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

An Interview with Myself

There is irony in that those who have long-considered themselves therapeutic rebels for bucking conventional beliefs are now old-school, clinging to the past. Everything evolves.

-Walt Fritz, PT

One wonderful aspect of being an educator in the manual therapy field is that others ask to interview you! Here is an interview I did for Budiman Misasny, the owner of Terra Rosa and host of my newly confirmed class in Sydney, Australia this coming February. This interview was also picked up by another of my CE educator colleagues, Joe Muscolino, DC.

Walt candidly talks about how he began his Foundation of Myofascial Release seminar, challenging unproven narratives held dearly by many, as a heretic, and why “Because it works” is no longer be good enough.

When and how did you decide to become a bodyworker?
After a few false starts at university, I shifted my sights toward physical therapy, graduating from the University at Buffalo (NY) in 1985. In theory, physical therapy includes bodywork/manual therapy, there is little resemblance between traditional physical therapy to what I now do. I would have never predicted that I would be a continuing education educator, as public speaking was not my strong point. In 1992, I began taking my first continuing education seminars in myofascial release (MFR) and craniosacral therapy (CST) and I was hooked. I was so impressed with the changes that I could make in my clients, even after only one weekend seminar, that I took all of the classes I could and spent the ten years instructing at myofascial release seminars for another teacher (John Barnes). John is well-regarded by many in the manual therapy community, but we no longer see eye to eye on many things and it was time to move on. After we parted ways, I slowly began my own line of myofascial release workshops, the Foundations in Myofascial Release Seminars, in 2006. At first, my workshops closely resembled the MFR I was taught but, over time, I reflected upon why I chose to leave my original training/teacher and began to craft my workshops with my own vision of providing less of a new-age driven experience and utilize the best available science to explain all aspects of the work.

Removing myself from my original peer group of MFR therapists, I had a chance to sample many of the explanatory narratives other manual therapists had shared with me. While immersed in a closed culture of any sort there is little exposure or acceptance of conflicting/contrasting views. I was having great success with the MFR I was taught, but began to understand that the supposed science presented in those workshops had little credibility or understanding beyond that peer group. Results were proof enough in my MFR family (and in most other modality groups) but this can lead to post hoc reasoning errors. I have success so the story I was taught and retell myself as to the “why” must be true. Once I left that MFR group I saw that most every modality line had similar claims of success, each laying claim to being the most effective/efficient modality for pain. “They don’t know what we know, so science be damned; they will catch up to us eventually” was a phrase often repeated in my trainings and those are pretty heady concepts to believe, but I did. I’ve gotten a lot of public flack since I left my MFR community over 10 years ago, many feeling I was disrespecting my teacher/mentor and criticising other MFR therapists who still follow that model. Those statements cannot be farther from the truth but are believed as fact when repeated frequently enough. I have gratitude to those who taught me the wonderful things I can do with my hands, though I now realize those things are probably not accomplished for the reasons I was taught.

What do you find most exciting about bodywork therapy?
Simply put, it is being able to help those who others were not able to help. I love being able to positively influence the lives of others, whether it is my clients or the therapists that I teach. I find it exciting that so many therapists are following paths such as mine, seeking more accurate and inclusive explanatory narratives to explain the effects of a manual therapy engagement. I always found it odd that every modality pushed an agenda of tissue-specific effect, or tissue-specific pathology (real or metaphoric pathology), but all are simply touching the skin. While I do not rule out potential evidence to come in the future, I see most of those tissue-specific models as lacking full validation. This may sound odd coming from an MFR practitioner and educator, but I continue to refer to my work as MFR due to the hands-on actions I’ve done with my hands for over 25 years, rather than feeling I need to fall in line behind one or more of the traditional, historical fascial narratives.

What is exciting to me is the realism that bodywork/manual therapy is not the only means of reaching people for their pain or movement dysfunction. Exercise and education are often crucial aspects of positive outcomes. But I now understand that a patient’s beliefs also drive the possible outcomes of our interactions. If a patient comes to me for therapy (I’m a physical therapist) and is expecting me to teach them extensive exercises and hammer into them beliefs about the need for core strengthening and postural improvement, I may sadly disappoint and not be able to help them as much as another patient who feels they would benefit most from a touch-based, manual therapy approach to get at what others have missed. But when my patient’s beliefs and expectations resonate and align with what I can offer, that is the magic of our work.

What is your most favourite bodywork book?
Just one? Netter’s Atlas of Human Anatomy might be one of them. The artistry is magnificent and every time I pick it up I am amazed just how well we function given the complexity of our body and brain. It is also one of my favorite teaching tools for clients. I always find it interesting how the various manual therapy professionals seem to learn from only one part of an anatomy/physiology book. If muscles were stressed in your training or continuing education, then all problems are explained and addressed from this muscle-based perspective. Fascial therapies are not different, which is testament to the newer fascial anatomy texts that have been recently published. None are totally inaccurate, in fact they show fascia to greater detail than ever pictured. But if you are presenting a segmented view of the body you are invariably overlooking the interaction of all of the parts. Netter’s may be a really nice way to move back from the ledge of tissue-specific beliefs and into a more wholly integrated view of the body. I again realize I am writing words which will cause disagreement, as fascial therapists often believe and state that they are working with the forgotten tissue. Unfortunately that only serves to once again artificially and inaccurately elevate one tissue to a position of greater importance than the rest of the body.

What is the most challenging part of your work?
I am going to break my work into two parts; my physical therapy practice and my Foundations in Myofascial Release Seminars.
First, as a physical therapist in private practice, I have many obstacles to overcome in dealing with stereotypes of just what physical therapy is. In many ways, massage therapists have it easier. A touch-based, bodywork-centered approach is what new clients expect, even though the modality and delivery may vary. Trying to move to more symptom-specific work is not always easy for the massage therapist. Mention physical therapy to the average person and their vision is very different than the way I practice. It is a pleasant surprise to most new clients, as they are not used to being touched and given so much one-on-one treatment by their physical therapist. But others may expect to be told their posture, weak core, or overall lack of physical exercise is the reason they have pain and expect to be given remedial exercises, postural training, etc. to address these problems. The scientific literature leaves little doubt that movement is one common denominator when aiding someone in reducing their pain, but movement takes many forms. A person in pain often comes in stating things, such as, “My back pain makes me feel so weak”. The therapist may even perform manual muscle testing (with rather poor levels of reliability) and find that the person is indeed weak, at least according to their tests. But are they testing a movement or muscle group that is truly weak/deconditioned/inhibited and is the root cause of pain, or are they asking a person in pain to resist the therapist’s testing in a movement that hurts? Exercise, one of many forms of movement, often helps the pain and the person will even feel and test stronger when the pain dissipates, validating the therapist’s beliefs, but is probably one of many post hoc reasoning errors we easily make. It is challenging to deal with these sorts of beliefs. Movement is beneficial, whether it takes the form of strengthening or dancing. To many, being given the ability to simply walk is the movement or exercise that helps to complete the circle of wellness, and I feel blessed to be able to play a part in that process.

As an educator, I see one my greatest challenges is attempting to break down the walls between the deeply seated beliefs and narratives set forth by others in our (fascial) field. If one spends time on social media, reading comments from therapists and advertisements from continuing education educators, the claims are dizzying, with each modality claiming overall superiority with the only measurement being the popularity of that brand of manual therapy. I/we are easily sold on modality claims, all seeking the holy grail of therapy. I’ve taken it as both a personal and professional challenge to educate therapists that there are universal aspects of our work, despite claims to the contrary, which make us able to reach our patients through simple concepts of pain science and safe touch. I was and still am regularly challenged to remove the words myofascial release from my course titles, as some feel that releasing the fascia is biologically plausible and others feel my heretical views should cause me to stop using the words and concepts that they hold dear. Having push back from both extremes tells me I am on to something, if so much emotion can be generated from both sides of the fascia belief spectrum.

What makes your Fundamental Myofascial Release unique?
I use the hands-on actions of myofascial release, embedded in what I believe to be a more plausible and inclusive model of potential physiological/neurophysiological action to reach my students and patients. In some ways, I am using the words myofascial release metaphorically, using them to represent the actions I do with my hands, rather than the belief that we are singularly and specifically impacting fascia to the inclusion of all else. I know that much of what I teach and believe conflicts directly with many of the beliefs and teaching of those in the fascia field, but diversity of thought is good and keeps us strong. No one has all of the answers, but we get closer each day.

I start my class exploring some of the possible limitations of the various fascial explanatory narratives and then try to build a simple, inclusive model, one that acknowledges the (?low) possibility of tissue-specific change, but also acknowledges the neurological and contextual factors inherent in our work. Understanding neurological possibilities opens the door for exploring new or different interventions.

I teach a form of myofascial release recognizable by its physical appearance as similar to what many learn and teach. But the keystone of my approach is utilizing a patient-directed, feedback loop driven model of evaluation and treatment. I see too many therapists relying on their experience, vast continuing education training, and self or externally ascribed intuitive abilities to determine what is at fault and what is needed in treatment. They may think they are including patient feedback in the equation, but not to a degree that I feel is safe. I teach and work from a perspective that strongly values and demands patient feedback to direct treatment. When was the last time you asked a patient, “is this stretch/pressure replicating a familiar experience” or “does this stretch feel like it may be helpful/useful?”. I would guess that it does not happen all that often. My Foundations Approach comes from a unique perspective of teaching the therapist to apply greater value to patient input and feedback. We spend the entire workshop learning these principles, all wrapped up in an MFR blanket of techniques. MFR has great effect. Studies seem to confirm this, at least the things that we do with our hands that we call MFR. Most of these efficacy studies, however, harken back to the old, historical narrative of facial change to explain why MFR works, without ever examining these beliefs. Are we really able to singularly and specifically isolate fascia as the source of pain/movement dysfunction and then selectively target it, to the exclusion of all other tissue/nerves/the brain to create change? To that I am quite uncertain.

How do you see the future of bodywork and massage therapy?
I believe that the science-based approach to bodywork will continue to spread, replacing unfounded modalities and approaches. Therapists will need to keep up with the changes or get left behind. Massage schools will need to better address this science and continuing education will need to keep pace as well. “Because it works” and post hoc reasoning errors will no longer be good enough. And I hope that I am able to leave my imprint on the manual therapy community by moving us toward a less ego driven model and into patient driven/directed models.

Walt Fritz, PT
Pain Relief Center and Foundations in Myofascial Release Seminars
Rochester, NY, USA
www.FoundationsinMFR.com

From Terra-Rosa.com.au

Walt Fritz

Author: Walt Fritz

4 Responses to An Interview with Myself

  1. Very informative interview Walt. I really appreciated my classes with you, years ago, on the Queen Mary. I resonate with your perspective on the clients healing entailing more than their Fascia alone.
    Keep up the awesome work. And thank you!
    Diana Spink ACMT, Specializing in MFR, Certified Bio-Craniopath CBC

    • Hi Diana,
      The fascia story is a compelling one, but so are most of the other stories that are told about tissue-specific effects and impacts of our work.Some may have truth, others less so. Look toward more plausible and acceptable narratives and you will always be in a good place.
      Cheers,
      Walt

  2. Walt,
    Again, such a thoughtful essay. May I add a suggestion to you (and all) in addition to your favorite Netter anatomy the fantastic Thieme atlas of muscular anatomy? The artwork is without parallel, and many unique views of muscle groups are enlightening as to synergistic groups. And the accompanying text is wonderfully informative.
    Also, the DVD’s of Dr. Jean-Claude Gumberteau–tiny camera, artheroscopic excursions through living fascia and muscular tissue–are an absolute must for insights into the jaw-dropping complexity and beauty of the living matrix of connective tissue. They have transformed my concept of working with the bodymind.

    • Deane,
      I’ve not seen the Thieme book, but will have a look. I believe one reason I am so find of the Netter book is it’s comprehensiveness. While I see the allure of many of the niche anatomy books, such as the newer fascia anatomy books, it continues to lead the therapist down the rabbit hole of believing that one system/tissue is of greater importance than the rest. The Netter text seems to keep that balance that keeps our wandering minds in check. Wander within the whole, rather than walling off.
      Walt

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