Barrett L. Dorko, P.T.

          "I just can't do it anymore. I've got constant pain in my wrist and forearm. I've started to drop things and now I'm feeling it in my shoulder."

          The speaker is not a patient in my office, but a therapist at a workshop. In her face is reflected both the discomfort she experiences daily and the terrible knowledge that her favorite therapeutic tool has betrayed her. Her hands these days curl in, no longer reaching to treat patients, but unable to fully rest either.

          Her history includes long periods of work on patients with heavy pressure. Specifically, this pressure was directed through a fingertip, a knuckle, or the thenar eminences. It differed from joint mobilization where the hard elements of the patient are grasped and leverage is applied. She has just pushed hard and slowly, often gathering the skin in rolls as if it were as compliant as dough.

          I seriously doubt there is a physical therapist anywhere who hasn't spent some part of his or her career trying to change their patients in this way. As a technique, it is common among a variety of bodywork disciplines and each has its own explanation for its use. It is commonly thought that heavy pressure mechanically distorts the myofascial unit in a beneficial way, that it promotes blood flow and relaxation.

          But I've read of how transient this relation is.1 Whether or not the force applied actually travels to the target tissues in the direction intended is called into question in an article by Threlkeld:2 "If 100% of an externally applied force could be transmitted to the long axis of a connective tissue structure, manual therapy could produce permanent elongation...however, (these forces) are not direct and are not completely transmitted."

          The ability of our bodies to disperse force makes it possible for an Indian fakir to lie on a bed of nails without being impaled. Of course, it is the vast distribution of weight along with the stillness of this direct pressure that makes it safe. But even a razor blade pressed directly on the skin will not break through without significant pressure. Movement enhances the razor's effect by overcoming the skin's ability to disperse force; the faster the movement, the easier the skin is to overcome.

          I can't turn my hand into anything remotely as sharp as a razor. I can't make it sharp at all. My fingertips and knuckles are hard, but blunt. With heavy pressure through them on a patient they become less like a hand and more like a weapon. By fashioning tools with our hands, humans moved from caves to condos. This had nothing to do with strength, but with dexterity.

          If you look at the body's ability to distribute slow, steady pressure from a blunt object, you wouldn't expect "soft tissue work" to significantly alter any patient in a mechanical or structural manner. Still, we press on, usually in hopes that it will "work" by stretching or deforming something beneath the skin beyond its elastic range.

          But the important changes that take place are more likely to be reflexive or circulatory, and there are easier ways to obtain these.

          The damaged hands of the therapist at the workshop are not unique in my experience. They were wonderful tools used the wrong way. When I took shop in ninth grade and one day used a screwdriver as if it were a chisel, Mr. Ceresi grabbed my wrist, looked me in the eye, and said, "What do you think you're doing?"

  1. Morelli M, Seabourne D, Sullivan S. Changes in H-reflex amplitude during massage of triceps surae in healthy subjects. JOSPT. 1990;12(2).
  2. Threlkeld AJ. The effect of manual therapy on connective tissue. APTA Journal. 1992;72(12).