A patient-centered model of manual therapy within the SLP patient population

Introducing manual therapy to professionals with limited previous exposure presents specific challenges. Giving a clear narrative that sufficiently respects the expectations of those present, though potentially tainted by exposure through social media, prior training, and by the many of the commonly held beliefs of just what might be causative, is not an easy task. Some look for simple explanation’s that set into motion the hands-on teachings, while others relish a more in-depth deconstruction of commonly held belief systems, with a more sensible explanation built up from the rubble. The goal for me is to find the sweet spot between those two extremes. Another challenge is to introduce the basic concepts behind manual therapy, building sufficient understanding and skill to allow the therapist to leave the seminar with the ability to do something with the skills learned, but still having the therapist understand that practice is needed to hone the craft. Layer on the issue of the full range of skill and experience level of therapists who take the seminar as some have prior manual therapy experience (many with many years of experience), while others take the class as a novice. Trying to hit the median skill level of a diverse group such as this is quite a challenge. However, presenting work in a manner that is novel to even the skilled practitioner and offers a different approach to intervention, then all start out on more even footing. Add into this dilemma is the need to present an evaluative and manual therapeutic intervention approach that meets the criteria set forth by the evidence-based model of care, respecting the clinician’s need for plausible models of explanation to warrant the use of manual therapy in the clinic and you have a somewhat daunting task. However, this is my task. You will leave my Foundations in Myofascial Release Seminar for Neck, Voice, and Swallowing Disorders with a deeper understanding of just how manual therapy, including the style of engagement I call myofascial release (MFR), can and may influence the disorders you see in your clinical setting. You will feel sufficiently trained to use the material immediately upon your return to work, with practice improving your understanding, sense of touch, and, hopefully, outcomes. You will understand that it is your patient who is the critical aspect of how treatment is determined and that no matter how well-trained and experienced the therapist might be, you will never know what your patient is feeling, nor will you know what they or what they think might be helpful unless you ask them. The goals of this seminar are to teach you how manual therapy may impact various disorders, how to apply the work, but just as importantly how to be curious and to ask questions. You are viewed as the expert in your field, but no matter how much of an expert you might be, you are only as helpful as your patient views you to be. Without gathering and honoring their perspective, which is 1/3 of the criteria set forth by the evidence-based model, we are operating blindly.

Below is an adaptation of an article I recently wrote that outlines how patients might view the form of myofascial release/manual therapy resented in the seminar. Working from the below list you, the clinician, may be able to see how I present the work, along with the role of the patient in such a model. It may differ significantly with many models of myofascial release and manual therapy, but I hope that this model becomes an evolutionary bridge between the older, historical methods, and newer concepts of care.

 The application of manual therapy and myofascial release differs between providers, sometimes quite dramatically. Most approaches seem to rely on the expertise of the therapist to determine what the problem (or cause) might be and apply the treatment that the therapist’s training and education have shown to be the correct path. Patients typically allow and even expect this model, having come under the assumption that the therapist is the “expert” and should know what is best. Even though this scenario often pans out the way it was intended, I see some glaring flaws. My first concern is the massive amount of variation in the way therapists, and health professionals in general, have been educated/trained and what they view as the causative problem. In the manual therapy world, invariably the therapist claims the problem to be the target of their training, whether it be trigger points, fascial restrictions, knots, or a wide range of other such beliefs, with little regard for the lack of outward validity of these targets. As an MFR-trained therapist, I saw the causes of my patient’s pain and other disorders to be previously unrecognized or intreated fascial restrictions, while the trigger point trained therapist sees problems the result of unresolved trigger points. Each clinician sees the problem as being the result of what they’ve been trained to find and treat, with little regard to the findings of others, creating a problem with external validity. Do others see the issue as being due to the same causes, or do they even accept the causes you feel are relevant? This lack of external validity calls into question reliance on claims made. My second issue is the amount of impressionability exhibited by most patients. They want to believe us and our claims, hoping that we have the answers to their issues, so much so that they can quite easily be led astray. I am not making accusations that therapists are purposely misleading; I am simply stating that all might be better served if we backed off on our claims. I try to ask myself, “Would my claims be accepted by the larger scope of the medical profession?” If not, I try to step back from my claims and seek one more mutually agreeable to others. For instance, my evaluation findings often concluded that fascial restrictions in the area in question were to blame for the patient’s pain. However, understanding that fascial restrictions are 1. not accepted as actually occurring in the manner taught to me, and 2. there is fully acceptable proof that we can singularly and selectively impact such fascial restrictions to the exclusion of other tissues, I no longer speak in such terms. What might I say? While I accept the concepts and understandings of behavioral/neuroscience and pain science, I also understand that many of those concepts stray far from what a patient expects to hear. As such I will negotiate a conversation and language that is not misleading or pathologizing but still gives them a simpler answer. I give them answers of what might be possibly contributing to their condition, such as, “you may have tightness within the soft tissue creating a situation of altered swallowing or vocal function, or your nervous system may not have allowed a return to your previous state after your injury happened.” I may allude to what they believe, allowing them to feel heard (even if I do not agree) but then quickly turn the conversation around to what they are feeling, vs. what I am thinking. My patient-centered approach deals less with what I believe is essential and more to what they think might be important.

Read through the information below to see if you can understand my approach. I wrote it in a format I will be sharing with patients in my physical therapy/manual therapy practice, so feel free to adapt it for your purposes.

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Walt Fritz, PT’s/The Foundations Approach to Evaluation and Treatment

I follow a somewhat novel way of performing an evaluation and applying the treatment, one that requires much more input from you, my patient. I need your feedback in determining such things as whether or not my input (stretching, pressures) feel like they would be helpful, hurtful or neither. I cannot know what you are feeling unless I ask/you tell me and I rely very strongly on this feedback in making treatment decisions. The need for feedback will most probably exceed what other health professionals have asked you in the past, allowing you (or requiring you) to contribute much more to the process. If you are expecting to have me make all of the decisions, then our therapeutic relationship may not work out.

? Before I begin, I will thoroughly explain the purpose of the session or technique and of my hand placement, followed by obtaining your permission to treat.

? I start in the area of complaint. Many therapists may try to convince you of the belief that your problem stems from issues (or causes) elsewhere in the body. While this could theoretically be true, I will begin where you notice your symptoms.

? I will lightly place my hand/hands on the area, but I initially do nothing. This slow introduction allows you to determine if my touch feels safe to you.

? If my touch feels safe, I will begin by adding graded pressures and stretch, trying to seek out areas of tightness.

? If I find tightness (or similar), I will lightly add a bit more pressure or stretch (what I term, “snagging the area”) to the area, to bring about your awareness.

? If you’ve not already given feedback, I will ask, “Am I reproducing a sensation that is familiar to you?”

? If you note nothing, I may linger a bit unless sensation is too negative. This lingering allows you time to process, but if nothing about the pressure or stretch is familiar, then I will move on.

? If I did replicate a familiar feeling, I would use the 0-10 pressure/pain scale to determine the intensity of the sensation, followed by 0-10, “At what number would you stop me?” You determine the pressures that you feel would be helpful, without me influencing your decision.

? I will adjust pressures according to your feedback.

? I may then ask, “Does this stretch feel like it might be helpful or useful?”

? If you respond to the previous question with, “yes,” then I will remain in the area and treat.

? If you respond to the previous question with, “no,” I will ask, “Is there anything about this stretch that feels like it might be harmful?” If you believe it might, I will immediately stop.

? If all feels right to you and you think that my stretch, pressures, or intervention feels like it might be helpful, my therapy involves me holding a slow, static stretch for long periods of time with the goal of improving your functional abilities and reducing any negative sensations. It is a very dynamic back and forth process between the two of us. I will require you to stay aware and present throughout the session, and I may repeat my questioning on numerous occasions throughout the session(s). Please remember, I cannot know what you feel unless I ask, and I will always ask. I will stop on occasion to allow you rest and to move a bit to see what you are feeling. The goal of my treatment is to let you move more freely, speak with less difficulty, swallowing with less problem, or otherwise decrease your complaints. I will typically follow-up with functional activities and home stretching or activities, as appropriate.

 Walt Fritz, PT will be teaching his patient-centered, science-informed version of myofascial release, the Foundations in Myofascial Release Seminar for Neck, Voice and Swallowing Disorders, throughout the United States, Canada, Taiwan, the UK (Wales, England, and Scotland)), Australia, and New Zealand. Full details are found at www.FoundationsinMFR.com.

#slp #dysphagia #dysphonia #voice