How many of you guys
have heard of fascia before? That's good. How many of you guys
watched the Olympics this past summer and
saw some things with a suction cup marks all over Michael Phelps and other
athletes like that? I'll explain some of
why we use some of those modalities and some of
the interventions for it. I'm directly responsible
for that being there. I taught with Team
USA back in May, just before the
Olympics happened. I worked with Team
USA swimming and Team USA gymnastics in the past. Some of those things are a product of some
of the things that we're trying to institute more of in the sports medicine world, but it's also very applicable
for the orthopedic world in general private practice as well as other orthopedic
clinical settings. When talking a lot
about fascia and why fascists really
this instrument for how your body
moves efficiently as a machine in terms of all the working
parts going together and synergistically firing
at the right times. Its a vehicle for that. We're going to really get
into the building blocks of what that all looks like and why it's really important for you to
have healthy tissues, not just in the muscles
and the tendons or ligaments or the disks
that you're familiar with, but also some of this
connective tissue stuff. We're going to talk about
why it's really important. We are very much focused in strength conditioning
both of Kenny and I work a lot
with the athletes, very high level athletes,
professional athletes. But we also do things with the general public and
tried to really make movement and awareness
issue more so than just an interventional thing that you come into
physical therapy for. It's really trying to promote your body's maintenance through the things that you can
do on a daily basis, not just coming in when you have a broken piece or part and
things of that nature. Today, what we're going to try to accomplish some of
these objectives, what I really want to
look at is some of the science of fascia and introduce some of the things
that maybe you haven't heard of in the past that you
should maybe be aware of. Then just some of the things
that we can pay attention to in terms of the way your body moves in three-dimensional space. Because that really matters in terms of the way
the muscles work together with the connective
tissue system itself. We're going to get into
some of these patterns that you can come to
understand in your own body. Some of the referred
pain patterns that can come out of things
like trigger points. How many of you
guys have heard of trigger points
before, muscle knots? There's little things that
are nodules in your body that hurt real bad when you roll
over them or push on them, or have somebody else push
on them for you, hopefully. Then we'll look at some
of the other patterns that happen in terms of some muscles are tight
in your body and other muscles aren't
working like they should. We can see these imbalances. You can really come to
understand in your body why things hurt chronically and more consistently
than other areas of your body and you can really identify some of these patterns. Kenny is going to talk a
little bit more about that and how to identify some of
the patterns in yourself. Then we're going to teach you three different
methods that we use, both in the physical
therapy arena, as well as things you
can do for yourself at home to try to
maintain and improve the mobility of your body using the fascial guidance that you can see between the imbalances that will happen in the body. We'll look for some of
these things in you today. Kenny and I work a
lot with athletes and some of the people
that also buy into and believe in this
fascial system being a really important component for the way your body moves both in through the lifespan as well
as in professional sports, are some of the
people I've worked with it even in the last year. I taught at this semester giant Sports Medicine
Conference last year. Then I worked with
the Oakland A's this past spring training. As the Chicago Cubs, you
guys have heard of them too. I worked with them also in spring training
in this past year. Then the big one was
Team USA last may. Right before the
real Olympics hit, we went and taught with Team USA mostly with the
swimming group, but they bled into some of
the other sports as well. The Detroit Lions I just did last month and then you
guys know this guy too. You can see some marks on
him every now and then too. These are people that
really value some of this information that
is different than the traditional mechanisms of musculoskeletal of anatomy where you're talking about the
origin insertion of a muscle. This muscle does this action
and if this is broken, we should look at
the action and how to identify how to fix that. We're going to teach
you guys how to look a little bit deeper into
the way things are connected and the way these things can
relate in your body in terms of the imbalances
that can come up. Does that sound fun? [BACKGROUND] All right, good. Hopefully I can come
up with good answers that you guys are
looking for today. Basically, the
connective tissue system is something that when we go to the anatomy as physical
therapists or as an MD or as a nurse practitioner, as an RN, you spend probably
about 10 to 15 minutes in your whole medical school or
physical therapy curriculum. Learning about this system, which is the largest
organ in the body. It's a very complex, densely
innervated, meaning, nerves go all through these different fibers and sends a lot of information
from your arms, your legs, your periphery, up into your brain. That's where you
perceive a lot of the other problems that
are going on in your body. Some of the things that
happen in your body aren't in the muscle you feel
this muscle pain, this idea that you have a knot in your body and sometimes
it's not the knot that's in the muscle that's causing
the pain growing up into your brain is some of the other connected
tissue elements. Those things can
transmit and sense very small changes intention
throughout your system. We'll show you some of
the demonstrations of why that's really important
to pay attention to. When we go into anatomy, we learn about
something like that. Looks a little bit like this. You guys has seen a schematic that looks like
this for your skin. If everybody looks at your skin, that top layer is
called your epidermis. That top layer has
no blood supply, basically all the
blood and nerves and all that really interesting
stuff is here in your dermis. Now to get from your epidermis down to your dermis,
It's only like 0.04, 0.02 millimeters down very, very small, very,
very superficial. It doesn't take that
far to go down there. Your epidermis is here,
your dermis is here. Then we learn that
your subcutaneous, your fat layers down there. Then the next layer
down is your muscle. That's how you move from the
connected tissue system. The next four months of
your anatomy curriculum where you learn about the origin, the insertion, the
nervous innervation, and the blood supply
for that muscle and where there's
muscles connect. We move past this really fast. This is a very
simplified schematic of the way the connective
tissue system is in your body. If we look at that very
superficial layer, the epidermis that we first saw, this is histology slides showing you the corneal layer
of the epidermis. Every 14-28 days the sloughing of this corneal layer
of the skin and it falls off and you have new
skin every 14 to 28 days. That's cool, you have
new skin all the time. The not so cool part is
80 percent of the dust in your house is probably
corneal layer of your skin. What I say to people is remember, you should judge a little
bit better of you. You have come over to
your house before you have dinner parties or
things of that nature. But that corneal layer
has no blood supply. The blood supply goes and starts right
here in the dermis. The dermis is where the
really interesting action is, especially the
receptor sites that feed different types of
information from your skin, your periphery, up into your
central nervous system, meaning your brain's
interpretation of what's going on in your body as it
relates to the surroundings. Don't get all lost
than the names of these glands and core
puzzles in this and things. Basically this is
sending pressure and touch information up
into your brain saying, Is this too hot, Is this too cold? Is this too much pressures? Is this too little pressure? What am I feeling
when I feel things? All that information is
very superficially right under inside the top layer
of the dermis of your body. The blood supply is there, the nerves that innervate there and send pain information
up to your brain, are there, not just
down in your muscles, they're actually in that
dermal layer as well. So nociceptive input
will go up into the brain from these layers because of the issues
receptor sites. When you think about the
areas of thickening, maybe you have the bottom
of your feet or the palms, or sometimes we get callusing over different
areas of your body, your corneal layer and some of the other layers before the dermis get a
little bit thicker. When you see some
thickening means your body is responding
to something in terms of pressures and the
type of stress that you put onto your body in tissue
changes throughout the body. But it's still very
incomplete on how we understand that initial
schematic of the epidermis, dermis, subcutaneous layer
before you hit the muscle. We're starting to
see when we look at more and more in-depth anatomy in terms of the
dissections that they're doing and the anatomy
review of some of these physiologic principles
is that there's a lot of other things going on in those layers that
we're not as well aware of or attention
made to that, when we first
initially learned it. Some of those layers
are something like this called the superficial
fascial membrane. This is a membrane that separates some of the fat from
some of the other fat. Again, this is just an
artist's rendition of it. It's not very precise in terms of the way
your body moves. But you have these other things that are going on that you didn't see in the
initial diagram. Below that second layer of fat, you're going to also have
your deep fascial membrane. Between each of these membranes, you have a little bit of liquid. That liquid is often what
we call hyaluronic acid. That helps the
mobility of each of these tissue layers to move and glide the way
they're meant to be. What do you guys think
happens as you age, as you get injured over the
course of the timeline. Dry out. Yeah. You dry out a
little bit, right? We lose water content and
you start to get sticky. Picture if I had like four or five different
pieces of paper, we're going to use
tissue paper right here because right here
in front of me. If I want to actually
get mobility to improve, it's not about time to stretch
these pieces of paper. How long do you think it would
take for me to stretch out these pieces of
paper right here and get mobility to improve? Could I do it? No, it'd be hard. It's not
going any where. I have to spend a long, long time to try to get those
tissue layers to move better. But now picture there's honey between these pieces
of tissue paper. As you age, that's what
happens and it gets sticky. But what if I was able
to move because there's better fluid between
each piece of paper. That's what you want to do
to restore your mobility. To improve your mobility, it's about the layers between the layers. Does that
make sense to you guys? It's about the fluid
dynamics that are in-between these different fascial layers that allows things
to move better. Often we try to do
these things called stretching from rolling
soft tissue work, going to massage, doing something different to assist the things. Maybe some things that leave marks that look
like cups that are, Michael Phelps type of thing. All those things are trying to promote fluid changes in there, not to lengthen the tissues. I'll show you guys
what the research says about stretching and the actual lengthening
of tissues in just a second. You guys are following
some of this stuff, you guys are starting to see the three-dimensional
nature of it. It's not just this, this, this, and it stuck there. It's how they, everything glides and moves one on
top of the other. You can picture this
for those of you that like to eat healthy and you take the skin off your chicken. Sorry for the vegans in the room, but you're going
to take that skin, you're going to peel it off, and you have all
this stringy stuff and all that stringy stuff links each layer to the other layer and that retinacula cutis
is what it is called, is a ligament that checks your skin from running
off your body. It stops it. Say, I want nice good fluid
dynamics between each layer, but I want to have
an actual check and endpoint to make sure my skin
doesn't fall off my body. Some of that sliding is available because of
the fluid and then these little stringy things
check that motion as you go through the normal mobility
that you do during the day. This is what we
probably should have learned when we went
through anatomy. Something that's a
little bit more complex, that shows each of
these other layers to understand that it's not just trying to get things to move and stretch through these
different tissue layers, but the gliding of one
layer upon the other. Meaning, I need
fluid to be between this superficial fascial membrane here and this deep
fascial membrane there, and more fluid between that
and the other fat that separates it from the muscle
and all of those layers. This is again an
artist's rendition simplified if thousands of these little layers that are all laid on top of each other and each of those layers
needs fluid between them. That's why things like
hydration is what, important or not important? [BACKGROUND] Really important. That's why things
like sleep is what, important or not important? [BACKGROUND] Nutrition is what, important or not important? [BACKGROUND] Most importantly,
movement is what, important or not important? [BACKGROUND] Really important
because if you stop moving, what do you think happens
to these tissue layers? You start to get
sticky again, right? Think about your body
not moving for a week because you had shoulder surgery and you got put in a sling, maybe four weeks,
maybe six weeks. How many you guys have
had shoulder surgery in the past? It's terrible. You got to get out of
that sling and you haven't moved it for six weeks, each of those layers are
starting to get really sticky. One layer to the next. When you get better
improvements in motion, it's not actually lengthening each of these tissue layers, it's trying to get mobility to improve between them.
Does that make sense? Excellent. We are
handcuffed by trying to learn this big dense
information called anatomy in a four-month period when we first introduced anatomy. We learn it really simplistically
in terms of origin to insertion on something like the bicep is very much
like how a robot moves. When we learn this, we have
to learn it and digest it because there's so
much information coming at us in this box. But do you think that
box is really the way the human body moves? It's not. It's very simplistic
and it's easy for us to digest so that we
can learn these things, but it's not the actual way you need to understand
the way your body is built to synergistically fire all these things
together at the same time. For that to happen,
you have to look at it more like the
new school terminator. Have you guys seen the
Terminator series? The old ones from
the '80s looked like that because that's before computer technology was able to produce some things like this. Basically when you look at
the new school terminator, everything is fluid,
everything is dynamic, everything fluidly moves together and synergistically
acts together. That's the way the
human body really is. When you go to learn
anatomy and when you go to try to practice
medicine with patients, sometimes we as doctors
get stuck in this. Pretty quickly you
have to move and understand how it
moves like that. Until you look at the whole
body in a holistic way, you're going to miss
some of these things that are working together. The functions of the
muscles are really interesting and we
learn these things about origin and insertion
to make an action happen. Like the biceps starts
here and finishes here and it makes
your elbow flex. Everybody try to
stick your arm out. Bicep, you feel that? Now bend your elbow. It contracts a little
bit and that's great. But how many other muscles do you think are working
at the same time? A whole bunch. There's three other
elbow flexors, there's other forearm flexors that cross the elbow that
also synergistically help, and then your antagonist mean the other side of
the muscles are also stabilizing to make sure the movement is smooth
and coordinated. A, there's a lot of things going on at the same time, and then B, as you move through space, your muscles change the action
that they actually have. As you move your hip, I'm going to move away
from the microphone, you're going to flex your
hip past 90 degrees. Some of the muscles
that go this way now make it go that way. Does
that makes sense to you? Some of the muscles that
are acting in one way as you move into space will
change the actions entirely. Some of the things that
we look at we need to shape in terms of a more three-dimensional
structure of how we look at the
way the body moves. Really it's interesting because that structure and that stickiness that
happens in some of the tissues I was talking about
before really drives home some of the ideas
that are promoting the newer way of looking
at the way the body moves. How many of you guys have
heard of tendonitis? Tendonitis is a very common
term that's thrown around, but tendonitis usually only
last anywhere from 6-8 weeks. After eight weeks or sometimes three months,
four months, six months, some people come in and they say they've had tendonitis for the last two years in terms of their hamstring or their patellar tendon or their shoulder. It's not really a
tendonitis anymore. Basically at that point, the tendon is starting to degenerate and the
stickiness that initially was the problem is just binding down
those pieces of paper. At that point it's
not a tendonitis, it's a tendinopathy and so
we call it a tendinosis. The stickiness that started very superficially now has
affected the tendon. So you have to do things to treat that a little
bit differently. We look at the way
the body moves at that point as trying
to stir things up that didn't heal the
right way instead of trying to calm down inflammation. When we talk about the
connected tissue system, this is often what happens to the body and the reason
why a problem that will happen to you 10 years ago resurfaces over and
over and over again. Because what happens
is you have some type of inflammation or
trauma that happens, say it's a shoulder strain. You've got bicipital tendinitis. You lifted something
or you reached for something and you got a
strain of your bicep tendon, it causes the
inflammation in there. What happens is your connected tissue system here
comes in and says, I'm going to try to
fix that and lay down some more connected tissue. I'm going to talk about the building blocks
of those in just a second. Those building blocks
are called collagen and collagen cross bonds
and skits real sticky; that's the honey
effect that I was talking about between
the pieces of paper. That leads to increase
in viscosity, meaning things are
getting stickier and they don't move as well
as they did before. That affects the
way the body moves entirely in that synergistic
pattern we just mentioned, and that leads to the way you move in terms of compensations. Those compensations
lead to something like, for bicipital tendinitis,
now you have neck pain. In addition to a
shoulder problem, your neck starts to get stiff, and then you lose
the ability to go into lateral flexion
of your neck. You guys can see how
this starts to affect up the chain and then probably
down the chain as well. You might start getting things like carpal tunnel 10 years later because you don't move quite the same as you did before that. You get the cycle to come in
and really stir itself up and leads to other pain and dysfunction up and down
what we call the chain, and we'll talk about the
chain in a second too. When we talk about some
intervention of physical therapy, meaning when do we want to
intervene with tools or with our hands doing massage or cross friction or foam rollers? How many of you guys have used the foam roller in the past? Very popular in GEMs. When is the appropriate time to start working on those things? Because of that inflammation,
because of that trauma, that's when the
actual collagen or connected tissue is
going to start to get densification to happen, meaning stickiness between
your pieces of paper. What the science
basically says is between day 7 and day 10, that's when you really
want to start working on moving some of
the tissue better. Now what happens when you
get bicipital tendinitis? How often do you guys see that
you don't want to actually reach for that bowl or that box up in the top
of the cupboard? How long does that last for? Sometimes two months,
sometimes five months, sometimes six months,
sometimes a year. When you start losing
mobility like that, it affects things up
and down the chain. That's what fascia is all about, that's why fascia is so important in terms of
the body's movement and restoration of that movement.
You guys follow me still? Good. I'm going to
talk about some of these building blocks and
we're going to get into them just because it's very
very interesting stuff. To have an awareness of this, it helps you formalize your idea of how to make
this better in yourself. These are just some of the
components of your fascia, your connected tissue system. The most important ones
that I'm going to draw your attention to are collagen, because collagen is
a sticky structure that makes things
all string together. I'll show you some
histology slides of that. Then really really important
is ground substance, and I'll talk about that in
just a second in relation to the way viscosity works in the body, like I
was talking about. Elastic fibers are cool too, everybody take your
skin and pull your skin up and then let your skin go. The reason it comes
back to the way it was is because of elastin. How many of you
guys have heard of a disorder called
Ehlers-Danlos Syndrome? Nobody? It's a syndrome where you have changes in
your elastin basically and you don't have the same type of contours of the elastin
that allow it to recoil and allows for normal stability across joints and across some of the soft
tissue structures. This is what that connected tissue system matrix looks like. Meaning this is the way it is all throughout that dermis and epidermis and subcutaneous layer in your body, like
what we saw earlier. You can see collagen is these white wavy kinky
things going all over, your fibroblasts
are the cells that make all the stuff through there, elastin is this orange, I am slightly colorblind
so it might be yellow, stringy stuff there. Then ground substance is this abstract thing which
is the white space. There's the spaces
between everything else that suspends
all these things. Think about ground substance as this spongy stuff that
just floats it all around. We'll come back to
that in just a second. From a histology slide, meaning you're
looking at this under a microscope in a very
thin slice of that, you can see collagen here is in pink and it strings everything
to everything else. Collagen you can
think of a spiderweb, to simplistically put it. Now, think about
spiderweb though in a early morning it
has dew all over it because that's a more complete
picture of the way that collagen and the
stringiness of it is really fluidly dynamic. It can slide and move, and it's not spiderweb
that's been there for five or six weeks and
you just haven't wiped down the cupboards or wiped
out the garage or whatever. That stuff is really
able to plastically slide up and down the chains that are connecting each
of those pieces together. Meaning there's a
lot of plasticity, meaning it's able to dynamically change throughout
your movement patterns. You can see the dots are still your fibroblasts and then your stringy purple things there, that's the elastin again. Now picture if this was a
really rigid structure. If you had all this stuff connecting everything
to everything else, do you think you
would move at all? We'd be stuck right where we are. But your body is that
second terminator, remember how
fluid-filled that is, how dynamic it can move, and how synergistically all of those things work together, that's why we have the
ability to move throughout. These bonds will break, reattach, and then when you come back
down, they'll come back, slide again and reattach again. Think about it as a really
high level of plasticity, a lot of ability to change. This is what it looks like. There's a really cool
French hand surgeon that goes in with a camera when he does some hand surgeries, and he takes pictures of
this and blows them up. You can see this is
collagen in vivo, meaning this is live tissue, it's blood filled, it's warm. It's very different
than what we learn in the cadaver lab when we learn anatomy which looks like that. This is what we learn when we learn anatomy in medical school, in PT school and all the
different things we do. Does that look the same
as that? Not even close. It's hard to wrap your
head around this A, because it's very expensive to get really good cadavers that are fresh and not involved in
things like that but also B, because once you break
through that spiderweb there, do you think it ever
comes back together? It's done. That's
what you have in your brains sometimes when
you're thinking about motion. You're trying to break up
these fibrous adhesions and we're starting to see
that the research says, it takes a lot more load and a lot more time than what
you're doing with stretching or foam rolling or some
other modalities to break apart bonds like this. They are dynamically sliding
up and down each other, and they're not meant to break, they're just meant to slide. That's where your
movement comes in, that's why movement
is so important, because that you don't
want to get sticky. You want to stay
continuously hydrated, and very very dynamic.
Does that make sense? It's not this, this
is what we learn and you got to get your heads
out of that a little bit, because that's not
real live tissue. This is the way it looks. Fascia is really
important because it makes all these
linkages come together, and we'll show you
some of the muscles that are linked together. How many of you
guys practice yoga? Any Yogis in here? How many of you guys know
what Downward Dog is? Downward Dog, I'm not
going to demonstrate, we'll have Kenny demonstrate, no, that's bad idea too. [LAUGHTER] But Downward
Dog is a linkage of probably about 17
different muscles all up and down the
back of your legs, all the way to your heels, and it starts way
up at the scalp. All those things are what
we call a kinetic chain, meaning things that are linked together and synergistically fire together and that chain is what you need to think of
when you have problems. Because sometimes I can't
go down and touch my toes, not because my
hamstrings are tight, but because sometimes
my nerves are tight. That's the fascia
that's not allowing the nerve to glide
through like it was meant to or sometimes it's actually my plantar fascia that's
really restrictive, and so that's why I can't
go down and touch my toes. If you think about my back, that's why I can't
touch my toes but it's actually the
whole chain up from the back of your legs all the way up to your scalp, and
the way that looks. Kenny is going to
show you some slides that really
demonstrate that well. The other thing that fascia
provides in addition to these kinetic chain linkages is a structural support system. How many of you guys run
or have run in your past, and had gotten any type
of lateral knee pain that maybe you thought of
as IT band syndrome? Have you heard of that?
An IT band issue. How many of you guys have foam rolled their IT bands and it hurts like no other?
Yeah, it's terrible. The IT band, you can
think of like a sheet and that sheet separates if
you tuck it in your quad, which is the front
of your thigh from your hamstring, which is
the back of your thigh. That fascial sheet is an encapsulating support
system to separate these two compartments
and make sure things are gliding and moving the way they're supposed to but
separate one from the other. Going around and teaching
a little bit more, I go and stay at
hotels where they tuck the sheets in way too tight. I'm a little claustrophobic and I need my toes to wiggle at night. [BACKGROUND] When I can't wiggle my toes at night, it
becomes a problem. You can think of the
IT band as that sheet that's very similar to that sheet that's
tucked in too tight. When we roll up and
down the IT band, that might help some
of that fluid dynamics between each of
those paper layers, but it's not going
to untuck the sheet. That's why sometimes,
we use things like suction cups to untuck the sheet, to pull on the sheet, and tug it out a little bit. We'll talk more about
that in just a second. But think about this
big tissue layer that looks almost
like an REI tent. How many of you guys go
camping? Think about a big nylon tent and
how thick that is. How long would it take for
you to stretch that out? Maybe half your lifetime. When you think about the IT band, you're not going to
stretch an IT band. You're actually going to try
to promote more mobility and less compression of it towards where the
other structures are. Again, fluid between the layers. You guys hear where I'm
trying to hit home on the fluid dynamics between
each of these layers. Back to these building blocks. Collagen basically, the
big take-home message here is that you start to lose the dynamic plastic collagen that you're built with
when you're young. As you age, you start to get more and more mature
collagen that no longer has as much plasticity. Meaning you get less
and less ability for it to be dynamic. That's not good, right? There's nothing we can
really do about that. You can keep yourself
healthy, you can exercise, you can drink lots of water. But no matter what,
you're going to decrease these ratios over time. You got to work harder,
and harder, and harder. I tell my patients, "That's why you retire
when you're 60, or 65, or whatever age it is. Your body is your full-time
job." That's what happens. [BACKGROUND] Because we got to fight
against this somehow. So they could just
pay us to do it. I know. That'd be great. I'd like that job. Then
we have this other stuff. Remember I talked about
the glycosaminoglycans, basically the protein sponge that suspends all these
other structures. This is a really important
sponge that basically grabs your fluid that's built up excessively when
you have overuse or you have an
injury that happens, and grabs some of
these molecules, and transports it down to lymphatic drainage
to flush it out. You guys heard of your
lymphatic drainage system, your lymph nodes, and
things like that? It tries to transport
it to these pipes and then get it back into
the circulatory system. That's a normal living,
healthy tissue. Now when you get
excessive overuse or you get trauma to happen, there's so much stuff that
it's trying to transport. These protein sponges try to soak up so much
fluid that it gets a bottleneck to these
pipes and it can't fit in the pipes anymore because
the molecules get too big. That's when you get that
thickened tissue, that edema. Do you guys know what
pitting edema is? It's a little bit more spongy
thick, viscous type tissue. The reason for that is the glycosaminoglycans have
grabbed so much stuff, it can't flush it out to the lymphatic drainage because you're getting a bottleneck. In simplified terms. It's
like the ketchup bottle. When you want things
to move better, what do we have to do
to things like ketchup? You have to put energy
into the system to get viscous tissues
to move better. The viscosity will reduce as you add energy into that system. That's really important. That process is
called thixotropy. Basically, you're
adding energy to make things less viscous, move better. That's why movement is
what? Really important. These other ideas are
things that relate back to how long you need
to spend doing this. In terms of time management, when you're talking about
the myofascial layers, those layers of the epidermis, dermis, superficial fascia membrane, deep
fascial membrane. Before you hit even the muscle, you need to spend at
least 120 seconds on each of those little areas. Now there used to be
studies that said, "We can't do that in 120 seconds. You need to spend at least
10 minutes on that." These are older
studies that came out studying rat tendon tails. They basically suspended a weight with a rat tendon tail to see how long it takes to get
some creep and hysteresis, so lengthening in those tissues. But for you in the
myofascial layers, you're thinking about something
along 120 seconds or so. When we stretch these tissues, we talk about the paper and
then the effect of that, you need to spend a lot longer
than 120 seconds to get anything to actually stretch
for a muscle or a tendon. When you actually stretch and increase your
range of motion, you're not lengthening
the tissue at all. What you're doing is like what we showed you with
the pieces of paper, you're allowing each
of those layers to glide a little bit
better, one upon another. You have hundreds, and hundreds, and hundreds of layers that need to be able to
glide like that. A lot of the research basically says that stretching is
not lengthening tissues. The take-home from this slide
is that stretching is good, but it's actually not going
to lengthen the tissue. It's going to promote mobility via probably fascial changes. Then it's going to promote
a lot of changes in where? In your brain's perception
of what tightness is. At the end of the day,
you need to trick your brain on what it feels
tension to be in your body. That's why a very simple
movement activities will promote really great changes in range of motion in your body. The research basically
says that if you had to spend six weeks doing
a stretching activity, you actually don't change the length tension ratio at all. That's what some of the
research shows, you guys. It actually stays
exactly the same. The actual lengthening of tissues is probably not possible
on the amount of time that you're spending doing
stretching even if you are a yogi. Sorry about that. But that's not a big deal
because at the end of the day, it's not just the way you move for stretching to try
to lengthen tissues. Everybody take your
right arm and go up as high as you possibly can. Now as I stretch, I'm a little tight in my lats, but I also feel the
back of my shoulder. How many of you guys feel
the back of your shoulder? That's actually not an issue of lengthening at all. Go
and drop your hands. When you guys did that, how many of you guys
felt the back of your shoulder more than
the front of the shoulder? Raise your hands
again if you felt the back of your shoulder. That's an issue of
space of folding. Sometimes we don't need a stretch to increase
the range of motion, we need the tissues
on the other side of the joint to be more mobile, and comes back to fluid, and comes back to space. Picture you're doing the
laundry and you have this drawer of towels. I hate towels and folding towels. I always try to get an
extra towel on there. I have to use my
hip to try to knock it because I don't
fold very well. But if I take my time and I fold all those towels just right, I go to push that drawer and
it just slides right in. That's the same thing as
your shoulder joint here. If you have enough
space here because everything's got more
mobility because the fluid make its space in terms of the health
of the tissues, everything slides in just right. Sometimes stretching isn't
just for lengthening, it's for actually promoting mobility on the other
side of the job. This all comes back to everything is linked
to everything else. Synergies is what we
talked about earlier on. When you think about this model we have this beautiful
place called Berkeley, here in California, and in Berkeley they
don't have a toys store, they have these types
of toys stores that always sell smart kid toys. [LAUGHTER] If you push on any rod or you pull on any string in that
particular model, it changes the pressure
and tension of every other rod and every
other string in that model. You guys see what I mean?
That's the way your body moves, that's the way everything
works together. We look at the way you
come to physical therapy, we understand you
have this disc issue, everybody gets a disc
issue at some point, and we have an L5 herniation, "Oh, my God my life is over." Well, everything that goes into this L5 herniation
is distributed in terms of forces up and
down the entire chain. An L5 herniation isn't the end of the world
for all people. It just means that this
particular area is wearing down a little bit faster
than this. But guess what? All those forces are
distributed really, really well because
the design is amazing, and you just have to
learn how to move again in terms of distribution
of those pressures. We think about it a lot
when we work on the joints, the arthrokinematics of things, but sometimes we need
to actually relate that to the soft tissue
structures as well. Meaning fascially, if
one area gets a lot of densification after
that shoulder surgery, or that bicep tendonitis
that was five years ago. You need to understand that
it's affecting your neck, and that neck is affecting
the way your shoulder moves, and that shoulder is affecting
the way your ribs move. We'll show you those pictures
in just a second as well. When we talk about some of
the other things that are deep and beneath
the fascial layers, meaning it's superficial
deep fascia membrane, we have the muscle
trigger points. We talked about trigger
points real quickly. But basically you get
these areas that have excessive levels of
calcium buildup, and you get decreased nutrition to these particular muscle areas, and they get these little
small contractures. This is an electron
micrograph showing 240 times this size
of that muscle. You could see the striations
of your skeletal muscle, and this area is a trigger point. That thickness, that fibrosis, that ability for those fibers
to not move now create some stickiness and that's within the muscle belly itself. We talked about the stickiness of each of the layers in the fascia, and now there's
also fascia within each of the myofibrils
of the actual muscle, and so those get sticky too. When that happens
you have a lot of excessive stimulation
of the nerves that say something is
wrong to your brain again, and the brain is the
control mechanism it sends signals down saying, "Yes, something is wrong." Just take your left hand and
grab your right forearm, and just run across the muscles on the top of your forearm. Those are the things you're using when you're on the computer 12 hours a day that
we do these days, and you guys feel any knots in there,
any thickened areas? Feel for an area that has a
little bit of a taut band, meaning a strenuous to it. Usually within that taut band, we have a little nodule, and the hyper irritable nodule is what we call a trigger point. Some of you also have them
in your neck or your traps. If you don't have
them in your forearm, reach for the back
of your shoulder. Everybody has one here
for the most part. Push on that, and you
feel that little lump, that little nodule there. Now, if you push in
the nodule and it has a referred pain pattern, meaning it doesn't just hurt there it actually
hurts somewhere else. Referral is up or down, that's called an
active trigger point. We have active target points
and latent trigger points. Basically we want to treat both, but those are those
densification, those are those thickenings
that I'm talking about of the fascia between
each of the layers, and they happen in
the muscles as well. A lot of research is
showing that that particular densification
sends information again from the periphery up to the brain and says
something's bad, and the brain has this
central sensitization, meaning it gets really, really hypersensitive
to all the things that happen in the
area because of it. That's a feedback loop that
stays chronically cyclic, meaning once something bad
happens you get stressed even, and that particular chain activates over and
over and over again. That's why they usually turn into these chronic trigger points. We have them all over
the body, your shoulder has one on the back of
your shoulder blade, and if you lay on
a ball or roller sometimes you'll
feel not just pain in the muscle or the back
of the shoulder blade, you'll feel pain down your arm. How many of you guys have
done that? You lay on a knot, or a ball, or a foam roller, and you don't feel it just there when you're rolling
through your back, you feel it in the
front of your shoulder, or you feel it up in your neck. Those are very, very
common as well. These are just some of those
common trigger points, and you can see pain referral isn't just from the joint itself, it's from sometimes the muscles within the surrounding
tissues of that joint. Sometimes people come
into me and they say, "I have an SIJ dysfunction." meaning sacroiliac dysfunction. Or, "I have terrible hip pain, I've had it for 10 years." I push on this little muscle which is gluteus medius here, and they have this pain that comes right back
to their hip pain. That's my pain, I'm not
touching the joint at all, it's not a hip joint issue. Sometimes, unfortunately
people actually go through hip replacements, and then six months later
that same pain comes back because they never looked
at trigger points. I'm not saying that happens
a lot, but it does happen, and so looking at
trigger points which is these little densification
within the muscle belly, that fascia between each of those muscle fibers
will really affect your pain transmission from the periphery backup to your
brain, the control center. What's cool is we're
starting to look at this more on diagnostic ultrasound. When you see this is up
here at the upper trap. This is that epidermis,
this is your dermis, this is some of the layers of that fascial membrane stuff, and then you have
epimysium, the muscle. This is your upper
trapezius muscle. This is the fascia that separates the upper trapezius muscle here to the muscle beneath it
called your supraspinatus. We can see a little bit of
a darkened region here. See this circle
bubble that was like that electron micrograph before showing you that there's a
bit of a densification here, and it's changed, and we call it hypoechoic nature of this tissue, and that identifies an area that's a little bit
in dysfunction. So there's not quite the same
type of tissue as others. We're starting to get
better as technology improves to identify
some of these things. Ten years ago we
used to think that trigger points was
a fringe medicine, it wasn't really
real medicine even. We're starting to identify
some of these things, and I'll show you guys
some MRI images in just second on some
of the other things. Kenny is now going to
talk about the way these chains are all
linked up together. Hi everyone. My part
is a lot shorter. I kept it a lot more simpler. I can't memorize all the things
that Daprato talks about. My memory went away with
my hair, that's my excuse. [LAUGHTER] When you talk
about trigger points, you talk about individual
traditional anatomy, you're looking at one muscle at a time, one joint at a time. But it's not how we
naturally move unless you're a really good dancer and you practice doing the robot. We focus on reaching, grabbing, moving our limbs
in a coordinated fashion. Now we have cells that are programmed to work in
concert with a certain pattern, but we'll find that our muscles work and lengthened
along a certain line, and now the fascia that connects them will also be
thickened together. In this example here we have
a picture of a chimpanzee. Something hanging from a tree, but some anatomy to us, and you look at the biceps, the forearm muscles, the pecs
forming this one long line. The exciting part
for me if there's a movement nerd,
I'm thinking well, if that animal had an issue with, let's say, the biceps tendon. From looking at it
just anatomically, we think strengthen the biceps. Get that one muscle be stronger. But what if there was a
problem with the pecs, or even the abdominals? Well, that line, if the
abdominals or pecs are weak, maybe the bicep is
overcompensating. You're really going
above and below. If you can get one
thing out of today, you think, "Well yeah, we have maybe a
rotator cuff issue or L5-S1 disc herniation." Treat that one area, but treat above and below
it. Does that makes sense? What we're trying
to get at is, yes, everything is connected, I think that as an oversimplification that
doesn't do it justice. Everything is connected
in specific way. You'll find these lines, and Thomas Myers was actually a massage therapist
who felt these lines, and so he was
thinking a little bit outside the box as well, and he's seeing these patterns. I'm going over. How many quotes do
you have in here? Myofascial tracks, basically the length of lines were not, thinking just muscle
although you do have to work on the muscles that's where the
trigger points are, that's what they mean
isolated tendinosis. But you can go beyond that, what else is the
muscle connect to? This is the exciting part. What's the movement
we're trying to help? In this case you're
pulling downwards, and if you're pulling downwards, we're going to think about, if I'm helping with that motion, we're going to strengthen
all those muscles along that same line, or we're going to
help the coronation movement along that line. Another common one,
superficial backline. We talked about your
ability to bend over. Well, [NOISE] I'm just going to go over far, I want
to talk about first. If you've heard of plantar
fasciitis, the bomber foot. You have pain in the bomber foot. That's one of the few parts of fascia that we actually
talked about before. It's obvious there, it's thick. It's really hard to cut away
so we have to point it out, otherwise we just cut fascia away when we're teaching
the anatomy class. But with plantar fascia at the bottom the common treatment. Yes, you massage the fascia
but what else do you do? We stretch out the
calf right above it. If you don't stretch
out the calf, this stays tight and it's
going to pull down here. You can even go beyond
that stretch above and then the next end,
the hamstrings. Oftentimes if your
hamstrings are tight, you might have heard
what's a common issue after that? Back pain. If someone's bending over and I'm going to have to
step out for a second, but if you're bending over and your hips can't bend over
where am I going to bend from? I'm going to bend from the back. We all know not to
lift up like this. You want to be able to bend, move the hips back by helping
improve the mobility here, which then you don't have
to move as much here. That's where everything is
connected and that's to me is the exciting part because it's not about
treating one segment, but how you move. That's a really fun part. This is just a picture
of anatomy of it. You'll see the actual connection, it's nerveless when you say
everything's connected, but this, you actually see it. Unfortunately, when
I learned Anatomy 2, it's like, let's cut it away, it's not labeled, it's
not in the textbook. But it's really important to see. You'll see, you can go
from here all the way up, all up to the body,
up to the neck. That's why sometimes when you're moving from your back
or move your hip, you can actually get a
little [inaudible] pain up here because there is
a direct connection. We talked about how to move,
improve the layers here, improve the sliding
and the gliding. That's the fun stuff that
we get to do in the clinic, whether it's a specific
kind of massage using the suction
cups, using tools, the calf scrape,
using a foam roller, or also just moving more. That's where yoga is so helpful
because it's making you move through all these
motions that you're not moving through in
your daily routine. If you're staying seated
like this all the time, guarantee you your
hip flexors will be tight, your hamstrings
will be tight. We'll see these common patterns that we'll talk
about in a second. Another common one, lateral line. You were to load up the
slides at this one, simple. Unless you're doing
like taekwondo and you're doing sidekicks, we're not going to
move as much here, a lot of side bending, but I would say focus on the
forwards and backwards. That's more fun to talk about. I'm going to skip to that
one, the spiral line. This one's great
because you talk about any powerful athletic
motion and if you golf. But it's not as easy as it looks. You're really doing
a lot of rotation and then you're whipping
that part and turning. If you don't have that rotation, where are you going to move from? One little joint, that's
going to blow out. You're going to
hurt your shoulder, you're going to hurt your knee. But if you can rotate
through your entire body, that's going to make that
movement so much easier. This is just a good illustration of all the different muscles. When we're looking at
someone with how they move, as a physical therapist, we're not usually focused
on just one part. Usually, you have
either back pain, shoulder pain, that's
the most common ones I see with golfers. Even if you have an issue there, we'll take care of it,
we'll let it rest, we'll stretch that, but
we'll definitely help with their trunk rotation going
all the way down to the foot. That's where just being
active is going to help you. Because when you're rotating, you're pushing off your foot, we're just going to
help move your hips, which help move your spine, and then that's going to help your shoulders move
along with it. We're not going to
go one at a time, unless you want to do
that in your dance moves, but you want to just spin
together and move together. Any questions so far? Feel free to ask questions. We'll
have time at the end. I know we're running a
little bit short on time, but for us it's fascinating. Like I said, when you're moving, think about how the
joints above and below, or off to the side
are also moving in concert with the particular area that you might be
having a problem with. When you're stretching,
don't just work on one muscle at a time, unless you have all
the time in the world. What I call vanity
days when I'm going to the gym and I want
to work on one muscle and I'm about to go to
the beach or back in the day when I was
getting ready for a date like I got to get my packs going, I'm going to do my push-ups. That's fine if you have
the time to do that. You can get your one
muscle to be a little bit bigger or stronger over time but if you're going to be more efficient
or you're going to do this every single day, work on all your
muscles together, so work on specific motions and that's what
this is getting to. In this case, you're doing some tai chi motion where
you're just turning sideways. Or you going to go dance,
or you're going to move, or you're going to
lift up something like this and pull
something like this. versus here, here,
doing wrist curls. Maybe you've seen some people
in the gym doing this, it's usually guys because we're trying to make
impressions here. The actual physiology behind everything is actually
really fascinating. But if you think of
things like slings, this is what really allows
us to generate power. Instead of just moving
one muscle at a time, we have these manual
muscle tests, we'll assess how strong you
are with one joint movement. This is what's
really fascinating. Imagine like a javelin
thrower or a discus thrower, as someone winds up, you're in a caprice stretch, and then you can
blissfully launch the weight really
far, really fast. Think of a baseball pitcher, to be able to throw a
100-mile power fastball. I think that's really amazing. But no way could I
just use my arm. We'll see studies where a baseball pitcher who
has less balance in their leg is more likely to hurt their shoulder or
elbow later that season. Everything really
is connected but in that very specific way. You have to go beyond just treating that one
specific body part, you want to see how
your whole body moves together so that everything
is nice and smooth. Low back. Why does the low
back have pain so often? It's that connection. We look at that spiral line before and all the
forces cross the body. That's why core exercise
is so important. More specifically core
exercises that cross the body. Back in the day, we
used to recommend lots of sit-ups and crunching. We don't do that as much anymore. It's nice to have that
nice little six-pack. But more importantly,
how do you move? How do you coordinate rotation? Or how do you resist rotation? Really stabilize your back. I think it does scar up a lot right here and
when this scars up, we have all those physiological changes that Daprato was talking about and that's where it's helpful if you go into therapy, we can help you loosen up. But if you begin to
learn how to move your back and move the
joints above and below, it's really going
to help you out in the long-term and prevent the injury from
coming back again. Postural Syndromes. Here's one of something to get a
little more practical. Because most of us
we end up sitting a lot or maybe the newer generations are
always on their phones. You ending having this
common movement pattern or postural pattern. Dr. Janda was one
of the first one to really describe this. I think you can look
over this later. I'm going to skip through this. But the biggest thing is what we call the crossed syndrome. This is really
simple to remember. We're looking at
just the upper body. Your head is normally a
little bit more forward. Rarely are you like this unless you're being a pompous and you're trying to impress people but most of us are
more relaxed here. What happens or what's
going on with my neck? It's a little bit stretched
out in the front. But if it stretched out in the front what does it mean the back? It's a little bit short up here. Where is a common area that feels good to massage
and stretch out? Right in the back of the neck. You can feel if
you put your thumb right at the base of your skull. Usually it feels pretty good. Now if it's really tight, you have a nerve that goes with those muscles
and you going to feel something down half your head. But if you lie down and you just massage
and pull up there it feels pretty good and
that's because those muscles are always working
to keep you here. We need to stretch those out. If we're look at the
top of the cross syndrome at the top, this part is shortened, this part is lengthened. This part also pulling forward, and then the shoulders
hunched forward. Why is it feel good
to massage here because they're always working. The simple treatment is just do everything that's opposite. Pull your shoulders back, elongate your head,
tuck in that chin. When you call it
a cross syndrome, it's easier from a physical therapist
standpoint we already know, alright, strengthen
here, massage here. strengthen the low back, let's pull the
shoulder blades back, and the pecs stretch. Basically, do the opposite
of what we're always doing out here and that's
going to help with this. One thing I glossed over when we look at the lines when
you raise your arm, we talked about earlier about how the tissues have
the fold in the back. This time, put one
hand on your ribcage, and on the other arm raise
your arm all the way up. Do you feel your ribs moving? It's nice if you're
doing it on purpose. But what happens all the
times that we get so tight on pecs that
when I raise my arm, my ribs have to move up and if I'm doing a
lot of reaching up, I have to clean something up top. My wife's making me
wash the windows and the next thing I know I have back pain and that's because I'm reaching up all time
and I'm moving, I don't have shoulder mobility where I'm I going to move from? I going to move from the back and I'm just going
to do all this to reach up and my
back's going to be hurting. What's the treatment? [BACKGROUND] Well, at first rest, don't move the back,
stretch the pecs. Stretch your shoulder
so that you can move your shoulder without
having to move the ribs. Again, you're moving
along with the line. So while the pain might
be coming from the back, in this case, the problem might be from a lack of
shoulder mobility. The lower cross is
another example. In this case, it's someone with, if you can call an
anterior pelvic tilt. Basically, your low
back is too arched. If you're sitting a lot, your hip flexors
get really tight, that's this muscle right here. If you're walking
around, it's someone with this stooped posture, leaning forward a little
bit. Just like this. If I need to stand up, I have
to move them back again. Again, the treatment isn't
just ice massage the back, it's get flexibility in the hip flexors
that are too tight. That's the only way you're
going to fix this long-term. Making sense a bit? Here you can look
through it again, but it's just a list of the
muscles that are short. What really interesting is that the division of what we call tonic muscles and phasic muscles. The way I remember is your tonic muscles
is when you're born, you're squished up and
try to fit in the womb. We're here in this position,
the fetal position. You're comfortable here, these
muscles that pull you in, they're the ones
that develop first. What happens after an injury? What movement pattern
do you usually see? If you have any friends or seen anyone who's dealt with
a stroke or an injury, we get into this
protective mechanism here. You could just open each muscle time or you can
work on this big opening, the big motions and that's where all the phasic muscles are. Because those are the ones that get lengthened and weaker. You think just opening
up your rotator cuff, stretching out your pecs, strengthening all the muscles in the back that help with this
and that's a big pattern. If you just think, don't be here, be happy and confident or I tell my students
walk like a boss. You're going to be out here
and opened up that's going to improve your posture and will help with
movement because we want to be out here you
don't want to be here. This will lead to
chronic tightening and specific areas of
eventually the pain. A list of the upper cross muscles which again just go
to here and don't do this too often and just
opened up. Thank you. Guys getting the picture now?
The way these things are connected is a very
predictable pattern. When you have
tightness in one area, don't just think about stretching that tightness out you have to think about strengthening
the other side that's not doing its job. That's why people usually
get stuck and they're not able to get over this hump of the particular impairment
they're suffering from because they're only
looking at the stretching part, and it feels good
for a little bit, but it's short-term fix. You have to do that in addition
to the strengthening of those phasic muscles Kenny's talking about to really
get the full picture. When we talk about
injury recovery and some of the things
that you could go through throughout the lifespan, it's not just how you can get
that one muscle stronger. It's like what Kenny is
saying everything's linked together and the way those things
are linked together allows things to fire in
a coordinated pattern. It all goes back to
the terminator again. What we do in the
physical therapy realm and what I'm going
to show you guys in terms of interventions is some things that you
can do simply at home. There's a lot of
these different tools out there that you use to make your fascia less
densified, less sticky. One of those tools
is the foam roller. You guys said that you've used the foam
roller in the past. But all of these
different tools are out there now and there's
a big market for that especially because the
sports medicine world has really drawn attention
to this and people say, "Oh, I use this because Steph Curry use
this or I use this because a 49 player showed on their Instagram that
they were using this too." There's the different
tools that you can use. These are all different
types of tools that are out on the
market and they can cost anywhere from eight
dollars which is sometimes these plastic washout tools to $2,000 which is a set
of these metal tools. There's all different types and all different marketing
combinations that go with it. At the end of the day, it's really important
to remember that the fascia mobility relates
back to hydration and layers, and space, and there's lots
of ways of doing that. Suction cups are the
next hype between that and some of the stages that the sports medicine
world is drawn to that. Some of the questions I have for people when I present
some of these things is, foam rolling it's great. It is a strategy to help promote some of those
mobility issues. But when we think about the way each of those layers needs
the glide, we need space. If you think about most of the things you get
done to your body, most of those things are
compressive in nature. Foam rolling is rolling
on something and squeezing it a
little bit to create hopefully more mobility
because more fluid will come in and reorganized some of the structures of
some of those layers. But foam rolling is still
a compressive nature, massage mostly if
you think about it, a compressive nature modality. Some of those changes are great, but there are short-term
changes you need to do the soft tissue
mobility things that we're talking about
here and we're going to promote
physical therapy clinic. But also you need to strengthen some of the things that
aren't doing their job. You get the synergistic
activity between the two. Some of those responses from a physiology standpoint are
that you get this hyperemia after you have an effect
of foam rolling or doing a scraping tool
or getting a massage meaning you get a
lot of blood flow in that area and it
flushes out some of the metabolic byproducts
that are stuck there. But it also helps bring
in nutrition for some of the tissues that
are not getting as healthily fed as they should, meaning metabolism will
improve in that area. This is just saying that
some of the other reason you feel better
afterwards is because that particular pain
that you went through is a counter irritant to the pain that you
usually suffer from. Meaning, if you do
something to massage out your thighs or your IT band
and it hurts a little bit. It changes the pain fibers that are running up
into your brain saying, this feels different
and you ignore the other pain that you're
used to chronically having. Now, is that a long-term or
short-term fix do you think? It's a short-term fix. At some point, you have to pay the piper and you have to go back to opening up the
way you are meant to be. At some point, you have to
learn how to move better and that's what physical therapy
can provide for you. We're going to draw
attention back to something else that's
decompresses in nature. I don't like that
I use these things that make dots all over
people actually, I do. It's cool to draw
attention to but this is the best thing I've found because if you think
about all those layers, I've been talking about
all this lecture. This is the only thing I
found that can pull on layers instead of pushing on layers because if you
think about massage, if you think about
joint mobilization, if you think about foam rolling, if you think about scraping. All those things are
compressive in nature. This is the only thing I've found that can be able to pull on some of the layers
to create more space. We saw how important
space was before. We started using
these techniques a [inaudible] in about 2008-2009. We've been doing that for a long time here in the Bay Area. It just got really popular, I'd say in the last three
or four years because of Major League Baseball and because of the Olympics that
have been happening. We started with
Natalie Coughlin and the real reason Michael
Phelps had it is because actually the cups had been passed down from swimmer to swimmer
because they say, "I feel a lot better when I get this particular
intervention done to me." We actually call this
intervention here in the physical therapy world
myofascial decompression. Cupping is more of a traditional Chinese medicine modality
where they leave the cups on statically
and they leave it on from five minutes to maybe
even 15 or 20 minutes. When we put cups on an athlete using myofascial decompression, we get the athlete to
move through that range. We're combining the soft
tissue things we're talking about with what Kenny talks
about movement re-education. That's what myofascial
decompression is and that's why it's different than
traditional cupping. When you see it on
Team USA athletes, or you see it on Cal athletes, or you see it on basketball
players or baseball players, they're doing movement
with a cup on there. That's a very different approach, very different modality and very different reasoning for why you would get that
done than traditional Chinese medicine approach to it. Seems to be very
effective for things. I'm trying to study this
more at UCSF and we just got funding for a grant to actually look more at structures. We're going to look at the
IT band of runners with it. This was a study actually
did last summer, where I took a cup and I put
it right here on the trap. Everybody feel that
trap, not that you had. I took a cup and
I put it right on there and I put a patient in the MRI because I
wanted to see what happened with that.
We've never seen this. There's no actual journal article that documents this
anywhere in the literature. I put that on there and then
I put them into the MRI, the drum roll happens and
this is what it looks like. It's really fascinating
because you can see what am I doing here. I'm creating space
where there wasn't as much space in terms of tissue layers from that
muscle to that muscle. It's all about space.
That's why we use these negative pressure
devices on athletes, like in Major League Baseball,
like in the Olympics, like in basketball, because
it creates more space. Simplify, that's why we do it. It's not a cupping.
It's not for toxins. The media really got it all wrong when they
covered the Olympics. They said toxins in 1,000 year-old approach
and these things. This is actually
stuff we just started using back in, like I said, 2009-2010 at Cal with
the athletes there. Really, you can appreciate
the space differences that you're going to see
while that's on there. This is another view. This is looking at the
shoulder front to back and you guys can see I have
the patient in the MRI. This is before I actually pump up the cup on the actual patient and then I put them back in the
MRI with the cup pumped up and it looks like
that. Pretty dramatic. When you get a lot of
pressure in there, you're actually going
to create a lot of decompression of that tissue. Then I took them out of the MRI, I took all the pressure out of the cup and I put them back into the MRI one more
time and it looked like this 30 minutes later. That is a lot difference
in thickness than that. That's why they feel like
they can reach further. That's why Michael Phelps has an extra inch or two of reach, meaning generating more power
on his actual catchphrase of swimming than he did before that because
he feels that length, he feels that space difference. You're going to feel a
lot different in terms of your ability to sit
up taller because now the pecs don't restrict the ribs and have to pull
them back and you're back doesn't hurt as much
but you have to pay the piper and you
have to strengthen the muscles that aren't
doing their job. You guys really see the take-home
message of this lecture is move more to make the muscles fire that
aren't doing the job while doing some of these
soft tissue things to really make it more mobile. Space between each layer. Pretty crazy though. This is actually stuff that's just in submission. It hasn't
been published yet. That's really exciting,
new frontier stuff that we're trying
to do here at UCSF. You can see there's
a lot of pressure that you can use for a
lot of different reasons. This is a knee patient
that has arthrofibrosis . You guys know arthrofibrosis is? Maybe basically, joint
is just sticky with all fibrous connective tissue and honey sticking all
those layers together. He's been like this
for 10 years and he gained probably about
15 to 20 degrees of motion in the last three
months working with this because all these
layers need more space. We've promoted more
space with this, even on chronic adhesions, even on things that have been on somebody for five
years or 10 years. You can have some promotion
of increased range of motion. It's much easier if it was
just six months ago as compared to six years
ago but you always have the ability to change
because the human body is dynamic and it's plastic and it's amazing at what it can do at all ages no matter
what age you are doing. In summary, what
we looked at today in backwards fashion of
what we've talked about. Why does some of this fascial
mobility really improve? Why does it work in terms
of trying to institute modalities to improve space
and improve mobility? Well, if you're looking
at it, [inaudible] you're going to break up some of the tonic type facilitate muscles and hopefully increase the firing of those
phasic muscles, the ones not doing their job. You can also decrease
some of the stickiness, the densification in
each of those layers. If you're thinking
about the Thomas Meyer or the monkey hanging
from the branch. You can decrease some of
the stickiness of each of those little segments
that is getting sticky. If you're thinking
about trigger points, some of the knots that we touched and thought about earlier. Then you can bring
in more blood flow, flush out some of the things that aren't
supposed to be there. Improvements in metabolism
in the local area. Then really importantly, I think is increasing that mobility. Remember, the ketchup
bottle with George, trying to put energy into the system to get resistance out of the system so that
you can move more freely because until you do that, your motion is going
to be restricted and impeded because there's
a resistance in the system. You have to put energy
into that somehow, either moving more,
or foam rolling, or doing suction cups, doing that myofascial
decompression, or even just stretching more and doing yoga so that you can get a decrease in that viscosity of the ground
substance hopefully. Think about decreasing your
viscosity and remember at the same time that you move more and you do all these things, you change the way
your body feels. You're changing the pain that the central nervous
system interprets as bad and you're changing it
into things that feel good. That's really the
take-home message of it. We have to look above and below and front-to-back
in which muscles are doing their job and not doing their job because at
the end of the day, where your pain is not usually the root of the
problem to begin with. The root of the problem
often is somewhere else because mostly where the pain is a secondary compensation. Think about that cycle I
showed you guys earlier. You're stuck in a cycle
and to break out of that, you have to find out how
to move the root better. You'll feel that once you start moving a little bit
more efficiently. That's where that
balance comes in. That's my spiel for today. These are a lot of
different articles you can read and check out.
This is what I had to read. This is like 10 percent of what I had to read
for all these things that we learn about.
Thank you guys. Questions? [APPLAUSE] Yes. I'm just curious how does
this suction thing work? Is it the same as [inaudible]? Yeah. The question is how
does the suction thing work meaning myofascial
decompression in our Western medicine based terms. Basically, what we use in the clinic is a
pneumatic device now. It's a pump that has a valve
and it sucks the pressure out of a plastic cup that has
another valve on top of it. Basically, you can
increase pressure by pulling a little bit of a gun and maybe four or five pumps will pull all the air out of
that particular vessel. Then you have that
drawn up muscle like you saw in the MRI picture
that I showed you? It can hurt depend on how
much pressure you use. Hurt is a very
subjective experience. With my athletes, they don't think it hurts at all, but again, they play football and rugby and baseball and lots of
different things. I think it hurts very badly
and I don't like it myself. [NOISE] I scream
when I get it done, but I know it's good for
me, so I do it sometimes. [LAUGHTER] It's different than Chinese medicine which often uses fire cupping to burn the oxygen in that area and create a vacuum
inside a glass cup. They use both and we use
mostly just the pneumatic one. Fire is dangerous in a clinic, dazzle on fire sprinklers
and things like that. I'll add on. One of
the big differences, you've ever had a traditional cupping when they use the heat, it's equivalent about,
say, half a pump. Yeah. We can get much more. We can increase the pressure. I will say, I am more
aggressive at it then maybe acupuncture because
we're making people move while the cups on them. We can put the cup on
in a separate layers. We're thinking in very
mechanical terms, but now we're having
to move through something and getting
an even bigger stretch. Whereas traditional cupping, you just stay in there to play music and you go sleep
for 10-15 minutes. Then the therapist comes
back and takes a cup off. Absolutely. Great
question. Thank you. Other questions?
We'll go right here. On this concept about how the different parts are
interacting, pulmonology, PT departments in
general or is this very cutting edge
stuff [inaudible]. That's a very complex question. The answer is yes. [BACKGROUND] The question is, is this common knowledge
amongst PT practices all across the country and all across the different disciplines, as well as I would
say orthopedics, or surgery, or different things. I'd say this is definitely
a pendulum that swung this direction in maybe the last five or 10 years
more than anything. Older clinicians that
don't like to stay up on literature as much
aren't going to be very familiar
with this at all. It's definitely something that is a little more cutting edge that we're trying to do here at UCSF to understand
the mechanics of why these things do
happen and help. It is a little bit
more cutting edge, there's a lot of things that
we try to promote here are, but we're seeing really
interesting results physiologically based on some of the studies that
we're doing with it, so the answer is yeah, you have to shop around
to find people that understand some of the things
we're talking about here. This next one was
that right there. I was interested in the nutrient exchange
when you were talking about the viscosity and then trying to get
through right by nature. Okay. She was asking about the nutrient exchange that happens when tissues are viscous. Think about something
that has a lot of tension in a system that you're trying to get a
fluid to go through. Some type of membrane that allows things to go through
and some things not to go through and it's got a lot
of pressure already in it, and you just can't get that pressure to go
through so you're not able to exchange
nutrients because of that. It's basically a viscosity pressure issue that
you're talking about. When you have excessive amounts
of pressure in that area, you're now allowing things to flow through it the way
it's naturally meant to go. That's a simplified version
of it, I would say. What about the nutrients? You're talking about
oxygen coming in, metabolic byproducts coming
out most of the time. Increasing the ATP production of that particular cellular area for the mitochondrial turnover, for ATP to actually provide energy for the system in
that local area is impeded because it needs things
coming in to constantly turn that mechanism or that
machine over with it. As we get older, I see that our mobility
gets more limited over time and why is that in
terms of what you said, and how do you compensate that? How do you make adjustments? Yeah, the question is the age-old question
of when you get older, why does it just get
harder and harder to increase or maintain
your mobility? Kenny, I'm going to turn it
over to you for that one. [LAUGHTER] You have some physiological
explanations, for instance, like in the spine, you'll see shrinking the disc and so it mixes some of
the joints approximate. You have some typical
arthritic changes. I think the biggest thing
though is that you're not guaranteed to lose all of the mobility but
if you don't move, if your typical movement patterns don't involve moving
to your end range, you will slowly lose that. It's a combination of yes, you do lose some mobility to move but if you compound that by
adding on by not moving, it will kind of be even faster. You can reverse some
of that process, if you start being more active, you start, moving through
your full pain-free range. You can get some of it back. Again, a lot of what
we consider to being tight or short muscles is not really of a
true shortening, but it is your central
nervous system regulating how much you're able to stretch or move
because it's like, "Oh, it's painful I don't
want to move there," but really we just do something to it and it changes how we sense it and then later we move, so when you're stretching, that's like the instant
thing like we're not lengthening your tissues. You're just changing
your perception how long the tissues are, and now you can move farther. Does that kind of make sense? I was a yes, you do
lose some mobility, but not nearly as much
as common perception. Yeah. Any supplement or gels in research that increases
the [inaudible] more. I wish I could turn
that over to Kenny. The question is, either
supplements or gels, are things you can get
at Costco for this? [LAUGHTER] The
answer for me is no. I wish I could take a pill to get my muscles bigger every day, but I have to go to the gym
five days a week. Okay. Hydration, I think is one
thing but supplements, the science on mostly
supplemental kind of consumption of things
is very, very thin. Even things like glucosamine or chondroitin sulfate or some
of these things, joint juice. Very thin in terms of
the mechanisms of it. We don't even understand how it's processed in the stomach
and going through the digestive system to
get out to the joints to actually have the effect
that we think they may have, so most of it is marketing. We don't have that
breadth of knowledge to study in terms of nanotechnology of what's going
on with those things yet. Okay. Great question. I wish I had the answer for. There was one more question in the back before we
can this way again. For the [OVERLAPPING]
myofascial decompression, of course, in educated
point of view, it looks really deforming and
horrible and I can see why athletes might jump on
it because [inaudible] like steroids years ago. Luckily not the same
deleterious effects, but yes. [LAUGHTER] My question is do you have
a long-term study on this? We don't know what the
long-term effects are. Absolutely. Someone who is
getting [inaudible]. Yeah, absolutely.
The question is, what are the long-term effects of something like this that is pretty aggressive modality
to the human tissues, right? It's that
kind of question? It comes back to we don't
understand the effects. Remember, four years ago
and eight years ago, the Kinesio tape that they had on the volleyball players' shoulders and abs and things like that. This is kind of a new hit fad for athletes because they see it as the next thing
that will give them an edge, and much of it probably is
psychological for them. We don't have to push
the muscle that hard in terms of the amount
of pressure that we use when we're working
with an athlete. I'll work with a football
player the day of a game before the game because he
wants to feel ''loose'' right, and so that MRI image you saw isn't the amount of
pressure I will pump up on somebody like that. Maybe it's only two pumps
or is that was 10 pumps. We do things that is a little bit less because it does make
the body feel different, and like Kenny is saying
at the end of the day, you have a large component of the central nervous system factor in terms of how you feel. Some of it is physical
that we're doing, but a lot of it is actually the mental changes that happen from the central
nervous system standpoint. [inaudible]. What was that? You're doing safety. Yeah, and actually
we're trying to study some of the safety
mechanisms of it. We're trying to see what
the tissues happen and then see what happens 48 hours later. Nobody studied these
things yet and so we're trying to
do that data now. Or five years later. Or five years later.
Yeah. I guarantee it won't be as bad as steroids. Okay. [LAUGHTER] Will see you but I am pretty sure of
that. Yeah, question there. Is morning stiffness
a fascia problem? Is morning stiffness a
physiologic problem. [BACKGROUND] Oh, fascia problem. Yeah, there's actually a
really interesting video you guys can watch if you
want to write this down, the fuzz speech, if you
google that or YouTube that, the fuzz speech is
anatomist named Gil Hedley that comes out with this idea that when you wake
up in the morning, you want to kind of move
and stretch because all your fascia during
the night is a little stickier when you wake up
the next morning and so the lack of motion for
eight hours or nine hours, hopefully, if you're
getting that, is really helpful to start
gaining that mobility again because if all of
those layers have not had a lot of movement to
promote that mobility, that exchange of fluid back
and forth and in and out, then you lose some of
that as you kind of going through the sleep at night and waking up
the next morning. That's a theory. It's not actually medically
proven or anything, but it does make sense. You think about what I said, you're stuck in a
sling for six weeks. Some of your range motion
losses not because the muscles are shorter,
they haven't shortened. Some of it is just
the fascia mobility that hasn't been accessed
for a long time. It makes sense in
that around too. Will go here and then
we'll go back there. Yeah. Yes. This is kind of silly
question but hydrating, do you just drink water or
is there a strategy as far as when do I drink water or
what to drink? [OVERLAPPING] Hydrate. The question
is hydration, is it a certain level
that you need to hydrate? Is it that 64 magic
ounces that they say, you know, whatever
nutrition guidelines come out the year before
or the year after. I think the science is
really out on that still, there's no really baseline that you need for a
particular body weight. There's actually a researcher
out of Ervine, I think, that just started
talking about hydration, that we push too much
hydration on people when sometimes the
thirst is the thing that actually is the cue
and you don't need to kind of hydrate prior to thirst. Thirst is a very good homeostatic cue from
your body saying, this is what I need right now and the idea of not getting to that point ever because
you pre-hydrate is not necessarily
scientifically proven at all. The jury is out on that one. That's good question as well. Yeah at the back. Thanks. It sounds like the fascia plane
online is important, and I think it's
interesting over the copying your [inaudible]
area segment, I noticed the PT lecture but since Kenny brought up working with a massage therapist, what's your thought on rolfing. Is the basic principle just about re-align the entire fascial
thing versus segmental? Yeah, so the question is compared to myofascial
decompression, what do you think of other massage interventions
like rolfing. I think they're very good
because you're trying to kind of pull away areas
of fascia that are stickier. Have you guys ever
experienced rolfing, anybody or heard of rolfing? So Ida Rolf very great pioneer in the kind of soft tissue
world of things and a lot of things that we do in the
sports medicine world still are based on things that
Ida Rolf came out with. We don't do cupping because we don't leave it there and
just have them sit there. Myofascial decompression introduces kind of negative
pressure to an area, but it's not just one
decompressive device, it's multiple devices. That's why Michael Phelps
had three or four marks on a shoulder or three or
four marks down his lattes. With those three
or four different interventional devices
going through motion, it kind of increases mobility
in a larger kind of scale. Instead of just a really
pinpoint isolation thing the way your hands
would with rolfing, this gets a larger scale of
that fascia plane to kind of be more mobile all at one time.
It's just more efficient. Rolfing is a great tool, but it's really time-consuming, and you're working on
one area at a time. With myofascial
decompression stuff, we are able to do
a larger kind of fascial plane all at
one time and improve that motion because
you're dynamically moving through a pattern and it's all about the pattern at
the end of the day. Yeah, we're gonna have
to wrap up questions, one more question, last one? That's it, we're done. [APPLAUSE]. [MUSIC]
