Remembering the Essential Partnership

Written by: Dain Hong / Treatment / June 2019

Evidence-based practice can be illustrated as an equilateral triangle with current best practice, clinical expertise, and client values represented at each of the vertices. Reality, however, may be more accurately represented as a scalene triangle with more emphasis on evidence and experience than client perspective.

The importance of partnership in clinical goal setting and achievement was echoed once again through a seminar I attended last month in May. It was a workshop led by Walt Fritz, a physiotherapist, on the topic of myofascial release (MFR). 

What is myofascial release?

MFR is a form of manual therapy that helps issues of pain and movement dysfunction. The course allowed me to develop a sense of touch to begin interactions with my clients. It raised the importance of allowing the clients, rather than myself, to inform and drive the intervention. As Fritz says, “Without this guidance, our work is merely a collection of things we do with our hands based on our ego.” 

Valuing clients as partners in recovery is crucial as they are the experts of their body, their pain and their concerns. Below, I share three components of client-centred care through the lens of manual therapy: finding relevance, honoring client narrative, and increasing accessibility. 

Finding relevance

The top three phrases Fritz used in his demonstrations of client engagements were “I’m looking to connect with your symptoms,” “does this seem relevant?”, and “does this seem like it can be useful?” Though his 20+ years of expertise can easily pick out the areas of tension through palpation of the client’s head, neck and torso, he holds back his first impressions and lets the client guide him. He allows the client to lead because he has learned over time that the areas he may find stiff are not always associated with pain, and those he may find flexible could be the source of reported discomfort. 

The greatest therapy efficacy is observed through consistent communication between the therapist and client, where the client reports what they feel and the location in which they feel it. This allows the clinician to identify the spot of perceived pain and stretch in various directions to check for pain. 

Often, Fritz uses rating scales of 10 to check-in with the level of pressure the client is feeling, and the level they may prefer. Since patient experiences of similar events can be as wide as a bell curve, with some reporting great relief after a session and others reporting pain, it is crucial to maintain an open channel of communication for movement in the direction of the client’s goals. 

Honoring the client narrative

Placebo is an aspect of therapy and of reality; there is no such thing as no-cebo. It is difficult to separate an individual from their placebo as cultural, social, and/or religious influence has layered their perspective. It is important for clinicians to recognize the narrative and to share their own so that the client has the opportunity to engage with a new narrative. 

For example, a client may believe that their slouched posture is the cause of their back pain. While research shows posture’s impact on voice and swallowing, it is weak in supporting the impact of postural-structural-biomechanical model in manual and physical therapies.However, if the client holds to this idea and feels relief after modifying it, there is no need for the clinician to dismiss it. 

The same principle goes for the belief that relief will come only through painful manipulation. “It doesn’t have to hurt to help,” Fritz reports, but if the client feels that the area of concern needs to ache to be healed, he will go out of his way to apply unnecessary pressure so that the client feels that have received what they needed.

Increasing accessibility

Therapy may appear to be intimidating, protocol-based work, but it can be a flexible and welcoming approach through accommodations the clinician makes. While it is a widely held conception that massage requires skin-to-skin interaction, the same effect can be achieved through massage over the clothes or a hand-over-hand (with the client’s own hand). This modification respects the client’s beliefs, needs, as well as their bio-psycho-social history. For example, such a consideration would be valuable when working with individuals with heightened sensitivity level, such as those on the spectrum. 

Similarly, therapy can be made more accessible when the clinician uses the client’s vocabulary to refer to their concerns. Rather than defaulting to buzz words like globus and adding to the list of mysterious pathologically-driven lingo the client has been diagnosing themselves with, the clinician can better connect with the client by using their descriptors, such as a lump. 

Overall, client engagement is indispensable in the recovery process, in the context of manual therapy, speech language pathology, and various kinds of clinical intervention. Through finding relevance, honoring the client narrative, and increasing accessibility, the clinician can empower the client to become an active partner in their journey to goal achievement, and thus contribute to impactful, desired changes in a time-efficient manner. 

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