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

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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

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

In April of 2016, I had the pleasure to meet Brian Fulton, RMT, who was a co-presenter at the Registered Massage Therapists’ Association of British Columbia’s Biennial Conference, “Manual Therapy: an Interdisciplinary Approach to the Science and Practice”. His talk involved the understanding of the placebo effect in manual therapy and since that time I have been intrigued by the concepts presented in his talk and in his book, “The Placebo Effect in Manual Therapy”. Conversations since that time affirmed that he and I shared much interest and skepticism regarding the published and inherited narratives surrounding much of manual therapy. Brian agreed to participate in an interview for this blog and also to respond to questions that readers might have.

Walt: Hi Brian, Thanks for agreeing to answer some of my questions. Would you share a bit about yourself?

Brian: Thanks for inviting me! I am a Registered Massage Therapist and have been practicing in Ontario, Canada since 1999. I began writing, both as a personal interest, and as a way of promoting the profession of massage therapy in 2000 when an opportunity arose for me to be the staff health columnist for a local magazine. Since that time I have found myself writing quite a bit on various health topics that interest me. This book was a great outlet for that writing urge, and it allowed me to explore a topic in depth that held great curiosity for me, but about which I knew very little.    

Walt: What drove you to have interest in this topic?

Brian: It has always seemed to me that many manual therapy professionals and gurus seem to be quite certain that their method or their approach is THE way to treat many issues, or to treat specific issues. However, I always found it odd that vastly different approaches often seemed to be able to generate positive therapeutic outcomes for a given pathology. For example with tendonitis, various electrotherapies are employed (even as stand-alone modalities), NSAIDs are used, hydrotherapy is used, subtle manual therapies, stretching, and not-so-subtle therapies (friction technique) all claim to have positive clinical outcomes, and each modality has its own narrative/explanation for the mechanism of action. As manual practitioners, we have all witnessed this phenomenon, and it begs the question, what caused the healing to happen? Is there some commonality in all of these treatments? Is there another active agent at play? My sense was that psychosocial factors might be coming into play and accounting for at least part of the healing. Study of the placebo effect is looks specifically at the contributions of those psychosocial factors. Furthermore, while many books have been written on this subject, almost all are theoretical.

So, in 2007, I undertook the project of writing a book that could put this theory into practice, and I wrote it with a specific audience in mind– manual practitioners. It took years to complete, since it was written in my spare time, and it took another full year to publish. When I began the project, people looked at this subject suspiciously, for a whole host of reasons. My vindication has been that now the biopsychosocial approach is very much in vogue, especially in pain science. This is no longer a fringe idea; it has gone mainstream. This is also evidenced by the creation of the Program in Placebo Studies and the Therapeutic Encounter (PiPS) in 2011 at Harvard University. Its stated purpose is “to bring together researchers who are examining the placebo response and the impact of medical ritual, the patient-physician relationship and the power of hope, trust, persuasion, compassion and empathic witnessing in the healing process. PiPS research is multi-disciplinary and extremely inclusive spanning molecular biology, neuroscience and clinical care, as well as interdisciplinary, ranging from the basic sciences to psychology to the history of medicine.”

Walt: Why do you feel it is important for manual therapists to understand the placebo effect?

Brian: One of the most important reasons for therapists to get a basic understanding of this information is that the placebo effect is a bona fide phenomenon, and it is ‘in play’ during every medical encounter, whether we think so or not. Just like global warming, our belief is not required for the very real effects to manifest. Positive effects are termed ‘placebo effects’, and negative effects are known as ‘nocebo effects’.   So, by not understanding the principles involved in this phenomenon, not only are you failing to optimize the effects of your manual therapy, but you are also at risk of undermining your efforts, thereby doing a disservice to your client.

Psychosocial factors play an important role in the therapeutic encounter, and as you read manual therapy research, you will see terms such as non-specific effects, contextual factors, psychosocial factors, and placebo effects. Having looked at this topic in depth, I would say that the differences in these terms are simply semantics. I would say that ‘psychosocial factors’ is actually the correct umbrella term. However I used the term Placebo Effect in the book, because there is over sixty years of research available on this phenomenon. As a Medical Subject Heading[i] it yields far more research on this phenomenon than any other term. Think of classic image of blind men describing different parts of an elephant.

Walt: Would you mind sharing a few passages from the book?

Brian: From the preface:

“If you think that this topic is not terribly important because your patients are responding only to your treatment modality and not a placebo effect, then I suggest you look at the 2011 peer-reviewed paper published by The Journal of Manual and Manipulative Therapy entitled Placebo response to manual therapy: something out of nothing? In it, the authors look at 94 different research papers on manual therapy and on the placebo effect and draw some relevant inferences about the placebo effect in manual therapy. Some of the papers that they look at clearly suggest that what you and I think may be happening isn’t exactly what is happening. The evidence points to a strong placebo component in what we do in our professions. The authors state, “We suggest that manual therapists conceptualize placebo not only as a comparative intervention, but also as a potential active mechanism to partially account for treatment effects associated with manual therapy. We are not suggesting manual therapists include known sham or ineffective interventions in their clinical practice, but take steps to maximize placebo responses to reduce pain.” [ii] The evidence-based model is not affecting many practitioners mindsets quite as quickly as it was assumed it might. This is happening for many reasons, but certainly one reason is that many of us in this field operate from instinct and our own practice logic. We are not easily swayed by one study that says our model is incorrect. However when multiple studies say the same thing, it is definitely time to change our ways and adopt the new paradigm.

Another review of evidence is a paper published in 2010 entitled Effectiveness of manual therapies: the UK evidence report. In this report the authors looked at 49 recent relevant systematic reviews, 16 evidence-based clinical guidelines, plus an additional 46 random controlled trials (RCT) that had not yet been included in systematic reviews and guidelines. The authors looked at 26 categories of conditions containing RCT evidence for the use of manual therapy: 13 musculoskeletal conditions, four types of chronic headache and nine non-musculoskeletal conditions. This report, published in Chiropractic and Manual Therapies (the official journal of the Chiropractic & Osteopathic College of Australasia, the European Academy of Chiropractic and The Royal College of Chiropractors) recognizes the important role that manual therapy plays in treating a wide variety of ailments, but even in this report the authors state, “Additionally, there is substantial evidence to show that the ritual of the patient practitioner interaction has a therapeutic effect in itself separate from any specific effects of the treatment applied. This phenomenon is termed contextual effects. The contextual or, as it is often called, non-specific effect of the therapeutic encounter can be quite different depending on the type of provider, the explanation or diagnosis given, the provider’s enthusiasm, and the patient’s expectations”[iii]. “

Here is another excerpt from the book. It is from an early chapter which introduces the reader to the placebo phenomenon.

“There are many interesting phenomenon surrounding the placebo effect in respect to what enhances and suppresses the actual response to the placebo pill or treatment. The following effects have been documented in research studies. They are not all laid in stone, as there has been some variability in the findings, but the trends indicate the following:

  • The effects of a placebo increase if the pill is physically larger, and yet smaller than normal sized pills also appear to have a more powerful effect. [iv]
  • Warmer-coloured pills work better as stimulants, while cool-colored pills work better as depressants.[v]
  • The effects will increase if the placebo is taken with increased frequency (conditioning theory).[vi]
  • Increased frequency of visits to the attending health professional increase the effectiveness of the placebo (conditioning theory).[vii]
  • Being told that a placebo will decrease pain will decrease most people’s experience of pain, and yet being told that that same placebo makes pain worse will increase most people’s experience of pain. (The nocebo effect)[viii]
  • A placebo can be viewed as a symbol. The more significant the symbol, the more powerful the effect is likely to be. Surgery is at the high end of that scale. The scale looks something like this:
    • capsules beat out tablets[ix]
    • injections beat out drugs administered orally[x]
    • injections that sting work better than injections that do not sting[xi]
    • medical treatment machines beat out injections[xii]
    • sham surgery is considered the most powerful placebo[xiii]
  • New or novel treatments (or drugs) often beat out older ones.[xiv]
  • The severity of pain being treated influences the placebo response. With increased pain there is increased placebo response.[xv]. A 2001 review found that invasive, uncomfortable, sophisticated or painful interventions tended to enhance the placebo effect.[xvi]
  • A placebo administered by a doctor is more potent than a placebo administered by a clerk. Even less effective is a placebo send via postal delivery.[xvii]
  • Brand name placebos work better than generic placebos.[xviii]
  • More expensive placebos tend to be more powerful than discounted ones.[xix]
  • It is well-established that people who adhere to their drug schedules experience better outcomes. It is the same with placebos. The better that people adhere to their placebo drug schedule, the better their outcome. This was even shown in patient mortality figures.[xx]
  • People have actually experienced withdrawal symptoms after long-term use of placebos.[xxi]
  • Placebos have been shown to be geographically and culturally sensitive to placebo treatments.[xxii]

Walt: The concept of the narrative has become a bit of an obsession with me on many levels.  We have discussed a bit of this in the past, namely my issue with certain aspects of the research on the placebo effect. You speak to the importance of the narrative, both to the patient but also to the therapists. If I am understanding you correctly, the apparent strength of the narrative can have effect on the outcome of the therapeutic intervention, no matter how accurate or inaccurate the therapist’s narrative might be. This is a bit troubling to me, as it sounds as if as long as the therapist sounds knowledgeable and tells a good story, the chances of improved outcomes go up. This makes sense, to some degree, as if a patient is given information that sounds plausible they have trust in the therapist’s knowledge and abilities. But if the story is bogus but told with certainty and an adequate sprinkling of science-like phrases, the placebo effect can be just as strong. Is this correct?

Brian: I appreciate your concerns, and there is no doubt that there are aspects of this phenomenon that can be exploited by a therapist of weaker moral character, but this could be said about almost any technique or modality. This is one of the reasons that we have regulatory colleges overseeing therapists to see that they are in compliance, acting ethically and professionally. Another driver keeping therapists from generating false narratives is the continuing education requirements from our regulatory colleges (in Canada) that oblige all practitioners to stay up to date with current knowledge. Much of what I was taught in school surrounding explanation of trigger points, Epsom salt use, stretching to prevent injury, massage flushing toxins, (and on and on) is no longer accurate. If I do not stay up to date as a health professional, then I continue to spread misinformation. So I would say that professionalism, ethics and regulation all help to prevent a therapist from knowingly generating a false narrative. Furthermore, if you look at the totality of the factors I examined in the book, professionalism and trust are also on that list, as well as narrative. If you create a false narrative, but then your client visits another health professional who explains to them that the explanations that you gave are not up-to-date and have now been disproven, you will have then lost the trust of your client. In reading my book or listening to my seminars you will recall that ‘trust’ is something harp on regularly as a theme that runs through all aspects of the therapeutic relationship and the placebo phenomenon.  

It is also important to keep in mind that ‘narrative’ is only one factor of many that surround this phenomenon. In the book I examine and write about the following other factors as well:

  • Conditioning
  • Expectancy
  • Motivation and Desire
  • Trust
  • The Power of Listening
  • Feelings of Care and Concern
  • Establishment of a Feeling of Control
  • Reducing your Patients’ Anxiety Levels
  • Receiving Adequate Explanation of the Pathology
  • Acceptance of the Mystery of Healing
  • Certainty of the Patient
  • Time Spent By the Practitioner
  • Use of Ritual
  • The Clinician’s Persona
    • Professionalism
    • Clinician’s Belief System
    • Confidence
    • Competence
    • Attire
    • Enthusiasm of practitioner
  • Clinical/Healing Environment
  • Practitioner’s Use of Humour

Walt: Also, the concept of how a patient’s narrative having great meaning has become more evident from listening to you and others speak. But, if a patient’s narrative is very inaccurate it can be conflicting with a patient’s understanding of pain. Is there a “best way” to deal with honoring a patient’s narrative to maximize benefit? Is there a time when re-education into newer understanding/narrative are best applied?

Brian: This is a very good question Walt. Certainly we need to meet our patients where they are, and speak to them in terms that they understand. So, there is no doubt that our explanations will take on a different manner depending upon their education, their cognitive abilities, their culture, and their own system of beliefs. As for the patient’s own narrative, I see no reason not to re-educate them toward a current understanding of pain science, healing, rehabilitation etc. There may be some situations where you might not want to disrupt their narrative, but I think that this would have to be examined on a case-by-case basis. The aspect of narrative that I deal with in the book is essentially whether the patient’s narrative is ‘working for them’. In other words, if their narrative leaves them feeling disempowered, unhappy, depressed, hopeless etc., then this would be evidence that their narrative is not working for them. Modern pain science has some hope and explanations for people feeling like they are powerless or not improving. We are not psychotherapists, and there will be times when we will want to refer out for issues beyond our scope of practice, but there are many things that I believe we can do to educate the patient and give them real (not false) hope. In this way, we are helping them to rewrite their own inner narrative to one of greater empowerment.

Walt: Brian, thanks so much for being a part of this discussion. I mention you and your book in each of my seminars as I feel the information you share is crucial to our understanding the nature of the therapeutic relationship.  I want to share with readers your website and contact information: www.fultonmassagetherapy.com. You can find Brian’s book, “The Placebo Effect in Manual Therapy” through Amazon.

If you have questions, please add them below.

For now,

Walt Fritz, PT

Foundations in Myofascial Release Seminars

References: The full reference list can be downloaded here.

[i] U.S. National Library of Medicine’s Medical Subject Headings MeSH®

[ii] Bialosky, 2011

[iii] Bronfort, 2010

[iv] Buckalew 1981, Thompson, 2005: 41

[v] de Craen, 1996

[vi] de Craen, 1999

[vii] Thompson, 2005: 40

[viii] Thompson, 2005: 71-82

[ix] Hussain, 1970

[x] Grenfell, 1961

[xi] Ernst, 2001: 17-30

[xii] Kaptchuk, 2000

[xiii] Kirsh, 2010: 111

[xiv] Shapiro: in Harrington 2000: 22

[xv] Levine, 1979

[xvi]Ernst, 2001: 17-30

[xvii] Thompson, 2005: 40

[xviii] Branthwaite 1981

[xix] Waber 2008

[xx] Simpson 2006

[xxi] Ockene, 2005

[xxii] Moerman, 1983

Walt Fritz

Author: Walt Fritz

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

  1. Thanks for the question Charles. I won’t speak to this particular exercise, but to the concept of self-care in general. Many placebo principles apply to self-care/homecare/remedial exercises in general. To begin with, I would say that one of many conclusions that can be drawn from examining the placebo phenomenon is that the locus of control needs to be shifted to the client/patient. There are many placebo issues that apply in this situation including:

    • Conditioning (Regularity of the exercise)
    • Expectancy (Projecting the benefits of the exercise to the client)
    • Motivation/Desire (Finding the client’s main motivator for performing the exercise)
    • Establishment of a feeling of control over their health and symptoms (Locus of control concepts)
    • Patient Compliance/Adherence (Use of things like a log to create accountability)
    • Reducing your Patients’ Anxiety Levels (as they gain control, their anxiety level will tend to be reduced)
    • Use of Ritual (with the homecare exercises themselves being the ritual).

    These are some of the concepts that I explore in my book, among many others. Examining the placebo effect is (as I see it) an exploration of the role psychosocial factors in the therapeutic encounter. However, as you rightly point out, psychosocial factors also play a role in self care aka homecare/Remex.

  2. A most intriguing interview about the placebo effect. As I understand it, this placebo effect is more or less simultaneous with actual treatment and to one degree or another not usually deliberate or even conscious by the manual therapist. Here, however, I want to add the fact that the placebo effect can be deliberately used to prove or disprove the efficacy of a manual therapy just as is done with drugs. How does one do a “placebo massage” for example?

    In 1989 I did such an experiment and the outcome was published in the Journal of Alternative and Complementary Medicine (April 1990) and at the Upledger Foundation Beyond the Dura–1989 conference in Florida.

    I discovered a form of joint mobilization that realigns spinal joints with a touch so light it barely dents the skin. This meant that a very light palpation of joint position and joint play could not be distinguished from this uncommon joint treatment by the patients. In other words, assessment and treatment were indistinguishable. The University of Victoria Department of Statistics designed the experiment and provided analysis of the data. 120 participants were selected by random numbers to either be treated or palpated. A physical therapist and chiropractor were the “blind” checkers and had no idea what took place in the experiment room. They examined everyone going in and coming out of this room and recorded their palpatory findings with regard to joint position and joint play before and after entering the experiment room.

    The results showed that this unique manual joint mobilization technique had only 1 chance in 100 of being due to chance or some “placebo effect.”

    I have treated over 8000 patients with this technique and taught it for Continuing Education Credits for the College of Massage Therapists of BC. Anyone interested in knowing more about Light-Touch Mobilization Technique (LTMT) is welcome to read about it at http://www.lighttouchmobilizationtechnique.com.

  3. Impressively-designed study David. I must say, I typically assume that it is almost impossible to design a true sham massage treatment, but you found a way to create a sham treatment, and got impressive results.

    When it comes to the hierarchy of study design, the randomized, double-blinded, placebo-controlled (RDBPC) study is still held in very high regard; however, comparative interventional trials can also be highly significant. An important historical footnote on this subject is the October 2000 the Edinburgh Revision of the Declaration of Helsinki. The World Medical Association drafted a document calling for new drugs to be tested against ‘the best current treatment’. The document further stated that new drugs should only be tested against a placebo when no proven treatment was available. However, the ‘International Conference on Harmonization of Technical Requirements for Registration of Pharmaceuticals for Human Use’ was taking place that same year. This proposal did not go over well with pharmaceutical companies, since it would make drug approval even more difficult. Realizing that Helsinki Declaration was about to be changed, this group thwarted attempts at raising the bar for drug trials and released a document explicitly stating that “use of placebos is generally acceptable in clinical trials (since it is much easier to beat a placebo, than the best available drug).” To this day, many people see the RDBPC study as the gold standard, when in fact what should matter most to the health consumer is that a given treatment/modality be the best treatment available for any given condition. This also solves the matter of trying to create a double-blind, sham (placebo) manual therapy treatment, which admittedly is close to impossible.

  4. Not sure how I missed this as I’ve been following Walt’s blog for many years now, but just wanted to say a huge Thanks to both of you for putting together this interview blog post!
    It’s great to hear Brian’s background & how he came about writing on this subject & Thanks again Brian for the heads up on the Irving Kirsch talk..
    Driving down in a few hours 🙂
    Walt, hope to meet you some day, maybe at a future SanDiego pain summit or similar if I head over that way again..

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