Every form of manual therapy has its unique way of engaging a patient/client, both physically and verbally. Talking is often frowned upon in massage/manual therapy, as it is believed to interfere with the relaxation response or allowing the patient to go deep. Those things are important aspects of some work, but not mine. My Foundations Approach emphasizes seeking out relevance at all times during both evaluation and treatment. To that end, verbal (and non-verbal) dialoguing is an essential aspect of this work. Patients come to us expecting us to solve their problems of pain or movement dysfunction and they may expect us to do this with minimal input from them. If prompted they may offer an occasional grunt, but they normally allow and expect the therapist to do their thing. My approach requires more effort on the part of the patient, as well as the therapist, which I will explain shortly. The point of dialoguing in the Foundations Approach is to not rely on any perceived expertise on the part of the therapist to drive treatment choices. Rather it relies on the patient determining/establishing relevance. Only when relevance has been established does treatment commence and while not minimizing the knowledge and experience of the therapist, is a more patient-centered/driven approach.

Most manual therapies involve palpation to some extent, often with the therapist drawing conclusions as to the cause of a patient’s issues from these findings. I think it important for us to understand that palpatory findings are by nature inaccurate, though our training and beliefs make us believe otherwise. To address palpatory inaccuracy, an in-depth awareness of anatomy allows the therapist to a have reasonable assurance of general locations of major muscles, organs, etc., but with an understanding of the depth of the tissues that overlie the iliopsoas, for instance, it should be obvious that it is impossible to “feel” the muscle in question. The only thing we can feel with certainty is the skin. Everything else is a guess. We can feel the presence of a known muscle by locating anatomical landmarks, having the patient contract the muscle in question, etc., which allows reasonable assurance that the therapist feels the presence of the iliopsoas deep under the skin and underlying tissues, but to say with full certainty that one can isolate the iliopsoas is inaccurate. Paul Ingraham sums this concept up quite nicely in his article, Palpatory Pareidolia.

My second point, that palpatory findings and conclusions are based more on a person’s training, education and beliefs than full anatomical certainty, is one the creates controversy amongst therapists. The multiple, competing lines of manual therapy/massage continuing education training teach concepts that are only understood primarily by the members of their own community, but poorly understood/believed by those outside the wall of these communities. As a continuing education provider who is an active observer of social media, the code words that are used by such communities is widespread and varied. Each will profess to be able to sense, palpate, and treat fascial restrictions, trigger points, myofascial lines, inhibited muscles, cranial restrictions, visceral torsions, postural imbalances/asymmetries, and probably dozens more of similar supposed pathologies. Those outside of each individual manual therapy community may struggle to find and understand the concepts, lacking training in said modality. If a patient were to shop the various practitioners who practice all of the many modalities/sub-modalities available to them they would be told countless stories of what is wrong with them, but can all of those assessments/diagnoses/proclamations be accurate? Can there be so many things “wrong” with our patients? Can so many different pathological tissues reside in the body? Most have never been validated by the medical community, but that does not seem to stop those inside of the therapy communities from claiming exclusive knowledge and understanding of the secrets of the (fill in the pathology of your choice).

Whether or not these closed-group pathologies exist or not, I still find palpation helpful, but in a more general way. I teach therapists to continue to utilize their palpation skills, but to use it simply as a starting point for evaluation, not as the end point directly into treatment. Instead of making the clinical judgement that the tightness they find is a problem/pathology that must be dealt with, I encourage and teach therapists to simply ask whether the found tightness (or thickness, ropiness, grumpiness, etc.) is familiar. Is their engagement, be it simple contact, pressure, stretch, etc., with this tightness reproducing a familiar aspect of their patient’s pain (or whatever negative experience drove them to our office)? This concept is a core principle of my Foundations Approach and takes a while for therapists to understand and adapt to, but it has the purpose of taking away the assumption that we have all of the answers. It empowers the patient to not only be an active participant in sessions, but to take a leading role in determining whether the intervention is meaningful. It requires the patient to participate in the evaluation and treatment process, and may take a good deal of training until they can accept and understand their role. Honing the dialoguing skills of the therapists is a necessary part of this process.

Open Ended Questioning
Utilization of open ended questions is vital to avoid leading the patient in any way. “What do you feel?” (open ended) is preferred over “Do you feel this?” (closed ended), as the first allows the patient to respond in any variety of ways and doesn’t limit them to sensation or awareness felt only in the area of intervention. The second by nature limits the possibilities of responses, as attention is drawn to a specific area/pressure and the response is limited to essentially yes/no. Some other examples of open ended questions, or closed end questions with an open ended follow-up that may help you determine of your findings have relevance are:

• What do you feel?
• How does this pressure feel?
• Is that feeling familiar?
• In what way is it familiar?
• Have you felt this before?
• Is my pressure recreating something you feel as a part of your (pain)?
• Does my pressure feel like it could be helpful or productive?
• How much pain (or other sensation) are you experiencing, on a 0-10 scale?
• At what number would you stop me? At what level would the pain, my pressures, your discomfort, etc become too much?

When your patient gives you a response, it may be in the form of a question, as they may not completely understand what you were asking. “What do you mean is that familiar?” is common one, to which I may reply, “Is the feeling you are having something you have felt before, as a part of your (pain). Is it familiar?” Many times the response will be negative, as either they have not made a correlation between the sensation you are producing and their symptoms. Give it a bit of time and allow them to process the information and sensory input. After becoming familiar with these dialoguing principles, as well as the Foundations Approach to evaluation and treatment, your success will improve.

One of the basic principles of my work is that I believe that my patient should understand why I am doing what I doing at all times during the session. If not, then I am not doing my job correctly. They should be able to feel that I am connecting with familiar aspects of their symptoms at all times. That may seem like a high bar to set, but those are my expectations. This is not to minimize work that comes from a perspective of body-wide or protocol base, as within that methodology there is logic. But the logic I follow is that there should be relevance noted by the patient at all times. I may be bringing their symptoms to their awareness, which is not the same as making them hurt, or I may be calming/quieting their symptoms. I may also be connecting with another more obscure aspect of the issue, but there should at all times be relevance. The point of the intervention is to eventually reduce/remove the negative sensation and improve the quality of movement.

The purpose of dialoguing should not be to probe into their psyche or personal/emotional past, but to simply establish relevance. I need to know if my pressures are relevant, for if there is no relevance, there may be no reason to work in that location. Many would argue that it is our responsibility to use our skilled palpatory abilities to uncover the problem and that we should know what is relevant. But I can poke around throughout the body of any random person and find areas that, to me, feel tight and problematic. But to that random person my findings may not be an issue. Insisting that the tightness is or may become a problem is a sure way to create the sense of pathology in the mind of the patient, which while good for business is simply wrong and unsupportable. The general medical community and social media sources seems to accentuate pathology/tissue damage as the cause of pain, which often has little evidence of accuracy. Finding areas of sensitivity to pressures is not pathologizing, but simply establishing relevance. My belief is that without establishing relevance or familiarity, there may be no reason to treat, at least in that specific area of the body. I also believe that these principles of establishing relevance make my Foundations Approach effective for the remediation of pain and movement dysfunction and can be applied to most any form of body work, manual therapy, and massage.

Dialoguing in the manner described above may feel awkward, at least at first, but will quickly become quite easy and a natural part of your sessions.

Enjoy,
Walt Fritz, PT
Foundations in Myofascial Release Seminars

Author: Walt Fritz