This weekend I had the pleasure of attending Functional Anatomy Seminars’ Functional Range (FR) Release seminar for the spine at The Training Room in Sewell, NJ. The weekend definitely proved to be quite valuable in my overall growth process as both a manual therapist and movement professional.
Below are the four most valuable nuggets I gleaned from the experience:
1. DON’T UNDERESTIMATE SPECIFICITY
I must admit, I was beginning to become one of those therapists underestimating the value of skilled manual therapy intervention; instead, favoring skilled strength, conditioning and global movement intervention. Moreover, due to the conflicting theories of methods for creating soft tissue change, I was beginning to view self soft tissue treatment as a near equivalent option to skilled manual therapy for addressing soft tissue mobility limitations. Although, there is no doubt in my mind that these type of interventions are paramount to an adequate physical activity practice, this weekend woke me up to the reality that use of a skilled manual practitioner is by far the most efficient and specific manner of making change to the structure of one’s soft tissue. No foam roller, massage ball, or mobility routine will ever be able to be as precise as the hands of a well trained professional. Furthermore, the value of this precision cannot be overstated in regards to assessment, treatment and prevention of injury.
Through a thorough discussion of the current scientific literature regarding soft tissue change, I was able to appreciate the relationship between the specific direction of force being applied to the tissue, the duration in which that force is applied and the resultant responses elicited by the nervous system that allow for actual soft tissue remodeling to occur.
I learned that the direction of force applied to the tissue cannot simply be compressive in nature, such as a foam roller "steamrolling" a broad tissue area. Instead, the compression must be specific to the tissue layer where the greatest restriction is identified. At the same time, the direction of manual force must be specific to the greatest "line" of movement restriction identified, combined with a specific passive joint motion in a counter direction. This direction of force is than enhanced with a less specific application of force via passive angular isometric loading (PAILs), where the direction of the line of restriction is resisted in order to promote active control over the new range of motion developed. Throughout this process, the duration in which the tissue in question is kept under a therapeutic load is much longer than that of other commonly practiced manual treatment protocols (a minimum of two minutes).
The information relayed combined with the extensive hands-on experience encountered this weekend convinced me that only when these specific criteria of compression, direction, movement and duration are met can we expect to actually make structural change to soft tissue.
2. A KINESTHETIC ANATOMY LESSON
With an overarching theme of the weekend being the great value of identifying specific soft tissue restrictions, it should come as no surprise that a large proportion of the course dealt with honing palpation skills in order for the participants to understand how to make distinctions between anatomically adjacent structures. Initially, a practicing manual therapist might feel skepticism towards the need to review such fundamental skills. However, by the time we were halfway through the weekend, I had learned more about the practical use of anatomy than I had in the previous decade plus of my career as both a physio and manual therapist.
The efficiency of this educational process was two-fold:
1. It was specific to the manual therapist
2. It was kinesthetic in nature
The specificity to the manual therapist was demonstrated by shifting focus from the traditional model of memorizing muscle attachments, innervations and actions to the practical demonstration of identifying problematic tissues and actually making change to them. This simplicity allowed me to associate what I was learning to cases I have encountered clinically, thereby, cementing the information in my brain.
The kinesthetic nature of the learning process was experienced by actually feeling the anatomy on a living three dimensional human body as opposed to simply reading about it, or studying cadaver dissections. Specifically, origins and insertions were felt as a means of making distinctions between palpated structures, as opposed to reading about them. Layering techniques were used in order to feel superficial and deep relationships of tissues, instead of viewing various 2D pictures. Furthermore, muscle action was perceived via touch through the assessment of tissue tension in relation to joint motion, as opposed to simply conceptualizing the relationship between one muscle attachment to another.
3. A SYSTEM IN WHICH TO THRIVE
Considering the above mentioned information regarding anatomical specificity, it should be apparent that extent of the skill and practice that is necessary to be a high level manual therapist is vast. This specialized skill can come with a downside, however, in that the outcome measures perceived by the manual therapist can be quite subtle and only noticeable to the practitioner. With this being stated, how can a client discern that the treatment being performed is actually valuable, and not simply the exploitation of an information asymmetry to market the practitioner's services?
The FR system, as per my understanding, addresses this quite well. This is done by appreciating that there are indeed outcomes/changes perceived during manual therapy that will be extremely important to the therapist, but need not be initially as valuable to the client. At the same time, there is an acknowledgement that any change made via soft tissue therapy needs to be plugged back into a system that demonstrates change more noticeable and meaningful to the client.
More clearly stated, if change is felt in the tissue it only becomes clinically meaningful when it translates to a change in the chief complaint of the client. With this being said, in order to make these noticeable changes, more subtle changes, only perceived by a skilled practitioner, must occur.
The FR system utilizes controlled articular rotations (CARs) as a means for assessing global joint and soft tissue motion in a manner that is easily comprehended by the client. The use of CARs allows both the therapist and client to discern and prioritize restrictions that are joint related (closing angle) versus those that are soft tissue related (opening angle). These simple yet comprehensive assessments in combination with the precise soft tissue assessment described above creates a metaphorical dance back and forth between subtle and obvious change that deciphers the meaning of the work being done by the therapist to the client.
Finally, as a manual therapist, it must be appreciated that no single weekend of training can give you great assessment and/or treatment skills with your hands. As is true with any physical endeavor, skill in using your hands to locate and assess problematic tissue takes time and specific practice. For those that are new to this practice, the fluidity of the FR system allows a therapist to progressively hone his or her skills while having other less specific means to help clients. Moreover, this system allows for networking opportunities based on the amount of time one has to individually assess a client with his/her hands. You can have all the theoretic knowledge of manual techniques in the world, but if you don’t have time with your clients in order to actually practice your craft, you will be less skilled than a practitioner that does. Identifying other practitioners with a practice model that allows for more hands-on time allows for better outcomes for your clients as well as better inter- and intra-professional relationships.
4. PROFESSIONAL EQUANIMITY
The FR system was created by Dr. Andreo Spina, and the weekend was led by Dr. Michael Chivers. Both men are Canadian-trained chiropractors. Spend less than five minutes looking at some of Dr. Spina’s YouTube videos and you will begin to understand the extent of his knowledge. Moreover, in spending the weekend with Dr. Chivers, it became blatantly obvious he was both a "wizard" with his manual skills, as well as fluent in the current scientific literature related to manual therapy and rehabilitation.
Even more apparent than the skill and knowledge of the founders/instructors was the collaborative environment that was maintained among professionals of varying scopes of practice throughout the weekend. As a practicing physiotherapist, I have unfortunately encountered far too many instances of “professional profiling” where members of my own profession belittled the value other professions. It is my opinion that this type of narrow thinking does nothing but limit one’s educational process. It is obvious to me that the FR system is not a system "created by chiropractors for chiropractors", but instead appears to be ideal for promoting professional equanimity, or a seamless integration of the skills of any professional that has the means to make positive change to the physical function of a human being. And that I believe, deserves recognition.
In conclusion, likely the most common reason individuals experience overuse or non-traumatic injury is due to a lack options for movement. Soft tissue restrictions decrease an individual’s movement options by restricting access to certain ranges of motion. A manual therapist’s job is to eradicate these movement limitations in the most specific manner possible, therefore providing the most thorough manner for increasing said movement options. The FR system for assessing and treating these movement hindrances is as specific and well-defined as any I have seen, and I am excited to improve my skills through its use.