Hold-times for stretching in manual therapy

I’ve been in the niche of manual therapy for nearly 3 decades. When I entered this world, via myofascial release (MFR) training, hold-times were recommended at a “minimum of 90-120 seconds”, as this was the time it was said to have taken for the fascia to begin to change from sol to gel. That conversion was seen as a necessary aspect of how and why fascia adapts to our input and pressures. That being stated, we were encouraged to remain in the stretch for longer time-frames, as most patients were said to have multiple restrictions. I got quite comfortable reminding in place with hold-times often far exceeding 5-minutes. That longer time-frame was also said to be important in allowing the patient to look and feel deeply into any emotional holding patterns that may be contributory to their fascial problems and problems in general.

After I left my formative MFR community in 2006, I heard stories of supposed newer scientific advances in the understanding of fascial anatomy and fascial change that moved the recommended time-frame of hold-times to a minimum of 5 minutes. These changes were reportedly based on how concepts of mechanotransduction were said to influence the work we did. That’s how science works; adaptation in models occurs as science uncovers more information. However, does the sol-gel theory or properties of mechanotransduction fully explain the reason why change occurs when long hold-times are utilized in a static engagement-type of manual therapy input is provided? Is there evidence beyond what is seen as credible by the fascial community that explains the reasons why pain and movement change when we linger for long periods of time? If so, do any of these explanations take into account newer models of manual therapy’s impact? (1-4, 6-10)

Earlier this year, during the Covid shut-down, I rewrote my entire seminar curriculum, which included rebranding the title of my work as a therapist and as an educator. As reported earlier, I moved my brand away from MFR and into Manual Therapy. While there were and are many reasons for this move, one was the limited cross-community credibility of silo-based perspectives that are taken in nearly all manual therapy/massage branded modality lines of education. As I learned it, MFR utilized slow and gentle pressures and long hold times that were said to be supported in the evidence. Early in my MFR career, I was struck by the vast difference in pressure application between MFR (as I learned it) and Rolfing®, which to many is also considered MFR. MFR, as I learned it, utilized slow and gentle pressures and long hold times that were said to be supported in the evidence. On the other extreme, Rolfing® uses quicker strokes that were much more aggressive/deeper, all of which were also said to be supported by the evidence. However, when I went into the research citations used by each camp (MFR as I learned it and Rolfing®), many of the same research articles are cited as proof of the work. I found that odd at the time, but I knew enough to keep my mouth shut and not challenge authority. Silo-based modality camps are like that.

Over the past decade, I’ve lost touch with what sources of evidence each of these camps now uses, and I suspect there have been updates all around. However, even back in the early 1990s, I suspected that there were some universal (less fascial-based) explanations for how and why longer hold-times seemed to have efficacy for producing changes in fight/flight, pain, and movement problems. None of these reasons were stated in my training, as silo-based models tend to stick with silo-based explanations.

While rewriting my curriculum earlier this year, I came upon a study by Cerritelli (2017) titled, “Effect of Continuous Touch on Brain Functional Connectivity Is Modified by the Operator’s Tactile Attention” (5). To summarize the study, the researcher wished to look at whether or not the clinician’s attention to the patient mattered. One might summarize this study to ask that if a clinician was distracted, would the potential therapeutic effect be less than if the clinician attended to the patient. Therapists often use vernacular from their modality or beliefs to summarize the need for attention to the patient, such as being grounded, but as far as I know, this was the first study of its kind to put those concepts into a research study. The study was set up with a patient being attended to at their ankle by a clinician. fMRI monitoring was made during the course of the “interaction” to determine if brain activity changed with the intervention. The clinician did nothing at the patient’s ankle except to have light pressure; no “therapy” was done of any sort. They were just asked to attend to the patient’s ankle. There were two test groups, with the only variable the state of the clinician. In one group, the clinician was supplied with headphones that transmitted loud sounds meant to distract the clinician. In the other group, the clinician had no such sounds to interfere with their attending to their patient.

The results showed that with the group being attended to by the clinician wearing the headphones (loud noises to interfere with their concentration), little change in patient brain activity was registered. But in the group where the clinician was allowed to attend to the patient without distraction, there was a decided shift in activation of brain centers toward improvements in functional connectivity. I will leave it to you to explore the paper to read the details of this result at the full-text link here. But what I found fascinating was that “improvements in functional connectivity” peaked at 15-minutes of hold-time (contact-time). Allowing for a sustained input, as we do in MFR-styles of engagement, may allow that added benefit of neurological input/output to maximize. While this does not count for positive changes achieved with other sorts of manual therapy, it may move the bar along into a better understanding as to why long-duration touch may be impactful.

As clinicians, much of the new evidence has shown that our outcomes are not due solely to what we do with the tissues but are a complex, multi-factorial cascade of effects from the periphery to the brain and back to the periphery. Behavioral factors may play a larger less than perceived local tissue-based responses (2, 3, 7, 9)). While what we see as outcomes of longer hold-times embedded within the MFR community may be due to mechanical properties attributed to the fascia, but we now know that these longer hold-times are absorbed by the brain of the patient, which possesses the capacity to downgrade fight or flight to rest and relax, modulate pain, and improve movement quality. I find all of this fascinating, as it moves the bar of proof from the questionable interpretation of evidence into “fascial evidence”, toward what are, to me, more plausible narratives, accepted by the wider scientific community, which is what we should be seeking. Such advances may reduce the perceived importance of fascia to a level where it is simply a part of the whole and not the forgotten tissue, as it has been represented to many. Peripheral input is detected via the various receptors throughout the tissues, be it skin, fascia, muscle, joints, etc., and sent to the brain for processing. The brain is kinda powerful and easily capable of making the changes that MFR therapists see as a sole output of fascial interaction.

Kolb (9) writes about the evolution of understanding of similar concepts in his article, The evolution of manual therapy education: what are we waiting for? He reports that such information has been freely available, information that puts the effects of manual therapy not on the individual tissues but on the whole person, though manual therapy educators continue to deny what is now known to push their beliefs onto therapists about their favorite tissue-based models. I think back with sad irony at many of the concepts taught to me by my MFR educator about how medicine as a whole was stuck in outdated mindsets when, in fact, MFR education lags behind modern neuroscience. In Kolb’s words, what are we waiting for?

This sort of information does not negate the value of what we do with our hands and words, but may (should?) make us question the way that we frame our work. Unlike what I was taught, hold-times may matter more to the patient’s brain than their tissues.

Cheers,

Walt Fritz, PT

Foundations in Manual Therapy Seminars and The Pain Relief Center

www.waltfritz.com

1. Bialosky, J. B. (2009, October). The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model. Manual Therapy, 14(5), 531-538.
2. 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.
3. Bizzari, P. F. (2019). Manual Therapy: Art or Science? In Physical Therapy Effectiveness.
4. Borrell-Carrió F, S. A. (2004). The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry (Vol. 2). Annals of Family Medicine.
5. Cerritelli, F. C. (2017, July 20). Effect of Continuous Touch on Brain Functional Connectivity Is Modified by the Operator’s Tactile Attention. Frontiers in Human Neurscience, 11(368).
6. Coronado, R. B. (2017). Manual physical therapy for chronic pain: the complex whole is greater than the sum of its parts. Journal of Manual & Manipulative Therapy, 25(3), 115-117.
7. Geri, T. A. (2019, July 24). Manual therapy: Exploiting the role of human touch. Musculoskeletal Science and Practice, 44.
8. Jacobs, D. S. (2011, May). Therapist as operator or interactor? Moving beyond the technique. Journal of Manual & Manipulative Therapy, 19(2), 120-121.
9. Kolb, W. H. (2020). The evolution of manual therapy education: what are we waiting for? ournal of Manual & Manipulative Therapy, 28(1), 1-3.
10. Tousignant-Laflamme, C. S. (2017, July). Does shared decision making results in better health related outcomes for individuals with painful musculoskeletal disorders? A systematic review. J Man Manip Ther., 25(3), 144-150.

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