With a broad-based education, credible continuing education, and critical thinking, I do think we can be less wrong about the work we do. I do not mean to criticize those who believe differently and certainly not those who taught me these concepts. Science moves forward and I thank those in my past.
What if I asked you to strip away the story you tell when describing your modality? Could you describe the actions of your hands without the jargon inherent in the story of your modality? It might be pretty hard to do, as it may be hard to separate actual plausible science, anatomy, and physiology from what you were taught as the science that supports the work you use. You have to use something that sounds science-like, but what if you had to change your story? Could you do it and would you even wish to try? You would need something to explain your work, though my explanation seems to get simpler by the year.
Changing one’s story is often viewed as shifty or even indecisive, as if you cannot decide or are trying to cover up something. I disagree. I’ve written extensively about how I moved from a narrative (story) of myofascial release in the traditional, folkloric sense, which credits so-called fascial restrictions as being the cause of most pain as well as the key to the remediation of pain into a story of simplicity and plausibility. Apparently my story was so compelling it garnered a request to tell it earlier this year at the Registered Massage Therapists of British Columbia Manual Therapy 2016 Conference. The story I now tell and teach is a simple one, one deconstructed from the stories of fascial fantasies. But as a therapist (PT) with over 30 years in practice, I’ve heard literally hundreds of stories on how we are creating change in the body as well as the cautions as to what will happen if we do not follow the recipe set forth in that line of training’s rulebook.
The story told by most manual therapy trainings might be called inherited narratives (Thanks to Phil Greenfield for this term) in that the beliefs and explanatory models have been passed down over time. While new science might be sprinkled in for good effect, most of these narratives have remained unchanged for long periods of time. The narrative I was taught in my initial myofascial release training was certainly an inherited one, as the concepts of MFR (and its explanatory model) stem from osteopathic literature from the early 1900’s. I have begun to use the term folklore to describe the way MFR is taught; as many therapists repeat the inherited narrative verbatim without questioning its validity or authenticity. But this is true for much of the work that we all do. If I attempted to deconstruct most of what I was taught in physical therapy school and eliminate all that was not fully vetted as valid, I may have little to do with my days. Though I’ve allowed the MFR story I was taught to slip away over time, initially it served me well and I questioned little of its truth. Over time, as I moved away from my MFR roots, the inherited narrative of MFR seemed to matter less and less. I also learned drastically conflicting stories from other people. Recognizing that my biases clouded my abilities to see real truth, I began to embrace the concept of attempting to be less wrong. Saying that I am less wrong, when it comes to explaining my work, may sound condescending or superior, but I believe that it comes from a place of humility. With a broad-based education, credible continuing education, and critical thinking, I do think we can be less wrong about the work we do. I do not mean to criticize those who believe differently and certainly not those who taught me these concepts. Science moves forward and I thank those in my past.
Many different influences caused me to change my story, though the need to do so was not due to a lack of efficacy, as I think the MFR work I did has always been effective. But the story I was taught way back in the early 1990’s always bothered me a bit. I found it hard to believe that in a continuing education class we were being taught concepts of anatomical/physiological structure and function not taught to other health professionals, including physicians. But I like a good story, so I played along… just to hear the ending. One key point of the MFR work I was taught was the concept that fascial restrictions go beyond the origins and insertions of individual muscles, which was said to explain why patients feel far-reaching symptoms while we are treating them. Such far-reaching sensations were a key aspect of explaining MFR from a fascial perspective, and I used this explanation with my patients for many years, as well as teaching it in the early days of my Foundations in Myofascial Release Seminars. It was a good story told by some pretty good storytellers and I had no better story to explain the phenomenon, until I learned one. Let me tell you about that new story.
Frequent feedback I heard when performing a technique that is termed a thoracic outlet release are reports of sensation or referral of familiar symptoms throughout the face. When my patients told me this, I used the story I had been taught and explained the concept of fascial restrictions and how they reach beyond the origins and insertions of individual muscles and can refer into far-reaching areas of the body (By then I told that story really well!). Most patients would just nod or grunt in apparent understanding, but I started to notice how frequently I heard these reports. This was surprising, since it was the belief that fascial restrictions were unique to each individual, based on their history of physical (and emotional) trauma. Why were so many people telling me nearly the identical referral pattern? I filed it away for future worrying (I do that a lot. Why waste good time worrying about such things when there were more pressing things to worry about? I tend to compile worry to-do lists). It seemed that with a sustained hold in the above mentioned (and below pictured) sequence, symptoms improved not only in the area of treatment, but also into the referral patterns through the face. Seeds of skepticism were planted.
Fast forward to a DermoNeuroModulation class I took from Diane Jacobs, PT. She speaks a decidedly non-fascial language and at a certain place in her lecture she displayed a PowerPoint slide regarding the anatomy and distribution of the facial nerve. She had spoken at-length about neurodynamic technique principles, exposing me to some pretty new and interesting perspectives on evaluation and treatment. She spoke about the potential for engaging a nerve anywhere along its length and having the possibility of impacting and allowing change anywhere along the nerve path. In essence, grab hold of a nerve anywhere and you have the potential to impact the entire distribution of that nerve. The photo below shows me performing the sequence formerly known as the thoracic outlet release (I have different names for technique sequences today…but that’s another story). If you can imagine where my patient is feeling a stretch or engagement, a wide range of response is plausible, including the front of the neck and upper chest region.
Now consider the anatomy plate shown below. It is a Grey’s Anatomy plate showing the distribution of the facial nerve. The facial nerve is the seventh cranial nerve and “controls the muscles of facial expression, and functions in the conveyance of taste sensations from the anterior two-thirds of the tongue and oral cavity. It also supplies preganglionic parasympathetic fibers to several head and neck ganglia.“(1) The facial nerve functions as a motor nerve as well as sensory and parasympathetic nerve and supplies the exact areas that my patients were reporting all in all those instances of so-called fascial referral. What might explain this phenomenon?
Take a close look at the anatomy plate below and you will see that the cervical branch of the facial nerve runs down through the upper and middle anterior lateral neck regions. When I engage my patients in the stretch shown above in the photo, I believe that I am lightly engaging the cervical branch of the facial nerve. I believe that I am providing neurodynamic technique-like engagement to the cervical branch of the facial nerve, potentially affecting the entire facial nerve. I believe that I am allowing my patients to feel effect into their faces and treating the facial region from this sequence, not from a fuzzy science explanation of fascial restriction, but from a biologically plausible model of nerve mobilization.
Sitting in Diane’s class and seeing the facial nerve in an enlarged image allowed me to immediately see that old, folkloric story of so-called fascial referral patterns in an entirely new light. Does this mean that fascial restrictions do not explain this phenomenon? Not definitively, but when faced with a decision to choose one explanation over another, I now choose the one that is less wrong. I choose the one that science supports without needing to tell a story.
Stories have their place, but they should be told as either fact or fiction. When stories blur I do not believe they belong in the treatment room, where we give skilled care to patients in pain and dysfunction. Try to be less wrong. Change your story.
What about you? Has your story changed?
For Now,
Walt Fritz, PT
Foundations in Myofascial Release Seminars
(1) Facial nerve text and image courtesy of Wikipedia. https://en.wikipedia.org/wiki/Facial_nerve
Fritz, I love your use of language and perspective on this. We have all assimilated many ‘folkloric stories’ over our years of training and practice.These days in our health professions there is such a push toward “evidence -based” medicine, yet another place where many feel obligated to present a different set of ‘folkloric stories’ to somehow attempt to justify or make real the mysteries of the human body and its responses to intervention. May we all move toward being less wrong there as well.
Sheila, Stories have their place, even folkloric ones, but I think we should be begin to preface our explanations to and education of our patients with appropriate disclaimers. Though if you believe the story to be true it may be hard to know when to preface. Keeping our explanations as simple as possible is a good place to start.
How my narrative changed:
A client arrived with a book: Strain-Counterstrain by Lawrence H Jones, DO. An osteopath told her that if she did the things in the book she would recover from her complicated injuries but he did not have the time to do it.
As I read the book, I began to understand that what I had begun doing instinctively, that is holding a position until I felt a response was changing habitual sequencing patterns in the central nervous system.
Myo: dose muscle tension change when hyper sensitised motor points are allowed to reset? I think so.
Fascia: Dose fascia change its characteristics when the central nervous system changes the impulse being sent? I think so.
Release: Do protective sequence patterns that have become counter productive release when the central nervous system perceives that there is no longer a threat? I think so.
Does my repeating this dialog while holding a pattern they perceive as connected to their pain give them relief? They think so.
A patient’s belief in a narrative can be an important aspect of our interaction. Brian Fulton’s excellent book, “The Placebo Effect in Manual Therapy” speaks to this at length. While I have stopped poking holes in their narrative I may, over time, all ow them to see the many ways people see pain/dysfunction and how many of the narratives are not entirely accurate. Most accept this very well.
Walt, Thank you again for your articulate expose on your evolvement in your practice. At the end of your article you state “cervical branch of the facial nerve runs down through the upper and middle anterior lateral neck regions.” By treating the longus capitus, rec. cap. anterior and rec. cap lateralis can you directly effect the cervical branch of the facial nerve?
Engaging the body in any part of the region of this (or any nerve) may cause the principles of neurodynamic technique to take effect, so yes to you question.
It is healthy to question your story or narrative, it gives credibility to your humanity and science. You will probably find that this too will change over time. In my 30 year bodywork experience I have found consistent neuro, scar fascial lymphatic and structural changes with accurate tissue manipulation. I see it as a question of what system you are intending to influence, where and how much to create balance in the body. Science is actually ill equipped to accurately determine the effects of our treatments. Meanwhile we are lured to wax poetic about the amazing benifits of human touch.
Our attempts to keep current with science will necessitate changing our story along the way. I do disagree with your stance on intention and what system we wish to influence. I think this is where we may have been sold other stories, in terms of our ability to not only selectively access individual tissue/structure, but also our ability to affect only those individual systems. I think our touch has great ability to influence, but I see it from a larger sense of central control.
” I think our touch has great ability to influence, but I see it from a larger sense of central control.”
I do not want clients to be reliant on my touch. Along the lines of Ben Benjamin’s “Listen to Your Pain” I try to enable the client to replicate what gave them relief. I have them touch, move, push pull and be aware of their ability to affect their pain. My message is “Pain is the body’s message to the conscious mind that you need to do something different.”
So Walt, how do you engage a nerve without also engaging the fascial system?
I think there is still much to be discovered, I would be hard pressed to take the idea that it is simply a nervous system response. Afterall the fascial system also carries the meridians. And understanding the fascial system is far from an exact or close to an exact or even close science. We need to look at all of the component parts and not exclude one because the nervous system provides a very neat and “plausible” story.
I also think the use of the folkloric is akin to saying its an old wives tale. I can understand where you are coming from and I still think the story is missing a very very important component. We really don’t understand fascia, and yes we engage nerves when we do fascial release or with dermoneuromodulation. You and can call it what we want and no matter what, the story is always incomplete. I absolutely agree the nerves are engaged in the releases. This doesn’t discount the possibility that fascial tissue does change with particular kinds of forces. If you add rotational forces to your release techniques, you get an entirely different kind of release through the body more akin to an acupuncture treatment.
Hi Bamboo, nice to hear from you again,
“how do you engage a nerve without also engaging the fascial system?”
That is a fair question, but might be better stated by asking how we isolate ANY structure within the body? It is the failing of most forms of manual therapy/touch, one that is easily overlooked in attempts to define supposed targets of our touch. The fascial system is certainly an aspect of the tissues that surround nerves, including the tunnels that surround each individual nerve and are thought to be part of the issue with tunnel syndrome-type problems. Many of the neurological concepts of intervention take a top-down approach to explaining changes in pain, etc, which often omit the periphery. It is certainly plausible that the multitude of other tissue/structure may play roles in our touch, fascia included, and while I have not completely discounted the potential for this to be proven some day, I grow and grew tired of everything explained by the mysteries of the fascia. As for fascia carrying the meridians, we have been taught vastly differing views of the body and how it works. I know that you, as an acupuncturist, believe things that I may not, and meridians are one of those such things.
Definition of folklore
1: traditional customs, tales, sayings, dances, or art forms preserved among a people
2: a branch of knowledge that deals with folklore
3: an often unsupported notion, story, or saying that is widely circulated
(http://www.merriam-webster.com/dictionary/folklore)
So no, I do not mean to say that I believe these are old wives tales. I think that most of the stories told in fascial education are passed down narratives from older osteopathic literature and beliefs, most of which are passed along without much critique. I do agree that the story is incomplete, but this does not give license to allowing any explanation to be acceptable, on the off-chance that at some point in the further it may be proven. Far-fetched teachings have been around for nearly as long as we have and are, unfortunately, still being taught. Much is not known about fascia, but that is not because people have not been trying. It may just not have that much to show us.
Being less wrong is an opinion, but one that can often be backed by science. You and I may not agree, but our rational, civil disagreement and conversation are what will accomplish meeting of minds somewhere in between where we are at right now.
Cheers,
Walt
What we call farfetched often ends up being proven to be true. We can’t discount meridians just because we can’t see them. We can experience the effect of a needle in the body, we can feel the changes in our wellbeing and see the changes that happen.
Unfortunately science is more eminence based than evidenced based. When this changes to include and to explore honestly all avenues of discovery without the biases expressed by “scientists” and science based practitioners we will have a very very different conversation. Right now the comments using phrases like pseudoscience, folkloric etc demean what was very important before to you. It gave you and me a handle with which to describe something of what we were doing. I really don’t think you need to go in that direction to support your perspective.
I think by not including the fascial system in the discussion of dermoneuromodulation, a great disservice is done to all of our practices. Just because we don’t clearly understand how it links to the whole system, we instead ignore as it has been ignored by the medical profession forever. It is time to stop it.
The other piece that distresses me a bit is the notion that we don’t touch anything but skin. If your (not necessarily your’s per se, but it might) reality is such that only the physically touchable, seeable and measurable is the only reality, you’r missing a lot. I think this system has its value for sure; it’s actually similar to what I do from an acupuncture standpoint. I think this is a lame attempt to put something we don’t understand as much as we want into a box that appears to have great validity. and it doesn’t.
I wonder if Diane ever worked on unembalmed cadavers. And how does she deal with all the mechanoreceptors within the fascial tissue?
Just because we don’t understand something doesn’t mean we can’t talk about it. Seeing the brain and the nervous system as the be all end all is in my mind missing a critical point of the physicality of the body. There are too many unanswered questions to rely solely upon one system.
We cannot engage a nerve without engaging the fascial system. Her techniques work the fascia more than the nerves. They may release trapped nerves. What tissues do nerves meet in? Do they go into muscle cells? They engage tissues and organs through the extracellular matrix of the fascial system. I don’t think we can engage anything in the body without engaging the fascial system.
The definition of folklore is clear. It appears to be used to disparage something while lifting the value of another system.
Another question is how does anyone know the treatment is actually treating nerves rather than the fascia? It’s the fascia that jams the nerves. So are we putting the cart before the horse? What’s the proof that it is the nerve that is being treated and not the fascia? Because of location? How does Diane know she is moving the nerves? Look at her techniques carefully. She’s engaging the fascia and the mechanoreceptors in the fascia. With rotational forces you can get a much bigger release through out the body.
We can continue agree to disagree. Let me know when you do a workshop in CA.
I have and continue to thank those in my past for what they have taught me, but I will not continue to accept all that I was taught, especially when much of it has been proven inadequate or incorrect. Much of MFR, manual therapy, massage, and probably acupuncture, is based on a narrative that has been simply handed down form one person to the next with little critical deconstruction of the underpinnings of that modality or mindset. We will disagree on giving anyone or any idea a pass, allowing them to claim nearly anything, on the chance that someday it may be proven correct. You find my words folkloric and pseudoscience demeaning, but I do not mean them as such. Pseudoscience simply refers to methods mistakenly regarded as being based on scientific methods and I am sorry if you find that offensive. Neither words are disparaging. As for Diane’s beliefs I might suggest that you join her Dermoneuromodulating group on Facebook (https://www.facebook.com/groups/5704079529/) and ask her yourself, as I will not speak for her. I have examined her techniques quite closely and marvel at the similarity to those we learned as MFR. But when you look at the broader world of massage/manual therapy, the crossover is similarly as uncanny, further calling into question the claims made by each and every modality, in terms of what they claim their specific tissue effects might be. If you look closer at Diane’s work, and some of the ways I describe MFR, we are describing aspects of skin neurology, with the skin being the only tissue we can be 100% certain we are impacting.
I am actually teaching at USC in LA next August: http://www.waltfritzseminars.com/myofascialresource/los-angeles-ca-foundations-in-myofascial-release-seminar-for-neck-voice-and-swallowing-disorders
Walt
Hi Walt,
You may not have meant to use those words disparagingly. Because of the way they are used consistently in a disparaging manner they always come across that way now regardless of who is uttering them.
I will check into her facebook page.
Best,
Bamboo