“The doctor poked, and prodded, and scratched his chin. He could find nothing wrong.” from Imogene’s Antlers, by David Small.

Imogene’s Antlers was one of my favorite books to read to my daughters when they were young. In it, the doctor was called in to examine Imogene, as she had spontaneously sprouted antlers. However, no matter where he poked or prodded Imogene, he could not find anything wrong with her. He couldn’t think of one name to call what she had. I wish more therapists and health/fitness professionals were like this doctor, but alas old habits continue. I will include myself into this group, as in the not-so-distant-past I was a name caller. The names I called the “stuff” I poked and prodded were fascial restriction, scar tissue, and adhesions. I am sure you have your own names you use to describe the stuff that you feel through the skin. Trigger points, subluxations, knots, spasms, metabolites, etc., are all names we give to that stuff, mostly based on what we were taught. When we use the techniques taught to rid the body of that stuff, the person improved, which gave us validation that the named stuff we palpated must have been exactly what we thought it was, as our interventions worked perfectly.

But how can we be sure of what we are feeling? Most forms of manual therapy, massage, and, yes, myofascial release have come up with names to call the stuff under the skin, the stuff that is said to be causing all of the pain/problems.  We poke an area and our patient responds positively that you just recreated their pain or symptom. If we stopped there and simply treated them, I think our outcomes would be much improved. But, instead, we “educate” our patients on just what it is we felt. We school them in fascial restriction/trigger point/scar tissue concepts and terminology, essentially convincing them that this is what they have. We think we are doing them a service, but maybe our effects are the opposite; maybe we are doing them a disservice. We are instilling into our patient’s brain the thought that there is something wrong with them; even though we have zero proof of that we just told them. Can telling our patients that they have fascial restrictions be harmful? Possibly, but it is certainly not factual. It would be factual if external sources would conclude the same thing, but that seldom occurs. How many times has a patient come from their doctor’s office after being told that their body is riddled with fascial restrictions that need MFR to help them? Probably very few and I was taught that the reason for this is that doctors are not educated to recognize fascial restrictions. Apparently their many years of medical school were filled with more important things. (Some doctors may have told the patient that trigger points were the cause of their problems, but recent advances in understanding have put some of those myths to bed [here, here, here, and here].)

What is the harm of telling a patient they have fascial restrictions as the cause of their pain (other than have no proof)? The nocebo effect is one very good reason. The nocebo effect may include the thoughts or beliefs we transfer to our patients regarding what is “wrong” with them. By telling them that fascial restrictions (or trigger points, or visceral restrictions, or craniosacral imbalances, or, well you get the point), you are essentially trying to convince your patient there is something wrong with them, when there may be nothing wrong. Pain does not mean damage, or something wrong. We perpetuate, or even increase, the patient’s catastrophizing by getting them to think there is something wrong with their tissues/muscles/fascia/joints/viscera. I recently read a lovely article on catastrophizing that is worth mentioning again.

So, if we shouldn’t call the stuff under the skin fascial restriction, etc., what should we call it? I’ve become fond of a term that John Quintner, MD, made me aware of recently on a LinkedIn post about trigger points, Mechanosensitivity. Mechanosensitivity can simply refer that an area of the body is sensitive to mechanical input and is a generic enough word to describe what I am feeling when I palpate tightness in my patient, a tightness that seems to somehow recreate a familiar aspect of their pain or symptoms. When my patients ask me what I felt (they always want to know, don’t they?), I tell them that the area is sensitive to mechanic pressure/stretch/input, probably affecting local nerves. Most patients (and therapists) will ask for more detail, which I will try to avoid responding to in exact terms, as soon as I do, I will be jumping into speculation. I will, at times, let them know what theories exist, but I will also introduce the concept of the nocebo effect and that I do not wish to in any way negatively influence their potential for probable improvement by introducing concepts that may create the opposite effect.

Could you do is? Could you avoid answering a patient’s questions by not using the terminology inherent in your training, telling them instead that they are exhibiting mechanosensitivity? If you knew that you would be doing them a service, not introducing potential negative thoughts and outcomes, would it be easier to do it? A few years ago I responded to this dilemma by using the term “frozen chicken” as a response to what we are feeling when we palpate that tight stuff. When a patient (or therapist) asks me exactly what the frozen chicken is, I artfully (or so I think) avoid the question but make them feel safe enough that I do indeed know anatomy; in fact I passed gross anatomy! Simplicity of thought and language does not equate to ignorance. As most of what we have been taught about that “stuff” under the skin has really not been vetted by science outside of the specific modality; there is little real credibility in much of what we say.

To paraphrase Diane Jacobs, PT, “Of all of the things (stuff) we claim to feel and detect in the body, including fascial restrictions, trigger points, craniosacral disturbances, visceral abnormalities, etc., what is the one and only one thing we can be certain we are contacting/impacting? The skin; all else is a guess.”

Mechanosensitivity. Try it. It rolls off of the tongue much better than “undiagnosed fascial restrictions”!

For now,

Walt Fritz, PT

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Author: Walt Fritz