Ryan Hayes RMT

The Race for the Root Cause: how terminology in manual therapy becomes cliche.

When reading manual therapy biographies, many of them state that the practitioner treats the root cause of a problem. While I fully endorse manual therapies and their benefits, I don't believe we should advertise this as something that we do. Why? Primarily, because we can't prove this claim. Often, before people show up in our clinic, they have seen doctors, they have tried medication, and they have negative imaging. Do we know something they don't? Maybe.

Grant it this isn't the route that every patient takes. We may be one of the first ports of call if a patient has an issue. However, if the long and winding road approach has shown no cause, what percentage of the time are we correctly quantifying a root cause and is this important? Yes. We are naming a root cause, but it is our root cause. We are making the most educated guess we can with the information that we have gathered. However, this information isn't validated.

Using our palpation, our knowledge of anatomy and physiology, and our clinical expertise, we ascertain either contributing factors or a single factor as the likely source of the problem and treat accordingly. Would a physiotherapist, chiropractor, and massage therapist all find the same factors in the same patient? What about comparing the findings of a new grad to a fifteen-year veteran? Is the root cause confirmable by everybody? Probably not.

Be clear of a desire for a result. Be clear of dogma. Be Clear. Be. - Hugh Milne

We can only ascertain a root cause to the best of our ability. There are many variables that go into the symptomatic resolution such as years of practice, type of practitioner, complexity of problem, diagnosis (if available) of problem, and longevity of a problem to name a few. There are so many variables contributing to the presentation of a symptom. We have eleven systems to consider. How do we navigate this conversation?

It is more practical to observe and treat the anatomy that we find in dysfunction and try to match it to the symptoms present. In this way, we are supporting systemic health rather than looking for a silver bullet. We can speak with confidence to what we find. We are neither guessing nor speculating. Otherwise, to use another trending word, we are falsely offering a patient certainty about something that has the most uncertainty: the root cause.

Manual Therapy: clarity or confusion?

As I have been reading manual therapy posts on social media recently, I have noticed that many of them sound eerily similar: they discuss the value of one specific manual therapy profession over another; they explain why everything should focus on neuroregulation; they describe how the biomechanical model is overused; they outline how mobility is the key to unlocking health. The posts are often presented in the same tone, explain things in the same way, and ask the same questions before giving answers to those questions.

Manual therapy and healthcare are not in competition. A person is not one isolated system. We should be supporting each other rather than trying to promote our own brand. It feels like the quest for clarity is creating a lot of confusion. People want professional identity yet seek individuality. If it isn't supported by research, it doesn't have value. There is so much marketing and browbeating in manual therapy that it seems we have lost sight of our fundamental aim.

Back to Basics

In simplest, and most overused, terms we are attempting to treat the root cause of a problem. In reality, there are so many variables that go into this (complexity of problem, longevity of problem, diagnosis of problem, skill of practitioner, type of practitioner, etc) that we are likely not going to know the exact genesis of an issue. We use our knowledge, our assessment, and our clinical experience to hedge our bets on how best to treat the patient. Nothing more.

One person's root cause is another person's compensation. Does it really matter? No. We treat what we find and try to optimize health. Whoever we are. With the knowledge and skills that we have. We should know our own strengths and weaknesses. We should know when our treatment has stalled. We should know when to refer out. Some problems will require a team approach. These are all basic things, but important things.

The Strength of Manual Therapy

The primary tool of the manual therapy practitioner is palpation. We pride ourselves on it. However, many practitioners never learn to effectively combine the skills of palpation and tissue engagement to optimize the application of our techniques. This triad is essential to effective treatment outcomes. We are taught these skills in isolation and left to our own devices to integrate them.

Superlative technique has its genesis in moment-to-moment perception of the client's channel of consciousness and their needs - Hugh Milne

As we evolve in practice and master the fundamentals, there are several things we should consider implementing to amplify the effect of our treatment:

Visualization - seeing the anatomy will focus our palpation

Broadening our field of perception - touch is systemic, we need to palpate on a wider lens to see how local tension contributes to distant tension

Listening to tissue feedback - being present to what the body is seeking rather than what we are proposing will make our techniques more efficient

There is no doubt that our interests and philosophy in treatment are diverse. What we all have in common is a desire for the individual to feel better. Far too often we decide what the body needs. We must listen to what the body requires. If we are unable to apply the foundational skills with effect, we have little hope of improving health in either the short term or the long term.

How to be Tissue Trauma-Informed.

With mental health being promoted in all aspects of life, manual therapy needs to be considerate of what this means for us as healthcare providers; in the least we should consider taking a course in Trauma-Informed Care. There are numerous free courses online providing an overview of topics to establish a baseline of knowledge. We should also be considerate of what this means for us on the cellular and tissue level; tension is tied to emotion.

What does being trauma-informed mean?

Firstly, there is an acknowledgement and recognition that trauma is multidimensional: trauma impacts biology, neurology, and psychology. By extension, trauma may also impact behaviour and sociological aspects of life. Supporting survivors of trauma minimizes re-traumatization while providing safety and empowerment. The symptomatic picture of trauma is variable and systemic with treatment often requiring a team approach.

Generally, a trauma-informed approach will recognize the four R's as established by the Substance Abuse and Mental Health Services Administration (SAMHSA):

Realizing - the widespread impact of trauma

Recognizing - the signs

Responding - by integrating knowledge into practices

Resisting - retraumatization

Further, there is also consideration given to safety and trustworthiness, empowerment and choice, cultural competence, and application of universal precautions that protect people who seek help but may not share (for various reasons) known experiences of trauma; physical, emotional, and psychological safety must be exemplified. We must consider our systemic biases.

As manual therapists, we can aid in supporting choice, building confidence, and giving back aspects of control that allow for small daily victories. For example, these victories could come in the form of performing daily stretches. Choosing to actively perform these exercises with consistency and efficacy is a form of success. This can build confidence.

What does being "tissue trauma-informed" mean?

We are manual therapists. We know that releasing tension can occasionally lead to an emotional reaction. The relationship between emotions and tension is bigger than the discussion of this article. However, many of us have experienced it on our tables more than once. From a massage therapy and osteopathic perspective, we must be observant of the vulnerability of tissue. This is different to tissue fragility.

"Part of the beauty of touching is that the body, especially at the level of the fine motility patterns, will tell you the truth" - Hugh Milne

We must approach the body with humility and patience. We must provide an ear to listen. We must be compassionate in our touch and transparent in our message. Trust is paramount. Vulnerability has a palpable presence. It often feels like either an absence of "energy" in the body or a hesitance of the tissue to touch. This level of palpation skill requires experience, practice, and awareness. However, gaining trust of the tissue will yield greater results.

Tension will not be forced into submission. We may feel tension beneath our hands, but the body may be either unwilling or unready to let it go. We have to be present to this. If the body is willing to accept treatment we may have to be in contact with the anatomy until it has become physiologically "ready" to participate in the work required to facilitate change. This waiting period will vary depending on the longevity of relationship to the patient, astuteness in discerning readiness, and quiet observation.

How does emotion present in tension?

In general, feeling somatic tension in tissue is enough in most cases. However, we also need to be open to the mood of tension. Some restrictions are overly eager when they realize help is at hand. Other tension may cower at touch and need to be gently coaxed out of its hiding place. Sometimes tension needs a moment to gather its resources to support the upcoming changes. Whatever the tissue presentation, we must be observant of the receptivity of the body to our techniques.

How do we quantify this sensory perception? It is a skill that is learned through time, presence, and openness. Like feeling temperature change in tissue with inflammation, vulnerability has a frequency that resonates. There is a tangible quality to it. Tension in anatomical form is not the only sensorial sign of dysfunction. We need to see the individual in their entirety. Body and mind.

Massage therapy is framed around the hard sciences. However, there is a philosophical and spiritual aspect to massage therapy that is more difficult to quantify. It goes beyond structure. It will not have meaning to everybody, but it can be taught. It is these skills that will help to discover when tissue may need extra compassion. This is being tissue trauma-informed.

Is Deep Tissue Massage a Commodity?

Deep tissue massage is harming patients and therapists alike. Patients often request deep tissue massage with the understanding that they will receive some sort of hard pressure that targets deeper muscles. Therapists try to fulfill these requests for pressure, which puts too much force into shoulders, wrists, fingers, and thumbs. Patients endure pain and leave their treatments feeling sore. Practitioners put deleterious pressure through their joints.

What is deep tissue massage?

Deep tissue massage is typically performed with either a hard or firm pressure. The general intention is to address deeper anatomical structures. Typically, these deeper anatomical structures will be muscles. Therapists often "warm up" superficial structures with lighter strokes before switching to harder and more focused techniques that address deeper tensions in the body. How deep do we need to go?

If we consider layers of muscles the answer is not far. The deepest muscles in the back are only covered by either the lats or the traps. The hamstrings and quads aren't covered by other muscles. The lateral hip rotators are covered by glute max, which can pose a problem. Tibialis posterior and the long flexors of the foot are covered by the triceps surae. The point is, we don't need to pull out the sledgehammer that many therapists use.

Oliver Twist or Goldilocks?

Just because we are asked for more should we acquiesce? It can be challenging to understand when and where to apply pressure; if we don't use enough pressure, we haven't engaged the tissue adequately. If we use too much pressure, we are overtreating the tissue. Like Goldilocks, there is a bandwidth of "just right." When we are in the right place, pushing with appropriate force, in the right direction, and for the right length of time, the tissue will release.

"You have to learn a thousand techniques in order to understand a single one. Then you only need one." - Hugh Milne

Massage therapy is one of the few health professions where the patient has a substantial say in how the treatment is applied. If a patient asks for more pressure, we comply. If a patient wants to spend an hour on the back, we comply. Chiropractors often don't adjust the cervical spine at the request of patients, but there can be valid risks with that specific application. Massage therapy wants inclusion and credibility, but we also allow subservience.

Unfortunately, it takes years to gain the skill necessary to effectively dialogue with different tissue types. Many practitioners will leave the profession before this happens. Tissue engagement isn't taught comprehensively in schools. Students are shown techniques, but not how to effectively apply them. Palpation is supposed to be our bread and butter, but we continuously fall short. We choose power over precision. This is a losing battle for the therapist.

How do we create longevity?

We need to work efficiently. We need good ergonomics. We must observe how tissue responds to pressure. We need to find alternatives to fingertips and thumbs. We must stop trying to force the body into submission. We should approach the body with curiosity and humility. We need to understand that treating individually is a thing we say rather than a thing we do: each technique is unique within the context of each individual treatment.

"Patience is the least used tool in the massage therapy arsenal."

Massage therapy is its own worst enemy. We are always looking for a silver bullet. I heard Bodhi Haraldsson say in an interview recently that the techniques we learn in school will carry us a long way in our careers. I agree. There are too many techniques that don't live up to the hype. We pride ourselves on palpation, but we really need to focus on tissue engagement. Massage therapy is a game of perception, not a game of strength.