Panel Discussion: Manual versus self-administered techniques?
Which is more important? Patient education versus a practitioners manual skill set - Special Thanks to Stef Dicarrado, Kinesiology Cscs and Jason Erickson for their huge contributions to this discussion:
Moderated by Brent Brookbush DPT, PT, MS, PES, CES, CSCS, ACSM H/FS
This Panel Discussion was originally posted on my facebook page - https://www.facebook.com/brent.brookbush - on March, 24th 2013
Barbara Kay I think both are equally important. We need to have competent and trained practitioners but we also cannot deny the necessity of patient education and prevention. The more we can educate and engage people in their own health, the less injury and unhealthy behaviors, hopefully. Individual Behavior change is really the key to getting people who have the education to actually implement it into daily patterns - this is the challenge for all health professionals. We can educate and even give proper tertiary care, but if the individual doesn't do what he knows he should be doing, then it's not going to help in the long term. Theory based behavior change and knowing how to motivate people to do self care must be a focus.
March 24 at 12:00pm
Brent Brookbush Hey Dr. Barbara Kay,
I hadn't really considered the point above from such a large conceptual picture of wellness, but great points.
I was specifically, thinking about stretching, mobilization and activation techniques… is manual skill more important than a home exercise program? Should personal trainers be concerned with their limited manual scope, or should they embrace their place in the health/wellness model as the masters of exercise and self-administered programs?
March 24 at 12:08pm
Barbara Kay Oh - well I will need to think about that for a little bit and get back to you later.
March 24 at 12:25pm
Brent Brookbush Fair enough
March 24 at 12:30pm
Jason Erickson I see both as being on a continuum. Each is very important, but the relative emphasis that should be placed on each varies depending on where the client is at. Barbara Kay pretty much had it nailed, IMO.
March 24 at 1:17pm
Brent Brookbush Thanks Jason Erickson, like the way your thinking… manual techniques are often more effective for making immediate gains, but those gains cannot be maintained unless the patient or client can manage the issue on their own. I think we are all on the same page.
March 24 at 7:30pm
Stefanie DiCarrado To throw in my 2 cents.. both are equally important. If a client is paying for a 1 on 1 session, the trainer should be using their manual skills to increase the effectiveness of the session. In way of practical application, here's what I think (please give feedback): from my perspective as both a client and now the trainer, I think the use of manual techniques with new clients who have no prior knowledge of trigger point release is very helpful in demonstrating how it feels when pressure is applied correctly and how it feels when the muscle releases. In my opinion, instructing someone on self-administered techniques will not be as effective without first giving them the "feel" for it. Once the client understands the method of application, the trainer can switch (temporarily) from manual techniques to the instruction & demonstration of self-administered techniques and have the client practice during the session so the trainer can correct as needed. Once the client demonstrates competency in self-administered techniques, they will do that as part of the HEP and the trainer returns to manual techniques during the 1 on 1 sessions.
Wednesday at 10:16am
Brent Brookbush Right on Stefanie DiCarrado… But, we do have to be careful to abide by the laws in our states (remember, personal trainers cannot do manual release techniques in most states), although I think that palpating an area to demonstrate where a foam roll, soft ball, ProUnit PerformanceTrainer, or @triggerpointperformance products…. should be placed… a trainer cannot actually release a muscle to demonstrate the appropriate "feel" of a release. This is going to need be done through careful explanation and demonstration. On the other hand, your suggestion works great for stretching…
As a physical therapist (well soon to be)… you will be able to use the methodology you outline above which in my opinion is absolutely ideal.
Wednesday at 11:22am
Stefanie DiCarrado Good point, thanks for the feedback
Wednesday at 12:38pm
Kinesiology Cscs I'll chime in: I agree with Brent -- in the medical fitness/sports medicine/integrative health atmosphere I work in as Fitness Coordinator, it is out of my (and my fitness staff) area of expertise and legal consent to perform manual release techniques on clients. This is actually a pet peeve of mine -- when I see trainers using a foam roller or other MFR prop on clients. What I do is explain to the client during our initial consultation/assessment the importance of self MFR; have them self perform MFR and a mobility test/re-test on the area for the purpose of showing them the acute (and obvious chronic) benefit; and then explain to them general program design following the F.I.T.T. protocol: Frequency = daily; Intensity = as much discomfort as tolerated; Time/Duration = a minimum of 90 secs up to several minutes per trigger point (many people make the mistake of spending too little time trying to release a trigger point); Type = various props for various areas of the body (and show them examples). I also explain they want to roll for the purpose of seeking out trigger points and once they have found the most tender areas, either lie on the area or floss it, as opposed to continuing to roll back and forth, on and off the trigger point (another common mistake I see). Additionally, I show/explain that some areas benefit by having the muscle on stretch while performing the self MFR.
Wednesday at 1:29pm
Brent Brookbush Nice Kinesiology Cscs… love your attention to detail… technique is extremely important to ensuring results.
Wednesday at 3:51pm
Jason Erickson As a massage therapist with hundreds of hours of training in trigger point therapy and hundreds more hours of continuing education, I strongly recommend against telling clients that the goal of self-treatment is to target trigger points. This is largely because most "musculoskeletal" pain is not attributable to trigger points, and emerging trends in pain science and other sciences fundamental to manual therapy are eroding the assumptions upon which the trigger point hypotheses of Travell and Simons are based. There are many, many other reasons that clients may be experiencing pain, and it is a disservice to mislead them to believe that trigger points are the culprit.
Further, the "F.I.T.T. protocol: Frequency = daily; Intensity = as much discomfort as tolerated; Time/Duration = a minimum of 90 secs up to several minutes per trigger point (many people make the mistake of spending too little time trying to release a trigger point); Type = various props for various areas of the body (and show them examples)" runs counter to modern manual therapy principles as used by massage therapists with advanced training.
Frequency: Should never be daily, even when treated by a professional. The soft tissues need time to adapt/change/heal. With aggressive approaches, an interval of 3-5 days between treatments should be the minimum amount of recovery time. Gentler approaches may permit greater frequency.
Intensity: Should be relatively painless, no more than mild discomfort (at most). Painful intensity tends to elicit protective responses that reinforce the problem, and increases the risk of damaging soft tissues. This requires greater patience and sensitivity, but it's worth it. In general, the trend in massage education (particularly advanced education) is increasingly towards painless manual therapy. There is NO demonstrable advantage to aggressive, painful intensity.
Time: Gentler pressures may require durations of 90+ seconds per area. Soft tissues that feel firm/hard should be given time to soften in response to gentle pressure/manipulation. If handled appropriately, muscles will palpably soften and permit the treatment pressure to "sink in" further. There is no demonstrable advantage to forcing one's way into deeper tissue layers. In most cases, attempts to do do will result in a hardening of the muscles and localized increase in discomfort - the opposite of what you want to happen.
Type: Hard objects/implements/tools should be employed with great care, foam rollers included. Softer items used for stretching, positioning, or tissue manipulation will feel less "dramatic" but are more likely to deliver the desired results. Tools/methods that rely upon damaging soft tissues to provoke a "healing response" should be avoided. This includes the FAT tool and other scraping implements, with the possible exception of use in the hands of a trained professional therapist. (Trainers don't count; not even Charles Poliquin himself. I am reluctant to consider ATCs unless they have significant experience focusing on soft tissue manual therapies.)
I think it is laudable to recommend that clients employ self-care methods, but be very aware of the limits of your expertise as a trainer. Just as most massage therapists should not be teaching stretching/strengthening without the appropriate professional training/certification/licensure, neither should trainers be delving into manual therapies without the appropriate professional training/certification/licensure. Better by far to establish relationships with therapists you can trust and whose expertise complements yours so you can refer to the appropriate professional(s).
NOTE: Edited to add "Gentler approaches may permit greater frequency." in response to Brent Brookbush's pointing out that I had only addressed frequency for high-intensity treatments.
Wednesday at 9:45pm · Edited
Kinesiology Cscs Very interesting response to my post, Jason. I'll give you some more background on why I posted what I did -- I learned what I posted from the physical therapists I work with, primarily our head physical therapist who is in her 21st year as a professional; was mentored directly under John Barnes; and has served as a primary physical therapist (for over a decade) for the Knicks, Yankees, Nets, Liberty, etc… Also, we are very much a teaching/educational facility and regularly have medical students, DPT students, and as recently as a few months ago we had a massage therapist come through. The massage therapist was specifically being mentored by the above mentioned physical therapist and I don't recall any conflict in views. I also know that Brent is well-versed in this area and didn't disagree with my post. Two hours ago I showed this thread to include my response to two other PTs I work with and they gave the thumbs up. So I'm intrigued and to be honest surprised by your response. You seem to be in complete opposition to what I said yet the guidelines I stated, which aren't my own, are being used by others in the healthcare continuum. So where do you believe this opposition comes from? Brent, your thoughts?
Wednesday at 7:06pm
Kinesiology Cscs By the way, I'm going to contact the massage therapist that came through our facility a few months ago, who is currently a first year DPT student, let her know what I said and how you responded, and see what she has to say. This has me very intrigued.
Wednesday at 7:08pm
Kinesiology Cscs Sorry to keep posting but after reading your response again, and correct me if I'm wrong, but you seemed to be specifically refering to manual therapy techniques, while I was refering to self myofascial techniques. In any case, I'm very fortunate to have working relationships with many different types of healthcare providers and will be running your response by them. Just this morning a Podiatrist I work with was suggesting to a patient who is suffering from foot pain to perform self myofascial release on her foot with marbles, daily, while her foot is placed on stretch. ….In any case, I'll get to the bottom of this if it's the last thing I do!!!!
Wednesday at 7:35pm
Jason Erickson I consider all forms of "self myofascial techniques" to be manual therapies, even those performed with tools/rollers/etc. Stretching, IMO, would be another form of manual therapy.
There is no doubt in my mind that you will find many PTs, DCs, MTs, and other health care professionals who have practiced according to those guidelines for decades and who still subscribe to them. They have been around for a long time and carry the perceived weight of being old, familiar ideas who have "stood the test of time". It will probably be a while before institutionalized training in manual therapies evolves beyond them, and that may require a gradual die-off of those who are designing and teaching the curriculums… probably a few more decades.
One of my mentors is Diane Jacobs, PT and co-founder of the Pain Science division of the Canadian Physical Therapy Association. She and many like-minded PTs, MTs, and so forth discuss pain science, manual therapies, and related topics (including training) extensively at the SomaSimple.com forums, the best single point of interaction I can recommend to you for in-depth investigation. If you really want the science and clinical reasoning laid out for investigation, you aren't likely to be disappointed there. The PTs and DPTs you mentioned will find peers with equally impressive qualifications should they choose to look into the matter.
Some of my other mentors have other qualifications that may/may not mean anything to you, as they are massage/manual therapists with national/international reputations as instructors. These include Aaron Mattes (also a Registered Kinesiotherapist), James Waslaski (also a CPT), Walt Fritz (PT and one of John Barnes' top proteges until Walt stopped drinking the Kool-Aid), Pat Archer (also an ATC), Kate Jordan, and others that are less well-known but who have decades of experience in practicing and teaching manual therapies. Some of them have worked with many professional athletes/teams, and have taught/mentored medical professionals of all levels.
None of that says anything about my personal expertise, but I present it so you understand that I'm not just pulling this stuff out of my pocket. It's good to get input and guidance from those whose expertise we trust. When we find areas of disagreement, we all have a chance to learn from exploring the matter. I am a huge fan of following debates between respected experts who have strong feelings about opposing view points.
Wednesday at 8:21pm · Like
Ryan Crandall I agree 100% with what Jason says.
Wednesday at 8:30pm
Brent Brookbush So my thought Kinesiology Cscs, Jason Erickson, and Ryan Crandall…
You are debating, but not debating… we are in agreement about 80 - 90% of what should be done…
Intensity: Mild Discomfort
Duration: Sustained hold until tissue pliability softens
Frequency: You kats are not arguing the same point… Jason, you describe a low intensity technique and then give the frequency recommendations for high intensity treatment… Graston would be a high intensity treatment… static release of trigger points with min to mod pressure is not high intensity and is thought to work via ischemic pressure and/or autogenic inhibition, neither of which are thought to cause tissue damage in need of repair and/or adaptation…. low intensity release may be performed daily with great benefit… we are all trying to avoid increasing inflammation except for very specific cases were more aggressive treatment is necessary.
Pain - Sorry to pick on your argument again Jason, but nobody inferred that trigger points were the cause of all pain. In my humble opinion trigger points are the result of increased neural drive to muscles "stuck" in a "less than optimal" length. In essence, an increase in neurotransmitter release and an inadequate degradation leads to accumulation and potential scar tissue development, further overuse may lead to local ischemia. Not all trigger points are active (in fact what we should be calling these points that we go after in most cases is "tender points." - That is what the latest edition of "Travell and Simons" states… We simply target trigger points when doing release techniques to improve muscle activity - in essence affect tone…. This leads to better results from our stretching and mobilization programs.
As far as were pain comes from… well… as you mentioned Jason it is really complicated. It is likely do to cell damage, the release of chemotactic mediators, and the stimulation of nociceptors. The tissues damaged by a dysfunction could be any tissue involved in the dysfunctional segment (i.e. lower leg dysfunction and soleus trigger points may be contributing to malalignment of the SI joint and eventual tissue damage that results in low back pain). To quote Perry Nickelston company, we should all stop chasing pain and start targeting the root of dysfunction.
Last, self myofascial release and manual techniques are not one in the same. It all has to do with feedback. A trained manual therapist learns how to recognize changes in tissue via there own receptors…
Self-myofascial release implies that the client/patient is instructed to respond to their own receptors.
You cannot expect a client/patient to do the job a trained manual therapist can do, but unless they learn how to manage the problem on their own they will never stay healthy. No one is cured (as in forever, as in the dysfunction will never come back) of movement impairment by any professional… there is no permanent fix… If you tell me you know the permanent solution, your are either lying, have poor follow up, or you have just cracked the code on human movement impairment and should be awarded the MacArthur Genius Grant. In essence, personal trainer must be allowed to teach self-administered techniques, and manual therapists who do not teach these techniques before discharging a patient are being irresponsible or worse… they are so greedy as to wish for client/patient dependance.
I spend every day searching for the Holy Grail of Rehab/Performance Enhancement… The first time fix, that returns an individual to perfect/pain free movement, lasts forever, and the really hard part… be able to do this every-time with every client/patient. This is why I am so dedicated to my "Predictive Models of Postural Dysfunction"… but let me tell you were I am at… Almost everybody who sees me gets better the very first session (unfortunately the cycle of pain and inflammation can make this part of the wholly grail darn near impossible), with time most individuals can return to ideal movement after their corrective work (age and nature of pathology play a huge role in this time period), and an integrated approach including activation, integration, and conditioning results in greater session to session traction…. some individuals see results coming just once a week, but everyone would benefit from daily work.
So those are my thoughts… I think we are actually all in agreement… I just see slightly different language used and a couple of arbitrary lines drawn in the sand.
Last,
Thank you for adding to this discussion… What I thought was possibly a poor question on Sunday, has turned into an awesome educational piece.
Wednesday at 9:12pm
Brent Brookbush Thanks for the edit Jason Erickson… You could call it my most annoying gift… I am able to find inconsistencies in any argument… like a pig to truffles… I am not even sure how or why my brain does it.
Wednesday at 9:48pm
Jason Erickson Yes, Brent, I think we are largely in agreement on the big picture and many of the details. Not wholly in agreement, of course, but that's what makes this kind of discussion interesting! Race you to that MacArthur Genius Grant?
Wednesday at 9:49pm
Jason Erickson That trait sounds like a wonderful gift, Brent. I wish more people had it.
Wednesday at 9:51pm
Brent Brookbush A race to the MacArthur Genius Grant? I'm not sure that's fair when I have such a head start Bazinga!
Wednesday at 9:56pm
Barbara Kay O…….M……..G…..
Wednesday at 9:58pm
Barbara Kay Ok Brent - I'll nominate you already
Wednesday at 9:58pm
Brent Brookbush That was as much for you, Barbara Kay as for Jason Erickson… LOL
Wednesday at 9:58pm
Barbara Kay I figured…
Wednesday at 9:59pm
Brent Brookbush I just hope Jason Erickson, watches "Big Bang Theory" and knows the "Bazinga" reference.
Wednesday at 10:02pm
Jason Erickson http://ts4.mm.bing.net/th?id=H.5035746962769475&pid=15.1
Bazinga!
http://ts4.mm.bing.net/th?id=H.5035746962769475&pid=15.1
ts4.mm.bing.net
Wednesday at 10:15pm
Brent Brookbush That is hilarious… my dog is now looking at me like I am crazy… laughing out loud at my computer… Well played sir… well played.
Wednesday at 10:17pm
Barbara Kay He's just now looking at you like you're crazy? Somehow I think you have probably gotten that look before.