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.
