Rani Lill; Copeland, Samantha; Rocca, Elena. (2020). Rethinking Causality, Complexity and Evidence for the Unique Patient. 10.1007/978-3-030-41239-5

Rules and Recipes: Moving On From Older Models Of Manual Therapy

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.

Tools From My Past, Reflecting On Change

Recognize those objects in the photo? They are pelvic wedges, used by some health professionals for a variety of reasons. Most rationales center around their use to balance the asymmetrical pelvis.

I learned why and how to use them in a myofascial release (MFR) course on the pelvis, somewhere around 1994. The theory was that pelvic asymmetry, or torsions, was due to injury, birth trauma, and other nefarious insults and needed to be corrected for the pain to lessen, gait, and posture to improve, and many more reasons.

I learned a lot in that class, much of it I used for many years. Those pelvic wedges are well-worn, as I balanced the hell out of many pelvises over a long time. And you want to know something? I helped a lot of patients with their back and related pain through the use of those wedges.

Then around 7-8 years ago I noticed that I was using them less often. In the present, they tend to stay unused. Why is that? Don’t I want to help people as I did in the past?

7-8 years ago is when I seriously began questioning all things therapy-related, both from a manual therapy perspective, but also from an exercise/strengthening perspective. I had departed my MFR world in 2006 after being told to conform or leave. (I chose to leave.)

But I stuck with those MFR principles and philosophies for a number of years and applied them in my work, including what I thought was balancing the pelvis. After a few years I began drifting into other worlds; into other ways to describe and define the effects of manual therapy in general, and MFR in specific. At first, I didn’t like what I read and learned, as there was a lot of confusion and uncertainty over just how manual therapy impacts the human being.

As I learned more, I saw the flaws in many of the simplistic explanations therapists use, as well as how the public views and repeats those simple concepts. Exercise, for instance, is often quite helpful, though I now know that those effects had little (if anything) to do with being weak. The common simplistic statement physical therapists tell their patients that being stronger will help you support yourself better, which leads to less pain was simply false. Or, the statement was so weakly true that it made little sense even to say it.

However, patients say things like that all of the time. It was much of what the core stability craze grew from. “Getting strong” is helpful, but the strength itself is not what diminishes pain. It is a complex combination of factors that vary from person to person. Movement is helpful. Motion is lotion.

MFR, and manual therapy in general, suffer from similar simplistic errors. When one reads through some of the latest evidence (Bialosky, 2009, 2010, 2018; Geri, 2019; Kolb, 2020), these papers read very differently from the way I learned MFR. But I can wager that if you underwent advanced training in any of the popular branded modalities in manual therapy, the science that you learned may not align completely with what others see as truth. How do you put all of that together?

Let’s go back to my wedges. As an MFR-based PT, I saw people coming to me for issues of pain in the low back, peels, hip, sacroiliac joint (SIJ), and more. Often, one of the first places I began my evaluation was at their pelvis. “If you don’t balance the pelvis, nothing will stick” was a familiar phrase I was taught in my MFR of training. Along with postural assessment, a pelvic assessment was key to knowing what was at fault and what needed doing (on my part). Pelvis assessment was done by palpating both the ASISs and PSISs (front and back landmarks on either side of the pelvis), as well as looking at possible upslip/downslip of the pelvis, etc. There were some SIJ assessments, to see if one side was stuck, as well as other assessment procedures, mainly postural. After all of this, I would put it all together and tell my patient why they were having pain (what I thought to be the cause) and what needed to be done to correct things. Many times patients simply agreed to what I said was wrong and trusted me to fix them.

That’s when the wedges came in.

I’d place the wedges in precise locations so that when my patient rested on them, with the assistance from my MFR intervention, their pelvis was released back into a better alignment. We might repeat this over the course of a few sessions and I would reach them homework to reinforce the pelvis corrections. And most got better.

Wedges are used by other professions and by other modalities, so we MFR therapists didn’t own the patent. But the way we used them was said to be unique. Other clinicians wasted their time with ineffectual chiropractic adjustments, etc., but none of them had the long-lasting effects as we did. (I spoke like that a lot back then.

So why did I stop using them? Why would I stop using them?

In today’s culture on social media, evidence and research seem to have taken a turn for the dark places.

Many mistrust research, feeling like scientists are always changing their minds and claiming all research is bought and paid for by big industries, etc. Science does self-correct continually, but that is the nature of the scientific method.

During the period when I left my MFR tribe, I began reading studies, many of which seem to refute what I had been taught and what I had witnessed as a clinician. For instance, in 1999 Levangie looked at the relationship between pelvis asymmetry and low back pain. While they found a weak association between the asymmetry of the PSISs and lower back pain, overall, “Pelvic asymmetry was not positively associated with low back pain in any way that seemed clinically meaningful.” One study does not make a believer out of many, and rightly so.

But the more I dove down this and related research rabbit holes, the greater dissonance I found with what I learned and practiced. While I could go on for quite a while on the weakness of the link, suffice to say there is sufficient evidence that made me question just what it was that I WAS doing.

The use of the wedges seemed to correlate in some way to my patient’s lower back pain resolution, but apparently, if I was to believe that dastardly evidence, it wasn’t because I reduced the asymmetry. (And for those of you who fancy yourself as a skilled assessor of pelvic levels, check out this systematic review of the reliability of palpating the PSISs. “Current methods of palpating for PSIS asymmetry do not result in levels of interexaminer reliability supporting clinical utility” (Cooperstein, 2019). Fake news, you say??? Try again. Another study points to the difficulty in accurately assessing pelvic tilts and ASIS/PSIS level due to inherent pelvic variations in pelvic morphology that render each side of the pelvis different from the other side. WE cannot measure what we think we are measuring when the underlying structure is not arranged as we think it is! Link

So what could it have been?

First off, I am not in any way calling anyone who used wedges ineffectual. Not in the least.

But what I am suggesting is that the process of using of wedges with a patient, from introducing the concept that pelvic misalignment may have a good deal to do with pain, to the rituals involved with the measurement of their posture and pelvis symmetry, to the rituals involved both with the precision of wedge placement as well as the exactness in which I proceeded with treatment, is a part of contextual factors that often go underappreciated. Add in neurological input through the patient’s skin/soft tissue which can signal to higher centers that things are happening, leaving the patient able to participate in the process of change (read those initial references I gave you for more on these concepts), as well as potential local reactions from the body, and often the pain is lessened. Does the pelvis change in a meaningful and lasting way? Many insist that it does and they claim to have proof. Maybe they do, but even if the pelvic alignment changes, how can we be certain of the cause? Meaning, was it the wedges? Our input over their skin/tissues, while on the wedges? The nervous system adapting over time to a novel stimulus? Or a wide range of other variables?

Those of you who use and swear by wedge usage, postural deviations as the cause of pain, and other similar narratives, there is a very strong chance you’ve already given up on this story, as there is too much cognitive dissonance occurring for you to remain.

However, as I learned more about how neurological and behavioral influences impact pain and movement quality, I saw that the wedges were simply a tool to access that entire human in front of me. I learned that I could use simpler tools to accomplish the same end, namely conversation and assuring a richly contextual therapeutic relationship, one that my patient played a larger role in creating.

I continue to use manual therapy (I dropped the MFR brand), though coupled with strong suggestions for movement (exercise, strengthening, walking, dancing, etc.) as a means to get them moving. Do I get better results than I did back in my MFR wedging days? That is difficult to accurately and objectively say, as such data is difficult to analyze. My patients seem satisfied, as are the insurance companies that often pay the bill.

Why don’t I use them anymore?

That I cannot completely answer, as I still see them as potentially useful. If other means did not seem to spark the attention of a patient then I may drag them out and put them into action. Should you stop using your wedges? Nope. Just realize, the wedges may have less important that you and I were led to believe. I can tell you in full honesty that it has been many years since I performed a standing postural assessment, pelvic measuring included. It has been that long since I pinned my patient’s pain on their pelvis being out of alignment.

Much of our training is about learning recipes and rituals. We take more training as we believe it will give us more skills, which it might. But additional training allows the educator additional access to your brain, filling it with the jargon and recipes of your modality. By using those recipes you set up a context that seems precise, but in the end, maybe no more helpful than that provided by the next person. I do find irony in the position put out by some modalities, educators, and clinicians who feel that they use no protocols or recipes; every patient is a unique experience. While that should be true, such clinical models often rely on recipes and rituals, such as “find the pain, look elsewhere for the cause (recipe), if you don’t balance the pelvis, nothing will hold (ritual), and many others.

Many argue against what I’ve said thus far by pointing to their experience and successes. Who can argue with all of those satisfied customers? No one, but what I will take issue with what you feel the reason you were able to help. Many modality educators make money off of the uniqueness of their product and love to inflate their outcomes and sense of importance. Surprised? Probably not, after all, one needs a good sales pitch in this world. But why is it that most of use take multiple lines of training and come up with our own unique hybrid approach? We are not following the rules and recipes of each of our mentors, rather, we are making that information our own. That’s life. Wedges are not magic. They are a part of a recipe, one I let go of and still manage to find ways to help my patients, probably just as much as any of you.

Another problem with rituals that involve my so-called skills is the dependency that this can create. If I pin my patient’s pain on their out-of-balance pelvis, restricted fascia, stuck SIJ, or any other tissue or structural-based problem, dependency may be fostered. It is very easy for a patient to sell themselves on needing us, now and if the pain returns, instead of educating them on strategies for them to take ownership. Many manual therapists do foster such independence through self-treatment education, which is better in keeping with what should be ethical standards of care. But how do you come across? Are you selling secret causation to patients? One that no one else knows the truth?

The moral of this story? Use wedges. Or don’t use wedges. Just understand that the experience of treatment is nuanced and multifactorial. Many factors go into why our patient improves, many more than I am listing here, that to reduce it as being caused by the use of wedges, or the use of MFR, or anything else you can think of. Including the things I think are important.

If you enjoyed some of the concepts presented here, or if they left you angry and frustrated, have a listen to a great podcast (not mine!). Dr. Oliver Thomson’s Words Matter podcast is a dive into evidence and approaches to manual therapy, exercise, and a better understanding of the words we use.

Happy wedging. Or not.

Hold Times For Stretching In Manual Therapy

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.

The Changing Face Of Myofascial Release

“My work is called Myofascial Release due to the style of engagement that most resembles traditional gentle, sustained myofascial release treatment. While a popular belief, I no longer believe that I am able to singularly and selectively target fascia (connective tissue) beneath the skin to the exclusion of all other tissues, as many in the myofascial release field believe. Having a broader, more scientifically plausible explanation allows the consideration of many more factors to influence our interventions.” Walt Fritz, PT

That has been my “disclaimer” for a while now, though it is frequently modified and updated.

Since 1992 I have been integrating myofascial release (MFR) into my treatment and have found it exceedingly effective in dealing with issues of pain and a very wide range of movement disorders. Success tends to reinforce the thought that we know what we are doing, as well as the stories about what we are impacting that were taught as a part of the training in MFR, which may be one of the biggest mistakes a therapist can make.

Even though this last sentence may seem absurd, my ability to help you does not mean that I knew what was wrong with you or what, if any, tissues were impacted/changed to cause your distress. The more that I’ve learned, the more I realize how little I know.

Myofascial release is not unlike most forms of manual therapy and massage, in that each modality claims that dysfunction is caused by problems within its target tissue, whether fascia, muscle, joints, viscera, or dozens of other anatomical structures or pathologies (real or metaphoric), and that practitioners of that modality are able to singularly and selectively target those problems to relieve or eliminate the issue.

Positive outcomes are used as proof of claims, though little credible evidence has been published to validate the claims, both in terms of dysfunction residing only in that tissue or that that tissue alone was impacted with the therapy.

The average consumer is seldom exposed to these truths, as once they get involved with a health professional or therapist who is either recommending or specializing in a particular modality or belief, the compelling narrative often takes over. The therapist, experienced as they are, often does provide significant relief from whatever the patient was seeking care for, providing further apparent validation to the stories told. Many patients never make it to a point where they start asking questions about the science and evidence behind the stories, as they were simply seeking relief. They then tell their friends or doctor about this therapist and how that therapist found the problem within the (fill in the blank with whatever tissue or pathology the therapist believed).

MFR is no different from others in that therapists claim to be able to identify problems based on patterns that resulted from so-called fascia restrictions within the body and to be able to selectively reduce or eliminate the restrictions.

Evidence tends to be outcome-based rather than based on actual scientific research.

While outcomes do matter, it does little to validate the beliefs of the therapist. MFR has dozens of published papers to show that is an effective modality in treatment, but nearly all of the papers use the near-century-old narrative to validate its effect. Open up a paper that speaks to MFR as being an effective modality and read the introduction. It may make sense to you, as that is how most of us are taught. But does the so-called science hold up to the scrutiny of outside critique?

Skilled manual therapy can provide tremendous relief of pain and improve the ability to move, sleep, breathe, swallow, play, dance, and much more. But why does every modality carry such different names and explanations?

If one had the ability to observe dozens of sessions with dozens of health practitioners using as many different forms of manual therapy/massage but used earplugs to block out the sound during these sessions, you might be struck by the similarity in the overall type of engagement throughout all of these practitioners. The earplugs would prevent you from hearing the stories told by the therapist, allowing you to be a simple visual observer of how a session progresses; seeing how the therapist’s method of interaction unfolds. While some sessions are done on dry skin or over clothing and others use a lubricant, such as massage lotion, and some methods move across the skin in a more traditional massage/like fashion while others stay stationary, there is a remarkable quality of similarity throughout all of these interactions.

Still, others may use what appear to be light pressures while others probe or push deeper into the body. If you were not wearing the earplugs you’d be witness to stories of how light pressure accomplishes outcomes and effects that deeper pressures cannot, and vice versa, or that certain kinds of evaluation/treatment pressures are able to selectively impact certain tissues/pathologies. You would also hear stories of how postural or asymmetry is a major cause of problems, while other therapists/modalities never mention these topics. But without sound, the visuals may be a bit confusing as most manual therapy is not that different from the next.

So what gives? If all of those therapists are using similar actions, can the widely varied science-sounding stories be true? Might there be simpler explanations that apply to all forms of manual therapy/massage?

Occam’s razor is a principle used in the scientific method that states, “(W)hen presented with competing hypothetical answers to a problem, one should select the one that makes the fewest assumptions.” (1)

In essence, the simplest explanation is typically the best one.

All of the wildly different explanations of MFR, deep tissue work, craniosacral therapy, Swedish Massage, Rolfing, and the dozens of other named modalities may be true, but are there simpler explanations that apply to all of them, instead of each one having its own science, known only to skilled practitioners of that form of therapy?

Explaining pain/problems based on muscular anatomy and pathology, such as spasms, strains, tears, remains a popular one, both with the public as well as those within the medical and health professions, but is it the whole story; the entire reason why pain exists? Patients frequently come to me blaming their pain on their posture, their weakness, their job/computer/cell phone use, or other issues, but are these true? Each tissue belief system and pathology-blaming has its followers, but each tends to practice within a rabbit hole; a hole that does not allow one to see what others are doing, thinking, or putting into practice.

Instead of each modality being unique, able to singularly and selectively able to influence one tissue, pathology, or disorder, might they all be quite similar, with only the difference being the explanation? Might they possibly be different roads to the same destination?

So if I do not believe all of the stories told by therapists and educators, what do I believe?

Looking at manual therapy and massage from a plausibility perspective, one might best start with the skin. Being the only tissue that we can be certain we are impacting, does the skin possess sufficient action potential to contribute sufficiently to the gains seen as a result of therapy? Without going into great detail in this shorter paper, many feel that it may. The published work of Michael Shacklock (2) and Nee/Butler (3) speak to the probability of pain and related dysfunction being a result of tunnel syndromes within the nerves of the body, with outcomes improved by specific nerve tunnel glides/stretches. While these originated as precise and patterned movements, the latest research puts forth the possibility of simpler therapeutic engagements of the nerves, which may be an aspect of even general manual therapy/massage. Another aspect of the skin is the richness of receptors whose sole purpose is to provide feedback to the brain for processing. Diane Jacobs, PT (4) speaks at-length of these receptors and how simple and gentle engagement of the skin may be sufficient to cause the brain to change the outcome to the periphery.

Can the brain alone change pain in the body? With ultimate control over all bodily processes, I think it would be safe to say, “yes”. Skin contact and probable impact is an unavoidable consequence of ALL manual therapy.

There is far greater to be said about indirect and contextual factors involved when receiving myofascial release, manual therapy, or massage from a dedicated therapist. There is a great deal of evidence that points to these factors as potentially playing more of a role than many therapists wish to believe. We (therapists) like to think that it is our skill and experience that improve our outcomes and it may, at last to some extent, but not for all of the reasons we think. Brian Fulton, RMT, in his book, “The Placebo Effect in Manual Therapy” (5) speaks at length to these factors and how the science story the therapist tells has an impact on potential outcomes, with the better told the story, the greater the potential for increased indirect (placebo) effects. This makes sense, as if we sound like we know what we are talking about and about to do, trust is increased. With trust often come greater outcomes. One problem with this research is that there are no provisions for the accuracy of the story. As long as it sounds plausible and is told in believable ways, potential outcomes improve.

These aspects of neuroscience and brain/pain science do not eliminate the possibility that tissue-specific results, such as releasing fascial restriction, from occurring. But the deeper we dive into the body the more speculation that must take place in order to rationalize the actions of our manual therapy.

Fascia may be releasing, trigger points may be disappearing, muscles may be lengthening/reducing tone, and all of those other promises that your therapist made to you may be happening…but there is a decided lack of irrefutable evidence that these are indeed happening. I’m not suggesting that you have an argument with every therapist or patient who makes claims such as these, as it is sometimes not an argument worth undertaking. There are many instances when I seek help from another health professional who provides me relief from or helps with an issue but has issues with their explanation. It would be egocentric to believe I have all of the answers and, as such, I remain open to the new and emerging science that points to potential changes in our target tissues as we treat. But the stories told do not always match the outcomes achieved. Neurological explanations for why manual therapy, myofascial release, and massage feel so helpful may not be completely correct and universally accepted, but these explanations might well be less wrong that many of the other stories. Every day, I am trying to be less wrong.

References

 

  1. Occam’s razor: https://en.wikipedia.org/wiki/Occam%27s_razor
  2. Michael Shacklock: Cinical Neurodynamics (2005).
  3. Nee, R.J., Butler, D: Management of peripheral neuropathic pain: Integrating neurobiology, neurodynamics, and clinical evidence. Physical Therapy in Sport 7 (2006) 36–49.doi:10.1016/j.ptsp.2005.10.002
  4. Diane Jacobs, PT: http://humanantigravitysuit.blogspot.com/
  5. The Placebo Effect in Manual Therapy, by Brian Fulton, 2015 (Link)

 

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?