The Thinking Practitioner Podcast:

Episode 183: Tight Tissue: What Are We Really Feeling (with Til Luchau & Whitney Lowe) 

Til Luchau  00:00

Doing the potato masher model of body work, where we think we just our job is to find the lumps and mash them out and make them smooth. Yeah, and then everything’s good.

 

Whitney Lowe  00:10

Welcome to the Thinking Practitioner Podcast,

 

Til Luchau  00:12

a podcast where we dig into the fascinating issues, conditions, and quandaries in the massage and manual therapy world today.

 

Whitney Lowe  00:19

I’m Whitney Lowe

 

Til Luchau  00:20

and I’m Til Luchau. Welcome to the Thinking

 

Whitney Lowe  00:22

Practitioner. Hello, everyone, and welcome here, where books of discoveries, manual therapy textbooks, e-textbooks, and digital resources help institutes achieve their instructional goals and inspire students to achieve theirs. They find that same spirit here on the Thinking Practitioner podcast, and they’re proud to support our work, knowing that we share the mission of bringing the massage and bodywork community thought-provoking and enlivening content that advances our profession.

 

Til Luchau  00:52

Books of Discovery has just released the new seventh edition of Trail Guide to the Body. This million copy bestseller takes another leap forward in empowering the next generation of manual therapists with all new palpation, video instruction, and a new primer on the nervous system. Instructions of manual therapy education programs can request complimentary review copies to the new seventh edition at booksofdiscovery.com, and you can explore the publisher’s full collection of titles at booksofdiscovery.com, where thinking practitioner listeners save 15% by entering thinking at checkout. I also want to thank our other sponsor, ABMP. The Thinking Practitioner podcast has been supported by ABMP since the beginning. Associated Bodywork and massage professionals. They are the premier association for dedicated massage and body work practitioners like you. When you join ABMP, you’re not just getting industry-leading liability insurance; you’re gaining practical resources designed to support your career, from free top-tier continuing education and quick reference apps like Pocket Pathology and Five-minute Muscles. ABMP equips you with the tools you need to succeed and grow your practice.

 

Whitney Lowe  02:07

And ABMP is committed to elevating our profession with expert voices, fresh perspectives, and invaluable insights through their CE courses, the ABMP podcast, and Massage and Bodywork Magazine, featuring industry leaders like my co-host Til and myself, thinking practitioner listeners like you can get exclusive savings on ABMP membership@abmp.com/thinking. So join the best there and expect more from your professional association. Hey, all right, good day, sir. How are you doing?

 

Til Luchau  02:40

I am good, and I’m glad to be here with you to see how you’re doing and to talk about our topic today. How are you doing first?

 

Whitney Lowe  02:48

I’m feeling a little good, but you know what? I’m getting older, and I feel a little stiff today. So, oh,

 

Til Luchau  02:54

really?

 

Whitney Lowe  02:55

Yeah, just noticing not moving quite so freely as oftentimes, and so

 

Til Luchau  03:01

yeah,

 

Whitney Lowe  03:02

maybe that’s maybe that’s something we should talk about.

 

Til Luchau  03:06

Let’s talk about it. Do you think that’s a feeling, or is like that an objective finding?

 

Whitney Lowe  03:11

It is both for me. It is a feeling which is then verified by palpatory examination. Okay, fine.

 

Til Luchau  03:21

All right, because that’s what we’re talking about today. It’s like, what are we actually feeling when we feel something that is tight or dense or hard? It could, you know, the question could be like, what’s a knot that we feel, or more interestingly, how does that correlate to what actually matters to clients, to actually what clients experience.

 

Whitney Lowe  03:45

Yeah, and I think what we’re going to find as we begin to talk through this is that there’s all kinds of things that might be playing a part in that that we want to try to tease apart a little bit and sort of look at our role in addressing what feels that way or what the person feels as tight.

 

Til Luchau  04:02

Yeah. Well, let’s start with tight. We’re gonna we’re gonna look at it from a few different angles, but let’s start with the tight thing because clients will say all the time, “I you know just feels tight here. That’s why they come to us. Something feels tight.” Now we don’t know yet at that point in the conversation, what might actually be happening, and how we might even approach it, because tight could be just a felt sensation, like a a sense of pulling, or a stretch, or tension there. So we might need to ask more what is what they mean, or have it described in a way to understand if that’s what they’re talking about. People also use the word “tight” to mean stiff or sore. “Tight” has become like shorthand for something that just feels achy, or “makey” is a different word. Something that feels sore or a little painful or uncomfortable or restricted. The because that word actually turns an experience into a mechanism just by itself. When someone feels uncomfortable in their shoulder and say says it’s tight, that already is starting to explain it as something that is pulling or shortened or has some tension to it in a way. When that might be the case, or it might not be. And if we again just go with that concept of oh, it’s tight, so I need to loosen it. That’s going to help some people. It’s going to not help a lot of people.

 

Whitney Lowe  05:34

Yeah, you know, I thought as we were talking about this too, sort of another scenario that that represents tight in a slightly different way, and this would be under certain circumstances, but that we don’t talk about very much, and that is like extensive inflammation, for example, that might technically make something be tight because your skin is tighter because there’s more fluid under the skin that is making the swelling up, and so it just it doesn’t move as freely, and it feels like your skin’s being pulled tight because it is.

 

Til Luchau  06:08

Okay, so that’s yeah. Let’s just look at that phrasing a little bit because it is again. That that assumes the objective finding is the one that

 

Whitney Lowe  06:17

is, yeah,

 

Til Luchau  06:18

and the subjective finding, the feels tight, is the one that is perceived, and so maybe isn’t actual. But we again to keep those separate is going to be really helpful here because the feeling of it being tight is is important, as is the mechanism. Yeah, and the other mechanisms on our list of what could make something feel tight include muscle tone and guarding, like literally, a muscle could be contracted, either like a resting tone or a protective tone or a protective pattern of of not relaxing. That’s the simple map that a lot of massage perspective goes to first. Says, how can I make this relax so that it’s not tight, so that that doesn’t hurt, and that those are leaps along the way. First, that it’s a muscle tone. Second, that making it relax is going to do something, and then third, that that’s the result that it’s not going to hurt.

 

Whitney Lowe  07:17

Yeah,

 

Til Luchau  07:17

sometimes there’s another kind of besides the swelling you mentioned, is another one too, which is fascial properties, fascial stiffness, changes in elasticity, resistance to deformation under load. It’s there’s a lot of ways to describe that when we, I’m thinking of some of our guests in the past. I’ll pull up their references in a second here, who have gotten very specific about this. How? What exactly we mean when we talk about fascial stiffness? Because there’s all the social media debates about you can’t stretch fascia, and the limits on our ability to permanently deform fascia are pretty agreed upon. But there is a stiffness or a viscoelastic property, hydration qualities, all kinds of things in fascia that change the way the stiffness or the tightness that it has, both when measured but also when perceived.

 

Whitney Lowe  08:14

And this is also is frequently what people refer to when they hear the term densification. Correct, that level one stiffness.

 

Til Luchau  08:22

This is a term again. I first heard it from Antonio Stecco. I’m not sure he originated or not, but that’s his explanation he uses for those denser things we feel. And in his model, that causes more distress to the nerve endings within or around that denser zone of

 

Whitney Lowe  08:43

fascia,

 

Til Luchau  08:44

and so that you know densification is one possible explanation for fascial stiffness. But like I said, there’s there’s overall hydration changes as well. There’s interlayer shear, like how much do layers slide against each other? That’s going to determine how stiff it is. There’s literal thickness, and there’s evidence to show that thickness correlates with pain, and painful things tend to be thicker. Whether that’s a cause or a correlation, we don’t know. But there’s a lot of different ways that fascia can play into this tight or stiffness thing that we feel.

 

Whitney Lowe  09:20

Yeah,

 

Til Luchau  09:21

go through those.

 

Whitney Lowe  09:22

There’s as we were, we’ll get into exploring this a little bit more too. But there is some comparisons that we want to make here between what clients are experiencing and telling us, and what we’re feeling and noticing with our hands. And that seems to be kind of a an interesting place to to look into this. And so, I’m curious. Like, what what do you kind of like when you’re doing this? Do you maybe what do you ask to try to help get that sensation, the clarity of that sensation with what the client says? Do you ask for more specific words, or like, you know, tell me more about what that really feels like? Okay, so

 

Til Luchau  09:56

back to that client that says it’s tight. What what are some extra. Things they might say at that point. Yeah, I’ll want to know what they mean. So I’ll say, when you say tight, can you describe that more? And they’ll sometimes they’ll have some more words. It’s worth a try. Sometimes they won’t. They’ll just go tight. You know, tight.

 

Whitney Lowe  10:13

Yeah.

 

Til Luchau  10:13

But they they might be gesturing in a way that has a quality to it that gives me information about what tight is like. They might model it with their hand. They might make a fist when they say type. Those are communications that are meaningful to me as a practitioner. Those do convey a tone, you know, tone, so to speak, of experience that gives me a empathetic or intuitive sense of what the experience of that is like for themselves. But I can get more specific too. I can say, is that a pulling? Is that a soreness? Is it you feel it when you move, or you just feel it when you’re still? I start to give some choices there too that helps narrow down what is meant by tight, for example.

 

Whitney Lowe  10:55

And I think when we’re whenever we’re talking about these kinds of open-ended, both questions and conversations with their clients, there is a line or sort of a fine line sometimes between what you’re suggesting of like giving them some ideas of descriptive words and then putting words in their mouth. Just leading the witness. Yeah, if you just give them one option, for example, then it’s a lot less clear or a lot less easy for them to give a variety of different sensations.

 

Til Luchau  11:20

Giving them one option, like oh, tight, yeah, like it. Does that feel like

 

Whitney Lowe  11:24

an electrical, you know, metal cable? There you go. That is one

 

Til Luchau  11:28

step better than just assuming what they need. Sorry, what they mean they mean about by tight. But no, the multiple choice options will help them find their own words. I suppose it’s just try to tell you what you want to hear.

 

Whitney Lowe  11:42

Yeah. Well.

 

Til Luchau  11:45

Okay. So this is in service of me knowing what they mean by tight. But there’s also the point of view that says I can feel as a practitioner, and what I feel I can work, and that that’s helpful for the client. This is true. We know all the times the other side of that experience where clients will, while we’re working on them and working something that we feel, they say, “How did you know that was there? I didn’t know that was tight, right? I didn’t realize that.” Or what’s they’ll ask you, “What do you feel there?” Because they’re feeling us feel something and they feel something and they want to figure out what that’s like from the outside. That’s a really rich phenomenon that we do feel things, tight or otherwise, and that our clients feel things too. But that can be really oversimplified into us just doing the potato masher model of body work where we think we just our job is to find the lumps and mash them out and make them smooth, yeah, and then everything’s good. Yeah, some things respond well to that, but there’s so many more possibilities you could say. Yeah, and there’s so many things that don’t respond well to that too.

 

Whitney Lowe  12:59

Yeah, so this seems like something that maybe has been ingrained in us from the very beginning of our training. So I mean, is that like why do you why do you suppose that it’s easy for us to kind of like get that assumption that just making something softer is what makes someone feel better?

 

Til Luchau  13:15

Still, because it works a lot of times. I mean, that’s that’s right. Yeah, you get it. You grab your friend’s shoulder, you start rubbing it. You feel for what’s lumpy, and you squeeze it, and they feel better. Yeah, and so it’s it’s and that’s there is that’s a lot of it. There’s a lot to that, but again, we turn that into a mechanism. Think, okay, my job is just to find the tight or dense things and make them soft. That’s again, that’s only part of the story.

 

Whitney Lowe  13:38

Yeah.

 

Til Luchau  13:39

So because

 

Whitney Lowe  13:40

and we’ll maybe touch on this a little bit later on too. That you know there might be instances where you will feel something that feels in what you would perceive as a practitioner tight, but making it softer is really not a good idea. Like in an instance where you know a muscle is or muscle group is guarding something that is injured and is trying to maintain stabilization in an area. So this is where our smooth the mashed potatoes is probably not such a good idea.

 

Til Luchau  14:11

An extreme example might be low back pain, perhaps associated with disc issues. Yeah, there could be lots of useful stiffness around that pattern that keeps people out of pain, and when we get in there and just do the potato masher thing, discs in particular are notorious for getting more troublesome after indiscriminate case of deep tissue work on the low back. So that yeah, it does take some discrimination and understanding like when softening might not be a good idea, and then but then there’s gradations too because even if it is you said injured, even if something is injured and we have some protective tightening, muscle tightening, let’s say that doesn’t allow us to move it freely, exploring. The edges of that, or helping reassure by investigating what is possible, is a really effective way to work with that.

 

Whitney Lowe  15:09

Yeah,

 

Til Luchau  15:10

rather than just again steamrolling it, we we find the protective tightening, you could say, and schmooze it, or ask the client to reevaluate it or give through our hands and through our movement and through our pressure. Really, do you really need to be having this much tightening? So many things get better with just a shift in the client’s protective responses.

 

Whitney Lowe  15:38

Yeah,

 

Til Luchau  15:39

even

 

Whitney Lowe  15:39

and that can be a little bit tricky to figure out sometimes because, for example, a person could be on the treatment table in in a non gravity well, it’s not a non gravity position, but non standard gravity position because they’re lying down on the treatment table, and you do something, and you know you’ve worked on an area that feels you know we’ll use the word tight to your hands, and that is some kind of protective biomechanical pattern there, and it really feels good to get those tight muscles to loosen up. And they’ll say at that point that they feel really good, but then it’s they get up and start moving around, and what was formerly a proprioceptive protective mechanism for an injury is now all of a sudden a bit more unstable because we’ve loosened all those muscles, so something could feel good immediately and maybe not be ideal in the in the long run for the short term. Anyway,

 

Til Luchau  16:30

there’s lots of times when that happens. Like you said, if it’s a protective, a functionally protective pattern, inflammation sure gets worse when you are too aggressive with it. There’s also, I mean, Tina Wang came and talked to us about hypermobility at another episode too. People where movement is the threat more than the solution, and deep work will often feel good to people in that situation because their muscles are so tired from protecting their movement that it feels really good to have some pressure, but again, without some discrimination, skill, pacing, and other options, just getting things soft on someone who’s already dealing with hypermobility challenges won’t be helpful. I feel worse later,

 

Whitney Lowe  17:15

right? So you know, frequently you discuss something that Robert Schleip had wrote about. I believe this was in your book where he talks about some different models’ ideas about this whole aspect around stiffness. Can you share some of those with us? Sure.

 

Til Luchau  17:32

This yeah, I wrote about in my book. It was it was Robert Schleip’s writings elsewhere. But if you don’t know Robert Schleip, he’s a fascial researcher and former Rolfer, he was a former mentor and colleague of mine at the Rolf Institute, and he’s been on the show a couple times. Actually, want to see if we can get him back to talk about this because, in some ways, his academic and maybe practitioner career too was about this question: What is happening when something is tight? And his focus has been on the fascia. What’s happening fascially? And he has really dialed it down in so many ways, and and fostered and supported and inspired and dialogued with other researchers who are after the same kind of question. But his after many years of research, and this again, this is about 10 years ago still, if I remember right, he narrowed it down to there’s probably three things that explain what’s happening when something gets softer under our hands. And his summary was that’s probably either a skeletal muscle change, so the muscles pull on the fascial structures, like just you could just think of a tendon as the most direct pull on a fascial structure, the tendon being fascia. But then the interconnections from the muscle muscular fascia out into other fascia, or from the tendon into other structures. Maybe that skeletal muscle is relaxing, and that helps our whole fascial network have less tone to it, so maybe we’re actually feeling a change in resting muscle activity. His second possible mechanism was the matrix of the fascial tissues has hydration changes in it. And 10 years ago, when he wrote this, we knew something about that. We know a lot more about that now, and that is a big part of this softening effect that we feel when we are feeling into the fascial changes with pressure. So where there’s there’s actually

 

Whitney Lowe  19:34

oh I’m sorry I didn’t mean to interrupt. I was just going to try to clarify: is this what we are talking about when we when we refer to like the hyaluronan increases as a result of the pressure and the stimulation of of greater lubrication in between tissues,

 

Til Luchau  19:50

changes in the availability of hyaluronan, free water bound water changes, hydration changes. Antonio Stecco came and talked about some of his work. Around that on one of our episodes too, but it’s basically the the idea of tissue as a sponge and the amount of water soaked into the sponge or free around the sponge is changing, and that really changes the way it feels to our hands and to an elastographer and things like that. Actually measuring that.

 

Whitney Lowe  20:19

Okay.

 

Til Luchau  20:20

The third, and he said it’s going to be one of these three things. Schip said when we feel something soften, it’s going to be one of these three things. The third thing he said is practitioner expectancy, and idiomotor effects, meaning ways that I think about things changing the motor effects of my hand. So he says expectations on the practitioner side could change the way I use my hand or my own body, or change how I interpret what I feel, so that I I feel my own relaxing say, and I think that’s the client.

 

Whitney Lowe  20:53

Or

 

Til Luchau  20:53

as I wait there, my own tension changes, and I expect that interpret that as the softening of the of the client’s tissue, for example, or I expect, you know, I expect that to happen, and so it does. All those factors in there. He says it’s probably one of those those three things: skeletal muscle, hydration changes in the fascia, and practitioner expectancy. He has done a lot of research on fascial contractability. We used to talk about fascia contracting actively more than we do now. We know from his work and others that it does have an active contractile component, but it’s pretty subtle and pretty slow, and could conceivably just cross into that threshold where it’ll change the way the tissue feels, but probably not as a major factor in what we’re feeling day to day.

 

Whitney Lowe  21:43

Yeah, that was particularly interesting. What you were mentioning too, and and he talked about this further too. the The role of the practitioner is feeling what you are sensing and feeling with your hands being part of that change. I found that really interesting.

 

Til Luchau  22:00

That is really interesting, and and this hydration change too is was a shift when he’s first started saying this is what we’re finding because we learned in my day that we melt fascia, that it melts like cornstarch, like thycostrophy, where it’s just the pressure makes it liquefy, and then and then quick pressure makes it firm. There is some of that quality and its different mechanical properties, but it’s much more complex than just a melting fascia, and it’s probably mostly due to hydration changes.

 

Whitney Lowe  22:33

Yeah, which is good. That for me personally, I think it’s good that we’ve gotten a little bit away from some of those models and those terms, because it did lead to a bit of misunderstanding about thermal changes happening there. When we use the word melt, everybody there was a lot of jumping into this idea that we’re the heat is what is doing this kind of thing to this tissue, and maybe there’s a piece of that, but it certainly there is to be the major

 

Til Luchau  23:00

factor. Well, yeah, literal temperature does really change the rate at which these changes happen.

 

Whitney Lowe  23:06

Yeah,

 

Til Luchau  23:07

so it’s you know warming things up is is a literal as well as metaphorical. Yeah, one

 

Whitney Lowe  23:14

of the we were talking a moment ago about some of the debates and critiques that are happening around this. So one one certainly that we’ve heard debated a lot, at least on social media and some of these forums and different environments, is that the tissue qualities aren’t linked to, or at least are not reliably predictive of pain. The quality of the tissue may not be predictive of the pain. So, is that still a fair statement in relation to what we’re referring to here with tissue quality that we feel, etc.

 

Til Luchau  23:48

But sure, but maybe some background is helpful there. It’s there when the I think Walt Fritz calls them the pain science wars or something like that. Yeah, I

 

Whitney Lowe  23:59

love them

 

Til Luchau  24:01

too. When and there’s now 1015 years ago when there were these.

 

Whitney Lowe  24:05

There’s a ceasefire going on, right? Meg is not entirely over. Did Tom?

 

Til Luchau  24:09

Who knows? There, when people started to really question our assumptions from and from the biopsychosocial point of view, that really de-emphasized the bio part of that, saying that all of our explanations up to this point, the argument went, were bio, meaning they were structural or tissue or tangible, and maybe there’s a lot more explanations for what happens in hands-on work, for example, that include the psycho and the social levels, and so or perceptive as well. So the extreme point of view in those arguments was there is no correlation, or so there were people who were saying literally and claiming it repeatedly: there is no evidence that there is a correlation between tissue quality and pain. That I thought that we’re. Softening tissues so that people feels better is just a random association we make post hoc based on what we’re seeing, not on any mechanisms that we can actually research and and verify. That’s probably extreme because there, even at that time and since then, there are there is evidence of at least correlation between tissue qualities and pain. It’s I think there’s probably still things we need to clarify or agree upon for sure on the causes of the what actually changes if we change tissue synchrosis. Does that reliably change pain? I don’t know that we’ve established that, but clinically, yeah, we know that we can work with things that feel tighter or feel denser, and have a change in the pain qualities for sure. But it’s it’s worth really keeping in mind that those are separate things. That was the point, I think, that the thickness or the density or the stiffness is not the same as pain, and it’s there’s not a one to one correlation, because all the time you’ll you’ll find people like the hypermobile question who don’t feel tight to our hands,

 

Whitney Lowe  26:14

yeah, but

 

Til Luchau  26:14

feel tight to themselves,

 

Whitney Lowe  26:16

yeah, and then

 

Til Luchau  26:16

when we work them, they feel better for a bit, and then they’ll often feel worse the next day because of having been worked so deeply.

 

Whitney Lowe  26:24

Yeah,

 

Til Luchau  26:25

or people that will get you’ll probably hear this all the time. You know, I feel tight. Don’t you feel that? And sometimes we do. Yeah, it’s really obvious something that’s contracted in a very in different ways, but often there won’t be a difference in someone’s palpated tissue tone or quality, but is still very obvious to them.

 

Whitney Lowe  26:48

Yeah, I’m going to do dwell on that for just a second. Ask your opinion about this. Like, if somebody makes a statement like what what you just suggested, oh, this feels really tight, and don’t you feel that? Is that reinforcing a nocibo message with them? Do you think if we validate, yeah, I feel what you’re feeling right in there. Have we have we sort of ventured into that sort of nocibo landscape there?

 

Til Luchau  27:17

Nocibo being the idea that we’re reinforcing an idea that it hurts, and so it does hurt.

 

Whitney Lowe  27:22

Yeah,

 

Til Luchau  27:23

the idea there’s. Uh, I don’t know it. I think. I think when we say, “Oh yeah, you’re messed up there,” then yeah, for sure.

 

Whitney Lowe  27:33

Yeah,

 

Til Luchau  27:33

and we. I hear that all the time. It’s it drives me. It’s one of my pet peeves. I really have to work with myself when I’m under the hands of practitioner. Feels my, whatever. and says, “Oh, oh man, I’m glad you came in.” I wonder, I wonder, and yeah, or even I mean, we were much cruder about it in general,

 

Whitney Lowe  27:53

you

 

Til Luchau  27:53

know, decades ago. But like, oh man, this is messed up. Yeah, yeah, which is it’s

 

Whitney Lowe  27:59

the worst traps I’ve ever found,

 

Til Luchau  28:01

yes, or that that kind of thing to frame the client’s perception into a context that makes it a problem. Yeah, I think is probably nociceptive. It does cause nocipic reaction.

 

Whitney Lowe  28:16

Yeah,

 

Til Luchau  28:16

but just pure description. Oh, you know, what do you feel there? I go, oh yeah, I feel something denser there. That’s just accurate perception, and we haven’t weighted it as a problem yet. Even we’re just validating, we’re just we’re correlating what they feel and what I feel.

 

Whitney Lowe  28:32

Yeah,

 

Til Luchau  28:34

and then I work it a little bit. I says, okay, so what’s happening? How do what’s that feel like now? They say, well, yeah, starting to feel better. I said that’s interesting. I feel it like glide easier too. So that’s just comparing our perceptions and maybe even correlating them. Yeah, I think it’s spinning them toward being a nociceptor or placebo, even.

 

Whitney Lowe  28:57

Yeah. So we had looked at a number of other research studies and things as we were looking for some of the base information for this episode here. Do you want to talk about the Stecco next study a little bit?

 

Til Luchau  29:11

We should. There’s there’s a lot of background that went into this conversation. This is 2014. We’ll put the references in the show notes. And he mentioned it on the his conversation with us, but it was interesting. One, he compared 28 neck pain patients with 25 controls, and the the treatment arm received his fascial manipulation method or some other treatment on the control arm, and the assessment included ultrasound and range of motion and pain reports, and there was a clear correlation between getting work and feeling better, and getting work and having thinner neck fascia, especially on the superficial layers, but also some of the deeper cervical fascia that changed his qualities. Now, again, it didn’t quite prove costation. It was more of a correlation. It was a small study, but since then there have been other ones like Wilke. He pooled 14 different studies that involved 1000 people, and found that people with low back pain had thicker thoracolumbar fascia, and a smaller subset also had higher stiffness. So the thickness was a really higher, highly correlated. The smaller correlation was stiffness, meaning that sometimes there’s maybe something we feel that correlates with their back pain. Other times there’s not going to be. So there’s no evidence in those associations. Those are in just comparisons, but they they do show more than again back in the pain science wars was being claimed by the side that there there is a correlation at least, and that and that there’s as that as the one measure changes, the other measure can change too. That they move in tandem,

 

Whitney Lowe  30:53

right? We had also. I’m sorry. Go ahead.

 

Til Luchau  30:56

No, I was going to say I want to try to get either Schleip to come back. He did another review about this year of 14 ultrasound studies around that thoracolumbar fascia. We had Helene Langevin come in and talk to us about her low back pain study too. So Schleip just did a review of 14 different ultrasound studies, and found again some correlations. There’s some limitations there that he that are interesting, and I want to hear how he weaves the thread through there because there were some really promising or interesting findings, and there were limitations as well too. So I won’t try to summarize from his recent study, but I want to try to see if we get him back to talk about that himself. Yeah,

 

Whitney Lowe  31:42

let’s let’s let’s have him dive in that. I know that is a topic he has been exploring extensively for many years, so it would be good to to dive in a little bit more with that. So, well, how does that how does that fit with some of the newer you know reviews and questioning whether these various different approaches, like myofascial release and you know massage and soft tissue manipulation of various different modalities, changes tissue tissue stiffness. Do you think there’s a an initial kind of takeaway that we can can look at?

 

Til Luchau  32:14

Yeah, I think it’s pretty clear that you can change tissue stiffness. Now, whether that changes and and that you can change pain,

 

Whitney Lowe  32:23

yeah.

 

Til Luchau  32:23

Whether that’s the same thing or not is really not established. And you know, there’s there’s lots of work to be done on dosing context. Who? What about the exceptions? All those questions are still really unanswered. Partly that’s the nature of research. You got to get one variable at a time and study it, and it takes time to put the whole picture together. If you ever do, but yeah, I think it’s we’re past the point of being able to say there’s no correlation. Obviously, most most clinical practitioners will agree that they can feel something denser, and when it changes, people feel differently too. We just, I mean, think the point in the episode here is like we just can’t assume that those are the same thing.

 

Whitney Lowe  33:06

Yeah. So that you know, kind of begs the question too. That so what are we in terms of kind of like what are we trying to look for and and achieve as as our goals and focus? So we always like the explanations. Yeah, I know. I do. I want to know why. What’s the reason? What’s the rationale here? So, can

 

Til Luchau  33:30

we? What do we still need to know to kind of like be able to say what we’ve done has changed the tissue consistency like that? Boy, what do we still need to know? Let’s ask, let’s ask Robert if we get him on the show, or let me give that some thought too. Because honestly, I mean, he’s done a lot of work with his elastometer, a little device he invented or adapted for clinical use, so you can actually check your client’s tissue elasticity during the session to see if this technique made a difference. Yeah, that’s actually if this understand your question right, but that’s less of my interest. I am actually less interested in the objective findings than I am in the subjective findings. I clients come to us because they hurt or they want to move easier or because they’re stressed, you know they feel stressed. I’m interested in the feel parts of that, like how can I help them feel differently? And mechanisms are really cool and fun, and they might help us get more accurate in our clinical application. They certainly help give us more accurate models, so that we don’t assume tight means contracted, for example. But I again, I’m I’m much more interested and oriented toward helping people feel better than understanding what we need to do to really nail down this correlation to tissue change. Tissue change isn’t my goal. As much as it used to be at all,

 

Whitney Lowe  35:01

right? And that kind of gets into an interesting question too about what is actually getting studied in the research, because oftentimes we do see that pattern, which is a research study is constructed around what they have the capability to measure an objective

 

Til Luchau  35:18

measure and tissue change, yeah,

 

Whitney Lowe  35:20

right. Probably some of those subjective responses that you’re talking about are probably the clinically most important, but maybe research-wise harder to isolate. That might be, you know, again the reason why they focus on some of those more objective findings.

 

Til Luchau  35:39

Yeah, and we’ve been talking so far in the conversation mostly about the like Schleip’s three mechanisms for what what’s happening when we feel something softening. There’s another. There’s a bunch of more explanations of why the client feels better, too. What happens for the client when we work something and it seems to soften or change in their perception, and sometimes that’s just like you’ve you’ve mentioned this a lot. Descending modulation,

 

Whitney Lowe  36:09

yeah.

 

Til Luchau  36:09

Our brain starts to turn down the signal, so that it actually there’s less there’s less signal reaching our processing center, so it’s it feels differently, or it could be just tolerance to the sensation, too. Yeah,

 

Til Luchau  36:25

or a change in the reactivity around a sensation. Again, I’ve said this other times in the podcast, but pain could be thought of as just aversion at the level of the insula, just movement away from a sensation. And if we can change it around toward interest or curiosity or toleration, pain becomes a sensation in a different way, and isn’t quite as threatening. So sometimes it’s just a recontextualizing of the sensation too that changes how it feels quite a bit.

 

Whitney Lowe  36:55

Yeah. So I’m curious with you and the things that you sort of like the way you look at what your desired goals are in working with somebody, you said you’re not as probably motivated or interested in tissue changes as you are in the subjective experience of those changes. So has that has that changed the way you work, or or has it in terms that all that’s

 

Til Luchau  37:18

completely shaped the way I work from the way I was trained and thought, and actually taught myself for at least a couple of decades, it really was an important shift. From again, it goes back to the old models of an objective in quotes obsess assessment, where we look at where someone is in space in terms of their alignment, or in quote distortions, and then we go to change those things objectively so that we can take a picture and it looks different afterwards. This used to be our model. It’s not only too high model. So many people work that way effectively and do good work, but that’s much less my approach now to understanding how does the client feel in terms of their mobility and in terms of their proprioceptive acuity, in terms of their pain, and to start with that as a starting point, what is their mobility and proprioceptive experience, and then look to work with that, and that’s what I’m actually looking to shift or expand. In the case of mobility, I want more options. I don’t want just more range of motion necessarily, but I want someone to either be immobile when they need to, or adaptable when they when that’s being called for.

 

Whitney Lowe  38:36

Yeah,

 

Til Luchau  38:37

balance being a great example when we need both. We need ways to like. It isn’t just about being floppy to balanced, and it isn’t just about being rigid. It’s about ability to modulate that.

 

Whitney Lowe  38:49

Yeah, and that I would agree too in terms of of looking at the way I sort of frame things and look for those different kinds different kinds of outcomes, and and most of the time those things tend to work together. The tissue change does seem to be coordinating and and consistent with the the desired or or reported sensations of improvement. But every once in a while, there’s different things. You know,

 

Til Luchau  39:19

you’re yeah. Tell me how your thinking about that has changed too, because I know that this is something you’ve thought about a lot.

 

Whitney Lowe  39:26

Yeah, I think it’s I think it’s very similar. I mean, we, and again, sort of you know, for me the as as best as possible the assessment, and again, this is looking through the lens of the way I tend to work, which is a lot more about pain management types of things, but the assessment of what what my hypothesis or theory is about what seems to be happening really drives the the choice of those treatment strategies, and then I I try to see like what are the objective indicators that I have you know move. In that direction, a lot of it is subjective reports of changes in sensation and feelings of you know decreased pain or greater freedom of moving of those kinds of things. So whatever it is that, but they definitely seem to correlate with decreases in in tissue stiffness most of the time.

 

Til Luchau  40:16

You know that’s that’s good. That is, and I think another as you’re talking, I realize another way this has changed my work is I really want to understand, even better than I did before, why the client is coming and what their complaint

 

Whitney Lowe  40:31

1. Yeah,

 

Til Luchau  40:31

what does tight mean to them? What is their actual experience of that? And it’s that idea that I I work with their disturbance even more than their tissue, I want to know what’s bothering them on an experiential level, and that’s a shift that’s happened as I work with these questions. The research with Stecco and Schleip have been turning points in my understanding of the role of tissue in that, as well as many of the things we talked about here on the podcast.

 

Whitney Lowe  41:03

Yeah, just out of curiosity, I was thinking about this in terms of the the treatment strategy process. You know, we talked about nocibo language and and not trying to use language that might potentially inadvertently aggravate or make something worse. But what about the whole sensation of like, boy, this feels like it’s really softening up. Can you feel that in there? I’m in like the reverse type thing. You ever try to encourage that sensation of suggestion? I guess it is power of suggestion. I guess that’s a logical compliment, and don’t give nocebos. Yeah,

 

Til Luchau  41:36

but there’s still. I’m interested in the client’s experience.

 

Whitney Lowe  41:41

Yeah,

 

Til Luchau  41:41

and there is a place for reframing, but that’s different than saying, “Oh, this is so good now.”

 

Whitney Lowe  41:46

Yeah,

 

Til Luchau  41:46

oh yeah, can you feel it? I mean, actually, I have seen that used really effectively and cleanly. There are ways that excites the client, something they can feel.

 

Whitney Lowe  41:57

Yeah,

 

Til Luchau  41:58

you know, you know, I know practitioner who will work and then have someone feel it themselves. Doesn’t that feel different? I go, yeah, it does. That’s actually a really tangible change that is reinforces the sense of benefit on the client side. So I’ve seen that used effectively. Maybe it’s just my training and and grounding in in my work as a psychotherapist, it really, from my point of view, really is unfolding the client’s experience, client-centered experience, really understanding what’s happening for them, and if there’s reframing, it’s it’s using their sensation and their actual data in a different context, not trying to feed feed them data or interpret you know or my interpretations As much,

 

Whitney Lowe  42:41

yeah.

 

Til Luchau  42:42

Maybe that’s you know. I probably in practice. I don’t know if I’m that clear about it, but I think there’s probably a place for placebo interventions around what’s happening. But in my way of thinking, I’m much more interested in helping the client discover that for themselves and using what’s already occurring to them to refine and expand their awareness of their body,

 

Whitney Lowe  43:05

yeah,

 

Til Luchau  43:06

as opposed to trying to interpret it for them or suggest things,

 

Whitney Lowe  43:09

yeah. This is as we’re talking about this, and we’re talking about you know the clinical experiences of of trying to get validation from our clients. You know the old “I can’t look over my shoulder when I’m backing up my car thing, and then all of a sudden you do some work with them, like, what is that like now? Can you look over your shoulder, like, wow, I can do that more easily? The immediate sort of sensation about that. But then there is the question, like, how long does that last? You know, is that just a a treatment room oriented result that we feel and they feel better, and then all of a sudden, within hours, it’s back to where it was, kind of thing. But you know, when we talk about tissue stiffness and and you know lack of mobility, I’m also reminded of the. I don’t know if you’ve ever seen this, and we may have referenced this on the on the show before the video that Andrea Spina did about the easily fooled nervous system, demonstrating this. He was showing a like a way in which there is a you know this is commonly done in continuing education courses where practitioners in the front of the room and brings a participant up out of the audience and says like oh look this person’s hamstrings are you know not very mobile they’re pretty tight. They have a limited range of motion. They do something to them, and then all of a sudden, there’s a significant improvement in that range of motion. And then he also he in this little video clip does something to somebody else in the audience, and then goes back and tests his his client’s hamstring length, which is now increased as for himself to doing something to somebody else, you know. So there is that whole thing about the clinical environment that we’re in. Yeah, how suggestive is it? Yeah,

 

Til Luchau  44:47

he’s exaggerating the non-local effect to the absurd. Because you can like check your hamstrings and then open, close your fist, and shake your hand around, and then your hamstrings will change. Right, the pencil push-ups where you, you know, focus your eyes on a pencil, get farther and closer from your nose, and your neck range of motion changes quite a bit.

 

Whitney Lowe  45:09

Yeah,

 

Til Luchau  45:09

I count those as real effects.

 

Whitney Lowe  45:15

Yeah.

 

Til Luchau  45:15

Now they, like you said, maybe they have a different duration. Maybe they don’t last as long. Maybe, but that’s okay with me. I’m going to take this position as almost as a as a devil’s advocate here. It’s okay with me because I’m more interested in learning than I am about the tissue change.

 

Whitney Lowe  45:34

Yeah,

 

Til Luchau  45:34

I’m more interested in someone having a different possibility of movement or imagination for what they can do, they name about a measurable, persistent change in their tissue qualities.

 

Whitney Lowe  45:48

Yeah,

 

Til Luchau  45:49

so that when someone you know does a pencil push up and can move their neck more, yay! Now let’s find a way to really live that, incorporate that that shows you that things can change. There’s lots of usefulness to that. We’re not done, but it doesn’t mean that the change was fooling the nervous system. I would disagree with that framing, or that it wasn’t real in the sense that only objective tissue-based results are real. And

 

Whitney Lowe  46:17

yeah,

 

Til Luchau  46:18

because the assumption there is that’s what lasts, and we don’t. We know those don’t last either. We know even when we do get a measurable tissue change, people are doing life all the time. Tissue is constantly changing anyway. There’s nothing here that we’re working with that’s permanent and enduring.

 

Whitney Lowe  46:32

Yeah.

 

Til Luchau  46:34

And my only hope is that my clients can learn, incorporate, be encouraged, explore, find ways to keep their proprioceptive acuity and their movement options, and then things are good.

 

Whitney Lowe  46:47

Yeah. So

 

Til Luchau  46:49

thanks for letting me get up on my soapbox for a minute.

 

Whitney Lowe  46:52

I loved it. Yeah, I loved it indeed. So if we kind of like try to wrap up the whole clinical practice idea in sort of a summary thing, if if I was to say someone comes in says their neck is tight and you find a sort of firm tender area, what do you do next? What’s what’s kind of like your your next go to strategy? I want

 

Til Luchau  47:13

to know what they mean, and I ask questions and have them do movements to find out their present moment experience of tight. I will then do an experiment with movement. Usually, my hands are a hands-on practitioner, so I’ll go do some work, and then I’ll check again about their experience of what they were first talking about.

 

Whitney Lowe  47:34

Yeah,

 

Til Luchau  47:35

because that’s is that change that’s going to be meaningful to them, and that’s also going to help me tune what I do, and and often it’ll be a couple rounds of trying something. We’ll see what’s changed, what we learned, and now try a little more of that or something different if it wasn’t on the right track. And together we find what does make a difference to what they were reporting.

 

Whitney Lowe  47:56

Yeah,

 

Til Luchau  47:57

and it’s not always. I should say, you know, it’s not always the thing they feel as tight. That’s not always where I work. It’s a much bigger artistic or non-linear approach that it’s you know bigger than our summary question can handle here. But that’s it’s that cycle of like I want to understand the experience. I want to try something. I want to recheck with their experience.

 

Whitney Lowe  48:20

Yeah, I want to also just briefly highlight something about what you’re talking about in terms of the way you’re working there. That’s a real powerful effect clinically, which is that these things that you’re doing to constantly check in with somebody about their personal experience that has a lot of real clinical power of benefit. I think of building that the the more really strong connected therapeutic alliance, because in our healthcare system in general, it’s just not that often that people repeatedly, that a practitioner is repeatedly really wanting to know how are you feeling, or what is feeling, what is this sensation like for you, and really delving into that in that level of detail. And I do think this is one of the most significant differences in the way that many of us will tend to work than the way that lots of folks have had experience. That that’s that’s really powerful and really beneficial.

 

Til Luchau  49:20

It does, and I know we’re wrapping up, but I just keep thinking of more things. I talked about how I really want to unfold what the client is experiencing, rather than lead their experience with leading statements. I would stand behind that, but I just want to say more. I have seen effective practitioners like the ones I mentioned. I’m just thinking of my colleague Boytek Kakowski, he is so good at helping clients feel something in their shape, something in their tissue. He does a lot of scar work. He does a lot of cranial work, where he’ll actually have the client feel it before and after, and his framing of that. Artful, so artful that people are enthusiastic about that those changes. So that’s his medium for dialog with the clients is through that. Now it’s he does it, I think, really cleanly and clearly and grounding in the client’s experience. That’s different than a problem only the practitioner can feel, and there’s no client of experience of that, and then the practitioner determines when it’s fixed or better. And again, the client just has to wait and see if their symptoms were better. Yeah, that’s a little more untethered, I think, in in the client’s experience, and has more ground, more possibilities of what misuse or even deception, or even explanations that soothe the practitioner but don’t sue the client. Put it that way,

 

Whitney Lowe  50:48

right?

 

Til Luchau  50:50

What else you want to add? What have I not covered that you want to make sure we mention? Anything at all?

 

Whitney Lowe  50:55

Yeah, my. I think we got to the main things that I was really curious about. I feel better already. I feel more free and mobile, and yeah, just talking about

 

Til Luchau  51:08

1. It’s amazing. Another amazing case. How about that? Amazing success. Yeah, buddy.

 

Whitney Lowe  51:15

So, yeah, I think we we hit on a lot of those kind of things, and the one of the key things I would like to just remind everybody is that we’re still learning a lot. We still have a lot left to learn. We have some interesting questions to investigate, and you know, continue to explore some of this stuff. And let’s let’s do. We will try to get Robert Schleip back on here to talk about this again, because this is certainly one of the areas that he has explored extensively, and and it’s it is pertinent to all of us that are doing manual therapy. In spite of me

 

Til Luchau  51:43

saying I’m less interested in tissue changes, I am interested in what Robert Schleip has to say about it. I always learn something, and he makes a very compelling case always for what in the research is useful to us as clinicians.

 

Whitney Lowe  51:56

Yeah,

 

Til Luchau  51:57

this episode is also brought to you by the Academy of Clinical Massage, and my co-host Whitney Lowe’s newly evolved orthopedic medical massage specialist program. If you’re a soft tissue specialist, you deserve a path to becoming a respected clinical expert with a practice that’s both financially rewarding and physically sustainable. That’s exactly what Whitney and the Academy of Clinical massage are here to help you build,

 

Whitney Lowe  52:22

and we have completely redefined advanced continuing education with a heavy focus on personalized learning, an interactive, self-paced path that adapts directly to your unique clinical background goals and interests. It’s designed to function as a complete practice accelerator system. You’ll master evidence-informed assessment protocols, treatment strategies, and deeper clinical reasoning to solve complex pain conditions with confidence. So visit us over at theacademyofclinicalmassage.com to start your personalized learning journey and thinking practitioner. Listeners can get $75 off their full certification program by entering the code thinking at checkout, and again, we would like to thank everyone for hanging out with us today, letting us reside between your ears for a little while. Thanks to all of our listeners and to our sponsors. You can stop by our sites for the video show notes and transcripts, as well as any extras. Over on my site, you can find that at academyofclinicalmassage.com. com and til where can people find that for you?

 

Til Luchau  53:25

People can get all those things on my website advanced dash trainings.com, and we want to hear your ideas or input about the show. We just got a nice email from someone talking about the last episode. We’re talking about what really matters to clients. It’s great when we get nice, complimentary, inspired emails like that. But we want the quibbles too. We want the ones like are you guys talking about that or what about this? I enjoy those a lot too. So email us at info@thethinkingpractitioner.com or look for us on social media and YouTube under our names. My name Til Luchau. Whitney, what’s your name?

 

Whitney Lowe  54:02

People can also find that under my name, Whitney Lowe, on those channels as well. And we would really appreciate if you could take some time to rate us on your podcast player of choice, whether that’s Spotify, Apple Podcasts, or wherever you happen to listen. It does help others find the show, so please take a few seconds to do that. And thanks again, as always, for sharing some time with us. Please spread the word, tell a friend, and we will look forward to seeing you in the next episode.

 

Til Luchau  54:29

Thanks, Whitney. Thank you, sir.