Cumpelik

JiriCumpelik-rehabchiropractorGroupI had the pleasure of hosting Jiri Cumpelik, PT, PhD from Prague.  His physiotherapy and yoga background create a unique blend and a wonderful course.  We had a great group assembled and here are a few of the points and reminders I took away.  [Disclaimer: All brilliance is the result of Jiri’s skills and the history of the Prague school.  Any inaccuracies are my own.]

Breathing:

  • Breathing is often coached into the abdomen.  What is more ideal is to coach lower rib (lateral) expansion.  This leaves the abdomen as a fixed point.
  • Breathing is disrupted if the 3 points of contact for the foot are not kept.  Supportive shoes or orthotics can do this. You will find lateral breathing diminished.
  • When the diaphragm has sternal support breathing is anterior upper abdominal; with costal support it is anterior mid abdominal; with lumbar (TL junction) support it is lower abdominal.  Ideally it should be all 3 simultaneously and lateral expansion of the ribs should occur effortlessly.

Foot contact:

  • The foot is dependent on 3 points of support. This afferent information feeds the system.  Yes, this creates arches.  However, supporting the arch creates the illusion of proper positioning, but it does so without creating any of the necessary afferent info.
  • If you were repairing an archway or a bridge… would you support the arch or would you support the pillars?
  • Arch support or back support without improving afferentation is analogous to putting your team in the right positions, but with little or no communication from the sideline about what play or defense they should be running.  It looks good, but the tendency will be towards chaos and compensation rather than organized, efficient force.
  • Foot contact is often more toward the heels than it should be.  In standing and walking we need to encourage forefoot weight bearing without loading/overloading the toes.  The same is true in squat and dead-lift. The pressure through the heel should feel like it is going into the ground with a 45 degree angle posteriorly.

Posture:

  • Proper sitting doesn’t require a cushioned, supportive,  high back executive chair.  It requires quality input.  Likely a firmer chair.   Think of the piano player, someone who sits for peak performance.  They gracefully sit on an unsupported stool/bench.  With all the practice hours required, why don’t they sit on something more resembling a desk chair?  Do they know something most of us don’t?
  • “It is easier to move a chair than a sack of sand.”  – Reference to firm posture rather than slouched, jello-like, amoebic positioning of some people.  Having structure and support makes movement and control of the body more effortless.  Postural control creates efficiency.
  • Posture can be driven from the foot as described above, it can also be facilitated through the hand.  “Stretch the pinky” (elongate and radially deviate) is a way to get support from the upper extremity.  This can be acheiecd open chain and during gait on the reach forward as well as during true supporting functions.
  • Sitting posture should not be on the “sit bones” as so many conveniently describe.  Looking at the shape of the pelvis is sitting on the ischial tuberosity realistic?  Would you design a system to balance on a roughened, round object?  It was suggested that sitting on the ischiopubic ramus was more ideal.  With a slight anterior lean, this provides a ‘flat spot’ to balance on.  Try it. See what your body tells you.  (remember to use a firm chair)
  • Forward head carriage is understood to be compensatory.  The chin tuck can improve this.  It can also improve posterior breathing.  However, too much chin tuck can impair lateral breathing.  (We do not want to sacrifice lateral breathing for the appearance of good head position.  You can pack the neck too far.  I am playing with finding the right degree of chin tuck based on breathing patterns.  If lateral diminishes, you’ve gone too far.)
  • It must be practiced, “All the time”.  While we discuss sets and reps, one of the main take homes was that the small, but important changes we were making needed to be integrated into all activities.  They should become part of your life.  This was likely the hardest, but most rewarding part.  It requires a lifestyle change, not simply doing some correctives periodically as prescribed.
  • Posture is synergy (or as McGill describes “the orchestra”).  To get synergy back, play a few leading notes (movements or positions that can stimulate quality positions):  abduct the toes, elongate the pinky, open your mouth, “Kaa” (depress the hyoid), tongue position/movement, eye movement, feeling ground contact, …. & many more.  Once the musicians know what tune they’re supposed to be playing others come on line, listen to your body and recognize the changes.

Random:

  • Hand positions (even open chain) can drive breathing.  See mudras and experience it for yourself.  Some beautiful demos during a course break.
  • Children will be able to control their sphincter when they can stand on one leg.  [As this often happens around 3.5 years and we see children potty trained earlier than this, we question what happens?  While uncertain, hyperactive pelvic floor seems very possible to me.]

Final Thought:

Contemporary clinicians and trainers (and just about everyone who reads this blog) are aware that we think in terms of the CNS rather than specific muscles or joints.  We reference muscles or joints for the ease of communication, but we appreciate the fact that we are trying to create neurologic change and are evaluating neurologic dysfunctions in movement.  Here’s where I think many of us fall short.

I’ve seen the Gray Cook, PT quote, ““The brain does not think in terms of individual muscles it thinks in terms of movement”  referenced hundreds of times.  The problem I see is while we think we’re training the CNS, many take from this quote “movement not muscles”.  I think too many omit the word “thinks”.  (You’ll notice Gray put it in there.)  Doing correctives to improve movement isn’t enough (but it is a good start).  The brain is familiar with half kneeling, bear position, etc, ….   however it also doesn’t think in these terms.  The brain knows goals.  I want, I need.  As we use positions and movement to improve dysfunction we must engage the brain in thinking.  Run the mental program of reaching for a desired object, operate the software to open the mouth and eat a sandwich, and focus on ground contact & pushing away.  These external cues feed the CNS what it truly wants and knows.  (Ex.  grab the car keys, reach for the doorknob, give me a high-five.)  Give targets and goals during exercise.  They can be physical or based on mental imagery.  You’ll be surprised how much changes even with a different image of what we’re doing.   Follow the same principles of movement, but get the brain running the software it needs to.

Finally, a public thank you to Jiri Cumpelik for sharing his thoughts, ideas, and views.

Link of interest: A blog post from Geoff Girwitz who attended Jiri’s workshop in Newark.

Stanford Cook McGill

Rehab 2 Performance logoI recently had the pleasure of writing a blog post for Rehab2Performance.com.

Two giants in the field, Gray Cook, PT and Stuart McGill, PhD, assembled to present their viewpoints on movement assessment, arranged and moderated by Craig Liebenson, DC.  Assessing Movement: A contrast in approaches & future directions was held at Stanford University and co-hosted by Stanford Sports Medicine and Rehab2Performance.  Such a prestigious location was fitting, and even led to Gray uncharacteristically appearing in a jacket (which didn’t last the whole day, and he quietly told me “jackets are for funerals and Stanford”).  For the nearly 350 professionals in attendance, it was nothing short of spectacular.  With representatives from Asia, Europe, and throughout North America ranging from students, to fitness professionals, performance coaches, and clinicians, there was a bit of perspective for everyone.

See the rest of the review on the Rehab2Performance Blog

Liebenson with Cook and McGill

Organized by Craig Liebenson, DC (left) a great conversation between Stuart McGill, PhD (center) and Gray Cook, PT (right) was held at Stanford University.

 

McGill

I had the pleasure of spending a weekend in Saco, ME listening to Stuart McGill.  As you may know, Dr. McGill is a wealth of knowledge, info, research, and clinical insights.  So I don’t become one more in the long line of people to misquote Stu on the web, I’ll let his work speak for itself, you can read his books, review his research, or watch his DVDs to get his opinions and I’ll simply offer a few things I took away from this weekend.  Here’s a few reminders, tips, tricks, concepts, or soundbites I took away from the seminar. 

  • Always look at both sides of an issue.  Make an argument for it and against it.  Almost all tools/methods/systems have strengths and weaknesses.  You need to know this!  I was surprised to see how many exercises, methods, experts Dr. McGill began with I love (Insert method/technique here) it’s great at (insert desirable outcome here), but we’ve also shown that (insert negative impact or side effect).  My translation:  Use all of these great tools, just understand when to use them and when to apply other strategies.
  • Smiling is wonderful, but you can’t lift hard, train hard, or be powerful while you do it.   Concentrate and maintain complete focus until you’ve nailed some quality reps.  Smile after you reach your goal.  
  • Train the nervous system.  The evidence is overwhelming, this is what makes the best athletes.
  • Know the physical demands of the person you’re working with.  Assess their current capacities and then design a program to fill this gap.  For athletes review tape of their competition and break down the movements.  From a fundamental standpoint, what movements are you seeing?  How often? How many times? What duration?  In what combinations?  Write it down and be specific.  Train these fundamental movements.
  • Dissociate.  Proximal stability gives distal mobility and power.  If you can’t separate ball and socket movement from spine movement, stop, peel back and try again.  This is an essential skill.  (Side note great, descriptions in Osar’s book. Osar’s Movement lecture here.)
  • While movement quality  is essential, the fact that speed and load change these unpredictably cannot be ignored.  McGill’s research demonstrated that individual’s patterns changed, in both directions (from ideal to compensated and from compensated to ideal), under load.  Make sure your assessment includes something that matches your patient/athlete’s demands.  Also realize that even though someone passes an initial screen this does not mean the get the ‘green light’ to do anything.  They may have a green light to train, but you need to constantly monitor and assess for quality movement.  Patterns change with speed and load.  (This leads us into the next point.)
  • Assess, assess, assess. Constant assessment and reassessment is performed to titrate the exercise to work at the edge of the patient’s abilities.  It is also necessary to evaluate progress or impact of the intervention.  Assess, reassess, repeat if desired.  (Feel like I’ve seen this pattern somewhere before.)
  • Small things make a huge difference.  As with so many things the difference of good and great, or great and world class are little things.  Don’t overlook the little things that can take your patient to the next level.
  • You need to respect someone’s congenital limitations.  Hip shape is not uniform.  Squat depth and peak abilities will be affected.  Also simple exercise like tolerance for the elliptical trainer, can be dependent on having enough hip motion to spare the spine.  Assess the movement of the ball and sockets. Scour (perhaps daily according to Dr. Cubos).
  • Exercise selection is a risk vs. reward decision.  Stated this way I doubt many will disagree, but when presented more scientifically such as EMG activation vs. joint load, my guess is many will choose to remain in their comfort zone and stick with the exercises ‘that have worked before’.  While EMG studies have their limitations, remember risk vs. reward and that any training capacity you can spare, can be used later.  In those who are injured or at risk, choose exercises judiciously.

Other McGill resources:
Cubos notes from similar course. 

McGill resources from Liebenson

Backfitpro resources

McGill Movement Lecture

Prior post with links to McGill NY times video and article.  Hate sit ups?

 

Concussion Conference

Being a strong proponent of active care I encourage many people to become more active, to move with better quality, and to then move more frequently.  For the majority, I think this is quality advice, but as with all clinical interventions a key component lies in knowing when not to apply that strategy.  Active care may be contraindicated in a few different conditions, but one is in those experiencing concussion symptoms.

Recently I had the opportunity to attend the 9th Annual Sports-Related Conference on Concussion and Spine Injury (May 18, 2012). While I must admit that my background in concussion management is not as strong as I would like it to be, I felt compelled to attend to strengthen my understanding so I would better be able to discuss this hot button topic with my patients and community.  Ultimately I see my role as a chiropractor in recognition of symptoms, prescription of sparing advice, reassurance, and referral for appropriate monitoring.  To do this effectively I needed to know more.  I found this conference to be a top notch assembly of exceptional health care professionals, former elite athletes, and researchers.  I left with an appreciation for all that goes into studying and managing concussions and appreciating that there is still a lot to learn.  Some points of interest, reviewed concepts, and things that peaked my curiosity below.

From William Meehan III, MD, the history of concussion was discussed.  It was known from the slaughterhouse that rotational acceleration was necessary to stun the animal and that blunt head trauma alone (head stabilized during the trauma) did not produce the dazed reaction they were looking for.  {Upcoming post on how often we know things before science catches up…. Soon.}  The role of second impact syndrome or repeated concussion is a hot topic these days, but was first described by Gronwall in 1975 who noted in his research that the 2nd concussion commonly took longer for recovery of symptoms.  Why are we sometimes so far behind ourselves?

(Overview) Management of a concussion:

  1. Rule out other injury (on the field ABCs, then consider fracture, intracranial hemorrhage, and other life threatening conditions)
  2. Physical rest (avoid working out so ATP & glucose is not stolen from the brain where it is needed for recovery efforts.)
  3. Cognitive rest (avoid mental activity using precious ATP & glucose that’s needed for healing.)
  4. Emotional rest (same rationale as above)
  5. Follow up and reassess for patient to be symptom free.
    1. Evaluate with PCSS- Post Concussive Symptom Scale
    2. BESS Balance Error System Score:  Double leg stance, Single leg stance, Tandem Stance (20s)
    3. Neurocognitive (ImPACT and similar tools):  Verbal memory, visual memory, processing speed, & reaction time
  6. When symptom free return to participation (RTP) stages
    1. Rest (physical, emotion, cognitive; as described above)
    2. Light aerobic
    3. Sport specific (low intensity) training
    4. Non-contact training drills
    5. Full contact
    6. Game play

 

Neuropsychologist Alex Taylor, PsyD reminded us that concussion is a silent disease.  Those suffering with it often appear healthy and normal.  Considering that 90% of concussions do not involve a loss of consciousness, MRI and/or CT are likely to be negative, and there are no dramatic outward signs (seizures, emesis, blood, bruise, cast, splint, etc), these injuries can often go under appreciated.  Particularly in students this can include parents, teachers, coaches, and friends.

He also noted significant role of computer based testing.  His explanation was that this testing was more sensitive than symptom reports only, but he emphasized the greatest sensitivity when combining the two:

–       64% accuracy with symptom reporting
–       83% accuracy with neuropsychologic (computer) testing
–       93% accuracy when combining both (the comprehensive approach is best).
–       As each individual recovers differently, evaluation and reevaluation is essential.

From Robert Cantu, MD – Ways to prevent concussions:

–       avoid taking unnecessary hits (non-contact practice)

  • CTE is more about repetition that significance of trauma; observe the most frequent positions in football – linebackers & lineman; mores than receiver.
  • Consider ‘hit’ count for kids, similar to pitch count in baseball.  Considering that pitching produces surgically repairable injuries and head trauma causes irreparable damage this should be given strong consideration.

–       proper technique (don’t lead with the head)
–       adequate hydration
–       having the right genetics  (good luck modifying this risk factor)
–       rules changes
–       strengthen your neck   *** see discussion below***

My side comment: (Note: I have no strong evidence to support this, just my thoughts.) 
Dr. Cantu was not the first or last to note ‘neck strength’ as a primary factor in concussion prevention during the conference.  As this was discussed my mind immediately jumped to the role of ‘core strength’ in prevention of back pain.  Core strength is/was commonly discussed as being preventative for back pain.  Research on this tends to be less decisive than the commonly accepted statement that a ‘strong’ core is protective for the back.  I wonder if this statement on ‘neck strength’ is equally well liked for it’s plausibility, but will also result in marginal or less than perfect correlation during research.  I suspect that the role of ‘timing’ of neck muscle activation plays a more significant role that ‘strength’. 

This was demonstrated well in Cholewicki’s work. [Here or even more clearly here.] To look at this in more common terms, let’s compare it to a car accident. I don’t think the ‘strength’ of the brake is the best determinant of injury during a motor vehicle accident, it is much more likely that the ‘speed’ or ‘timing’ of applying the brake has a more significant correlation on how well injury can be avoided.  Particularly when considering the role of external perturbation in Cholewicki’s study and the fact that some of the concussion-causing trauma is unanticipated.  The natural timing and response of the cervicocranial stabilizers appears to have the best chance of being protective by mitigated rotational forces.  (Again, this is just my speculation.)  During a brief conversation with Dr. Cantu he noted that he was unaware of any research done on concussions and cervical timing.

Childhood concussions with Dr. Gerard Gioia – a wealth of info, but this one resonated with me as it sounds much like what we (should) do to properly manage so many NMS conditions.  Have them do activities they can tolerate, help them learn what they can and can’t do, and “Teach them the sweet spot”. This results in active rest and active management which is then gradually increased.

Clinical Pearls:

-Younger brains need to be managed more conservatively.

-For unknown reasons, concussed females show a greater decrease in neuropsychological scores than males.

 

Ted Johnson (former NFL All-pro middle linebacker (paraphrased):

 

This is an exciting time for medical providers and scientists with all the new research.  It’s a terrifying time for patients as there is much attention, but so little is known.

Most of my concussions came in practice, not in games.

Players don’t know the long term effects of concussions.  I didn’t know & don’t tell me I did!

Before meeting my current concussion specialist, I was recommended for electroconvulsive therapy (ECT) because they didn’t know what else to do with me.

 

Links of interest:

Ted Johnson @ Harvard Concussion Conference NESN story & video

Ben Utecht:  Tell me if his story makes you wonder about the significance of these injuries.  Not only did he not recall being at his friends wedding, he didn’t recall that he sang at the wedding.  Doesn’t seem like an occasion you should need photographic evidence to refresh your memory.  http://espn.go.com/nfl/story/_/id/7966792/concussions-affect-now-singer-ben-utecht-life

CDC Concussion info (with good video for the lay public)

Mass Dept of Health Concussion resources

Sports Legacy Institute

 ImPACT testing

Dynamic Neuromuscular Stabilization DNS-B reviewed

I had the pleasure of visiting Athlete’s Performance Institute in Phoenix, AZ and attending Dynamic Neuromuscular Stabilization recently.

I won’t even try to fully capture the full scope of DNS in this blog.  The system, developed by Dr. Pavel Kolar, is based in developmental neurology and applies the principles of turning and creeping into assessment of the core (integrated spine stabilization system) and phasic movement of the extremities.  Understanding the anticipated movements of these inborn patterns allows us to perform resisted exercise or reflex locomotion to refresh these subcortical patterns to the standard operating procedures of cortical movement.  For those versed in the traditional chiropractic model of treating the nervous system and the innate, you have not seen more evaluation and influence of the nervous system or innate abilities than you will find in DNS.  This technique may very well be the bridge from the beginnings of our understanding to some of the contemporary developments and methods.

For those who wish to know more about DNS, follow this link.

A few key points:

  • Joint centration is essential and non-negotiable.
    -positions can be modified as needed, but joint centration must remain.
    – decentration of one joint will undoubtedly lead to decentration of another joint.  (An undesirable chain reaction.)
  •  What is centration?  Centration is the position of maximal joint contact.  This allows the most even distribution of forces through the joint as well as balanced muscular coactivation around the joint. 
  • Why do we want centration? Maximal motor control and power with minimal load/stress.
  • Breathing and abdominal bracing (spine stabilization) are intimately related and are interdependent.  Both must be maintained or the integrated spine stabilization system is compromised and stability is lost.
  • Evaluate and train in multiple positions/patterns.  The ‘key link’ Janda described will be evident in multiple evaluations.  Retraining this key link will require repetition and myelinization through training in multiple positions.
  • Newborns begin with primitive, reflexive patterns.  With afferent input (stimulation) there are genetically preprogrammed movement patterns that develop at specific neurologic ages. Failure of proper neurologic development indicates a ‘central coordination disorder’ that may be indicative of CNS pathology.
  •  “Form follows function”: failure to follow typical developmental movement patterns can have morphologic consequences.  (ex. flat foot, acetabular angle, pelvic tilt, kyphosis, etc)  Louis Sullivan coined this phrase in the world of architecture, but it clearly has its place and value in human development as well.
  • Zones of support during developmental positions create areas of dense proprioception.  These areas can be used for stimulation during isometric exercise and reflex locomotion.
  • Tactile and/or verbal cuing is used when altered motor patterns are seen.  When verbal or tactile cuing is not sufficient to improve faulty patterns, then reflex stimulation may be necessary.
  • During reflex locomotion there is a vector to follow, often towards the point of support (punctum fixum) or the next joint in a phasic limb.  The vector is not a specific direction, but within a general region from the stimulation point.  The exact vector is within a ‘cone shape’ and is determined by the clinician based on anticipatory reaction generated from stimulation.

There is a broad application of the principles of DNS as they are based on universal principles of inborn, preprogrammed movement patterns.  Applications range from evaluating and treating developmentally challenged babies, to restoration of normal movement patterns in painful or restricted adults, to allowing maximal motor control and muscle activation in elite athletes.  I should also mention that maximum distribution of joint forces is also applicable to all ages and situations as it will ensure proper development and maturation, help prevent future injury and joint pathology, and prolong athletic careers. This diverse applicability makes this system a valuable tool.

For their help in learning part B of the principles of DNS, many thanks to the folks at API (Darcy Norman, particularly as he helped out the B group), Ken Crenshaw & the AZ Diamondbacks organization, the Prague School instructors and Pavel Kolar, Clare Frank who instructed the B group, and course organizer Craig Liebenson.

The question that remains for me is, where is the line between good enough and not good enough?  With DNS functional testing there is almost always something wrong with the pattern.  From little flaws in stabilizer activation to completely inadequate coordination of breathing and bracing. What do we attack and what do we leave alone?  In FMS we talk about fixing 0s and turning 1s and asymmetries into 2s and symmetrical patterns. This is easy to follow. Valdimir Janda talked about fixing the ‘key’ link, but not getting bogged down in trying to teach perfect movement.  I’ve yet to find where this line is for DNS.  The line may be clear in the case of the elite athlete, we want everything to be as perfect as possible to give them the competitive edge.  However, for the average patient or average athlete, when do we call it ‘good enough’ vs. continuing the quest for perfect patterns.  For now I’ll try to let the clinical audit process sort it out (I’m curious to hear others opinions on this question, and if I ever come up with a more concrete answer I will be sure to post it.)

MORE INFO:
For the best review of this course I know of (including this one) see Jeff Cubos’s blog.

Interviews by Phil Snell of myrehabexercise.com during the DNS course in Arizona as follows:
Dr. Alena Kobesova -DNS interview

Dr. Clare Frank – DNS instructor interview

More interview and info available on Phil Snell’s blog.

For those looking to attend DNS courses check here.
There is a Scarsdale, NY DNS-A course in August 2012.

Stecco’s Fascial Manipulation Reviewed

I had the opportunity to take Fascial Manipulation Part 2 recently in Dallas, Texas. I thank Drs. Antonio Stecco and Warren Hammer for sharing their time and expertise in this method, as well as Part 1 in Newark, NJ in April.  Fascial Manipulation© (FM) is a technique developed by Luigi Stecco, PT over 30 years and now carried forward by his children, Carla and Antonio Stecco, who are both MDs by training.  While Luigi developed this fabulous system of analysis and treatment, his children have taken on the task of further evaluating the anatomy and principles behind Fascial Manipulation©.  Their efforts are clear with a quick search of pubmed which produced almost 100 articles during my recent search.  New techniques are often copyrighted and taught, but rarely do we see this level of effort go into supporting and explaining the methods.  Carla will also again be presenting at the 2012 Fascial Congress.

What is Fascial Manipulation©???
Let’s start with what we know from other sources…. the body moves in complex patterns and the brain activates movements, not individual muscles.  We are seeing this concept more readily adopted in the areas of functional assessment and functional training, but have not seen it to any great extent in the soft tissue world.  Many techniques are still teaching treatment of individual muscles.  (One notable exception is FAKTR.)  With the concept of movement patterns in mind Stecco’s Fascial Manipulation teaches movement verification (MoVe) through assessing movements based in each plane of the body (sagittal, frontal, transverse).  Dysfunction in these planes is detected and then narrowed to a particular region by limiting the number of regions involved in the MoVe.  (This assessment method reminds me of the SFMA breakouts.)  Planes are dedicated an abbrevaited as follows: (Sagittal Plane: an-Ante, re-Retro; Frontal/Coronal Plane: le-Latero, me-Medio;  Transverse/Horizontal Plane: ex-Extra, and in-Intra).  The ‘sequences’ of points drawn through these planes/lines are similar to the lines drawn in Anatomy Trains by Tom Myers, however the detail and clinical application in Fascial Manipulation: Practical Part is much more detailed and clinically oriented.

Fascial Manipulation also simplifies anatomy for us and creates a common language for practitioners around the globe to speak.  For example: Any point in the head is known as Caput, abbreviated, cp.  Any point in the neck is Collum, cl.  (Arm=Humerus=hu; Forearm=Cubitus=cu; Lumbar=Lumbi=lu; Pelvic=Pelvi=pv; Coccyx=cx; etc).  There is no differentiation of individual muscles, ligaments, or tendons although reference to these familiar anatomical structures are used to help practitioners learn the Centers of Coordination (cc) which are points of possible densified tissue to be evaluated by palpation and possibly treated and Centers of Perception (cp) which are the areas where symptoms are reported.  For example finding the cc or cp referred to as Anterio-Collum (an-cl).  [While a bit confusing at first the language becomes second nature quickly…. finding the points on the other hand takes a bit longer.]  Finding these points through palpation is the second step in FM.  Step 1: MoVe. Step 2: Palpatory Verification (PaVe).  The most densified, most painful, or points with the most radiation are compared to MoVe and treated.

In Part 2 of Fascial ManipulationFascial Manipulation Dallas Class  Centers of Fusion (CF) are introduced.    From the Fascial Manipulation Workshops website: “While CC points regulate unidirectional muscle fibers of a single mf unit, CF coordinates intermediate muscle fibers, activated during movements between mf units. Luigi Stecco realized that it was necessary to coordinate two or three myofascial units involved in complex global movements where the forces of myofascial units converged. CF will be taught to be used for single segments, along myofascial diagonal and myofascial spirals.”

After MoVe and PaVe assessment, the results of the 2 are compared.  Points are selected along the most significant plane.  Typically several points (perhaps 3-5) are treated in each session.  While the majority of these points will come from the most significant plane, a point or two from the antagonist sequence is also treated, and any relevant CF points can be treated as well.  The ultimate goal is balance of the fascial system which is designed to reduce altered stress and strain on joints, reduce symptoms, and improve fascial proprioception contributing to faulty movements.

Intro to Stecco’s Fascial manipulation (youtube video 1min 39sec)
Antonio Stecco – Shoulder Tx (FM Assessment & Treatment with Antonio & Carla 12min 31sec)
Interview with Drs. Warren Hammer & Antonio Stecco
(6min 49sec)

An incomplete technique:

Despite the many significant connections, the incorporation of movement patterns analysis in evaluation, and the authenticity of a system that requires test and retest improvement within the same visit (like McKenzie or the Clinical Audit Process), Fascial Manipulation© is an incomplete system.  I say this not to detract from the exceptional work of the Stecco family, or to lessen the value Dr. Warren Hammer added by bringing this work to the U.S., but to acknowledge that for many with soft tissue dysfunction FM can serve as a starting point, but not an end point.

Concepts significantly lacking from FM include movement pattern training and failure tolerance.  There is an interplay or overlap of these 2 concepts, as you will see below.  Research has shown presence of proprioceptors within fascia and it is hypothesized that this plays a significant feedback role in controlling and coordinating movements and I believe it does.  However, we fail to acknowledge that movement patterns come in 2 forms; inborn pure patterns and those developed from habit and repetition.  Despite removal of densifications in fascia and associated improvement proprioceptive feedback the system does not retrain faulty movement patterns, which are programmed in the CNS, nor does it reactivate the natural inborn movement patterns (see DNS for how this can be done).  Allowing someone to continue operating with faulty mechanics will lead to accumulation of stress/strain, eventual crossing of a tissue’s failure tolerance, and then reinjury.  Without addressing this component FM is in my opinion an incomplete system.  Further, we know that failure tolerance can be increased through appropriately loading of tissue (see Stuart McGill’s work or research on eccentric loading of tendons).  Proper levels of strain can increase tissue strength and resilience which alters failure tolerance.  Failure to address this component in a previously injured tissue also detracts from the outcomes of FM treatment.  A final note on tissue tolerance; incorporation of microbreaks during prolonged or repetitive activities have been shown to have significant impact on how quickly a tissue reaches its failure point.  Instruction and education in this principle would also be a nice addition during a course of FM treatment.

For those looking for ways to teach/train appropriate functional movement patterns, to appropriately engage stabilizing musculature, and for patient review of microbreaks you may wish to check out, www.myrehabexercise.comIn addition to instruction, this site can help reduce the time and effort needed to reinforce your Fascial Manipulation in Dallas with Antonio & Warrenin-session training with proper home instruction for your patients.  (I had the opportunity to spend some time with the sites creator, Dr. Phillip Snell, during breaks at the Fascial Manipulation 2 seminar, and believe he and I see eye to eye on the addition of these principles to the FM technique.)

To reinforce the concepts above, I present the following analogy. Imagine playing soccer on a field atop a hill.  Now let’s imagine that the field shrinks to the size of a basketball court, or indoor soccer pitch if you prefer, or perhaps even smaller.  Imagine the challenge of keeping the ball on top of the field and keeping the game going.  In FM we are thinking of balancing forward movement (an) with backward movement (re) as well as lateral movement (la) with medial movement (me).  The same is true in the oblique directions (ir, ex).  If we balance our movements with each plane, like kicking the soccer ball around our small field, it will remain atop the hill and we can continue to play and enjoy our game.  When the balance is disrupted, for example too many kicks to one side, the game stops as the ball rolls down the hill.  The stoppage of our game would be similar to crossing a tissues failure tolerance or suffering an injury.  With FM treatment we can restore balance and get the ball back into the middle of the field, but what prevents this from occurring again?  (Remember we’re playing on a small field.)  Teaching movement pattern training would be analogous to teaching the players of this soccer game better ball control (they are less likely to have uncontrolled forces or unexpected vectors on their kicks) and the ball will likely stay atop the hill.  Therapeutic exercise (such as stability training or eccentric loading) can increase the failure tolerance of tissues, this would be analogous to taking our small field and expanding it back to the dimensions of a standard field (allowing more margin for error and greater forces within the game).  By doing either of these we increase the likelihood that the game continues. To review my obscure analogy, the goal of FM is to balance tissue tension, like trying to keep our ball in the center of the field.  This technique is well-developed, with emerging research, and clinically applicable concepts.  However, trying to keep our ball in the center of the field, without giving significant consideration to training ball control, and ignoring the fact that the field size could be increased, creates a situation where recurrence/reinjury is more likely.

 For more information on learning Fascial Manipulation© visitwww.fascialmanipulationworkshops.com