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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{ 4 comments… read them below or add one }

Kay B Meyer July 2, 2016 at 9:40 pm

I am copying the paragraph here that most inspires this veteran SLP and MFR Practitioner. Veteran SLPs report that new grads are coming into their first jobs with a very different sense of where to begin treatment. “Evidence-Based Practice” has been drilled into their consciousness, and new clinicians are less confident about their own observation skills than we may have been 20 and 30 years ago.

“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.”

Reply

Walt Fritz, PT July 3, 2016 at 1:13 am

Hi Kay,

Fortunately I get some new therapists interested enough in manual care to take my Foundations in Myofascial Release Seminar for Neck, Voice, and Swallowing Disorders. I try to bridge the gap with evidence-based practice, as there is some credible evidence for myofascial release and manual therapy in voice, swallowing, and similar issues, but it doesn’t tick the boxes to make it to the top of SLPs search queries. Thanks so much for being an advocate!

Cheers,
Walt

Reply

Jennifer Hoerth March 6, 2017 at 9:27 am

MFR of the anterior head and neck is an incredibly effective treatment for dysphagia. I have been able to document increased ROM, function and swallowing safety with patients I have worked with in my speech therapy practice. The medical histories of my patients who have benefited have included Parkinson’s disease, post CVA, head and neck cancer, MS, ALS, to name a few. I’ve been using this modality since 2009 and use it with other approaches. Speech therapists need more therapeutic touch in their practices. As a profession we haven’t had enough connection to the anatomy we treat because we have not been trained to put our hands on our patients. It improved my practice on so many levels because of the touch aspect alone.

Reply

Walt Fritz, PT March 6, 2017 at 10:41 am

Hi Jennifer, Thanks for your comments. Adding a manual therapy method, such as myofascial release, in the evaluation and treatment of the diverse diagnoses seen by an SLP can only add to your/our efficacy. I love interacting with SLPs in my seminar who, as you said, had not been trained in hands-on work, but see the ease of it and its potential.
Walt

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