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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.

Getting To Yes. Using Negotiation In The Therapeutic Process

 

 

In this article, I want to dive deeply into options available to the therapist, explicitly using a patient-centered, negotiation-driven model of care. A model such as this becomes a therapeutic partnership, an alliance set up for a common goal. Contrast this model to a therapist-centered model. While therapists immersed in their expertise may take umbrage to my characterizations, I ask a bit of patience to allow this explanation to play out. While we may be making changes in the tissues, our in the periphery, we know that the central nervous system is picking up our manual care and shuttling it to the brain.

I believe in using negotiation throughout the process of patient evaluation and negotiation.

Without negotiation, the application of intervention becomes one-sided. Without negotiation, intervention derives from the beliefs and experience (ego) of the therapist, possibly missing out on an outcome that has better meaning to the patient. Negotiation is the core principle I use in my process of manual therapy. While learning manual therapy, or more specifically myofascial release (MFR), may seem like an entirely new intervention, I see it as quite parallel to your current skillset. We are all working toward improving function. MFR is simply another road to explore. Please note that I consider myofascial release a subset of manual therapy, as are the many styles of intervention available to therapists. One might include manual circumlaryngeal treatment as a separate subset, though all are not so dramatically different to warrant their classification. Manual therapy is a common denominator in all of these approaches. 

Getting to Yes,” by Roger Fisher, was a best-selling business book published in 1991. The Amazon.com summary states, “­­­­­­­­­it is based on the work of the Harvard Negotiation Project, a group that deals with all levels of negotiation and conflict resolution. Getting to Yes offers a proven, step-by-step strategy for coming to mutually acceptable agreements in every sort of conflict.” I remember hearing of it earlier in my career, and the memory surfaced recently as a potential frame of reference with regards to the work I teach. While the phrase, getting to yes, might be somewhat narrowly focused, with regards to the outcome of manual therapy, I do see it as a productive and necessary step to fulfill before determining treatment. The concepts presented in “Getting to Yes” have meaning today.

The timeline of a therapist’s inclusion of manual therapy/MFR has a typical pattern, one that I’ve witnessed since beginning my MFR training in 1992. The applications matter little, whether the commonly seen problems of and movement disorders faced by the PTs well as trying to reduce the severity of the impact of dysphagia, dysphonia, trismus, or the full range of other diagnoses facing the SLP.

The timeline often proceeds as follows: when first exposed to a new type of intervention strategy, typically through continuing education, the clinician conservatively doses the therapy, not quite sure of its value or their level of skill. As they gain experience and pursue additional training, therapists use the modality with greater comfort. An illusion is formed, thinking that their expertise and knowledge improve the ability to determine the cause of a problem better.

With that confidence often comes the belief that they have a better ability to determine both what is wrong with the patient and that they know what to do to remediate the issue.

These seem logical conclusions based on principles of advanced learning, but might moving into such certainty begin to minimize the patient’s perspective and preferences? No matter our profession, we are seen as experts in our respective fields, well-prepared to understand the deeper issues underlying a disorder and knowing which intervention to choose to apply. This line of reasoning seems standard practice in most of healthcare and typically meets with success; however, are there ways to improve outcomes? Are there ways to enhance patient by-in? Are there ways to better honor the three aspects of the evidence-based model (EBM)? I ask readers to keep in mind the three equal elements of EBM: 1. The published evidence, 2. Clinician’s experience applying the evidence, and 3. Patient perspectives and preferences with regards to the evidence and the clinician’s perspectives.

I believe that patient perspectives and preferences are given far too little emphasis and respect across the broad spectrum of healthcare, though recent trends in narrative medicine and other more-patient-centric approaches are beginning to create changes. I propose a method that elevates patient perspectives and preferences to carry equal weight with both the evidence as well as clinician experience applying said evidence.

In my years learning and applying MFR, I’ve been exposed to many models of learning. Being encouraged to pursue additional MFR course work was a given and actively encouraged and, at-times required. Working from an intuitive approach was highly stressed, though ill-defined. I was invited to develop my intuition; to work toward having a deeper understanding of processes that, in essence, allowed me to see inside; to be able to determine what was wrong with my patient by merely looking at them. These skills involved conventional evaluator methods, such as postural assessment and movement observance. Still, I was also encouraged to “read” the body, seeing patterns, colors, and holding patterns that would lead me into knowing what treatment needed to be done.

If all of this sounds far-fetched, welcome to the world of pseudoscience. To many, these concepts are logical but are often merely logical fallacies. Using the approach as taught did seem to result in positive outcomes and armed with such power, why would I have stopped believing in the basic tenants of the MFR approach?

In the typical manual therapy intervention, the clinician is tasked with determining if their preferred style of treatment might be useful. That task alone is biased, especially if, in the eyes of the therapist, manual therapy is one of their go-to tools. I recognize this bias as my own, though I try to see through it. For nearly thirty years, myofascial release has been my bias, my tool, my belief. People come to me daily in pain or living with dysfunction, and I apply my biases toward their issues. Over the years of using MFR, I saw the trend I sank into, objectifying their condition as a simple set of fascial restrictions set in place from injury, trauma, surgery, or other conditions; conditions that my skillset was especially good at remediating. Every patient became the nail, well-suited for my hammer. My biases were reinforced by success with many of the patients who sought me out. If the theories behind my fascial training were correct, then my interventions should be helpful, which they were. No dilemma existed, even though many outside my MFR family saw significant problems with the explanatory narrative utilized in MFR, as well as many other modalities targeting tissues and pathologies. 

To the uninitiated, those new to manual therapy, this dilemma seems pointless. But to those who’ve spent time exploring the various modality rabbit holes, the dilemma is real. How can so many modalities have the answer? Can each tissue/pathology-based manual therapy model truly singularly and selectively access and intervene in that dysfunction? Can there be so many unique tissue-based problems in the body that lies in wait for the therapist specially trained in a model devoted solely to that problem?

These questions are often seen as heretical by devotees of tissue and pathology-based manual therapy modality families as they question the fundamental underpinnings that are taught. Such talk is often squelched. However, these are conversations that are needed. 

Manual therapy is often helpful for a wide range of disorders, whether in the niche of voice and swallowing, or the larger body of conditions impacting human existence. But does it work in the manner described by its champions? Diving deeply into the evidence pulls out a relative lack of irrefutable proof of both the tissue-based dysfunctions said to be responsible for the disorders which we treat as well as our ability to selectively impact those tissues for intervention. Such omissions are lacking in nearly all of the published scientific literature that studies the efficacy of manual therapy, though many readers of the evidence fail to see the problem. In most manual therapy papers, there is a conflation of the mechanism of action and efficacy. Proving efficacy is often allowed to be sufficient proof of the stated mechanism of action. In a recent article I wrote, Anatomy matters…but which anatomy?, I speak to this problem and how time and research have moved the bar from tissue-based explanations of causation and therapeutic impact to brain-based models. The complexity of the human condition is seldom reducible to problems in one tissue, be it muscle (tension or spasm) or fascia (restrictions), especially within the context of a biopsychosocial model of dysfunction. 

Despite enormous progress in scientific understanding of pathologies and models of care, we are still not at a place of full understanding. Instead of choosing a tissue or pathology-based model of manual therapy, I’ve modified my process toward one of allowing the patient to be the focus of care rather than my skill and beliefs.

While I fully admit I am unable to completely abandon my knowledge, training, and experience (ego/bias), I attempt to temper it and foster a relationship where my patient plays a more active role in determining treatment. In my seminars, I speak to this as a point of demarcation between many other modalities. In many trainings, whether it is a model teaching manual circumlaryngeal treatment (MCT) or more broadly applied myofascial release and manual therapy training, the clinician is tasked with locating the problem, which is often based on palpation. The clinician’s training strongly biases this palpation. While one therapist, trained in MCT, for instance, may feel excessive muscle tension, another clinician, trained in myofascial release, may feel fascial restrictions. It is quite possible that what they are feeling as a result of their palpatory expertise is indeed the same “thing,” though the therapeutic diagnosis/assessment will differ significantly.

These palpatory findings are typically the determinant for intervention; in essence, “I’ve found the problem that needs to be addressed.” Patients seek us out for this skill and is simply a derivative of the standard model of medical care. They give over trust to us, hoping that we can help. The evaluative findings are turned into treatment dosing. 

In my view, this common model lacks one major component; no matter how much I know, how much training I’ve had, I am unable to determine what a patient is feeling. I am unable to palpate when a patient feels might be helpful or harmful. I am unable to palpate or evaluate a patient’s expectations, preferences, and perspectives. None of these are possible when evaluation evolves into an intervention without including the patient in this process. So, with all of this uncertainty, why do I strive to get to yes? How does using a patient-centered model, one that instills ownership to the patient’s perspective and preferences, a matter within the uncertainty mentioned above? I believe that it matters because of the uncertainty. In the future, more will be understood about how manual therapy impacts the local tissues, though I would predict it will be an indirect effect, that is, one mediated by and through the brain and central nervous system. Those who inform my views are researchers such as Roy (1) and Holzman (2), who point to higher levels of control in terms of why changes might be elicited in the periphery.  

I continue to use palpation in my intervention and teach it during each of my seminars. But instead of palpating to locate the cause or even the actual location of a condition, like most other manual therapy models, I use palpation to begin a process of communication with my patient.

In older models, palpation leads to the conclusion; “I’ve found your (muscle tension, fascial restriction, etc.); let’s see what we can do about this.” Treatment typically follows the findings of palpation. I propose a model that uses that same palpation, though not to conclude, instead I use it to begin a conversation with my patient. I cannot discard all of my experience, as I’ve been through these steps thousands of times in the past, most probably in cases nearly identical to the one facing me at that moment. But I’ve also seen sufficient numbers of patients to know that many times I get it wrong. I do believe that our ego tends to dismiss those memories quite easily and hold on to the times that we were correct. But I try to temper my successes with the knowledge that I do not know what my patient is feeling, what they hope for, and what they might fear unless I ask. I have no way of truly knowing if they will ask me to move into pain, which could mean more aggressive work because they feel it must be helpful or because they’ve been told to expect it unless I ask.

I have no way of knowing what sort of threshold to pressures that they might have, whether it is wide or narrow unless I ask. I have no way of knowing if the things that I’ve located through palpation, or other evaluation means, feels like it could be significant, could feel useful, or could feel harmful unless I ask. Despite all of my training and experience, I can never know the answers to these and countless other questions, unless I ask. But most manual therapy training is built on a process that doesn’t ask; the input of the patient is often minimized or at least deferred to the clinical expertise of the therapist. Many times, this all works out well in the end, but are they ways to improve upon this process? 

Coupling our expertise and training with the expectations and perspectives of the patient is the crux of my approach. It is what gets us to yes. It brings the therapeutic process into a partnership, an alliance.

Of course, we can’t just ask our patients what they think is wrong with them, ask them what we should do, and then do it…or can’t we? The way I teach my work is to use palpation only as a place to start a meaningful conversation about what brought them (the patient) into my clinic. As soon as I feel something that, form my past, feels interesting, I see if I am getting the attention of my patient. I immediately try to ascertain if they are feeling something familiar, something they’ve felt before or associated with the condition or issues that brought them to see me. I put them to work in ways many have never experienced. I, in essence, force them to help me help them. I work toward finding a tactile cue that connects with a feeling that they’ve felt before, good or bad, and is somehow relevant to them. I do very little selling of an approach or beliefs. If what I’m palpating does not replicate one of these conditions, then I move on. If it does connect with their experience, I ask them if the stretch that I am performing feels like it might be helpful? If so, I ask them if they would like me to hold the stretch for a while to see if we can change the outcome? If there is anything about my palpation-found stretch that feels like it may not be helpful, I will ask them if it feels like it might be harmful? If so, I immediately stop. I am attempting to get to yes with them; to find a pressure, stretch, or engagement that they feel will be useful; helpful. I let them decide what constitutes a yes, not me. I allow them to decide what level of pressure or engagement is too much or ineffectual, not me. I require them to be a full participant in the therapeutic process and put them in a position of responsibility for helping me help them. Getting to yes, to me, forms a crucial tipping point in the process that moves us from evaluation into treatment. 

Have you ever heard of a patient/client leaving a massage session, for instance, saying something like, “that therapist was so good that they were able to find things I didn’t even know that I had!” I have, and I detest such statements, only because the therapist did a somewhat unethical job of selling pathologies onto a vulnerable public. Nothing I find is meaningful unless confirmed by my patient. All of this is hard work, though I think it to be good work.

Getting to yes. That is my mandate.

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?

Myofascial Release: An Evolving And Simple Definition

 

Urged on my peers on both sides of the argument, here is an initial version of what I hope becomes a more permanent way to describe the work I use and teach. Comments, suggestions, and criticisms are always welcome (post below). Edits will be made to this post as comments come forward, both here as well as from social media.

Myofascial release (MFR) is one style of manual therapy that uses slow, still, prolonged stretching through clothing or directly on the skin to facilitate change in the patient. Whether having its primary effects on fascia, as historically believed, or on skin, muscle, other tissues, or the nervous system in general, it is realistically a more complex direct and indirect interrelationship of overlapping systems. The goal of MFR is most often to reduce the feeling of tightness and to lessen pain, allowing for more freedom of movement and improvement in functional abilities. While other forms of MFR vary, The Walt Fritz, PT form of MFR relies on direct patient feedback to drive evaluation and treatment, assuring that interventions are patient-specific. (edit 5/13/18)

Myofascial release (MFR) is a style of manual therapy most typically associated with its historical roots, which relied on perceptions that one could label pain and various movement disorders a result of tightness/restriction within the fascia/connective tissue. Most therapists using MFR were taught that they were able to selectively and singularly impact these fascial restrictions to the exclusion of other tissues, with the goal of reducing pain and restoring more normal movement patterns, with any mention of the nervous system added as afterthoughts. While MFR has been a popular and effective form of manual therapy for decades, the claims made by its proponents have yet to be proven, though these issues exist for nearly all forms and brands of manual therapy and massage.

Most brands of MFR, manual therapy, and massage claim that pain/movement problems are due to one specific tissue and make claims to be able to specifically impact that particular problem, all while having remarkably similar styles of engagement as the next type of therapy.

While it may be possible to be able to target one tissue under the skin for intervention, more plausible explanations come from neuroscience-based explanations, as well as the potential impact of contextual factors. These models look at more central mechanisms to explain the local effects of manual therapy, including MFR. Using such principles as neurodynamic technique, where nerve tension is reduced, allowing more freedom of movement and less pain, as well as skin/superficially embedded receptors that can signal the effects of MFR at the local level, with changes in pain/movement problems being an outcome of brain output via the central nervous system. These ideas work from the knowledge that the nervous system is in ultimate control, though in partnership with, the remainder of the soft and bony structures in the body. Though neuroscience-based models also lack full proof, they may be “less wrong” than many of the various other models.

Briefly, MFR has a typical style of engagement that uses slow, still, prolonged stretching to facilitate change in the patient. Whether having its primary effects on skin, fascia, muscle, nerves, or other tissues, its goal is to reduce the feeling of tightness and to lessen pain, allowing for more freedom of movement. I call my work MFR in reference to a very recognizable style of hands-on engagement typically associated with myofascial release, rather than due to thoughts that it is fascia that I am selectively engaging.

With such uncertainty, where does that leave the therapist and consumer? Therapists still treat in the manner they were taught, with hands-on interventions typically very helpful. The best choice may be to keep explanations simple. While it may be the fascia, muscle, joints, knots, trigger points, or a host of other tissues and pathologies are responsible for our problems, we can only work through the skin. Everything else is a stretch (pun intended!).

Pathologizing: Our Words Matter

As a physical therapist trained in the 1980’s, biomechanical explanations for pain and movement disorders were the norm.

As I drifted into a myofascial release manual therapy in the early 1990’s, the biomechanical model was reinforced and made more narrow through the beliefs that pain and movement dysfunction stem from issues of fascial tightness/restriction. All had evidence to support their views, as well as well-presented logical assumptions.

Myofascial suffered from testimonial-type of evidence, which seemed very compelling to a casual scientific observer (me), who was unwilling to question the sources of presented information.

Biomechanical still are well represented throughout the manual therapies, as evident by the daily squabbles regarding the importance, or lack of, with such issues as posture, weakness, and asymmetry when it comes to both pain as well as movement disorders.

This post is not intended to address these issues, but to briefly discuss the language we use when conversing with our patients/clients. 

The Power Of Our Words

Patients pay us to help them.

This help is most often accompanied by the thorough evaluation, after which we proclaim our findings on both what is wrong with them and what should be done to rectify the situation.

We may call this our assessment or diagnosis, depending on the scope of practice allowances and limitations of your profession. Patients expect it and we feel it necessary to give them what they want and deserve, but is it always in their best interest, especially when there is a lack of consensus on the validity of our assessment’s claims?

Biomechanical factors and judgement, such as poor posture being the cause of pain, are popular and logical assumptions which many of our patients believe and you may believe it to be true as well, but is it always true?

While at the computer, I leave my Facebook notifications turned on, which is probably one reason I am so easily distracted. As I was writing this post a notification came in that I will sanitize and post here:

I’m new to this group, but curious as to many issues a (named surgical procedure) could help with. My biggest issues are forward head posture – my (type of) therapist once told me it was the worst she had ever seen – neck/shoulder/upper back tension that my chiropractor gave up on treating because he didn’t understand why he couldn’t fix it, jaw clenching, anxiety, etc). Anyway, does anyone have a recommendation for a practitioner in (certain city)?”

The writer of this post was speaking from genuine self-concern and must have found some solace in her therapist’s statement about the severity of her forward head, but what does she now do with that?

If she is the worst case her health professional has ever seen, it would seem to me that makes it less likely that she can be helped. There is information easily available that casts doubt on the degree of forward head posture and neck pain, but that therapist has planted a seed in the patient’s brain that she is one of the worst out there, at least from her therapist’s perspective.

Do we really need to say things like this?

Below are some studies that were recently posted to a thread on one of the many groups there, all speaking to the effect of the power of our words. If you’ve never given this much thought, please read through some of the abstracts and papers.

Our words have power, and often the message conveyed negatively impacts outcomes.

Easy to Harm, Hard to Heal: Patient Views About the Back.

CONCLUSION: Negative assumptions about the back made by those with LBP may affect information processing during an episode of pain. This may result in an attentional bias toward information indicating that the spine is vulnerable, an injury is serious, or the outcome will be poor. Approaching consultations with this understanding may assist clinicians to have a positive influence on beliefs.

The enduring impact of what clinicians say to people with low back pain. (Full-text link)

CONCLUSIONS: Health care professionals have a considerable and enduring influence upon the attitudes and beliefs of people with low back pain. It is important that this opportunity is used to positively influence attitudes and beliefs.

Importance of psychological factors for the recovery from a first episode of acute non-specific neck pain – a longitudinal study. (Full-text link)

CONCLUSIONS: Psychological factors emerged from this study as relevant in the early phase of acute neck pain. Particularly persistent anxiety and depression at baseline might be risk factors for a transition to chronic pain that should be addressed in the early management of neck pain patients.

‘Talking a different language’: a qualitative study of chronic low back pain patients’ interpretation of the language used by student osteopaths. 

CONCLUSIONS: The language used by student osteopaths’ influences patient beliefs about LBP in a variety of ways. The current study furthers understanding of how language contributes to these beliefs, identifying ways through which communication can contribute to improved healthcare through enhancing patient engagement.

Words That Harm, Words That Heal. (Full-text link)

Both positive and negative beliefs are important in patients with spine pain: findings from the oioc registry.

CONCLUSIONS: Our study demonstrates that both negative and positive beliefs are associated with perceptions of disability, however, in this study only positive beliefs were associated with treatment outcome.

Do you have any studies to share regarding this topic? I’d love to have a look!