Notes from Walt Fritz’s Workshop at the 2017 Voice Foundations Symposium

by Walt Fritz, PT on June 4, 2017

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

 

Respectfully,

 

Walt Fritz, PT

Rochester, NY

 

All information copyright Walt Fritz, PT 2017

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