Recently, I had the honor of interviewing Dr. Spina via email. Dr. Andreo Spina is a Canadian chiropractor who is the Director of Sports Performance Centers, just outside Toronto. But he is most notably known as the creator and director of the popular Functional Anatomy Seminars, which focus on soft tissue assessment and palpation (Functional Anatomic Palpation Systems), soft tissue release and rehabilitation (Functional Range Release), and mobility conditioning and joint strengthening (Functional Range Conditioning).
(Q) Thank you for taking time out of your busy schedule to talk to me. It seems like your approach to treatment, rehabilitation and conditioning includes a heavy scientific basis. Was this something you saw missing by health professionals that spurred you to create Functional Anatomy Seminars?
(A) I believe that there is a general confusion in the manual therapy world as to what constitutes “evidence-based” care. There are people on one side that want nothing to do with evidence and research and choose rather to work with tradition, hearsay and beliefs. Then you have people on the opposite end of the spectrum that seem to believe that if direct research has not been conducted on a concept, it is reason enough to dismiss it entirely.
Of course like most things, the true answer lies somewhere in the middle. There are indeed concepts and methods that have not yet been subject to vigorous, direct scientific inquiry (the vast majority of manual therapy falls into this category), but as is often said, absence of evidence is not evidence of absence. Ideas always precede research, and it is important that the creation of new ideas is cultivated to ensure forward progress. However, the generation of ideas should be borne from the knowledge that already exists. If it is not, then the idea simply constitutes someone’s random opinion. In other words, where no direct evidence exists, we should ensure that our methods are created on the foundation of indirect, correlated evidence. We should at the very least be able to generate a scientifically grounded theoretical construct to explain why we do the things we do. This is what I found missing from various techniques of assessment, treatment and rehabilitation. Methods are utilized and then we look to research to see if there is justification for them. If there is, then people are happy to say they are “evidence-based”. However, if there isn’t, rarely do people change or alter their methodology.
For my systems, I worked in the opposite direction. I looked at what existing evidence has to say about how to maintain tissue health, how tissues respond to external force application (soft tissue work), how tissues respond to internal force application (exercise, muscle contraction), etc. Then I developed my systems out of this information.
(Q) I find your work and philosophy to be very similar to sports conditioning and training, where the goal is to move a sports movement from the conscious to the unconscious. Once this is mastered, there is an increased challenging activity in which the end goal is the same. Is this an accurate summation and analogy?
(A) It is. The fact is that most, if not all sporting activities are performed by the unconscious mind. In fact, many great coaches and teachers have spoken about clearing the mind and entering the flow state (or “the zone”) in order to optimize performance.
Assuming that the goal is to improve performance, training must take the conscious action of training and ensure that the nervous system can respond accordingly during live execution.
The idea of gradually increasing the complexity of training is essential as it allows the athlete to be able to unconsciously handle the many, many variables that one is subjected to during real time athletic activity.
(Q) I see lots of patients with restricted ankle joint range of motion, which I believe is the originating factor for their particular injury. How do you approach the ankle in terms of prevention and increasing mobility?
(A) That is, of course, a very difficult question to provide a detailed answer for over this medium. Generally however, I will say that it is not enough to simply stretch tissues to improve mobility. Passive stretching leads simply to the ability to passively achieve a particular range. In order to utilize that range for movement production, one must train the nervous system to be able to control newly acquired ranges. This includes developing strength, balance and coordination in new ranges. It is in this way that ones improves functional mobility, which is the ability to actively utilize ranges of motion.
With regards to prevention, luckily, the acquisition of mobility as outlined above tends to reduce the likelihood of injury simultaneously. The more the nervous system is familiar with the potential ranges of a particular joint, the more likely it will be able to compensate for variables as they arise during activity.
(Q) I have started using orthotics as a rehabilitation modality, more so than something longstanding. My goal is to train the foot through such things as intrinsic muscle exercises. What is your view on orthotics?
(A) It has always struck me as strange that if you have a shoulder, knee or back injury, most manual therapists will assess the condition, provide a diagnosis, and then proceed to treat the problem using a combination of therapeutic techniques coupled with a prescription of rehabilitation exercises. On the other hand, if you have a foot problem, people are often simply handed a brace (orthotic) and sent away. It’s as if people consider the feet to be completely different from the rest of the body. As if they don’t weaken when placed in a cast for prolonged periods of time as do the “other” parts of the body. As if they don’t require ongoing training to maintain them as do the “other” parts of the body. This is simply not logical.
I have always said that we are born with the most technologically advanced shoes ever created. They are so advanced that placing more stress on them actually makes them structurally and functionally better. They are called feet.
An entire industry has been built on trying to treat and/or “prevent” foot pain and dysfunction in humans. We are constantly being told that our feet need “support” and our arches need to be “maintained”. Products abound with promises of decreased pain and increased comfort (soft shoes, athletic shoes, orthotics, etc.). However, the problem is that the “cures” that are offered are, to a large extent, contributing to the cause. It is thought that the evolution of Homo Sapien bipedalism began approximately 4.2 million years ago. In contrast, the first shoes are believed to have been used only ten thousand years ago (by the most generous estimation). What does this fact tell us? From an evolutionary perspective, footwear was invented only a moment ago. What are the long term consequences of this unnatural invention? A dramatically increased prevalence of *enter foot diagnosis here–plantar fasciitis, metatarsalgia, etc.*
To answer your question, I completely agree with you. Orthotics should be used as all other braces that we prescribe, as a temporary solution. The rare times that I prescribe them to patients, they are prescribed in conjunction with a foot-strengthening program, geared at getting the person out of them as soon as possible.
(Q) Plantar fasciosis is a common injury in my office. Unfortunately, it usually is long-standing when they come in, with scarring of the fascia. How do you treat fasciosis and what would be your expectations in terms of healing time?
(A) I approach the treatment of all human tissues in much the same fashion. The organization of tissues depend on the force inputs created by movement. When tissue becomes disorganized (scarred, fibrotic) due to injury or prolonged bouts of immobilization (as is created by “supportive footwear”-shoes, orthotics, etc.), it is the job of the therapist to send signals or inputs into the cells by way of soft tissue application, coupled with specific exercise inputs so that they will reorganize said tissue over time. Such reorganization cannot occur with one treatment encounter. Tissue requires multiple inputs over time to create lasting alterations. Thus the prognosis for complete “healing” is in the range of weeks/months vs. hours/days as is commonly believed.
The confusing factor for some is pain. When using pain as an outcome measure, people are fooled into believing that alterations in pain are directly coupled with changes in tissue. This is not the case. Thus even if someone “feels better” after a treatment, no scientific literature will support the idea that any lasting structural changes have been accomplished. What that means is that even when the pain begins to lessen, work still needs to be done, so exercises for the foot should continue.
In most cases of this condition, I utilize Functional Range Release (FR) soft tissue techniques to being the messaging process and reinforce this signal with the prescription of tissue stretching coupled with contraction, i.e., placing stretch on the plantar fascia, while contracting the tissues on the undersurface of the foot. This is done in an attempt to progressively adapt the tissue to the loads. Of course this process is impossible to explain, but that is the gist of the treatment plan.
Aside from that, all of my patients are placed on an intrinsic foot-strengthening program. The beginner exercises can be seen on the following link:
(Q) It seems like modern society has a hugh impact in using making us unhealthy, in terms of shoegear, diet and lack of movement. What do you suggest your patients or anyone can do in order to live healthier and happier?
(A) They further we stray from what we are naturally selected to do, the unhealthier we become.
If you look at the history of our species, we evolved in a time where we were required to move frequently in order to hunt, gather, defend ourselves, etc. This is evidenced by the fact that the human body actually produces rewarding chemical signals when we move (for example, the “runner’s high”) that makes us feel better. So the conclusion that can be drawn is to move more.
The same goes for our diet. Our systems were shaped during a time where we ate real food-be it meat from animals who lived in the wild, or fruits and vegetables grown in a natural setting. So eat real food as much as possible.
Although we assume that we have always lived in what can be considered “modern civilization”, on the timescale of human evolution, civilization was invented yesterday. Thus our bodies have not adapted to many of the unnatural stressors that we place on it.
Quite simply, eating real human food and moving like humans were meant to move makes humans better humans.
(Q) Again, thank you for your time. Tell us if you have anything new and exciting coming up in 2015 which you can share with us.
(A) I have a full schedule of teaching both my soft tissue therapy seminar, Functional Range Release (FR), as well as my functional mobility development seminar, Functional Range Conditioning (FRC) all over the globe in 2015. In addition to that, I am currently developing a few new seminars to add to our curriculum.
If you want to learn more about them, please visit http://www.functionalanatomyseminars.com/ You can also follow me on Twitter and Instagram: https://twitter.com/drandreospina and http://instagram.com/drandreospina
Please take the time to read this again and perhaps again, because there is much useful information in this interview. As always, please contact me if any questions.
Health and happiness!
I had the opportunity to interview the preeminent researcher in the fascinating world of FASCIA, Dr. Robert Schleip from Germany. He has singlehandedly changed the way I,and many others should treat patients with soft tissue injuries, particularly plantar fasciitis (heel pain). Fascia is a continuous web of tissue that surrounds the bones, ligaments, tendons and muscles of the ENTIRE body! Its all-encompassing nature, highlights the fact that it has a major impact on injuries and prevention and also the interconnection of the entire body. Below is the e-mail interview:
(Me) I have been fascinated by your work. What type of response have you been getting here in the U.S.?
(RS) There has been an avalanche of interest from the US, yet also Canada. Not only in our work but in the new field of fascia research in general. Most interest comes from manual therapists, yet also from sports medicine people, yoga instructors, manual art specialists, and others.
(Me) Tell my audience about your background. I believe it is important that the scientific and medical community works hand and hand
(RS) I have been a bodyworker since three decades. Mainly as a practitioner and instructor of the Rolfing method, yet also as a Feldenkrais teacher. Based on my frustration with a pseudo-scientific foundation of my work, I began to enter the field of academic science myself, first as an avid reader and participant of conferences, and then 6 yrs ago I became an active laboratory scientist myself. Together with a small team of colleagues at the University of Ulm in Germany, and in combination with my PhD dissertation, I could show that normal fasciae, i.e., the dense muscular connective tissues, have active contractile properties. This was awarded with Vladimir Janda Award in 2006 and has stimulated several further studies since then. I was also involved in organizing the first International Fascia Research Congress, at Harvard Medical School in Boston in 2007, which was a hugh success. It was booked out months in advance and received an enthusiastic coverage in the scientific media; and soon we’ll be having the 2nd such congress in Amsterdam.
And you are right: I strongly agree that scientists and health care practitioners should work closer together. Yet this is exactly what is currently happening in the field of fascia research. The current excitement that everybody feels in this field is not only because the cinderella effect, in which the tissue which was most neglected in orthopedic research in the last few decades is achieving an almost superstar position since that first Harvard congress. Moreover, that excitement, which has some qualities of a gold digger’s rush, is largely colored by the interdisciplinary mixture of the people entering this field and the mutual cooperation of clinicians, researchers, movement therapists, nutritionists, and many others.
(Me) Tell us the results of your studies in regards to contractile cells in fascia (myofibroblasts).
(RS) Pathological fascia such as Frozen Shoulder or hypertrophic scars contain so-called myofibroblasts, which are connective tissue cells with smooth muscle like contractile properties. These tend to densify and to contract the fascial matrix. What we did is look for the presence of such cell in normal human fasciae. Basically we found such contractile cells in all fascial tissues that we looked at, although at different cellular densities. Additionally we suspended pieces of fascia in an organ bath environment and stimulated them wth specific cytokines or with mechanostimulation. Here we could show, that many of the fascial pieces could actively contract and relax in a smooth muscle like manner. This finding may have implications of understanding many conditions and therapies which involve hypo-trophic or hypertrophic fasciae. Possibly manual therapies, yet also stretching or yoga or Pilates practices, may be targeting the active ability of fascial tissues to regulate their tonicity independently of the muscular tone.
(Me) Tell me the results of your studies of fascia in regards to water content.
(RS) We repeated and extended some earlier experiments from a group in Montreal, which showed that when a ligament or other fascial tissue is being stretched isometrically, that is yields and looses some of its original stiffness by the well-known feature of creep or viscoelastic relaxation. We could show that this yielding or temporary softening is due to a loss of tissue water from the ground substance; i.e. that some water is squeezed out of the tissue, like in squeezing a wet towel or sponge. When one then gives the tissue a sufficiently long resting period, it sucks up again with water and regains its original stiffness. Yet quite surprisingly, if the previous stretch was strong enough and the resting period long enough, then the tissues in our experiments filled up to a state of supercompensation, where they filled with more water than they had lost during the stretch and in which they ganied the state of “strain hardening”. This means that they ended up being stiffer than before, for about 1 or 2 hours after the original stretch.
It seems like the stiffness and elasticity of fascial tissues depends to a very large degree on the regulations of their water content. Water makes up about two thirds of the volume of fascial tissues. And most of that biological water seems to be in a bound state, in which the water molecules are arranged in an organized fashion similar to a liquid crystal, or like the surface tension that allows a spider to move on top of a water pond. Aging tends to go along with a loss of hydration in tendons, and degradation of the normal water molecule coating around the elastin fibers. It seems like the dynamic changes of the various water content and water binding properties of fascial tissues have a very profound effect on our bodies; and that many practices like massage, sports activities, or stretching are influencing those properties. We now have the technology, e.g. with modern magnetic resonance imaging, to study those changes in water molecules, and I can’t wait to see the results of some of those studies in relation to specific preconditioning practices in sports, or in manual therapies.
(Me) As a podiatrist, I am interested in this information in regards to plantar fasciitis or more precisely, plantar fasciosis. Do you think stretching should be a first-line treatment for this condition?
(RS) Yes, in my Rolfing practice, which I still maintain two days a week I find that the plantar fascia in those people is not only thicker, but is seems to be also much drier and less elastic. One can often palpate some rope-like or ribbon-like dry strands in the sole. These feel similar to the rat fascia in our lab after they have been exposed to air for several minutes. So I think stretching is most likely a very good treatment. However, the stretching should not be done with the intention of stretch the collagen fibers inside, but to squeeze out the fluid contents of the tissue similar like in squeezing a sponge or a wet towel, such that it will soak up with new water molecules immediately afterwards. If done slowly and repeatedly one will find that dense tissues like the plantar fascia can regain their original youthful juiciness and elasticity.
(Me) I have used massage therapy (myofascial release) for stubborn cases of plantar fasciosis. Do you think this would be a good first-line treatment?
(RS) Yes, absolutely. But is takes several months of fascial tissues to change their morphology, muscles can do that much faster. So it may take some patience to yield a complete healing response from the plantar fascia.
(Me) Any exciting new research results you can share with us?
(RS) Yes, we found strong indications that acute back pain is generated in a large proportion of the cases by microinjuries in the lumbar fasciae. In many cases, the discs are not the causal factor for the pain, yet the lumbar fascia shows signs of injuries, inflammation, scarring and adhesions. And this fascia is densely innervated not only with mechanoreceptors which are important for proprioception, but also with free nerve endings which can drive the central nervous system mad and lead to chronic long term pain syndrome.
(Me) Thank you for your time and I hope to meet you in the near future
(RS) It’s been a pleasure, hope to see you maybe at the next fascia congress in Amsterdam this October.
I know it a little technical, but I feel Dr. Schleip’s work is so important, because it gives a legitimacy to massage therapy and similar manual therapies. Feel free to send a line for clarification or for any questions you may have.
Happiness and good health!
I am planning to do several talks to local shoe stores to inform the staff about certain common foot and ankle injuries and how to approach them. Here is a handout of what I talk about:
• Arguably the most common foot complaint
• When first seeing a podiatrist, it has progressed from fasciitis to fasciosis
• Fasciitis is an inflammatory condition of the fascia on the bottom of the foot
• Fasciosis is collagen degeneration with no inflammatory cells present
• Seen in all types of people, but common thread is usually a sudden increase in activity; pain after a period of rest that goes away after 5-10minutes and at the end of the day
• Treatment involves: rest, supportive shoegear in conjunction with therapy that causes an inflammatory response, i.e., aggressive stretching, self-massage, injection (cortisone/anesthesia mixture or just anesthesia)
• Orthotic therapy maintains the healed/healing plantar fascia, along with prevention of any biomechanical abnormalities that caused the condition
• Has become common, especially for individuals who have worn high-heeled shoegear for a long period of time and want to start wearing flatter shoes
• When first seeing a podiatrist, it has progressed from tendonitis to tendonosis
• Tendonitis is an inflammatory condition of the tendon about ¾ inch from the back of the heel bone
• Tendonosis is collagen degeneration with no inflammatory cells present
• Pain is present after a period of rest that goes away after 5-10 minutes and with increased activity
• Treatment involves: rest, supportive shoegear in conjunction with therapy that causes an inflammatory response, i.e., Alfredsson stretching protocol, aggressive cross friction massage
• Orthotic therapy maintains the healed/healing Achilles tendon and may incorporate a heel lift to decrease stress upon it
• A condition mostly due to biomechanical abnormalities
• It is an inflammatory condition of the capsule (sheath surrounding the joint with nerve and artery supply)
• Pain usually in the ball of the foot, is mild in the morning, but increases as the day continues and is usually sharp in nature with no radiation.
• Mostly like to compensatory overload of the second metatarsalphalangeal joint, due to inadequate functioning of the first ray (i.e., too short, too long, too stiff, etc.)
• Treatment, involves rest, supportive shoegear and use of adequate orthotic therapy that restore normalcy to the first ray joint.
Happiness and good health!
- About Armstrong Podiatry
- barefoot running
- Bowen Therapy
- Children feet
- Fascial Manipulation
- Foot and ankle injuries
- Foot type
- Massage therapy
- Overuse injuries
- Physical Activity
- Resistance training
- Robert Schleip
- track and field