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.