Oct 05, 2014. Sunday Times Of India
As Functional Manual Therapists, we don’t want to simply return you to a ‘normal’ state of function. All of us have untapped existing potential and our goal is to help you discover and achieve your optimal potential
Functional Manual Therapy ™ (FMT), is a comprehensive approach to physiotherapy which optimizes the musculoskeletal and neuromuscular systems to not only eliminate pain, but bring life to a patient’s optimum potential. The co-developers of FMT — Gregory Johnson, PT, FFFMT, FAAOMPT and Vicky Saliba Johnson, PT, FFFMT, FAAOMPT of the Institute of Physical Art (IPA), USA view the body as an interconnected system and recognize that small injuries or inefficient postures and movements can disrupt the homeostasis of the musculoskeletal system and slowly create compensations throughout one’s body. These compensations can cause pain, which makes it difficult to use our body correctly for simple activities such as walking or complex activities such as sports. A Functional Manual Therapist treats these compensations and dysfunctions by normalizing the mechanics of the system, retraining the muscles to function as needed with the right strength and educating the patient to move efficiently so they maintain their gains and prevent future injury or pain.
This is why FMT — as practised by the four American Physical Therapists certified as Functional Manual Therapists: Steven, Kaysi, Mike and Katherine, along with their 21 Indian colleagues at VARDAN — makes such a difference. VARDAN is a joint initiative between The Times Group and the Institute of Physical Art (IPA), USA, where the Indian Physical Therapists complete the course work as part of an 18-month intensive residency program.
Steven Kofsky, DPT, CFMT emphasizes two important lessons he has learnt while working in the area of sports medicine and sports related injuries — one is that old, seemingly insignifi cant injuries that we thought had healed, can affect us later. The other is that to help someone become completely better, the therapist must treat the dysfunction and help re-educate the neuromuscular system through the range of activities the person uses.
While these lessons are valid for the wide variety of issues that FMT addresses, from chronic or acute pain to recovery post surgery, Steven talks about the foot and ankle as it is an area of the body that people often neglect “If left unattended, ankle injuries can result in pain in areas further up the chain of motion, like knees, hips and spine,” says Kofsky. Popping a few painkillers and applying heat to the affected area may provide temporary relief but with FMT the therapist finds out the actual source of the pain and addresses it.
“There are 28 bones comprising the foot and ankle and each plays a part in efficient movement. If the joint between two bones becomes dysfunctional and does not move as it was intended, it puts pressure on the surrounding bones, joints and soft tissues to compensate, potentially causing the whole foot and ankle, and even the whole leg, to become dysfunctional,” explains Kofsky. Treatment of the foot and ankle is not complete without neuromuscular re-education, so that the body is capable of controlling the restored movements that lead to improved function.
He cites the example of a female soccer player who had her ACL (a ligament in the knee) surgically repaired for the second time in one year. The patient had also undergone appendix surgery some 10 years earlier, had strained her hip flexor muscle and had also repeatedly started straining her ankle. “After watching her walk, it was clear that the first area we needed to work on was her appendix scar and right hip. From there we progressed to her right ankle. Throughout her treatment she was also doing exercise for her knee, but to help her move efficiently and avoid hurting her knee again we had to address the dysfunction caused by the appendix surgery, hip strain and chronic ankle sprains.”
Kaysi Gray, DPT, CFMT has additional specialization training in the treatment of pelvic fl oor disorders and talks about the symptoms that present when the pelvic fl oor is not functioning properly. Explains Gray, “The pelvic fl oor is a group of muscles that attach from the front of our pelvis towards the back of the pelvis. It is literally the base of our trunk and serves many functional roles — in our urinary, digestive, reproductive and of course musculoskeletal system. When this muscle group is unable to perform its functional role, symptoms of incontinence, constipation and pain can present itself. There are many individuals who experience pain within their pelvis in general, sometimes it is dysfunction localized to the pelvic fl oor, and sometimes it is related to the patient’s organs, nerves, or lower back. Within the realm of FMT we are able to thoroughly assess the person’s structure and function and identify the key elements causing the symptoms.”
Kaysi helps people with conditions such as incontinence or constipation using FMT techniques. In the case of incontinence, the focus is appropriate fl uid intake and pelvic fl oor strength. The physical component of incontinence is the strength and endurance of the pelvic fl oor muscles. The issue of incontinence is likely to occur when this muscle group is weak or restricted. “With FMT, we are able to treat any mechanical restriction of the pelvic fl oor muscles which may be compromising the muscles ability to fully contract or relax, as well as build up strength in the muscle group,” she adds.
In the case of constipation, if the cause is suspect to be related to diet, the person is referred to see a dietitian. If the cause is suspected to be mechanical, the attempt is to restore mobility of the digestive system through FMT.
In the case of a pain syndrome, the fi rst step is to thoroughly assess the area and get a good understanding of the patient’s history to identify key structures that could be causing the pain. “In this scenario we utilize many FMT techniques to address myofascial restrictions, joint impairments, nerve impingement and/or visceral restrictions. Once the mechanical restrictions causing the pain have been addressed, we teach the patient to move in ways to enhance the strength of the pelvic fl oor. An example of this would be educating a patient to sit more properly along their pelvic fl oor and not slouch/sit on the coccyx and sacrum, specifi cally a person presenting with coccyx pain,” says Kaysi. “We enhance function through exercise. The pelvic fl oor is an essential part of the core muscular system and as such a good core stabilization program improves strength and stability of the lumbar pelvic region,” she adds.
Looking at and fi ne-tuning movement was always a passion for Katherine Kulp, DPT, CFMT, a former ballet dancer who enjoys working with dancers. “Ballet puts a lot of stress on the lower lumbar spine and hips, and just about everything in the lower extremity,” she says, of the opinion that FMT could be very useful for Indian dancers. Dancers have the ability to put their bodies into positions that others cannot reproduce. The same applies to gymnastics, ballet, etc. and that can exacerbate stress points. Often, if a dancer is having problems with a specifi c movement, an FM therapist can not only mobilize the joint and help the muscles, but also his or her experience in dance can make a huge difference. Says Katherine about FMT, “Fortunately, I had the opportunity to see FMT and understood that here was a way to address not only the symptoms and the pain but also restore function to help a person realise their potential. With FMT we have the tools to address how to get the person there! That’s the difference with the FMT approach.”
Katherine has also worked with the medical establishment in the US on treating headaches with FMT instead of medicine. She is interested in chronic cervical dysfunction and building concussion (head trauma) management programs.
There are many causes of headaches — sometimes they can be mechanical in nature, often the cause can be postural — FMT helps address both. “Posture involves mechanical, neurological and muscular movement and as FMT brings these together, we can be effective in a very high number of headaches caused due to postural issues. Some headaches have causes that need medication, training physicians on how to tell the difference is part of my role,” she states, adding that many people think that the headaches are a head issue, but in many cases, a certain area of the head is just a referral point for the shoulder!
Mike Binet DPT, CFMT, has engaged in a diverse exploration of coursework, bridging from neuro to orthopedic philosophies of care. His area of interest is pediatric and young adults with neurological involvement. Mike simplifi es, “the condition causing a problem often has to do with the brain and nerves, that is neurological involvement — conditions such as cerebral palsy and traumatic brain injury. We continue to treat these individuals into adulthood as FMT still has the best set of tools for it.”
Mike believes that every patient that walks in through the door is a neuro patient, as everyone has a neurological angle. Some of the recent research on which Gregg and Vicky Johnson have developed a lot of the FMT philosophy demonstrates that when a joint is out of alignment, the associated stabilising muscles also turn off, specifi cally talking about the spine. “So when we bring the joint back in alignment, we have to also go back and retrain those muscles from a neurological and motor control standpoint, otherwise it will not be successful,” he says.“If we look at cerebral palsy, for instance, people see tightness in the extremities and weakness in the core. That is not necessarily because of the initial brain injury,” Mike explains. “If the core can be activated, there will be relaxation in the extremities and improved function.” The FMT practitioners at VARDAN are confi dent that when a patient walks in, they are best placed to identify the greater potential and carry patients through to reach that goal. “Part of our responsibility is also not to over-promise, but help out with integrity,” says Mike.
The experts quoted in the article are Certified Functional Manual Therapists and a part of VARDAN, a Wellness initiative by The Times Group