Fascial manipulation: how fascia glide affects movement and pain

This is session number 85 of the Performance Place Sports Care Podcast. I really hate children singing. Welcome to the Performance Place Sports Care Podcast, where you can learn about sports injury theory, rehab, diagnosis, and how to understand the doctor lingo you didn't understand at your appointment. And now, your host, Dr. Sebastian Gonzales. Hey, everyone. Thanks for joining me again. It's Dr. Sebastian Gonzales with the Performance Place Sports Care Podcast. By the way, I might change names pretty soon here. We'll see. I don't know yet, but I've gotten some feedback now because they don't like the name because it's just not as descriptive as what it could be for the podcast.

So, I don't know if you've got some suggestions. Let me know. Feel free. I am open to hear what you have to say. But anyways, we today are going to have on a doctor who has been around for quite a while, and it is Dr. Warren Hammer, DC. He's a chiropractor. Who really took a big venture into soft tissue work, and eventually he landed into the fascia realm. So, he will tell you all about fascia. Fascia manipulation is his specialty, and that is a workshop series that they actually give, which he really wants a lot of chiropractors, PTs, and movement therapists to learn this kind of stuff. So, he will tell you a little bit about that today, but also, too, I want you guys to realize how it can help you with your conditions, with your patients as well.

So, if you're missing out on some of the soft tissue work, Warren Hammer is one of the great people to learn about it from, because he's been, I mean, he graduated school in, I think he said the 60s or 1960. And back then, there was, I believe, from what I understand, is there was a lot more adjusting involved. There was some soft tissue work, but he's been through the whole progression series of soft tissue. And I read some of his articles back when, actually, before I was even in chiropractic school, I read some of his articles and part of his book. So, it was, it's interesting to me, and I really want to reach out to him so I can see what he had learned and why he landed on fascia manipulation as his main thing now.

So, in case you want to know, I really hate children singing. And if you know me well enough, I think one of the very worst songs in the entire world is that one song at Christmastime that has children singing. And if you guys don't already know what it is, it is Christmas Shoes. I do not like, I do not like the Christmas Shoe song. It's not too bad until it gets, like, when, I mean, it's kind of slow. I don't really like it, and obviously it's a depressing song. It's very, not fun. But either way, you get to the kids singing, I just do not like it. And perhaps it's because when I grew up, there was the We Sing series, which was just a bunch of tapes or cassette tapes you'd put into your car, and then there'd be a bunch of kids singing.

And then the kids in the back would sing it, too. And I don't remember if we actually listened to We Sing, but I feel like I heard it a couple times, like, when I was growing up, and I thought, I don't like this. It's just, children singing, I think it's just too much trouble. I just do not do well with trouble. I grew up in the 90s, and we like bass, okay? Trouble just does not sound really good to my ears. Now, just a couple house-cleaning things before we actually get into it with Warren Hammer. I want you to remember, go on to review this podcast for me on iTunes. And if you don't listen to iTunes, by the way, let me know what you listen on, because I don't have an Android, and I don't know anything about what you're supposed to listen to on an Android.

I should probably know that by now, since we're into, what are we now? This is session number, you're going to find the show notes at session number, or p2sportscare.com slash 85. And we'll have a transcription there, a player, and so on. So, it's going to be session number 85, and I still don't know how to listen on an Android device. How odd, huh? Okay, before we go in, I want to make sure, just as I'm talking about every week, I really do believe with a passion in these patient education tools that I am starting to make, that I am making, such as this podcast, such as posters, such as infographics.

I want you to share these things, so if you have not gone onto my website yet, p2sportscare.com, you'll find I'm a provider, or I'm a professional, and you're going to find a bunch of tools that you can use with your patients to help them understand what they're actually doing in your office, because that's a hard thing, you know? We've got to know to be empathetic with the patients, we have to speak with confidence, but also, too, they want to understand. They do want to understand, they want to get better, so we just can't throw random treatments at them, at least I don't think so. So, as we get into Warren Hammer here, just to let you guys know, he has been, again, around soft tissue for a very long time, so if you want to reach out to him, I will put a contact for him in the show notes, but if you want to reach out to him as well and take a fascial manipulation workshop, the website is fascialmanipulationworkshopsisplural.com, he also has a Facebook page as well.

So, we're going to get into a ton of stuff, what fascia is, why it glides, some center of coordination is what we call it, what actually it does in regards to pain receptors, how it's a receptor system, how it goes and feeds the brain, some of where it tells body or where it's at in space, what he feels about trigger points, and what he feels that chiropractors now and PTs should be learning as they're getting out of school. So, here we go with Warren Hammer. Okay, everyone, as promised, we're going to welcome on Dr. Warren Hammer. Doctor, what's going on? Well, lots, lots of going on, and, you know, I've been in practice since 1960, I can't even believe it.

60? And I'm more excited than I've ever been in my life, because I'm using or investigating a method or part of the body that I've realized is so important for the well-being of patients. And it's called fascial manipulation. Mm-hmm. And I asked everyone, or I prefaced this before I had you on, just so everyone knows that we're going to be talking about fascia today. So, I thought you'd be a great person to ask about everything detailed to fascia, not just easy stuff for, or easier stuff for the patients, I understand, but also you can just get into some deep stuff for clinicians as well, since we have some listeners on.

All right, that'd be a great idea. Awesome. So, well, how'd you get into fascia? Because I know that you've been, I mean, actually, I read some of your articles when I was in school, and I actually read your, I read part of that book, I forget what it's called, Soft Tissue Exam. Yeah, Functional Evaluation of the Soft Tissue, yeah. That's, I wrote three textbooks, three different editions of the same book. The last one came out in 2007. That sounds about right. Well, actually, what got me going into fascia about maybe 30 years ago, not fascia, I should say, just soft tissue, I attended a seminar given by a physical therapist who worked for James Syriax in England.

A lot of people don't remember him anymore, but he was an MD, orthopedic surgeon, and he just revolutionized the world of soft tissue. He figured out how to evaluate individual joints, and he emphasized, at that time, friction massage, which I still use at times, on particular tendons and ligaments. And he had pre- and post-testing, and it was fantastic. And I sat in that room for three days, and my mouth was open, and I knew, why didn't I know this, you know? And that literally, I think, was the real boost that I had in my life to get me into soft tissue. Although, I originally took courses with Raymond Nimmo, Receptor Tonus, all of that.

I always seemed to take courses in soft tissue. As a matter of fact, after a few years in practice, I mean, I went to Gonstead 21 times. I mean, I'm a pretty good adjuster or manipulator, however you want to call it. And I was never really satisfied as much as I should have been or felt I should be using just manipulation. And, you know, so I realized, wait a second, you know, the joints are a passive structure. They're moved by muscles. So what about the muscle system? So I got into that in a lot of different techniques that I've taken. And about six years ago, I received a textbook from Luigi Stecco, a physical therapist in Italy.

And it just so happened they've been teaching fascial manipulation in Italy at that point, maybe 10, 12 years. Not only Italy, but all over Europe. And I looked at the book and I wasn't too sure what it was about, but it seemed very interesting. And eventually I went to Italy. I was a guest in Luigi's home. I watched him practice for three afternoons. His son was there, Antonio, who is a medical doctor, Ph.D., and he was, like, interpreting. But it was, like, amazing to me because I'm watching people come into this office. You know, he takes a very adequate case history and treated them. And it's, like, semi-miracles I'm watching here.

And I said to myself, oh, I have to learn this stuff. So the first courses I took were in Italy. They were teaching it in English. And then, because I was already lecturing on soft tissue, I said, how would you like to bring it to the United States? And they definitely wanted to. So I originally brought Antonio to this country, and we set up seminars all over the place, all over the country. And eventually, like, three years later, I became a certified instructor. Now there's about four certified instructors in the United States, and seminars are being given all over. As a matter of fact, last year, seminars in fashion manipulation were given in between 40 and 50 countries, 10,000 hours of instruction.

It's really starting to move, and it makes sense. And what makes sense to me is not only the results I see, but the literature that backs it up. And I will say right now, I think there's more literature backing up fashion manipulation than all the soft tissue courses ever created. And that's a big, big statement. Yeah. But there are a lot of places to go for the literature, like pubmed.com. You said look up Stecco in there, right? Yeah. You just put in Stecco C for call, and Stecco A for Antonio, or just fascial manipulation, and you'll get at least 120, 150 articles. Nobody gets into pubmed by just writing an article.

You have to come from a peer-reviewed journal. A couple of doctors have to decide if it's good for the journal, if it's adequate for the journal, meets their standards. So, all kinds of articles. I mean, application of fascial manipulation and chronic shoulder pain, anatomical basis, clinical implications, treating patellar knee tendinopathy with fascial manipulation. I mean, it goes on and on. Expansions of the pectoral girdle muscles into the brachial fascia, morphological aspects, spatial disposition, the ankle retinacula, which is filled with what they call proprioceptors, et cetera, et cetera.

So, that makes me feel happy. Yeah, yeah. Because a lot of stuff I've done, and everybody, you know, it's really not that much behind it, and it's something somebody thought about and decided they'll create a course. But there still are a lot of good soft tissue courses around, and I'm not saying fascial manipulation is the only course around, but to me, at this point, it's something that I think everybody should become aware of. I had a couple friends that went to the fascial manipulation course, and I talked to them as we were setting up this podcast, and I said, hey, what was your opinion on it?

And they said, in regards to soft tissue, it was one of the best seminars that they've ever gone to. And they've gone to, I think, Factor, Active Release, Graston. They've done a bunch of the stuff, but they were really blown away by the fascial manipulation course. Right. I think I was the first chiropractor in the United States to use Graston. Oh, yeah. And I helped write the initial manual, and I still use Graston technique, but I don't use it. I use it in a different manner now, based on areas that I have found or I've been taught that seem to be more potent. And we're going to get into that, I think, a little today to tell you why those points are important.

Yeah, I think, too, we should make sure to differentiate as well, because with, I know you've gone through a lot of soft tissue treatments and so on, but what is the difference between soft tissue and fascia? Because I bet a lot of patients are like, well, this is, I don't understand, you know, what's the same thing? Yeah. Well, I think what we have to do here is I have to give a short version of the anatomy of fascia. Okay. Because, you know, a lot of people don't really realize what it is. But basically, the first research congress, they've had four international conferences on fascia. Amsterdam, the first one was actually at Harvard.

That's where I actually met Antonio. But basically, it's defined, actually, as the soft tissue component of the connective tissue system that permeates the human body, forming a whole body continuous three-dimensional matrix of structural support. It actually interpenetrates and surrounds all organs, muscles, bones, nerves. It creates a unique environment for body system function. I usually tell a patient, I say, you know, if I took everything out of your body and left the fascia, you would see a three-dimensional outline of your body. Now, just thinking about it from a philosophical point of view, you need to tell me we have something that covers everything in our body.

And anatomists, even today, still consider it, well, just a covering. They don't really realize what it is. And the biggest thing that it is, basically, to me, is that it's a sensory organ that literally reports to the central nervous system about what it's covering. And this is even, not only the muscles, et cetera, the musculoskeletal system, this even applies to the internal organs. As a matter of fact, in fascia manipulation, they have a part one, two, and three. And three has to do with functional fascia manipulation of internal dysfunction. But that's another whole world right now to even get into.

But first of all, again, I think we were talking about anatomy, okay? Yeah, yeah. You can think of the fascia as having a superficial layer and a deep layer. And the superficial layers have, like, three of their own layers. But the main area is called the superficial fascia, which is a little elastic. And you've got all of the superficial vessels, nerves, lymphatics, that are in that superficial fascia. And there are techniques that are very important where you are treating superficially to affect the lymphatics, to affect a lot of different things. Then you have the deep fascia, which literally actually envelops, for example, all the muscles of the body.

And it's interesting that one of the main functions of deep fascia is to transmit muscular forces at a distance. And, you know, this is really sort of involved. And actually, I would recommend for a great understanding of the fascial system is Carla Steckel's text entitled, Functional Atlas of the Human Fascial System. You can get it probably on Amazon. Carla only worked on unembalmed cadavers. I mean, after three days, they weren't adequate for her. You actually have some of the best views of fascia anywhere in the world. This book, which talks about the physiology of fascia, how far fascia functions throughout the body, should be at every medical school, every chiropractic school.

A fascia should be a course. It should be a core curriculum course, which we're really close to getting in a couple of chiropractic colleges right now. But it's just an amazing book. She used me as the English editor. She writes what I call Italian English. And it took about a year and a half or so until we got that book out. And it's totally amazing. And probably what I'm talking about is coming from that textbook. Are you fluent in Italian now, then? What's that? Are you fluent in Italian English now? Not at all. Italian English I'm fluent in. Not that much in Italian. My wife speaks fluent Italian, so that helped a lot, too.

Oh, cool. I'll put a link to that book so everyone can find that as well. Yeah. So you mentioned the deep and superficial fascia and the deep fascia. Before going on yesterday, I did a little bit of research just to see if I found some good pictures of these types of things we're talking about. Is there a way that you can describe, if so everyone can visualize, where the deep fascia lays? Because... Yeah, I want to do that. Good, good. Thank you. There are two types of deep fascia. There are two types of deep fascia, basically. One is called the aponeurotic fascia, and the other part is called the epimiceal fascia.

So, basically, the epimiceal fascia covers practically all of our body. It adheres very closely to the muscle, especially the muscles of the upper limbs, the lower limbs, and a lot of the trunk muscles. And, again, that does transmit a muscular force, but we'll get into that. As a matter of fact, I always say, if you look at a chicken and you see this glistening membrane on the surface of the belly of a chicken, that glistening membrane is epimiceal fascia. Are we talking about live chickens here? Pardon me? Like, feathered, like you de-feathered them first? I'm thinking about it. Because chickens don't have exposed bellies, so you've got to pluck them first.

Do you? I don't hang around chickens that much. Okay. Well, you can look at the turkeys. Oh, okay, okay, okay, got it. Well, what's really important, also, is what they call the aponeurotic fascia. Now, that's really interesting, because that glides on the epimiceal fascia. So, consider an arm or a leg. You have this fascia that covers the muscle itself. And this aponeurotic fascia that covers groups of muscles. And this is a very interesting fascia because it has two to three layers, and in between is what they call loose connective tissue. Now, one of the things we're going to get into is, in order for fascia to move, it moves on loose connective tissue.

And one of the main ingredients in this loose connective tissue is hyaluronic acid. And that allows the physiological sliding of the layers of fascia. And that is a big key that I'll be talking about. So, you have the deep fascia, superficial fascia, and you also have the internal fascia. They divide it into visceral, vascular, and glanular layers of fascia, which is taught in part three. But here's the thing you have to understand for, I guess, what we're talking about today. We talked about the epimiceal fascia. And that's sort of a very thin, tough structure that surrounds the entire surface of the muscle belly.

And it actually helps to separate muscles from each other. It gets formed, like, to the muscle belly. And then, underneath the epimiceum is what they call the perimiceum. And this divides muscles into what they call fascicles or bundles. It provides a conduit for blood vessels and nerves. And the perimiceum now is surrounding the bundles. Now, we get into the bundles, and you'll find that every single muscle fiber is surrounded by fascia. And that's called endomyceum. So, and the interesting thing is all of these tissues are interwoven. They're sort of considered like a continuous sheet of connective tissue that encases the muscle.

And it also contributes to the tendons of the muscle. So, one of the things we have to understand here is that all muscles have a fascial connection. So, the most important thing that I ever found out in my life was that the soft tissue, as I said before, is not just a protective covering. It's a sensory organ. By sensory organ, I'm talking about it having receptors. For example, the largest, the most important receptor regarding our muscles is called the muscle spindle cell. And here's the big news. The big news is that a muscle spindle cell is not in the muscle. It's in the layers of the, especially the peramyceum and some of the epamyceum that has to glide when we move over our muscles.

Okay. So, that is really important. Every time a muscle contracts or is passively stretched, the nerve endings, especially the, also, other receptors, the gold guide tendons, for example. But especially the muscle spindles, they're stretched and activated. So, every time we move, when a muscle contracts, the fascia that is attached to it, they call it the myofascial expansions, are stretched. And when they're stretched, they stimulate the receptors. And it's the stimulation of the receptors that is so important for the function of the muscle. So, years ago, I said, well, the joints weren't enough.

Maybe it's the muscles. And then I realized, well, it's the fascia that has a tremendous control over the muscles. They, the spindle cells, they inform the central nervous system about the continuing changing status of muscle tone, movement, and loss of elasticity. So, I mean, here we go. When you use a muscle, when you use a muscle, there are two main nerves. They call it the alpha motor nerve, which is the motor unit that attaches to what they call the extrafusil fibers, the muscles that do the contracting. And then you have another nerve. It's called the gamma nerve. Now, the gamma nerve, which is 31% of the total motor nerve of muscles, has one main function.

And its function is to stretch the spindle cell. It shouldn't be a muscle spindle cell. I don't know if I said it before. It should be a fascial spindle cell. They should change the name. And when this nerve stretches the spindle cell, the spindle cell now is stretched. And remember these annular spiral flower end rate and fibers? These now are sensory impulses. That goes back to the central nervous system and tells the nervous system all about the muscle. So, in other words, just contracting the muscle is really not telling much. For example, where's the muscle in space? I mean, the spindle cell monitors muscle lengths.

It signals the rate of change in muscle lengths. It informs the central nervous system of the continually changing status of muscle tone, movement, loss of normal elasticity, position of the parts. I mean, where's your muscle in space? The absolute length of the muscle, the rate of change, the velocity of the length of the muscle. The spindle cell wants to keep the skeletal muscles at a certain level of contraction, regardless of the length of the muscle. So, let's face it. That's really important. Yeah. And the biggie, as I say, it's in the fascia. So, here comes the gamma. I said, okay, let's do your job, stretch, so we can find out what's going on.

Well, spindle cell might be saying, you know, I'd love to stretch, but I can't fully stretch because something's preventing me from stretching. And that's where we manipulate the fascia. That's where the fascial manipulation comes in. We have to affect that area. Absolutely, because in these areas, when we palpate it, we find that there is a densification. So, that's really getting into the fascial manipulation itself. Because if the paramycele fascia, epamycele fascia is unable to glide, then the muscle spindles are prevented from changing the length. Now, when that happens, some parts of the muscle will not function normally during movement.

There'll be a diminution of muscle force of particular muscle fibers. This will now alter the vectors of force acting on the joint. This will cause unbalanced movement of the joint. This has to result in uncoordinated movement and even eventual joint pain. So, the fascia houses the spindle cell. And really, it's considered like a key element in peripheral motor coordination and proprioception. You know, this hasn't necessarily been proven yet, but you have people, they're doing muscle strengthening. Well, what if they have densifications? What if there are spindle cells that aren't firing off?

That has to mean that all the fibers, when they are working, the brain doesn't know, for example, how individual muscles are functioning. Let's the muscle tell it. So, it sends back the amount of strength and tension, you know, to do the lifting. But there are fibers there that can't be working properly. I'd love to see a study to show, after fascia manipulation, whether they are able to perform better strengthening exercises for themselves. And they're doing that in a way. They're working on balance boards and improving proprioception. People are using rollers and all this, which is fine, and it helps.

But what if you had a way of going specifically to particular points and freeing up densification? And that's really when we get into probably what are we doing in the fascial manipulation. Yeah. I went to a fascial conference with a friend of mine. He's a Ph.D. chiropractor at the University of Pittsburgh. And who was there but Siegfried Mensah. Now, he is probably the world's leading expert on muscle pain and neurophysiology. And we didn't ask him the question, but we sent him an email. I actually have permission for that email. And what he said in the email is actually in Carl's book. And the question was, can fascial adhesions have an adverse effect on spindle cells?

Now, he doesn't even know about fascial manipulation. His answer was, structural disorders of the fascia can surely distort the information sent by the spindles to the central nervous system and thus interfere with a proper coordinated movement. He said particularly the primary spindle afferents are 1A fibers. These are the sensory fibers that go back to the central nervous system. They're so sensitive, he says, that even slight distortions of the paramycium will change their discharge frequency. Well, we have other proof of that besides him saying that. But he's saying that because, you know, based on the literature.

So, that's big news. Well, so actually, so what I'm hearing too is that with, I know a lot of people are probably thinking, how does fascial manipulation, like, apply to, say, movement patterns or, say, Achilles tendonitis, things like that? And it sounds like then, just to break things down for people, is that the fascia provides a receptor system to tell your brain, to tell your body where it's at in space so you can move well, right? Right. Okay. That's proprioception. That's the definition of it in a way. Yeah. These are receptors performing normal proprioception. Yeah. Because I know that I've had some people ask before that, like, well, so how does tissue work help me move any better, right?

Or, so. That's a great question. That, to me, is the main contribution in a way. Everybody talks about the kinetic chain. You know, the hip bone, the knee bone, and all of this stuff. And, oh, you had a knee problem, and now you have an ankle problem. Okay, let's see where it's tight. Let's see where it has to be stretched. Fine. As we reached the election to the trainers of the Arizona Diamondbacks. And the first thing we said was, you guys are probably the best stretchers and strengthens in the world. But you notice you have a lot of recidivism. A lot of these problems keep reoccurring. And why?

Because you're doing it to incoordinated muscles. Now, in fascial manipulation, they have created what they call the myofascial unit. And these units are in every segment. There's like 14 segments. You know, your arm, your forearm, your wrist, your shoulder, whatever. And they use this myofascial unit, which is basically a motor unit. It's the alpha motor neuron affecting muscles, which is part of the myofascial unit. Actually, the myofascial unit is activated by the alpha motor neurons, etc. And instead of discussing single muscles, nerves, or bones, fascial manipulation combines the muscle, the fascia, and the nerve together within this myofascial unit.

And it shows the connections of these units, for example, on a limb or a trunk, by way of these units. And within the units are points. And this is probably the most difficult thing to learn. But these are particular points, and we call them centers of coordination. And there are other points called centers of fusion, which are centers of coordination, which fuse together. Okay. But that's a little beyond us right now. Yeah. I actually wrote that down on my questioning series. Oh, really? Yeah. Okay, but here's the thing. Here's the thing. You all have... Here's the other thing that I didn't even mention.

What do you think is in the fascial system? You won't believe it. The acupuncture system. That's where it is. I thought I was in school for a second there. So, frankly, as I tell acupuncturists who more and more of them have taken the courses now, and I'm for acupuncture. It's a great way of healing, but it needs a little more. As far as I'm concerned, number one, they talk about chi. They talk about energy and fun. What is it? What is chi? Well, because it's in the fascial system, I consider acupuncture sort of a connective tissue type treatment. You're stimulating fibroblasts. You're having immediate effects within the connective tissue.

I mean, faster than a nerve impulse. And it's a way of things changing and creating changes within tissue. But the thing about it is, a needle will stimulate a point. But that point, based on the connective tissue theory of spindle cells, etc., has to be freed. It has to be broken down. Otherwise, it's still there. Otherwise, it's still not functioning in a connective tissue sort of way. So, something has to be done to that. It's so funny. A while back, we had an acupuncturist coming for the second session. I said, well, how's it going? He says, great. He says, I think my results are better. I said, well, you realize you have to break down this densification.

So, he says, well, I am. I said, what are you doing? He said, well, after I'm through with the needle, I go in and I move the needle around, you know, to break down some of the tissue. I said, that's going to hurt somewhat. Right. Well, they can always do that, like, dry needling, sparrow pecking thing. Just keep stabbing it. Well, anyway. So, what we teach is the location of these points. But, the interesting thing is we do a very, very thorough examination based on history. And, as we all do, but we do it a little differently in fascial manipulation. We're interested in causation. And, I would say that the average patient comes in and they usually blame the last thing they did as the cause.

Well, what happened? Well, I have a pain in my right shoulder. Okay. When did it begin? Oh, about a month ago, you know. And, I know what happened. I brought my shoulder back too far. Oh, really? Well, how about the other three people you play with? Did they bring their shoulder back too far? Did they have that problem? Oh, no. But, I know I went further than they did. And, you get these things. Yeah. Now, you could have overuse, no question about it, but, or trauma, or poor posture. But, the thing about it is, in their history, based on what goes on in the fascia, the fascia is the kinetic chain to me.

Because, let's say, this particular patient has a tennis elbow that hardly ever bothers her anymore, but she's still maybe a little aware of it. Or, maybe she, 20 years ago, she fractured her wrist. All of these things had to alter the fascia. All of these things had to alter the communication of those areas throughout the upper extremities. So, basically, what you have to find out about is, is it a shoulder, or is it due to the elbow, or is it due to the wrist, or is it due to an older neck injury they had? And, what we do is, we go over the 10 different, actually, acupuncture lines. They're not all exactly on the acupuncture point, but we're palpating now for density along particular lines.

Now, maybe this patient, on evaluation, when they bring their arm up laterally, has the most pain. You would think it would be the lateral line, and probably 50% of the time it is. But, it could be an internal rotation line, an external rotation line, a medial lateral line. And, it could be intermediate lines. So, it's about 10 different lines that we go through. So, I'll compare, for example, the shoulder with the elbow and the wrist, if I feel, based on their history, that they could be previous causes. And, let us say, I find real density around, let's say, the anterior line, or the sagittal line of the wrist and the elbow.

And, then I go to that same point on the shoulder, and the patient says, oh, that's where it is. But, I'm finding that when I palpate, because we have to feel this density of tissue, it's smooth. There's no density over the anterior point. But, it's very painful when I touch it. But, now I'll go down to an anterior point, maybe around the biceps, or maybe in the forearm. And, oh my God, that is sensitive. They never even knew they had that pain. But, it's been there, and, in many cases, of course, you're going to treat, we call it balancing. If you treat sagittal, sagittal, if you treat the front, you're going to look in the back, too.

But, that's other stuff. But, here's the thing. You can treat this patient by way of an elbow point and a wrist point. It never touches shoulder. As a matter of fact, you... So, they can have... Excuse me, let us... Go ahead, I'm sorry. Oh, so, results on that, that I'm sure you've had people that, in that same exact type of case, you don't even touch the spot, or don't even work with the spot that they're complaining about. You work elsewhere, like the elbow or wrist, and they have automatic... I may never touch the spot. They have automatic... I may never touch it. And, they feel better. Same thing.

Cool. All the time. You've got a hip, you've got an old knee problem, and now they're suffering with the hip, or a low back case. Ten years ago, we fractured his leg. For nine years, he's had a back pain. Well, you can go along pathways, and if you could match up, say, a lateral point in the leg with a lateral point in his pelvis or lumbar spine, and they're all densified, by just treating the leg point, you could immediately get a change in flexion, an increase in flexion. And that's what the beautiful thing about this is. How do you know you're on the right line? Because, if it's a shoulder patient, I may just treat a point at the wrist, a point by the elbow, and then, maybe their chief complaint is when they brought their arm up into external rotation.

Hmm. It feels a little better. Boy, that's music. Because when I feel that, I hear that, I say, I'm on the right line. Well, let's say they put their arm back in the external rotation, and it's the same. Well, I might treat a few more areas. It's still the same. Well, I'm probably on the wrong line. Maybe, in bringing their arm up, it was the external rotation, internal or horizontal plane that was involved. So, it's really, what I like about this, you're not just going where their pain is, or you happen to palpate some nodular area. You're going to an area based on a sequence, based on a system, and knowing exactly where to go.

And that means a lot. Those points could be way, let's just use that shoulder case again. Is there possible for the points that would have the greatest effect to be into the lower extremity, or just really far away from the shoulder? Okay. Yes. Because that's part two, where we teach spirals and diagonals. You could have a shoulder problem on the right side, right shoulder, and maybe the left leg was involved years ago. Well, I've actually had an unbelievable case like that, and luckily it happened in front of a class. That's a goal right there. You get the names of the people in the class to prove it, but this guy had a shoulder.

Problem with abduction. He'd go to about 90 degrees, and it was painful, and it was chronic, and he was getting all kinds of therapy for it. And we actually didn't think of a spiral. We worked along the upper extremity on certain points based on his history, and he was able to maybe get another five or ten degrees. Well, he talked about this Achilles area, and actually it was a point on the calcaneus. And, you know, we have what we call retromedial, antilateral, we call it diagonals, but then we cross the body. And so we may hit a few points on the leg and then go along that sequence, which is a spiral sequence, and then go to the shoulder area and find those points saying, Hey, this looks like a spiral.

Well, this was like one of those miracles, and it only happened once. But I worked on the lateral portion of his calcaneus. It's called the retrolateral 2, PES, or foot. And just worked at it, and it was extremely sensitive. He never even knew he had it. And I'm just working on it maybe three minutes or so, trying to break down the density, trying to free it up so that I feel the smoothness. And I don't know, I just said, all right, get up and let's see if anything happens here. Well, as soon as I'm talking to you right now, the shoulder goes totally up, close to 180. And I said to myself, and everybody stood up and actually applauded.

It was like a magic show. It was amazing. That's cool. But I haven't had that happen very often. But I have treated a lot of spirals, and so has everybody else in facial manipulation, whereby we usually look at spiral situations where people are doing a variety of movements. They're using a lot of different parts of their body at the same time. They may have pain in a variety of areas. So there are certain things that make you think of a spiral. And that's just part of our course that we teach. Yeah. As a matter of fact, go ahead. I'm sorry. I had someone, it was a doc that he took your course, and I was asking him about fascia.

It was about a year or so ago, and I said, can you explain it really easily to me? And so he tugged on my shirt down at the bottom at the waist, and he's like, do you feel that in your shoulder? And I'm like, oh, yeah. So I keep thinking of it as like a green man suit, you know, like those body suits, just sensory-wise. But go ahead. Well, again, you're talking about, which I think is the most important, is the kinetic chain. Because I feel that most people that come to your office, unless they have a direct trauma to that area, will usually have some other area that might be the initial factor in their past.

Sometimes it's a little concurrent. It's also with them, but very minor. And sometimes they totally forgot about it. And these are problem cases, because these are cases that sometimes you have a hard time treating, because you're concentrating on the site of pain. I always talk about Carl Leavitt, you know, the MD from Prague, and very famous, and he wrote a lot of books. Very big and soft tissue, and everybody quotes him on the line he states, where if you're treating, the doctor who's treating the site of pain is lost. Well, obviously, if you fractured your leg, that's a site of pain. You're going to treat that.

Yeah. But so many areas of pain don't have an actual apparent reason. Where does it come from? So all of our tough cases, think about it. It has come from somewhere else. So what fascia manipulation gives you is the opportunity to figure out where else could it be coming from. Because if somebody doesn't show a result by the second visit, or really some change, I'm questioning myself. And I have to tell you, at my stage of practice, I've cultivated a couple of orthopedic people. And I know what's going to happen, but what does happen, they normally send it to their PT. And I say nothing negative about PT.

I learned a lot, and I still learn it from PTs. But the thing about it was, it didn't work. So he said, all right, send it a hammer, you know, something like that. Now, I don't get all those people well either, but I'll say I get 75 to 80% of them better. And it's really, it's so interesting. I mean, I'm not a machine. I'm not just doing one thing over and over to people. It gives you a way to think. You become like a Sherlock Holmes. I mean, you're analyzing, you're evaluating, and we have great support groups. You know, we have blogs. We have people, Fashion Manipulation USA. We've got 200, 300 of them.

We were sending and questioning each other. We have master courses we just had recently. We have a guy, his name is Stefano Casade, who is a PT in Italy, four years of school. But he hurt his elbow. So he found out about a guy named Luigi Stecco giving some courses. He must have taken eight courses before he graduated. That's all he does. That's all he does now with Fashion Manipulation. If somebody needs rehab and stuff, I think he refers them out. But he's a great instructor, too. We just had him down for a master's course in Scottsville some months back. And he's toured all over the world. For example, he has been to Israel at least 20 times.

As a matter of fact, they now have a Fashion Manipulation instructor, two of them in Israel. They're PTs. And he states that at least 200 PTs are using FM as one of their primary ways of evaluating patients. And that's big. And that's happening all over the world. In Poland, you'll wait a year before you can even take the course. Dang. It sounds like the U.S. is just a little behind on it. Yes, they are. I'm really disappointed. Why do you think that? Well, I have my own theory. I feel maybe 10 or 15 percent of people in every profession are willing to take the giant step and think out of the box.

Because when you do that, you know, you're making a living, you're happy, you don't want to make a change. Or sometimes they take a course and they'll take a few things of it from it. But that's not doing Fashion Manipulation or your patient's justice. And in the beginning, we had a waiting list. We had 40, 50 people at a time taking seminars. And then it started to slow down. It's picking up again. You know, another of my theories is that you have somebody in town getting great results of Fashion Manipulation. They don't want to tell their fellow practitioners about it. That's funny. They want to be the only one in town.

Yes. Whatever it is, right now I'll give a commercial. You can go to Fashion Manipulation Workshops with an S dot com and you'll see some courses. And even we have in there advertisements from other providers like me. There's about three or four of us in the United States who run courses. Yeah. I will put a link in the notes for everybody, too. And you have a Facebook group. I'm going to put a link in the show notes for everybody, too. And I saw you have a Facebook group, too, as well, on that, right? I might. I should pay more attention to Facebook. Well, hopefully it's running itself. Everyone's talking to each other.

I know. I guess I just haven't got into it like a problem. I know. It's a great source. Well, hopefully this podcast will help the person practicing next to the fascial manipulation person, the only one in town. He'll go in and check out the course. Right. Yeah. That is the hard thing. I know that, well, actually, probably, I'm sure there's going to be some DCs or chiropractors listening to this podcast, too. I mean, you've gone so deep into soft tissue work, even from the beginning. And why did you even decide to go that route since, you know, I'm sure back in the 60s, a lot of manipulation was taught, right?

Yeah. I mean, it was a little bit going around. I think NIMO was around then, one of my early courses. Why? You want to get political here? I mean... Sure. I think our profession, if we're ever going to really move forward, we have to really get a lot of soft tissue into it. As a matter of fact, what I really loved, and it's just happening this year, is the, what do they call it? The Nibulazione Faciali Associazione, that's my Italian, but it's the Fascial Nebulation Association in Italy. I go every year, and as a teacher, you have to sort of go, and I want to. And we have great lectures with Carla and all of them down there.

They're doing research continuously. Carla is an orthopedic surgeon and a professor of anatomy, and that's why I'm telling everybody about that book, Functional Atlas. And the interesting thing about Carla, we're on an offshoot here. I said, Carla, why don't you put into the book, Fascial Manipulation? She says she's not interested in promoting Fascial Manipulation, although she'd like to. She says she wants people to understand the way fascia works and what it's about. So she mentions zero courses there. But, of course, she's one of the top people in fascial manipulation, doing a lot of research, along with Antonio.

So where was I just now? I was talking about the chiropractic profession we were talking about. Yeah, why? 15% only wants to step out of the box, or in any profession, right? Yeah, well, and I think that's true of most professions. But what really annoys me about chiropractic is that we're seeing about the same percentage of people in this country that we saw maybe 50, 60 years ago. And we need something else. I still think our manipulation of spine and joints has tremendous research on it, equal to everybody. But you have to add something else. Obviously, the set joint and everything that occurs from it is not necessarily the total answer.

Yeah. Otherwise, we'd be seeing more than 50% of the population, 10% or I'm not saying 5%, 10% was seen as low percentage. Yeah. Actually, remember the other day when we were talking about degrees and you said, I said, hey, I don't know if anyone really cares what degrees we have and stuff. And you said you should do a survey or question your people on that. Do you remember that conversation? So I did, actually. And I thought I would share the results with you because just on the idea, like my idea with I think the reason why we don't see a lot of, a large percentage of the population is because I don't think we know how to communicate extremely well.

But so I put on, it was a Facebook one. It was, what makes you believe that a doctor will help you? Like it's the right doctor for you, right? So there was four choices. There was a lot of degrees. There was confidence in speaking, empathy, and high price. And which one do you think, there was an overwhelming win so far from what I saw. What would you pick? I told no clinicians to answer. So this was all patients. Well, obviously, it's probably not the amount of degrees anymore. It wasn't degrees. That was actually, that got one or two answers, though. But there was one that got zero by the time I'd looked into.

Really? Yeah. It was actually, empathy was extreme. Extreme. Which I was surprised. I thought it was going to be confidence, but then high price was zero at the time when I looked. High price is zero. They had no, like no one cared. I should have put, I feel like I should have put low price, but I feel like that wouldn't show value. If nobody cares, why don't they seek out high price doctors? Well, I don't, I don't think it is. I mean, I feel like that's more of like a demonstration of value or just, I mean, if empathy is the thing, if we can, I feel like if we can teach docs to, they know all the stuff.

But then how to relay it in patient terms and understand what they're going through. I feel like we're going to get a better chunk of the population or, I mean, that can probably apply to any profession, healthcare, you know. Well, I think empathy is so essential. People have to feel that you care and they believe you can help them. But you've got to back that empathy up with something. Oh, for sure. Yeah. You get a case like you touch the Achilles and the shoulder gets better. I mean, that's like complete 100% buy-in. Your price won't matter at that point. Yeah. Through my life, I went to Parker seminars years back.

I'd get this big feeling of enthusiasm, but it would die off. The only thing that ever gave me enthusiasm was feeling that I was competent, that I think I can get the patient well. And I felt why, that I could get them better well. And would you believe it? I still have that nervous feeling. Can I get this patient well? And I never feel 100% confident. I gave a commencement address. I'd give it a four, three or four different colleges. And I said, yeah, you're graduating. You think you know it all. I said, well, the day, the only day you can think you know it all is when you get every patient that you accept as a patient well.

Then you know it all. Therefore, you never know it all. And it's a constant search. It's a constant search for knowledge. I mean, I've given up reading a lot of books I'd like to read because I'm always trying to read more about fascia. I'm trying to memorize Carl's textbook. You know, it's like my Bible. I read it every day, some parts of it, you know. And I only wish in my whole life I can remember what I used to know. Yeah. But it's fun. I bet that, or when did you do the, where did you do that commemoration speech? I don't remember who did ours, but. Well, yeah, I did it at, well, two at Bridgeport, New York Chiropractic College.

Where else? Yeah, that's about it. Actually, six, three at Bridgeport, I had one in New York, four. Yeah. Well, I think that's, I think what you said is a good point because that, like, not only just knowing that you can help everybody that you accept, but also knowing which ones not to accept and refer them out. I think that's a good point you made, so. Very much, yeah. So, since there's other chiros and PTs and healthcare professions probably listening to this, as we start to close up, what is one thing that you would like them to know as they're graduating school or in their first year of practice?

Well, never be satisfied with your present-day knowledge, that's for sure. You have a patient that did not respond, don't blame it on a patient. You know, what else could you have done? Is it something else? A park I used to teach, I remember years back, 80-10-10. 80% gets better in spite of the patient. 10% maybe got well because of you, and 10% never get better. I never accepted that. I don't believe 80% of the patients do get well. I mean, what do you mean by well? How do you define it? They feel good for six months or a year? You know, interesting, I'll never forget this, when I was in Luigi's office, Antonio said to me, most of these people have not seen his father for the last two to three years.

So, if there's something better out there, maybe a little prove what you do. I mean, what are we in practice for? It's to help people get well, and not just to make a living, you know. I mean, to take fascial manipulation, you really have to work hard. I mean, it's four three-day weekends for part one and two. And then if you take part three, that's seven days. We're going to have a part three in June in Atlanta, and we have two medical doctors coming down who use this in their practice almost primarily. And it's to treat functional problems of the fascia, not disease, not liver cancer, anything like that.

But there's a whole functional thing that goes on that people are taking pills. And, you know, why do you have chronic constipation? Why do you have reflux? So many things. And, again, it's the fascia. It's the effect on the autonomic nervous system, on smooth muscles, on the nerve endings, the investing fascia that covers organs. That's what has to move, too. By the way, everyone, too, I will put links for, I think this is going to come out in April, actually. So I'll put some links to the seminars as well that are coming up with the workshops. Okay, great. Great. Well, you just go to my website.

You'll see a few there. They're on warnhammer.com or the fascial manipulation. No, fascialmanipulationworkshops.com. You emphasize the S a lot. Is there another website that has no S on it? It has no S on it? Yeah, the workshops. No, that's my particular one. Well, you can go, actually, to fascialmanipulation.com, which is the European worldwide fascial site, and go to English, and they'll show seminars. Yeah, I think I've found that anything, if I Googled fascial manipulation, this came up. So it was one of the top searches anyways. What would you tell patients to realize as they're being treated by a new clinician or a different clinician?

To realize? Well, I tell them that I doubt very much that they have to come for a long period of time, and they will feel the result within two to three visits for sure, and they will continue to get well. And this is not necessarily something they have to do the rest of their life, although we are getting into maintenance a little bit in the fascial manipulation world, but it's just getting results and getting people well. I mean, you see people with conditions for months to years, and all of a sudden they're experiencing relief. I mean, all of a sudden now, the central nervous system is now aware of their muscular system in a very dynamic way.

Things are now firing off. You know, you have spindle cell function, dysfunction in the thigh. That will affect the knee. That then will affect the leg. And it goes right down the line. I was thinking earlier that you said the ankle bone is connected to the shin bone and so on. You should just make a fascial song. You should make a fascial song? Yeah. Yeah, the deep fascia is connected to the superfished fascia. We can do that. Yeah, retrolateral passes. That's a retrolateral general. I can see it now. It might be your closing part of every fascial manipulation seminar. Yeah, we'll have a song.

Exactly. Is this going to be on a recording? Oh, heck yeah. Why not? Okay. I mean, I can cut it if you want me to, but everything so far has been golden, so you've made my life so easy that there's no editing. All right. That's good. Okay, so last thing then. Well, anyway, I didn't talk about, there's something I should mention here. Yeah, please do. Okay. In order for fascia to glide, we talked about the aponeurotic fascia having layers that glide. It's on top of the epimycule fascia. And in the epimycule fascia is where the myofascial units or the points are. Now, in order for the glide to occur, you have to have a fluid for the gliding to occur on.

And we really feel it's hyaluronic acid. You'll find hyaluronic acid between deep fascia, underlying muscles, the epiperi, the endo. It's in every one of those areas where the fascia glides. It's around vascular areas, neural areas. It is synthesized by a cell that called a seco found. You called it the fascia site. And it's in all our cell membranes. And what happens is that when there is injury, overuse, whatever, the fascial molecules become entangled. And the theory is, and there's some studies on it, that when you, what you're treating is not necessarily the collagen fibers of the fascia, but you're freeing up the molecules of the hyaluronic acid and allowing it to become in a more fluid state so the gliding can occur.

As a matter of fact, Antonio Stecco has a great study called Evaluation of the Role of Ultrasonography in the diagnosis of chronic neck pain. And he took ultrasound views. It was two muscles. They used the S-sternocleodomastoid and the sclenus medius. And in the chronic patients, they showed a sickening of the spaces between the collagen fibers. And then they used fascial manipulation on it. And they had, you know, pretty good results. But rather than the results so much, what's interesting is that he was able to figure that when the space in a loose connective tissue was thicker than 0.15 centimeters, you could almost make the diagnosis of a fascial cause.

The thickening of the loose connective tissue, altering the functioning of the fascia. So a lot of times people think, well, they're breaking up scar tissue. No, they're not breaking up scar tissue. They're breaking up a densification. I mean, scar tissue, you know, you could have scar tissue. You want to tear the fiber. And you have, you know, fibers that are absolutely stuck to each other. And you can't, there's no space. There's nothing in there. But in fascial manipulation, we talk much more about densification, about a lack of glide. And you can palpate, and you can palpate it. As a matter of fact, palpation is the chief diagnostic message we have.

Where are we going? I mean, why just rub on a spot? And the beautiful thing is we rub maybe on a series of points. We go back and forth until we feel the lack or the freedom of the glide, the lack of density. And that's essential. Because if they don't end up with a lack of density, what were you doing there in the first place? Yeah. I tell us to massage people, I tell us to a lot of people, oh, it hurts over here, so they rub over there. I mean, or trigger points, that bugs me the most. Random treatment trigger points. I mean, I have a great orthopedic friend, and he's a great doctor, and he's always doing trigger points.

I said, okay, you pick the trigger point in the trap, and the patient feels better. But that trigger point could be, it doesn't have to be, but it could be a myofascial or a center of coordination in a myofascial unit. How is that upper trap related to the scapula, to the neck? Instead of treating one point, have the ability to look at the sequence, at the chain, because that one point is most of the time temporary. It's rare that in fascial manipulation we ever treat one point. We'll look at proximal, we'll look at distal. And that's the whole thing, as I said before, really getting at the kinetic chain.

So there's so much. So getting back to hyaluronic acid, they're injecting it in bone-to-bone knees now. It's an important chemical that's necessary for function. And one of the tenets, I guess, of fascial manipulation is that we're really freeing up the loose connective tissue, which is allowing the gliding of the tissue of the paramycium, for example, in which the spindle cell is located. So the viscosity of the tissue is what we're trying to change. And you feel the change by way of your palpation, by way of the reduction of the density. I'm looking at it right now. Actually, I looked at this yesterday.

There's a PowerPoint that I should just link to because it was public on here. But it has a bunch of slides on hyaluronic acid sliding between tissues and organs. It cites the STECO study analysis of the presence of hyaluronic acid in between deep fascia and muscle. So there's a lot of pictures, is my point. I might just put this on the show notes. Well, if you want, I could send you slides. I mean, we've got literally thousands of slides. That'd be great. Sure. Okay, so then as we're closing the podcast here, then how should everybody reach you? The website's good, or is there any other way that you'd like to be reached?

Oh, me? Yeah. Well, I have an email. Soft tissue, but it's S-O-F-T-I-S-S-U. So it's only one T and no E at optonline.net, optonline.net. I'll be happy to answer anybody who wants to communicate. Awesome, awesome. All right, cool. That was great. There's a ton of great information. I think everyone's going to learn something from it. Definitely a little bit more of a technical podcast, but you held my attention, so I'd definitely listen to this walking around. Oh, you're probably the hardest person to convince anyway. No way. I don't think so. I'm easy. I'm joking. All right, cool. I'll come right back.

All right, thank you. It was a pleasure. Thank you. Okay, thanks, Dr. Warren Hammer, for being on. That was great. By the way, everyone, if you have not ever spoken to Warren, he prefers to be called the Ham. I did not know that until we started speaking. So you can call him the Ham or the Hammer. So, you know, when you've got a last name like that, why not? Heck. So if you're looking for the transcription and show notes for this and any link that I mentioned on the podcast or we mentioned, go on to p2sportscare.com slash the session number, which is, in this case, 85. You will find it all there.

Share it with friends. And by the way, I had no idea about this until someone actually, they came into my office. I said, you know, I listened to that one podcast you sent me. Or sorry, I read that podcast you sent me. And I said, read it? How'd you? What? You read it? And he's like, yeah, I just don't. I don't like listening to that stuff. And I said, you actually read that? And he's like, yeah, I'm a speed reader. You know, he's like, I can actually get through it faster than I could listen to it. And I'm like, you're kidding. Like, people actually read these transcriptions. So, heck, I'm going to make a very good attempt to transcribe every single podcast that I do now, although I do promise to transcribe the ones where I have an interview with somebody because I think I owe it to them to get the transcription done since they spent the time with me.

So, again, if you're looking for those show notes, go ahead and get them on the website. And if you have not explored the site already, there's a ton of stuff on there, a ton of articles, a ton of videos, a ton of things that you probably, if you're wondering how I treat patients with X, Y, and Z conditions or some of the stuff that I like, it's all on there. Just go on to I'm a patient, look for the injury section. If you scroll all the way down, you'll find the large comprehensive articles like the low back one is probably about 40 pages now on a Word doc. The core one is 30 pages on a Word doc, and they're extremely comprehensive.

I've had them proofread quite a few times. So, if you find a spell in there, please do tell me. Lastly, again, go onto the website and find on the shop page if you're a doc. Get those patient education posters. It's something I strongly recommend. I'm not just selling people things to sell things. I mean, I really do think these will help you. I think they'll help you and your patient communicate better, which is what all this is about. And if you heard me speaking to Warren about it, it's patients want to feel like you understand. They want you to be confident with what you're saying, and they care about your degrees, but not a ton.

So, it's not about price. It's about being understood. So, these are tools for that. They are for the patient. They're patient-centric. They're not throwing Netter's anatomy in front of them because that's extremely hard to understand. There's too many things going on. Let's just make it easy for them, right? Okay. I will see you guys next week, and don't forget to be very good to each other. Take care.