Walt Fritz, PT, with “Foundations in Manual Therapy: Voice and Swallowing Disorders” was recently interviewed by nicespeechlady.com owner Bekah Wilson Nice, SLP. Below is the transcript of the interaction, highlighting Fritz’s seminars.
- “Please share with everyone a three-sentence summary of what your courses encompass — what is your elevator pitch?”
”My seminars introduce manual therapy to the SLP as an adjunct, or occasionally a stand-alone intervention for the remediation of voice, swallowing, and related disorders. Unlike many forms of manual therapy that state a targeted tissue, I believe in following the evidence that says such tissue-specific beliefs are limited and incomplete. I teach the SLP a sound evidence-based intervention from a strongly patient-led perspective.”
- “What is new on the horizon for you during this time?”
“Lots of news on my front! First off, my ASHA approval just was approved (waiting for the official “seal” from them). Up to this point, my seminars were approved through a Boston-based hospital who helped out smaller CE providers through cooperative arrangements. Having my approval will allow me more options with regards to online CEs as well as greater ease of adding other seminars in the future.
To accompany this ASHA approval, I will be rebranding my seminars. The ‘Foundations in Myofascial Release Seminar for Neck, Voice, and Swallowing Disorders’‘Foundations in Myofascial Release Seminar for Neck, Voice, and Swallowing Disorders’ will become ‘Foundations in Manual Therapy: Voice and Swallowing Disorders.’‘Foundations in Manual Therapy: Voice and Swallowing Disorders.’ The reason for the rebranding is that as my knowledge of the mechanism of action of manual therapy grows, I now realize that concepts that claim to target specific tissues, structure, or pathologies, such as myofascial release claims to address myofascial restrictions, are not valid and supportable. Though many still believe such claims, as well as continue to teach such claims, in the broader view of current understandings of the impacts of manual therapy, such claims are not the current best-practice models. What the current evidence states are that the impacts of manual therapy come from a potential cascade of peripheral, central, and behavioral perspectives, and that is how my work and teaching has evolved. The new title, which includes the words ‘manual therapy,’ represents a more honest representation of what I teach and believe.
The reason for the rebranding is that as my knowledge of the mechanism of action of manual therapy grows, I now realize that concepts that claim to target specific tissues, structure, or pathologies, such as myofascial release claims to address myofascial restrictions, are neither valid nor supportable. There are plenty of outcome-based studies that appear to validate those older tissue-based viewpoints, but as we should all know, outcomes do not equate to valid mechanistic evidence.
Second, as my physical therapy practice is closed during the Covid-19 crisis and my in-person seminars are all on hold, I am taking this time to do a full rewrite on my course syllabus. The new version will contain a wide range of new evidence to support this work as well as address some concerns that SLPs who took my seminar in the past had over the lack of protocols. As I watch the new syllabus unfold, I see a better-organized structure and better referencing of the evidence to support each aspect of the hands-on training. A value-added aspect to having taken one of my seminars is that it allows you unlimited access to any future syllabus revisions via a free Facebook Group home only to those who have completed the seminar. Also included in this group is free access to video content that shows all of the hands-on techniques taught in the workshop, so there is no up-selling of DVDs, etc.
Lastly, I was invited to be a part of an inspiring program. Two UK colleagues of mine and I are putting together the first Master of Arts in Manual Therapy: Voice and Swallowing Disorders. If all goes as planned, the program will roll out in the UK next year, and there is a possibility that we will also offer it in the US in the future. My role is content expert in manual therapy, and I am completely absorbed in writing that curriculum as well. This program is exciting as I will be over in the UK 1-2 times/year to teach my part of the program, and we will be having specialists in voice and swallowing to play their role in both the background material as well as the interventions.”
- “What do readers not know about you and your courses?”
“While I think I may have covered some of this above, one of the most significant issues I would love SLPs to know is that I expect that after a 2-day seminar I hope that each professional feels sufficiently trained to begin to use the content immediately. While the seminar does teach manual therapy, which is using hands-on stretching (and related interventions), I see the real strength of the work I use and teach is the progression into a patient-led intervention. We all are well-versed in the evidence-based practice model; however, I see most professionals glossing over the 1/3 of the EBP model devoted to patient preferences and values. The way I teach manual therapy is one that elevates the decision-making power of the patient to one on a near-equal level as the clinician. For many, this is a difficult bridge to cross, for both the patient and clinician, as it requires us to give up a bit of our ego and allow the patient to participate more in treatment decisions. It can be hard for the patient as well as many expect us to do all of the heavy lifting with regards to evaluation and treatment planning. But in the end, working from a patient-led perspective, is better in keeping with current understandings of the biopsychosocial (BPS) model as well as what I feel were some of the original intentions of EBP.”
- “What is something that is a misconception about manual therapy for the SLP?”
“Primary is the view that one can target a single tissue for intervention to the exclusion of other tissues. Muscle tension is a perfect example, as excess muscle tension has been described as the cause of primary MTD, and early views of manual circumlaryngeal treatment were thought to impact that tension directly. I speak at length to these old views in each seminar and how that belief has been altered over the past 20 years. We now see the impact of MCT, and all manual therapy, not as having access to that muscle tension but having access to a functioning nervous system that detects input from our hands in the periphery and sends that input to the brain via afferent nerves. Current best-practice understandings of this sort of input from the periphery is that it is the brain that makes the decision to downregulate that high tension. We are merely giving the CNS options at the periphery. All manual therapy has this sort of impact. While we may be having a local impact at the periphery with muscle tension or fibrotic tissues, we know that the brain and CNS are involved to a greater extent in bringing about the changes seen with manual therapy.
One other point I’d like to make with regards to possible misconceptions, though this would apply to my version of manual therapy. While our evaluative measures and tools are essential, one of the more critical aspects of my interview and evaluation is to see if I can get my patients to relate and speak to the feeling of their issue. At times this is quite easy. ‘My swallowing is difficult right here, and it hurts.’ They point to a spot and immediately can relate and remember the feeling of that swallowing issue. However, many times our patients cannot translate a problem into a feeling, or they may not even admit that they have an issue. My work works best when the patient can relate and remember what their issue feels like, as that is a crucial part of the evaluation; I need to replicate an aspect that, to them, feels familiar. Think about the 10-year post-HN cancer patient who was found to have a poor swallow via testing. They may come to the SLP saying that their physician told them that they are having issues with swallowing, but they cannot relate to that report. The surgery and radiation were so long ago that they have long accommodated to that limited swallow, so much so that it now feels normal. They have little buy-in as they cannot relate to the diagnosis. They cannot feel the swallowing issue. What I’ll often do with someone like this is to use some simple manual therapy-style repositioning sequences, much like manual circumlaryngeal techniques are used to determine if a vocal change is possible via repositioning. If I provide a repositioning of the larynx and related and my patient feels greater ease of swallowing, I’ll give them a compare/contrast experience by allowing the neck region to be allowed back into ‘normal’ and ask them to swallow again. By repeating this a few times, they are often surprised how much easier it could be to swallow, though they had not even noted the issue. That will usually be sufficient to give them a ‘feeling’ of their dysfunctional swallow and build buy-in to the intervention methods.
While I think I may have covered some of this above, one of the most significant issues I would like SLPs to know is that I expect that after a 2-day seminar I hope that each professional feels sufficiently trained to begin to use the content immediately.”
- “What has been the most surprising lesson for you along the way?”
“That’s an easy one; how little I know about the world of an SLP! When I was initially invited to teach a one-off seminar for SLPs in Chicago back in 2013, I knew almost nothing about the challenges an SLPs faces in their practice. As a PT, I had worked alongside SLPs in the various job roles I had in the past, including home care, pediatric, and developmental disabilities. Still, I was very unprepared for the questions that came from that group of therapists in Chicago. Since that time, I’ve learned a lot about the challenges of facing your professional. I know my place as a PT teaching to SLPs; I am looking to create a bridge between my world, one filled with manual therapy, and the world of the SLP.”
- “What frontiers are there in terms of research in the field when it comes to manual therapy and SLPs on the horizon? In other words, if doctoral students were to want to perform research on manual therapy and the SLP, please list five excellent areas to research at this stage, knowing what you know of the research to date?”
“—Deepening the understanding of the complexity of manual therapy’s impact. For instance, to dive down the BPS rabbit hole, or, following along Nelson Roy’s recent papers on MTD and the influence the brain plays in both causation and intervention. (Roy, 2019)
—Taking existing evidence that demonstrates the usage and success of manual therapy with globus, MTD, dysphagia, and other SLP-related disorders, and modify the protocols presented in those studies to ones more in line with patient-led approaches. The more I read the various protocols for the use of manual therapy in the SLP patient population, the more I see a more extensive range of allowance of what constitutes a protocol within the literature. I’d love to see an SLP use some of the patient-led principles I teach and incorporate them into a study. (I’d like to help!)
— The one area where the least amount of evidence exists is with manual therapy intervention in the post-radiation fibrosis patient. The studies or writings in the scientific literature that I’ve come across are written in such ways that allow too much vagueness to be included as proof. While I do see a large amount of cross over in the use of mechanical devices for trismus and the use of manual therapy, be it clinician provided or patient provided, I’ve not seen any studies that address this possible comparison.
— I’d love to see a study that uses the same manual therapy intervention style, mine or another, along with a control group, but to include a patient-led or patient-included evaluation and intervention method in one group. In contrast, the second group involves treatment dictated by the clinician. With what we know about the importance of patient preferences and values, might add that into a manual therapy study for voice or swallowing show a difference in outcomes?
— While not precisely research, I am always eager to read scientific articles that outline the complexities of any intervention, be it manual therapy or otherwise. Traditionally, manual therapy papers are written from perspectives of singular tissues or pathologies, often metaphoric pathologies. I include trigger points as metaphoric pathologies as, despite over 50 years of research, nearly every study done on trigger point therapy are outcome-based studies and not a mechanism of action studies. Nelson Roy has done a stellar job of building a more complete understanding of what is involved from a causation perspective, with regards to MTD, as well as studying the complex nature of what goes into an intervention. I love the uncertain nature of all interventions, although we are supposed to know how it all works. I believe there is beauty in allowing oneself to accept that uncertainty as an aspect of the evidence-based work that we do. Manual therapy, as with all interventions, are involved, though we do tend to simplify them for the sake of explaining it all to our patients. Unfortunately, I believe that after a time, we end up believing those simple stories ourselves.”
- “What has been a surprising population along the way that has benefitted from manual therapy, and why?”
”While I’ve got a lot of fun stories of those patients/populations, I’ll pick one. The elite singer is often a patient (client?) of the SLP. Though we hear a stellar voice, the singer typically have themselves filled with pathologies and shortcomings. I’ve enjoyed the limited number of singers, beginner and advanced, who I’ve worked with, as well as observing my work done vicariously with elite singers by people who I’ve trained. There is a fair amount in the evidence of manual therapy’s utility with elite singers, but I continue to be impressed by how we can take someone who sounds so wonderful and allow them to both sounds and feel like they sound, even better. I am fully aware that manual therapy is not the tool for everyone, which is why I said from the onset that manual therapy is an adjunct to existing intervention strategies. I do hear feedback from SLPs incorporating this work into their existing work that they benefit from having another inroad with the difficult patient.”
- “How are you received in general by different sects of the SLP community, and why?”
“Hmmm, does one ever really know how others view them? I can say that the SLPs I’ve met over these past seven years have been quite receptive to what I have to offer. I’ve been fortunate to have been allowed to present workshops at the Voice Foundations Symposiums, as well as a few conferences dealing primarily with SLP-related issues. I’ve had doors opened for me in your community by a few wonderful SLPs who have supported my work from the onset. I do know that some dislike my ‘uncertain’ approach and hesitation to commit to a fully protocol-based approach. I’m willing to lose a few people along the way as I feel so strongly about allowing the patient to lead, or at least walk down the therapeutic road alongside me, and many manual therapy approaches teach the opposite.”
- “Where do you see manual therapy for the SLP evolving within the next ten years? What are the new frontiers?”
“The new frontiers will hopefully be one that forges ahead to view manual therapeutic effects as being more strongly determined by the brain and perceptions of our patients versus those things we think are wrong or that we are doing with their tissues. That is my hope for this work with the SLP community as well as the larger therapeutic communities that I am involved. Old habits are tough to let go of, and many seasoned therapists have difficulty parting with old beliefs. There is a small but growing community of manual therapy educators who are progressing the narratives in directions such as those I’m advocating. That is the future.“
- “What are both some non-beneficial and beneficial actions SLPs tend to make when first utilizing this form of work?
“The most significant benefit of this work comes from those who begin to apply the principles from day one in the clinic. The longer one waits, the more difficult it will be ever to begin. I remind SLPs that most patients genuinely have no clue what you all do for a living or at least a deeper understanding of your job(s). So, when you walk in with a new patient, they have no clue that SLPs typically may not use manual therapy. It is the SLP who feels awkward; patients are, for the most part, willing to do what is necessary to get better. Fake it. They’ll never know that this is the first time you are using manual therapy. Another problem a newcomer might have when applying this modality is not to give sufficient time for a process to unfold. I go into this in-depth in the seminar, as it often takes time for a patient to begin to relate what you are trying to accomplish, so give them that time. I came across a fascinating study that looked at the effect of touch when the clinician was either listening to tones that distracted them or when they were paying attention to the patient. There was no therapeutic mandate to reduce ankle pain, for instance. The researchers were monitoring brain function of the patient in both groups. They found that there were more positive associative brain actions occurring in the patient whose skin was being touched by a clinician who was attending to their touch, versus the clinician who was being distracted by sounds through headphones. And not only did the attentive clinician have better responses from the patient, but there was a heightened impact when the touch took place for more extended periods, up to 15 minutes. This is one of the first pieces of evidence that may provide a new link as to why longer intervention styles, such as the one I teach, may have different effects than those who apply the techniques in shorter duration intervals. (Cerritelli, 2017)”
- “As a final question — why manual therapy and why now in this day and age for the SLP?”
”Manual therapy has been a regular part of the SLP profession since 1990 when Aron Aronson introduced its use with MTD. Its use with voice issues have become more accepted but is still not fully embraced in the dysphagia community. Newer studies are beginning to change those views. Manual therapy, under different guises and brands, is offered on many fronts in the continuing education field, so there is little that is novel about its use. I am hoping that the ‘why now’ is that we are now better understanding how biopsychosocial approaches an integral part of must be all that we do, and I see the version of manual therapy that I present as being entirely faithful to the BPS and EVP models. At least that is what I hope.”
Walt Fritz, is a physical therapist in the Rochester, NY area who has been using manual therapy as a primary intervention since 1992. He has been an educator since 1995, and his work has evolved from “myofascial release” into a more accurate term: “manual therapy.” He teaches his Foundations in Manual Therapy: Voice and Swallowing Disorders seminars to a variety of health professionals, including SLPs, across the globe. You can learn more about his work through articles and videos, along with viewing his introductory and advanced seminars at www.waltfritz.com.
Cerritelli, F. C. (2017, July 20). Effect of Continuous Touch on Brain Functional Connectivity Is Modified by the Operator’s Tactile Attention. Frontiers in Human Neurscience, 11(368).
Roy, N. D. (2019, March 1). Exploring the Neural Bases of Primary Muscle Tension Dysphonia: A Case Study Using Functional Magnetic Resonance Imaging. Journal of Voice, 33(2), 183-194.
Wilson Nice, M.A., CCC-SLP, is the owner of nicespeechlady.com.
Nice created nicespeechlady.com as a platform for medical SLPs to have free access to practical clinical resources on nicespeechlady.com. She also enjoys blogging and writing news articles on medical SLP issues. Nice works full-time as a home health SLP.
Disclosure: Foundations in Manual Therapy: Voice and Swallowing Disorders is a sponsoring advertiser of nicespeechlady.com.