Show Notes:

10: Whitney and Til consider the debates about tissue-based effects in manual therapy, and share their views about when it makes sense to think about the actual tissues and physical effects of hands-on works.

In this episode,

  • Why would people say that the tissue doesn’t matter in manual therapy?
  • Examples of tissue-based narratives; the arguments for, and against
  • Til and Whitney ask each other, “What tissue effects do you think about when you’re working?”

Join two of the leading educators in manual therapy, bodywork, and massage therapy, as they delve into the most intriguing issues, questions, research, and client conditions that hands-on practitioners face. Stimulate your thinking with imaginative conversations, tips, and interviews related to the somatic arts and sciences. With Whitney Lowe and Til Luchau

Resources discussed in this episode: 

  • Rathbone A, Henry J, Kumbhare D. Comment on: A critical evaluation of the trigger point phenomenon. Rheumatol (United Kingdom). 2015;54(6):1126-1127. doi:10.1093/rheumatology/kev028, 
  • Jacobs D. Dermoneuromodulating. Victoria: Tellwell Talent; 2016,
  • AcademyOfClinicalMassage.com
  • Advanced-Trainings.com

Anatomy image courtesy Robert Schleip, ©fascialnet.com 

Sponsor Offers:

Your Hosts:

Til Luchau Advanced-Trainings        whitney lowe
Til Luchau                          Whitney Lowe

Thanks for listening and subscribing to the podcast! Make sure to connect with us on Twitter, Instagram and Facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on Apple Podcasts!

Your Hosts:

Til Luchau Advanced-Trainings
Til Luchau

whitney lowe
Whitney Lowe

Thanks for listening and subscribing to the podcast! Make sure to connect with us on Twitter, Instagram and Facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on Apple Podcasts!

(The Thinking Practitioner Podcast is intended for professional practitioners of manual and movement therapies: bodywork, massage therapy, structural integration, chiropractic, myofascial and myotherapy, orthopedic, sports massage, physical therapy, osteopathy, yoga, strength and conditioning, and similar professions. It is not medical or treatment advice.)

Full Transcript:

Tip: use the printer sharing-icon for a pdf!


The Thinking Practitioner Podcast:
Episode 10: When Does the Tissue Matter?

Broadcast date: 3/25/2020
©Copyright The Thinking Practitioner Podcast, Til Luchau & Whitney Lowe

Whitney Lowe:

So, good morning Til, we're actually recording this episode just after the first of the year, it was the New Years day, after New Years today, so how are things happening for your new year out there in Colorado?

Til Luchau:

New Year was great, I think we don't broadcast this until March or April or something like that?

Whitney Lowe:

I think so.

Til Luchau:

But I had a good time, busy getting ready for the upcoming year. We've got a couple exciting trips going to Google to teach a few times, I know you've done that as well. What you up to Whitney, what's new with you?

Whitney Lowe:

Yeah, I got a lot of big projects on the slate for 2020. So, this is going to be a big year for us, so I'm excited to hit the ground running this morning. I think we've got some interesting things we're going to dive into this morning as well I believe?

Til Luchau:

Yep, today's topic, when does the tissue matter? When does the tissue matter, and you suggested that last time after we had recorded our episode on descending modulation. What made you toss that up as a topic?

Whitney Lowe:

We got talking about this a little bit after our last episode, and I think it sort of was a segue into some of the things that we were talking about. So, to me it seemed really relevant for us to dive into this in greater detail in this episode as a sort of a follow up to we had done last time, because there seem to be a lot of relevance here. Just for everybody to kind of get on the same page of what we were talking about. We are looking at, there's a fair amount of debate in the manual therapy world about how accurately can we target specific tissues. And what are we actually doing to them when we do many of our therapies, or interventions that we are engaged with.

Whitney Lowe:

So, this sort of came up as a question, when does working towards, or when does targeting those specific tissues matter? Is it physiologically accurate to say we're doing some of the things that we're doing and what are some of the approaches that should frame how we look at the things that we're doing. This is I think a direct spinoff of what we were talking about with some of the things on descending modulation last time.

Til Luchau:

Yeah, and strategically when as a manual therapist, a body worker, a massage therapist, when would you be thinking about the tissue? When would you be thinking about central nervous system or other factors that we're working with? And just to recapitulate the descending modulation idea as a kind of counterpoint to this question. In descending modulation the brain turns down the intensity of the nociceptive signal, is the signal that's coming from some sort of tissue-generated event before that signal even reaches the brain and it might be interpreted as pain. So the brain can turn down that signal on its way to the brain and as a result we are thought to experience less pain. And it's also getting a lot of interest as one of the key ways that manual therapy probably reliefs pain. And it's not usually thought of as a tissue effect in its own right, it's more about changing the signal versus changing the stealth or the mechanics or the structure. And then so then-

Whitney Lowe:

I would say this kind of gets back to what you had said last time about, and I was talking about the variant of our episode of perhaps the most important tissue we're working on is the brain, kind of taking off on that piece from there.

Til Luchau:

Mm-hmm (affirmative). And so that begs the question, if you take it far enough, if the question comes up, if you can do so much with just changing the signal or changing the way the brain responds to a signal, should we just focus on that? Maybe the tissue isn't as relevant as we thought.

Whitney Lowe:

Yeah, yeah.

Til Luchau:

Okay, the next question there is, why would we even wonder that? Why would people even say the tissue doesn't matter. Is it just because there's descending modulation going on, or are there other kind of questions or wonderings, or even objections to the tissue-based narrative?

Whitney Lowe:

Yeah, to me I see some of this stuff happening because all the time we see this in the world of science, and certainly we see it in manual therapy world where there's sort of these pendulum swings. Once a new theory becomes sort of pervasive, a lot of people swing really far in one direction, and then they'll swing far back in another direction. And I think we're seeing some of that pendulum swing being impacted and affected because of some of the recent research that's come out, and the emergence of the focus on pain science looking at the brain affects that we talked about last time with descending modulation. And by all means, it is absolutely fascinating what we have learned about how pain works in the body, and how some of the effects of what we're doing might be much more related to brain changes than some of the things that are happening in the tissues.

Whitney Lowe:

But I think that's also caused some people to perhaps go maybe a little bit farther than we really are accurately responding, or have good accurate backup information about whether not tissue effects are really apparent that are happening there. So for example, I've seen a few of these things happen because with some of the research that's come out we see some of the changes that we refer to in manual therapy being less about what we're actually doing to those tissues to change them. Because some of the things that we've learned have not supported some of the narratives that have been around for a long time about what we're actually doing when we actually manipulate soft tissue.

Whitney Lowe:

Other examples, like the inter-rater reliabilities, like how accurate is it from practitioner to practitioner of palpating specific things in tissues, whether that's myofascial trigger points, or anatomical landmarks, or changes in position like of a pelvis we talked about the similar discussion.

Til Luchau:

Yeah, so you're talking about the lack of agreement that one practitioner might have with another.

Whitney Lowe:

Yeah.

Til Luchau:

And that being something that makes this question the model that we're just working with stuff or with just tissue.

Whitney Lowe:

Yeah, so the question often is, is there ? If all these people can't find the same myofascial trigger points, are we in fact really doing something to those trigger points? Are we in fact doing something to those particular tissue? And that's a valid question-

Til Luchau:

All right.

Whitney Lowe:

... to be asking.

Til Luchau:

We got to do trigger points some time by the way.

Whitney Lowe:

Yes, we will certainly get that, and I'm sure we'll light some fires there as well, so yeah. And I've seen some advocates of certain approaches, especially with the emphasis on the neurological changes, arguing that well truly the only tissue we can touch and actually truly palpate is the skin. And there are all these cutaneous neural receptors in the skin that can change things throughout the body. And therefore we should really just be focusing on those neural changes, because you can't really touch anything else below the skin. And to me this is where you get into a little bit of a problem in making the distinction between touching something and affecting something. Because I would agree that you can only touch the skin, unless you talked about intraoral TMJ work or something like that. But otherwise with manual therapy, yeah, we're just touching the skin. But I'm not comfortable saying we're only affecting the skin, because-

Til Luchau:

Okay, when I write up something on a piece of paper, am I touching the paper? Am I touching the pencil?

Whitney Lowe:

Yeah, you're not touching the paper.

Til Luchau:

Okay.

Whitney Lowe:

I would say you're touching the pencil.

Til Luchau:

Interesting.

Whitney Lowe:

But you're affecting the paper.

Til Luchau:

Here we go.

Whitney Lowe:

Because your pencil is leaving a mark on the paper. So, that's a good analogy there. So I think we need to be careful a little bit about semantics, things like, yeah, maybe you're only touching the skin. But if you can't affect deeper tissues, then how can people get injured from an impact trauma, you know? You can definitely affect deeper tissues in there. So I think those are some of the big questions that have caused questions or curiosity about whether not we can really affect and do things to some of the tissues that we're talking about. So since we've talked about some of these tissue-based approaches, let's look at that a little bit here. What are some examples of some of these tissue-based narratives that we hear people talking about, like when you hear these discussions about what we can do with manual therapy. What are some of those things that we talk about, that we're supposedly doing at least?

Til Luchau:

We got some examples there. And I just wanted to say a little bit more about what you said. We've set this up as a dichotomy and often gets debated that way. Are we affecting the brain? Or are we affecting the tissue? And of course the answer is yes to both. And there's very few people probably that would argue just for one, if anybody.

Whitney Lowe:

Yeah.

Til Luchau:

But to tease them apart in this way is an interesting exercise, and it got me thinking too. Because again, something like descending modulation or other approaches really emphasize, or contextual effects emphasize the brain effects, while other effects traditionally emphasize, sorry, other modules emphasize the tissue effects. So some of those narratives, some of those modules will be the idea that we're melting the ground substance with our pressure. And we were taught that in anatomy 101. We were melting the tissue and helping it reorganize through a kind of melting effect. There is some sort of viscoelastic change it turns out, but the literal melting is not quite as clear obviously as we used to think. And there are lots of questions about its duration etc. and the mechanism behind that. We were breaking up at the-

Whitney Lowe:

And I'm, excuse, wonder if I can-

Til Luchau:

Sure.

Whitney Lowe:

... inject for one moment too. I just want to talk about for just a moment, the importance of language in semantics, because this is a really good example of that when you talk about something like melting the ground substance. I've seen this extrapolated into other places where people talk about for example doing some type of work in melting fascial tissue, a very deep tissue of the body, simply by moving it around. And the word melt implies a thermal change. And you cannot produce those kinds of thermal reactions simply through manual therapy. Now I mean, I don't know any practitioner, and maybe there are some out there who have super, super hot hands that can penetrate deeply into the tissue to actually melt things. So we have to be careful with some of those narratives that we create and the words that we use to describe them.

Til Luchau:

Well yeah, to be fair, I think it was always a metaphor rather than a literal kind of thermal melting. But yeah-

Whitney Lowe:

I get that, but there's a lot of people who have taken that and made it literal. Have talked about who I have heard describe things as melting because of the heat of our hands-

Til Luchau:

I see, I see.

Whitney Lowe:

... or melting tissues, so.

Til Luchau:

Well-

Whitney Lowe:

I think it's intended that way, but I think some people picked it .

Til Luchau:

No, you're right. And I hope I get to this list, because everyone we could dive into, because ... And I know we're going to also we got fascia flagged in the future as a place we can really dive into this questions. The breaking up adhesion model, again some question, there's people who say it absolutely doesn't happen. There's people that say, "Well clearly it does happen." But that's a narrative that you could say emphasizes a tissue effect or tissue mechanism. We're organizing the fibers, we often would describe the work as once it gets melted, then we can reorganize it or that the collagen glaze then a new pattern. Probably something to that, but not quite the way we thought where we're just combing out the codes and fibers with our fingers.

Til Luchau:

Stretching type fascia. I know we have stretching as a flagged topic too, and that's one where semantics again mean a lot. That what we mean by stretching, and what do we mean by tight. Those are really good questions, but again, the simplistic way in any of us were taught, doing whatever it was years ago. Probably not the literal things happening in the body. And you've had this one stretching broadening muscle fibers, you want to say anything about that?

Whitney Lowe:

Yeah, I mean this is something I was taught with for example massage strokes which are sort of sweeping broadening strokes across the directional muscle fibers I was taught what we're doing is spreading individual muscle fibers apart and helping to encourage pliability in those tissues. And really beginning to think about this many years later about, "Hey, wait a minute, now as small as those individual fibers are, and we're working through multiple layers of tissue, am I really capable of spreading individual muscle fibers apart with the way that we're working?" And it seems a whole lot less physically possible now. But yeah, it works. It does some really good things to people and it feels really good.

Til Luchau:

I guess this is like a list of tissue-based narratives we have known and loved and maybe not thinking about quite so much.

Whitney Lowe:

Yeah.

Til Luchau:

Not to say they're false. It's also to say that, "Well, we've refined our interpretation, or maybe diminished the emphasis in our model."

Whitney Lowe:

Yeah.

Til Luchau:

You said elongating muscle tissue?

Whitney Lowe:

So would it be appropriate to say these are just friends now and no longer those who were having a romantic relationship with -

Til Luchau:

I know, it's married to our exes.

Whitney Lowe:

It's right.

Til Luchau:

Our exes. Elongating muscle tissue, that was yours yeah?

Whitney Lowe:

Yeah.

Til Luchau:

That's along with the stretching thing.

Whitney Lowe:

Exactly yeah.

Til Luchau:

The micro-tearing model that actually when we get a tissue change it's from little micro-tears in the fabric of the tissue. Well, that model was really built into a lot of especially deep pressure or fascial models and maybe not as much as we thought. And then we're changing structure. Emphasis on the thing, the structural part of that. And this was a argument that goes all the way back to either Rolf and Moshe Feldenkrais. They were friends, colleagues and friendly rivals. And she called her work structural integration and his emphasis, Feldenkrais' emphasis was on the brain, and he just ... The story goes he, teaser he called his work, functional integration, it's he knows the function of the structure. But these models do suggest that the literal thinking of the structure is a tissue-based narrative, which may need revision.

Til Luchau:

And then I had it in their circulatory models, because we're often thinking about, at least strictly speaking you could say the different fluids of the body, blood, lymph are connected tissues. But we're also thinking about a physical effect in the tissues. We were thinking about moving either blood or lymph around. Would you agree?

Whitney Lowe:

Absolutely. And that certainly is one of the strongest tissue-based narratives that gets taught in the massage therapy world early on in our treatment approaches is that we are supposedly increasing tissue circulation again, which is been somewhat questionable in terms of how you actually measure that and what circulation you're talking about. But it certainly does seem to be that there is a strong argument that there was the possibility of a number of types or circulatory model effects, especially with your manual lymph drainage techniques and things like that.

Whitney Lowe:

So clearly I think some of those things happen. Some of the ones that we did originally describe maybe not so much the way we had described them. But I think it's a very valued tissue-based narrative for some of the things that we're doing for sure.

Til Luchau:

Yeah some of these are still open questions.

Whitney Lowe:

Oh yeah.

Til Luchau:

It's there, it's not like they used to think and now we know they're false. There's still debate going on obviously, and there's still good evidence on both sides of the question honestly.

Whitney Lowe:

Yeah, I think the thing that we see happening here is that we've had some research, and it's some analytical self-investigation about these things to really question a little bit of what we're doing. And make sure that we're, and I'm going to say that this actually goes back to something that I was talking about in our episode a couple episodes back about the challenges facing our profession when I talked about the, what do we call it, the sort of or story-based educational process that we had in our field versus a truly academic one. I think we're moving away from that as the dominant model so that now we have a little bit more sort of questioning processes happening along many of these lines as we develop into more of an academic approach from what we're doing. So I think that's a good thing for us to look at here, so all these different things.

Til Luchau:

And have we laid out the examples sufficiently and some of the arguments or questions against them? Do you think it's time-

Whitney Lowe:

Yeah, I think so. There's one other-

Til Luchau:

Why not, okay.

Whitney Lowe:

... that I just wanted to briefly touch base on before we take a quick break here, and that's, one of the arguments against some of these tissue-based narratives is that manual therapy does not really apply the intensity of biomechanical forces that would be required to produce some of these effects that we say occur. Now like for example, and we'll get into it I'm sure as we dub into some of the fascial and muscle tissue, elongation topics later on. But the idea that what we're doing with our hands in manual therapy is really pulling, stretching, and elongating some of these tissues doesn't fit with what we understand to be the type of, or the amount of force that would be required to make those tissues have mechanical length changes in them. So that's just one of the other arguments that has come up against some of those kinds of narratives.

Til Luchau:

Here is some interesting history, I'm trying to go down this tangent too far. But I remember it was the early 90s, Peter Levine was the author, and published a PhD thesis on the Physiology of the nervous system and eventually became his trauma work and it he said, he did some calculations and said, "Rolfing at that time, it's pressure couldn't change the tissue." And it was heretical, it started a fire storm. We were so mad at him and asked him for his references and all that kind of stuff. And he said, "Well, they're buried in my garage, so." He moved on. But later they came back around and again, "Yeah, sure enough, if we really try to do the physics involved it doesn't seem to work out."

Whitney Lowe:

Yeah, yeah. And people get really, really defensive about that kind of thing and need to, I think need to recall or remember, we're not saying it doesn't work. It doesn't have been official effects. We're saying the narrative around why we're ... Or how we're describing what this effects actually are may need some adjustment. But that's not to say that this doesn't have beneficial therapeutic outcomes, because it does.

Til Luchau:

And I think in this conversation we're trying to distinguish the baby from the bath water in a way.

Whitney Lowe:

Yeah.

Til Luchau:

I'm trying to say, it's not, neither one of these deserves to be thrown out, or believed lock stock and barrel, so let's see what have gone on and looking when I get behind.

Whitney Lowe:

Yeah. So let's dive into, we're going to look into some other things, especially related to treatment oriented things here after just a brief moment from an input from our sponsors. So our halftime sponsor today is ABMP. This episode is sponsored by ABMP, the Associated Bodywork & Massage Professionals. ABMP membership includes over 50 member discounts on everything from massage tables and supplies to cellphone service and all members can access over 200 continued education courses with three CE hours.

Whitney Lowe:

You can read ABMPs award winning member magazine, Massage & Bodywork which both Til and I write for, as well as many other great offers over at massageandbodyworkdigital.com. And listeners who join ABMP as new members can save $24 on their membership at abmp.com/thinking. So with ABMP you can expect more.

Whitney Lowe:

And in terms of expecting more, I want to know what else can we expect out of our look at these tissue effects today. So I'm going to turn this in a different, slightly different direction here and want to talk a little bit about treatment processes when we're working clinically. So, what type of tissue effects do you think about, or do you think about them when you're working in terms of the rationale behind why you're doing the things that you're doing?

Til Luchau:

All right, yes. That's a really fair question, where does this rubber really meets the road. And how does this affect how I'm actually working with clients. And honestly, I'm thinking about tissue all the time, I really am. I think my target tissue is the brain. Or even one step beyond that, my target is experience. It's not even a thing. And yet, just like people it's not just, we're not just a body, we're not just a mind. Even the question has a kind of cartesian and dualism to it.

Whitney Lowe:

Yes.

Til Luchau:

But I really, it's not about breaking it down into is it the tissue, or is it the brain, is it the nervous system, is it the fascia? I'm thinking about experience all the time, and my handle on experience is tissue. Back to Ida Rolf, she said, "Well of course there's psychology." She was quoted as saying, "There's no such thing as psychology, there's only physiology." And this quote got back to her and she said, "No, I never said that. Of course there's psychology, but the body's where I'm getting my hands on," that's what she said. So that was a formative idea for me as well. And so I'm almost thinking-

Whitney Lowe:

I like that idea of what she said to you that the term handle. That that's our handle for how we're approaching what we're doing. That's the way that we choose to make our intervention. I often talk about this in our training programs about the lens of bias that we all had. We tend to look at things through a particular lens. And as soft tissue manual therapists we look at things, we look at the world often through muscle and soft tissue colored glasses. That's the way that we look at things. But that's our handle, that is how we engage with things and how me make our intervention. But you're really right that we don't want to create the sense of dualism of it's either brain or body. Because it is so often it's all of those things wrapped up together.

Til Luchau:

Yep, and if I'm honest, I go right to the table with the client, I'm feeling for physical tissue-based phenomenon. I'm tracking their responses at the same time. And their breathing, their coloration, their sense of expansion or contraction. But I'm also feeling in their tissues a tissue quality. And I still don't know what it is. But if you're going to say I'm kind of weird, but you might know what I'm talking about. I can feel when something hurts, I think.

Whitney Lowe:

Yeah.

Til Luchau:

Of course the pain is their experience, I'm not merging with them, intruding their experience as much as I feel something with my hands that seems to correlate to them being sore, stiff, tight, all those things. And then I can work it with my hands just like you and a lot of other people to help shift that. In some ways that's a very physical, tangible tissue-based process.

Whitney Lowe:

Yeah, yeah. And even if the brain is behind a lot of that change by let's say altering muscle tone in response to the touch, it is still-

Til Luchau:

One explanation for this changes and feel in our hands.

Whitney Lowe:

That's certainly a brain-based explanation for it. It is the fact that the touch made the change that makes this still a tissue oriented kind of perspective that cannot be dismissed from what we're doing. And the thousands and millions of times that this has been replicated in the treatment room by each of those individual clients and you and every other practitioner out there have done this. We know something happens. We know in fact something like this does happen. We are still probably trying to wrap our minds around what exactly is happening, but we do know something like that is happening for sure.

Til Luchau:

I also think about gliding a lot.

Whitney Lowe:

Tell me about that.

Til Luchau:

Well, rather than getting in there and trying to lengthen a "short structure" I'm putting air quotes around that too. Any more I'm thinking, this came from my reading into the research of what was this fascial oriented work really doing, really as in measurable and observable change. And there's pretty good evidence that we can affect gliding pretty measurably and clearly with our hands and work. We're not going to, see the forces involved, we're not going to permanently deform the fascia without doing permanent damage as well. But we can have changes in the gliding qualities between structures. So I feel lot of things adhered perhaps, or were they not gliding? And I work with movement and the client's awareness and my hands to get more of a sense of gliding, a movement there between layers and between structures. I do like that.

Whitney Lowe:

Yeah, so your reference to gliding is about inter tissue gliding in relation to each other, I suppose not necessarily talking about gliding on the skin, but-

Til Luchau:

Oh thank you.

Whitney Lowe:

... the gliding between adjacent tissues.

Til Luchau:

That's right, absolutely.

Whitney Lowe:

Which I then think gets perceived by the client as things like increased pliability, greater freedom of movement-

Til Luchau:

Yes.

Whitney Lowe:

Sense of ease in the body, all those-

Til Luchau:

Nice.

Whitney Lowe:

... good feelings that we're aiming for in our treatment approaches.

Til Luchau:

Yeah, or like the form, just working in this thing like the flexes and the form, about two parallel structures in there. If I don't think about mashing them, if I don't think about stretching them, but instead I think about helping them glide against each other differently. Then people move their hands completely differently. They have a different sense of how their individual fingers move. And then I guess one more. The other thing I'm thinking about a lot in terms of tissue when I'm working is the inflammatory reactions in those tissues. Can I somehow with my touch either calm those, or facilitate those, or sometimes provoke those?

Whitney Lowe:

Mm-hmm (affirmative).

Til Luchau:

Inflammatory reactions in the tissue-based effects, because they are modulated by the nervous system of the brain, but that's not their primary mechanism.

Whitney Lowe:

Yeah.

Til Luchau:

They really do happen in the tissue and in the immune system.

Whitney Lowe:

Yeah, and I think there's some of all of those things that are potentially happening, and it is one of our challenges that I think is worth trying to identify when some of these different things are happening specifically so that we can know ideally for our treatments the kind of things that we'd like to facilitate. And the kind of things that we'd like to inhibit. Like we like to find ways to inhibit negative tissue responses and negative biocycle social responses or the way in which people react to certain treatments or certainly enhance and facilitate those positive types of things. So that's why there is an importance in trying to figure out what's happening when we do the things that we do.

Til Luchau:

Well okay, and so then turnabouts for a play, how about you, tissue-based effects you think about when you're working right at the table?

Whitney Lowe:

Yes, there's some interesting things that came up for me a lot when I started, well some of this happened with first questioning some of the rationale behind some of the different techniques that I had been employing for years. Like I think I discussed this earlier talking about broad based fiber spreading techniques and things like that, that I was taught that didn't quite seems to make sense. Some of those are the types of things that were coming up for me. But a big one for me, and this was kind of interesting. This was when I started learning a lot more about the whole pain science approach had to do with assessment. Because that's the world I had lived in a great deal, I've been focusing a lot of my time and career on orthopedic assessment, which is all about identifying pain responses for an individual.

Whitney Lowe:

And I started looking at this as, well if so much of this subjective pain experience is really about the individual's brain and not about the specific tissue damage problems in many instances. And I think I was over extrapolating that model to think, "Well then maybe that doesn't really matter so much. Or how am I reproducing pain with all these different orthopedic evaluation procedures? Or is that even important?" If the pain experience is really dominated by the way the brain is working and this whole idea of the descending modulation is the strategy for addressing it. Should I even be focusing on trying to find out which tissue is involved, or which tissue is originating those no susceptive signals in producing the pain.

Whitney Lowe:

And I took quite a long time grappling with that question, and it caused me a lot of sleepless nights and angst in trying to figure out why I'm doing what I'm doing, because I was also in the midst of rethinking, rewriting my assessment book. And like, is this going to completely go counter to everything that I had learned or was working with. And I think for me it took me going around a big circle to come back around to recognize there is some real value in looking at this from the relationship of individual tissue pain producing processes to how you might go about that treatment. And that kind of comes back into the treatment perspective as well that yeah, there's a lot of times when a tissue might no longer be damaged. Let's say in a chronic pain complaint. Some tissue that was originally injured continues to be painful long after the tissue damage has probably healed. But there's still persistent pain there. But I still think the evocation of pain responses from that particular tissue lets me target my treatment approach to that particular tissue with significant benefits.

Til Luchau:

All right. This is good. You're saying that any time there's ... You're answering the question where, that's a tissue answer.

Whitney Lowe:

Yeah.

Til Luchau:

Because anatomy is always tissue-based. Because if it's a pain, it's a place in the pain, whether it's re-centered or chronic then it's going to target the tissues. The tissue's going to be there.

Whitney Lowe:

Yeah.

Til Luchau:

And new treatment's a waste.

Whitney Lowe:

Right. And so in answering that question, coming back around to why is that really important or valuable to know, from a treatment perspective there's a couple of things that, and again this kind of gets back to our whole descending modulation thing that we were talking about last time. I realized there's some real benefit in a targeted tissue-based treatment approach as well. So for example, if, and I'm just going to make this up. A client comes in with a former ankle sprain or something like that. And I go and work on that tissue in that particular region, having identified that as the primary problem. They get a whole biocycle social response of feeling like, I'm doing something therapeutical with that injured tissue that makes them feel better. That engages them in the process, gets them working on the same team with me of we're working on that problem. And that kicks off all these sort of beneficial biocycle social responses in them about the nature of what they feel pain in their tissues to be about. So I think from that perspective that's highly valuable.

Whitney Lowe:

Also when we talked about the gating theory last go round where saying that some of the manual therapy applications that we apply can stimulate neural receptors that then can overcome or sort of bypass the nociceptive signals that produce pain, because of the movement and or physical intervention of us working on those particular tissue. So it's got a very beneficial means of decreasing pain sensations coming from a particularly targeted tissue.

Til Luchau:

Where do you want to go from here?

Whitney Lowe:

Well, that's a good question, it's like what do we want to be looking at as a result of that? So how does this impact what we're going to be, what we're going to continue to look at the way we're doing our treatments. So for me I like what you said earlier about this being a bigger, broader perspective. It's not one versus the other. But it really is looking at a lot of these things from several different perspectives. And saying, "You know what, it's all part of the bigger whole." And there's just a couple other things I just want to make a point here too where I think these things are particularly important. I still think there are mechanical tissue-based effects that we can have in certain types of situations, like after a significant injury where there is scar tissue adhesion. Let's say like after a ligament sprain where you might potentially have ligaments adhering to adjacent tissues.

Whitney Lowe:

And we go in with friction massage or something like that. I still think there are potential benefits in like you said, enhancing the gliding, the mobilization between adjacent tissues. I do think that's an important mechanical fact that we can still see some benefits from.

Til Luchau:

Okay, you said adhesions, or you're thinking of actually separating those?

Whitney Lowe:

Yeah, yeah. Because we do know that for example immobilization immediately after a pretty severe injury with significant soft tissue damage often leads to adhesive development because those tissues are not gliding appropriately during the rehabilitation phase. And I think there are some things that manual therapy may be able to do to encourage that tissue gliding movement more effectively. And we also do know that there is some research that indicates that manual therapy may have some benefits in things like encouraging fibroblast proliferation in tissue healing. We talked about tendon disorders in one of our previous episodes. And this is one of those things where there is some evidence that pressure and movement to these tissues may encourage fibroblast proliferation to help some of that tendon healing, so.

Whitney Lowe:

Those are some of the things that I see still potential benefits for a lot of the mechanical effects that what we're talking about with those tissue-based approaches. So any other thoughts that you have or things that you see particularly partnering with that as well?

Til Luchau:

Well yeah, I mean we can go on forever. But just to begin to wrap it up. I think about the sensory aspect of the tissues all the time. And when Peter Levine came in with this equation that says, "Well, we can't actually remold the fascia," was his claim. Robert Schleip pretty quickly came back and says, "Well, maybe affecting is more like what Feldenkrais was saying. Maybe it's the brain and the nervous system responses." And he became a career long investigation of that questions. Like how does the nervous system influence fascial function and the way fascia feels under our hands. And the model he put forth is that actually the fascia is the location, the tissues are the location for the nerve endings. And so they're being directly mechanically influenced, the nerve endings by the qualities of the fascia around them. And there's still research being done to really dial that down to say how much of it's mechanical, how much of it's neurological, how much of it's inflammatory. All those factors are in there.

Whitney Lowe:

Yeah.

Til Luchau:

There's also big question around passive versus active restriction to the tissue question.

Whitney Lowe:

Mm-hmm (affirmative).

Til Luchau:

In other words, again back to Robert Schleip, his experiments with people going in for surgery under anesthesia had much greater shoulder range than without anesthesia. And that's pretty commonly observed that when someone's anesthetized, in other words their nervous system is put on hold, their range of motion increases significantly. And for him that suggested the nervous system had a big role in that kind of movement restriction question. And yet, there are things like manipulation under anesthesia, and the fact that different joints respond differently to surgery. That said, oh the tissue actually does have a contribution, the passive quality of the tissue, nevermind muscle tone, which start to get turned off by anesthesia. So that's one of the apart. It's actually, I've been thinking all the time, "Which of this feeling is passive tissue quality, and how much is active regulation of tone." And I think more and more I'm targeting active regulation of tone more and more. Did you want to say something?

Whitney Lowe:

No, I was just going to say, I think that the big takeaway that we keep coming back to with all this is that there tends to be, and some of this is just because of fundamentalist camps that sometimes tend to evolve out of these discussions of trying to pit this as a one versus the other type of approach. And I think we keep coming back to this idea that both of these things are happening to some different degree. And what we want to ideally try to find ways to do is to enhance the real beneficial results and decrease the negative types of results in different ways that we're approaching this.

Til Luchau:

Well you and I agree on that. And I just, I don't know why, but I tend to be a devils advocate here and say, even that is an argument. Is it both, or is it one? And that might be a really deep fundamental, it's an argument between vitalism and fundamentals, and you could say that might be a world issue right now too in a sense.

Whitney Lowe:

Yeah, right.

Til Luchau:

So anyway, couple more of my ways that I actually use the tissue-based approaches on the table. We're physical creatures. I'm touching a body. I'm not doing, I'd actually do some supervision and stuff by phone, but I'm not doing my manual therapy by phone. If it was just descending modulation, we could just find ways to be really good at descending modulation and just do that. And some people do. But I'm a hands on therapist. It feels great to my body when I get skilled touch and that's what I use in my work, and that involves a body, tissue is what we touch.

Whitney Lowe:

Maybe we should make some predictions about how long it will be before we start seeing certified descending modulators.

Til Luchau:

Maybe we should start that.

Whitney Lowe:

It's right.

Til Luchau:

Maybe we should start that. And then, my last bullet point that I want to make sure I mention was that it's confidence on our own narrative that matters, maybe more than anything else in terms of the research into comparing modalities. The significance of outcomes when you compare one modality to the other is small compared to the matter of practitioner confidence in that modality.

Whitney Lowe:

Yeah.

Til Luchau:

In other words, if I believe in it. If what I do make sense to me, it's a lot more likely to have beneficial effects on the client than if I'm doing a method or a modality that I'm not quite sure about.

Whitney Lowe:

So yep, we keep looking and keep exploring and finding fascinating different ways to shine the light I think on the different things that we're doing. So, that's certainly a nice extension on our discussion of descending modulation and the impact of how it affects and impacts our work. So, I would say we'll probably let that rest for today, and we'll I'm sure pick up different pieces of these puzzles a little bit farther down the road here.

Til Luchau:

Planning there to chew on and some openings and some bigger discussions.

Whitney Lowe:

Yeah, yeah. Absolutely.

Til Luchau:

Thanks Whitney.

Whitney Lowe:

Thank you. Yes, always.

Til Luchau:

So our wrap up announcements. Really thanking our sponsors. They make it possible for Whitney and I to do this for free. You guys don't have to pay for this at all, because our sponsors help cover the cost. And so make sure you do stop by the website, the podcast website for the show notes, for CE credit updates and the extras we offer there. That website is thethinkingpractitioner.com.

Til Luchau:

Or you can find stuff on Whitney's website related to this podcast. What's your web address Whitney?

Whitney Lowe:

Yep, and people can find there's additional information there at academyofclinicalmassage.com, no the in front of that. So academyofclinicalmassage.com. And you can always send us additional questions also or input or feedback directly to us at the email address, info@thethinkingpractitioner.com and find us there on social media. I would also like to say a big thank you to all the listeners, the people who are out there making this podcast successful. We've had quite a good bit of great response from folks from just launching here. So please do pass the word on to everybody else. We appreciate you taking the time out of your life to listen in on our conversations.

Til Luchau:

Yep. Rate us there at the different places you listen. Tell your friends, shares. That's how the word gets out, that's how we keep being able to do this work. Thanks Whitney, I'll see you next time.

Whitney Lowe:

That sounds good, we'll see you in two weeks.

 

Huge thanks to our founding sponsors:

           ABMP massage therapy            Handspring Publishing

 

Live Workshop Schedule

Stay Up to Date With The Latest News & Updates

Get our free Techniques e-Letter:
  • ...so we can skip notifications about things not in your area.
  • Note: You'll occasionally receive the latest schedule updates, tips, secrets, resources, and more.
    Check out our ironclad 
    privacy and SMS policies. You can unsubscribe/stop at any time.

  • This field is for validation purposes and should be left unchanged.

This Month's
Free Online Course

Our gift to you.
Includes CE, Certificate, and Extras.

Follow Us

Join us on FaceBook, Instagram, and Twitter for information, resources, and upcoming classes!

0 Comments

Submit a Comment

Pin It on Pinterest

Share This