Many thanks to The Voice Foundation for making me feel welcome and inviting me to present my version of myofascial release for vocal dysfunction. I had prepared for my Friday workshop expecting 20-30 participants and, needless to say, I was a bit surprised at the very large turnout. As a result I lacked supplies for everyone to fully participate in the tongue exploration. My apologies. I did want to sum up the purpose of my work and of the training I do for those who may have missed parts of the workshop or got lost in the crowd.

Myofascial release has moderate levels of evidence (see below) showing its benefit in a range of voice-related conditions and is historically described as a manual therapy that selectively targets tightness (restriction) within the connective tissues, or fascia and reduces (releases) them with slow, sustained pressures. Modern views of manual therapy, myofascial release included, cast doubt on such abilities to selectively target one specific tissue/structure under the skin to the exclusion of all else, identify fascia as the responsible tissue, and have knowledge that we caused it to change. These challenges and disagreements exist for all forms of manual therapy/massage, though most in the field ignore these skeptical claims. These comments are in direct opposition to what is commonly and, by many, currently taught. If one looks at the claims made in the dozens of manual therapy courses and workshops offered, one cannot help but question the clinician’s ability, no matter how well skilled, to be able to identify pathology, real or metaphoric, and selectively target the tissue in question, all from outside the skin. Also, there is little evidence to show that more aggressive/abrupt soft-tissue mobilizations are any more effective that gentler techniques, though a patient’s narrative may dictate that these sorts of pressure be used less they perceive the work as ineffectual. We must be aware of the placebo effects of all aspects of our work, including patient narratives and expectations.

I was asked why I call my work, myofascial release when I no longer believe that it is the fascia (and the restrictions we are said to release) that is the primary pathology and primary target of my treatment. This question comes up frequently, as many in the world of neurobiologically-explained manual therapy feel that fascia does not release in the way described by those teaching the work, and they get pretty snarky when advising me to stop calling what I each myofascial release. While I understand the confusion, the intervention of myofascial release is what I have been doing with my hands for the past 25 years. I am still doing much of what I was taught in those early years, but today my brain is thinking very different thoughts of action and effect. We reach for a Kleenex™, no matter the actual brand name. Myofascial release is my Kleenex™.

I spoke of the multitude of possible ways that myofascial release/manual therapy intervention may be creating and allowing change. One cannot overlook possible tissue-specific changes, even if the credibility of these models makes it less likely. Reduction of muscle tension is a concept accepted as a part of manual therapy to the laryngeal region, but just how muscle tension reduction occurs is murky. Are we applying techniques that primary lessen tension at the local level or are the effects mediated from a feedback loop from the periphery, back to the brain, with reduction of tension/tone the output? We may be stimulating skin-based mechanoreceptors with our therapy, specifically Ruffini and Merkel receptors, which will provide a very fast afferent feedback to the brain, allowing the brain to decide if any changes are warranted. Ruffinis, for instance, are slow adapting lateral skin stretch Type II receptors. Given their function, stimulation is unavoidable with the slow, sustained pressures inherent in the type of myofascial release I teach. A very interesting known effect of Ruffini stimulation is inhibition of sympathetic activity (source), which may also explain changes seen as a result of therapy. A slow, calm touch may impact autonomic tone, with reduction of muscle tension and improvement in voice, etc. We may be tapping into cutaneous or peripheral nerve tunnel syndromes, with a slow, prolonged stretch reducing the tunnel tension along the paths of those nerves and thereby reducing the aberrant sensations or motor compromises. Lastly, our touch, especially when applied in a patient-centered model of evaluation and treatment, may be simply allowing awareness of the problem and processing time may allow for change to be made on the part of the patient. All, some, or none of these factors may be the actual reason for successes with vocal dysfunction when myofascial release treatment is used, but I feel that it is impossible to separate single aspects of the previously mentioned possibilities. When we touch in an appropriate and safe way, reduction in pain, strain, fatigue is often noted, allowing improved function. This is a simple model, but one that I feel best represents what is known and still unknown.

My patient-driven model relies less on the expertise (and ego) of the practitioner and more on whether or not relevance has been replicated with the evaluation pressures, stretch, and engagement. Given questionable reliability of palpation, reducing reliance on palpatory findings (source), at least when used to identify perceived pathologies, assures the therapeutic process has greater meaning for the patient. I allow the patient greater ownership in the process, which means that they will drive treatment decisions. This is done in the context of the professional relationship, where the clinician guides the process through skilled evaluation that narrows in on symptom replication, but without full validation on the past of the patient, treatment is meaningless. This approach does not work for all patients (or clinicians), as many patients will not assume the role of decision maker and some clinicians will not delegate that role to others. But for my work, this patient-driven feedback loop model of evaluation and treatment is what drives my work.

The two evaluation and treatment sequences demonstrated in the workshop were merely two places to touch. I will always validate a patient’s complaints by starting my touch evaluation in that specific part of the body. In the case of the first sequence, where we placed our hands over the upper anterior neck, encompassing the hyoid region, my goal would be to lightly search with broad, non-threatening pressures, until I locate and area that interests me or seems to interest my patient. In my actual 2-day seminar, much time is spent working on this skill and even more time spent establishing a dialogue to assure patient validation has been received. With practice, I find it quite easy to replicate aspects of vocal dysfunction without needing the patient to voice. While it is acceptable for them to speak, sing, etc., it is also entirely possible that you may be able to find and replicate aspects of their vocal dysfunction while they are at rest. Treatment easily follows this evaluation validation, with stretch/pressures/engagement moving in the same direction that you used to validate the symptom. This may all seem very vague, but with more training and even more independent practice, the clinician typically find success with this model.

In the second sequence (apologies for those who did not receive gloves or gauze), we lightly grasped the tongue from various angles, seeking out both palpable density and/or perceived dysfunctional areas, and more far-reaching reports of relevant sensation. Given the reach of the extrinsic and extrinsic muscles and nerves of the tongue and related structure, it is very common for reports of rather broad distribution to be reported. I am always seeking to connect my findings with my patient’s symptoms, whether primary or secondary. Once connected with and validated by the patient, treatment follows easily. In the case of the tongue pull, traction would be applied in a slow and sustained manner to allow the many possible processes of change to occur. Tension would be maintained until fatigue sets in on the part of either person involved, or sensations begin to dissipate. Rest can be a part of each intervention, followed by retesting and additional treatment.

Why hold for long periods of time? In the past I used to tell people that it takes time for the fascia to properly release. Now I believe we are allowing the nervous system to adapt. Same technique, but with different beliefs.

Why move into replication of symptoms (mild provocation)? Again much if this is the convention of how I have worked for the past 25 years. I am not trying to cause pain to my patient, but to only take them to the edge of awareness of their symptoms. Over time, with assurances that the patient continues to feel the relevance, they can allow their nervous system to process both the input (my stretch) as well as their reaction to it, with the goal of improving vocal quality and reducing strain, pain, and fatigue.

Why did I ask you to forget anatomy? I respect all of your knowledge and experience, but at times, anatomy may trick you into not treating. For instance, in another important sequence, I move into the retrolaryngeal region, attempting to approximate the posterior aspect of the thyroid cartilage. By nature this cartilage is hard. If the clinician encounters the cartilage in palpation and knowing what it is, they may not intervene. It should be hard and they were validated with their touch. But with the patient-centered approach, pressure on the cartilage may completely replicate relevant symptoms. Anatomy knowledge is not ignored, as I often work in areas of potential concern (carotid artery region), but I try not to let anatomical knowledge cause me to miss something.

Myofascial release treatment can be applied as a stand-alone intervention, but is most often integrated into a normal session. As mentioned above, the work can be done in silence or without movement, or used in conjunction with speech, singing, and movement. Length of sessions varies from very short intervention to extended sessions (an hour or longer). It would be a fallacy to state that longer is better, as many times short touch intervention, with appropriate validation/awareness of the dysfunction on the part of the patient, can provide improved awareness and be an impetus for change. Frequency and duration varies as well. I most often see patients once weekly for 50 minute sessions. Duration may be very short, depending on gains made. While at times treatment can be ongoing or of a long duration, I feel that it should only do so if accompanied by consistent gains.

 

My full 2-day seminar covers the body from the lower rib cage/diaphragm region, up through the thorax/intercostal region, into the anterior neck and retrolaryngeal regions, and finally up through the mouth and tongue region. It was certainly beyond the scope and time of the workshop to give anything more than a glimpse into this manual therapy/myofascial release intervention, but I hope it was of interest to you. If you have questions of any sort, please contact me at waltfritz@me.com.

A full list of the references use to validate the work taught in my Foundations in Myofascial Release Seminar for Neck, Voice, and Swallowing disorders can be found here. Please note that these resources are constantly being expanded, so check back frequently.

I recently wrote an article for an online news website titled, “Fitting myofascial release into an evidence-based culture” that may give insight into questions about the evidence.

I teach the 2-day Foundations in Myofascial Release Seminar for Neck, Voice, and Swallowing Disorders across the United States, as well as abroad, with three classes coming in February of 2018 in Australia, hosted by the Australian Voice Association. If you would like information on hosting a class at your facility, send me an email.

Note: If anyone who attended the workshop has photos they would be willing to share with me, please email them to walt@myofascialpainrelief.com.

 

Respectfully,

 

Walt Fritz, PT

Rochester, NY

 

All information copyright Walt Fritz, PT 2017

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Myofascial release in the head and neck cancer patient

by Walt Fritz, PT on June 2, 2017

“Ignore the claims, as belief that one can somehow selectively target fascia, muscle, or other structure without providing simultaneous stimulation to  all structure is fantasy.”

(This post was written over a year ago but remains relevant. The evidence used to validate this work and this continuing education seminar is constantly updated, with the latest version on this page (scroll down to find it). You can also read a recent online article I wrote, “Fitting myofascial release into an evidence-based culture”, by clicking here.)

Myofascial Release in the Head and Neck Cancer Patient” is the title of the presentation I made last October (2015) at the 18th Annual Head and Neck Conference: Focus on Rehabilitation, at the Greater Baltimore Medical Center. Was I a bit nervous? You bet! I’ve taught myofascial release (MFR) to therapy professionals for twenty years now, but to give a 30 minute talk in front of a general conference, alongside SLPs and voice professionals, physicians, dentists, and other clinicians was a first for me and I was nervous but excited to share my information. (Though it was the first and last time I will use PowerPoints in a lecture! That’s another story.) Using myofascial release in the area of the head and neck has become an increased interest over the past number of years and teaching this work to speech language pathologists and other voice professionals took off in 2013, when I co-presented a class in Chicago with Benjamin Asher, MD titled “Listening With Your Hands“. Since then I have developed the Foundations in Myofascial Release for Neck, Voice, and Swallowing Disorders (renamed for 2016) where we teach a focused MFR/manual therapy approach to the upper chest, neck, and mouth regions. Helping other health professionals understand what a manual therapy approach can bring to disorders which are not typically associated with “musculo-skeletal tightness” can be a challenge at times, especially if one gets bogged down with the terminology inherent in the MFR vernacular. My talk was directed toward the power of touch on a swallowing/voice challenged population in general, and specifically to patients who have undergone surgery and radiation for head and neck cancers. I spoke to some of the existing published research that shows MFR to be a valuable asset in the recovery from head/neck cancer, but also its effectiveness when manual therapy is used during radiation treatment (“A novel manual therapy program during radiation therapy for head and neck cancer – our clinical experience with 5 patients“). This is a newer paper that demonstrates the safety to perform myofascial release, along with other rehabilitation oriented modalities to the neck region, concurrently with radiation treatments, to reduce pain and improve mobility. While still not answering the all-important question “how does it work”, it shows that when we place our hands on patients and act in a certain way (called myofascial release), patients improve.

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Teaching to/with speech language pathologists and other voice professionals has taught me a great deal. In an honest and humble way I share with them my relative lack of experience in their world and knowledge, at least compared to them, but impress upon them that there is a shared language of touch that can benefit those patients that are not typically touched with manual therapy during treatment for their issues. I share with them my experiences entering into their world, reproducing familiar aspects of patient’s swallowing, voice, or related issues, and easily transitioning evaluation findings into treatment. In a verbal or written exchange it is very difficult to translate this last comment into understanding on the part of the receiver. Most swallowing, voice, or similar issue facing the SLP does not involve pain and are not typically thought of as an issue of “tightness”. But when one gently and thoughtfully reaches into the patient’s neck or mouth region and palpates an area of density, it is not uncommon for the patient to begin to relate to the felt sense that their symptoms are reproduced from that palpation. This is what I teach in my Foundations in Myofascial Release Seminar for Neck, Voice, and Swallowing Disorders. Palpation by itself is unreliable for showing changes in tension, but it can be a valuable asset when used in a non-judgmental fashion such as advocated in this work. We are not palpating to find or identify structures or diagnoses, we are simply palpating for an area that correlates with a patient’s symptom reproduction. Once it is found and the patient validates the sensation as relevant/familiar, one simply continues with the pressure/stretch as a means of treatment, with the goal being a lessening or cessation of the symptoms.

Why is there little scientific evidence on MFR used with head and neck cancer/disorders? Possibly because most of the explanatory models are far-fetched and as a result garner little interest from the general medical community. In other posts on this blog I have written regularly on this topic and will continue in the future. If MFR enthusiasts could let go of thoughts that they can reach into the body and selectively stretch the fascia, there may be more common ground with other modalities/manual therapies, including circumlaryngeal massage. If one can see the true nature of manual therapy without getting bogged down by the claims most make, it becomes obvious that myofascial release is not unlike most manual therapies or massage. While techniques, approaches, and named modalities differ, often drastically, with pressures used ranging from light to deep, and from using movement to remaining still, all have common denominators.

Claims/reports of positive outcomes do not validate the statements made as to what was being impacted by the manual intervention. It may seem that I am invalidating the effects of my own work (myofascial release), which I am to some degree. MFR has been shown to be an effective hands-on manual therapy approach to a wide variety of conditions, including some for the swallowing and voice patient, but the explanatory model is weak at best. To be fair, most explanatory models for manual therapies are quite weak or based on concepts that are not able to be validated by quality research. Some have a decent amount of science-informed background, but very little manual therapy passes the test for evidence-based practice.

When explaining how myofascial release and manual therapy acts on the voice/swallowing, or similar mechanism/dysfunctions, I will acknowledge the past models of fascial restriction/change, but introduce more scientifically plausible models of neurological origin. Understanding how, for instance, neurodynamic technique can cause a reduction in neural tension both local and in a more far-reaching way, or how altering autonomic (sympathetic/parasympathetic) balance can bring about great change in function. And simple stretching and/or light pressure to the skin will create a quick afferent feedback to the brain for a possible change in local state. While not the answer to all of the problems we face, they are more plausible and acceptable than most of the existing explanatory models. Adding these explanatory concepts to an SLPs existing repertoire, including circumlaryngeal massage, as well as allowing the touch, pressure, and “intent” to vary from how circumlaryngeal massage is typically taught brings one right into the realm of myofascial release, at least as I teach.

At my 2015 lecture at the Greater Baltimore Medical Center, I spoke of these new explanations as possibilities, but moved on to intervention. The evidence is important, as is the science behind the work, but without effective treatment the science means little. I look forward to diving deeper into your world (of the SLP/Voice Professional), finding ways to treat the issues you deal with daily from a manual therapy perspective.

How do you incorporate myofascial release/manual therapy into your work with voice and swallowing issues?

For now,

Walt Fritz, PT

All upcoming Foundations in Myofascial Release Seminars for Neck, Voice, and Swallowing Disorders may be found at: www.FoundationsinMFR.com

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An Interview: Massage & Fitness Magazine’s Nick Ng

April 28, 2017

I met Nick Ng face-to-face two years ago, though he and I had co-existed on some Facebook groups long before that time. He took my Foundations in Myofascial Release Seminar for Neck, Voice, and Swallowing Disorders class in San Diego and, as I viewed him as decidedly science-literate, I was curious how he would interpret […]

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Fitting myofascial release into an evidence‑based culture

April 19, 2017

“Myofascial release” and “evidence-based” are phrases that are seldom spoken together. Papers exist telling us how and why myofascial release (MFR) is not an evidence-based treatment model/modality. In today’s therapeutic culture, one that demands that we work from evidence-based perspectives, it is at time difficult to find much in manual therapy that appears to meet […]

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A patient-directed model of manual therapy

April 15, 2017

I think our patients deserve more. We are the experts. Be it myofascial release, manual therapy, massage, or any of the countless other terms used to describe what we do, we are trained to call ourselves the soft tissue experts. Patients seek us out due to our experience and expertise with pain and movement dysfunction. […]

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The Placebo Effect in Manual Therapy: An interview with Brian Fulton, RMT

March 14, 2017

In April of 2016, I had the pleasure to meet Brian Fulton, RMT, who was a co-presenter at the Registered Massage Therapists’ Association of British Columbia’s Biennial Conference, “Manual Therapy: an Interdisciplinary Approach to the Science and Practice”. His talk involved the understanding of the placebo effect in manual therapy and since that time I have been […]

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Say Nothing

March 3, 2017

Finding errors on an article or post that has been out there on the internet is irritating. having someone else point it out is irritating times two! Here is a link to an article I wrote last year for Nik Ng’s Massage & Fitness e-magazine (subscribe here) titled, “Say Nothing”. Regular readers will recognize by […]

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Reflections and notes from the road

February 26, 2017

Just finished teaching my Foundations Approach Upper Body class this weekend in Las Cruces, New Mexico and have a few hours of free time at the airport before the flight home. Reflections on a class are best stated immediately, as memories fade quickly. The professions of participants in my classes vary widely, with interest spread […]

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The Good (and Bad) of a Simpler Narrative

January 21, 2017

What we do, ultimately, is help people feel more comfortable in their bodies so that they can move more easily and, in effect, heal themselves. The past ten years of my professional career has been devoted to working toward a more accurate narrative to explain the work I do. The story of how this came […]

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More Mental Floss for the MFR Brain: Changing Your Story

November 20, 2016

With a broad-based education, credible continuing education, and critical thinking, I do think we can be less wrong about the work we do. I do not mean to criticize those who believe differently and certainly not those who taught me these concepts. Science moves forward and I thank those in my past. What if I asked […]

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