Manual Therapy vs. Touch-Based Cueing

Can touch be non-denominational?

Thirty-seven years of a physical therapy career has taught me much but left me confused about just as much. I have learned the value of movement, whether presented as strengthening for the remediation of problems or a more generic movement for those same outcomes. I have seen the importance of balance, though now I shy away from seeing the solving of issues being dependent on achieving perfect balance. Moreover, I’ve seen touch help move people through their dysfunctions, though I no longer worship one form of touch as I once did.

For the past fifteen years, I’ve spent much time trying to learn more about what I was taught about touch, its supposed specificity in correcting connective tissue disorders, and the more general benefits of touch. Silo-based empires are built from tissue-based narratives, and the practitioners of those narratives help countless patients with this information. With positive outcomes, few students question the explanations that underpin the intervention (A post-hoc fallacy issue). Questioning authority in those silos of training is frequently discouraged, as all are expected to follow the party line. Such was my past; I suspect it to be that of many others.

However, when we emerge from the shadow of a master and begin to retake our power, specific problems must be resolved. When the teachings of a single information source are helpful, many decide to search no further. However, engaging in learning in multiple domains often shows us that each of those work styles is useful, even equally so. How do we justify such dilemmas? For instance, in manual therapy/massage interventions, when one learns both fascial-based and muscle-based manual therapy (MT) and finds both equally helpful, uncertainty and dissonance may occur, creating questions surrounding each narrative.

In my newer role as an educator for speech-language pathologists, voice professionals, and other clinicians with similar interests, I am witness to parallel camp alignments as I was when teaching to a primarily physical and massage therapy audience. Laryngeal MT focuses on muscle tension as causative. In contrast, others see poor alignment (posture), technique, breathing style, tongue resting posture, and other characteristics as the primary problems that need remediation. All find ways to help, but few agree on the correct diagnostic criteria or preferred intervention strategy.

Further problems exist within those who touch. In the United States, MT is traditionally reserved for those with a specific “license to touch” or those whose professional scope of practice allows for manual therapy-type styles of treatment to be used. Others, voice coaches included, may be entitled to touch but only for touch-based cueing (TBC). MT and TBC are commonly considered disparate interventions, but are they? If I may, I want to present a scenario played out across these two intervention methods.

A licensed health or medical professional may see a patient’s problems as stemming from improper head carriage, believing that excessive forward head carriage is limiting voice production (or swallowing efficiency, tongue resting position and efficiency, etc.), and prescribe a course of MT to help “balance” the muscle/fascia. Imagine a hypothetical intervention where the clinician places pressure on the patient’s chin and provides sustained input to align the structures better, stretch the tissues, and correct the head posture. They would verbalize the need to use specific pressures, sustain the input for specified lengths of time, repeat it for a set number of repetitions, and repeat this sequence a certain number of times daily. Someone with my background might say, “I’d like to hold this stretch for a sufficient time to release the tight fascia holding the head forward.” All these statements would be said to be based on evidence. Over time, the patient would probably show better head alignment and functional voice (or swallowing, breathing, etc.), seemingly validating the clinician’s methods.

Now imagine another professional not allowed to use MT (of any name or brand) legally but who finds TBC permissible within their profession. They may also see a client’s forward head as the root of a voice issue. After a satisfactory explanation, they may reach out and similarly touch the client’s chin as the clinician described previously. However, they may only pressure the client to present their proposal. “Try tucking your chin back to align the head and neck better.” Often, this intervention would prove successful, resulting in an improved voice (or swallowing, tongue resting posture, breathing pattern).

These two scenarios and outcomes are often seen as resulting from different processes. The licensed professional using MT principles would see the results due to successfully applying the correct MT intervention. In contrast, the professional in the second example may believe the success of the encounter was due to bringing awareness to their client and allowing them to self-input into creating their change. These perceived differences set the stage for the mechanisms of the two intervention outcomes to be distinct and unique.

Such separation in beliefs and perspectives is common and generally accepted. “Staying in one’s lane” has many legal and logical underpinnings and keeps each camp from infringing on the rights and privileges of another and placing the patient/client at risk. However, what if the line between the two interventions mentioned above was less distinct than commonly thought?

Traditional and historical explanations of MT created stories of specific types of pressure necessary for addressing specific tissue-specific problems. My myofascial release (MFR) background taught me that slow, gentler, sustained pressures were needed to “release” restrictions in the connective tissues. I was somehow isolating facia with the exclusion of other tissues and structures. Other forms of MFR teach that shorter duration and more assertive pressures were necessary. Both therapy styles “worked” and even shared some explanatory evidence that was said to validate the rationale. (I noted this irregularity early in my MFR training but had the decency to keep my mouth shut out of fear of banishment from that tribe!) However, over the past few decades, research has been published to cast doubt on these and many other tissue-specific narratives.

Bialosky et al. (2018), Geri et al. (2019), and Kolb et al. (2020), to name just a few, have shown us that manual therapy effects extend far beyond the local tissues (or pathologies). Outcomes are seen as being the result of a variable and multifactorial cascade of influences. These impacts extend from the peripheral structures through central and autonomic nervous system influences and include behaviorally-based assessments and changes on the part of the person being treated. Contextual factors matter, too. When working with voice, Nelson Roy (Roy et al., 2017) showed us that changes resulting from peripheral manipulation of perilaryngeal tension appeared, at least in part, to be a brain-based adaptive response rather than an isolated peripheral change. Suppose we accept that manual therapy interventions are more complex than the single tissue/pathology narratives that are commonly taught. In that case, we can see ourselves (the clinicians) as partners in clinical encounters rather than the creators of change. Sure, our touch, instructions, or supervision plays a role, or the patient would have solved their problem without our help. However, when we begin to balance power with our patients, elevating them to the position of decision-maker, our role becomes more apparent (Jacobs & Silvernail, 2011). The likelihood that changes occur within the MT interaction solely due to our specialized knowledge and specificity of touch is low (Bialosky et al., 2018), and the possibility of changes being a result of improved awareness on the patient’s part rises.

There is also a wide variation in how MT touch is applied, from ultralight touch styles of craniosacral therapy and others to very assertive (aggressive) pressures of deep tissue work styles. Again, all are helpful when patient perspectives and values are matched with the appropriate caregiver. The research lacks clear evidence pointing to one form of MT (touch) being superior to others.

If it is accepted that MT’s sole role is not to create peripheral local changes via specialized input, then do the similarities between MT and TBC appear more closely aligned?

Touch taps into many possibilities. McParlan et al. (2022) speak about touch’s ability to connect with the “priors” of another person, bringing awareness from the past into the present moment. In my early MFR training, this phenomenon was said to be due to emotions being stored or stuck in the restricted fascia. When a skilled clinician releases that fascia, the emotions can be felt and acknowledged. That is a nice story, but one that is pure speculation on how complex interactions and awareness occur. If, by touching with either MT or TBC-like pressures, we connect someone to relevance or understanding from the past, this occurrence may give them a reason to change or an awareness of the problem.

The more I search, the more possibilities I find for how and why touch is impactful. As I dive deeper into each explanation, I see a substantial overlap between touch styles. Such overlap leads me to conclude that manual therapy and massage intervention may have global impacts on the receiver in markedly similar ways to touch-based cueing.

2022 by Walt Fritz, PT

Foundations in Manual Therapy Seminars

www.WaltFritz.com

Works Cited

Bialosky, J. E. (2018). Unraveling the Mechanisms of Manual Therapy: Modeling an Approach. The Journal of Orthopaedic and Sports Physical Therapy, 48(1), 8-18.

Geri, T. A. (2019, July 24). Manual therapy: Exploiting the role of human touch. Musculoskeletal Science and Practice, 44.

Jacobs, D. S. (2011, May). Therapist as operator or interactor? Moving beyond the technique. Journal of Manual & Manipulative Therapy, 19(2), 120–121.

Kolb, W. H. (2020). The evolution of manual therapy education: what are we waiting for? Journal of Manual & Manipulative Therapy, 28(1), 1–3.

McParlan, Z. C. (2022). Therapeutic Alliance as Active Inference: The Role of Therapeutic Touch and Synchrony. Frontiers in Psychology, doi.org/10.3389/fpsyg.2022.783694, 1-16.

Roy, N. D. (2017, March 1). Exploring the Neural Bases of Primary Muscle Tension Dysphonia: A Case Study Using Functional Magnetic Resonance Imaging. Journal of Voice, 33(2), 183–194.