Updates in Manual Therapy for 2023/Answers About Trends, A Print Interview with Walt Fritz

Walt Fritz, PT, with “Foundations in Manual Therapy: Voice & Swallowing Disorders,” was recently (print) interviewed by Nice Speech Lady LLC, owner Wilson Nice, SLP (on 1-19-23).

Below is the transcript of the interaction, highlighting current issues in manual therapy for voice, swallowing disorders, and more.

What would you list of the top three things that you wished all speech pathologists knew — that are good news?

“1. PTs might be just as inexperienced in applying manual therapy as the SLP (though we would never admit that!). Over the past 10-15 years, the PT profession has devalued manual therapies of all types, elevating exercise to a higher place in terms of patient value. As such manual therapy training is less commonly taken, especially with newer graduates.

2. Manual therapy can be simple to incorporate into your existing treatment framework.

3. Manual therapy doesn’t require special equipment and can be applied with your patient seated or lying down.”

What questions do you love hearing participants ask time and time again?

“As most manual therapy models specify a tissue — or pathology-based problem, the clinician is tasked with seeking out those problems through palpation. In my original manual therapy training (myofascial release), you would have been charged with finding the fascial restriction causing the voice or swallowing problem. Take a class in laryngeal massage, and you’d be tasked with finding the muscle knot responsible for the voice or swallowing problem. Take another class, this time in manual circumlaryngeal treatment, and you’d be tasked with finding the high muscle tension that was said to be causing the voice or swallowing problem. But if you could step back from each of those models and see that each was directing you toward the same area, the same palpated felt-sense experience, you’d begin to wonder, “are there common denominators in all these models of treatment?”

When we are evaluating, what is it we are searching for?

“My approach is to acknowledge the poor validity of palpation as a predictor of dysfunction and instead palpate for patient awareness. I teach clinicians to use palpation to direct the patient to an area relevant to them (and not to us). This request is often confusing for the new learner, as there is an abstraction that disconnects them from their expectations. But implicit in the shared decision-making model I use is handing over to the patient a fair amount of responsibility. Please provide information on trends we need to look out for in the research.

Historically, manual therapy is presented in the literature as a (relatively) aggressive form of intervention, with the clinician in the role of the operator (clinician-as-expert model). The patient is given little opportunity to provide input during the treatment. However, given newer models trickling in from the more general literature (and more input from the many SLPs who have learned my gentler approach), I hope to see more studies using a more comprehensive range of intervention styles. Additionally, manual therapy is seen more frequently in voice research. Still, with a growing number of SLPs utilizing manual therapy, I expect to see it become more common in dysphagia literature. Look outside the SLP literature for how others use manual therapy with disorders that overlap with those of the SLP. While there may be push-back from some for turf-infringement, there is much relevant information coming out of the physical therapy, osteopathic, massage, and
myofunctional literature.”

From within the field of speech pathology, what are some misunderstandings (and clarifications you would like to make) toward SLP-manual therapy?

“I still come across SLPs who feel that manual therapy is not within the SLP’s accepted scope of practice (SOP), even though it has been an accepted inclusion since at least the early 1990s. I’ve also encountered SLPs who feel that if a study does not explicitly mention that an SLP can do the work mentioned in the study, a study that precisely describes the disorders that are part of their SOP, they are not ethically allowed to use the intervention. Interpretations vary so widely. I tend not to intervene on these sorts of issues or arguments but instead point to the brilliant vagueness of your SOP.”

From outside of the field of speech pathology, what are some misunderstandings (and clarifications you would like to make) toward SLP-manual therapy?

“Though I’ve not witnessed this issue personally, at nearly every live class I present, I will hear from an SLP who has had push-back from PTs on who should be able to perform manual therapy. I’m unsure where these ideas come from, though I can guess. My profession has always been one that feels like the entire person, head to toe, is within our SOP. Occupational therapists? Stick to the upper body and functional tasks, SLPs? Stick to a narrow range of stereotypical interventions that PTs see you working with. This problem is compounded by research from PT-based publications on interventions (manual therapy and exercise-based) with crossover into the SLP domain, empowering PTs to take on diagnoses that the SLPs see as their domain. In a perfect world, I see SLPs, PTs, and even OTs using various interventions, including manual therapy. Even if each sees a patient with the same problem, utilizing manual techniques for the same issue, the different context each discipline would be applying will benefit the patient more than if used by only one professional.”

How have systems for speech pathologists to learn about how to acquire manual therapy skills changed through the years?

“As I’ve only been a tangential part of your profession since 2013, I can’t comment on the years before. However, I poll SLPs in each of my classes to ask who has done training in manual therapy. A few have, though more have replied that they learned circumlaryngeal manipulation from a supervisor rather than formalized training. For many years, the CIAO coursework has included a myofascial release for dysphagia class. Though I’ve not taken that training, I know it to be a different work style (more aggressive). I have heard excellent feedback from clinicians who have done that training. On-the-job manual therapy instruction seems the norm for many, which is a solid way to begin a learning journey. I know of some informal manual therapy mentoring of newer SLPs by clinicians who have taken my training(s) and feel confident in their abilities, which I think is fabulous. I now offer a few follow-up classes to the introductory seminar. There is the ‘Balancing the Body’ class (online class only) and the ‘Advanced Voice and Swallowing Disorders’ class (in-person or online), which will allow SLPs to develop a depth of training and a deeper understanding of not just the hands-on aspects of the work, but the all-important patient-centered approach I insist on.”

What is your advice for those looking to find out more about manual therapy for the SLP?
“Ask colleagues, in-person or online, about their experiences using manual therapy. Begin to look at the literature to see how it applies to your patient populations. I keep an extensive research list updated and available at https://waltfritzseminars.com/resources-2-2/research/. Look at the many videos and interviews available on my website. Talk to skeptics; I believe in looking at both sides of any topic. Finally, consider taking a live (or online) class. I feel the live class environment is best for absorbing the full depth of this work, but many opt for the online class, being both more affordable and requires no travel. I also encourage questioning clinicians to contact me directly with their questions.”

Walt Fritz, PT, has been a leader in providing education in non-manipulative forms of manual therapy in speech-language pathology, voice intervention, laryngeal disorders, breathing disorders, oral motor dysfunction, and related communities. Unlike historically more aggressive or tissue-based approaches, which view problems as the result of a single tissue or behavioral fault, Walt’s blended views allow newer models that point to multifactorial causes and effects. This model requires adaptation by most new practitioners, as lowering our view as the “expert” and elevating patient perspectives is not an easy task. However, a shared decision-making approach results in patient/client empowerment and boosts outcomes. Walt has taught thousands of speech-language pathologists, vocal coaches, registered dental hygienists, massage therapists, physical therapists/physiotherapists, occupational therapists, osteopaths, chiropractors, and ENTs his work through workshops worldwide.

Casting such a wide net has added value to a range of rehabilitation settings and performance interventions, including positive results with world-renowned performers. Walt makes his information available through live hands-on seminars, online courses, many podcasts, videos, and articles, and his book, Manual Therapy in Voice and Swallowing: A Person Centered-Approach (Compton Publishing LTD., March 2023). His in-person classes are a lively blend of lectures, demonstrations, and immersive, hands-on learning that prepare the participant to apply in their practice. He has a progression of online courses targeting his voice and swallowing curriculum and a comprehensive online course for clinicians seeking a more general view of a shared decision-making model of non-manipulative manual therapy.

He holds a BS in Physical Therapy and a BA in Community Mental health, both through the University of Buffalo (NY), and is currently an MA Candidate at the University of Wales Trinity Saint David (UK). He sees patients through his Upstate New York practice for voice/swallowing-related problems and more general concerns.

Wilson Nice, SLP, is the owner of Nice Speech Lady, a medical SLP platform for functional, practical and evidence-based SLP clinical resources.