Shared decision-making allows and encourages power-sharing in all aspects of health and medical decision-making, including sharing the best available evidence while offering a range of treatment choices.
Massage and manual therapy are interventions based on acquired skills derived from education, experience and further education. We learn about the anatomy, physiology and biomechanical relationships of muscles, fascia, posture, movement and dysfunction, all intended to teach us how to help people with pain or movement problems.
But what does this education teach us? Does it inform us how to interact with another human being, or does it compartmentalize that person into a problem needing fixing?
Do our clients respond like the mechanical models taught to us? Can we apply our training and, without outside assistance, know we are accurately defining the client’s condition and determining the correct intervention?
The Clinician-as-Expert Model
The clinician-as-expert model is universally accepted in massage and manual therapy. Theoretically, through our training, we are seen by the public as capable of determining the cause of a musculoskeletal-related problem and developing the proper treatment plan, with clients confident we can remedy their problems.
I was educated through this model in physical therapy school, with it being reinforced through continuing education and decades of clinical experience.
As much of my career has been spent using a model based on such principles, myofascial release (MFR) training taught me about the mysteries of the fascial body and how to influence it with selective touch. I immersed myself in that world for over a decade and became proficient at helping people with their problems by applying those fascial concepts.
Witnessing people improve, I viewed those outcomes as the result of knowing the correct techniques and touch style. I ignored those who worked from alternate perspectives, seeing them as ill-informed about the true nature of movement disorders.
Based on the culture of the MFR model (and most other training models), I saw myself capable of making evaluative and treatment choices for nearly every client who came through my clinic door, as that is the traditional power structure set up for us throughout our education.
Staying loyal to a very clinician-as-expert model, I was not exposed to other approaches that fostered client input as one of the primary drivers for therapy. Although I was never taught not to incorporate a higher level of client input, such a perspective was not seen as a priority.
I would speculate that those trained in muscle-based models undergo similar experiences: Learn the muscles and apply the massage or manual therapy-based interventions to those muscles, and the client improves.
The trigger-point therapist follows a parallel but unique model and helps people, probably to an equal extent as those using other therapeutic models.
Posture-based therapeutic perspectives see problems and solutions as being accomplished through postural correction.
The list of the number of approaches from which we can train is endless, and each holds unique views of problem-explanation and treatment solutions.
Success breeds confidence but probably reduces the incentive to question one’s beliefs. Success with the traditional clinician-as-expert model further reinforces the opinion that we need little input from the client.
The Shared Decision-Making Process
Despite the individual explanations for the remediation of musculoskeletal problems we are given, the consensus from the more general scientific literature shows that the receiver’s nervous system is a driver in any therapeutic interaction.
Understanding the nuances of how another person responds to our therapeutic touch and knowing that change comes from within the individual,1,2,3 how can I ever know what another person is feeling, fearing, hoping for or anticipating until I include them in the decision-making process?
More recently, as my curiosity led me to explore other therapeutic models and constructs, I noticed the term “shared decision-making” repeated across the spectrum of medical and health models.4
Simply put, shared decision-making allows and encourages power-sharing in all aspects of health and medical decision-making, including sharing the best available evidence while offering a range of treatment choices.
The clinician should provide such information without bias, allowing treatment decisions without influence or coercion. At face value, the expectation that clients will participate in their medical and health decisions seems logical, but is it always the case? Although shared decision-making is more recently mentioned as a recommended (and necessary) condition with manual therapy, how are we accomplishing this?
In my evolution as a clinician, as I saw the potential benefit of leaning toward a shared decision-making -based approach, tempering my views on causation and the best techniques to help with the problem with handing over some of the decision-making was not easy, at least in the beginning.
However, with time, a pathway became clear.
Include the Client in Decision-Making
How are you, the massage therapist, getting your client involved in making treatment decisions? How are you educating your clients to view themselves as capable of decision-making?
As I travel to teach my specific style of manual therapy, I’ll ask clinicians these questions. I’ll often receive guarded responses like, “I’ll ask the client if the pressure is good (or too much)” or “I’ll ask the client if I’m getting to their issue.” While these inclusions are a start, I think we can do better.
Power in relationships is seldom, if ever, equally apportioned. Instead, power shifts occur with regularity. Outside of relationships built upon hierarchy (employer/employee), when power is permanently skewed toward one person, the quality of that relationship tends to decline.
Thinking back on your life, can you envision circumstances where power battles or inequities doomed a relationship? If so, why are therapeutic relationships different? Clients quickly transfer power to us, possibly out of hope and expectation that we can help them, with our reputation as the expert creating an ease of perceiving our opinions as fact. But what if we discouraged this transference of power?
What if we set up the clinical encounter so the client better understands that owning their power could benefit them? How might we empower our clients to feel their opinions matter?
Maximize Improvement in Quality of Life
The manual therapy model I use in my practice and teach others doesn’t focus on resolving a tissue- or pathology-based problem. Unless a client enters my practice explicitly requesting it, we aim not to release their fascia, stretch their muscle, eliminate their trigger points or correct their posture.
Instead, I work with the client to maximize functional improvement in their quality of life. But without a client‘s contribution, I’m only working on what I perceive to be their goals.
To ensure I’m working from my client’s perspective, the shared decision-making model I use might rely on questions such as:
• “Does this pressure or type of input feel like it might be helpful?”
• “Is there anything about this pressure that feels like it may be harmful or a waste of time?”
• “Would you like me to change what we are doing, or do you think this could be useful?”
• “Would you care to put your hands over mine to better narrow in on what you feel is the problem or solution?”
These are just a few ways I invite my client to participate in decision-making. I’m still an active participant, offering options and suggestions, as this model is one of shared decision-making, but I strive to keep my biases to myself.
While I think specific mechanisms might be involved in the problem and believe a particular intervention style might be helpful, I try to keep my feelings neutral. I work to allow my clients to see themselves as capable of participating in decision-making.
There is Not One Best Choice
As shared decision-making implies, decisions are shared, and I will, when requested, contribute my thoughts, but I do so only to allow them to see that there is not one best choice. “We have options; which do you feel is best?”5
Many (most?) manual therapy and massage models are performed with minimal conversation. If relaxation is the goal, conversation is seen as a hindrance to that outcome. My early MFR days taught me to stay quiet, except for urgings to “go deep and look at the emotions.” Conversation between my client and me was said to distract them from their process.
But what if you changed those rules and norms? What if the conversation let the client better inform you of their values and expectations?
Imagine you told your client at the onset of a session that you do things differently. What if you said to them that despite the norms of the past massage or similar interventions they’ve received, your sessions are run differently?
I introduce this perspective to new clients with comments such as, “The way I approach treatment makes me a bit of a unicorn, as no matter how much I know, I’ll never know what you are feeling until I ask. I believe in including your feelings and opinions in the treatment, and I feel that if you help me in this way, we stand a better chance of helping. Initially, you may seem ill-equipped to help in the manner I’m requesting. But with time, the process becomes clear. Your opinion matters.”
Including shared decision-making in your massage or manual therapy session may seem awkward for you and your client, but you may find it a worthwhile experience. It is impossible to teach the nuances of shared decision-making in a short article such as this one, so I invite you to take a free online course from my website explaining more details of such an approach.
While I use a style of manual therapy treatment that involves prolonged, static engagement, shared decision-making principles can be broadly applied, including in traditional massage-based models. We all seek ways to stand out from the crowd of our competitors, including obtaining specific training or credentials. Shared decision-making allows you to stand out.
A recent client, seeing me for a persistent lower rib pain issue, made a remark that sealed my decision to practice (and teach) from this shared decision-making model. “I’ve seen a lot of practitioners for this problem, but you are the first person who has asked me my opinion. You are also the first person who allowed me to see that my opinions had value. I like this.”
Did I help her more than past practitioners solely because I utilized shared decision-making? She seemed to believe so, and with her opinions fully respected, shared decision-making was the key for this individual.
References
1. Bialosky JE, Cleland JA, Mintken P, et al. (2021) The healthcare buffet: preferences in the clinical decision-making process for patients with musculoskeletal pain. Journal of Manual & Manipulative Therapy, DOI: 10.1080/10669817.2021.1989754 .
2. Geri T, Viceconti A, Minacci M Testa M, Rossettini G. (2019). Manual therapy: Exploiting the role of human touch. Musculoskeletal science & practice, 44, 102044. https://doi.org/10.1016/j.msksp.2019.07.008.
3. Kolb WH, Wallace McDevitt A, Young J, et al. (2020) The evolution of manual therapy education: what are we waiting for?, Journal of Manual & Manipulative Therapy, 28:1, 1-3, DOI: 10.1080/10669817.2020.1703315.
4. Cook C, Tousignant-Laflamme Y. (2023) Shared Decision Making for Musculoskeletal Disorders: Help or Hype? https://sites.duke.edu/cemmt/2023/03/01/shared-decision-making-for-musculoskeletal-disorders-help-or-hype/
5. Fritz W. (2023): Manual therapy with voice and swallowing: A person-centered approach. Devon: Compton Publishing Ltd.
About the Author
Walt Fritz, PT, is a New York-based physical therapist who has been involved in the continuing education field since 1995. He has evolved historical myofascial release principles of care into a biologically plausible approach grounded in shared decision-making. He teaches his work to massage therapists and other professionals internationally through his Foundations in Manual Therapy Seminars.