The Good (and Bad) of a Simpler Narrative

by Walt Fritz, PT on 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 to be has gotten old and has been told and retold, but suffice it to say I did not decide to change my story willingly. But as the saying goes, hindsight is twenty-twenty and the move away from an older, less accurate myofascial release narrative has been a good one for my career and professional reputation. The friendships I’ve made over the past few years have been pivotal in framing the narrative I now teach on a regular basis to professionals who take one of my Foundations in Myofascial Release Seminars.

Changing the core narrative used to explain the actions of my hands and the results of the interactions/engagements I have with patients was not an easy one, as the fascial tissue-specific explanation I was originally taught seemed to make sense. Said to be derived from actual science and proof, I learned and then applied myofascial release (MFR) as I was taught and people’s pain improved and they moved more easily. What else needed to be said? Nothing, at least for the first 15 years of my MFR practice. But then cracks started to appear in the narrative. If one exists only in the insular world of any group, all that is heard and restated/repeated is the inherited narrative of that group’s beliefs. This was quite true in the MFR community which I belonged. Frequent was the encouragement to ignore outsider’s criticism of our work, as we (the insular world of MFR therapists) knew what they didn’t. Fascial restrictions were unable to be imaged on any sort of diagnostic testing, nor could it be seen in a blood test or anything resembling plausible proof. We knew how to find and release the fascial restrictions that others could not find. Results were what mattered and I was able to achieve really nice outcomes with my patients. That was proof. What should have raised red flags did not.

But when I began looking outside my MFR world, reading the narratives that all of the other dozens of modalities and sub-modalities stated as “proof”, massive overlap was evident. In its simplest form, manual therapy, massage, myofascial release (and all of the other titles we give to our work) all entail touching, pulling, pushing, stretching, lifting, and pressing on the skin and all layers deeper to the skin. Each modality claims singular or shared ownership of their ability to selectively target tissue-specific structures under the skin (muscle, bone, fascia, lymph ducts, joints, dural tube and cranial structures, to name a few) and unprovable pathologies (fascial restrictions, trigger points, cranial restrictions, subluxations, visceral adhesions, scar tissue restrictions, neural inhibition patterns, etc.) and has created a narrative to explain each of these. When viewed in isolation, especially when confronted with a proponent of each, the story they tell can seem plausible, especially when they apply their work to you with success. What is it about human beings that are more likely to believe a story or explanation if the outcome is positive? A person’s (therapist’s) narrative and the science they use to support their narrative may/can have nothing to do with positive outcomes.

Much of this is boring repetition for many readers, but provocative heresy for others. I was in the latter camp ten years ago, as nothing could sway my beliefs from the MFR science that I was taught, as I had the proof (positive outcomes) to back it up. But then the lines began to blur. I was exposed to manual therapists who held very different beliefs, some with beliefs so simple that it seemed that my work was nothing but charlatanism. (A side note: nearly 20 years ago I began writing a book called “The Charlatan”. It was based on the myofascial release work I was taught and how a therapist’s claims could be seen as a fraud, until the eventual therapeutic outcome proved this wrong. I never finished it, nor will I. It would be a very different book now.) I’ve written at-length about my trial by fire on SomaSimple, with many of the therapists who were on the opposite side of the discussions now folks who I consider friends and mentors driving my narrative change. Most are manual therapists, sporting various credentials and degrees, but all were willing to look beyond their training to see how each modality and brand overlaps with others and not afraid to tell the Emperor that he had no clothes. It is this overlap that drove the simplification of my narrative. But there is both good and bad to changing one’s narrative.

The audience I teach has broadened considerably over the past three years to include speech language pathologists (SLPs) and voice professionals. Their exposure to most of the variations and controversies in manual therapy training is quite limited, which I believe to be a good thing. They have no prior training in such concepts as emotional past/memories being stored in fascial restrictions (yes, that is really taught), or the dozens of other tales taught in modality-based CEU training so rampant in the manual therapy world. I believe that I irritate some therapists with statements such as this, but holding our beliefs and our profession up to the light is necessary and healthy. There is less unlearning to do on their part (with less un-teaching on my part) and it is much easier to introduce possible explanations for our manual touch and engagement in terms of its effects on swallowing, voice, and other disorders/dysfunctions in the SLP world. Manual therapy is not uncommon for SLPs and certainly not out of their scope of practice, with manual circumlaryngeal therapy/massage (MCT) a fairly common intervention. But manual touch/engagement is seldom expanded from the common diagnoses that MCT is used for. I teach an approach to therapy that semi-ignores the diagnosis and attempts to determine if symptoms can be affected/reproduced with simple engagement. If so, then I feel we stand a fair chance of being able to influence the issue(s).

Myofascial release has made its way into the SLP field, with a few providers teaching from the traditional range of approaches, from light to deep work, with short strokes to long holds. Reading through the shorter explanations given on the websites of these providers, I can see a similar inherited narrative repeated from those that are commonly seen in the PT/MT world (fascial-based beliefs). I include these older, inherited narratives in my teaching, but have expanded it to include neurological-based explanations that include the concepts of neurodynamic technique/tunnel syndrome effects, skin-based mechanoreceptors, as well as autonomic effects, and including the indirect effects of our simple presence and perceived expertise. Each of these concepts could fill an entire day of teaching or more, but I try to keep eyelids from closing and move into the actual work before I lose everyone (I can talk a lot!). I tell my students that despite beliefs and statements to the contrary, there is no affirmed explanation for one exact way that our touch influences pain and. The best we can do is look at the potentials, deciding on which are most plausible, and move forward. I have no issue with presented the inherited narrative of MFR, or any other work, but realize that these views are quite narrow and limited.

I believe that crafting a simpler narrative involves a learning and telling a story that moves beyond one single inaccurate or incomplete story, to one that acknowledges the various potential stories or narratives that may be occurring simultaneously. A simpler narrative may require more learning on your part and while many patients are disappointed that I cannot give them the single true answer to what is wrong with them (this is the bad referred to in the title of this article), I see this as a good thing. I tell them that no matter what is occurring under their skin, that I will be honest in saying that I am uncertain, but when we do actions or engagements in certain ways, people often feel better (the good). I will not try to sell them on a story (good), even though many are seeking to be sold/told on a tissue-specific or pathology-based story (bad). Instead of telling them the one thing I think is wrong with them, I will give them possibilities, including things they’ve been told in the past. My guesses as to what is wrong (the cause), is more a product of my training, education, and beliefs than it is on anything factual. My old cause tended to be told in fascial stories, which I know now to incomplete, at best. No matter how inaccurate, refraining from tearing down a patient’s beliefs as their narrative is an important part of the therapeutic relationship, at least initially. Ease them into new information. I will tell them that if they had been a patient of mine 10 years ago I would have sounded considerably smarter than I do today, as I would have told them a very believable story of fascia and its influence on pain and dysfunction. But I am now better informed and am no longer willing to sound as smart as I did in the past.

The good in believing in and telling a simpler narrative is the brutal honesty it entails; The bad is that it is hard to brand and sell. How does one sell a narrative that is not based on tissue-specific techniques or pathologies? Trigger point therapy is an easy sell, as the public has been sold on that trigger points not only exist but that they have been told/sold that they possess the worst trigger points the therapist/doctor had even seen. The latest literature, however, states otherwise that this is a false belief. Link. An ironic aspect of the MFR training I received was that I was taught that those outside the MFR community (essentially everyone else in the world!) were said to be guilty of viewing the body in reductionist ways; they did not see the whole-body picture of fascia’s influence on pain and dysfunction. Instead they were said to view the body based solely on individual components/systems (the reductionism). But science does not support these views and points to a much more complex explanation that varies widely from person to person, in effect making those beliefs of my ex-fascial community reductionist.  Stating that fascial restrictions are the key to all ills is reductionism. But I do not hold my past trainings as the sole perpetrator of such reductionism, as most of the teachings within manual therapy/massage suffer similar problems. Thoughtful consumers of continuing education have the ability to sample the wares, so to speak, listening and learning, applying what makes sense and discarding what is nonsensical. Be it manual therapy, exercise/movement therapy, or even the verbal interaction of a pain-science approach to pain, most are helpful. Successful outcomes seduce the therapist to believe their explanations/beliefs were correct, but a person’s (therapist’s) narrative and the science they use to support their narrative may/can have nothing to do with positive outcomes.

 

The good aspect of manual therapy intervention training and continuing education is that it exposes the therapist, and their patients by association, to a wide range of beliefs and interactions. Many feel that by having many tools in their therapeutic toolbox they will be able to offer more ways to help. Listening and learning new narratives can offer the discriminating therapist an opportunity to compare and contrast it to their existing knowledge-base. The bad aspects of learning a new narrative comes from the seduction of believing you are finding the Holy Grail of Modalities. It does not exist. Others take a different approach to the tool box analogy. They feel if one has a sound understanding of science, then the tool matters little. If it was the tools that made the change, then how can so many different tools (modalities) all be so effective? Only the Holy Grail Modality should have such good effects. It may be more that we are spending time listening and engaging with a person that has the effect and the tool matters little. I like this view.

A simpler narrative is seemingly hard to find/learn, but complex narratives abound. Look at the offerings of CE trainings; it takes a long time and lots of money to become proficient in most modalities, which aligns well with the hierarchical learning structure to which most are accustomed. Anything worth learning takes time and money, right? It must be complex or difficult, or why spend all that time and money? I have had therapists contact me, inquiring if my current 3 classes are all that I offer. They are looking for a line of training that offers them opportunities to work their way up the learning ladder and become a master. I used to apologize for having so few classes, but now I stand tall and tell people that we, as licensed therapists, have the education that included all that was required for a state board to feel us proficient to touch and interact in a therapeutic manner. Good continuing education should sprinkle new thoughts and concepts onto that education and the therapist should then be able to take that information and soar. Some get it, others move onto the training that offers a dozen or more classes, all leading to becoming a certified master. Oh, well.  I’ve spent a lot of both time and money getting to where I am right now, but in hindsight it may not have been so difficult or costly. We need a starting place, and most who are reading this article have that, be it a degree, license, or certification to touch. Most are required to take continuing education in order to renew their license and stay current, but must this be multi-tiered, hierarchical trainings? CE credits are available for a wide variety of learning experiences. Though they differ from profession to profession and from state to state, there are opportunities to both assure license renewal as well as expand your knowledge-base with current, credible science. (Check your state’s practice act for details). I believe that a large amount of science literacy combined with a small amount of hands-on training can be much more than adequate to create a very successful practice (the good). Science literacy can lead you to a simpler narrative that you can then apply to your practice.

How to gain science literacy? Below are a number of groups, including more than a few from Facebook, that have become my go-to sources for not only current, relevant research and literature, but also the ability to interact with some pretty smart people on a daily basis. I’ve moved beyond exposing myself to belief floggings by not getting quite so defensive about my positions and have stopped flogging others. While some may have a specific therapeutic population in its name, most are inhabited by a much wider range of brains that the name implies.

Skeptical Massage Therapist Group

Explaining Pain Science

Touch Science

OM Myofascial Release Group (yes, that’s my group!)

Biopsychosocial Application for Practitioners

SomaSomple

NOIGroup

Writings by: (include Amazon affiliate links)

David Butler

Lorimer Moseley 

Michael Shacklock

Diane Jacobs

Todd Hargrove

Paul Ingraham

Brian Fulton

Nick Ng’s Massage & Fitness e-Magazine

Blogs:

Pain Sense and Sensibility, By Sandy Hilton and Cory Blickenstaff

This list is far from complete, so please feel free to add more names/websites/books in the Comments section below.

Many of the websites and groups contain bibliographies and suggested reading lists than can guide a curious mind down rabbit holes so deep that you may never (want to) come out (The Good). I in no way am implying that all manual therapy continuing education is bad or wrong. I see many of the big names in the CE world communicating and sharing on a daily basis on some of the various groups mentioned above. Exposing oneself to immediate access online has its pros and cons, but it does show how many are willing to interact and be vulnerable, not afraid to have their views deconstructed by a wider audience.

Build a simpler model to explain your work. It may seem more difficult and complex, at least initially, but a model that cares less about tissue-specific effects or real/imagined pathologies to explain can be a goal.

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.

For Now,

Walt Fritz, PT

Foundations in Myofascial Release Seminars

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{ 4 comments… read them below or add one }

David Goldeen January 29, 2017 at 8:30 pm

so what is your new narrative?

Reply

Walt Fritz, PT January 29, 2017 at 9:16 pm

Hi David,

My new narrative involves looking at the simplicity of the therapeutic relationship, autonomic engagement, indirect effects, and a combinations of skin-based mechanoreceptor response and the probable actions of neurodynamic technique. While I do think it may someday be shown that fascia plays a role, as you and I were taught, right now the evidence I’ve read just isn’t there to explain the problems and solutions we involve ourselves with. I think that coaching and pre-set expectations play more of a role in the emotional responses we might see than any plausible belief that emotional holding patterns reside within the fascia. It has been a few years since we last spoke in person and my views have morphed even farther away from fascia explained changes. Not throwing the baby out with the bathwater, just realizing how myopic it is to think we can selectively target fascia to the exclusion of all else when we tough and engage.

Cheers,
Walt

Reply

Thor Hanson February 7, 2017 at 3:48 pm

I don’t follow along with all that Fritz has to say, but I think he is on to something here. Explaining my how MFR practice worked has always been long winded gobbly gook, which I eventually reduced to “advanced care for muscles and joints”. Less story. People still ask. And I’m coming to see I’m barely even thinking of the structural integrity of the vascular system holding 120 PSI in rubbery hoses. Or that the nervous system might be more than a mucus trace, structurally, throughout the body.
Another way to look at all of this work is that humans (and other animals) respond to touch. The body responds with entirely different cascades of electro-chemical-nervous flows when given a punch in the stomach or a first kiss. We don’t know why. We affect each other the most at close range. Intention seems to matter more than technique, as some techniques counter each other’s approach. Follow that far enough and we could talk about laying on of hands and faith healing. I’m still not ready to make that jump in my marketing.

Reply

Walt Fritz, PT February 7, 2017 at 9:40 pm

Hi Thor,
No need to leap to explanations of faith healing. Touch has effect (affect). Stay with the simplest explanation and don’t over-promise. If others outside of your specialty need an “education” to understand your take, then I think the narrative you/I tell needs revision.

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