“Sensory input, an emotional crutch?”...
(Following the theme of authority, survivorship and confirmation bias, critical thinking when it comes to training and rehab via sensory stimulation).
Some definitions of fascia and manual therapy
Fascia can be described as a tough membrane of fibrous, protective tissue that encases the body's muscles 1 2 3, and can be categorised into biomechanical, physiological, neurological and psychological subsections 4. Fascia is innervated by mechanoreceptors which are sensory structures that relay internal/external information to the central nervous system and are responsive to touch or manual pressure 5. Myofascial or self-myofascial release is the manipulation of fascia and is believed to be an effective treatment for improving circulation, relieving pain and increasing mobility 2 6. Manual therapy of fascia and or skeletal muscle and joints is classed as a pseudoscience and is often used to treat patients by alternative therapists such as osteopaths and chiropractors 7 8. Manual therapy currently has little to
no useful scientific evidence supporting long-term effectiveness in rehabilitation or sports performance 4 9 10 11 12 6 13.
Why is it used?
Research indicates that manual therapy is heavily related to psychological and neurosensory mechanisms and shows that short-term structural change via various techniques may relieve pain or increase range of motion in individuals by manipulating the soft tissue momentarily
4 14 15 16 17. This can be considered useful in a sport performance-related environment and may even speed up recovery from delayed onset muscle fatigue and increase range of motion before a bout of training. However, in relation to adaptation, it could be argued that gradual loading of tissues using methods such as post-activation potentiation (PAP) 18, through a specific range of motion may achieve the same outcome as well as being more task-specific and saving time 19 20 21 22. The effect of short-term changes in tissue via manual therapy or self-manual therapy and its efficacy on long-term recovery and performance could be a step further in the discussion. For example, how does short-term manipulation in range of motion out of its normal position followed by direct loading affect the tissue long term? Is there a potential for concern over manipulating structures beyond a predisposed condition? Moreover, what is a practitioner's incentives for treatment methods and recommendations overall, especially with an understanding of the lack of long-term effectiveness 23.
Are we conditioned to understand body or the mind?
Within medicine, the biomedical approach is the standard model used in healthcare practice throughout the world today 24. Primarily its strengths are that it gets to the bottom of the pathology for treatment, rather than focusing on preventative measures 25. The baseline perspective of the biomedical model is “health” which constitutes a disease-free state. It offers a dualistic view of body and mind but does not account for psychological or social conditions 26. Although reductionist in its approach it reduces the cost to treat and process patients 26. The drawbacks are that this process marginalises individuals and the potential frameworks that underlie their symptoms. Despite being useful in several ways, the biomedical model has failed to demonstrate the placebo effect rationale 27, which has been discussed as a specific link between psychological condition and clinical pathology 28.
The biomedical model is the primary treatment method across a broad range of healthcare systems and could be seen as an indoctrinating methodology, which might explain the reliance on a broad range of systematic processes to relieve pain. Conversely a psycho-social understanding or bottom-up vs top-down approach could drive more comprehension of pain mechanisms and bridge a gap creating longer-term solutions to short-term problems 29 30.
Discussion of efficacy
Regarding the possible manipulation of fascia, it is an ongoing topic and does seem that the majority of reviews are seeking more longevity or quality of evidence to determine its effectiveness. In recent years research projects, systematic reviews and meta-analysis studies have highlighted the ineffectiveness of many manual therapy techniques, often summarising the similar outcomes on subjects and low-quality studies calling for further understanding 31 32 33 34 35. Nevertheless, practitioners continue to use and recommend these methods to fit a various protocols and the abundance of research in this area might only highlight that misunderstanding further. This may bring into question a rationale for using specific trade tools and marketing them to improve well-being.
Other examples that are still being used despite the considerable body of evidence to suggest a high rate of placebo are, percussion therapy, kinesiology tape and dry needling to name just few 36 37 38 39 40 41 42 43. If these methods are still being used despite a lack of scientific consensus on its effectiveness, then from an individual or practitioner’s perspective it might seem that the jury is out and if a positive placebo effect is shown and no harm is done, this may well legitimise its use further.
Arguments against research might suit most bias´s, and it can often be related to the quality of studies and sometimes inconclusive results. If the short-term effect is more potent than any long-term progress, this might sway decision making.
However, this might also be delegitimising more long-term clinical and coach practices that are doing excellent work, using appropriate testing, asking the right questions and applying evidence-backed techniques and critical thought that show they are treating case by case with appropriate feedback. No doubt, marketing is targeted and divisive and may benefit from enhancing short term results.
Not one size fits all
Strength and conditioning specialists and clinical practitioners may often run tests that aim to troubleshoot, or problem-solve while increasing trust and confidence from the individual. Sensory input and a healthy dose of placebo might leave both practitioners and patients feeling much better; the individual perceives results and practitioners consider their position valid. Repeating the process over several sessions might further improve the individual's situation. The focus might be that practitioners and coaches could apply carefully considered individual pathways toward each case with a more hands-off approach to display confidence and trust rather than rely on manual stimulus to catch all dogmatic bias.
What is the alternative?
Utilising reactive indexing 44 45, range of motion testing 46 47, strength and force output 48 49 50, can help determine markers of improvement in rehabilitation or readiness to train for sports performance. This can create a focal point for positive activation and objective methods of improvement that ushers’ individuals in the direction that is more supported by the research pandering less to a particular bias and a need to utilise more inferior non-evidence-backed techniques.
If the work is done there can then be a rationale to reward the central nervous system with sensory stimulation to improve recovery and or wellness and reduce stress provided it is applied with efficacy and methodology in the right setting. The idea might be less leaning on it as an emotional crutch for the ego, but as a tool in the box of individual and practitioner showing that it might not be about fixing a problem but understanding the cause and preventative measures long term.
The bigger picture
The 2020 pandemic might have taught humanity that being underprepared has grave consequences. However, it has also shown that strong capabilities in problem solving and innovation are key drivers in achieving results.
In strength and conditioning, helping individuals understand how to develop skill and capacity is critical, encouraging confidence in fear-avoidance situations and furthermore, deemphasising fads and fallacies is paramount in succeeding at autonomy and understanding. Perhaps if the supply-demand is reduced in unnecessary areas, and a less dualistic methodology is implemented, it might be increased in regions that are more critically based on improving overall health and well-being “long-term” in recreational and performance sport.
10. Smith MS, Olivas J, Smith K. Manipulative therapies: What works. Am Fam Physician. 2019.