Terra Rosa E-mag Issue 20 by Terra Rosa

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www.terrarosa.com.au Open information for Bodyworkers No. 20, June 2017

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ontents

Fascia as a Sensory Organ: Clinical Applications —Robert Schleip

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Fascial Unwinding —Paulo Tozzi Working with the Sternocleidomastoid— Til Luchau

Principles of Fascia Training — Robert Schleip

All Parts are Equal, or are they??—Marjorie Brook

Can we alter the Thoracolumbar Fascia? — Jeff Tan

To Flex or Extend? — Joe Muscolino

Research: Are we asking the wrong questions in the wrong way? — Jenny Richardson

Systemic inflammation and neuroinflammation in

fibromyalgia patients 54

Research Highlights

Six Questions to Marjorie Brook

A Chat with Eve Pereeda

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FASCIA AS A SENSORY ORGAN: Clinical Applications by Robert Schleip 2 Terra Rosa E-mag No. 20

It is now recognized that fascial network is one of our richest sensory organs, the fascial element of the muscle is innervated by approximately 6 times as many sensory nerves than its red muscular counterpart. Fascia contains four types of sensory nerve endings, which are responsive to mechanical stimulation: Golgi organs, Ruffini receptors, Pacini corpuscles, and Interstitial receptors. These sensory nerve endings can be called fascial mechanoreceptors, meaning that they respond to mechanical tension and/or pressure. These mechanoreceptors have been found in intramuscular, as well as extramuscular, and fascial tissues. Therapists working with fascial tissue now understand that these mechanoreceptors respond to various kinds of touch (Table 1). This article provides examples of how specific techniques can be utilized in order to optimize an intended stimulation of specific mechanoreceptors in fascial tissues.

Stimulation of muscle spindles The ‘petrissage’ from Swedish massage – a form of deep, rhythmical kneading – that can be best applied for this purpose. In order to use the myotatic reflex arc in a muscular relaxation direction, the therapist uses both hands to grab hold of two larger muscular tissue portions and moves them towards each other in a compression manner. Using a more rhythmical style, the therapist attempts to quickly decrease the length of the muscle spindles in the zone between the two hands. A different version of this basic technique is sometimes used in sports massage for the purpose of increasing muscle tone before an athletic performance. In this case the two hands move away from each other in a rhythmic fashion, thereby inducing a stretching effect – rather than compression – in order to ignite the wellknown myotatic reflex in a way that stretches muscle spindles and thereby exerts a stimulatory effect on the active muscular tonus regulation. In contrast, in the style described here, the two hands attempt to create a rapid tonus decrease within the spindle fibres, which is expected to induce a tonusdecreasing effect on alpha motor tonus activity.

Stimulation of Golgi receptors In myofascial mobilization it is typical that slower tissue deformations are created, with a focus on relaxation rather than on tonus augmentation. The Golgi receptors are a good target for such an approach, since stimulation of these neural receptors tends to induce muscular relaxation in those muscle fibres that are mechanically linked with the area of stimulation. However, when applying stretch in tissue areas that are serially arranged with soft and compliant muscle fibres, all stretch can be ‘swallowed’ by the softer myofibres (rather than the more rigid collagen fibres) and the Golgi receptors within the collagenous fibres may not sufficiently lengthened. One way to prevent this seems to be a cross-fibre mobilization across the muscle belly area (rather than the muscular attachments) in order to minimise the spreading effect towards the compliant muscle fibres. A common technique, often taught as part of the Bowen method, involves cross-friction across the muscle bellies, which might induce at least a temporary regional muscular relaxation via stimulation of related Golgi receptors. If one wants to work within the more tendinous areas, another approach is advocated. Here the client is asked to activate the related myofibres against external resistance, while the therapist applies a moderate to strong stimulation (usually 10–50 N/cm2) to the tendinous collagenous tissues that are tensed by the respective muscular contraction. One way of achieving this seems to be by using the post-isometric relaxation technique, as frequently used in the proprioceptive neuromuscular facilitation or (PNF) concept. Here the client is usually instructed to contract a joint musculature against the handheld resistance of the therapist for a period of between 60 and 90 seconds and a ‘tissue release’ is often observed during the subsequent relaxation. Sometimes there is also a brief antagonistic contraction included immediately before the final relaxation. A more advanced and proprioceptively stimulating approach was taught as ‘pandiculations’ by Thomas Hanna (1998). Here the therapist also provides an Terra Rosa E-mag No. 20

Table 1. Overview of the different sensory receptors in myofascial tissue, the responses triggered by their stimulation, and the manual techniques that can evoke those responses. From Schleip (2017), Reproduced with permission.

external resistance to the actively moving body part of the client, however, client and therapist cooperate in such a way that the client is instructed to move against the resisting hand of the therapist in a super-slow continuous fashion. Subsequently the respective limb is pulled back towards the body, again against a moderated resistance of the therapist; and this movement is also performed in a smooth and super-slow fashion. Client and therapist direct most of their mindful attention toward achieving a non-erratic movement quality (i.e., without any perceived ‘stop and go’ interruptions). As soon as such an erratic moment is detected, the client is instructed to return to the position immedi4 Terra Rosa E-mag No. 20

ately before it happened, and then try to repeat the movement at an even slower speed and, hopefully, with less bumpy movement orchestration. This active resistance phase – with the client participating in both concentric as well as eccentric activation – is usually practiced for between 60 and 90 seconds and – as in the PNF technique – is followed by a brief moment of isometric contraction of the antagonistic muscles. In addition, the therapist provides a strong myofascial stimulation (but not beyond the comfort zone of the pressure–pain tolerance of the client) to the fascial tissue area within the tendinous portions of the related musculature.

For example, when sitting, a client may be instructed to slowly raise her right shoulder against the external resistance of the therapist. Then she is asked to gradually lower her muscular activation in order to allow the downward pushing force of the therapist to gradually lower the shoulder to the starting position. Each of these two movements should occur in a smooth, uninterrupted, continuous manner, lasting at least five seconds each. Whenever a tiny ‘jerk’ is detected by either the client or therapist, the movement is repeated with increased mindfulness from the position shortly before it occurred. During all of this the therapist works with a deep stretching myofascial release approach on the aponeurotic insertions of the upper trapezius on the superior nuchal line of the cranium. After approximately 60 to 90 seconds the myofascial hands-on work is finished and the client is asked to perform a downward active shoulder movement for one or two seconds only, with her elbow pressing isometrically against the resisting hand of the therapist. Finally, the client is asked to relax and to subjectively compare the perceived height and sensation of the treated shoulder with the other shoulder.

Stimulation of Pacini corpuscles The following example is for the stimulation of spinal joint receptors in the cervico-thoracic region. The client is asked to lie comfortably on her right side with the therapist sitting behind the client’s back. The therapist starts with a prominent spinal process, for example, from C6, C7, or T1, and lifts this process a few millimetres away from the table toward the ceiling. It is then wiggled two to four times in a random manner before it is lowered again to the starting position. This is repeated in slightly different lifting directions, varying between slightly more cranial and more caudal lateral directions. The lifting amplitude is calibrated so that the maximal delay occurs between the movement of the manipulated vertebrae and its two adjacent neighbours. The intention of the therapist is to show the central nervous system of the client that the spine in this region is not a rigid column but rather a series of mobile elements that are arranged like a string of

pearls. If successful, this may support a related reformation of the respective cortical mapping of what is called ‘body schema’ representation in the brain. One or two minutes are spent in this way on each vertebra before the neighbouring vertebra is approached in a similar manner. The natural breathing movements of the client are carefully observed. Sometimes during a slow lifting movement of a thoracic spinous process a normal inhalation movement is slightly increased in time and amplitude (maybe 10% more than usual). If this happens, the therapist may play with the concept of ‘taking a ride’ on this extended inhalation and lifting the vertebra a tiny bit more (and for a second longer) at the apex of the inhalation movement. If successful this may result in a release-like response around the costo-vertebral joints of the respective vertebrae on the side on which the lifting movement causes a temporary decompression. Note that it may take 10 minutes to apply this technique to the spinous processes of, for example, C6 to T5. In most cases the technique does not need to be repeated for the opposite side-lying position – at least not in those cases for which the main intention is to produce a more refined representation of this spinal area in the client’s body schema in terms of a mobile rather than rigid body portion.

Stimulation of Ruffini corpuscles Here a slow but firm touch is provided that exerts a lateral tangential shearing motion to the skin, as well as to fascial membranes below the subcutaneous loose connective tissue. Once the pressure achieves a slow gliding of the therapist’s hand in relation to the skin of the client, the speed of this gliding motion is calibrated toward the slowest possible continuous speed. For a beginner this may be a speed around 5 cm per second, while for a more experienced therapist much slower gliding motions of around 1 cm per second or less are possible. If possible the client can be instructed to assist this technique by conducting a slow active movement participation that provides an expansional stretch to the working area (Fig. 1). Terra Rosa E-mag No. 20

Figure 2. Myofascial tissue illustrated as a school of fish. A therapist working with myofascial tissue may feel several of the motor units responding to the touch. If the therapist then responds supportively to their new behaviour, the working hand will feel other fish joining this release, and so on. Photo (c) Schleip.

Figure 1. Example of the use of AMPs (active movement participation) with the client during a Ruffini-oriented release technique. While deeply melting with one hand into the tissue and specific joints of the upper thorax, the therapist guides the client to support his myofascial work with subtle and random slow-motion participations. Here the client performs a lateral bending movement of the thorax combined with a cranially directed extension (following the elbow) in order to increase an opening of the thoracic vertebral joints. Photo (c) Schleip.

During the gliding motion, the therapist feels for the optimal vectorial direction of his/her hands – whether slightly more vertical/horizontal, more distal/proximal, or more medial/lateral, etc. – at which the local tissue relaxation response spreads out most readily toward a larger, more spacious tissue response. The analogy of a school of fish can be employed to foster the related empathic palpatory sensitivity of the therapist (Fig. 2).

Stimulation of free nerve endings The recent discovery of the tactile C-afferents in the dermis of the hairy skin of humans (and other mammals) has led to an increase in research on ‘affective touch’. Based on this, therapeutic methods – usually involving gentle and slow stroking – are explored, and these provide the cortical insula with a sensation of nurturing touch, also called ‘social touch’, 6 Terra Rosa E-mag No. 20

which can induce a general sense of well-being and relaxation in the client. The depth of responses can involve profound shifts in immunological, psychosocial, and neurophysiological parameters (McGlone et al., 2014). For related instruction on this intriguing aspect of therapeutic touch the reader is referred to the new literature on this subject, for example, Lloyd et al. (2015) and McGlone et al. (2014). Another method for stimulation of C-fibres or Adelta fibres (both terminating in free nerve endings) targets the high density of their related nerve endings in the periosteum (i.e., the fascial envelope around bones). This approach is inspired by the ancient Chua K’a method, as taught by Oscar Ichazo (Hertling & Kessler, 2006). Here strong pressure is applied to bony surfaces until a slight sympathetic activation is observed in the client. This response may involve a slight dilation of the pupil, an increased and elongated inhalation, an increased circulation in the face, and/or a turning of head and eyes toward the respective body part. It should be an expression of the so-called ‘orienting response’ in behavioural biology, during which an animal responds to a new challenging stimulus by straightening its neck upwards toward the perceived place of stimulation in a general state of alertness. Care should be taken that an avoidance-and-withdrawal response is avoided, which expresses itself in very

different behaviour involving a flexion movement of the trunk and limbs, a turning away from the perceived stimulus location, a shortening of the neck, and either a halt in breathing or an augmented breathing speed. The client may be instructed to participate with an active movement that intensifies the perceived pressure with an assertive gesture, such as arm abduction and pushing the elbow into the working stimulus of the therapist. The use of tools – such as in instrument-assisted manual therapies – could help with more precision. Once a slight sympathetic orienting response is achieved, a moment of rest – without any touch – is added, during which the therapist waits for at least three to five of the client’s breathing cycles until a parasympathetic shift (or general relaxation) is observed. Subsequently a spot on the periosteum in very close proximity to the first spot is treated in a similar manner. If there is a hyperalgesic zone, the treatment starts first in the nearest area with a normal pressure sensitivity. Once a relaxation response is achieved there, gradually periosteum zones nearer to the hyperalgesic spot are treated. The goal is a gradual desensitization process leading to increased resilience to pain. Most likely this process will involve an activation of cortical descending modulatory pathways (Bingel & Tracey, 2008).

Summary 

Stimulation of spindle receptors can be facilitated by quick compressional impulses to the muscle bellies.

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Golgi receptors can be stimulated by techniques that require temporary resistance by the client.

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Ruffini techniques attempt to apply slow shear sensations while finding the respective optimal vectorial direction.

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Pacini corpuscles require constantly changing novel sensations.

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Free nerve endings can be stimulated by work on the periosteum.

Picture CC0. Public Domain

This article is an extract Chapter from the book “Fascia in the Osteopathic Field” (Liem, Tozzi, Chila Eds), Handspring Publishing, 2017. Reprinted with permission from Handspring Publishing.

References Bingel, U., Tracey, I. 2008. Imaging CNS modulation of pain in humans. Physiology. 23:371-380. Hanna, T., 1998. Somatics: Reawakening the Mind’s Control of Movement, Flexibility, and Health. Da Capo Press, Cambridge MA, USA. Hertling, D, Kessler, R. M 2006. Management of Common Musculoskeletal Disorders. Lippincott Williams & Wilkins, Philadelphia, p. 170. Lloyd, D. M., McGlone, F. P., Yosipovitch, G.2015. Somatosensory pleasure circuit: from skin to brain and back. Experimental Dermatology.24(5):321– 324. McGlone, F., Wessberg, J., Olausson, H. 2014. Discriminative and affective touch: sensing and feeling. Neuron. 82(4):737–755.

Terra Rosa E-mag No. 20

FASCIAL UNWINDING by Paolo Tozzi

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Fascial unwinding (FU) is a relatively common osteopathic technique, specifically addressing fascial dysfunctions, with the aim of releasing tension, reducing symptoms, and restoring function. Despite the fact that some kinds of precursors of this approach have been around since the early years of osteopathy, the origins of FU are still uncertain, with its protocol of application being only recently defined. It has been indicated for a variety of conditions mainly affecting myofascial tissue, ranging from inflammatory processes to chronic disorders. In fact, its gentle application as well as its safe and indirect nature has made it suitable for acute presentations, while it can also be successfully applied for long-term symptoms.

Origins The osteopathic origins of unwinding methods are still unclear, although they have been described for decades by several osteopathic therapists (Ward, 2003a). Since the early 1920s, William Neidner, a student of Sutherland, who defined his approach as fascial twist, applied specific direct manipulative techniques to the myofascial tissue in the osteopathic field. Neidner was engaged at that time in researching effective treatment for muscular dystrophy in children. By observing and palpating the entire fascial organization of the body, he noticed that people in good health tend to show a clockwise fascial torsional pattern from head to feet (Centers et al., 2003). He then proposed that myofascial tissue dysfunctions could be globally released by various types of techniques relying on the use of the limbs as long levers for the untwisting manoeuvre (DeStefano, 2011). This approach employed mainly torsional forces to the extremities, aimed at restoring a balanced fascial tension by finding and maintaining a myofascial barrier until it yields. This would also promote symmetry of the transitional areas of the spine as well as reinstate compensatory postural patterns. Mitchell in his first published work (1958), suggested applying such direct methods of treatment to the myofascial tissue before addressing any articular dysfunctions. Lately, this procedure has been indicated at the conclusion of a treatment program, after more local strain patterns have been released (Centers et al., 2003), since it induces a profound relaxation in the patient. The idea of ‘twisted’ fascial patterns existing in healthy conditions as a result of postural adapta-

tionwas then re-evoked and readapted in the 1970s by Gordon Zink. He hypothesized alternating myofascial patterns occurring in healthy individuals at the level of the body diaphragms, showing preferential rotations and inclinations at around the corresponding transitional areas of the spine (Zink & Lawson, 1979). Zink defined it as common patterns that show, from the top down, a preferential left– right–left–right rotation. Ideally, diaphragms should be aligned and move in a rhythmic, coordinated fashion during breathing. However, they commonly rotate and side-bend around their structural pivots to compensate for various physiological forces (e.g. uneven foetal positions during pregnancy, motor cerebral dominance, etc.) or non-physiological stressors (e.g. leg length discrepancy, etc.) (Pope, 2003). According to Zink’s model, the health status of an individual is equal to his/her ability to compensate to any given stressor, in such a way that the total homeostatic potential would remain basically the same. In other words, the greater the individual’s capacity for adaptation, the better his or her state of health will be. This is why central myofascial patterns, alternating in a functional manner, are so important and useful in maintaining the autoregulation of the organism. When this function is overwhelmed or disrupted, the myofascial structures lose their alternating pattern, showing signs of rotation and side-bending consecutively in the same direction. This results in loss of adaptive abilities in the area involved, increasing energy expenditure, altering function, and affecting posture by overloading the correspondent spinal transitional areas (Defeo & Hicks, 1993). These patterns can be manually assessed and treated (Zink & Lawson, 1979), either positionally or by means of patient cooperation through voluntary muscle contraction. A more dynamic concept based on the unwinding of the intrinsic fascial tensions was probably introduced by Viola Frymann: ‘The principle of this profound technique is to place the patient in the position that they were in at the moment of injury, and permit fascia to go through whatever motions are necessary to eliminate all the forces imposed by the impact.’(Frymann, 1998a) Nowadays, FU is formally described as: ‘a manual technique involving constant feedback to the osteopathic therapist who is passively moving a portion of the patient’s body in response to the sensation of Terra Rosa E-mag No. 20

Photo: CC0 Public Domain

movement’ (ECOP, 2011). In this sense, FU has been considered as a form of indirect myofascial release: ‘the dysfunctional tissues are guided along the path of least resistance until free movement is achieved’.

surgery. A somatoemotional component has also been included, suggesting that FU might release trauma-induced energy stored in the myofascial system.

In spite of the different definitions, FU remains a dynamic, indirect technique usually applied to the myofascial–articular complex, aimed at releasing fascial restrictions and restoring tissue mobility and function.

FU is generally indicated for any myofascial condition, including those related to surgery or sports injury, such as tennis elbow, plantar fasciitis, shin splints, muscular and tendinous injury rehabilitation (Weintraub, 2003), or any repetitively strained or overused joint and related myofascial structures.

Indications Thanks to its safe and gentle application, as well as its broad versatility, FU has been used for decades by osteopaths, craniosacral therapists, and myofascial workers. However, its origin and main application remains within the osteopathic field. It has been usually described in relation to the release of physical features associated with fascial restrictions, and it has also been indicated for unwinding the so-called craniosacral mechanism (Frymann, 1998b). In this sense, the main aims are to correct somatic dysfunction, to release pain, musculoskeletal tension, and fascial restriction (Ward, 2003b), especially following injury (Frymann, 1998b) or 10 Terra Rosa E-mag No. 20

Furthermore, it has been advanced as an integrative approach for a variety of visceral techniques, aimed at releasing tension in and around serous membranes, visceral ligaments, and capsules (Stone, 2007a). In a very subtle and gentle form, it has been proposed for pregnant patients too, in the prepartum or intrapartum period, to promote an optimal foetal position in a more accommodating and tensionally balanced environment (Stone, 2007b). Finally, FU may be also suitable for approaching scar tissues. A scar is considered to be active if at least one of its layers does not move freely and resistance to passive movement in at least one direc-

Unwinding. CC . Source: https://www.flickr.com/photos/bonsaitree/19868304890

tion can be palpated (Lewit & Olsanska, 2004). FU may be used within hours or days from surgery, as it requires no significant range of motion through the scar or incision sites (Stone, 2007c). It aims to restore mobility by releasing tissue adherences and fibrotic material, so as to improve sliding motion between the involved tissue layers and enhance fluid circulation, cell nutrition, and tissue regeneration. FU can be performed on any single articulation or group of articulations, or even the whole body. For the latter, the simultaneous cooperation of two therapists may be required if the patient is an adult, but in the case of infants or children a single therapist is usually sufficient. Most of the time FU is addressed to the neck, arms, or legs, as these are mobile regions where strain and trauma easily manifest. However, not everyone is responsive to FU. Pa-

tients who are unable to relax may not be responsive. Therefore, alternative strategies should be used. In some cases, unwinding may happen spontaneously while the therapist is applying other techniques. For instance, neck unwinding may occur spontaneously during the performance of myofascial release technique (Weintraub 2003) or suboccipital decompression. Finally, some patients may be particularly predisposed to respond to this method, that they can even be instructed on how to gently self-unwind. In fact, following a guided meditation session, patients may learn how to connect with their own myofascial system, feeling for any tension within, and for the ways such tension wants to release. This experience, under the operator’s guidance, may allow a spontaneous and effective body unwinding, bringing tissues back to their natural tensional state, often resulting in emotional – as well as physical – release. Terra Rosa E-mag No. 20

FU has been demonstrated to be a beneficial integrative technique: to reduce pain and improve sliding fascial mobility in patients with non-specific neck pain (Tozzi et al.,2011) to reduce pain and improve visceral mobility in people with low back pain (Tozzi et al., 2012) in the treatment of adult scoliosis (Blum, 2002), spondylolisthesis (Kuchera, 2003), and tension-type headaches (Anderson & Seniscal, 2006). No injuries have been reported in the literature as being attributed to indirect or fascial techniques (Vick et al., 1996) apart from an isolated, documented case (Kerr, 1997) following the Rolfing method. However, it has been speculated that adverse reactions are not fully or adequately reported in the osteopathic scientific literature (Vick et al., 1996). In addition, it must be noted that a myalgic flare may occur within the first 12 hours after treatment, usually lasting not more than 24–48 hours (DiGiovanna, 2005), similar to muscle pain after a vigorous workout. As regards applying most of the indirect techniques to a local site, the absolute contraindications are: recent closed head injury; acute vascular accident; bleeding or aneurysm; and acute visceral infections (WHO, 2010). Relative contraindications are malignancy, open wound, severe osteoporosis, infection, bone fracture, joint dislocation, and gross instability (Nicholas & Nicholas, 2008).

Protocol The unwinding process can be applied to the whole body or to any part of the body, especially the limbs and neck. The neck or extremities can be treated regionally or used as levers to manipulate the trunk. ‘Unwinding methods refer to operator-induced spontaneous bending and twisting maneuvers affecting both upper and lower limbs’ (Ward, 2003a). FU application can be described by the following phases: 1. Evaluation: that implies a thorough assessment of the myofascial system to identify any sign of fascial restriction. In this process it is fundamental to consider the entireness of fascial tissue, extending 12 Terra Rosa E-mag No. 20

mostly in a spiral pattern from the extremities to the axial part of the body. Due to its ubiquitous nature and structure, any disruption of fascial function at any level may potentially produce an effect elsewhere in the organism. Abnormal areas of tension within this system, following a recent or longstanding injury, surgery, or any sort of repetitive strain, creates adaptive compensatory patterns, following the path of least resistance. This can lead to altered structural alignment, impaired movement patterns, joint restrictions, pain, poor energy levels, and decreased vitality (Hruby, 1992). Therefore, a bodywide postural evaluation should be accurately performed, together with hands-on assessment of the tone and texture of the myofascial tissue, joint range of motion, muscle testing, and subjective complaints of pain and/or loss of function. The ultimate goal for the operator is to identify the dysfunctional body region to be worked on, including the dysfunctional vectors in the fascia. These are preferential patterns of tissue motion, perceived by the therapist as movements toward ‘ease’, usually mirroring directions of past injury or trauma. 2. Induction: at this stage, in particular, a state of relaxation from the patient is required. The operator approaches the involved area with a gentle touch, reinforcing the procedure by visualizing the anatomy of the region being worked. He or she initially induces motion, usually by lifting and holding the area in a relaxed position, so as to reduce the influence of gravity and overcome reactive proprioceptive postural tone. Alternatively, a distraction or compression force on related joints can be added to prompt the process. For example, in leg unwinding, with the patient supine, the operator lifts and supports the leg under the ankle, while a mild compression toward the hip joint can be added to promote the unwinding motion. The scope is to hold tissues in a balanced and relaxed state, remaining sensitive to fascial clues that suggest any direction of spontaneous expression of inherent tensional patterns. 3. Unwinding: the operator supports the patient while focusing on the area of major fascial tension, allowing any spontaneous movement to manifest. This is probably the most difficult phase of the procedure, because of its dynamic nature that requires high sensitivity, kinesthetic appreciation, and fine palpation skills from the therapist. The latter should sense movements arising from the inherent motion

of dysfunctional tissues that should not be directed or forced but just acknowledged and followed. Such patterns of motion are mostly unpredictable: shearing, torsional or rotational components may arise, usually following a spiral path, sometimes very subtle, sometimes extremely vigorous, either rhythmic or random, but always at their own individual pace. The unwinding process should never be allowed to occur as a ‘fulcrumless’ circular motion, since that would be unlikely to produce any therapeutic effect. Instead, a precise fulcrum should be identified, around which tissues may express their dysfunctional pattern. Such a fulcrum should be the point of major fascial restriction being addressed. During the entire procedure, the patient gives constant feedback to the operator, whiles the latter supports and amplifies the range and intensity of movement, guided by inherent fascial tensions, until a spontaneous release is perceived. During this process, it may happen that the therapist feels uncomfortable with keeping the same hold of a given structure in unwinding mode or, even worse, that the manoeuvre becomes unsafe by making the patient unstable on the couch. In both cases, the operator should stop the technique to choose a more effective hold, and by instructing the patient to assume a safer position. 4. Still point: this is only occasionally present. It involves a cessation of the unwinding process, resulting in a still point where no motion occurs and tissues are ‘silent’. The patient’s cooperation may be requested at this stage, such as forced respiration, to promote tissue changes and release. 5. Release: a collapse of myofascial tension may be felt together with warmth and a ‘melting’ sense in the tissues that are being worked on. A release may take seconds to be obtained when working on recent and mild restrictions, whereas longstanding or severe injuries may require more than one session. In some cases, an emotional release may occur, or be induced, during the unwinding method. 6. Reassessment: tissue should be re-examined after release has been achieved, and a sense of balanced tension within and around the myofascial tissue should be verified. Any combined therapeutic exercise and traditional manual modalities may then be found to be more effective in achieving enhanced function.

If total body unwinding needs to be performed on an adult patient, normally the cooperation of two therapists is required. In this case, with the patient lying supine, one therapist lifts and holds both legs at the ankles; while a colleague lifts and holds the head, with the patient’s arms raised up in between the osteopath’s elbows and trunk, and the patient’s hands resting on the osteopath’s flanks (Fig. 1). Both therapists focus on the areas of major fascial restriction in the respective halves of the body. A simultaneous unwinding may then take place, usually requiring a change of hand-hold and constant monitoring of patient position. If the adult patient is constitutionally smaller than the operator, or if the patient is a child, a single therapist can easily perform total body unwinding. Finally, if scar tissue needs to be worked, the procedure remains basically the same, although FU is applied in a combined manner in this case (i.e., by simultaneously performing a direct and an indirect manoeuvre). One operator’s hand takes a contact on the dysfunctional scar, with a focus on the points of major restriction, fibrosis, and tension. He or she then chooses the most appropriate lever to unwind the scar tissue – that is usually a limb or the head and neck, depending where the scar is located. Whatever structure has been selected as leverage, it is held and maintained in a relaxed position with the other hand (Figure 2). The combined fascial unwinding can now be performed: with one hand the therapist applies a direct fascial technique on the scar, by engaging and holding the tissue barrier; then the locally gathered tension is unwound in indirect fashion by means of the lever being supported by the other hand. Once the barrier yields, the operator looks for any further tissue restriction. Once this is found, the lever will be used again to unwind the given tension. The procedure goes on until a complete release of the scar is achieved. A still point may occur, requiring some form of patient cooperation to allow change to occur.

A Clinical case A 30 year-old secretary presented with a constant dull ache in the coccygeal region, with occasionally acute episodes when sitting for more than 2–3 hours. No other symptoms were associated with this pain. The onset was a year before, two months after she gave birth to her first child, following a caesarean section. Since then, she also suffered with Terra Rosa E-mag No. 20

Figure 1. FU technique with two therapists. The picture shows a common hold for applying a total body FU on an adult client with the cooperation of two osteopaths. The patient lies supine on the couch. One operator stands at the feet, lifting and holding the legs at the ankles. The second therapist stands on the opposite side, lifting and holding the head. Alternatively, he may leave the head of the therapist on the couch and use the arms as levers instead. In this case, the arms of the patient should be raised up and supported from the elbows, with the hands resting on the osteopath’s flanks. If a strong leverage is needed, both head and arms may be employed as levers, as shown in the picture. Photo (c) Tozzi.

recurrent haemorrhoids and cystitis. The examination revealed: a pelvic positional unbalance (tilted right and rotated left); a remarkable dysfunction of the pelvic diaphragm (R>L); a dysfunction of the right broad ligament of the uterus, causing a torsion of the organ toward the right side; an active suprapubic scar (R>L); a somatic dysfunction of L1– L2; a reduction in most planes of the sacrum and coccyx mobility and motility; an SBS right torsion; and a left TMJ dysfunction. The pelvic region was primarily addressed during the first treatment. The scar was released with FU combined application using the hold shown in Fig. 2. Once the scar tension yielded, the same technique was continued to release the right broad ligament of the FU applied to scar tissue. When applied to actively dysfunctional scar tissues, FU can be performed in a combined manner. One hand takes a contact on the scar tissue, right where the points of major restriction are perceived. In this case, the contact will be suprapubic, on the scar that resulted from the caesarean section. The other hand supports the better leverage that can be used to unwind the scar. In this case, it will be the lower limb closer to the side where major scar restriction has been found. While the cranial hand performs a direct fascial technique on the scar tissue, moving against the barrier, the caudal hand will be using the limb as leverage to unwind any 14 Terra Rosa E-mag No. 20

tension that has been locally gathered. The manoeuvre is continued until a full release of the tension is achieved uterus. Then the pelvic diaphragm was approached by the use of inhibitory pressure and direct myofascial release. Articulatory techniques were applied to the lower limbs, pelvis, and lumbar spine. The patient was instructed to perform every day specific exercises for reinforcing lower abdominal muscles and pelvic muscle tone. The second visit was planned after one week. The symptoms improved consistently, appearing only in a mild form after 5-6 hours of sitting. No signs of dysfunction were found in the areas worked during the first treatment. The lumbar dysfunction and the craniosacral alterations, although still present, were showing a mild improvement of palpatory features. The former was corrected by the application of a direct manipulation through a sitting lift technique, while the latter was normalized though a TMJ decompression manoeuvre, followed by an SBS decompression technique and an occipitosacral balancing. The patient was then asked to return for a third check in two weeks’ time, while water gym and general stretching were recommended twice a week for at least three months.

Centers, S., Morelli, M. A., Vallad-Hiz, C., et al. 2003 General pediatrics. In: Ward, R. C. (Ed.), Foundations for Osteopathic Medicine. 2nd Edn. Lippincott Williams & Wilkins, Philadelphia, PA. p. 324. Defeo, G., Hicks, L. 1993 A description of the common compensatory pattern in relationship to the osteopathic postural examination. Dynamic Chiropractic. 11:24. DeStefano, L. A. 2011 Greenman’s principles of manual medicine. 4th Edn., Williams and Wilkins, Baltimore, MD. p. 155. DiGiovanna, E. L. 2005 The manipulative prescription. In: DiGiovanna, E. L., Schiowitz, S., Dowling, D. J.(Eds), An Osteopathic Approach to Diagnosis and Treatment. 3rd Edn., Lippincott Williams & Wilkins, Philadelphia, PA. Ch. 118. Educational Council on Osteopathic Principles (ECOP)2011 Glossary of osteopathic terminology usage guide. American Association of Colleges of Osteopathic Medicine (AACOM), Chevy Chase, MD. p. 29. Fernández-Perez, A. M., Peralta-Ramírez, M. I., Pilat, A., et al. 2008 Effects of myofascial induction techniques on physiologic and psychologic parameters: a randomized controlled trial. J Altern Complement Med 14:807– 811. Frymann, V. M. 1998a The collected papers of Viola M. Frymann, DO. Legacy of osteopathy to children. Am Acad Osteopath., Indianapolis, IN. p. 82. Frymann, V. M. 1998b Fascial release techniques. In: The Collected Papers of Viola M. Frymann,DO. Legacy of Osteopathy to Children. American Academy of Osteopathy, Indianapolis, IN. pp. 72-82. Figure 2. FU applied to scar tissue. When applied to actively dysfunctional scar tissues, FU can be performed in a combined manner. One hand takes a contact on the scar tissue, right where the points of major restriction are perceived. In this case, the contact will be suprapubic, on the scar that resulted from the caesarean section. The other hand supports the better leverage that can be used to unwind the scar. In this case, it will be the lower limb closer to the side where major scar restriction has been found. While the cranial hand performs a direct fascial technique on the scar tissue, moving against the barrier, the caudal hand will be using the limb as leverage to unwind any tension that has been locally gathered. The manoeuvre is continued until a full release of the tension is achieved. Photo (c) Tozzi.

Hruby, R. J. 1992 Pathophysiologic models and the selection of osteopathic manipulative techniques. J Osteopath Med 6:25 –30.

This article is an abridged version of the Chapter “FASCIAL UNWINDING TECHNIQUE” from the book “Fascia in the Osteopathic Field” (Liem, Tozzi, Chila Eds), Handspring Publishing, 2017. Reprinted with permission from Handspring Publishing.

Nicholas, A., Nicholas, E. 2008 Atlas of Osteopathic Techniques, 2nd Edn. Lippincott Williams & Wilkins, Philadelphia. p. 116.

References Anderson, R. E., Seniscal, C. 2006 A comparison of selected osteopathic treatment and relaxation for tension-type headaches. Headache. 46:1273 –1280. Blum, C. L. 2002 Chiropractic and pilates therapy for the treatment of adult scoliosis. J Manipulative Physiol Ther 25:E3.

Kerr, H. D. 1997 Ureteral stent displacement associated with deep massage. WMJ 96:57-58. Kuchera, M. L. 2003 Postural considerations in coronal, horizontal and sagittal planes. In: Ward, R. C. (ed.), Foundations for Osteopathic Medicine. 2nd Edn. Lippincott Williams & Wilkins, Philadelphia, P. A. pp. 629–630. Lewit, K., Olsanska, S. 2004 Clinical importance of active scars: abnormal scars as a cause of myofascial pain. J Manip Physiol Ther 27:399–402. Mitchell, F. L., Sr. 1958 Structural pelvic function. In: Barnes, M. W. (Ed.), Yearbook of the Academy of Applied Osteopathy. American Academy of Osteopathy, Indianapolis. p. 79.

Pope, R. E. 2003 The common compensatory pattern: its origin and relationship to the postural model. J Am Acad Osteopath 13:19–40. Stone, C. A. 2007a Visceral and Obstetric Osteopathy. Elsevier Churchill Livingstone, Edinburgh. Stone, C. A. 2007b Visceral and Obstetric Osteopathy. Elsevier Churchill Livingstone, Edinburgh. p. 297. Stone, C. A. 2007c Visceral and Obstetric Osteopathy. Elsevier Churchill Livingstone, Edinburgh. p. 278. Tozzi, P., Bongiorno, D., Vitturini, C. 2011 Fascial release effects Terra Rosa E-mag No. 20

Photo: CC0 Public Domain

on patients with non-specific cervical or lumbar pain. J Bodyw Mov Ther 15:405-416. Tozzi P., Bongiorno, D., Vitturini, C. 2012 Low back pain and kidney mobility: local osteopathic fascial manipulation decreases pain perception and improves renal mobility. J Bodyw Mov Ther 16:381-391. Vick, D. A., McKay, C., Zengerle, C. R. 1996 The safety of manipulative treatment: review of the literature from 1925 to 1993. J Am Osteopath Assoc 96:113-115. Ward, R. C. 2003a Integrated neuromusculoskeletal release and myofascial release. In: Ward, R. C. (Ed.), Foundations for Osteopathic Medicine. 2nd Edn. Lippincott Williams & Wilkins, Philadelphia, PA. p. 960. Ward, R. C. 2003b Integrated neuromusculoskeletal release and myofascial release. In: Ward, R. C. (Ed.), Foundations for Osteopathic Medicine. 2nd Edn. Lippincott Williams & Wilkins, Philadelphia, PA.

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Weintraub, W. 2003 Tendon and ligament healing: a new approach to sports and overuse injury. Paradigm Publications, Herndon, VA. p. 66-67. World Health Organization (WHO) 2010 Safety issues. In: Benchmarks for training in osteopathy. WHO, Geneva, Switzerland. p. 17. Zink, J. G., Lawson, W. B. 1979 An osteopathic structural examination and functional interpretation of the soma. Osteopath Ann 7:12-19.

A comprehensive textbook covering history, nature, function and properties of fascia, all aspects of osteopathic management of disorders that are mediated by fascia. 630+ pages, Contributions from leading authorities , 30+ authors (Huijing, Schleip, Stecco, Myers, Gracovetsky, Guimberteau, Tozzi, van der Wal ,and more...) Available at: www.terrarosa.com.au

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Working with the Sternocleidomastoid With Til Luchau

Image 1: The sternocleidomastoids (SCMs) are frequently injured by being eccentrically overstretched (red) in hyperextension whiplash injuries. Image courtesy Primal Pictures, used by permission.

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Listen to the word as you say it: “sternocleidomastoid.” Even its name is special, the six syllables rhyming with themselves in a threebeat cadence that rolls off the tongue like no other anatomical name. And whether you hear this unique muscle’s name as a rapper’s multisyllabic rhyme, a poet’s lyrical trochee, or simply as a mouthful of Latin jargon, your hands-on work with the sternocleidomastoids (less poetically known as the “SCMs”) can be a crucial part of addressing many client complaints. These include cervical pain and stiffness, the effects of whiplash (Image 1) jaw issues, and several other primary indications as listed in the sidebar, page 22. In addition to that list, hands-on work with the SCMs has also been said to help with a host of other less-obviously related conditions, such as facial, sinus, and nasal pain; vertigo, dizziness, car sickness; tinnitus and hearing loss; upper chest soreness; persistent coughs; swallowing difficulties and throat pain; and more.[1] Not only is the SCM implicated in an extraordinarily large number of client complaints, but it is also involved in many (if not all) head and neck movements. Connecting the cranium to the shoulder girdle and axial skeleton by wrapping diagonally around the neck, the SCMs lift the sternum and

clavicles; turn, bend, and flex the cervical spine; as well as extend, rotate, and tilt the head. And no other neck muscles seem quite so sensitive as the SCMs, probably due to the many nerves associated with them and their enveloping connective tissues, the outer (or investing) layers of the deep cervical fascia (Image 2). This multilayered fibrous membrane also encloses the trapezius, as well as the muscles of mastication (masseter, pterygoids, temporalis), and is perforated by, enfolds, and interfaces with numerous sensory and motor nerves (Image 3). For example, the deep cervical fascia of the SCMs’ inner interface forms part of the carotid sheath, which surrounds the vagus nerve, the main parasympathetic trunk. The SCM’s inner fascia also gives rise to the prevertebral fascia, which extends across the anterior surfaces of the cervical vertebrae.[2] Injury to the prevertebral fascia and its associated sympathetic ganglia is thought to be a physical cause of the dizziness, anxiety, and other sympathetic autonomic disturbances sometimes seen after hyperextension whiplash injuries.[3] And although pain (especially chronic pain) can have many aspects in addition to any tissue-based contributors, the SCM’s fascial layers seem to be involved in many cases of chronic neck pain (CNP). In a recent randomized clinical trial comparing the

Image 2: The SCMs are sandwiched between layers of the deep cervical fascia (green), which wraps the entire neck. Image courtesy Advanced-Trainings.com Terra Rosa E-mag No. 20

Image 3: The SCM is surrounded and perforated by numerous sensory and motor nerves, lymph vessels, and vasculature (the external jugular vein visible on the SCMs surface, making it crucial that your work here be sensitive and gentle. Image from Bourgery, JBM. Traité complet de l'anatomie de l'homme: comprenant la médicine opératoire. 1830-1849.

cervical fascia in people with and without CNP, the fascia of the SCM (and medial scalene) was on average significantly thicker and stiffer in those with pain. Fascia-oriented manual therapy was seen to improve both these measures; tissue thickness, stiffness, and reported pain all decreased as a result of hands-on fascial work.[4]

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SCM Differentiation Technique In the Advanced Myofascial Techniques series as taught by the Advanced-Trainings.com faculty, we use the SCM Differentiation Technique in our “cold” whiplash protocol, which is most appropriate only after any initial autonomic reactivity and muscle spasm have diminished (usually several weeks or more after the initial injury, though sometimes longer). It can be used cautiously and very gently

Images 4 and 5: The SCM Differentiation Technique involves delicate, comfortable, but specific finger placement around the medial border of the SCM, feeling for fascial elasticity and differentiation between the muscle and its underlying structures. Use active client eye movements, followed by slow, active neck rotation, all the while monitoring the clientâ&#x20AC;&#x2122;s ability to leave the SCM largely relaxed. Images courtesy Advanced-Trainings.com Terra Rosa E-mag No. 20

with mild “hot” whiplash, but only when there is an absence of muscular spasm so as to avoid aggravating the already irritated condition. This technique is also useful any time we want to increase the client’s ability to move the neck and head without undue contraction or dominance by the SCM, since the technique’s purpose is to gently differentiate the outer layers of the neck, and simultaneously teach new, easier movement possibilities. Start with your client side lying, without a pillow if that’s comfortable, as this allows you to work the upper SCM in a slightly lengthened (eccentric) state (Images 4 and 5). Because it does not involve sliding on the skin, too much oil or lubricant will make this technique difficult to perform. Follow the video link and the instructions here, and pay special attention to gentleness, patience, and increasing client awareness, rather just on tissue effects alone. Finish by repeating the technique in a seated position to help the client apply their new awareness to an upright posture. Preformed correctly, this technique will leave your clients enjoying lighter, easier and more comfortable movement.

Key Points: SCM Differentiation Technique Indications • Neck pain or stiffness • “Cold” whiplash (3–6 weeks or more since injury; no muscular spasms) • Positional or postural issues, such as head-forward position or torticollis • Headaches: both tension-type, and migraines • Jaw pain, tension, and TMJD • Other indications, as described in the text. Purpose • Increase elasticity and layer differentiation of the deep cervical fascia, especially under (medial to) the SCM • Reduce and re-educate SCM tonus by refining proprioceptive coordination of SCM engagement in movement initiation. Instructions • After other preparatory work, use gentle, specific, and static (not sliding) pressure medial and deep to the SCM. • Cue active client movements, as described below.

Watch Til Luchau’s SCM technique video at https://youtu.be/EfRR_32r_Bg

• Monitor client’s comfort and ability to fully relax, and modulate pressure and pace accordingly.

Til Luchau is a Certified Advanced Rolfer, the author of Advanced Myofascial Techniques (Handspring Publishing, 2016) and a member of the AdvancedTrainings.com faculty, which offers distance learning and in-person seminars throughout North America and abroad. Contact him via info@advancedtrainings.com and Advanced-Trainings.com’s Facebook page.

• While maintaining SCM relaxation, slowly look left and right with just the eyes

Originally published in Massage & Bodywork magazine, USA.

References [1] Shifflett, CM. (2011) Migraine Brains and Bodies. North Atlantic. [2] Lee, K.J. (2012). Essential Otolaryngology (10 ed.). McGraw Hill. 559–60. [3] Gifford, L. ed. (2013). Topical Issues in Pain 3: sympathetic nervous system and pain, pain management, clinical effectiveness. Physiotherapy Pain Association. 34. [4] Stecco A. et al (2014). Ultrasonography in myofascial neck pain: randomized clinical trial for diagnosis and follow-up. Surg Radiol Anat 2014 Apr; 36(3):243-53

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Movements

• Once ability to move the eyes with relatively relaxed SCM is established, add slow, gentle neck rotation, looking for ways to move head without overcontracting the SCM. • Possible cues: “Let the back of your head turn as much as the front.” “Leave your head heavy.” “Use your eyes instead of your muscles to start the movement,” etc. • Repeat with client sitting or standing. Homework • Practice head rotation with relaxed SCM when side -lying, seated, and standing, with special attention to initiation of movement with out over-contraction of SCM. For More Learning • “Neck, Jaw & Head” and “Whiplash” in the Advanced Myofascial Techniques series of workshops and video courses. • Advanced Myofascial Techniques, Volume 2 Chapters 8-10. (Handspring 2016)

Advanced Myofascial Techniques, by Til Luchau , two beautiful, information-packed guides to highly effective manual therapy techniques. Vol. 1 focuses on conditions of the shoulder, pelvis, leg & foot, while Vol. 2 on neck, head, spine and ribs. They provides a variety of tools for addressing some of the most commonly encountered complaints. With clear step-by-step instructions and spectacular illustrations, each volume is a valuable collection of hands-on approaches for restoring function, refining proprioception, and decreasing pain. Invaluable for practitioners, teachers, and students of hands-on manual therapies.

Advanced Myofascial techniques : The Knee Issues This DVD shows the complete way to learn advanced myofascial techniques that dramatically improve your ability to work safely and effectively with knee issues. Terra Rosa E-mag No. 20

Principles of Fascia Training by Robert Schleip 24 Terra Rosa E-mag No. 20

Fitness Training is a trend and fashion, there have been popular such as aerobics, stretching, yoga and Pilates, Tai Chi and so on. The main theme of all training, however, is movement. Ultimately, scientific knowledge should be able to help in improving or refreshing training programs, which has indeed happened in recent years as a result of fascia research. Incorporating knowledge about the functionality of fascia can influence previous training methods and normal exercising.

The Four Principles

You do not have to discard or replace everything that you are used to, however, because much can be easily integrated into existing programs. The new fascia exercises merely widen the spectrum—they do not radically change it. If you are clear about the role of fascia in motion, you can also improve your performance using a program that you already follow.

The image of the circle with a cross was not chosen by chance: the circle is evocative of the continuum—the four functions considered as a whole. The coordinated system in the middle shows the four different training dimensions that are necessary in order to reach the fascial tissue. They differ from each other and have to be considered individually. All of them actually belong together, and all four should be exercised in order to ensure that all types of fascial tissue in the deeper layers and fibres are stimulated as well. Detailed exercises corresponding to each principle are given in the Fascial Fitness book.

Fascia training therefore does not replace any previous training programs; it complements and enriches them by means of a component that has generally been missing. In other words, it simply completes the picture. Fascia training offers an additional pillar to the current emphasis on muscular, cardiovascular, and coordination training—it adds the finishing touch to your personal training program.

Our fascia training needs to be versatile; it is structured according to four principles, which correspond to the four basic functions. For each of these four basic functions there are specifically tailored training impulses—the four dimensions of the fascia workout. If you compare the concepts with each other, each basic function is associated with a particular form of training.

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Here are the four dimensions of Fascial Fitness.

1. Stretch (Basic Function: Shaping) Stretching is a natural strain and stimulates the mechanical qualities of the fascia, which is the shaping substance. Many kinds of movement, but stretching in particular, will activate the long fascial chains. For centuries, stretching exercises have been part of training programs, especially for dancers and acrobats. Regular stretching can actually extend the range of motion and this includes not only the muscles but the joints as well; however, it can do a lot more, as discovered from years of research. Yoga, which has experienced global success, is based on the stretching of fascial tissue. The slow, methodical stretching which is endured for long periods has a physiological impact: the blood pressure and the pulse are changed significantlyâ&#x20AC;&#x201D; they both decrease. Therefore, when fascial tissue is stretched, signals are transmitted to the autonomic nervous system; this activates the parasympathetic nervous system, which is then followed by a relaxation response. The mystical effects of yoga in meditation and in the calming of stressed modern minds are essentially based on this fact. But yoga does even more: it also acts on the fascia. Yoga can help people with back pain, and this has now been scientifically proved. An essential factor in this is the stretching component. An American 26 Terra Rosa E-mag No. 20

study showed that back pain patients who did yoga stretching exercises achieved results that were as good as those for patients who completed a conventional back training program. This in turn has strengthened the reputation of yoga, which is now accepted by health insurance companies. Stretching, however, has been caught in the crossfire of the theories of modern exercise science since the 1980s. While it had been recommended for decades as a form of injury protection when performed before sports, many sports scientists later questioned its protective effects and even cautioned against the use of static stretching before athletic performance. However, now the same scientists are partly paddling backwards since more and more studies do reveal some long-term tissue remodeling effects. Today there are different types of stretching, including dynamic, ballistic stretching (for example, reaching to the floor with your fingertips and stretching in short bursts), and slow, long-duration, static stretching (carefully taking a stretch position and remaining there for a long time without rocking). From a fascial perspective, we use both forms of stretching: small elastic bounces in a stretched position, as well as slow static stretching. They each serve a different purpose and support various physiological connective tissue types. We do not consider the exclusive stretching of isolated, indi-

vidual muscles as very effective. In contrast, the exercises in our program take the form of a playful, creative full-body workout and specific stretching for longer myofascial chains. These are simple exercises, including small modifications of known stretching exercises, with which one can optimally stimulate the whole muscle-fascia system.

2. Spring (Basic Function: Movement) Springing exercises, such as jumping or swinging the upper body, stimulate the elastic storage capacity within the fascia, which is important for basic movement functions. This generally applies to all muscular fascia tissues, but especially to the tendinous portions. The principle of storage and release of tensile energy is applied in all exercises of this kind, as they involve elastic recoil motions. One variant is the preparatory countermovement in which the tendons and fascia are extended and loaded with tensile power, similarly to when a javelin thrower extends back. This tension increase is an important factor in everyday move-

ments: bending and getting back up, and lifting light or heavier objects, are based on the regulation of preparatory tension in the fascia. Full-body spring exercises stimulate the long fascial chains; if you exercise in all directions, these long chains will be included.

3. Revive (Basic Function: Supply) The reviving of the fascia in our program takes place through a kind of self-massage. Foam rollers are commercially available for this, but alternatively other tools such as tennis or rubber balls can be used. In all of these exercises, mechanical pressure and shear motion are applied to the connective tissue; this simply leads to a liquid exchange in the fascia. The tissue is literally squeezed like a sponge, transporting metabolites and lymph away, and then partly refills with new and fresh water from the blood plasma in the small capillaries. This exchange stimulates the metabolism and improves fluid supply to the fascia, but also to associated organs,

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thereby invigorating and regenerating the fascia. The fluid renewal effect can be achieved using various manual physiotherapy techniques. Fascia loves pressure, specifically an optimum therapeutic dose of variable pressure, as if wringing or squeezing a sponge. It reacts particularly well to the application of this persistent, slow, gentle pressure application. We use such techniques in Rolfing; treatments such as myofascial release and many osteopathic techniques also use the same effect. As we found out in Chapter 1, pressure also triggers a cascade of signals toward the autonomic nervous system and in the direction of our muscles. The right amount of pressure reduces fascial and muscle tightness, so that tension and adhesions can be resolved. The massaging and invigorating exercises in our fascia training rejuvenate the tissue; the result is not only a refreshed body but also one that is significantly more mobile. There is now a rapidly growing market for such fascial treatments using pressure, such as self-myofascial massage roller, 28 Terra Rosa E-mag No. 20

blackroll training, MELT method, FasciaReleazer, and many more. The exercises with a foam roller shown in this book can be used in a daily training regime, and also as a quick self-treatment, because they can release tension and alleviate pain and soreness.

4. Feel (Basic Function: Communication) The perception of body motion is extremely important for all movements and for the brain (See Chapter 1 in the Fascial Fitness book). In movement science, but also in psychology, this body perception and its effect on the body image in the brain are now considered to be fundamentally important. The perceptual quality of movement has great importance, especially from the viewpoint of increasing physical inactivity in modern life. It clearly also

plays a major role in many neurological and also psychological diseases. There is a lot of research literature under the general topic of embodied cognitive science. In fascia training we stimulate body perceptions via sensory impulses and exercises that raise your body awareness. Small movements—subtle changes in the location or in the direction on which you are focused—help you to appreciate perceptual nuances and to explore them with a spirit of curious discovery. This sensitivity occurs in a variety of exercises, which are fun oriented, so that you enjoy the exercises with your body. All this will—via the fascia— heighten the fine-tuning of your movement

perception and coordination, and improve your total agility and fitness. Important note: Avoid becoming distracted during practice. Keep your mindful attention oriented to your body; only then will there be a benefit that registers in your brain. In this way, lasting changes will be achieved by your training.

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WHICH TYPE OF CONNECTIVE TISSUE DO YOU HAVE? There is a whole range types of connective tissue which all occur naturally. The two ends along a continuous spectrum constitute two poles: (1) people with firm, strong tissue; and (2) those with naturally very loose, soft connective tissue. Some connective tissue types are prone to develop typical weaknesses or hurdles during training, and not all exercises are appropriate for all types. The two opposite poles may be described as: The Viking: firm connective tissue—strong and compact type with a high degree of stability and lack of flexibility. The Flexible dancer: loose, soft tissue—more delicate, more flexible type, such as is frequently found in contortionists, in Indian temple dancers or circus artists. Both variants are normal, with equal frequency of occurrence. Men are more frequently found on the Vikings side, whereas women are more prone for the types with soft connective tissue. This tendency is due to physiological differences between the sexes: 

Men have more muscle mass; they have stronger muscles as well as stiffer muscular connective tissues.



The collagen fibres in the subcutaneous fat of men are more tightly arranged than that of women.



Women tend to have looser connective tissue, since (among other things) joint stiffness needs to change for pregnancy and childbirth.



Women store different types of fat, and more of it, in the subcutaneous layers than men; this is a natural mechanism that acts as a reserve for pregnancy and lactating.

However, there are also Viking women, who have firmer connective tissues; likewise, there are also many men who are very mobile or dancer-like. We know that, in most cases, the state of a person being much more flexible than average develops from early childhood. The girls and boys who are flexible by nature can easily do the splits, whereas the less flexible have to practice and might never succeed. Ballerinas and gymnasts mostly belong to the 30 Terra Rosa E-mag No. 20

flexible type, although they also need a lot of muscle power as well. Among men, the Viking types are often those whose external shape is more stability oriented (like Obelix) and who are good at carrying heavy weights. Hyperflexible men on the other side are more likely to be dancers, gymnasts, and acrobats. However, there is a natural continuum here—some individuals are relatively close to one extreme, while other body types are more oriented in the middle. Both connective tissue types are susceptible to specific symptoms. The flexible dancer types with soft connective tissue usually are prone to develop cellulite, herniated discs, and stretch marks after pregnancy. Strong connective tissue types, who we refer to as Vikings, often suffer Achilles tendon ruptures, and tend to have more severe scarring after wounds. In the hands, problems with connective tissue can lead to deformation of the fingers. This disease, although usually benign, can be quite unpleasant; it is classified as a form of fibromatosis, a contracture of the connective tissue. The underlying cause is clearly a badly managed collagen synthesis in the fascia, and the myofibroblasts (the cells in the connective tissue that can close and wound and contract) are more active. Men are two to eight times as likely to be affected by this fascial contracture as women. Viking types have more shoulder problems, such as stiffness or frozen shoulder. Parallel to the hand syndrome mentioned above, connective nodes and stiffness are common in the feet, medically termed as plantar fibromatosis (fasciitis)—this also occurs in Viking types more often than in average or in flexible dancer types. As you can see, the advantages and disadvantages of both types are quite evenly distributed. For individuals at either pole of the tissue spectrum, namely Vikings and dancer types, different styles of training are recommended. We therefore have specific notes for both types in the exercise chapter. You can now do the self-test to see where you stand: Test A is valid for everyone. After taking the test you will know which category you are in. However, if

you only manage to achieve a few points, you should then do the additional Viking test. As this Viking test shows, many people are mixed types, with an average connective tissue quality, and are only locally

stiff. They are reasonably mobile, usually do not get cellulitis that easily, can train to become very agile, and with regular practice can even do the splits.

The Self-Test: Determine Your Connective Tissue Type Test A: Are You a Flexible Dancer? 



Can you bend your thumb backward until it touches the forearm? Per hand: 1 point.



Can you bend your little finger more than 90 degrees backward, toward the forearm? Per hand: 1 point.

Can you bend with straight knees and place both palms flat on the ground? 1 point.

Can you not only straighten your elbow joint, but extend it even further? Per arm: 1 point.

Evaluation The maximum score is 9 points. Score 6 or more points: you are most likely to be a flexible dancer type, with a genetic tendency for soft, pliable connective tissue.



Can you hyperextend your knee joint? Per leg: 1 point.

In case you have achieved less than 6 points, we recommend you now perform also the following Viking test (Test B). And in case you have achieved only two or less points in this Test A, you are entitled to enter Test B with a ‘bonus’ of 3 Viking points.

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Sit on the floor in a straddle position. If you can get your legs apart no more than 50 degrees: 1 Viking point.

Test B: Are You a Viking? If you try to join your hands behind your back (either with the right hand above or below), and the minimum distance of your hands is more than one hand lengths: 1 Viking point.

While sitting, try to touch your forehead to each knee by lifting your leg and leaning forward accordingly. If you can touch neither your right knee nor your left knee with your forehead: 1 Viking point.

Sit on a chair without leaning on the backrest. Turn your entire upper body and head as far as possible to the right and then to the left, while your pelvis and legs remain stable. If you cannot turn to 90 degrees or more in either direction: 1 Viking point. Sit up straight on a chair without leaning on the backrest. Place one hand on the lower abdomen, with your thumb in front of the navel, and the other hand on your sternum. Without moving your lower abdomen and your bottom hand, now try to stretch your breastbone and your top hand upward, away from your bottom hand as far as possible. If you cannot achieve more than one hand width of movement in this stretching motion: 1 Viking point. Stand up, with the knees extended, and bend forward in order to get your fingers as close to touch the ground as possible. If the minimal distance between your fingertips and the floor is one handlength or more: 1 Viking point.

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Depending on your age and sex, you may now deduct the following Viking points. If you are: Male and over 35: deduct 2 points Male and 35 or under: deduct 1 point Female and over 35: deduct 1 point Female and 35 or under: deduct 0 points. Evaluation 5–9 points: you are most likely a Viking type with a genetic disposition for an increased joint stability and less flexible connective tissues. 3–4 points: you have limited mobility and are closer to the Viking type, but a genetic Viking makeup is not clearly identifiable. Your training condition and your lifestyle are probably influencing your flexibility to a similar degree as your genetic makeup. 1–2 points: you have only local stiffness, but your general makeup is not the typical Viking type. You probably lie somewhere in the range of normal (i.e. average) flexibility in our Western society. This article is an extract from the book Fascial Fitness: How To Be Vital, Elastic and Dynamic in Everyday Life and Sport by Robert Schleip and Johanna Bayer, Lotus Publishing 2017. The article is reprinted with permission from Lotus Publishing.

Leading German fascia researcher and Rolfing practitioner Robert Schleip describes how recent research findings can be translated into a practical exercise program for everyday use. Over 80,000 copies sold in Germany. Available at: www.terrarosa.com.au Terra Rosa E-mag No. 20

All Parts are Equal, or are they??

3D Female Skeleton Anatomy by Bernhard Ungerer. CC2.0

By Marjorie Brook, LMT

When a person has back surgery or has had a limb amputated, it is standard for them to go through a rehabilitation process, including physiotherapy or massage therapy to be prescribed. However, if a woman has breast surgery, rehabilitation (massage or physiotherapy) is not automatically prescribed and often not even suggested.

34 Terra Rosa E-mag No. 20

When a woman chooses to have her breasts removed, reconstructed, increased or reduced, it's important that she understands not only the benefits of the procedures, but the risks as well. Chronic pain and postural problems can appear years later if rehabilitation is not completed following breast surgery. Breasts are composed of mammary glands, connective tissue, blood vessels, nerves, and lymph vessels. Breast tissue can extend from the border of the breastbone near the center of the chest all the way to the armpit, and overlies the second to sixth ribs. The breast has an auxiliary tail, which is a tail of tissue that extends up into the armpit region. The breast lies on top of the pectoralis major muscle. Breast tissue is part of the fascial web of connective tissue, which runs continuously throughout the body from head to foot and superficial to deep without interruption. Any alteration, even the slightest damage to the fascial network has major ramifications. The body's balance and symmetry can be significantly altered after a mastectomy, augmentation or reduction. This is something many women aren't informed of or prepared for. Scar tissue is also a very important fact which women need to be aware of and prepared for. Unpredictable development of scar tissue is quite common after any surgery and can have long-term effects on the body.

The TUG procedure uses skin and fat from the inner portion of the upper thigh, the incision scar will be hidden near the crease of the groin. The flap is named for the transverse upper gracilis muscle to which the skin and fat are connected. Muscle may be removed as part of the TUG flap.

Early intervention following breast surgery by a massage therapist can play a pivotal role in helping women heal and regain full function. After mastectomy surgery a woman may experience tightness or pulling originating from her incision, which spreads across her body. This is caused by scar tissue, which is the body's way of healing from surgery. The result can be very dense tissue under the incision, which is painful and can restrict the arm's range of motion (ROM). The restricted ROM puts women at risk for a painful condition known as frozen shoulder. Scars can range in size after a breast-conserving lumpectomy or a mastectomy procedure that removes the entire breast. Either way, most breast cancer patients are left with some sort of surgical scar as a by- product of their quest to heal.

Radiation treatment for Breast Cancer has its own list of complications. This type of therapy not only changes tissue characteristics by making it more susceptible to breakdown, it continues to make tissues tighter for 2 to 5 years following treatment. It can also lead to: 

skin tightening



limited arm and shoulder mobility



chest expansion limitations

In order to rebuild the breast, tissue is taken from another area of the body. It can be taken from several different locations. One host area is the Latissimus Dorsi. In the following picture you can see how much of the body is affected by this location. Terra Rosa E-mag No. 20



restrictions in and around the area of treatment

Breast reduction surgery is still largely considered to be a cosmetic surgical procedure. However, it is most often performed to relieve significant physical and emotional problems resulting from overly large and/or heavy breasts. Public opinion still sees it as cosmetic but 9.5 times out of ten it is being performed to reduce pain or to alter the overall structure. According to the American Society of Aesthetic Plastic Surgery, 112,964 breast reductions were performed in 2011. Breast reduction surgery leaves permanent scarring. The operation using the anchor technique leaves three scars: 

one around the nipple (areola)



one from the nipple to the crease below the breast (this is the worst scar as it takes the most tension)



one from the breast bone to the armpit along the crease below the breast

surgery. Women who have breast augmentation frequently experience: 

limited upper extremity mobility (range of motion)



arm weakness and swelling



fatigue



shoulder dysfunction



back pain



chest pain

Scar tissue can occur at any time after the augmentation has been performed, not just within the first few months. Capsular contracture is the term used to describe scar tissue that can form around breast implants which may cause the breasts to harden, look or feel different, and may cause some discomfort from the tightening of the capsule. Capsular contracture is an unpredictable complication, but it is also the most common complication following breast augmentation. Scars left by breast augmentation surgery are usually hidden in the crease beneath the breast (inframammary fold incision), around the nipple (peri-areolar incision) or in the armpit (transaxillary incision). Rehabilitation/therapy and physical activity are integral to recovery and to reduce post-breast surgery side effects such as:

The severity of scarring largely depends on the individual. Most women are completely unaware of how the scar tissue is affecting them. Kelly Bowers, a massage therapist from Washington, DC, wrote: "I had breast reduction surgery in 1992. By 2012 I rarely thought of it and certainly didn't think the scars were an issue any more. They were barely visible! Then I had scar release work. I was stunned at how far I felt the effects of the work. I felt it from my shoulder to my hip! I'm delighted I had a chance to experience this work and finally take care of these scars as they deserved to be taken care of." The American Society for Aesthetic Plastic Surgery also reported that breast augmentation is the most popular surgical cosmetic procedure for women, with more than 316,000 procedures performed in 2011. Yes, augmentation is an elective cosmetic surgery, but it is still a surgery that alters the body. Rehabilitative therapy is necessary after any 36 Terra Rosa E-mag No. 20



scar tissue/soft tissue immobility



flexibility limitations



limited range of motion



decreased strength

Even if a woman does not actually develop pain or limited function directly after the procedure, at some point pain and disability will become present if scar tissue is not addressed in a timely and proper fashion.

Marjorie Brook is a International Instructor/ Therapist. She is the creator of the S.T.R.A.I.T Method, a specialized therapy for fascial scars & adhesions. She teaches throughout the USA, Canada, South Africa, Australia, New Zealand and Europe. Marjorie offers continuing education courses in Scar Tissue Release, Stretching and Strengthening, and Body Mechanics. For more information at www.marjoriebrookseminars.com.

SCAR TISSUE RELEASE Marjorie Brook World-renowned Scar Tissue Therapist, the STRAIT method A Powerful tool To enhance your Therapy Find out how to assess fascial restrictions and Discover how to breakdown scar tissues & adhesions from Superficial to Deep Fascia

 Scar Tissue Release Fundamental: 28-29 April 2018  Integrated Therapeutic Stretching for the lower body: 4-5 May 2018  Scar Tissue Release for the Abdominal & Pelvic Region: 6-7 May 2018 “ Marjorie presented comprehensive evidence-based instruction. This was the first time I have heard someone combine the physical and emotional impact of scar that we as therapists see every day - which can be very long lasting and life changing for many. Marjorie offered a very clear understanding of the scar tissue, adhesions and changes to connected tissues. When it came to practice at the workshop, you knew exactly what you were working on, in your head, and then your hands had the opportunity to start feeling the variance and extent of these changes. We had a range of people with very significant scars who generously allowed everone to practice new hands on skills. The 2 days allowed for feedback regarding the emotional impact of the hands on scar release work. Burns, old ( and traumatic) Caesarian scars, traumatic avulsion scars and skin cancer scars were assessed and treated over the 2 days. A great learning experience and a great opportunity for having your own mature scar treated in a comprehensive way. ” Denis Stewart, Occupational Therapist I place Marjorie high among the best Stretching Practitioners in the world. She is a cutting-edge teacher, students across the nation rate her as exceptional.” — Aaron Mattes, MS, RKT, LMT, Pioneer of Active Isolated Stretching Terra Rosa E-mag No. 20

Visit www.terrarosa.com.au for more information

Can we alter the Thoracolumbar Fascia? By Jeff Tan There seems to be an evidence-based myth flowing around the Social Media which stated that fascia cannot be altered. So, what does research really say? Two recent studies, published in the January 2017 issue of Journal of Bodywork and Movement Therapies, evaluated the effect of self-myofascial release via foam rollers on the thickness and mobility of the thoracolumbar fascia. In the first study by Sanjana, Chaudhry, and Findley from the USA evaluated the MELT method, a self-treatment that used soft balls and foam roller. Using ultrasound imaging, the thickness of thoracolumbar connective tissue was analyzed in 22 volunteers with chronic lower back pain pre- and post-treatment. The results showed that, immediately after 30mins of MELT self-treatment, participants exhibited a significant decrease in connective tissue thickness and pain. The perimuscular zone connective tissue thickness decreases 27% after treatment. A similar result was also found after 4 weeks of MELT treatment. Significant increase in flexibility (as measured by forward bending test) was also observed. In another study by Griefahn et al. from University of Applied Science Osnabrück, Germany, 38 healthy athletic active men and women participated where they were randomly assigned to a Foam Roller Group, a Placebo Group, and a Control Group. After the intervention, the Foam Roller Group showed an average increase of 1.79 mm in the mobility of the thoracolumbar fascia as measured by sonography. The Placebo Group had a slight average improvement of 0.17 mm, while the Control Group showed a non-significant improvement. Nevertheless, no significant changes were observed with regard to the lumbar flexion and mechano-sensivity of the treated muscles. Both studies demonstrated that the connective tissue is a viscoelastic material, i.e. it is composed of solid-fluid components, and it will change with applied stress via manual therapy. So how about the research (widely mis-cited) that shows fascia cannot be deformed? The article was authored by Chaudhry, Findley, (the same authors as above), Schleip and colleagues in 2008. The study titled “Threedimensional mathematical model for deformation of human fasciae in manual therapy” calculated the relationship between mechanical forces exerted by manual ther-

38 Terra Rosa E-mag No. 20

apy and deformation of human fascia. Note plastic deformation in engineering means irreversible change (in shape) of a material due to applied force. The authors calculated force required to produce plastic deformation for fascia lata, plantar fascia, and superficial nasal fascia. The model calculated that very large forces, outside the normal physiologic range, are required to produce even 1% compression and 1% shear in fascia lata and plantar fascia. However, superficial nasal fascia can be deformed relatively easy. The study’s conclusion is that the palpable sensations of tissue release that are often reported by manual therapists cannot be due to deformations produced in the firm tissues of plantar fascia and fascia lata. However, palpable tissue release could result from deformation in softer tissues, such as superficial nasal fascia. References Chaudhry, H., Schleip, R., Ji, Z., Bukiet, B., Maney, M. and Findley, T., 2008. Three-dimensional mathematical model for deformation of human fasciae in manual therapy. The Journal of the American Osteopathic Association, 108(8), pp.379-390. Sanjana F, Chaudhry H, Findley T. Effect of MELT method on thoracolumbar connective tissue: The full study. Journal of Bodywork and Movement Therapies. 2017 Jan 31;21(1):179-85. Griefahn A, Oehlmann J, Zalpour C, von Piekartz H. Do exercises with the Foam Roller have a short-term impact on the thoracolumbar fascia?–A randomized controlled trial. Journal of Bodywork and Movement Therapies. 2017 Jan 31;21(1):186-93.

Not just Foam Rollers BLACKROLL® delivers unsurpassed German Engineering giving you premium tools for myofascial release

“"I have to confess that I firstly underestimated the efficacy of myofascial self treatments with BLACKROLL® products. Today I suppose that a rather big part of the documented successes can be accredited to the concept of self-efficacy. The patient is not passively lying down waiting for his or her treatment but is put into an active role. In many cases this is very important in terms of a sustainable success." Dr. ROBERT SCHLEIP

Available at www.terrarosa.com.au

Terra Rosa E-mag No. 20

To Flex or Extend? By Joe Muscolino When a client presents with a pathologic lumbar disc, there is a divide in the world of manual and movement therapy: Do we treat the client with flexion or do we avoid flexion and instead treat the client with extension? There are proponents for each method, and unfortunately these proponents often divide along rigid ideological lines, each one believing that their approach is the superior one. As is often the case, whenever two differing treatment approaches exist, usually both are valid. So how do we decide which method to use with the next client who presents with a pathologic disc?

40 Terra Rosa E-mag No. 20

As with all clinical orthopedic work, the answer lies in choosing the correct treatment approach based on the specific pathomechanics of the client’s condition and the needs of the client at that moment. Not all pathologic disc conditions are the same, and therefore not all clients with a pathologic disc condition will respond the same. Making the best decision requires a clear understanding of biomechanics, which ultimately rests on a fundamental understanding of musculoskeletal anatomy and physiology, in other words, kinesiology. Note: Because a pathologic disc is potentially a very serious condition, with possible permanent effects, it is important to refer any client who presents with this condition to a physician. Referral does not mean that the client cannot also be treated at the same time by a massage therapist. A client with a pathologic disc condition can be under the supervision of a physician and also benefit from massage and other manual therapies.

Figure 1 The lumbar spine has a normal lordotic curve of approximately 40-50 degrees. Figures © Joseph E. Muscolino.

The Lumbar Spine The lumbar spine is composed of five vertebrae that sit on the base of the sacrum. Because in anatomic position the pelvis/sacrum is anteriorly tilted approximately 30 degrees, there is a natural lordotic curve to the lumbar spine. The healthy lordotic curve varies from individual to individual, but on average is approximately 40-50 degrees (Figure 1).

Figure 2 Disc and facet joints of the spine. Intervertebral foramen, IVF. Figures © Joseph E. Muscolino.

Lumbar Spinal Joints At each segmental level of the lumbar spine, there are three joints: an intervertebral disc joint located anteriorly, and paired left and right facet joints located posteriorly. The disc joint is composed of three major parts: cartilaginous vertebral endplates that cap the bodies of the vertebrae, a fibrous annulus fibrosus that is located circumferentially between the vertebral bodies, and a thick gel-like nucleus pulposus in the center bounded by the fibers of the annulus fibrosus. The facet joints are synovial joints, located between the inferior articular processes of the superior vertebra and the superior articular processes of the inferior vertebra. Each facet joint is bounded by a fibrous joint capsule contain-

Figure 3 Pathologic discs compressing spinal nerves. A bulging disc is seen at the L5-S1 disc and a herniated disc is seen at the L4-L5 disc. Osteoarthritic (degenerative joint disease) bone spurs are seen on the body or L3. Figures © Joseph E. Muscolino. Terra Rosa E-mag No. 20

ing synovial fluid; and the joint surfaces are capped with articular cartilage. Also located between each two adjacent vertebrae are two intervertebral foramina (IVFs), through which the spinal nerves from the spinal cord pass. An IVF is formed by a notch in each of the two adjacent vertebrae, that when placed together form the foramen for the entry/exit of the spinal nerve (Figure 2).

Lumbar Joint Function The degree of motion that exists in any region of the spine is primarily determined by the thickness of the discs, whereas the direction of motion best allowed is determined by the orientation of the fact joints. In the lumbar spine, the facet joints are oriented in the sagittal plane. For this reason, sagittal plane motions of flexion and extension occur freely in this region. From anatomic position, the lumbar spine allows approximately 50 degrees of flexion and approximately 15 degrees of extension. This totals 65 degrees of sagittal plane motion; quite impressive given that this motion occurs across only five segmental joint levels. In addition to motion, the spine is a weight-bearing structure; the lumbar spine must bear the weight of the entire body above it. The disc joints bear approximately 80% of the weight; the facet joints bear the remaining 20%. It is important to note that as weight bears through the disc joint, the nucleus pulposus is compressed, pushing it outward away from the center and against the fibers of the annulus. Weight bearing also affects the facet joints by compressing their joint surfaces.

Box 1 Degenerated Disc In addition to bulging and herniated discs, there is third pathologic condition of the intervertebral disc known as degenerative disc disease (DDD). DDD involves breakdown/degeneration of the annular fibers and desiccation of the nucleus pulposus. This results in thinning of the disc, which can be seen on X-ray; the space that the disc occupies between the adjacent vertebral bodies will be decreased in height. DDD is a normal part of aging and is usually asymptomatic. But if it is advanced in degree, it can potentially cause symptoms. Thinning causes approximation of the vertebral bodes, which decreases the size of the IVFs, increasing the likelihood of nerve compression within the IVF (compare the healthy disc in Figure A with the degenerated disc in Figure B). Because DDD involves degeneration of the annulus, it also increases the chance that the annular fibers will weaken and bulge, or perhaps herniate. Interestingly, if the nucleus pulposus is sufficiently desiccated, it exerts less pressure against the annular fibers and the likelihood of a bulging or herniated disc actually goes down. This is why the incidence of nerve compression from pathologic disc conditions decreases in senior citizens. Figures © Joseph E. Muscolino..

Pathologic Disc When the intervertebral disc is healthy, the nucleus is confined within the fibers of the annulus fibrosus. However, the accumulation of physical stresses to the disc can weaken the annular fibers. These stresses can be macrotraumas such as a car accident or a fall; and/or they can be repetitive stress microtraumas that occur due to such things as poor postures or the ongoing compression force of weight bearing. Regardless of the cause, if the annu42 Terra Rosa E-mag No. 20

“As with all clinical orthopedic work, the answer lies in choosing the correct treatment approach based on the specific pathomechanics of the client’s condition.”

lus is weakened, weight-bearing compression upon the nucleus can cause it to bulge the annular fibers outward, creating what is known as a bulging disc. If the annular fibers are sufficiently stressed, they can rupture, allowing the nuclear material to extrude through the annulus; this is called a ruptured disc, prolapsed disc or herniated disc. Lumbar pathologic discs most often occur in the lower lumbar region, at the L4-L5 or L5-S1 joint levels (Figure 3). Pain from a pathologic disc can occur due to the irritation of local structures, such as the annular fibers themselves or the posterior longitudinal ligament. However, the more serious consequences of a pathologic disc are usually due to compression of neural tissues. Because of how stress forces are usually placed on the intervertebral discs, bulging and herniation most often occur posterolaterally. When this occurs, the disc protrudes into the IVF and can compress the nerve root, causing symptoms into the lower extremity on that side (midline posterior bulges/herniations occur less frequently because the annulus fibrosus is reinforced in the midline by the posterior longitudinal ligament). Because the nerve roots of the lower lumbar spine contribute to the sciatic nerve, pathologic lumbar discs usually cause symptoms of sciatica referring down into the lower extremity. Therefore, there are two major factors at play when a client has a bulging/herniated disc. One is the disc lesion itself, in other words, the weakened or ruptured fibers of the annulus fibrosis. The second is

the encroachment within the IVF of the annulus or nucleus pressing on the nerve. Once the pathologic disc is present, a third factor occurs. Because of the irritation caused by the compression upon the nerve root, it usually becomes inflamed. Given that the IVF is a narrow closed space, there is little chance for the swelling to escape, so it remains in the IVF, further compressing the nerve root. It is often the size of the bulge/herniation plus the swelling that is responsible for the nerve compression and resulting symptoms. It is important to point out that the IVF can also be narrowed due to calcium deposition (bone spurs) at the joint margins; this condition is known as osteoarthritis or degenerative joint disease. When the size of the IVF narrows, it is also described as foraminal stenosis.

Flexion versus Extension The question now becomes: What are the mechanical forces of flexion and extension upon the lumbar spine, and how do these forces affect the pathologic disc and nerve compression? It turns out that each movement has positive and negative effects upon the lumbar spine (Box 2).

The Effects of Flexion The worst effect of flexion upon the lumbar spine is that it compresses the anterior disc. This has two consequences. First, it drives the nucleus pulposus posteriorly against the posterior annular fibers. Second, it pulls the posterior annular fibers taut (FIGURE 4A). The combination of the tensile force

Box 2 - Positive (+) and Negative (-) Effects of Flexion and Extension Upon the Lumbar Spine Flexion

Extension

(-) Drives the nucleus posteriorly against posterior annular fibers (-) Places tensile force upon the posterior annular fibers, pulling them taut (+) Increases size of IVFs

(+) Relieves pressure on posterior annular fibers (+) Relieves tensile force upon the posterior annular fibers (-) Decreases size of IVFs

(+) Unloads the facets

(-) Loads the facets

(-) Loads the discs

(+) unloads the discs

(+) Stretches the paraspinal musculature

(+) Strengthens the paraspinal musculature Terra Rosa E-mag No. 20

flexion as part of the treatment program for a client with a pathologic disc. However, flexion also has positive effects upon the lumbar spine. As the lumbar spine flexes, the IVFs increase in size approximately 19%. This can be very helpful if there is compression of the nerve root within the IVF, which usually is a major aspect of a pathologic disc condition.

Another positive effect that flexion has upon the lumbar spine is not directly disc-related, but important none-the-less. Flexion unloads compression force from the facets. This can be important if the client has irritation or inflammation of the facets, common in people who have the typical lowercrossed syndrome marked by excessive anterior pelvic tilt and hyperlordosis of the lumbar spine. However, it is important to note that the presence of compression force upon the facets can indirectly affect the client with pathologic disc. Via Wolffâ&#x20AC;&#x2122;s Law, which states that calcium is laid down on bone in response to physical forces placed upon the bone, compression loading of the facets can lead to osteoarthritic (also known as degenerative joint disease) bone spurs, which can further narrow the size of the IVF, increasing the likelihood that a bulging or herniated disc will cause compression of a nerve root there (See Figure 3).

Of course, if the facets are unloaded, the compressive load that is removed from the facets must be placed somewhere. Given that flexion is an anterior motion, the load is shifted anteriorly onto the discs. In typical anatomic position, the discs normally bear 80% of Figure 4 A, Effects of spinal flexion. B, Effects of spinal exthe weight-bearing load and the facets normally bear tension. Figures ÂŠ Joseph E. Muscolino. the remaining 20%. So not only does flexion preferentially load the anterior discs, it also increases the pulling these fibers taut as the pressure from the nu- overall compressive load on the discs. cleus is exerted against them can lead to their degen- Flexion has another positive effect: It stretches all eration. The fibers begin to fray; and cracks form posterior tissues of the spine, including the paraspiwithin them. This can lead to weakening of the pos- nal (erector spinae and transversospinalis) musculaterior annulus and eventual bulging and/or herniture. Tight paraspinal musculature is often responsiation. Unfortunately, most activities of life are perble for directly causing low back pain. More imporformed down in front of us, requiring repetitive flex- tantly for a pathologic disc, if the paraspinal muscuion movements of the lumbar spine. For this reason, lature is tight, it pulls in toward its center, thereby proponents of extension decry the use of further creating a compression force upon the discs of the 44 Terra Rosa E-mag No. 20

spine. Increasing compression of the discs can then increase nucleus pressure upon the annulus, thereby increasing the size of the bulge or herniation. Therefore, loosening tight paraspinal muscles can benefit a client’s pathologic disc.

The Effects of Extension The position of lumbar extension places compression upon the posterior disc instead of the anterior disc. This has two important sequelae. First, the annulus is driven anteriorly instead of posteriorly, removing its pressure from the posterior annular fibers. Second, the tensile force upon the posterior annular fibers is removed, so that it is no longer pulled taut. The combination of these two factors can have the direct effect of lessening the degree of a posterolateral bulge or herniation, thereby decreasing compression of the spinal nerve roots within the IVFs. Note: Extension will cause the same negative effects upon the anterior annular fibers that flexion causes upon the posterior annular fibers. However, because of the relative lack of extension postures during our life, there is less accumulated physical stress to the anterior annular fibers, and therefore less likelihood of bulging/herniated discs anteriorly. Further, the anterior disc is reinforced by the anterior longitudinal ligament, which is very strong. And even if there were an anterior disc bulge or herniation, there are no neural tissues located anteriorly that would be compressed. If the extension position is created by the client actively engaging their extensor musculature to move their trunk against gravity up into extension, there is the added benefit of strengthening paraspinal musculature. This can help to stabilize the spine and protect the discs (and facet joints) from excessive physical stress. Strong paraspinal musculature is also better able to meet the demands placed upon it, lessening the likelihood that it will be overburdened and strained. However, extension can also have negative effects upon the lumbar spine. Extension decreases the size of the IVF by approximately 11% (FIGURE 4B).

Given that the greatest consequences of a bulging/ herniated disc are due to the neural compression of the disc upon the spinal nerve within the IVF, decreasing the size of the IVF could potentially increase compression of the nerve, further inflaming it and worsening the condition. The position of extension also compression loads the facet joints; as stated previously, via Wolff’s Law, this could increase bone spur formation at the facets, which could further decrease the size of the IVF. The upside of this is that loading the facets commensurately results in unloading of the discs. So not only does extension remove loading of the anterior aspect of the disc, by shifting weightbearing to the facets, it decreases the overall load upon the discs.

Flexion and Extension Treatment Techniques If we choose to use flexion as our treatment approach for a client with a pathologic disc, it is typically done by performing double knee to chest stretching. By bringing the knees to the chest, the client’s pelvis posteriorly tilts, thereby moving their spine into flexion (Figure 5A). Flexion distraction technique is another flexion-based treatment option that is available for those therapists with tables that allow for the caudal (foot) and/or cephalad (head) end of the table to drop (Figure 5B). Regarding self-care directions for the client, either double knee to chest and/or a sitting trunk flexion stretch (Figures 5CD) can be recommended. The benefits derived from flexion are opening up the IVFs and stretching the paraspinal extensor musculature, as well as decompressing the facets. If we choose to instead treat the pathologic disc client with extension, although it is possible to stretch the client’s trunk into extension, it is not logistically easy to do so. For this reason, extension oriented treatment strategy is often based on directing the client to perform self-care stretching and strengthening extension exercises (Figure 6). This approach has been made popular by the physical therapist, Robin McKenzie; for this reason, extension exerTerra Rosa E-mag No. 20

B C

â&#x20AC;&#x153;Ultimately, the goal of all manual and movement therapy is graceful and pain-free functional motionâ&#x20AC;?

Figure 5 Flexion techniques. A, Therapist-assisted double knee to chest stretch. B, Table that allows for flexion of the spine. C, Self-care double knee to chest stretch. D, Self-care trunk flexion stretch.

46 Terra Rosa E-mag No. 20

Figure 6 Extension self-care exercises. A, Passive extension of the spine supported by the forearms. B, Active extension created by contraction of the paraspinal extension musculature. Figures courtesy of Joseph E. Muscolino.

cises are often called McKenzie exercises. The benefits derived from extension are based on relieving stress on the posterior annular fibers and strengthening the paraspinal extensor musculature.

To Flex or To Extend? If both flexion and extension positions can be beneficial for the low back, and specifically for a pathologic lumbar disc condition, it brings us back to our original question: When a client presents with a pathologic lumbar disc, do we utilize flexion-based treatment techniques or do we avoid flexion-based postures and instead recommend that the client perform extension exercises for their low back? Looking at the biomechanics of a pathologic disc with nerve compression within the IVF, it would seem that the answer lies in which aspect of a pathologic disc is more problematic for the client

when they present: The bulge/herniation of the annulus or the compression of the nerve root within the IVF? This might be a difficult question to answer because neural compression due to a pathologic disc involves both factors, which is why each approach works with some clients, and not with others. A clue might lie in whether the size of the IVF is decreased for other reasons such as osteoarthritic bone spurs or the presence of inflammation/ swelling. Bone spurs can be seen on X-Ray as well as on CT scan or MRI. If IVF narrowing is occurring largely due to osteoarthritic bony hypertrophy, flexion might be the better course. The more information you have from radiographic findings, the better able you might be to decide whether to use flexion or not. For this reason, it is important to request that the client either give you a copy of the radioTerra Rosa E-mag No. 20

graphic reports, or you consult directly with their physician. The presence of swelling is more challenging to determine, but as a rule, the more acute and aggravated the condition, the greater the likelihood that swelling is present. Therefore, acute disc episodes might favour a flexion approach. Conversely, if the client is experiencing a pathologic disc episode that is chronic, an extension approach is more likely indicated. Given that inflammation usually subsides with chronicity, extension would seem to be the wiser choice in the long term because it unloads the posterior annular fibers, decreasing the bulge or herniation. Whichever approach is used to relieve the client’s episode in the short run, an understanding of lumbar disc mechanics seems to indicate that extension is the best approach for the long run. In the absence of detailed radiographic findings and/ or other information that would help us make this decision, a default guideline might be to simply choose one approach and follow it for a number of sessions: a period of two to four weeks would be a fair length of time to see if the approach is working. If the client responds favorably and begins to clearly improve, continue with this approach. If the client does not improve, or if the client’s condition worsens, then the alternative approach can be tried. What is most important is to understand the pathomechanics of a pathologic disc condition as well as the (bio)mechanics of flexion and extension as treatment approaches. Working from a fundamental understanding of the kinesiology of the body allows for critical reasoning and therefore creative application of assessment and treatment techniques, which ultimately results in a more successful clinical orthopedic practice!

Box 3. Decompression and Movement Flexion is problematic because it compresses the anterior spine; and extension is problematic because it compresses the intervertebral foraminal spaces and the facet joints. Therefore, whether flexion or extension is performed, spinal compression occurs. It might be argued that what is most important is not necessarily whether the therapist employs flexion or extension, but rather to avoid compression of the spine. Therefore, with either approach, many therapists recommend that the client focuses on elongating the spine so that it is decompressed. A helpful cue for the client is to ask them to imagine that there is a string that is pulling their head straight up. It should also be emphasized that movement in most every direction is of paramount importance. No posture is necessarily bad, as long as the client doesn’t get stuck in it. The human body is meant to move. Movement works our muscles and joints, stretches and strengthens soft tissues, facilitates neural patterning, and promotes the circulation of body fluids, including a pumping action of the nucleus pulposus so that nutrient supply to the disc tissue of clients with pathologic disc conditions is improved. Ultimately, the goal of all manual and movement therapy is graceful and pain-free functional motion.

“…whenever two differing treatment approaches exist, usually both are valid.”

Text © Joe Muscolino, Figure illustrations by Giovanni Rimasti, photographs by Yanik Chauvin Joseph E. Muscolino, DC, is a chiropractor in private practice in Stamford, CT who employs extensive soft tissue manipulation in his practice. He has been a massage educator for more than 25 years and currently teaches anatomy and physiology at Purchase College, SUNY. He is the author of multiple textbooks including The Muscle and Bone Palpation Manual, The Muscular System Manual and Kinesiology (Elsevier).and Advanced Treatment Techniques for the Manual Therapist: Neck (LWW). Joseph teaches Continuing Education Clinical Orthopedic Manual Therapy (COMT) certification workshops around the world and Australia. Visit Joseph’s website at www.learnmuscles.com or his professional facebook page: The Art and Science of Kinesiology.

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Research: Are we asking the wrong questions in the wrong way? By Jenny Richardson Have you read much research about massage? Neither had I until recently. But the more I read, the more I think we need to have a discussion in our industry about what research truly provides “evidence” for the work we do. I am no expert in research – although I am back at university, trying to improve my understanding of research methodology so that I can participate more fully in the discussions about massage, pain, effectiveness of massage, mechanisms of how massage works and all the topics that can get so heated in online discussions. So please, take this article as a starting point for your own ideas and questions, rather than an expert viewpoint. I hope though, that it might spark ideas and discussion so that we can do this thing called “research” better.

Massage research primarily aims to use the RCT design in an effort to provide the best evidence possible for the effectiveness of massage in different situations and for various conditions. In some areas the evidence is showing that there are significant benefits from massage (oncology massage, pregnancy massage, mental health). However, in the domain of injury, pain and dysfunction, the evidence has not been so convincing. Generally systematic reviews of such studies conclude a “weak evidence” for massage in clinical situations.

The accepted “gold standard” of research is the “double blind randomised controlled trial” (RCT). The rigour of design is considered to provide the best quality of evidence for determining a causeeffect relationship between a particular treatment and an outcome. RCTs have several important features:

Does this mean massage doesn’t really work and massage really is best kept for relaxation, relief of stress and general wellbeing?

 Allocation of participants to control or study

groups must be random  All groups must be treated the same except for the variable being studied.  Control or minimisation of as many confounding variables as possible.  Where possible patients, therapists and data analysts should not know which treatment is being provided to any given participant. 50 Terra Rosa E-mag No. 20

I don’t think so – and I think most massage therapists would immediately think of all the clients who have walked out of their door with less pain, more movement and a relaxed smile because they truly feel better. So, what goes wrong? Are we seeing benefit where there is none? Is it a placebo effect? I would like to suggest that in our attempt to undertake credible and acceptable research, we are designing studies that do not reflect how massage is actually used and therefore perhaps giving us results that may not represent the “real world”. In the “Review of the Australian Government Rebate

Photo: CC0 Public Domain

on Natural Therapies for Private Health Insurance” 1, the committee commented extensively on the poor quality of research in massage and determined that the benefits of massage could not be determined until better research was undertaken. In particular they stated “To allow for more firm and conclusive statements about the effectiveness of massage therapy for a particular clinical condition, more rigorous, multicentre, and well-designed clinical studies assessing the effectiveness of massage therapy for a particular patient population are required. RCTs need to combine treatment approaches so as to properly reflect the way that massage therapy is applied in practice. Also, there is little data about what constitutes an effective massage therapy session. Further research is required regarding optimal treatment parameters such as number of sessions or duration of sessions required, combined with longer-term follow-up of patients to assess the longterm effectiveness of massage therapy” (p97) Given that the review was scathing of many natural therapies, I was very excited by the above comments. It seems a very positive step to find that a group of medical and health professionals could recognise that studies needed to be truer to the real practice of massage rather than even more controlled. In fact, a recent study2 aimed to evaluate massage in a cohort study rather than an RCT – observing and analysing the outcomes rather than controlling for every variable. They allowed the participant to choose from a list of massage therapists, attend in a normal clinic setting and provided up to 10 sessions over 3 months. One of the primary aims was to evaluate the use of such a study rather than show any particular outcome, and yet the researchers concluded that there was a clinically significant benefit from massage for patients with low back pain. A number of meta-analyses 3,4 outside the massage field have examined whether less “rigorous” designs can be utilised and still show meaningful results. Concato, Shah & Horwitz, (2000, p1890)4 concluded that “the summary results of randomized, controlled trials and observational studies were remarkably similar for each clinical topic we examined”. Studies to date have tended to apply/ describe the application of massage therapy in two, opposite extreme ways. Firstly, in an attempt to control all variables, the therapist will be instructed to perform an exact sequence of strokes for an exact amount of time. Alternatively, there will be little or no description of “massage”. Neither of these is actually useful

in determining the effectiveness of massage therapy. The majority of massage therapists customise their massage sessions to each client. There is no one single muscle that is always the cause of back pain, no one technique that resolves it every time. In addition, every client has a different injury history, a different way of using their body and a different set of activities that they perform. Massage therapists typically take all of these issues into account when determining a treatment plan for a client. A study that utilises a strict protocol for all participants can really only be said to have determined the effectiveness of that protocol – not of “massage”. However, when the study is published, and shows only “weak evidence” (if any) for “massage” being beneficial for back pain, it gets added to the list of other similar studies. At the opposite end, if no description of massage is given, we know very little about what did or didn’t work. What level of skill was the massage therapist? Did they treat with general massage or specific to particular areas? How did they assess which areas? What was the history of the client that might have Terra Rosa E-mag No. 20

affected the treatment? Does any of this affect the outcome? It is in this area that I think we can best utilise random controlled trials – with some caution. We have many assumptions about massage that get passed from teacher to student over and over. However, there is very little research considering whether those assumptions are valid. There are many questions about what might constitute “effective” massage for pain and injury before we ever get to the question of whether “massage” is “effective”. For example  What pressure is most effective in which situa-

tions  How long should a session be? How often should

someone with acute pain get treated? With chronic pain?  How does massage best interact with home care

or exercises or other treatments?

 What skills are most important for massage thera-

pists to have and utilise and in which situations?

So what can we do? This is why I am back at university, trying to get my head around research so that I can better understand how we might design research that is rigorous and valid – but still reflects the way massage does – or does not – work in the clinic before we judge it to be ineffective and unsupported in the area of injury and rehabilitation. The purpose of a randomised controlled trial is to try to evaluate whether an intervention causes a particular outcome, with as little confusion from other variables as possible. However, I think we are attempting to fit massage into a study design that doesn’t allow the intervention to work in the way that it potentially might in the real world. Just as research is important so that we don’t jump to conclusions about what does work - I think we need to be careful that we are not jumping to conclusions about what doesn’t work before we are truly sure that we are measuring the things that matter. Article © Jenny Richardson

 Is a general massage focusing on full body reduc-

Jenny Richardson is the owner of Canberra Myotherapy and has been practising massage and myotherapy for over 10 years. She is passionate about understanding how the body works and using this to help clients with chronic pain.

tion of tension more effective – or is it more useful to treat particular areas?  Should those areas be the ones that have pain – or

is the pain just the symptom and other areas also require treatment for the best effect?

I say “with caution” as I personally believe that massage or any treatment is only truly effective if it takes into account the client/ participant as an individual. What injuries they have previously had, how the current injury was sustained. What their preferences are. What type of communication is most useful for them. I truly think that generalisation of massage effects across a large number of people, even if they have the “same” pain or condition, is problematic. What if the outcome in massage is actually based on all of those variables together? A plant needs water, soil, nutrients, and light - so any study that just provides one of those “variables” may not show an outcome. Likewise, the majority of massage therapists think of treating the whole person, not just a particular symptom. It may be that attempting to isolate any particular variable as part of a study is doomed to reducing the possible outcome. Therefore, in addition to the client as an individual, I also believe it is problematic to focus on any one variable, even though I think we should understand each variable better when making clinical decisions about how to treat a particular client. 52 Terra Rosa E-mag No. 20

References Review of the Australian Government Rebate on Natural Therapies for Private Health Insurance. Professor Chris Baggoley AO ,Chair, Natural Therapies Review Advisory Committee, Department of Health. Massage: p85-99 http://www.health.gov.au/internet/main/ publishing.nsf/content/phi-natural-therapies 1

2 Elder,

W.G., Munk, N., Love, M.M., Bruckner, G.G., Stewart, K.W., Pearce, K., (2017), Real-World Massage Therapy Produces Meaningful Effectiveness Signal for Primary Care Patients with Chronic Low Back Pain: Results of a Repeated Measures Cohort Study. Pain Medicine 2017; 0: 1–12. doi: 10.1093/pm/pnw347 3 Concato,

J., Shah, N. & Horwitz, R. (2000). Randomized, controlled trials, observational studies, and the hierarchy of research designs. The New England Journal of Medicine. 342(25): 1887-92 4 Benson,

K. & Hartz, A. (2000). A comparison of observational studies and randomized controlled trials. The New England Journal of Medicine. 342: 1878-1886. DOI: 10.1056/NEJM200006223422506

Photo: CC0 Public Domain

Systemic inflammation and neuroinflammation in fibromyalgia patients Researchers have expected that chronic inflammation probably plays a role in the pathophysiology of fibromyalgia (FM). Neuroinflammatory mechanisms have been considered as central to the pathophysiology of many chronic pain conditions. However proving this hypothesis appears to be challenging. Previous studies on fibromyalgia on human and cerebrospinal fluid (CSF) proteins only looked at a few cytokine candidates and the results are inconclusive. Instead of analyzing only a few substances at a time, a new research from Sweden analysed 92 inflammation-related proteins simultaneously. The research sleep. Manual therapists who have worked with FM was published in Journal of Pain Research. and chronic pain have learned that the best results The researchers investigated the CSF and plasma seem to come when their treatment takes into acinflammatory profiles of 40 FM patients compared count the entire nervous system's (or entire perwith CSF from healthy controls (n=10) and plasma son’s) level of sensitivity, activation, resource, and from blood donor controls (n=46). The authors resilience; and that duration, pressure, pace, and frefound evidence of both neuroinflammation (as asquency all need to carefully be tuned to the individsessed in CSF) and chronic systemic inflammation ual’s response (which can be different every time).” (as assessed in plasma). It provides a concrete evi“Personally, my ears perk whenever there’s a new dence for an extensive inflammatory profile in FM development around the immune system's relationpatients. Hence, FM seems to be characterized by ship to pain; we have a lot to learn about inflammaobjective biochemical alterations. This dispels the myth that it is all in the head, idiopathic or even psy- tion, and are still elaborating the larger principles of how and when our work can be most effective with chogenic. inflammatory and conditions; and of course, how our The authors also clearly stated the limitation of this approach might need to adapt or expand in order to study (FM patients were all female and the control is best help clients and patients with either chronic limited). The authors further hypothesize possible pain and FM.” mechanism, include (1) central sensitization due to neuroinflammation? (2) an inflammatory risk factor that was present prior to the development of chronic pain (eg, a genetic susceptibility) (3) consequence of References the chronic pain condition, e.g., pain-related stress, Bäckryd, E., Tanum, L., Lind, A.L., Larsson, A. and Gordh, T., inactivity , depression, etc? Interestingly, inflammatory profiles similar to those now found in FM have been previously observed in studies of both chronic pain and neuropathic pain. According to Til Luchau, author and instructor of myofascial therapy “FM seems to respond to manual therapy similarly to chronic pain conditions. Empirically, both FM and chronic pain can, in many cases, be easily aggravated by too-direct, too-fast, too-long, or too-frequent work; or can show symptoms that seem to move around; or seem linked with mental or emotional agitation, depression, inactivity, and poor

2017. Evidence of both systemic inflammation and neuroinflammation in fibromyalgia patients, as assessed by a multiplex protein panel applied to the cerebrospinal fluid and to plasma. Journal of Pain Research, 10, p.515. Sanada, K., Díez, M.A., Valero, M.S., Pérez-Yus, M.C., Demarzo, M.M., García-Toro, M. and García-Campayo, J., 2015. Effects of non-pharmacological interventions on inflammatory biomarker expression in patients with fibromyalgia: a systematic review. Arthritis Research & Therapy, 17(1), p.272.

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Research Highlights Responsiveness of Myofascial Trigger Points to Single and Multiple Trigger Point Release A new study by Albert Moraska and colleagues from the University of Colorado assessed the effects of single and multiple massage treatments on the pressure-pain threshold (PPT) at myofascial trigger points (MTrPs) in people with myofascial pain syndrome expressed as a tension-type headache. The study was published in the February 2017 issue of American Journal of Physical Medicine & Rehabilitation. The study involved 62 participants with episodic or chronic tension-type headache, they were randomized to receive 12 twice-weekly 45-min massage or sham ultrasound sessions or a wait-list control. Massage therapy focused on trigger point release (ischemic compression) of MTrPs in the bilateral upper trapezius and suboccipital muscles. The study showed that PPT increased across the study timeframe in all four muscle sites tested for massage, but not sham ultrasound or wait-list groups (significant in suboccipital and upper trapezius). Post hoc analysis within the massage group showed an immediate increase in PPT, a cumulative and sustained increase in PPT over baseline, and an additional immediate increase in PPT at the final (12th) massage treatment. The authors concluded that single and multiple massage applications increase PPT at MTrPs. The pain threshold of MTrPs has a great capacity to increase; even after multiple massage treatments. This suggests that multiple treatments can still benefit clients with MTrPs. Real-world massage is effective for treating Lower Back Pain A new study from Indiana University-Purdue University published in the journal Pain Medicine finds that massage may provide lasting relief for clients with chronic lower back pain. The common re54 Terra Rosa E-mag No. 20

search design involved treatment with standardised massage sessions, rarely found in the real-world. In this new research, therapists were free to design massage programs according to the patients. The researchers recruited 104 people with persistent back pain who were referred by their doctors to licensed massage therapists. Modalities used by therapists varied including Swedish massage, active isolated stretching, myofascial techniques, lymphatic drainage, trigger point therapy, neuromuscular therapy, craniosacral therapy, reflexology, Reiki, acupressure, and positional release. The treatment was 10 sessions over 12 weeks. After 12 weeks, more than half of the patients reported improved outcomes in terms of pain reduction, and meaningful physical and mental improvement. In addition, the improvement still lasts after 24 weeks. Several people improved so much that their scores on a standard screening test dropped below the threshold for disability. While improvement was observed across the board, there were few demographic trends. Adults older than age 49 years had better pain and disability outcomes than younger adults. People with obesity tended to improve, but those gains didn't last. People taking opioids were two times less likely to experience meaningful changes, compared to those not taking them. The study has limitation as it does not have a control. However as noted by Prof. Aaron E. Carroll from Indiana University School of Medicine “given the natural course of back pain — that most of it goes away no matter what you do — the ideal approach is to treat the symptoms and let the body

Research Highlights heal. Non-invasive therapies seem to do that well enough.” Massage therapy effective for the health and wellbeing of older people The proportion of people over 65 years is rapidly rising in Australia and many parts of the world. These issues potentially place an increased demand for quality long-term care for the older person. A critical review undertaken by researchers from Riverland General Hospital in Berri, SA, explored the potential benefits of massage within daily routine care of the older person in residential care settings. Fourteen studies dated 1993–2012 were critically evaluated and the authors found that massage may be advantageous from client and nursing perspectives. Clients’ perceive massage to positively influence factors such as pain, sleep, emotional status and psychosocial health. Evidence also demonstrates massage to benefit the client and organisation by reducing the necessity for restraint and pharmacological intervention. The authors concluded that massage offers benefit for promoting health and well-being of the older person along with potential increased engagement of family in care provision. Integration of massage into daily care activities of the older person requires ongoing promotion and implementation. The study was published in International Journal of Older People Nursing. Hormone receptor expression in human fascial tissue Researchers from University of Padova, Italy, recently investigated the role of hormones in myofascial tissues. They are interested to the fact that many epidemiologic, clinical, and experimental findings point to sex differences in myofascial pain in view of the fact that adult women tend to have more myofascial problems with respect to men. They hypothesized that is possible that one of the stimuli to sensitization of fascial nociceptors could come from hormonal factors such as estrogen and relaxin, that are involved in extracellular matrix and collagen remodeling and thus contribute to functions of myofascial tissue. They conducted an experiment using immunohistochemical and molecular investigations (real-time PCR analysis) of relaxin receptor 1 (RXFP1) and estrogen receptor-alpha (ERα) localization on sample of human fascia collected from 8 volunteers patients during orthopedic surgery (all females, between 42

and 70 yrs, divided into pre- and post-menopausal groups), and in fibroblasts isolated from deep fascia, to examine both protein and RNA expression levels. They assume that the two sex hormone receptors analyzed are expressed in all the human fascial districts examined and in fascial fibroblasts culture cells, to a lesser degree in the post-menopausal with respect to the pre-menopausal women. They found that hormone receptor expression was concentrated in the fibroblasts, and relaxin receptor 1 (RXFP1) was also evident in blood vessels and nerves. These results are the first demonstrating that the fibroblasts located within different districts of the muscular fasciae express sex hormone receptors and can help to explain the link between hormonal factors and myofascial pain. It is known, in fact, that estrogen and relaxin play a key role in extracellular matrix remodeling by inhibiting fibrosis and inflammatory activities, both important factors affecting fascial stiffness and sensitization of fascial nociceptors. The study was published in European Journal of Histochemistry Foam Roller work can change the pressure pain threshold of the Ipsilateral and Contralateral Muscle Groups Foam rolling is a popular intervention used by allied health professionals and the general population. Current research suggests that foam rolling may have an effect on the ipsilateral antagonist muscle group and produce a cross-over effect in the muscles of the contralateral limb. A new study from Canada examined the acute effects of foam rolling to the left quadriceps on ipsilateral antagonist hamstrings and contralateral quadriceps muscle group pressure pain threshold (PPT). This research was published in Journal of Sport and Rehabilitation. Twenty-one healthy adults (age= 27.52 ± 8.9 years) participated using a video-guided foam roll intervention on the left quadriceps musculature. The results showed a significant difference between pre-test to post-test measures for the ipsilateral hamstrings and contralateral quadriceps suggesting an increase in PPT.These findings suggest that foam rolling of the quadriceps musculature may have an acute effect on the PPT of the ipsilateral hamstrings and contralateral quadriceps muscles. This study also follows a past research which found that foam rolling on plantar flexor muscles of one side of the limb can affect the PPT on the contralateral limb, suggesting that other mechanisms such as Terra Rosa E-mag No. 20

Research Highlights a central pain-modulatory system play a role in mediation of perceived pain following foam rolling. Clinicians should consider these results to be exploratory and future investigations examining this intervention on PPT is warranted.

Running exercise strengthens the intervertebral disc There is currently no evidence that the intervertebral discs (IVDs) can respond positively to exercise in humans. Some authors have argued that IVD metabolism in humans is too slow to respond anabolically to exercise within the human lifespan.

In a new research from Deakin University in Vicoria, Australia, the authors show that chronic running exercise in men and women is associated with better Postoperative adhesions are pathological attachIVD composition (hydration and proteoglycan conments that develop between abdominopelvic struc- tent) and with IVD hypertrophy. Via quantitative astures following surgery. Considered unavoidable and sessment of physical activity, they further find that ubiquitous, postoperative adhesions lead to bowel accelerations at fast walking and slow running (2 m/ obstructions, infertility, pain, and reoperations. As s), but not high-impact tasks, lower intensity walking such, they represent a substantial health care chalor static positions, correlated to positive IVD characlenge. Despite over a century of research, no preven- teristics. tive treatment exists. Authors Geoff Bove from University of New England These findings represent the first evidence in huCollege of Osteopathic Medicine, Massage therapist mans that exercise can be beneficial for the IVD and Susan Chapelle and collegaues conducted an experi- provide support for the notion that specific exercise ment to test the hypothesis that postoperative adhe- protocols may improve IVD material properties in the spine. sions develop from a lack of movement of the abdominopelvic organs in the immediate postoperative The study was published in Scientific Reports. period while rendered immobile by surgery and opiates. The researcher further tested whether manual therapy would prevent their development. The researchers used a rate model to test their hypothesis. Attenuation of postoperative adhesions from Manual Therapy

In a modified rat cecal abrasion model, rats were allocated to receive treatment with manual therapy or not, and their resulting adhesions were quantified. Macrophage phenotype was also characterized. In separate experiments they tested the safety of the treatment on a strictureplasty model, and also the efficacy of the treatment following adhesiolysis. The experiment shows that the manual treatment led to reduced frequency and size of cohesive adhesions, but not other types of adhesions, such as those involving intraperitoneal fatty structures. This effect was associated with a delay in the appearance of trophic macrophages. The treatment did not inhibit healing or induce undesirable complications following strictureplasty. The results support that that maintained movements of damaged structures in the immediate postoperative period has potential to act as an effective preventive for attenuating cohesive postoperative adhesion development. The article is published in an open access journal Plos One.

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Maximise Oxygenation

CORE MYOFASCIAL THERAPY with George Kousaleos Sydney, October 2017 "George Kousaleos was one of the most influential people in the manual therapy profession on my career and my success. His amazing CORE Myofascial Therapy training should be the foundation of every manual therapist's practice. His incredible knowledge of the human body, his compassion, and his kind heart, make him one of my greatest mentors in the manual therapy” - James Waslaski LMT; Author & International Lecturer Integrated Manual Therapy & Orthopedic Massage

CORE Myofascial Therapy Certification

CORE Sports and Performance Bodywork

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Sydney 27,28,29 October 2017

Sydney CORE Myofascial Therapy 1: 20,21,22 October 2017 CORE Myofascial Therapy 2: 23,24,25 November 2016 An intermediate to advanced, six-day workshop designed to give practicing massage therapists in-depth knowledge and hands-on experience in full-body myofascial treatment protocols. With this knowledge and skill, you will be able to improve your clients’ structural body alignment and increase their physical performance.

This 3-day seminar will examine the basic styles of performance inherent in all athletic disciplines. Utilizing structural integration and myofascial therapy theories and techniques that are appropriate for each style of performance, we will focus on developing training and event protocols for endurance, sprint, power, and multi-skilled athletes.

“Getting the basic Myofascial Spreading done on my first day resulted in a dramatic improvement of my body alignment “ Mic, Townsville

George Kousaleos, LMT is the founder and director of the Core Institute, a school of massage therapy and structural bodywork in Tallahassee, FL. He is a graduate of Harvard University, and has practiced and taught Structural Integration, Myofascial Therapy and Sports Bodywork for the past 30 years. George has served as a member of the Florida Board of Massage Therapy and was Co-Director of the International Sports Massage Team for the 2004 Athens Olympics.

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6 Questions to Marjorie Brook

1. When and how did you decide to become a bodyworker?

5. What advice you can give to fresh manual therapists who wish to make a career out of it?

I had always thought about massage, it called to me. while working in my first career choice, broadcasting, I looked into taking classes. However once I realized the commitment and cost I let it go. I was working for ABC News when the beginning of the end of real news occurred- OJ Simpson. I was so disgusted that I literally quit one night after an important story on autism was canned for a few more minutes of utter nonsense. I went on a hiking trip to Alaska, came home and signed up for massage therapy school and never looked back. Best decision I ever made!

There is one major decision that all therapists need to think long and hard on. “Are you a Massage Therapist in business for yourself or are you a Business person who’s chosen field is massage?” Neither one is better than the other, just very different and will determine what type of therapist you will be.

2. What do you find most exciting about bodywork therapy? Simply put…the difference you can make in another’s life by just being there for them when no one else has or at the right moment when they needed you the most. 3. What are your favourite bodywork books? I do not really think I have a favorite. I just love acquiring knowledge. 4. What is the most challenging part of your work? Getting people to understand the necessity, the sheer power of scar tissue release and therapeutic stretching. Two of the most important areas of therapy that almost everyone overlooks, from the medical professional to the lay person, as being of no consequence. 58 Terra Rosa E-mag No. 20

6. How do you see the future of manual therapy? Manual Therapy will always be in demand – touch has been around since the beginning of time. Unfortunately, I fear the money side taking over and ruining the profession. There are just too many Therapists who prefer, for whatever their reasons, to take technique class online &/or cheap, short as possible, classes at conventions only. Plus there are the organizations that offer them and except them for their requirements. You simply cannot learn a “hands-on” therapy from a video (You can use it as a review, by all means, yes. But to learn and fully understand the implementation of it no) or in three hours. It is truly an oxymoron.

A chat with Eve Pereeda

Eve is a massage therapist and owner of the Inverell Massage Clinic.

Why did you choose to open a massage clinic in rural Australia?

Where did you study massage therapy?

In the city there are already many massage clinics. In the rural areas we have a lot of hard working people and I saw that this as a good location to set up my business.

I studied massage in Thailand at many different schools with a variety of Teachers, learning different styles of Traditional Thai Massage Including the Royal Thai Massage. In Australia, I studied and got my Diploma of Remedial Massage, Advance Bodywork KaHuna Massage, and an Instructor in Thai Massage,. How did you become a massage therapists? In Thailand I was working a lot in the office with computers and I suffered shoulder pain (office syndrome). So I went and had a massage and it helped me greatly. I wanted to understand why and how the massage helped reduce the pain. So I went and leant massage

What do you find most exciting about massage therapy? Seeing the difference in my Clients after they have had treatment. I love to see them smile without pain. I love learning more skills and tools to help people. What is the most challenging part of your work? Keeping up with the washing and folding

How has being a massage therapist changed your life? People have come to see me suffering from injuries affecting their quality of life. Seeing these injuries reminds me that i need to look after myself as well as my clients, friends and family.

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