The Negotiation of Pressures

by Walt Fritz, PT on December 30, 2017

In manual therapy/massage literature there is little, if any credible, repeatable peer-reviewed evidence to show one type of pressure being superior than another…

 

  • “Using a soft touch which is generally no greater than 5 grams – about the weight of a nickel – practitioners release restrictions in the soft tissues that surround the central nervous system.” (source)
  • “It has been suggested that ischemic compression therapy using either 90 s(econds) low pressure up to the pain threshold or 30 s stronger pressure up to pain tolerance can create immediate pain relief and MTrP sensitivity suppression” (source)
  • “In the past, it was suggested that you hold pressure the trigger point at the individuals’ pain tolerance of a 7-8/10 (10 being excruciating pain).  It is now accepted that even a 7-8/10 may be to high to get a proper release, so authors and researchers suggest holding the trigger point at a level of a 5/10 until the individual experiences a decrease in symptoms, at which point you can either go deeper into the tissue (look for trigger points that are in deeper muscles) or move to another location and search for trigger points” (source)
  • “Pressure during deep-tissue work must be significant but always stays just below the client’s pain threshold.” (source)

Uncertain as to how much pressure to use? Well, the above statements should straighten things out, right?

Regular readers of my blog know my take on pressures, but if you are new:

In manual therapy/massage literature there is little, if any credible, repeatable peer-reviewed evidence to show one type of pressure being superior than another. But there is also little that shows static pressures/stretch, of the type often used in myofascial release, to be superior than dynamic/movement stretching/massage. Sure, you will find published studies showing many different styles of pressure having positive outcomes, which mistakenly leads therapists to feel their work has been validated. Read enough studies and you may realize that just touching may be sufficient to produce potential positive outcomes, though that is a tough sell to most therapists. Having paid my way through a very expensive MFR curriculum a few decades back, I wanted to be taught how slow, light, static engagement is superior than all other forms of manual therapy/massage. The work I was  taught and still continue to use/teach was and continues to be quite effective. But is it better than others? Probably not. Successful therapeutic outcomes are far more complex that simply the style and amount of pressure that you use and beyond the scope of this post. So how to decide on the proper amount of pressure?

I recently had a patient in my PT manual therapy practice who had a fair amount of experience as a therapist trained in craniosacral therapy. After hearing this I fully expected the patient to request the very light pressures that are typical of that line of training. (Disclaimer: Using and sticking to using only 5 grams of pressure used to drive me crazy!!! I know the craniosacral narrative quite well and what they say happens if you use more than 5 grams, but attempting to use pressures that do not even let me rest my hand on someone drives me frickin’ crazy! Even when I was taking CST classes I cheated and used more. Things seemed to happen in a positive way no matter what sort of pressures I used, which validated my belief that the CST narrative was less than stellar. Now, with a much better understanding of pain science, indirect/contextual factors, and the potential benefit from very light stretching to the skin I can better understand why those 5 grams of pressure may work for some therapists. Back to my story.) But, instead of requesting/expecting light pressures, this patient wanted me to hammer on them, repeatedly asking for a LOT more pressure than I normally use! Some pretty scary pressures were requested and I had to recalibrate. Understanding that patient expectation often play a big role in outcomes I found myself in a bit of a negotiation. Even current models of Evidence Based Practice allow that fully 1/3 of the model is based upon patient values and preferences (link). My big take on pressures is that whatever I am doing my patient should feel that my pressures are replicating a familiar aspect of their condition. This could mean bring their pain, etc., to their awareness (NOT hurting them, just making them aware that what I am doing is familiar) or reducing the intensity of the symptom. My pressures should feel helpful to them, or at least potentially helpful. They should never leave a patient feeling that the work we are doing may not be good for them. Logical, but not always a common approach in manual therapy/massage/myofascial release. I do not think enough therapists ask their patients for input/guidance beyond, “Are you OK with this pressure?”.

During recent sessions with this patient I found myself trying to draw them back from the ledge a bit, but equally found myself taking a look over the edge of the ledge a bit. This patient and I negotiated a pressure that they felt was potentially effective while staying within my beliefs as to what pressure was necessary. I am fairly certain that I’ve done this in the past, but never actively being aware of the negotiations that were occurring in the moment.

The concept of negotiating pressures has taken on meaning to me. As shown at the top of this page, from  statements culled from various websites, pressures are taught in somewhat predetermined ways, mostly based on the inherited narrative or a story used to support the type of therapy/modality. It may have been presented in a manner that sounded well researched and even scientific in origin, but digging deep may prove that to be false. But the pressures may have worked well for you. I must admit that my MFR training seemed to give me permission to use a variety of pressures, but words like, “Intuition” were bantered about when trying to figure out how much to use. I still maintain that light to moderate pressures are sufficient to allow awareness and help to elicit change, but now I allow myself to be a bit of a car salesman, negotiating pressures until we both agree.

How do you determine pressures? Do you think that one level of pressure is superior than others? If so, why?

For now,

Walt Fritz, PT

Foundations in Myofascial Release Seminars

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Pain Relief Center in Rochester, NY

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{ 8 comments… read them below or add one }

Marlene Mayman December 31, 2017 at 10:16 am

Good thoughts, Walt. I too am very aware of pressure as I work with my clients. Clients appear to really appreciate this because several have commented on my attentiveness in their testimonials. In addition to thoroughly talking about pressure and the importance of honest feedback during our first intake together, and stating that I don’t believe massage should be painful and I want my pressure to be as firm or as light as they prefer, I have various verbal cues I use. The very first time I check in on the pressure with a client I ask, “is this pressure good, or shall I go lighter or deeper?” Then I reuse a similar phase — “good, lighter, deeper?” — once or a few times depending on the perceived need as I continue to work. To change it up I also sometimes ask, “is the pressure where you want it?” As you alluded to, asking “is the pressure good?” isn’t good enough. I’ve adapted my own phrasing to the work I’ve learned from you, so when doing a myofascial hold I will ask, “does this feel positive, neutral or negative?“ … along with asking about the level of skin stretch and whether it seems to relate to their discomfort or whatnot.

In many cases it seems that I strive to use less pressure rather than more (clients who want “deep tissue” notwithstanding), and this stems from the personal experience that set me on the path to learn about pain science. After I graduated from massage school I rented a space that had two offices, and one of my massage teachers sublet the second office from me. I was having back pain issues at the time and we did trades for rent. My teacher insisted that working on my quads, IT and hamstrings was necessary. As he dug into me I found myself grimacing in pain and gripping the table trying not to leap off it, while he met my protests with the claim that super deep work was good for me and what I needed! I endured three sessions of that and I was done. I started seriously thinking about whether treating pain with more pain was really necessary. It just didn’t seem like the right approach. It was soon after that that I started down the pain science path, for which I am grateful!

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Walt Fritz, PT January 1, 2018 at 9:33 pm

All good points and observations, Marlene.

“whether treating pain with more pain was really necessary.” We seem to think and treat alike, or at least quite similarly. To me, making someone hurt, and trying to sell it to them as needed, is just plain wrong. But, and it is a big but, many people’s expectations are that such work is needed. I will attempt to negotiate which may mean I drift into deeper pressures than I am typically using in order to meet them and their expectations. However, I have my limits and will refer out if someone wants me to beat the snot out of them.

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Hans A. Quistorff, LMP January 1, 2018 at 9:26 pm

Like you I negotiate with my client. With long standing clients this can often be completely non verbal if we are familiar with the reflex when contact is made. The most important communication for me is whether the pressure connects with the anatomy train and antalgic reflex that is producing the repetitive stress. This requires a question that is not too specific that causes them to search for sensations and give me a narrative answer. If I ask a leading question [do you feel something …] they will follow my narrative and we may miss the actual origin of the problem.
I am good at recognising patterns but over 22 years I have learned there are a multitude of cause for any pattern. Both the client and I have to find the cause of the pain because usually at the start of the session neither of us knows.

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Walt Fritz, PT January 1, 2018 at 9:36 pm

Cause can be elusive. Cause can be seen as entirely different, depending on one’s training and beliefs. I have stepped back from believing I ever know the cause of a problem but stress more replicating relevance in my patients. Many ways to work successfully and I learn this every day from reading other therapists comments and observations.
Thanks, Hans.

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Kelly Beach January 7, 2018 at 11:43 pm

Nice discussion Walt. Have been there myself many times over, and what I found is, yes, you have to use what the client expects. In fact, in many ways, we have to address what the client wants, or they really do not wish to come back. In a similar thought pattern for instance, we may assess the pain is not coming from where they feel it, but if we do not touch where they feel it, they can feel unheard or gypped and not return. Part of the point of running the business and helping a client long term, is in fact, having them come back!
Back to pressure, I have experienced where I thought I was light pressure also and a client wanting really light touch, which also takes a lot of communication.

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Walt Fritz, PT January 8, 2018 at 9:32 am

Hi Kelly, I do understand the desire to have a client return and I certainly do not try to impose my beliefs on them so strongly that they do not wish to return. I also try to use what I;ve learned up to this point to allow them to feel less pain and not need to return. But ultimately it is a balance to listen to them while honoring what we believe and know. Negotiation.

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Kay Warren January 16, 2018 at 12:49 am

Pressure is a funny thing. The level of pressure needed for one person to release can be either too light or too heavy for someone else. If I am going after a trigger point, I use the lowest pressure that elicits a response, so I can make sure that this particular spot is part of the immediate problem. Then I back out to a level they can handle. If the sensitivity doesn’t start fading by the 15 second mark, I move on, & come back to it in a minute.
Individual Sensitivity is key. We don’t really discuss pain scales well. We all “know” we rate pain on a one-to-ten scale. I have seen continuing educators say we need to hold them at the point just under where discomfort becomes pain. I feel that that is too much. Also, my “10” in pain is very, very different than someone’s 10 who went through 45 hours of completely natural childbirth because they are lethally allergic to nearly every narcotic either grown or made. What do I find useful is to define a “5”. I define a “5” as that level of discomfort that makes you subconsciously start holding your breath. Regardless of where your 10 is, everybody has a 5. I then tell my patients/clients that I don’t want to get them there. I do let them know that this work can be kind of sensitive, but I prefer not to get them above a 3, or a 4 at most. My clients tell me that they appreciate that I don’t want to take them to the edge & make them stay there. Doing it this way means that it sometimes takes me longer to get certain things released, but I do it at a pace and sensitivity level they can handle. They’re usually happy to come back to me instead of having a love-hate relationship with their next appointment.

I understand why CST wants you to go light. Sometimes, when going light, it feels like they are drawing me deeper, and for me, it has worked well just to follow it. In order to do that, I really have to put myself in a Zen sort of space. Being a muscle-specific, deep tissue sort of therapist, that is a challenge. Once I’m in it, my sense of time is utterly shot. I can get in, do what I can, ease on out, look @ the clock, & see that 2 hours have passed. . So, when someone really needs CST, I usually refer them to another therapist I know. If she weren’t an ND with her own practice, I would hire her in a heartbeat.

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Walt Fritz, PT January 16, 2018 at 8:43 am

Thanks for your comment, Kay. Pressure is indeed a funny thing. I really enjoy hearing how others navigate it’s usage while honoring the patient. I too, at times, deeply enjoy the light touch of a CST-style of engagement, but to me it must still connect with a relevance I can feel, rather than being told what it is accomplishing. I believe we need to set the bar higher for ourselves and move beyond the perception that our experience and expertise drives the agenda.

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