Incorporating manual therapy

Incorporating manual therapy

Incorporating manual therapy into current interventions: Tips from peers.

In the eleven years that the Foundations in Manual Therapy: Voice and Swallowing Disorders course has been taught, one of the more frequent questions facing new learners is a deeper understanding of how manual therapy (and shared decision-making) is to be incorporated into the treatment routines of SLPs and other professions. Due to these questions, a new video series has been started. I’ve polled clinicians of all types, including SLPs in a range of work settings, on how they’ve incor[prated the work into their daily routines. While all will be presented from a basic framework of questions, I do hope that the range of responses allows you to see how this work can fit in with and enhance your current strategies.


 

Walt Fritz
Author: Walt Fritz

Sorry, comments are closed for this post.

A sample chapter from Manual therapy in voice and swallowing: A person-centered approach

A sample chapter from “Manual therapy in voice and swallowing: A person-centered approach

Writing Manual therapy in voice and swallowing: A person-centered approach has marked a high point in my career. It resulted from decades of experience in the manual therapy tenches, including some difficult life lessons. Documenting many of the underlying problems with typical manual therapy narratives, ones that often go unchallenged, it builds from a wider range of explanatory narratives to craft an approach that depends more on the individual patient’s life experiences rather than the clinician’s often biased views. In reality, it is a blend of the two, but an approach that attempts to never let one stomp on the other. The book is both theoretical and practical, hopefully meeting the needs of many audiences. 

Details on purchasing the book may be found at this page of the website. The book chapter, Building a model, may be accessed here.

Walt Fritz
Author: Walt Fritz

Podcasts and Articles

Podcasts and Articles

Walt Fritz, PT’s Podcasts, Videos, and Articles

Over the past few years I’ve been fortunate enough to participate in a number of podcasts and interviews that are available for listening. They range from voice/swallowing-specific, to more general interviews that speak to various aspects of the manual therapy work that I teach. Strongly represented are principles of the patient-centered model, shared decision-making, a blended multifactorial-explained model, all of which move forward from older tissue-specific models of manual therapy. Also included are published articles I’ve written to better define this work.


Rob Klienberg, PT, invited me to an interview for his website, Rock the Recovery. Our talk centered around my history at a physical therapist and my creation of the Foundations in Manual Therapy: Voice and Swallowing Disorders seminar. You can read the interview here

 

I’ve been a long time admirer of The Thinking Practitioner podcast, and the work of Whitney Lowe and Til Lucau. Til asked me to chime on dealing with chronic cough with a real patient, in this case massage and manual therapy educator Ruth Warner. You can watch the podcast here on YouTube.

I was honored to be asked by Judy Rodman, renown performer and vocal coach, to talk about my work on her podcast, All Things Vocal.

https://youtu.be/jJubFqFQod8
  • Eric Purves, RMT, asked me to appear on his podcast, “Purves Versus”, where we discussed the importance of finding an acceptable balance in our understanding, our communication and how we teach continuing education. Our treatment interventions aren’t always just about one tissue or a special technique, they are more complex than that and the outcomes people experience are more strongly related to the strength of the therapeutic relationship. You can listen to our talk at this link.

  • Brett Kane had me as a guest on his 21st Century Vitalism podcast. Our conversation included:

SHOW TOPICS
Following Evidence Based Practice
The Power of Placebo and Nocebo
How the Therapeutic Relationship Creates Change
Shared Decision Making in a Therapeutic Setting
Is Pain Neurological or Structural?
Touch and Emotions
Why Being an ‘Expert’ Might Not Be Ideal
The Benefits of Not Knowing in a Therapeutic Setting

https://youtu.be/h3ioYDFSQ1Y
  • Discussing Person-Centered Model Approaches of Manual Therapy for SLPs. I had the pleasure to again be interviewed by Wilson Nice, SLP, on her Nice Speech Lady podcast on shared decision-making and how it applies to the SLP.
https://www.youtube.com/watch?v=sbUwYszMAd4
https://youtu.be/4HBV8B2B_vQ
  • I teach my manual therapy for voice and swallowing disorders seminars in person and online. This includes a hybrid one-on-one version of the Introductory and Advanced classes taught in my Upstate New York office. Thanapat Yartcharoen (Film) is a vocal coach from Thailand who had taken my Introductory Foundations in Manual Therapy: Voice and Swallowing Disorders and Balancing the Body classes on previous visits to the United States. On this visit, he spent two days in my clinic, where we worked through the extensive content of the Advanced class in a one-on-one setting. Film asked to film a post-class interview for his Thai vocal performing clientele and was kind enough to share the video with me.

  • Takeaways from manual therapy: At the recent class in Eugene, Oregon, I sat down with Melody Sheldon, ClinScD., CCC-SLP, to talk about the class for her podcast, Speech Plus so much more. You can listen below. 

Join me as I speak to the hosts of The Agent Voice, for a talk on power imbalances in the therapeutic setting.

https://youtu.be/NesBSq3f0G8
  • In a repeating theme of mutual respect, Stephen King and I got together once again to talk about what it means to be an evidence based, shared decision maker in manual therapy. You can watch the talk here on YouTube.
https://www.youtube.com/watch?v=rbFTnh87JxA&t=159s
  • Based on overlapping concepts and ideas, the orofacial myology and myofunctional community have been regular attendees at my live workshops. I was honored to be interviewed by Brittny Sciarra, RDH, on her Eye Spy With My Myo Eye podcast. You can watch the entire interview here.
https://youtu.be/UnfH9kT0sAc
https://www.youtube.com/watch?v=IfbgPNUpoJQ
  • Crossing the Chasm, when it comes to transitioning to a new system of beliefs, seems a rite of passage for many in the therapeutic communities. The Chasm, in this case, refers to the well of uncertainty regarding how we explain our various work. In manual therapy, the Crossing often refers to moving from older, historical views of tissue-based or pathology-based explanations into updated and multifactorial explanations. My leap was gradual, and I explain how the process went in this interview. Though presented from a physical therapist’s perspective, the evolutionary process is faced by many, be they massage therapists, physical therapists, speech-language pathologists, and more. Jamie Johnston, RMT interviewed me for his MTDC Community. Give it a watch here.
https://youtu.be/tneHJZE8wrQ
https://youtu.be/LpZrvzTi2UI
  • I was there for Episode #22 of Theresa Richard’s Swallow Your Pride podcast, where I dive into dysphagia, from a manual therapy perspective, and I’m back in Episode 215, Mastering Manual Therapy. You can listen here.
https://youtu.be/Jkd8Y5mSdGE
  • Interview with Rachel Lynes, from UK-based The Sing Space, where we talk of manual therapy’s usefulness with the singer and include a bit of self-treatment. Link
  • Juliette Caton, from the UK Podcast Vocal Scope, and I spent some time speaking to the role of manual therapy and the performing voice. Link
  • On the UK-based Naked Vocalist podcast, hosted by Steve Giles and Chris Johnson, I spent some time talking about manual therapy’s purpose in voice and performance, as well as moving through some self-care routines. Link
  • I joined Rani Lill Ajum, P.hD. in philosophy at the Norwegian University of Life Sciences and Stephen King, UK-based vocal coach and vocal massage therapist, for an hour-long talk about complexity and causation in the manual therapy patient. Complexity; simplified.
  • Stephen King and I sat down to talk about skepticism, tongues, and omohyoids. Link
  • I was asked by the National Spasmodic Dysphonia (SD) Association to write an article on manual therapy’s potential use with SD. Link
  • After attending one of my Voice and Swallowing Disorders in New York City, massage therapist/educator Beret Kirkeby wrote a review of her experience. Link
  • At the request of the Association of Massage Therapists (Australia), I wrote an article on The Vocal Athlete (nods to Marci Daniels Rosenberg and Wendy Leborgne!) Link Similarly, I wrote a similar article for the Massage New Zealand Magazine titled, Myofascial Release/Massage with the Vocal Athlete. Link
  • Watch a few videos of laryngeal manual therapy being expelled externally, with FEES views internally here, here, and here.
  • Join me on the Healing Ground Podcast with Dr. Carly for our talk on Voice and Swallowing Disorders and integrating a patient-centered model into manual therapy interventions. You can catch the podcast at this link.
  • Robert Gardner II, LMT and online educator, sat down for another one of our talks. This time about the common denominators in Manual Therapies and Massage. You can catch the whole interview here.
  • Daniel Pablo Albillo, from the Australian-based Knowledge Exchange, and I talk about the biopsychosocial aspects of manual therapy. Link
https://youtu.be/423n3MK8Nx8
  • A video podcast with Matt Phillips of the UK-based Sports Therapy Association. Link
  • On their podcast Pain Reframed, Liz Peppin and Jeff Moore take me down the rabbit hole of manual therapy’s tawdry image regarding its place next to exercise in the physical therapy profession and how it has a place in today’s market. Link
  • Scott Dartnall and I sat down for a longer talk on the concept of Mastery and some of the problems with that term and concept as they apply to those using manual therapy as an intervention. Link
  • Mark, from 2 Massage Therapists and a Microphone, and I discussed all things MFR, unpacking much of the BS from the tissue-based beliefs of the MFR (and other) communities. Link
  • Haley Winter allowed me a number of podcasts on his How’s the Pressure podcast, with a longer format interview on what was, at that time, my version of MFR. You will also find my input on a variety of topics relevant to the massage and physical therapist scattered throughout a number of other interviews on his website.
  • Nick Ng, from Massage & Fitness Magazine, and I sat down after a teaching trip to Hong Kong to discuss my approach to manual therapy. Link
  • Robert Libbey, RMT, and I sat down for a talk that began with my hand (surgery) and drifted into some mutually agreeable topics on narratives and education in manual therapy. Link
https://www.youtube.com/watch?v=YUyNUPhqZ0o
  • Dr. Joe Muscolino interviewed me for his website, Learn Muscles, on being an educator. Link
  • For the Massage New Zealand Magazine, I wrote a referenced article on Shared Decision-Making in the Manual Therapies. Link
  • Seeing one’s work reach those in need is rewarding. After reaching a seminar in Kansas, one of the speech-language pathologists continued working with a patient who came in to act as one of my models in the seminar. You can watch his story here.
  • While still referring to the work that I teach as MFR, I was asked to write an article for Massage Magazine on treatment to the region of the diaphragm. Link
  • As a contributor to Massage & Fitness Magazine, I wrote and article titled Finding My Voice: A Patient-Centered Perspective, Link, Say Nothing, Link, and Let Your Stories Mature and Grow, Link.
  • In an issue dedicated to research, I wrote A Deconstruction of Beliefs: A First-Person Account for the Massage New Zealand Magazine. Link

Please check back as this list grows.

There is a deep list of videos that provide the curious leaner much information on the approach used in this work. The Manual Therapy: Voice and Swallowing Disorders YouTube page is a place to start. For more general manual therapy videos, check out this page. For self-help videos suitable for sharing, click here to be taken to that YouTube page.

A podcast that I respect and recommend is Dr. Oliver Thomson’s Words Matter podcast. Covering a wide range of topics, with relevance to the PT, MT, and SLP, Dr. Thomson unpacks the factors at-play in the therapeutic relationship. He is also working his way through the CauseHealth (see below) book with the authors, with each chapter covered in separate podcasts. You can listen to Dr. Thomson’s podcast at this link.

CauseHealth is a project to address complexity in causation regarding therapeutic interactions. They’ve made their latest book, Rethinking Causality, Complexity, and Evidence for the Unique Patient available at no charge , and can be downloaded here. No matter your profession I cannot recommend a source more highly.

Cheers,

Walt Fritz, PT

Foundations in Manual Therapy Seminars and The Pain Relief Center

www.waltfritz.com

Please consider checking out my online course offerings, , including a full hands-on online course. You can find the information here. Also, read up on my in-person seminars at the links in the menu on this page.

Walt Fritz
Author: Walt Fritz

Getting to yes. Using negotiation in the therapeutic process

Getting to yes. Using negotiation in the therapeutic process

Getting to yes: Using negotiation in the therapeutic process.

Walt Fritz, PT
(Updated January 2024)

In this article, I want to dive deeply into the options available to the therapist, explicitly using a patient-centered, negotiation-driven model of care. A model like this becomes a therapeutic partnership, an alliance for a common goal. Contrast this model with the more common therapist-centered model, where the clinician is seen as the expert, capable of independently making decisions about diagnosis and treatment. While therapists immersed in their expertise may take umbrage to my characterizations, I ask for patience to allow this explanation to play out.

Though I was trained in the clinician-as-expert model of manual care, over the past two decades, I’ve transitioned my physical therapy practice and continuing education classes into one featuring shared decision-making (SDM), allowing negotiation throughout the treatment process. With negotiation, the application of intervention becomes balanced. Without negotiation, intervention is driven solely by the therapist’s beliefs and experience (ego), possibly missing out on an outcome that has better meaning to the patient.

“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 reaching 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 regarding the manual therapy I currently use and teach. While the phrase, getting to yes, might be somewhat narrowly focused regarding the outcome of manual therapy, I see it as a productive and necessary step to fulfill before determining treatment. The concepts presented in “Getting to Yes” have meaning today.

Like most other intervention methods, manual therapy (MT) training has a predictable pattern, many of which I’ve witnessed since beginning my formalized MT training in 1992. Whether it be the commonly seen problems of pain or movement disorders faced by physical therapists and massage therapists or the need to reduce the severity of the impact of dysphagia, dysphonia, trismus, and the full range of other diagnoses facing the speech-language pathologist, orofacial clinicians, and others, the application, brand, or style appears to matter little. 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. With experience, the therapist uses the modality with greater comfort. With apparent positive results, additional training will often be pursued or encouraged. An illusion is usually formed, where the clinician believes that as their expertise and knowledge improve, their ability to determine the cause of a problem and the correct technique is also enhanced. With that confidence often comes the belief that they can better determine what is wrong with the patient and know how to remediate the issue. Such confidence allows the clinician to feel prepared to help another person through a process that the person knows little about. However, might acting with such certainty minimize the patient’s perspective, values, and preferences, perspectives that can both help and hinder a process?

No matter our profession, we are seen as experts in our respective fields, well-prepared to understand the deeper issues underlying a disorder and know which intervention to apply to remedy that problem. This reasoning seems standard practice in most healthcare and typically meets with success. However, are there ways to improve outcomes? Are there ways to enhance patient buy-in? Are there ways to better honor the three aspects of the evidence-based practice model (EBP)?

I ask readers to keep in mind the three equal elements of EBP:

  1. The published evidence,
  2. Clinician’s experience applying the evidence, and
  3. Patient perspectives and preferences concerning the evidence and the clinician’s perspectives.

Those three legs are taught in most health-related curriculums and were established to improve the quality of interventions. However, of those three inclusions, I believe that patient perspectives and preferences are given far too little emphasis and respect across the broad spectrum of healthcare. Recent trends in narrative medicine and other more patient-centric approaches are beginning to create change, but manual therapy models seem to have lagged behind others. I propose a method and model that contrasts sharply with traditional MT clinician-as-expert training approaches (where the therapist is seen as capable of making treatment decisions on the patient’s behalf). I propose elevating patient perspectives and preferences to carry equal weight with the evidence and the clinician’s experience applying said evidence. Some call this approach a shared decision-making (SDM) model, a moniker I use throughout my writing and coursework.

I’ve been exposed to many learning models in my years of learning and applying MT. Being encouraged to pursue additional coursework was a given, actively encouraged, and sometimes required. Early on (myofascial release and craniosacral training), working intuitively 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 another person. I was taught to determine what was wrong with my patients through various means by merely looking at them. These skills involved conventional evaluation methods, such as postural assessment and movement observance. I noted postural deviations from an idealized norm and observed movements that deviated from similar idealized perspectives. I was taught how to interpret those findings based on the model being introduced. Postural deviations were seen as problematic due to explanations steeped in physicals and biomechanics: if the machine is not well-aligned, it is bound to fail. We were taught to align the body for optimal performance. These are not uncommon perspectives and continue to be presented in current educational models. But the human body and condition are not machines. It is complex and unique, capable of adapting to stressors and conditions that appear to belie traditional mechanistic models of explanation.

I was also encouraged to “read” the body, seeing patterns, colors, and holding patterns that would lead me to know what treatment needed to be done. Suppose all of this sounds far-fetched; welcome to the world of pseudoscience. To many, these concepts make sense but are often mere logical fallacies. Using the taught approach seemed to result in positive outcomes, and armed with such power, why would I have stopped believing in the basic tenets of that myofascial release approach I had learned?

The clinician determines if their preferred treatment style might be helpful in the typical MT intervention. That exercise 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. Myofascial release had been my bias, tool, and belief for at least twenty years. 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 tribe saw significant problems with the explanatory narrative utilized in MFR and many other modalities targeting tissues and pathologies.

This dilemma seems nebulous and meaningless to the uninitiated, those new to manual therapy. But the dilemma is real to those who’ve spent time exploring the various modality rabbit holes. How can so many modalities have the answer? Can each tissue/pathology-based manual therapy model truly singularly and selectively access and successfully intervene in that dysfunction? Can there be so many unique tissue-based problems in the body that lie in wait for the therapist specially trained in a model devoted solely to that problem? Is it a “myofascial restriction” that is remediated by an MFR therapist? Is the trigger point therapist remediating that trigger point, or are they applying a work that patients benefit from, no matter the mechanism of action? Is the gentle, affective touch used by the craniosacral therapist really balancing the body’s craniosacral rhythm and movement of spinal fluid, or is their light touch impacting autonomic centers, capable of introducing the same changes the CST clinician believes are due to other pathologies? These questions are often seen as heretical by devotees of tissue and pathology-based manual therapy modality families as they question the fundamental underpinnings taught. Such talk is often squelched. However, these are conversations that need to occur.

Manual therapy is often helpful for many disorders, whether in the niche of voice and swallowing or the larger body of conditions impacting human existence. But does MT work in the manner described by its followers? Diving deeply into the evidence pulls out a relative lack of irrefutable proof of both the tissue-based dysfunctions that are responsible for the disorders we treat and our ability to impact those tissues for intervention selectively. Such omissions are lacking in nearly all 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 (or positive outcomes). Proving efficacy is often allowed to be sufficient proof of the stated mechanism of action. The complexity of the human condition is seldom reducible to problems in one tissue or region, be it muscle, fascia, tongue ties, postural deviation, flexibility, or strength, especially when viewed through the lens of biopsychosocial understanding.

Despite enormous progress in scientific understanding of pathologies and models of care, we are still not at a place of complete understanding. Instead of choosing a tissue or pathology-based model of manual therapy, I’ve modified my process to allow the patient to be the focus of care. This shift represents a movement towards patient empowerment rather than my skill and beliefs being the centerpiece. While I fully admit I cannot abandon my knowledge, training, and past experiences (ego/bias) entirely, I attempt to temper such factors by fostering a relationship where my patient plays a more active role in determining treatment. In my classes, I speak to this as a point of distinction between other modalities and perspectives. In many trainings, whether it is a model teaching manual circumlaryngeal treatment (MCT) or more broadly applied myofascial release and manual therapy, the clinician is tasked with locating the problem, 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 think through this palpation is the same “thing.” Such conflicts are seldom spoken of across MT circles, as each prefers to stay within their tribal narratives.

In my view, the historical “clinician-as-expert” model lacks one major component; no matter how much I know how much training I’ve had, I cannot determine what a patient is feeling. I cannot palpate what a patient feels might be helpful or harmful. I cannot palpate or evaluate a patient’s expectations, preferences, and perspectives. Working in a one-way fashion, where the clinician is tasked with determining what is best for another human being, allows only one person’s voice to be heard.

So, how can one overcome these obstacles? How does using a patient-centered model that instills ownership of the patient’s perspective and preferences matter within the uncertainty mentioned above? I believe that it matters because of the uncertainty. We cannot be sure if our tissue-based beliefs are accurate, which is a troubling concept. Sure, many outcome-based studies point to positive outcomes when a model of care is applied. But none of those studies dives deeply into understanding the complete mechanisms of action that touch and MT play. Lacking a comprehensive mechanism of action for the results of our work requires us to exist in an uncertain world. However, there is hope.

Those who inform my views are researchers such as Bialosky (2028), Geri (2020), Kolb (2020), Roy (2019), and Weppler (2010), who, through various perspectives, point to higher levels of influence and control in terms of why changes might be elicited at the periphery. They are not negating the possibility of what we’ve learned about local effect manual therapy models but instead point to other influences and factors that drive change. The tapestry we work with (and from) is a rich one.

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 actual location of a condition, like most other manual therapy models, I use palpation to begin a communication process with my patient. In older models, palpation leads to the conclusion, “I’ve found your (muscle tension, fascial restriction, trigger point, 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. However, palpation is used to begin a conversation with my patient. “This area seems tight; does this feel familiar to you?” From this point, SDM starts.

In MFR, my evaluation findings led me to know what needed to be done. I was a fascial expert, a trait few of my patients shared (or even understood). My treatment suggestions may have seemed foreign to most patients, but my reputation and the hope that I would help allowed them to trust me. I cannot discard all my experience, but the more I learn, the more I mistrust my instincts. I’ve learned to trust my patients more and work to temper my beliefs with the knowledge that I do not know what my patients are 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 their pain or dysfunctional feelings or lighten up my touch and pressure into a feeling they identify as helpful unless I ask. I have no way of knowing what sort of pressure/pain tolerance they might have unless I ask. I have no way of knowing if the things I’ve located through palpation or other evaluation could be significant, beneficial, or harmful unless I ask. Despite all 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 patient’s input is often minimized or at least deferred to the therapist’s clinical expertise. Usually, this all works well in the end, but are there ways to improve 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. “Yes, that feels helpful,” or “Yes, I think this might be useful.” Getting to yes 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?

I recently listened to a podcast from a few well-regarding physical therapists who were speaking about shared decision-making and patient-centered care. With a note of sarcasm, when talking about patients not knowing the nitty-gritty of physical therapy, one quipped, “Well, it’s not like we can ask our patients to choose what exercises they wish to do.” This remark provided a laugh to the other expert PT. In their world, expertise drives interventions, despite many studies published over the past ten years showing that the specificity of exercise interventions matters less than once thought. Exercise is helpful, but few physical therapists know why (Powell, 2022). Rather than choosing the correct intervention, some authors have linked the alliance built between patient and provider as one of the more significant influencers of change (Alodaibi 2021). Manual therapy studies have shown similar issues. For instance, the specificity of MT for laryngeal dysfunction was seen to be unnecessary when compared to more global MT treatment Ternström et al. (2000). Manual therapy intervention is complex, so far as mechanisms at play and quickly move into behavioral aspects of the therapeutic relationship, patient expectations and fears, and many more concepts that remain in the shadows. Our educational and continuing education poorly prepared us for these uncertainties.

The way I teach my work is to use palpation as a place to begin a meaningful conversation about what brought them (the patient) into my clinic. As soon as I feel something that, from my past, feels interesting, I see if I am getting my patient’s attention. 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. In essence, I force them to help me help them. I work toward finding a tactile cue that connects with a feeling 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, 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 want 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 without any form of coercion. I am attempting to get to yes with them, to find a pressure, stretch, or engagement that they feel will be useful and 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. Many will defer to me; “do what you think is best; I can take it.” With such responses, I will work to allow them to see their place in this therapy. If a more painful treatment I desired, it should come from them and not from me. I let them know that while many believe it must hurt to help, others feel quite differently and that the research doesn’t support that view. But if their lived experience wishes deeper, more painful intervention, I will work with them to meet their needs and desires. If they prefer lighter pressures, I need to assure them they are not sabotaging their process. I require them to participate fully 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 to 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 possibly did a somewhat unethical job of selling pathologies to a vulnerable public. Nothing I find is meaningful unless confirmed by my patient. All of this is hard work, though I consider it good work.

Getting to yes. That is my mandate.

Walt Fritz, PT
Foundations in Manual Therapy Seminars
www.WaltFritz.com

Alodaibi, F., Beneciuk, J., Holmes, R., Kareha, S., Hayes, D., & Fritz, J. (2021). The Relationship of the Therapeutic Alliance to Patient Characteristics and Functional Outcome During an Episode of Physical Therapy Care for Patients With Low Back Pain: An Observational Study. Physical therapy, 101(4), pzab026. https://doi.org/10.1093/ptj/pzab026

Bialosky, J. E., Beneciuk, J. M., Bishop, M. D., Coronado, R. A., Penza, C. W., Simon, C. B., & George, S. Z. (2018). Unraveling the Mechanisms of Manual Therapy: Modeling an Approach. The Journal of orthopaedic and sports physical therapy, 48(1), 8–18. https://doi.org/10.2519/jospt.2018.7476

Geri, T., Viceconti, A., Minacci, M., Testa, M., & Rossettini, G. (2019). Manual therapy: Exploiting the role of human touch. Musculoskeletal science & practice, 44, 102044. https://doi.org/10.1016/j.msksp.2019.07.008

Kolb, W. H., McDevitt, A. W., Young, J., & Shamus, E. (2020). The evolution of manual therapy education: what are we waiting for?. The Journal of manual & manipulative therapy, 28(1), 1–3. https://doi.org/10.1080/10669817.2020.1703315

Powell, J. K., Schram, B., Lewis, J., & Hing, W. (2023). Physiotherapists nearly always prescribe exercise for rotator cuff-related shoulder pain; but why? A cross-sectional international survey of physiotherapists. Musculoskeletal care, 21(1), 253–263. https://doi.org/10.1002/msc.1699

Roy, N., Dietrich, M., Blomgren, M., Heller, A., Houtz, D. R., & Lee, J. (2019). Exploring the Neural Bases of Primary Muscle Tension Dysphonia: A Case Study Using Functional Magnetic Resonance Imaging. Journal of voice: official journal of the Voice Foundation, 33(2), 183–194. https://doi.org/10.1016/j.jvoice.2017.11.009

Ternström, S., Andersson, M., & Bergman, U. (2000). An effect of body massage on voice loudness and phonation frequency in reading. Logopedics, phoniatrics, vocology, 25(4), 146–150. https://doi.org/10.1080/140154300750067520

Weppler, C. H., & Magnusson, S. P. (2010). Increasing muscle extensibility: a matter of increasing length or modifying sensation?. Physical therapy, 90(3), 438–449. https://doi.org/10.2522/ptj.20090012

Walt Fritz
Author: Walt Fritz

2 Responses to Getting to yes. Using negotiation in the therapeutic process

  1. For example I find the palpation that indicates it may be connected to the issue and the client agrees. I ask the client to move. [step forward with one foot] If they ask which one, I say I don’t know. Only their brain knows which movement is the safest. After spending some time evaluating that move and position, whether it is involved in the complaint, makes things better or worse; can we cautiously try the opposite move to see if that leads to more discovery.

    • Hi Hans, I marvel at the way we come up with ways to engage our patients in meaningful action. I am even more appreciative of models that minimize the concept of nocebo introduction (pathologizing), based on the tissue-based narratives most were taught. Bravo for your approach!

21 Questions: Manual Therapy for Voice and Swallowing Disorders – A YouTube Playlist

21 Questions: Manual Therapy for Voice and Swallowing Disorders

July 2023: While this post is dated regarding the title of my work (I evolved away from “Myofascial release/MFR” and into “manual therapy” due to issues of credibility), the content remains quite relevant. The playlist has expanded well beyond the original 21 videos to give the viewer a deeper understanding on the ins and outs of manual care for voice, swallowing, and related disorders. You can view the entire series of videos at this link

I was recently in the UK to take a seminar and stopped by the Vocal Massage practice of Stephen King in Covent Gardens, London for some filming. In advance of this July’s MFR for Neck, Voice, and Swallowing Disorders that I will be presenting in Birmingham, England, and Dundee, Scotland, I was sent a list of questions by one of my UK hosts, SVS Associates, to introduce my work to the UK speech pathologist and voice communities. What unfolded was a rather free-form interview, captured in 21 separate videos, plus one longer format video that shows my style of interview, evaluation, and intervention with a vocal performer. He also allows us to hear him, both pre- and post-treatment.

You can watch the first Question and view the demonstration video below. If you have questions, please post them as comments here on the blog and I will respond. The entire playlist may be accessed via this link: 21 Questions


For now,

Walt Fritz, PT

Foundations in Myofascial Release Seminars

Walt Fritz

Author: Walt Fritz

More Mental Floss for the MFR Brain: Changing Your Story

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 you to strip away the story you tell when describing your modality?  Could you describe the actions of your hands without the jargon inherent in the story of your modality? It might be pretty hard to do, as it may be hard to separate actual plausible science, anatomy, and physiology from what you were taught as the science that supports the work you use. You have to use something that sounds science-like, but what if you had to change your story? Could you do it and would you even wish to try? You would need something to explain your work, though my explanation seems to get simpler by the year.

Changing one’s story is often viewed as shifty or even indecisive, as if you cannot decide or are trying to cover up something. I disagree. I’ve written extensively about how I moved from a narrative (story) of myofascial release in the traditional, folkloric sense, which credits so-called fascial restrictions as being the cause of most pain as well as the key to the remediation of pain into a story of simplicity and plausibility. Apparently my story was so compelling it garnered a request to tell it earlier this year at the Registered Massage Therapists of British Columbia Manual Therapy 2016 Conference. The story I now tell and teach is a simple one, one deconstructed from the stories of fascial fantasies. But as a therapist (PT) with over 30 years in practice, I’ve heard literally hundreds of stories on how we are creating change in the body as well as the cautions as to what will happen if we do not follow the recipe set forth in that line of training’s rulebook.

The story told by most manual therapy trainings might be called inherited narratives (Thanks to Phil Greenfield for this term) in that the beliefs and explanatory models have been passed down over time. While new science might be sprinkled in for good effect, most of these narratives have remained unchanged for long periods of time. The narrative I was taught in my initial myofascial release training was certainly an inherited one, as the concepts of MFR (and its explanatory model) stem from osteopathic literature from the early 1900’s. I have begun to use the term folklore to describe the way MFR is taught; as many therapists repeat the inherited narrative verbatim without questioning its validity or authenticity. But this is true for much of the work that we all do. If I attempted to deconstruct most of what I was taught in physical therapy school and eliminate all that was not fully vetted as valid, I may have little to do with my days. Though I’ve allowed the MFR story I was taught to slip away over time, initially it served me well and I questioned little of its truth. Over time, as I moved away from my MFR roots, the inherited narrative of MFR seemed to matter less and less. I also learned drastically conflicting stories from other people. Recognizing that my biases clouded my abilities to see real truth, I began to embrace the concept of attempting to be less wrong. Saying that I am less wrong, when it comes to explaining my work, may sound condescending or superior, but I believe that it comes from a place of humility. 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.

Many different influences caused me to change my story, though the need to do so was not due to a lack of efficacy, as I think the MFR work I did has always been effective. But the story I was taught way back in the early 1990’s always bothered me a bit. I found it hard to believe that in a continuing education class we were being taught concepts of anatomical/physiological structure and function not taught to other health professionals, including physicians. But I like a good story, so I played along… just to hear the ending. One key point of the MFR work I was taught was the concept that fascial restrictions go beyond the origins and insertions of individual muscles, which was said to explain why patients feel far-reaching symptoms while we are treating them. Such far-reaching sensations were a key aspect of explaining MFR from a fascial perspective, and I used this explanation with my patients for many years, as well as teaching it in the early days of my Foundations in Myofascial Release Seminars. It was a good story told by some pretty good storytellers and I had no better story to explain the phenomenon, until I learned one. Let me tell you about that new story.

Frequent feedback I heard when performing a technique that is termed a thoracic outlet release are reports of sensation or referral of familiar symptoms throughout the face. When my patients told me this, I used the story I had been taught and explained the concept of fascial restrictions and how they reach beyond the origins and insertions of individual muscles and can refer into far-reaching areas of the body (By then I told that story really well!). Most patients would just nod or grunt in apparent understanding, but I started to notice how frequently I heard these reports. This was surprising, since it was the belief that fascial restrictions were unique to each individual, based on their history of physical (and emotional) trauma. Why were so many people telling me nearly the identical referral pattern? I filed it away for future worrying (I do that a lot. Why waste good time worrying about such things when there were more pressing things to worry about? I tend to compile worry to-do lists). It seemed that with a sustained hold in the above mentioned (and below pictured) sequence, symptoms improved not only in the area of treatment, but also into the referral patterns through the face. Seeds of skepticism were planted.

Fast forward to a DermoNeuroModulation class I took from Diane Jacobs, PT. She speaks a decidedly non-fascial language and at a certain place in her lecture she displayed a PowerPoint slide regarding the anatomy and distribution of the facial nerve. She had spoken at-length about neurodynamic technique principles, exposing me to some pretty new and interesting perspectives on evaluation and treatment. She spoke about the potential for engaging a nerve anywhere along its length and having the possibility of impacting and allowing change anywhere along the nerve path. In essence, grab hold of a nerve anywhere and you have the potential to impact the entire distribution of that nerve. The photo below shows me performing the sequence formerly known as the thoracic outlet release (I have different names for technique sequences today…but that’s another story). If you can imagine where my patient is feeling a stretch or engagement, a wide range of response is plausible, including the front of the neck and upper chest region.

_mg_0282

Now consider the anatomy plate shown below. It is a Grey’s Anatomy plate showing the distribution of the facial nerve. The facial nerve is the seventh cranial nerve and “controls the muscles of facial expression, and functions in the conveyance of taste sensations from the anterior two-thirds of the tongue and oral cavity. It also supplies preganglionic parasympathetic fibers to several head and neck ganglia.“(1) The facial nerve functions as a motor nerve as well as sensory and parasympathetic nerve and supplies the exact areas that my patients were reporting all in all those instances of so-called fascial referral. What might explain this phenomenon?

Take a close look at the anatomy plate below and you will see that the cervical branch of the facial nerve runs down through the upper and middle anterior lateral neck regions. When I engage my patients in the stretch shown above in the photo, I believe that I am lightly engaging the cervical branch of the facial nerve. I believe that I am providing neurodynamic technique-like engagement to the cervical branch of the facial nerve, potentially affecting the entire facial nerve. I believe that I am allowing my patients to feel effect into their faces and treating the facial region from this sequence, not from a fuzzy science explanation of fascial restriction, but from a biologically plausible model of nerve mobilization.

 By Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See "Book" section below)Bartleby.com: Gray's Anatomy, Plate 790, Public Domain, https://commons.wikimedia.org/w/index.php?curid=541634

Sitting in Diane’s class and seeing the facial nerve in an enlarged image allowed me to immediately see that old, folkloric story of so-called fascial referral patterns in an entirely new light. Does this mean that fascial restrictions do not explain this phenomenon? Not definitively, but when faced with a decision to choose one explanation over another, I now choose the one that is less wrong. I choose the one that science supports without needing to tell a story.

Stories have their place, but they should be told as either fact or fiction. When stories blur I do not believe they belong in the treatment room, where we give skilled care to patients in pain and dysfunction. Try to be less wrong. Change your story.

What about you? Has your story changed?

For Now,

Walt Fritz, PT

Foundations in Myofascial Release Seminars

(1) Facial nerve text and image courtesy of Wikipedia. https://en.wikipedia.org/wiki/Facial_nerve

General banner Ad for all classes

Fritz-affiliate-ads-v2

text2join-2 052516-page-001

NVS banner for blog

Walt Fritz

Author: Walt Fritz

14 Responses to More Mental Floss for the MFR Brain: Changing Your Story

  1. Fritz, I love your use of language and perspective on this. We have all assimilated many ‘folkloric stories’ over our years of training and practice.These days in our health professions there is such a push toward “evidence -based” medicine, yet another place where many feel obligated to present a different set of ‘folkloric stories’ to somehow attempt to justify or make real the mysteries of the human body and its responses to intervention. May we all move toward being less wrong there as well.

    • Sheila, Stories have their place, even folkloric ones, but I think we should be begin to preface our explanations to and education of our patients with appropriate disclaimers. Though if you believe the story to be true it may be hard to know when to preface. Keeping our explanations as simple as possible is a good place to start.

  2. How my narrative changed:
    A client arrived with a book: Strain-Counterstrain by Lawrence H Jones, DO. An osteopath told her that if she did the things in the book she would recover from her complicated injuries but he did not have the time to do it.
    As I read the book, I began to understand that what I had begun doing instinctively, that is holding a position until I felt a response was changing habitual sequencing patterns in the central nervous system.
    Myo: dose muscle tension change when hyper sensitised motor points are allowed to reset? I think so.
    Fascia: Dose fascia change its characteristics when the central nervous system changes the impulse being sent? I think so.
    Release: Do protective sequence patterns that have become counter productive release when the central nervous system perceives that there is no longer a threat? I think so.
    Does my repeating this dialog while holding a pattern they perceive as connected to their pain give them relief? They think so.

    • A patient’s belief in a narrative can be an important aspect of our interaction. Brian Fulton’s excellent book, “The Placebo Effect in Manual Therapy” speaks to this at length. While I have stopped poking holes in their narrative I may, over time, all ow them to see the many ways people see pain/dysfunction and how many of the narratives are not entirely accurate. Most accept this very well.

  3. Walt, Thank you again for your articulate expose on your evolvement in your practice. At the end of your article you state “cervical branch of the facial nerve runs down through the upper and middle anterior lateral neck regions.” By treating the longus capitus, rec. cap. anterior and rec. cap lateralis can you directly effect the cervical branch of the facial nerve?

    • Engaging the body in any part of the region of this (or any nerve) may cause the principles of neurodynamic technique to take effect, so yes to you question.

  4. It is healthy to question your story or narrative, it gives credibility to your humanity and science. You will probably find that this too will change over time. In my 30 year bodywork experience I have found consistent neuro, scar fascial lymphatic and structural changes with accurate tissue manipulation. I see it as a question of what system you are intending to influence, where and how much to create balance in the body. Science is actually ill equipped to accurately determine the effects of our treatments. Meanwhile we are lured to wax poetic about the amazing benifits of human touch.

    • Our attempts to keep current with science will necessitate changing our story along the way. I do disagree with your stance on intention and what system we wish to influence. I think this is where we may have been sold other stories, in terms of our ability to not only selectively access individual tissue/structure, but also our ability to affect only those individual systems. I think our touch has great ability to influence, but I see it from a larger sense of central control.

  5. ” I think our touch has great ability to influence, but I see it from a larger sense of central control.”
    I do not want clients to be reliant on my touch. Along the lines of Ben Benjamin’s “Listen to Your Pain” I try to enable the client to replicate what gave them relief. I have them touch, move, push pull and be aware of their ability to affect their pain. My message is “Pain is the body’s message to the conscious mind that you need to do something different.”

  6. So Walt, how do you engage a nerve without also engaging the fascial system?

    I think there is still much to be discovered, I would be hard pressed to take the idea that it is simply a nervous system response. Afterall the fascial system also carries the meridians. And understanding the fascial system is far from an exact or close to an exact or even close science. We need to look at all of the component parts and not exclude one because the nervous system provides a very neat and “plausible” story.

    I also think the use of the folkloric is akin to saying its an old wives tale. I can understand where you are coming from and I still think the story is missing a very very important component. We really don’t understand fascia, and yes we engage nerves when we do fascial release or with dermoneuromodulation. You and can call it what we want and no matter what, the story is always incomplete. I absolutely agree the nerves are engaged in the releases. This doesn’t discount the possibility that fascial tissue does change with particular kinds of forces. If you add rotational forces to your release techniques, you get an entirely different kind of release through the body more akin to an acupuncture treatment.

    • Hi Bamboo, nice to hear from you again,
      “how do you engage a nerve without also engaging the fascial system?”
      That is a fair question, but might be better stated by asking how we isolate ANY structure within the body? It is the failing of most forms of manual therapy/touch, one that is easily overlooked in attempts to define supposed targets of our touch. The fascial system is certainly an aspect of the tissues that surround nerves, including the tunnels that surround each individual nerve and are thought to be part of the issue with tunnel syndrome-type problems. Many of the neurological concepts of intervention take a top-down approach to explaining changes in pain, etc, which often omit the periphery. It is certainly plausible that the multitude of other tissue/structure may play roles in our touch, fascia included, and while I have not completely discounted the potential for this to be proven some day, I grow and grew tired of everything explained by the mysteries of the fascia. As for fascia carrying the meridians, we have been taught vastly differing views of the body and how it works. I know that you, as an acupuncturist, believe things that I may not, and meridians are one of those such things.

      Definition of folklore
      1: traditional customs, tales, sayings, dances, or art forms preserved among a people
      2: a branch of knowledge that deals with folklore
      3: an often unsupported notion, story, or saying that is widely circulated
      (http://www.merriam-webster.com/dictionary/folklore)

      So no, I do not mean to say that I believe these are old wives tales. I think that most of the stories told in fascial education are passed down narratives from older osteopathic literature and beliefs, most of which are passed along without much critique. I do agree that the story is incomplete, but this does not give license to allowing any explanation to be acceptable, on the off-chance that at some point in the further it may be proven. Far-fetched teachings have been around for nearly as long as we have and are, unfortunately, still being taught. Much is not known about fascia, but that is not because people have not been trying. It may just not have that much to show us.

      Being less wrong is an opinion, but one that can often be backed by science. You and I may not agree, but our rational, civil disagreement and conversation are what will accomplish meeting of minds somewhere in between where we are at right now.

      Cheers,
      Walt

  7. What we call farfetched often ends up being proven to be true. We can’t discount meridians just because we can’t see them. We can experience the effect of a needle in the body, we can feel the changes in our wellbeing and see the changes that happen.

    Unfortunately science is more eminence based than evidenced based. When this changes to include and to explore honestly all avenues of discovery without the biases expressed by “scientists” and science based practitioners we will have a very very different conversation. Right now the comments using phrases like pseudoscience, folkloric etc demean what was very important before to you. It gave you and me a handle with which to describe something of what we were doing. I really don’t think you need to go in that direction to support your perspective.

    I think by not including the fascial system in the discussion of dermoneuromodulation, a great disservice is done to all of our practices. Just because we don’t clearly understand how it links to the whole system, we instead ignore as it has been ignored by the medical profession forever. It is time to stop it.

    The other piece that distresses me a bit is the notion that we don’t touch anything but skin. If your (not necessarily your’s per se, but it might) reality is such that only the physically touchable, seeable and measurable is the only reality, you’r missing a lot. I think this system has its value for sure; it’s actually similar to what I do from an acupuncture standpoint. I think this is a lame attempt to put something we don’t understand as much as we want into a box that appears to have great validity. and it doesn’t.

    I wonder if Diane ever worked on unembalmed cadavers. And how does she deal with all the mechanoreceptors within the fascial tissue?

    Just because we don’t understand something doesn’t mean we can’t talk about it. Seeing the brain and the nervous system as the be all end all is in my mind missing a critical point of the physicality of the body. There are too many unanswered questions to rely solely upon one system.

    We cannot engage a nerve without engaging the fascial system. Her techniques work the fascia more than the nerves. They may release trapped nerves. What tissues do nerves meet in? Do they go into muscle cells? They engage tissues and organs through the extracellular matrix of the fascial system. I don’t think we can engage anything in the body without engaging the fascial system.

    The definition of folklore is clear. It appears to be used to disparage something while lifting the value of another system.

    Another question is how does anyone know the treatment is actually treating nerves rather than the fascia? It’s the fascia that jams the nerves. So are we putting the cart before the horse? What’s the proof that it is the nerve that is being treated and not the fascia? Because of location? How does Diane know she is moving the nerves? Look at her techniques carefully. She’s engaging the fascia and the mechanoreceptors in the fascia. With rotational forces you can get a much bigger release through out the body.

    We can continue agree to disagree. Let me know when you do a workshop in CA.

    • I have and continue to thank those in my past for what they have taught me, but I will not continue to accept all that I was taught, especially when much of it has been proven inadequate or incorrect. Much of MFR, manual therapy, massage, and probably acupuncture, is based on a narrative that has been simply handed down form one person to the next with little critical deconstruction of the underpinnings of that modality or mindset. We will disagree on giving anyone or any idea a pass, allowing them to claim nearly anything, on the chance that someday it may be proven correct. You find my words folkloric and pseudoscience demeaning, but I do not mean them as such. Pseudoscience simply refers to methods mistakenly regarded as being based on scientific methods and I am sorry if you find that offensive. Neither words are disparaging. As for Diane’s beliefs I might suggest that you join her Dermoneuromodulating group on Facebook (https://www.facebook.com/groups/5704079529/) and ask her yourself, as I will not speak for her. I have examined her techniques quite closely and marvel at the similarity to those we learned as MFR. But when you look at the broader world of massage/manual therapy, the crossover is similarly as uncanny, further calling into question the claims made by each and every modality, in terms of what they claim their specific tissue effects might be. If you look closer at Diane’s work, and some of the ways I describe MFR, we are describing aspects of skin neurology, with the skin being the only tissue we can be 100% certain we are impacting.

      I am actually teaching at USC in LA next August: http://www.waltfritzseminars.com/myofascialresource/los-angeles-ca-foundations-in-myofascial-release-seminar-for-neck-voice-and-swallowing-disorders

      Walt

  8. Hi Walt,

    You may not have meant to use those words disparagingly. Because of the way they are used consistently in a disparaging manner they always come across that way now regardless of who is uttering them.

    I will check into her facebook page.
    Best,
    Bamboo

Follow by Email
Facebook
Google+
Twitter
YouTube
Pinterest
LinkedIn
Reddit