Ryan Hayes RMT

A Body of Evidence.

Manual therapy is becoming a quagmire of misleading information, false narratives, and corporeal propaganda. Unfortunately, science and research have yet to explain many of the mechanisms involved in numerous manual therapy techniques. As such, a Cambrian explosion of modalities now claims to do all sorts of things that have no basis in truth. Many of these modalities substitute anecdotal evidence for fact.

Worse, many people pass off poor research articles as evidence of treatment efficacy. In many cases, people have misunderstood the article. They have either skimmed the Abstract or absorbed the Conclusion without thinking critically about whether or not it is a good research design. Presentation of a paper as proof of positive outcomes will be open to criticism. It can take decades for physiological mechanisms and treatment effects to be understood.

There is no doubt that manual therapy in its numerous forms has positive impact. Yet there is an inability to demonstrate consistent results that support the claims of different modalities. This is not limited to new variations on old approaches; the progenitors of present modalities are also not well supported in mechanical application and physiological effect. We should be getting more consistent results than we actually do. Why is this not so?

Consistency in massage therapy:

While there is a standard pedagogical approach to massage therapy, there is no requirement to upgrade skills once a student has graduated. This means a practitioner could go their whole career without taking a post graduate course. Practitioner skill, both technically and clinically, is widely variable; this calls into question the progress that can be achieved without incorporating new skills and knowledge into our practice.

Consequently, we have a proliferation of niche treatments, tangential approaches to existing modalities, and garrulous and unoriginal posts about the trend of the day. Often, these claims expound upon a new direction in manual therapy attached with an article that doesn't actually support the claim. Unfortunately, consistent results are challenging in research as there are so many variables to consider. We can't even agree on treatment of chronic low back pain.

This isn't to say that old modalities are not effective and new modalities are all skullduggery. In some cases, treatment has accepted effects without a clarified mechanism of action. In other cases, treatment may piggyback off existing knowledge that has not yet been verified in either methodology or approach. Certain mechanical applications may be understood, but not in the context being presented. Research cannot keep up with therapeutic expansion.

Separating fact from fiction:

We must think critically about new modalities. We must think critically about therapeutic claims. We must think critically about research proposed to validate specific techniques. This does not mean there isn't credibility in emerging treatments. However, we must refrain from disbelief and antagonism in exchange for active dialogue and transparent communication. We can use existing knowledge to apply known mechanisms to logical and creative applications.

While research continues to gain traction in manual therapy, social platforms and marketing continue to advertise the next quick fix. We should exercise caution over blind acceptance of new success stories. Evidence-based techniques, modalities, and mechanisms don't support many new claims. While this doesn't make the claims invalid, it does mean that questions can and should be asked. Language matters. Knowledge matters. Integrity matters.

A Bone to Pick: the periosteum.

The periosteum is a fibrous membrane that surrounds most bones. It is only absent at joint surfaces where cartilage is found and at major tendinous insertions such as the Achilles. The periosteum is composed of two layers. The outer layer is constructed of dense, irregular connective tissue. This layer contains fibroblasts, which makes it an excellent therapeutic target. The inner layer is adjacent to the bone tissue proper and contains osteogenic cells.

The periosteum is rich with nociceptors making it a potential source of pain. It is not uncommon for bones to receive impact forces that may manifest as either bruises, fractures, or shin splints. Shin splints can be a repetition injury created by faulty mechanics that direct force improperly and denature the periosteum. While it is imperative to restore the mechanics, it is also imperative to remove embedded tension from the periosteum.

The fibrous layer of the periosteum also contains blood vessels and lymphatic vessels that nourish, remove waste from, and provide immunity for the bone. Conditions that cause either trauma or inflammation to the periosteum can create pain. The tensegrity of the periosteum should be optimized as efficient fluid dynamics must be viewed as one of the most important physiological processes to minimize stagnation, congestion, and to improve healing.

Type I Collagen Fibres:

The periosteum is anchored to bone via Sharpey's fibres. These fibres also attach ligaments, tendons, and in the case of intervertebral discs, cartilage to the bone matrix. Sharpey's fibres are primarily type I collagen fibres. Type I collagen fibres are the most extensive in the human body. Collagen fibres establish tensile strength and mechanical stability to numerous tissues in the human body. Sharpey's fibres transmit muscular forces to the skeleton.

Due to its collagenous framework, it can be surmised that inefficient biomechanical function may cause unnatural force distribution either through or along a bone. This can manifest as tension within the periosteal layer. Therapeutic modalities can modify collagen through physiological and mechanical means. Direct pressure can disrupt abnormal cross-links and adhesions; mechanical loading can stimulate mechanotransduction nurturing fibroblast activity.

As type 1 collagen is found in tendons and ligaments, and tendons and ligaments are accepted as being treatable using manual therapy, by extension the periosteum is an area of the body that should be considered in treatment. While type III collagen is the dominant type within muscle fibres, type I collagen is found in endomysium, periomysium, and epimysium; this provides support, strength, and elasticity to muscle fibres and tendons.

Summation:

The periosteum is the fibrous outer layer of bone. It is constructed of the same type of collagen that is found in tendons and ligaments. This structure allows periosteal tension to be found through palpation. As manual therapy is a useful tool in treatment of structures containing type I collagen fibres, the periosteum becomes an excellent target for therapeutic intervention. With practice, it is easy to discover and remove tension within the periosteal layer.

Tension through the periosteal layer may conversely create tension in the ligaments and tendons that attach to it. Muscular tension may also be perpetuated through this anatomical connection via the extension of Sharpey's fibres into the bone. The inclusion of vascular and lymphatic structures within the fibrous periosteal layer makes it an attractive target for manual therapy modalities. Expand your evaluation to include tension in bones and see what happens!

Corporeal Mythology: the three Fates.

In Norse mythology, the three fates weave the threads of destiny for humans and gods. The Norns, named Urd, Verdande, and Skuld, live at the Well of Fate beneath the world tree, Yggdrasil. Urd represents the past. Verdande represents the present. Skuld represents the future. As the three fates weave the threads of our existence, the manual therapist aims to unravel those same threads back to perfection. That perfection begins with the embryo.

Like the triad of Norns, our embryological threads contain three primary germ layers: the ectoderm, mesoderm, and endoderm. The ectoderm primarily forms the nervous system, the epidermis, and most of the senses (taste, sight, hearing, smell). The mesoderm becomes the muscles, bones, connective tissues, circulatory and lymphatic systems, the urogenital organs, portions of the skin and internal body cavities. The endoderm becomes the epithelial linings of the digestive and respiratory tracts and associated organs such as the liver, pancreas, and thyroid gland.

The creation of the germ layers marks the beginning of our Fate. From this point on, the threads of the fates will intricately weave their tale expressed corporeally as the physical and psychological state of our existence. Not only do the individual threads get tangled, but all three anatomical threads entwine leaving a tangled mass of life experiences. The role of the manual therapist is to unravel the threads of past and present to allow an unfettered thread into the future.

Untangling the threads of tension:

When we consider the manifestation of tension, we must understand that this tension is a combination of the germ layers and their anatomical constituents. They grow together. They function together. They live together. Therefore, we cannot expect to treat one thread to the neglect of the others. The person we see on the table is the physiological summation of their extant being. The body is a diary of their physical and psychological existence.

What began as three individual strands has now become a convoluted ball. Our job is to take this ball and unravel the entanglement of the fates. However, the human body is much more complex than three pieces of yarn. This is neither a simple nor a short process. The more complex the problem the more entwined the yarn. The longer the life the longer the yarn. The fabric of the individual is woven into the tapestry of their cells.

A ball of yarn is not randomly created. The threads tangle in a very specific, but unfathomable way. We do not know the past until we have unlocked the present. We must unravel the threads in the way that is accessible to us in that moment in time. Like deciphering the map of a maze, there is a fastest way to the middle. The path may hit dead ends. There will be many twists and turns. Ultimately, there is a most efficient way.

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

When we pick up one thread, we must acknowledge that it is attached to the whole person. A tension line may be long. A tension line may be short. A tension line may contain only one primary structure. A tension line may contain several anatomical structures. It is imperative to consider the continuity and expanse of any line of tension in order to comprehensively release it. We must gather the tendrils together and dissolve them.

These lines of tension will contain either the cause of that tension or the compensations and adaptations associated with other buried tension. With a chronicle of undocumented history, it is challenging to discern where it all began. Like a mountain range jutting high into the sky, thus can the layers of primordial history present as current symptoms. Be wary of a problem that has persisted for years: the global picture has evolved a new landscape around it.

Reconfiguring the landscape:

The threads of life represent a physiological timeline. The layers form the strata of a person's history. Much like a connect-the-dots puzzle, we can only navigate one number at a time. Only when that line of tension has been resolved will the next line present itself. Connecting all of the dots will complete the treatment picture for the day. We must leave the body in a place where it can reorganize and self-regulate. The analytical and the intuitive must be mastered.

Taoist Touch is interactive; that is, in Taoist Touch you begin to respond to the form and dynamics of the tissues in the way you think they are asking you to, not how you may think they need responding to - Hugh Milne

The more we impose judgement upon the body, the further we move away from the truth. The body is omniscient. What we think is irrelevant. To believe our ego can control the fates is fallacy. The only truth is to Know. The Knowing comes from openness, receptiveness, and humility. The Knowing comes from knowledge. The knowledge comes from reflection. The reflection comes from experience. To err is human. To Know is Divine.

The False Attribution of Healing: taking credit for a body of work.

A symptom does not denote a cause. A symptom denotes a sensory perception of the state of our internal milieu. We do not treat symptoms. We do not treat diseases. In reality, we don't treat intangibles. We are but mere extras in the movie of your healthcare journey. We believe we are responsible for the resolution of symptoms. In most cases, we aid in creating conditions for the body to carry on doing what it has done for thousands of years: surviving.

We are not soothsayers. We step in when the body may need a little nudge to move past a particular blip on the homeodynamics radar. Different professions provide different sorts of nudges. Heart surgery is not manual therapy. However, we are all providing varying interventions with the hope that the body will regain control, right the ship, and move towards a better state of health. In the least, we hope to mitigate symptomatic presentations.

But what is our actual role? As manual therapists we aim to quantify dysfunction and find ways to optimize physiological efficiency. The efficacy of this procedure will be dependent upon many things: the profession; the knowledge of the practitioner; the skill of the practitioner; the ability to quantify dysfunction; and the ability to correlate dysfunction with symptomatic presentation. This is just scratching the surface! But is this the whole picture?

Are we healers?

To heal means to become either healthy or whole again. Typically, healing refers to the natural biological process of tissue. Do manual therapists do this? Some therapists will argue that we are healers. Yet, we are more akin to facilitators. In some cases, we are purely observers. Our role is to remove obstacles that impede the optimal expression of health. We should aim to stimulate the self-healing mechanisms that are already in place.

Part of the problem lies in that we believe we can either discern the cause of a symptom or treat the area of a symptom and expect resolution. We believe we have the answers. The body is too complicated for this simplistic binary approach. There are trillions of cells in the body. It would be like looking at a bucket of sand and pinpointing which beach it came from. Our role is to support health rather than guess at dysfunction.

Far too frequently we take credit for "fixing" the innate cellular mechanisms that keep us healthy on a day-to-day basis. We believe we know better than the body. We falsely presume that the work we do with our hands is the curative element in a person's pain. That is not to say we don't have a role in health, but we can only treat what the body allows. Far too often we are thwarted in symptomatic resolution by judgement and bias.

A recipe for success:

Manual therapy is much like following a recipe: we know some of the ingredients; we know the finished product; we just don't know the proportion of the ingredients and how to combine them. Therefore, we fill in the blanks with guesswork. There are a few things that can help our culinary exploits hit a bit closer to the mark:

Do not assume you know what is wrong - you may be treating false assumption.

Do not neglect the whole in favour of a part - the body is an integrated organism.

Treat what you find and aim to match dysfunction to symptom.

Nurture a happier environment for the tissues and let them govern themselves.

When we support health, we listen to the body. Just like a friendship, if we are asked for something and do the opposite, we will likely be met with resistance; if we listen and act accordingly our relationship will thrive. The key is to learn how to listen. Listening with our hands is not innate. That's why we have ears. Seeing with our hands is not innate. This is why we have eyes. We need to learn how to put multiple senses into a sense of touch.

We need to use our hands as both our ears and our eyes. Once we understand this concept, we can begin to apply it with more and more precision. Our treatment results will evolve in leaps and bounds. Our longevity as a practitioner will increase as we are working with the body as opposed to against it. We put less energy into the system, which means our own body won't degrade as much over time.

When we learn to take our ego out of the equation and just treat in observation, a whole new world of trust will open up. If we continue to think we know best, we will continue to get in our own way. Simplicity trumps complexity. We don't need to try fifteen techniques and end with a flourish when we can achieve better outcomes with one well applied technique. What is that one? The one that the body needs.

Retirement Plans Should Include Both Wealth AND Health Management.

We spend years working hard to create financial stability for the day we retire. During those years, we put enormous stress through our minds and our bodies that accumulates over time. Later in life, people retire from their job only to be battling the pains of the previous decades. We need to start depositing in our health account early in life so that we can live out retirement pain-free and active.

The Ergonomics of Youth:

Technology today has created more postural problems than ever before. People grow up on mobile phones, tablets, iPads, laptops, and computers. In many cases, ergonomics aren't a consideration until people finish school and get out into the workforce. Even then, it often takes pain to necessitate an either an ergonomics assessment or pain management support.

Some businesses do invest in their employees and provide an ergonomic workspace. However, having an ergonomic setup does not mean people sit appropriately at their desk. Further, long hours can prevent people from leaving their desks at all. Many people choose to eat at their desk rather than getting up and going for a walk.

Ergonomics education needs to start in childhood. Children sit hunched over devices and scroll incessantly with their fingers and thumbs. In some cases, children may spend hours a week in positions that can be the progenitors to neck pain, low back pain, and arthritis. We don't perceive the cumulative effects until we cough and throw our backs out decades later.

Turning Back the Clock:

A decade ago, the population seeking help with low back pain and neck pain from years working at a computer were middle age. So many young people in their 20s and earlier are suffering from the same problems now. As our parents didn't grow up with devices, their pain is showing up at a later time in their lives. The present generation were born into technology.

This is a real problem. Young people come into clinic with extreme rigidity through the neck and thoracic cage. These pains are not a one treatment fix. It can take 3-4 treatments to fully open and remobilize the facet joints, costovertebral joints, and costotransverse joints. Fast forward this accumulation over three decades and we are looking at a bigger problem.

It is imperative in the technological age to seek support for the postural perils of everyday life. This means exercise, stretching, ergonomics, manual therapies, and other behaviours that facilitate movement. The sooner people invest in their health, the greater the likelihood that the retirement years can be pain free.

It is never too late to diversify your health portfolio:

There are many types of health options in which people can invest. These can be as simple and inexpensive as taking a daily walk to having a team of several healthcare professionals to support, optimize, and meet our physical needs. So many people don't use their benefits; unused benefits are an investment that you choose not to cash out.

Not every profession has the luxury of benefits. However, creating a short-term and long-term health schedule can create a visual map of goals. This may include a morning meditation before you begin your day, a few stretches in the evening to counteract a day of work, a hike on days off, a massage every few months to restore alignment, and a yoga/pilates class.

A schedule creates a plan. A plan creates a habit. A habit compounds over time to create better health outcomes. We don't need a lump sum investment. We need consistent small deposits that are achievable. Success builds continuity. Continuity in summation builds health. In retirement we can spend our health on the activities we wish to pursue. Health IS wealth.

The Philosophy of Palpation.

Philosophia means "love of wisdom." Derived from ancient Greek, philosophy is a critical and systematic study of fundamental questions pertaining to existence, knowledge, values, reason, mind, and language. For a quarter of a century, I have applied these principles to palpation. In basic terms, palpation is the examination of the body using touch. In practice, palpation is a back-and-forth communication that supports the innate healing mechanisms of the body.

Where the journey began:

In 2002 I graduated from Sutherland-Chan School and Teaching Clinic. This renowned school in Toronto, akin to many schools in Canada, primarily focuses on Swedish massage as the main technique of choice. Swedish massage is a widely used modality that can help many different problems that appear on your table. However, it is limited in its application and has little consideration for what the body feels about its use: we choose how and where to apply it.

A year into practice I was bored. I was bored with the repetition. I was bored with the lack of results. I was bored with the mundane application of the same techniques that could be done on autopilot. I felt I had chosen my career poorly. I wasn't challenged. I wasn't engaged. In 2004 I took a craniosacral (CST) series with Grace Chan. This was a career changing moment for me. Unlike the active techniques of Swedish massage, CST sits in quiet observation of natural physiological mechanisms and supports the healing power of the body.

This method of treatment was a pivotal discovery for me. I took the CST principles of observation and communication with the body and applied them to my Swedish massage. I began to ask the body questions: how do you want me to apply this technique? How hard should I push? How fast should I go? Where is the best place for my hands? How long should I push here? To my surprise, I started using much less energy and got much faster results. Palpation for me became a challenge. How fluent can I become in this communication?

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

Haptics and the phemonology of touch:

Haptics refers to the psychological and physical study of active, exploratory touch. The phemonology of touch explores the lived, bodily experience of tactile perception. Manual therapy is a convergence of these two aspects of the philosophy of touch. Touch goes beyond the physical experience of the practitioner. Touch goes beyond the physical experience of the patient. Touch is a synergistic dance wherein the patient leads and the practitioner follows.

Let's use the GPS in car as an example. A GPS is designed to provide the quickest route from A to B. We don't need a GPS if we know where we are going. However, we can't always account for either traffic, construction, lane closures, one-way streets, and the multitude of other things that can delay our arrival. We may get there eventually, but it could take a while. The application of manual therapy techniques can be viewed in the same way: there is a best route.

The body is much more complex than city infrastructure. We must consider muscles, bones, nerves, blood vessels, organs, and many more structures that can hinder our objective of decreasing pain and restoring function. A comprehensive knowledge of anatomy is instrumental in restoration of mechanics, reducing tension, and optimizing health. The interconnectedness of anatomy means we must widen our palpation field.

Palpation is a state of mind:

Palpation is not about pressure. Palpation is not about assumption. Palpation is not about a specific technique. Palpation is all techniques combined. Palpation is about listening to the needs of the body without either bias or judgement. Palpation is about supporting homeodynamics without imposition. Manual therapy is treated as a physical process. However, manual therapy is very much a psychological process: it is the psychology of the cells.

Palpation requires active mental engagement. Palpation requires give and take. Palpation requires an attentive and sympathetic touch. Manual therapy is compassion for the cellular environment. We must respect the history of the body. We cannot predict how the life of an individual has affected the tissues. We must perceive the narrative and respond in kind. This perspective is not taught in school. It takes reflection and presence to practice this way.

All bodies exhibit this intelligence. We need only encounter it once to begin our journey of discovery. Results will happen faster. Change occurs with less effort. Treatment effects last longer. Contributing factors become observable. Local change becomes global change. The conversations become more complex over time, but the philosophy stays the same. Palpation is a progressive skill that is never beyond evolution. Mastery begins with the Self.

Being Heard: when compassion becomes clinician-splaining.

Most everybody wants to be heard in one way or another. We want our words to be acknowledged, understood, and validated. Some people are heard way too much! Most people are heard way too little. Yet being heard is one of the most basic needs of being human. It is through conversation that we express how we feel about our interactions with the world around us. However, the body expresses how it lives and feels through symptoms.

We have 30 trillion cells in the human body. Like a population, the individual cell has a small voice. When cells aggregate and become tissues the voice swells. The tissues become organs and the dissent is more noticeable. Create an organism and the power of communication can be verbalized to give voice to how our body feels. The problem is this description is unreliable. Our interpretation of our symptoms based on sensory perception is inherently flawed.

Further, in the absence of symptomatic presentation we can't presume that everybody is happy. There just isn't enough stimulus to reach a pain threshold. Even then, pain is variable. Pain is enigmatic. Pain is individual. The manual therapist can support that happiness by listening to the needs of the cells and offering the appropriate response. However, the perpetuation of chronic pain is not easily explained by either pain science or neuroscience.

The biopyschosocial model:

As the name implies, the biopsychosocial model consists of biology, psychology, and sociology. People in distress due to either injury, pain, or trauma will likely find themselves receiving help for either one or all of these treatment niches during their time in medical care. Often, the type of problem will dictate the type of treatment that is sought. For example, trauma may involve psychotherapeutic help while a muscle injury may require manual therapy.

Like a human population, cells want to be content in their environment. Unfortunately, the body has to resort to pain and dysfunction to alert us to its malcontent. At this point, things have already progressed far enough along to necessitate some sort of revolt. Pain is often an endpoint of compensation and adaption that becomes untenable and unsustainable. The problem may have been years in the making.

Manual therapy and the application of the biopsychosocial model
Being heard has a sociological component expressed through support of the patient. Being heard also has a biological component expressed through the sentient cell. Practitioners understand how to communicate with language but lack the skill necessary to listen through touch. We often feel the strain through tension but can't translate that into the appropriate response via touch; at best we use guesswork and previous experience to varying success.

However, when we learn how to pyschologically communicate through touch the conversation takes on a different tone; we support health rather than seeking dysfunction. This approach completes the biopsychosocial triad. When a patient feels heard and when a body feels heard both the body AND the mind can relax. A mind that doesn't have to focus on the body can rest. The psychological component of pain can now be taken out of the equation too.

Almost 100% of the time we look for the cause of a problem. We want to fix it. This is the antithesis of being heard. It is clinician-splaining. We assess, we palpate, and we decide wherein the problem lies. We treat accordingly and hope for the best. We listen attentively at intake, we support psychologically within our scope, but we don't listen physically. We can touch the vertices of the biopsychosocial model. After all, isn't listening to the body our job?