Posted on 2020-10-01 21:50:17

An Introduction

I have been in this manual therapy niche for almost 3 decades.

Hold times were taught at a "minimum of 90-120 seconds" when I entered this world through myofascial release (MFR) training, as this was the time it was said to have taken for the fascia to begin shifting from sol to gel.

But as most patients were said to have several restrictions that would need to be worked through, we were advised to stay around longer. With hold-times sometimes well exceeding 5-minutes, I got very comfortable remembering in place.

The supposed new developments in the understanding of fascial shift pushed the time frame of hold times to 5 minutes after I left the formal MFR tribe in 2006, based on how principles of mechanotransduction were said to affect the work we did.

That's how science works, since science uncovers more knowledge, adaptation in models happens.

Did the sol-gel hypothesis, however, or do mechanical transduction properties completely justify why many of us hang around for very long hold-times? Is there evidence that comes into play beyond fascial science when we remain with our techniques for long periods of time and, if so, are there additional aspects of our experiences that cause longer hold-times to have effects beyond or other than that fascial science?

I rewrote my entire seminar programme during the Covid shut-down, which included the rebranding of what I use as a therapist and what I teach as an instructor. I switched my brand away from MFR and into Manual Therapy, as mentioned earlier.

While there were and are many explanations for this change, one was the silo-like viewpoints that are taken in almost all educational lines of manual therapy / massage branded modality. Each alleges validations from various sources of proof and research that often disagree with the way the therapy is implemented. I was struck early in my MFR career by the immense disparity between MFR (as I studied it) and Rolfing in the application of pressure.

MFR was slow and gentle, using long hold periods that the evidence was said to confirm. On the other hand, Rolfing used faster strokes that were much more powerful and it was claimed that their evidence confirmed these types of strokes. But there were a LOT of the same research articles when I went through the research citations used by each camp. If that was weird at the time, but I knew enough to keep my mouth shut and not question authority.

I have lost contact with what evidence outlets are currently being used for both of these camps and I believe there have been adjustments all over, but even back in the early 1990s, I believed that there were more universal (less fascial-based) reasons for how and why longer hold-times seemed to be successful in generating changes in problems of fight / flight, pain, and movement.

I came upon a study by Cerritelli (2017) titled, "Effects of Continuous Contact on Brain Functional Communication Is Changed by the Tactile Focus of the User" without bogging down this post too much. The researchers decided to look at whether the clinician 's attention to the patient mattered or not, to sum up the analysis. This research may be summarised to question why the possible therapeutic impact would be less if a clinician was disturbed than if the clinician attended to the patient.

Therapists frequently use vernacular to summarise the need for the patient's attention from their modality or values, but as far as I know, this was the first study of its kind to bring such ideas into a research study. The research was set up with a patient being cared for by a clinician at their ankle. In order to assess if brain function changed with the intervention, fMRI testing was carried out during the "interaction." Except for light pressure, the clinician did nothing on the patient's ankle; no "therapy" of any type was performed. They were only asked to attend to the ankle of the patient. Two control groups were present, with the only variable being the clinician 's condition. The clinician was equipped with headphones in one community that transmitted noisy noises, intended to distract the clinician. The clinician had no such sounds in the other party to interfere with their treatment for their patient.

The study showed that little improvement in patient brain activity was reported with the community attended by the clinician wearing the headphones (loud noises interfering with their concentration). But there was a determined change in activation of brain centres towards changes in functional integration in the community where the clinician was permitted to attend to the patient without distraction.

In the full-text link here, I will leave it to you to explore the paper to read the specifics of this outcome. But what I found most interesting was that "functional connectivity changes" peaked at 15 minutes (contact-time) of hold time. Enabling a continuous input, as we do in MFR-styles of interaction, will optimise the added advantage of neurological input / output.

As physicians, a great deal of recent research has shown that our findings are not exclusively related to what we do with the tissues, but are a dynamic , multi-factorial cascade of peripheral, brain, and peripheral effects.

Behavioral variables can play a greater role than local tissue-based responses that are perceived (BIalosky, 2009 , 2010, 2018; Geri, 2019, Kolb, 2020). What we see as consequences of longer hold times embedded in the MFR culture may be due to the mechanical properties assigned to the fascia, but we now know that such hold times are absorbed by the patient's brain, which has the ability to downgrade fight or flight to rest and relax, modulate pain, and increase the quality of movement.

I find it all interesting as it shifts the bar of proof from the dubious interpretation of proof into "fascial evidence" into reasonable narratives embraced by the general scientific community, which is what we should be searching for. Yes, the value of fascia can be reduced to a degree where it is merely a part of the whole and not the forgotten tissue taught to all of us. Peripheral feedback is sensed in the tissues via the different receptors, whether it is skin, fascia, muscle, joints, etc., and sent for processing to the brain.

This kind of data does not negate the importance of what we do, but the way we frame our work will (should?) make us doubt. Hold-times can matter more to our patient's brain than to their tissues, unlike what I was taught.