Terra Rosa Emag #21 by Terra Rosa

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ontents

Fascia and the Mind-Body Connection

—David Lesondak 6

Fascial Net Plastination Project – January, 2018 —Francesca Philip

There is a Third Layer of the ITB

Fascial tissue research in sports medicine

“Oh Baby – now that’s a scar!” Scar Release & C-sections

—Marjorie Brook, LMT 16

Can We Give Precisely Define Deep Tissue Massage?

Michael Phelps’ Forward Head Posture and Swimmer’s Shoulder

Thoracic Hyperkyphosis – The Critical Component of Upper Crossed Syndrome — Joe Muscolino

A Cient-Centered Model of Manual Care — Walt Fritz

Frozen Shoulder: The role of muscle guarding

Response from Clinical Anatomist John Sharkey

Fascial Manipulation® – Stecco® method: The practitioner’s perspective — Julie Ann Day

The Value of Confidence -Til Luchau

Altered patterns of pelvic bone motion determined in

subjects with posterior pelvic pain 44

The Efficacy of Vibrating Rollers

Research Highlights Terra Rosa E-mag No. 21

Fascia and the Mind-Body Connection by David Lesondak 2 Terra Rosa E-mag No. 21

hat there is a distinct relationship between thought, emotion, and the body should be apparent to anyone involved in the realm of fascia -oriented bodywork. For some, the idea that we are actually working with fascia is controversial but for the purposes of the next 1,420 words let’s accept that we are doing just that. So what is it about fascia therapies that have the potential to induce such strong emotional expressions? For as long as I can remember I have been fascinated by this relationship. And there’s a lot of interesting things out there that begin to explain the pathways of just how such a thing is possible. One of the most startling is the existence of the myodural bridge1,2. The myodural bridge is a literal connection – a fascial, fibrous, physical connection between the dura mater and the sub occipital group. Further investigations reveal the existence of proprioceptive nerve endings in the myodural bridge and suggests both the regulation of dural tension and cerebrospinal fluid flow3. Someone, somewhere, said “What you don’t express, you repress.” Repression takes energy. Repression creates tension. Think back to the last time you really wanted to say something but were afraid, or really wanted give someone a piece of your mind but didn’t. Was it easy to modulate your emotions in those circumstances? Did it create a fair amount of tension in your body? If you’re being honest, I would wager it did. So lets go into the extreme and think about the physiology of the startle response, particularly the contraction of the neck muscles. And while it is possible, albeit difficult, to regulate the startle response, it is considered innate. So innate that it is referred to as the Moro Reflex in newborn babies. Fold in anxiety-induced startle response, PTSD, and a dash of fear. We’ve all seen people like that. Is it any wonder that when that tension releases, however momentary or lasting, that there can be a concurrent expression of emotion? I’m not suggesting a simple cause and effect here, release the sub occipitals and release the trauma. If only if were that easy. We’d all just get a Stillpoint inducer, then Netflix and chill as needed. Life and the body is a little more complicated than that. Let’s go back to the anatomy. The dura mater is part and parcel of the fascial system, often specifically referred to as the meningeal fascia. The meningeal fascia covers and interpenetrates the nerves. It includes the dura, arachnoid, and the pia mater. The pia is the finest expression of the neural aspect of the fascial system, following all the twists, turns, and contours of the

brain all the way down to the ependyma, where the cerebrospinal fluid is produced. The individual collagen fibre direction in the pia are unidirectional. Some think it capable of communicating tensile forces throughout the meningeal network4. And there’s another intriguing study indicating a relationship between collagen laxity and anxiety5. This makes me wonder if there might be a natural level of pre-tension in the brain, just as there is in the body. Speculation aside, a vital player in this game is a class of cell known as the glia. And the story of the glia has curious parallels to the story of fascia and the fascial network6. And in terms of tension, glial cells also possess integrins, the cell receptors that respond to pressure, vibration, and are linked to the collagen network. A neurological outlier, glia cells outnumber the neurons nine to one in humans (animals have a lower ratio). They were ignored in the early days of neuroscience in favour of the neuron which were less abundant but far larger. In an interesting example of confirmation bias, in this case that bigger is better, they were ignored in favour of the neurons. Glia were thought to be inert, mere structural support and scaffolding for the neurons. Sound familiar? That changed in the early 1990s when it discovered that not only are the glia not inert, but that they communicate to each other and to the neurons7. Put another way, the cells previously thought to be the stuffing between the neurons are talking to each other. Since then there has been an explosion in glia research, with discoveries that they can regulate synaptic activity8, may be essential to the formation of muscle memory9, and play a role in chronic pain10. In fact, prolonged exposure to opioids cause glia to release pro inflammatory agents11. Glia are also attributed, by their top researchers, to imbuing the body with the ability to move and perform physical tasks with grace and ease. This too, has a familiar ring. Most of the literature divides the glia into 4 types (though some of the literature will refer to only 3) the one I want to focus our attention on is the Schwann cell, the only glia cell to arise from the mesoderm, the same embryological layer as our connective tissue. Schwann cells are found in the peripheral nervous system, and while there are at least 3 distinct types, the ones that hold my interest the most are the perisynaptic Schwann cells (PSCs). PSCs live in the neuromuscular junctions, where the motor commands of the central nervous system are performed. PSCs are considered indispensable to Terra Rosa E-mag No. 21

Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436

short-term plasticity in the neuromuscular junction12. It is here where the Schwann cells interact with fascial mechanoreceptors, rather like they do at the myodural bridge. PSCs are vital to the healthy formation of both Golgi and Pacini receptors, and where PSCs are absent, these mechanoreceptors cannot regenerate after injury. They have an interdependent relationship13. Just as we are beginning to map the fascial pathways of force transmission in the muscles and bones (the musculobonular system?) so too I believe we are discovering the pathways that more intimately link our mind, body, and emotions via the pathway just described. But corollary is not causation, nor is association attestation. It is my fervent wish that some researcher(s) somewhere will begin to put some of these pieces together. It has been my direct experience that glia scientists are ignorant of fascia science, and why should it be otherwise? Our own silos are so deep and rich that it is easy to stay 4 Terra Rosa E-mag No. 21

happily inside them. However, I believe the deeper one digs into the mechanisms between the mind and the body, one is left with the realization that this unitary relationship is so. That it is ineluctably interconnected. And while it is useful, even necessary, to separate and isolate things for study, that we are irrefutable one. And that the fascia seems to be the interface of that oneness. References: 1) Von Lanz T. Uber die Ruchensmarkshaute. I. (1929) Die konstruktive Form der harten Haut des menschlichen Ruckenmarkes und ihrer Bander. (The structural form of the hard skin of the human spinal cord and its bands). Arch Entwickl Mech Org 118:252â&#x20AC;&#x201C;307 2) Khan j l, Sick h and Kortike J G (1992) Les espaces intervertĂŠbraux postĂŠrieurs de la jointure craniorachidienne. Acta Anat (Basel). 144 (1) 65-70

3) Scali F, Pontell M E, Enix D E and Marshall E (2013) Histological Analysis of the rectus capitis major’s myodural bridge. The Spine Journal. May; 13 (5) 558-563 4) Nam MH, Baek M, 2014, Discovery of a novel fibrous tissue in the spinal pia mater by polarized light microscopy. Connect Tissue Res. 2014 Apr;55(2): pp. 147–155 5) Bulbena A, Gago J, Sperry l, and Berge D (2006) The relationship between frequency and intensity of of fears and a collagen condition. Depress Anxiety, July;23 (7) 412-417. 6) Lesondak, D. (2017) Fascia and the Brain, Fascia: What it is and Why it Matters, Handspring Publishing, pp. 87-104 7) Nedergaard, M, (1994) Direct signaling from astrocytes to neurons in cultures of mammalian brain cells. Science, Mar 25;263(5154):1768-71 8) Eroglu C and Barnes, B A (2010) Regulation of synaptic activity by glia. Nature. November; 468, 223–231 9) Hassanpoor H, Fallah A and Raza M (2012) New role for astroglia in learning: Formation of muscle memory. Medical Hypothesis. December; 79 (6) 770–773 10) Fields R D (2009) New culprits in chronic pain, Scientific American. November; 50–57. 11) Johnston I N, Milligan E D, Wieseler-Frank J et al. (2004) A role for proinflammatory cytokines and fractalkine in analgesia, tolerance and subsequent pain facilitation induced by chronic

intrathecal morphine. J Neurosci. August; 24 (33) 7353–7365 12) Colomar, A, Robitaile, R., Glia Modua Costandi, Mo, (2012), Snapshots explore Einstein’s unusual brain, Nature News (online) Nov. 16, 2012 13) Kopp D M, Trachtenberg J T and Thompson W J. (1997) Glial growth factor rescues Schwann cells of mechanoreceptors from denervation-induced apoptosis. J Neurosci. September; 17 (17) 6697–6706

David Lesondak, BCSI, ATSI, FST, FFT, VMT, is the author of the international bestseller, Fascia What it is and Why it Matters (Handspring 2017). He is a member of the Allied Health professional staff in the Department of Family and Community Medicine at the University of Pittsburgh Medical Center. A Fascia Specialist in UPMC’s Center for Integrative Medicine, David lectures and teaches hands-on course worldwide. For more information www.fasciamatters.health

Available from www.terrarosa.com.au

Terra Rosa E-mag No. 21

Fascial Net Plastination Project – January, 2018 Francesca Philip

There aren’t many reasons to visit Guben, Germany. With a population of only 1800, the town boasts little in the way of tourist attractions. In winter, the temperature rarely reaches positive digits, the streets are slick with ice, and the dark settles in hours earlier than it should. The grey sky is rather dull and gloomy. But that’s where I spent one week in January, my coat pulled up to the tips of my frozen Australian ears. Guben was one of the most exciting experiences of my life. On my first morning in town, I escaped the cold by stepping into a crowded entry foyer. The atmosphere was 6 Terra Rosa E-mag No. 21

festive and bright. Old friends hugged and laughed, pinkcheeked, while new acquaintances echoed introductions. Every person had a different accent, a different title. I found some of my old friends, people I’d worked with on past projects—my buddy from Singapore, colleagues from San Francisco. Still, the air was thick with suspense. See, while Guben has few claims to fame, this building, the Gunther von Hagan’s Plastinarium, is one of them. All around us, thousands of plastinated models stood arranged—hearts, muscles, lungs, bones, all perfectly preserved in poses and museum cases. A few rooms over from the lobby was a laboratory, waiting for the gathered guests to don lab coats and level scalpels.

Now is probably a good time to mention that all of us had flown into Guben for a human dissection workshop. Specifically, the Human Fascial Net Dissection and Plastination Project. We were anatomy nerds, and we were about to do more with fascia than anyone had ever done before. This project was a long time in the making. It took years of appealing to the Plastinarium before Dr. Robert Schleip (Germany), a renowned fascial anatomy teacher, was finally authorized to lead our dissection team at the Guben laboratory. He and his co-leaders, John Sharkey (Ireland) and Dr. Carla Stecco (Italy), had a clear purpose: they wanted to study three-dimensional fascial anatomy on human bodies in an educational setting. In other words, they wanted our team to be the first in the world to plastinate fascia. If successful, the pieces produced would be presented at the Fascia Research Congress in Berlin in November 2018. Coming at the workshop from a massage therapist’s point of view, I was excited that our project would give me an insight into the mechanisms of the body. For all my work in anatomy and movement education, I’ve always been frustrated at the limitations posed by textbook learning. Even working on bodies from the outside fails to give me a window into the real processes I’m trying to employ to heal and help my clients. Only interactive dissection courses have allowed me to appreciate crucial insight into how the body is really held together. Of course, not every massage therapist loves the idea of working with cadavers. Some lack the financial resources for it; others lack the stomach. And both restrictions are understandable! But neither should be a barrier to a therapist’s education. That’s why plastination of fascia was a thrilling idea—finally, we would be able to take one of the least understood parts of the body out of the lab. With any luck, we would make fascia more than a buzzword. We would make it accessible. Our first day in the Plastinarium lab showed just what a diverse crew of participants we were. Our ranks included

Photos © Fascial Plastination project.

movement specialists, doctors, coroners, physical therapists, pilates and yoga teachers. John and Robert made it clear that such a combination was exactly what they’d hoped for. We were each to bring our passion and unique skillsets to the dissection table. After a few introductory lectures, we began to brainstorm sub-projects. We broached and debated the benefits of dissecting full iliotibial bands, complete posterior diagonal lines, and superficial fascia of major joints. Often, the expert plastinarium staff would weigh in on which proposals might work and which would leave us with nothing but chemically-dissolved collagen. Together, we began to make progress. By Thursday, the fourth day of the workshop, the steady thrum of work filled the lab. My group’s original attempt to render the fascia of the knee had failed. Rendering fascia, a process developed by Gil Hedley, requires you to dissolve the adipose globules from the structural network of fibers. After deciding we did not have sufficient time to produce a rendered piece, I moved from table to table, lending a hand where I was needed. There were so many projects that it was dizzying. While Robert had to leave mid-way through the day, Carla Stecco entered our midst with fresh passion and focus. With her to help guide us, no one’s hands were ever idle. After hours of careful differentiation, I stepped back from work to take a breath. One of my colleagues did the same. We gazed at the room, awed by how enthralled everyone was in their tasks. “It looks like a dissection quilting bee,” she noted. I blinked—it really did. The next morning, my friend Jo Phee and I walked into the Plastinarium with the bittersweet awareness that this was our last day. Most of our projects lay completed, waiting only for the next stage of chemical treatment to Terra Rosa E-mag No. 21

make them permanent. Our final group discussion was analytical and reflective. Deep questions arose: if fascia is the new frontier of anatomy, would this project contribute to a common good? Would the information gleaned be of any benefit or interest to humanity? The understanding of the importance of fascia is so new [if you don’t want what follows, please add a period after ‘new’], with studies, research and applications coming from all corners of the globe. Would this small mission be a first step in doing together what we could not do alone? I’d heard it said that if the body is considered the physical home of the heart and soul, then that would make fascia the locus of the emotions. Watching my colleagues grow from strangers to close friends after only one week of diving into fascial layers, I could only wonder if the spirit of the fascia somehow strengthened the connections we made. This group’s profound amount of collective wisdom truly inspired me. That evening, I stood at the train station and waited for my train back to Berlin. Around me, Guben was much the same as it was on my arrival—dreary, grey and icy. My coat was still tucked up to the tips of my Australian ears. But there was a new fondness in my heart for the little town. It had given me opportunities I had never thought I 8 Terra Rosa E-mag No. 21

would receive. In its streets, I’d walked with people I never thought I would ever work with. And in the Plastinarium lab, I had contributed to a project that I hoped would nudge the anatomical world just a little further. On that platform, I called my husband, back at home in California. “Enjoy yourself,” he said. “You never know when you’ll be able to go back to Germany.” “Oh, I do,” I said. “You do?” he asked, surprised. “When?” I grinned. “November, for the Fascia Research Congress.”

Francesca Philip has been in the high-tech industry, and is now a massage therapist, rehabilitation specialist, group fitness instructor, personal trainer, and Pilates instructor. Currently, she is considered a movement specialist. Her practical experience has allowed her to help seniors, students and athletes achieve their wellness and fitness goals. Fran is an Australian who now lives in Silicon Valley with her husband, daughter and lifetime collection of “great chats”.

There is a Third Deep Layer of the Iliotibial Band A new research from orthopeaedic surgeons from Austria shows the existence of a deep layer of the ITB. Fascia Latae and Iliotibial Band (ITB)

The thigh is enveloped in a layer of fibrous tissue known as the fascia latae, which thickens in the lateral thigh and is described as the iliotibial band (ITB). The ITB is well recognized as having two layers, one superficial to the tensor fasciae latae (TFL) muscle, and the other deep to the TFL. But it is not generally known that the ITB actually has a third layer that lies deep to its other two layers. Therefore, the ITB actually has three layers: superficial, intermediate, and deep layer.

The deep layer of the ITB. From Putzer, D., Haselbacher, M., Hörmann, R. et al. Arch Orthop Trauma Surg (2017). https://doi.org/10.1007/s00402 -017-2820-x (Creative Common License)

The ITB The ITB attaches on the iliac crest and extends distally to the anterolateral side of the proximal tibia onto an attachment site known as Gerdy’s tubercle. The three layers of the ITB fuse in the region of the greater trochanter and form the proximal ITB. The superficial layer arises from the ilium superficial to the TFL, while the intermediate layer arises from the ilium slightly distal to the proximal attachment of the TFL and lies deep to the muscle. The superficial and intermediate layers of the ITB merge at the distal end of the TFL and serve as the tendon for the TFL.

from Austria recently published a study. Their interest in the detailed anatomic knowledge derives from their interest in minimally invasive total hip arthroplasty surgery.

The study used ITBs from 20 human cadavers, where both hips were included resulting in 40 measurements with reference to the anterior superior iliac spine (ASIS) and the tibia. The deep layer of the ITB was exposed up to the hip joint capsule, and width and length measurements were taken. Sections of the deep layer of the iliotibial band were The ITB is connected intimately with the TFL anteriorly and removed from the hips and the thickness of the sections the gluteus maximus (GM) posteriorly in the region distal was determined microscopically after staining. to the greater trochanter. The ITB is not fixed at the greatThe Deep Layer of the ITB er trochanter, but uses it as a diversion point. The distal tendon of the gluteus maximus and a major portion of ITB intermingle near the gluteal tuberosity on the proximal posteromedial femur.

The deep layer is a constant structure arising from the supra-acetabular fossa between the hip capsule and the tendon of the reflected head of the rectus femoris. This deep layer merges into the ITB just distal to where the superficial and intermediate layers of the ITB fuse.

However, even though many studies on the ITB have been done and much is known, little information in the anatomy literature is available regarding the (third) deep layer of the The mean maximum thickness of the deep layer was 584 μm, in other words, a millionth of a meter. Its width was ITB. found to be approximately 3 cm (3.3 ± 0.6 cm). And its The Austrian Study mean length was found to be approximately 10 cm (10.4 ± 1.3 cm); however, unlike the superficial/intermediate asIn an effort to better understand the structure of the ITB, especially its deep layer, a group of orthopaedic surgeons pect of the ITB whose length (50.1 ± 3.8 cm) was found to Terra Rosa E-mag No. 21

band as an aponeurosis (which according to these authors is a different connective tissue structure than proper fascia). Such a distinction may indeed be possible when focusing on the previously known superficial portions of the iliotibial band only. But not with this newly described third layer! What I found particularly intriguing in this study is, that this third layer of the iliotibial band is mostly (in 83% of the cases ) not connected with the tensor muscle, and of course also not connected with any gluteal muscle. One should then ask the question: Are there any other muscular forces to whose tension this fascial layer will be adapting its morphology? I would suspect that this could be the expansional tension of the vastus lateralis, which by contraction will increase its diameter and thereby stretch the overlying fibers of the iliotibial band. While this will also effect the other two layers of the iliotibial band, the described independence of this third layer from the usual proximal muscular extensions puts an additional emphasis on the importance of the vastus lateralis for the functioning of the iliotibial band.

be related to the length of the thigh and body, the length of the deep layer of the ITB was instead found to be dependent on the length of the TFL.

Conclusion This research study has given more definitive evidence of not only the existence of the third “deep” layer of the ITB, but also information regarding its morphology, and by extension, its function. This deep layer of the ITB acts both as a second enveloping structure on the deep side of the TFL, as well as a fascial structure that sits over and stabilizes the anterior aspect of the hip joint. What does it mean? Dr Robert Schleip commented: “This is another wonderful example that in musculoskeletal anatomy almost everything is quite different than we originally learned from our classical anatomy books; at least if we stop the century old nonsense of considering fascia as a mere packing organ and ‚cutting it away‘ in anatomical dissections. For example many standard texts describe the fascia lata as ‚proper fascia‘ and the iliotibial 10 Terra Rosa E-mag No. 21

For me this is one more reason not to trust standard anatomy books anymore, and in this example to expand my frame of perspective from the usually considered proximal muscles when treating runners knee or similar iliotibial band pathologies, and to include additional muscular forces, such as from the vastus lateralis. One more good thing: If you run into somebody wanting to fiercely debate for a clear distinction between fascia and aponeuroses, this new paper will serve you well in making them ponder about their clear and righteous distinctions and to possibly increase their acceptance of a more continuation-oriented fascial net perspective in understanding musculoskeletal dynamics. “

Consensus Statement:

Fascial tissue research in sports medicine Fascial tissues deserve more detailed attention in the field of sports medicine. This consensus statement, published in British Journal of Sport Medicine, was authored by 12 international scientists, including Paul Hodges, Andry Vleeming, Thomas Findley, Robert Schleip and others, This statement is an outcome of the Second International CONNECT Conference held at the University of Ulm, Germany in 2017.

dependent on the mechanical properties of myofascial tissue linkages. Initial in vivo evidence points towards a significant role of myofascial force transmission for the locomotor system. It has also been shown the existence of (1) remote exercise effects and (2) non-local symptom manifestations in musculoskeletal disorders. Injury of fascial tissues: cellular and mechanical responses to damage

Excessive or prolonged loading or direct trauma to fascial tissues initiates micro and macro changes necessary for tissue repair. These effects may also contribute to pathological changes that modify tissue function and mechanics, leading to compromised function of the healthy tissue. Exercise, physical modalities and pharmacological Injuries to a variety of fascial tissues cause a significant loss of perforinterventions have all been shown to reduce the inflammatory promance in sports and have a potential role in the development and cesses associated with fascial tissue injury and fibrosis. perpetuation of musculoskeletal disorders, including lower back pain. A major goal of clinicians is to return athletes and patients to activity, Mechanobiology of fascial tissues: effects of exercise and disuse training and competition after injury. Thus, a better understanding of Human tendons respond to the application of chronic overloading by their adaptation dynamics to mechanical loading as well as to bioincreasing their stiffness and to chronic unloading by decreasing their chemical conditions promises valuable improvements in terms of stiffness. The mechanisms underpinning these adaptations include injury prevention, athletic performance and sports-related rehabilitachanges in tendon size and changes in Youngâ&#x20AC;&#x2122;s modulus. tion. Interventions for fascial tissue pathologies in sports medicine The consensus statement reflects the state of knowledge regarding the role of fascial tissues in the discipline of sports medicine and call Foam rolling seems to improve short-term flexibility and recovery from muscle soreness and decrease latent trigger point sensitivity. for more research. Nevertheless, the physiological mechanisms remain unclear. PrelimiMolecular adaptation of fascial tissues nary evidence suggests increases in arterial perfusion, enhanced fascial layer sliding and modified corticospinal excitability following Molecular crosstalk between extracellular matrix (ECM) molecules and cellular components is an important determinant of fascial tissue treatment. Manual therapies, such as massage, osteopathy or Rolfing, are frequently used to improve fascial tissue regeneration or physiology and pathophysiology. Small functional and structural alterations in the ECM result in complex cellular adaptation processes athletic performance, but their efficacy remains to be validated. and, vice versa, changes in cell function and structure leading to ECM Finally the authors added that advancing this field will require a cooradaptation. Therefore, fascial tissue homeostasis is the result of a dinated effort of researchers and clinicians combining mechanobiolocomplex interplay and dynamic crosstalk between cellular compogy, exercise physiology and improved assessment technologies. nents and the ECM. ECM is affected by ageing, sex hormones and Reference: ZĂźgel, M., Maganaris, C.N., Wilke, J., Jurkat-Rott, K., Klinginflammation. ler, W., Wearing, S.C., Findley, T., Barbe, M.F., Steinacker, J.M., VleemMyofascial force transmission ing, A. and Bloch, W., 2018. Fascial tissue research in sports medicine: from molecules to tissue adaptation, injury and diagnostics. Br J Experiments showed that intermuscular and extramuscular fascial Sports Med, http://dx.doi.org/10.1136/bjsports-2018-099308 tissues provide a pathway for force transmission, which in part, is

Components of the fascial system. The fascial system includes large aponeuroses like the first layer of the thoracolumbar fas cia (A), but also a myriad of enveloping containers around and within skeletal muscles (B) and most other organs of the body. The internal structure of fascial tissues is dominated by collagen fibres which are embedded in a semiliquid ground substance. From ZĂźgel et al. 2018 (CC BY-NC 4.0)

Terra Rosa E-mag No. 21

“Oh Baby – now that’s a scar!” Scar Release & C-sections By Marjorie Brook, LMT According to the World Health Organization1, caesarean (c -section), rates continue to rise around the world. The rate in Australia is 33% and in the United States of America it is 32.2%, which works out to 1-in-3 women2. But no matter how well-trained the surgeon may be, there will be scar tissue formation after a C- Section. Scar tissue needs to form to help the wound heal, but there is a tiny problem: adhesions. Adhesions occur internally when the body undergoes severe trauma such as a surgery, inflammation or infection. Unfortunately, most doctors either fail to disclose or show concern in regard to adhesion formation and a protocol to minimize it and the issues that can arise from them has never be established.

The most common incision for a C- Section is made horizontally (often called a bikini cut), which is just above the pubic bone. The incision is cut through the lower abdomen at the top of the pubic hair just over the hairline. The muscles of the stomach are not be cut but they are pulled apart so that the doctor can gain access to the uterus. In an emergency caesarean the incision will most likely be a vertical incision (from the navel to the pubic area) which will allow a faster deliver. The surgeon also pulls the bladder down to protect it during surgery. Scarring from the incision builds up underneath the incision as well as in the uterus. As the c-section scar starts to heal and the uterus reduces back adhesions form.

Scar tissue after a C Section is not preventable. Scar tissue is fibrous tissue that replaces normal tissue after an injury.

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While it contains the same materials as normal tissue, the quality of the scar tissue is inferior to that of the tissue it replaces. It is very important to understand that the scar that you can see is actually only the tip of the iceberg. All surgeries involve multiple layers of sutures and go much deeper than just the visible scar on the surface.

Another significant factor to be considered is the effect of adhesion formation on the internal organs. The organs are supposed to slip and slide around each other. Organs need this movement in order to function properly. When adhesions are present, the sliding surfaces stick to each other and drag across one another causing tensional pulls. The resulting restrictions can cause limited range of motion and pain in other areas of the body. It can take up to two years after a surgery or trauma to fully heal. Pain and issues may not even surface until well after the Mom has “recovered” from the surgery. Years can pass and by then, the symptoms may not be associated with the scar.

Common complaints after a c-section can include sensitivity of the scar itself and nerves being caught up in the scar tissue causing itching, hyper or hypo sensitivity. This will make pants irritating or leaving the Mom unable to feel anything from the scar to the pubic bone. Leaning over to

Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436

pick up baby can be painful. The tensional pull from the scar may cause postural changes, that along with a decrease in the support of the back from the abdominal muscles could result in back pain. The scarring can cause the adjacent muscles to develop trigger points that refer pain to areas like the clitoris or urethra.

There can be issues with lower digestion such as irritable bowel syndrome or constipation and bloating. Adhesions around the uterus, bladder and fallopian tubes can lead to painful intercourse, frequent urination and fertility challenges. Letâ&#x20AC;&#x2122;s not forget the emotional issues that can arise as a direct result of the scar. There is the self-consciousness about the appearance of the scar. Some women will not touch the scar and surrounding area. A simple pull or pressure on the scar can cause a continual minor or a sudden major PTSD reaction. Lack of sleep and mental stress from chronic pain that doctors do not acknowledge and family members do not understand can be detrimental. Scar tissue can have an adverse effect on every one of the bodies systems. They are interconnected and encased by

the fascia and the smallest of restrictions can cause problems. The good news is that there is much that can be done to minimize and correct the issues. C-section scarring can be improved or corrected altogether by releasing the tissue and proper therapeutic rehab (every expecting mother needs to be trained in pelvic floor exercises for both pre & post pregnancy). As the scar tissue is release layer by layer, and fibres encouraged to lay down in the proper alignment, the softer it becomes and function can be restored to the tissue surround the area. This reduces tensional pulls and reduces the adhesions. The tissue needs to be released in all directions, proper circulation (lymph included), range of motion restored and body mechanics re-established. The body needs time to heal, so for the best results light therapy such as myofasical release and lymphatic massage can start right after the surgery. Gentle range of motion stretching and proper body mechanics (how to feed, pick up and carry the baby etc) should be done in accordance with the motherâ&#x20AC;&#x2122;s ability and healing. After twelve weeks the tissue can be released via the STRAIT (Scar Tissue Release And Integrated Therapies) Method a Terra Rosa E-mag No. 21

three-dimensional, fascial-release system that works to minimize scar-tissue development and the subsequent physiological restrictions. As tissue is forever remodelling there in no time limit to working on scars. A difference can be made and balance restored no matter how old the scar is.

References: 1

World Health Organization http://www.who.int/

Centers for Disease Control and Prevention www.cdc.gov 3

William’s Obstetrics Twenty-Second Ed. Cunningham, F. Gary, et al, Ch. 25.

“I was fortunate enough to have a massage with Marjorie in Sydney, Australia on her recent visit. I was astonished by the immediate results and by Marjorie’s open, giving attitude. Post massage benefits included greater energy, improved posture, a huge sense of release and opening to my abdomen which had felt frozen after surgery. It was such a relief. Emotionally I felt noticeably stronger after the treatment.” Deborah S, Australia.

“I found Marjorie after doing a search for a solution to my csection scar and pain. She is a miracle worker. After just one session my scars have flattened significantly and the color has improved. She has helped with my back pain and sleeping problems. She is also very personable, caring and easy to talk to. I highly recommend her to anyone that has scars, surgery, or any kind of pain.” Jennifer G, USA.

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Several caesarean sections Is: supra-umbilical incision Im: median incision IM: Maylard incision IP: Pfannenstiel incision From: Wikipedia

“As a physiotherapist and practitioner in KMI structural Integration l have followed the course with Marjorie Brook about Scar Tissue releases (STRAIT METHOD). In my daily practice it is evident having knowledge about scar tissues and skills how to treat them. Understanding the influences of scars on posture and movement is important not to forget to mention the influences scars may have on the psyche. The course given by Marjorie Brook is helpful to that. Bringing you knowledge, giving you tools to treat, all in her enthusiastic way of presentation. “ Harry Hoogenbosch, KMI Amsterdam, NL.

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: 27-28 April 2019 • Integrated Therapeutic Stretching for the Upper body: 3-4 May 2019 • Scar Tissue Release for the Thoracic Region: 5-6 May 2019 “ 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. 21

Visit www.terrarosa.com.au for more information

Can We Precisely Define Deep Tissue Massage? With comments by Art Riggs A recent article published in Journal of Bodywork and Movement Therapies by authors from Israel attempted to objectively define deep-tissue massage to provide an evidence-based therapy. However, massage therapist and instructor, Art Riggs, commented that gallant as their effort is, the task of defining deep tissue massage is not only impossible, but is unproductive. Deep-tissue massage (DTM), is a term commonly used as a form of “deep” therapeutic massage, but the term was also used loosely implying many different modalities. It is unclear what elements define DTM and makes it unique. Researchers from Department of Physical Therapy in BenGurion University of the Negev, in Israel attempted to clarify this by conducting an evidence-based research on DTM to establish its efficacy and safety. The research paper was published in the April 2018 issue of Journal of Bodywork and Movement Therapies. The definition of Deep Tissue Massage Not surprisingly, the researchers cannot find a commonly accepted definition of deep tissue massage in the literature. Steve Capellini and Michel van Welden in their book “Massage for Dummies” jokingly gave a non-massage definition of Deep Tissue as Kleenex stuck deep between the cushions on your couch. In massage therapy, some referred DTM as “myofascial release” (MFR), “trigger point therapy” and “neuromuscular therapy” while others consider it as the application of Swedish massage strokes using strong pressure. Carole Osborne-Sheets in her book Deep Tissue Sculpting states: “ …. as a generic category, myofascial work includes sculpting, structural imbalance, self-massage … it also includes Rolfing, Chua k'a, Lomi-Lomi, Hellerwork, postural integration, MFR, trigger point therapy …”. The authors of the paper suggested the term DTM is commonly used to describe the intention or aim of the therapist to target a deep tissue by applying a greater pressure or force. To avoid confusion, they suggested differentiat16 Terra Rosa E-mag No. 21

ing the terms “deep massage” and “deep tissue massage”. Deep massage can be used to describe the intention of the therapist to treat deep tissue by using any form of massage.

Meanwhile, deep-tissue massage should be used to describe a specific and independent method of massage therapy, utilizing the specific set of principles and techniques as defined by Art Riggs in his book Deep Tissue Massage: “The understanding of the layers of the body, and the ability to work with tissue in these layers to relax, lengthen, and release holding patterns in the most effective and energy efficient way possible within the client's parameters of comfort”. The authors particularly endorsed Art Riggs’ definition which has the following principles: • Slow strokes. • Diagonal applications (except for treating MTrPs). • Maintaining depth of treatment according to targeted tissue. • Understanding of the differences between deep and forceful applications. • Using body weight to generate the force transmitted through the hands, knuckles or elbows. • When working on a muscle belly parallel and crossfiber strokes should be included. • Include stretching or activation of muscle. • Special attention to origin and insertion of muscles.

• The application should be within the client's parameters of comfort (minimally painful or no pain at all). As for the root techniques, the authors again quoted Art Riggs (2007) “… deep tissue techniques … are based upon broad principles of massage, and must be taught in that context”. For instance, pressure application can be perpendicular, oblique or transverse to muscle fibers, depending on the desired outcome, and still be considered DTM. On the other hand, these principles can be identical to other forms of massage which are not DTM. They stressed that techniques are not method-specific. Evidence-based DTM The authors from Israel tried to find clinical studies on DTM. However, they were confounded by the heterogeneity of techniques and protocols used in published studies. The authors listed some studies on Myofascial Trigger Point treatment, which may be part of DTM, but not necessarily following the principles as stated above. The authors first evaluated the effect of DTM on heartrate and blood pressure. Two studies listed in the review seem to be interesting and relevant, Cambron et al. (2006) defined DTM as the intention to access deep layers. In their case series, it was demonstrated that some forms of massage can cause a decrease in blood pressure while others cause an increase. What the authors defined as DTM did not influence blood pressure. In contrast, trigger point therapy caused a minor increase in blood pressure. Ce et al. (2013) evaluated the efficacy of five modalities in recovery after a heavy-duty cycling exercise by using deep

and superficial massage as two of the modalities. Their definition was based on the intention of the therapist. Preliminary measurements showed that therapists apply 650 N/m2 for deep massage and 190 for superficial. The authors found that neither a deep nor superficial massage influenced recovery rate. They also found that stretching and deep and superficial massage do not influence blood lactate levels after heavy-intensity cycle exercise. The authors found few studies that showed favourable outcomes from deep tissue massage in pain populations (such as chronic low back pain). In particular, a study by Frey Law et al. (2008) used delayed onset muscle soreness as a model to evaluate the efficacy of DTM for “deep muscle pain”. In this study, the authors demonstrated that both DTM and a superficial massage were able to reduce hyperalgesia (elevated pain pressure threshold), but only DTM reduced stretch pain (with only 11 mm difference between the groups). In this study, the term DTM was used to describe the intention to treat deep tissue with the application of “deep kneading”. Few studies also show various forms of DTM can help patients with decreased range of motion. Nevertheless, there are several rare serious adverse events were found related to deep tissue massage, mostly as a result of the forceful application of massage therapy. The authors ended the paper by stating “future research on massage therapy should be based on a common definition, classification system and the use of common comparators as controls.”

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Comments by Art Riggs

goals and strategies.

Author, therapist, and instructor Art Riggs was amused to find his writings referenced in a scientific article, stating, "I've forever been confused about what deep tissue massage actually is, both in my therapeutic work and in teaching." Art further commented:

In reality, the term deep tissue is actually misleading; many of the techniques that they list actually may be performed in other modalities and often treat superficial tissue.

Two different clients with different issues would probably have very different definitions of the work. The authors of the article do a fine job of attempting to define an unquantifiable skill. Gallant as their effort is, I feel the task of defining deep tissue massage is not only impossible, but is unproductive. The line along the continuum between “regular” and deep tissue massage is not sharp and can’t be clarified by a list of techniques. I remember great debate 35 years ago about whether to call one’s self a massage therapist or a bodyworker, not only for one’s ego, but as a reason to charge more for doing bodywork. An accurate description of the practice should not only cover the varied eclectic techniques and philosophies that they list, but also some of the things that exclude work from being classified as deep tissue massage. I do like the authors’ distinction between deep massage; (the all-tocommon practice of performing any form of massage while simply pressing harder) and offering a different form of therapeutic bodywork called deep tissue massage based upon advanced training and emphasis upon varied 18 Terra Rosa E-mag No. 21

• Superficial fascia release—Ask any Rolfer® or myofascial specialist working with superficial fascia, and they may strongly deny that they are performing deep tissue massage, although fascial work is usually involved in deep tissue protocol. • Working on superficial muscles such as pectoralis major; any of the muscles of the rotator cuff; specific muscles of the arm and leg including the IT band; and of course, dozens of other superficial muscles that need skilful work to align, lengthen, and patiently release adhesions rather than just squeezing. • Conversely a great amount of the skill of deep tissue massage does, indeed, entail the skill of working through superficial tissue to access deep restrictions. Examples would be isolating pectoralis minor deep to pectoralis major, focusing work on the deep rotators under gluteus maximus, and flexing the knee to shorten and soften gastrocnemius for easy access to soleus.

• Accessing deep tissue does not necessarily imply that the work has to apply a lot of pressure under the “no pain/no gain” fallacy. Work to deeper layers can be quite

subtle and is different from hard pressure. The length of this response prevents giving details of specific techniques, so I will confine myself to discussing the broader issue of “evidence-based research” which by definition is constrained by its attempt to control multiple complex factors of techniques, strategies, variations in patient symptoms, and therapeutic benefits into strict parameters to study results. The whole in deep tissue massage is much more than the sum of the parts. One could easily add (or subtract) many of the authors’ specific techniques and strokes such as trigger point, cross fibre friction, stretching, etc. that would fall not only under the umbrella of deep tissue massage, but other modalities. Like the clubs in a golf bag, the actual techniques often have less to do with the specific club one chooses and a lot more to do with the terrain, the actual symptoms being treated, their causes, the indefinable skill of touch, intuition and creativity that the therapist uses to satisfy the needs of the human being behind the symptoms. Attempting to strictly control these factors under the guise of evidence-based research seems futile and misleading. It seems crucial to distinguish between a limited academic list of techniques and the actual practice of giving a deep tissue massage SESSION in real life, based upon a blending of the therapist’s skill, the wildly varied public perception of proper deep tissue therapy, and the individual needs of the client.

Practical applications Let’s leave this topic of definition and semantics of deep tissue massage and discuss some practical applications for a bodywork practice. The tools and philosophy of a deep tissue practice are so varied that each practitioner must

be thoughtful about blending their individual expertise (having an eclectic tool box, but not being a “jack of all trades/master of none”) and philosophies to satisfy clients’ varied definitions of a deep tissue massage. I hear three basic complaints from the public about Massage: • By the numbers /one size fits all routines or protocols for everyone that don’t address the needs of clients, sometimes called McDonald’s massage. • Excellent general massage that feels good at the time but does not address the specific complaints or request for issues of the client, who often complain, “I felt good for an hour, and then went back to normal.” • Deep tissue therapists, mimicking a medical model, focusing solely on complaints, without a plan for integrating a whole body. This often results in a client walking out disorganized as the therapist plays hopscotch in isolated areas in what Tom Myers and others call “chasing pain.“ One financial drawback to this type of practice is that you only see clients when something is wrong rather than having the rewards of a large base of grateful regular clients and a consistently full practice.

I know countless very gratified and successful therapists who combine very pleasing full body massage while using specific skills of deep tissue massage on specific areas. Many clients long for a session that offers the benefits of relaxation while being a therapeutic part of a health maintenance program. These therapists consistently report a rewarding full practice of regular clients who love their work and refer to others.

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Michael Phelps’ Forward Head Posture and Swimmer’s Shoulder A recent social media post showed photos of Michael Phelps with rounded shoulders and forward head posture. Comments were made that there is no such thing as perfect posture. That all posture is normal, and surely biomechanics do not matter. The proof is Phelps who has won 28 Olympics medals despite his poor posture. However, such simplistic thinking is problematic. Phelps’ posture is common in competitive swimmers: head forward, rounded shoulders, flat lumbar spine, hips forward, and slight posterior pelvic tilt. Swimmers develop strong and hypertrophied musculature of the chest, upper back, arms, and shoulders, but not necessarily in balance and not necessarily in all other parts of the body. Muscle imbalance can caused swimmer’s shoulder, which is prevalent in competitive swimmers. Note that swimmer’s shoulder is also often written as swimmers’ shoulder. A 2017 review published in British Journal of Sports Medicine1 stated that a large number of shoulder revolutions in swimmers could easily overload soft tissue structures around the shoulder which lead to pain during daily activities, swimming, and at rest. Competitive swimmers practice 6-7 days a week with an average swim being up to 14,000 meters each day, which requires up to 16,000 shoulder revolutions per week1. There is a price to pay for this. One study found that 47% of collegiate swimmers experienced shoulder pain persisting for three weeks or more, causing eventual alteration or cessation of their normal swimming routines. Another 20 Terra Rosa E-mag No. 21

study of high school competitive swimmers showed that 72% used pain medication to manage their shoulder pain during practice. Nevertheless, there is still a belief among many in the swimming world that shoulder pain is normal and should be tolerated to complete practice. Swimmer’s shoulder is a condition which includes several pathologies including rotator cuff tendinitis, shoulder instability, and shoulder impingement. Swimmer’s shoulder is a result of several factors such as postural malalignments, altered scapular kinematics, and muscular imbalances surrounding the shoulder and scapula. Stephanie Lynch and colleagues in an article2 commented that forward head posture can cause muscular imbalances and may change the position of the scapula and decrease the ability of the scapula to rotate upwardly, a common characteristic found in patients with shoulder impingement. Upward rotation of the scapula is necessary to increase the space between the head of the humerus and the acromion process above. Shoulder impingement syndrome usually involves the distal tendon of the supraspinatus, the subacromial bursa (also known as the subdeltoid bursa), and the long head of the biceps brachii. Rounded shoulder posture is associated with a protracted position of the scapula, caused by a muscular imbalance between a shortened pectoralis minor and a lengthened rhomboids and middle trapezius muscles. This condition increases anterior scapular tilt (also known as upward tilt in which case the inferior angle of the scapula lifts up away from the thoracic rib cage wall) and scapular inter-

nal rotation (also known as lateral tilt in which case the medial border of the scapula moves away from the thoracic rib cage wall), which are associated with shoulder impingement. These altered scapular mechanics create shorter pectoralis minor length and decreased serratus anterior and lower trapezius activity. 3

In addition, another study found that swimmers had significantly greater decreased subacromial space distance during the training season compared with non-overhead athletes. Decreased subacromial space will likely predispose the person to have shoulder impingement syndrome. Lynch’s 2010 study2 examined a program to correct the forward head posture of 28 elite swimmers. The program consisted of an 8-week stretching and strengthening program aimed at correcting the posture. The strengthening exercises targeted the periscapular muscles (muscles around the scapula) with an emphasis on scapula stabilization. The stretching intervention was aimed at increasing the flexibility of the pectoralis musculature and cervical neck extensors. The results showed that the exercise intervention successfully decreased forward head as well as the rounded shoulder postures in elite swimmers. Shoulder function, although not statistically different following the intervention, demonstrated a trend toward a decreased level of perceived shoulder pain and dysfunction.

The 2017 review1 looked at musculoskeletal dysfunctions associated with swimmer’s shoulder and found that:

• Swimmers combine endurance, strength, flexibility, and control repetitively.

• High levels of training easily overload soft tissue structures around the shoulder and lead to pain and • Swimmer’s shoulder pathophysiological factors include reduced endurance, incoordination or weakness of the shoulder muscles, a lack of scapular stability, poor posture, and lack of core stability. The authors summarized differences in musculoskeletal function in swimmers with and without shoulder pain in the table below. Specifically, the review identified that: • Reduced shoulder and core trunk endurance are present with swimmers who reported shoulder pain, but it is unclear if poor endurance is a cause or effect. • Swimmers with shoulder pain showed an increase in glenohumeral motion in the form of laxity and instability. It is unclear whether laxity predisposes swimmers to pain or if it occurs in symptomatic swimmers because of cumulative microtrauma. • Swimming may alter scapular position, but it is unclear if these changes are related to the development of shoulder pain. • Forward shoulder posture due to an anteriorly tilted scapula may play a role in the development of shoulder pain in swimmers.

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• Alterations in shoulder rotational and flexion ROM are seen in swimmers with shoulder pain but cannot be concluded that these deficits are a risk factor for developing shoulder pain.

Comments by Joe Muscolino All in all, yes, many elite athletes can have poor posture; another example is that Usain Bolt has scoliosis. And certainly there is no such thing as a perfect posture. But this does not mean that postural distortion patterns from repeated use, overuse, misuse, and abuse are healthy either. Elite athletes suffer a high degree of injuries. Further, certain distortional posture patterns may be unhealthy for regular life or for certain activities, but perhaps not for the sport that excessively demands that pattern and therefore causes it. For example, the rounded trunk and shoulder posture (Vladimir Janda’s upper crossed syndrome) that may be caused by excessive cycling is likely not a functional deficit for cycling itself because that is the posture required for that sport (although because of the excessive stress and demand on certain tissues, it might cause pain in time). So, harking back to the initial comments of this blog post article that mentioned someone stating that bad posture cannot matter because Michael Phelps was able to win all those medals with his bad posture, it is worth pointing out that perhaps if Michael Phelps were to try a sport that required more trunk extension and shoulder retraction and lateral rotation, he might not fare as well as someone who did not have his posture. But an old saying said: “There is no such thing as a bad posture, as long as you don’t get stuck in it.” The problem is that remaining in a certain posture for extended period of the time does tend to get us stuck in 22 Terra Rosa E-mag No. 21

that posture because of neural facilitation, from the brain, that causes increased muscle tone (tightness) in certain muscles. And because of fascial adhesions. Both of these factors would likely lead to decrease potential for movement in the opposite direction because of the lack of soft tissue flexibility. The Role of Manual and Movement Therapy Manual and movement therapists can help these athletes improve their structural balance. Therapists may not “fix” the postural distortion pattern, but therapists might be able to provide balanced muscle tone across joints, whether it is across the shoulder joint complex in swimmers, or other joints for other athletes. From an overview of all the available evidence-based research, as well as a common-sense approach of critical thinking applied to fundamental principles of soft tissue and bony biomechanics, creating more balanced musculature and therefore a more balanced musculoskeletal posture just might help reduce the incidence of pain and injury in athletes. It certainly should decrease dysfunction!

References 1

Struyf, Filip, Angela Tate, Kevin Kuppens, Stef Feijen, and Lori A. Michener. "Musculoskeletal dysfunctions associated with swimmers’ shoulder." Br J Sports Med (2017): bjsports-2016. 2

Lynch, Stephanie S., Charles A. Thigpen, Jason P. Mihalik, William E. Prentice, and Darin Padua. "The effects of an exercise intervention on forward head and rounded shoulder postures in elite swimmers." British journal of sports medicine44, no. 5 (2010): 376-381. 3

Hibberd, Elizabeth E., Kevin G. Laudner, Kristen L. Kucera, David J. Berkoff, Bing Yu, and Joseph B. Myers. "Effect of swim training on the physical characteristics of competitive adolescent swimmers." The American journal of sports medicine 44, no. 11 (2016): 2813-2819.

Differences in musculoskeletal function in swimmers with and without shoulder pain (From Struyf et al. 2017) Shoulder muscle performance Muscle activity during freestyle swimming

Less activity of Upper Trapezius, Rhomboid, Anterior Deltoid, Middle Deltoid (hand entry); less activity of Serratus Anterior; higher activity of Rhomboid (pulling phase); less activity Subscapularis (mid-recovery) less activity of Anterior Deltoid and Middle Deltoid; higher activity of Infraspinatus (hand exit);

Muscle activity during breaststroke swimming Less activity of Teres Minor; higher activity of Subscapularis (pulling phase); less activity of Middle Deltoid, Upper Trapezius, Subscapularis; higher activity of Infraspinatus (mid-recovery) Muscle strength

Tendency of reduced Internal Rotation strength

Muscle endurance at the shoulder

Less abduction and external rotation endurance

Core endurance

Less core endurance

Shoulder range of motion

Higher (≥100°) or lower (<93°) External Rotation ROM; Reduced shoulder flexion and Internal Rotation ROM

Laxity and instability

Greater Glenohumeral laxity and instability

Shoulder posture

Greater posterior humeral head position; shorter pectoralis minor

Scapular dyskinesis

Tendency to greater incidence of scapular dyskinesis; decreased scapular upward rotation after swim practice

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Thoracic Hyperkyphosis – The Critical Component of Upper Crossed Syndrome Joe Muscolino Upper Crossed Syndrome and Thoracic Hyperkyphosis The postural distortion pattern known as upper crossed syndrome has many components to it. It involves: • thoracic hyperkyphosis • hypolordosis of the cervical spine • hyperextension of the head upon the atlas at the atlanto-occipital joint • forward head carriage • protraction of the shoulder girdles • medial (internal) rotation of the arms at the glenohumeral joints. Each and every one of these components is important in and of itself, and can cause pain and dysfunction. But for many clients, one of these components, thoracic hyperkyphosis, is the primary critical component, and if not sufficiently addressed, will lead to failure to improve the rest of the pattern. Thoracic Hyperkyphosis I would propose that the critical, the essential, component of upper crossed syndrome is thoracic hyperkyphosis. At least for middle-aged and senior clients, this is the primary postural distortion that usually drives all the rest of the postural distortions of this larger distortion pattern. And if not treated, will lead to failure to achieve any lasting improvement for our clients who present with this condition. Following are the steps by which thoracic hyperkyphosis causes the rest of the postural distortion pattern to occur. Hypolordosis of the Cervical Spine The cervical spine sits on the top of the thoracic spine. The superior surface of T1 acts like the pedestal upon which the cervical spine rests. If the angle of T1’s superior body changes due to thoracic hyperkyphosis, the curve of the cervical spine must change. When the thoracic spine is hyperkyphotic, the superior surface of T1 becomes much more vertical than with a healthy thoracic posture. As a result, C7 of the cervical spine must begin being projected much more anteriorly, and the rest of the cervical spine follows the kyphotic posture of the thoracic spine, therefore being less lordotic, hypolordotic. Because lordosis is 24 Terra Rosa E-mag No. 21

Upper and Lower Crossed Syndromes. Permission Joseph E. Muscolino. Artwork: Giovanni Rimasti.

a curve of extension, a hypolordotic neck is in greater flexion. This posture results in increased loading of the cervical discs (the more anterior of the spinal joint complex). Increased loading increased compression and the likelihood of disc pathology. Posteriorly, cervical flexion opens up the facet joints, which places them in a less stable posture, decreasing the ability of the cervical spine to absorb weight bearing shock forces that occur with each step we

proprioception (our ability to sense our position in space and our movement through space). To compensate for this hypolordosis of the lower and middle cervical spine, the posture of the head at the AOJ must become hyperextended, in effect, hyperlordotic. This results in jamming of the facet joints, increasing the weight-bearing load upon them. By Wolff’s law (calcium is laid down in response to physical stress), the osteoarthritic process would likely be accelerated. This also allows for adaptive shortening of the upper cervicocranial extensor musculature in the suboccipital region (e.g., rectus capitis posterior major), leading to hypertonicity and myofascial trigger points. Further, the increased pull of these muscles upon the scalp increases the chance of the client developing tension headaches. The increased extension of the head at the atlanto-occipital joint also leads to a constant stretching pull upon the suprahyoids, which can lead to increased tension stresses upon the temporomandibular joints (TMJs), which can lead to TMJ syndromes. The Sternocleidomastoid Anterior (Forward) head carriage, Permission Joseph E. Muscolino. Artwork: Giovanni Rimasti.

take. Further, a hypolordotic, flexed cervical spine leads to adaptive shortening of the flexor musculature of the neck: scalenes, longus muscles, and the sternocleidomastoid. Hyperextension of the Head at the Atlanto-Occipital Joint So now we have thoracic hyperkyphosis leading to hypolordosis of the lower and middle cervical spine. When the lower and middle cervical spine is hypolordotic, the head would not be level – the eyes would be oriented downward toward the floor, which would make it difficult if not impossible to see where we are going. Further, the inner ears would not be level making it more difficult to judge

When we look at the adaptive shortening of cervical spinal musculature as part of upper crossed syndrome, the sternocleidomastoid (SCM) is particularly relevant. The SCM crosses the lower and middle cervical spinal joints anteriorly so it flexes the lower and middle cervical spine. But it crosses the upper cervical spinal joints, especially the atlanto-occipital joint, posteriorly, so it extends the head at the AOJ. For this reason, the SCM is adaptively shortened and tightened with both the hypolordosis of the (lower and middle) cervical spine and with the hyperextension of the head at the AOJ.

The Chicken and the Egg By the age-old wisdom of the chicken and the egg, once a postural distortion results in adaptive shortening of musculature, in other words, locked-short musculature. This increased muscle tightness then plays back on the skeletal postural distortion, in effect, locking it in place. The skeletal postural distortion causes the tight musculature, which causes the skeletal postural distortion – the chicken and the egg. Forward Head Carriage Now that thoracic hyperkyphosis leads to the lower cervical spine being hypolordotic, the head is projected anteriorly to the body so that instead of its center of weight being balanced over the trunk, it is imbalanced over thin air. This should result in the head and neck falling into flexion (until the chin essentially hits the chest) due to the force of gravity, unless some force opposes this movement. That force will likely be isometric contraction of the cervicocranial extensor musculature in the back of the neck (e.g., upper trapezius, splenius capitis, semispinalis capitis, etc.,). This leads to use, overuse, misuse, and abuse (a la Leon Chaitow’s famous verbiage) of these muscles, leading to tightness, and likely myofascial trigger points, pain, and dysfunction. Protraction of the Shoulder Girdles

Sternocleidomastoid – Permission Joseph E. Muscolino. The Muscular System Manual – The Skeletal Muscles of the Human Body, 4th ed. (Elsevier, 2017).

Returning now to the upper extremity, when the spine Terra Rosa E-mag No. 21

etc.,)â&#x20AC;Ś HOWEVER, the critical component that usually drives all of this postural distortion pattern is the thoracic hyperkyphosis / hyperflexion. At least this is almost always the case with middle-aged and older clients.

Solution?

Thoracic Joint Mobilization into Extension. Permission Joseph E. Muscolino.

rounds forward into thoracic hyperkyphosis (hyperflexion), the natural pull of gravity on the shoulder girdles (scapulas and clavicles) is to make them fall forward, in other words, protract. Protracted shoulder girdles result in shortening (locked short) of the protractor pectoralis musculature and lengthening (locked long) of the retractor musculature (rhomboids and trapezius, especially the middle trapezius). Beyond causing the creation of myofascial trigger points, a tight pectoralis minor can also cause pectoralis minor syndrome version of thoracic outlet syndrome, resulting in neurovascular compression of the brachial plexus of nerves and/or subclavian/axillary artery and vein. Medial Rotation of the Arms When the thoracic hyperkyphosis leads to to the shoulder girdles falling forward into protraction, they also fall inward, leading to increased medial (internal) rotation of the arms at the glenohumeral joints. Beyond shortening the pectoralis major (and latissimus dorsi and teres major) musculature, and stretching the infraspinatus and teres minor, leading to locked short and locked long musculature with all of its effects as previously explained in this article, all overly shortened and overly lengthened muscles become weaker by something known as the lengthtension relationship curve. Also, with a medially rotated posture of the head of the humerus, the lesser tubercle would now be lined up with the acromion process during abduction of the arm, leading to the increased likelihood of impingement syndrome of the distal tendon of the supraspinatus and subacromial bursa when the arm is raised into abduction. There, upper crossed syndrome can even lead to shoulder tendinitis! Putting it all Together Putting all this together, upper crossed syndrome can result in many â&#x20AC;&#x153;firesâ&#x20AC;? that need to be put out all around the body with competent manual therapy, as well as competent movement therapy (strengthening and stabilizing, 26 Terra Rosa E-mag No. 21

So what is the solution? What is the critical component? Whatever manual and movement therapy is necessary to lessen the thoracic hyperkyphosis. Most every manual and movement technique can have great value here, especially those oriented at stretching the anterior tissues and strengthening the posterior tissues, but I would like to propose one specific technique, that if left out, at least in most of our middle-aged and older clients, will result in a futile attempt to ameliorate this condition. That is joint mobilization of the thoracic spine into extension. We must introduce extension motion into the facet joints of the thoracic spine and it must be specifically targeted to reach the joints that are hypermobile. This usually requires very specific application of force, in other words, joint mobilization. General stretching of the spine into extension with a client who has rigid thoracic joints stuck in flexion will usually result in the person initiating the movement from the joints of the spine that can move into extension. This will often be the lumbar spine (or perhaps some thoracic spinal joints that are mobile and compensating for the hypomobile rigid joint levels). Thus we have the typical hypomobile tissues being allowed to persist due to the compensatory hypermobile tissues. Treatment must specifically target the hypomobile joints, hence joint mobilization technique. Joint mobilization can be done Grade IV (slow oscillations) or Grade V (fast thrust). The application depends on your licensure and technical expertise. Please always stay within your legal and ethical scope of practice. The point of this article is to make the case that for most of our clients who present with the postural distortion pattern known as upper crossed syndrome, it is important, perhaps absolutely necessary, to include thoracic spinal joint mobilization technique into extension as part of the treatment plan to address the thoracic hyperkyphosis.

Clinical Orthopedic Massage Therapy with Dr. Joe Muscolino

The Neck Clinical Orthopedic Manual Therapy (COMT) for the Neck covers the major clinical orthopedic assessment and treatment techniques for the neck.

31 May-1 June 2019

Joint Mobilization This workshop covers motion palpation and joint mobilisation of the entire spine (cervical, thoracic, and lumbar) as well as the sacroiliac joint and rib cage. The essence of a joint mobilization is to stretch the arthrofascial intrinsic tissues of the joint (ligaments, joint capsules, short deep muscles) . A Valuable hands-on workshop 2-3 June 2019, Sydney.

ATMS, AMT, Approved CPE/CEU Points Donâ&#x20AC;&#x2122;t miss this unique experience to train with Dr. Joe Muscolino. "Joe Muscolino is a master of his profession! His broad knowledge on the human body and extensive experience made the workshops interesting and engaging. I would highly recommend his workshops to any Terra Rosabody-worker. E-mag No. 21 27 I, Terra Rosa e-magazine, No. 11 (December 2012) myself, can't wait for the next one!" Zuzana G, North Sydney.

A Client-Centered Model of Manual Care By Walt Fritz, PT

The application of manual therapy and myofascial release differs between providers, sometimes quite dramatically. Most approaches seem to rely on the expertise of the therapist to determine what is “wrong” and apply the treatment that their training and education has shown to be the correct path. Clients typically allow and even expect this model, having come under the assumption that 28 Terra Rosa E-mag No. 21

the therapist is the “expert” and knows what is best. Even though this scenario often pans out the way it was intended, I see a few flaws with this model. My biggest concern is the massive amount of variation in the way therapists (and health professionals in general), have been trained and what they view as the problem, or cause. Invariably the therapist claims the problem to be

the target of their training, whether trigger points, fascial restrictions, knots, etc., with little regard for the lack of outward validity of these targets. The lack of outside validity calls into question reliance on claims made. My second issue is the amount of impressionability owned by most clients. They want to believe us and our claims, hoping that we have the answers to their issues, so much so that they can quite easily be led astray. I am not making accusations that therapists are purposely misleading; I am simply stating that all might be better served if we backed off on our claims. I try to ask myself, “Would my claims be accepted by the larger scope of the medical profession?” If not, I try to soften my claims. For instance, my evaluation findings often concluded that fascial restrictions in the area in question were to blame for the client’s pain. But understanding that fascial restrictions are (1) not accepted as actually occurring in the manner taught to me, and (2) there is fully acceptable proof that we can singularly and selectively impact such fascial restrictions to the exclusion of other tissues, I no longer speak in such terms.

What might I say? While I accept the concepts and understandings of pain science, I also understand that many of those concepts stray far from what a client expects to hear. As such I will negotiate a conversation and language that is not misleading or pathologizing but still gives them a simpler answer. I give them answers of what might be possibly contributing, such as, “you may have tightness within the soft tissue creating a situation of pain, or your nervous system may not have allowed a return to your previous state after whatever injury happened.” I may allude to what they believe, even if I do not agree, but I

quickly turn the conversation around to what they are feeling, vs. what I am thinking. Read through the information below to see if you can understand my approach. I wrote it in a format I will be sharing with clients in my physical therapy/manual therapy practice, so feel free to adapt it for your purposes.

Walt Fritz, PT’s Foundations Approach to Evaluation and Treatment I follow a rather novel way of performing an evaluation and applying the treatment, one that requires much more input from you, my client. I need your input in determining such things as whether or not my input (stretching, pressures, etc.) feel like they would be helpful, hurtful or neither. I cannot know what you are feeling unless I ask/ you tell me and I rely very strongly on this feedback in making treatment decisions. The need for feedback will most probably exceed what health professionals have asked you in the past, allowing you (or making you) contribute much more to the process. If you are expecting to have me make all of the decisions, then our therapeutic relationship may not work out. • Before I begin, I will fully explain the purpose of the session or technique and of my hand placement, followed by obtaining permission. Terra Rosa E-mag No. 21

• I begin in the area of complaint. Many therapists may try to convince you on the belief that your pain stems from issues (or causes) elsewhere in the body. While this could theoretically be true, I will begin where you feel your symptoms. • I will lightly place my hand/hands on the area, but I initially do nothing. This slow introduction allows you to determine if my touch feels safe to you. • If my touch feels safe, I will begin by adding graded pressures and stretch, trying to seek out areas of tightness. • If I find tightness (or similar), I will lightly add a bit more pressure or stretch (what I term, “snagging the area”) to the area, to bring about awareness. • If you’ve not already given feedback, I will ask, “Am I reproducing a sensation that is familiar to you?” • If you note nothing, I may linger a bit unless sensation is too negative. This lingering allows you time to process, but if nothing about the pressure, stretch, etc. is familiar, then I will move on. • If I did replicate a familiar feeling, I would use the 0-10 pressure/pain scale to determine the intensity of the sensation, followed by 0-10, “At what number would you stop me?” You determine the pressures that you feel would be helpful, without me influencing your decision. • A will adjust pressures according to your feedback. • I may then ask, “Does this stretch feel like it might be helpful or useful?” • If you respond to the previous question with, “yes,” then I will remain in the area and treat. 30 Terra Rosa E-mag No. 21

• If you respond to the previous question with, “no,” I will ask, “Is there anything about this stretch that feels like it might be harmful?” If you believe it might, I will immediately stop. • If all feels right to you and you feel that my stretch, pressures, or intervention feels like it might be helpful, my therapy involves me holding a slow, static stretch for long periods of time with the goal of reducing your pain or helping you to improve your functional abilities. It is a very dynamic back and forth process between the two of us. I will require you to stay aware and present throughout the session, and I may repeat my questioning on numerous occasions throughout the session(s). Please remember, I cannot know what you feel unless I ask, and I will always ask. I will stop on occasion to allow you rest and to move a bit to see what you are feeling. The goal of my treatment is to allow you to move more freely, with less pain or difficulty. I will typically follow-up with functional activities and home stretching or activities, as appropriate.

Walt Fritz, PT will be his client-centered, science-informed version of myofascial release in Sydney, NSW during August of 2019, with MFR for Neck, Voice, and Swallowing Disorders on 7-8 Aug 2019 MFR for the Upper Body: 10-11 August 2019, and MFR for the Lower Body: 13-14 August 2019. Full details and registration at: www.terrarosa.com.au You may contact Walt at walt@myofascialpainrelief.com.

Foundations in Myofascial Release with Walt Fritz Neck, Voice, and Swallowing Disorders: 7-8 Aug 2019 The Upper Body: 10-11 Aug 2019, Sydney The Lower Body : 13-14 Aug 2019, Sydney

This foundational course presents an in-depth introduction to a client-centered, science-informed version of myofascial release. Walt Fritz PT is a physiotherapist with a private practice in Rochester, NY USA and head of the Foundations in Myofascial Release Seminar™ Series.. Walt has taught his version of MFR with a sense of humour and humility throughout the USA, Canada, the U.K., Jamaica, and now Australia. “Wow what an amazing course . Walt was an amazing instructor, knowledgeable, approachable and very helpful to help us achieve our learning goals. Walt made sure that we got the MFR technique and understood how to apply it to practical situations. I have been able to apply my new skills learnt and have had positive outcomes for my clients. “ Lisa, Newcastle, AU.

Visit www.terrarosa.com.au for registration & detailed information Terra Rosa E-mag No. 21

Frozen Shoulder: The role of muscle guarding Frozen shoulder, also called adhesive capsulitis, is a common shoulder condition characterised by the pain and stiffness in the shoulder. It causes a restricted range of motion (ROM) at the shoulder. Frozen shoulder’s pain is reported to be worse at night, and is aggravated by sleeping on the affected shoulder often leading to the patient waking up several times a night. This condition tends to afflict individuals who are aged 40 and over and is more predominant in diabetics and people who have suffered a stroke, thyroid disease, recent surgery or Parkinson’s disease. Although spontaneous recovery can be expected in some cases, the average length of symptoms is 30 months. As the name suggests, it was thought to be caused by shoulder capsule chronic inflammation and fibrotic adhesion of connective tissues surrounding the glenohumeral joint. However, the pathoanatomy of this condition is not yet fully understood. Researchers from Australia conducted a preliminary crosssectional observation study to investigate if muscle guarding caused movement restriction in patients with idiopathic frozen shoulder. The study was published in the October 2018 issue of Musculoskeletal Science and Practice.

32 Terra Rosa E-mag No. 21

Five patients with painful, global restriction of passive shoulder movement volunteered for this study. The patients were scheduled for capsular release surgery for frozen shoulder. Passive shoulder abduction and external rotation range of motion (ROM) were measured before and after the administration of general anaesthesia. The observation showed that passive abduction ROM increased following anaesthesia in all participants, with increases ranging from approximately 55°–110° of preanaesthetic ROM. Three of these participants also demonstrated substantial increases in passive external rotation ROM following anaesthesia ranging from approximately 15°–40° of pre-anaesthetic ROM. See the video here https://twitter.com/LuiseHollmann/ status/1017339041803481088 This case series of five patients with frozen shoulder demonstrates that active muscle guarding, and not capsular contracture, may be a major contributing factor to movement restriction in some patients who exhibit the classical clinical features of idiopathic frozen shoulder. These findings highlight the need to reconsider our understanding of the pathoanatomy of frozen shoulder.

Response from Clinical Anatomist John Sharkey to article on frozen shoulder following anaesthaesia

(Sharkey. 2017) or changes in fascial densification (Pavan, et al. 2014). While this brief response does not provide the opportunity to discuss this important topic in comprehensive detail it does provide the opportunity to highlight the need to investigate every option in terms of therapeutic interventions and not assume we have had the only word or the last word on frozen shoulders.

This is a most interesting observational cross-sectional study providing results that, while based on a small cohort of patients, calls into question the current assumptions concerning this painful and life impacting “syndrome”. The results identified in this observational study call for a larger investigation. As a Clinical Anatomist I have had a special interest in the topic of Frozen Shoulder, or adhesive capsulitis, for over three decades.

References

Adhesive capsulitis infers that the joint capsule of the shoulder has adhesions and inflammation thereby limiting the motion available at the shoulder or glenohumeral joint. While this condition is common, its underlying origin is not well understood. This condition is more common in females than in males. The non-dominant shoulder is more affected than the dominant shoulder. The arm generally and the glenohumeral joint specifically is a highly mobile and complex anatomical structure providing the widest ranges of motion of any joint in the body. When I am teaching anatomy via cadaveric dissection I instruct students not to open the shoulder of cadavers until I am present at the table. In over thirty years of teaching anatomy and having performed many hundreds of dissections I have rarely found a truly adhered capsule on cadavers who were identified as having adhesive capsulitis when they were alive. This has led me to the conclusion that many people are “diagnosed” with a specific pathology that they simply do not have. What this recent observational study demonstrates is that even when a true adhered capsule is present the joint can demonstrate near normal range of motion under anesthesia. What does this mean for practicing therapists in the clinical setting? This finding suggests that it is not the adhesion alone that restricts range of motion. Motion is possibly restricted by a protective neuromuscular “splinting” resulting in hypersensitivity (i.e. central sensitization) in the contractile and neural tissues resulting in pain on attempted movement. According to Latremoliere and Woolf , “Central sensitization represents an enhancement in the function of neurons and circuits in nociceptive pathways caused by increases in membrane excitability and synaptic efficacy as well as to reduced inhibition and is a manifestation of the remarkable plasticity of the somatosensory nervous system in response to activity, inflammation, and neural injury.”

Latremoliere A., Woolf C. J. (2009). Central sensitization: a generator of pain hypersensitivity by central neural plasticity. J. Pain. 10, 895–926. 10.1016/ j.jpain.2009.06.012 [PMC free article] [PubMed] [Cross Ref]

Pavan, PG., Stecco, A., Stern, R., Stecco, C. 2014. Painful connections: densification versus fibrosis of fascia. Curr Pain Headache Rep. 18(8):441.doi:10.1007/s11916-014-04414 Sharkey, J. 2017. The Concise Book of Dry Needling: A Practitioner's Guide to Myofascial Trigger Point Applications. North Atlantic Press

John Sharkey MSc. Clinical Anatomist (BACA) Anatomical Society (Full Member) Exercise Physiologist (BASES) BioTensegrity Interest Group (Founding member) Dry Needle Trigger Point Specialist Senior Lecturer and Programme Leader MSc NMT University of Chester johnsharkeyevents.com Director National Training Centre 16a St Josephs Parade Dorset Street Dublin D07 F6CR Tel: 00353 18827777 Fax: 0035318308757 email: john.sharkey@ntc.ie

A treatment plan must take into account the possibility that the true source of pain and limited range of motion is due to a protective or guarding increase in contractile tone. This observational paper also highlights the need to rule out other possible sources of pain and changes in range of motion, such as myofascial trigger points Terra Rosa E-mag No. 21

Fascial Manipulation® – Stecco® method: The practitioner’s perspective Julie Ann Day Despite the plethora of information that we have access to these days, don’t we still turn to our peers for inspiration and guidance? The immense popularity of Twitter is just one example of how we seek information from others. Clinician’s don’t always have the time to peruse through all of the available literature regarding any given subject but having access to other colleagues’ insights and experience can guide us in new, thought-provoking

directions. As an Australian-trained physiotherapist who moved to Italy many years ago, since 1998 I have had the chance to study with the founder of the Fascial Manipulation® Stecco® method, Luigi Stecco, who is also a physiotherapist.

The Fascial Manipulation® - Stecco® method is a manual therapy based on biomechanical models that introduce new paradigms for incorporating the fascial system into the interpretation of musculoskeletal and internal dysfunctions. In turn, as these models are based on anatomical studies and dissections that have investigated the complexity of the fascial system they offer an approach that has a solid anatomical rationale. A significant number of professionals have recognised and embraced these models in their clinical work and, in 2017, approximately 2,500 therapists from over 50 countries attended courses addressing this method. While teaching this method in numerous countries, I have witnessed this growth of interest in the Stecco models, particularly over the last 10 years. During this time, I have encountered a wide range of therapists who have impressed me with Fig. 1. List of Contributors

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Fig. 2. Fourteen functional segments composed of parts of muscles, one or more related joints and their fascial surround. Latin terms are used to describe these segments (Illustration reproduced with kind permission from Handspring publishing).

their background knowledge, clinical experience and, yes, curiosity. In effect, the opportunity to share the impact that the Fascial Manipulation® - Stecco® method has had on modifying the clinical practice of a selection of these practitioners was the chief catalyst for compiling a new book called ‘Fascial Manipulation® – Stecco® method: The practitioner’s perspective’ (2018). Professionals from different countries, including USA, Canada, Finland, Japan, Israel, Poland and Italy, and different disciplines, such as physiotherapy, osteopathy, chiropractic and massage therapy, have contributed to this book. While there are several texts books by Luigi Stecco that explain in detail the theoretical bases and practical applications of the Fascial Manipulation® - Stecco® method (Stecco 2004, 2009, 2016, 2017), as well as a number of articles regarding clinical research into this method, this new book places emphasis on the value of clinical expertise and clinical judgement skills in such an emerging field. What struck me most while editing and compiling this book was that this representative group of 16 professionals had no particular need to adopt a completely new paradigm. They were all successful in their careers when they first encountered Stecco’s proposals. While completing

and publishing quality clinical research is vitally important, it does not always provide clinicians with practical guidelines that readily assist them in their work. Case reports are often more immediate examples that clinicians can relate to. Quite rightly professionals who have contributed to this book have approached these new models from an analytical position yet, effectively, it was the clinical results they witnessed by applying the Stecco models that convinced them to explore the method further, integrating it into their work to varying degrees. These colleagues, and many others like them, have inspired me to keep teaching this method, sharing what knowledge of fascial anatomy I have gained over the years and continuing to explore possible clinical applications. Clinical experience is one of the three cornerstones of the Evidence Based Medicine (EBM) triangle, the other two being the best available literature and patient preferences. Clinicians in all health fields are actively encouraged to cultivate evidence-based practice (EBP) approaches, and professionals have an ethical obligation to inform themselves about current evidence, to update their skills and knowledge and to apply the best available treatment modalities. However, for a number of reasons, professionals are frequently coerced into thinking that published Terra Rosa E-mag No. 21

compared many human anatomy textbooks with the diversity of vertebrate and invertebrate anatomy from the animal world, along with texts concerning acupuncture and myofascial trigger points, before developing models that focus on the role of fascial tissue in 1) musculoskeletal and 2) internal dysfunctions. Through his anatomical studies, Stecco realised that fascia is structured in a way that is suited to coordinating and perceiving the movements of the human body. According to the various anatomical layers of fascia, he divides the fascial system into 14 functional segments (Fig. 2). Each segment is governed by myofascial units that make up myofascial sequences, diagonals and spirals for musculoskeletal dysfunctions; tensile structures and catenaries for internal organ and apparatus dysfunctions and quadrants for superficial fascia dysfunctions. Stecco has identified and mapped key areas in these fascial structures where lack of sliding between fascial layers can apparently alter proprioception, muscle recruitment and internal functions, leading to symptoms of non-specific pain or myofascial pain. Therapists use his models to identify alterations in these key areas and then apply either deep friction or more superficial techniques to restore inter-fascial gliding (Fig. 3).

Fig. 3. Practitioner using her elbow to apply deep friction to the lumbar region (Photograph reproduced with kind permission from Handspring publishing).

research alone validates any given approach and that the other two cornerstones of EBP impact on their treatment choices to a much lesser degree. Yet we still look to our peers, particularly those who have more experience than us. What they are interested in, the trends they are exploring and their opinions can have great value for all of us. In this new book, each professional has been asked to present a case study, or a short case series, in which they have applied the Fascial Manipulation® method and to discuss how their understanding of the musculoskeletal system and the role of the fasciae in interactions between the musculoskeletal and internal systems has been modified since encountering this approach. The book is particularly useful for practitioners who are interested in approaching fascial work and would like to know more about the areas where it can be applied have already started to explore the models presented by Luigi Stecco by attending some of the courses and simply want to know more by hearing about the experiences of others who are currently applying this method. So, what’s new in ‘Fascial Manipulation® – Stecco® method: The practitioner’s perspective’?

The introduction presents some historical background to the development of the Fascial Manipulation® - Stecco® method. Some of you may not be aware that Luigi Stecco 36 Terra Rosa E-mag No. 21

The fascial system is a very complex, three-dimensional and multi-layered network. Simplified models are essential because they provide a sort of GPS we can follow to understand how tensional compensations spread throughout the body, where to act to resolve these tensions and, perhaps most of all, how to backtrack and re-think about our hypotheses whenever our manual therapy does not give the desired outcome. In the Introduction to this new book, you will find an outline of the two Stecco models and the assessment process used in the Fascial Manipulation® - Stecco® method, and readers can refer to these outlines to follow the clinical reasoning used in the case reports presented in each chapter. Those who are interested in exploring these models further can consult the more detailed texts by Stecco.

Chapters have been divided into three main sections: Musculoskeletal dysfunctions: in this section you will find case reports dealing with the application of the Fascial Manipulation® - Stecco® method in cases of low back pain, TMJ dysfunction, chronic ankle instability, severe sciatic-type pain in an elderly patient and runner’s knee pain, as well as several cases dealing with extended pain patterns. Internal dysfunctions: here you can read about the treatment of chronic neck pain, thoracic outlet syndrome, chronic polyuria, Bell’s palsy sequels, post-partum urinary incontinence, the resolution of partial nipple necrosis and bilateral calcaneal pain. Some of these cases sound like they could have a musculoskeletal origin but symptoms were addressed by following Stecco’s model for internal dysfunctions.

Other perspectives: this section presents a case series report on postural changes after treatment, some new proposals for Fascial Manipulation® - Stecco® method practitioners to consider and observations from a physiotherapist who applies this method in neurological paediatric cases. The concept of this book is to give voice to clinicians who in some ways have been pioneers in exploring a new paradigm for musculoskeletal and internal dysfunctions. Not all clinicians are in a position to carry out scientific studies, so their opinions and experiences often remain unheard. I hope you will find their reports as interesting as I do.

References: Day J A (Editor) Fascial Manipulation® – Stecco® method: The practitioner’s perspective (2018) Edinburgh: Handspring publishing.

Julie Ann Day is an Australian trained physiotherapist with over 35 years of clinical experience. In 1998 she began studying Fascial Manipulation® with Luigi Stecco, the Italian physiotherapist who developed this method, and she has translated four texts by Luigi Stecco from Italian to English. An authorized teacher of Fascial Manipulation® since 2002, Julie has taught Level I and Level II courses of Fascial Manipulation® in Italy, Canada, USA, UK, Poland, Finland, Denmark, and Australia, as well as presenting numerous workshops and presentations on this subject at International conferences. She is one of the founding members of the AMF (Associazione Manipolazione Fasciale) and has been an active part of its Executive Council.

Stecco L. (2004) Fascial Manipulation for Musculoskeletal Pain. Padova: Piccin. Stecco L. (2016) Atlas of Physiology of the Muscular Fascia. Padova: Piccin. Stecco L, Stecco A. (2016) Fascial Manipulation for Internal Dysfunctions-Practical Part. Padova: Piccin. Stecco L, Stecco C. (2009) Fascial Manipulation: Practical Part. Padova: Piccin. Stecco L, Stecco C. (2014) Fascial Manipulation for Internal Dysfunctions. Padova: Piccin.

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The Value of Confidence Til Luchau

When it comes to having the size of practice you want, what really, truly makes a difference? After more than 30 years training and coaching thousands of bodyworkers, from entry-level to expert, I’d formed some opinions about how to build a full and satisfying practice; and I had a ready repertory of advice to give. But though I had a long list of practitioners who had built fulfilling practices using this advice, I also knew good therapists who just couldn’t seem to get enough clients, even after years of trying. Was the difference something the practitioners did? Or, their attitudes and beliefs? Or something else, like their gender, location, or personality? Other than collecting a lot of success stories (which some would say did little more than strengthen my confirmation bias), I’d nev38 Terra Rosa E-mag No. 21

er really tested my opinions and advice about how to build a great practice. So, when a large professional organization asked me to teach an online course on the “psychology of a full practice” a few years ago, I didn’t want to just list my own opinions and ideas, no matter how good I thought they were. I wanted to know, in concrete, data-driven terms: what beliefs or attitudes do successful practitioners have, and what tangible actions do they take, that set them apart from those that don’t have the practices they want? Working together with fellow business coaches, other educators, and a good data analyst, we designed a largescale survey to look for correlations between practice

satisfaction (including both size and quality) and a variety of attitudes, characteristics, and actions. Though (with 144 questions) the resulting survey took some time for participants to complete, it proved popular, with over 2,000 practitioners completing it (including massage therapists, bodyworkers, structural integration practitioners, and a very long list of related hands-on specialties). We targeted both practitioners in private practice, and those working for someone else. Professionals from sixteen countries participated and in very similar proportions to the profession as a whole1: survey respondents were 83 percent female/17 percent male, an average age of 49, and in practice for an average of 11 years. Confidence Analyzing the data revealed a treasure trove of surprises, both in terms of what did, and what didn’t relate with practice-size satisfaction. Though I’ll share more of these highlights in future articles, one of the most significant factors was self-assessed confidence in one’s own skills. No matter what their practice size, practitioners were much more confident in their “soft” skills, such as touch and listening, than in their “hard” skills, such as anatomy or assessment. This generally lower level of technical confidence suggests there are opportunities for schools, educators, continuing education providers, and regulatory agencies to help boost practitioners’ cognitive skills and confidence. But even more interesting was that in all 6 skill areas assessed (which included a range of cognitive and relational skills), lower self-confidence was strongly correlated with saying that one’s practice size was “much too small” (Chart 1).

Chart 1: Our survey of over 2,000 professional bodyworkers revealed stronger collective confidence in “soft” (relational) skills than “hard” (cognitive) skills. It also showed a large gap in selfassessed confidence in all areas between those who described their practice sizes as “much too small” compared with those who said they were “just right.” Vertical scale shows percentage of practitioners in each group who strongly agreed with statements expressing confidence in each respective skill area. Chart courtesy Advanced-Trainings.com.

Not surprisingly, too much self-criticism was also a significant detriment to practice satisfaction. Two thirds of those with too-small practices strongly agreed with the statement “I am often critical of myself and my abilities,” while less than half of those with just-right practices agreed (Chart 2). Of course, not all confidence is good, and not all selfcriticism is bad. Over-confidence has its downsides too: egotism, arrogance, grandiosity, insensitivity, and a lack of caution or humility could be thought of as pitfalls of an excess of confidence, or self-confidence out of proportion to other’s perceptions. And without self-criticism, there would be no drive to improve. But when confidence is too low, or self-criticism too high, the survey’s results suggest that our practices suffer. While our survey measured the practitioners’ confidence in themselves, there is interesting evidence that practi-

Chart 2: Self-criticism also correlated with too-small practices. Percentage of respondents who agree or strongly agree with the statement “I am often critical of myself or my abilities,” by practice-size satisfaction. Chart courtesy Advanced-Trainings.com.

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Enhancing Confidence Twelve great ideas for increasing confidence in your skills from our panel of expert advisors, survey-takers’ comments, and from the many stories shared in our discussion forum: 1. Rack up lots of experience. If need be, give sessions away for feedback. Keep working. 2. Stick with it. Our data showed that confidence and practice satisfaction both went up significantly with time.

Chart 3: In an influential study of practitioners’ confidence in their methods, clinicians (n=60) gave patients placebos for dental pain relief. One group of clinicians knew they were giving a placebo; the other group of clinicians believed they were giving active pain medication (but were unknowingly also giving placebos). Pain was significantly less in patients whose practitioners thought they were giving actual pain medication (bottom line), suggesting that practitioner expectation and confidence can have a meaningful impact on patients’ subjective results, such as pain. After Gracely et al, 1985.

tioners’ confidence in the efficacy of their methods can influence their client’s perceived results as well (Chart 3), suggesting that it’s important to believe in your modalities and techniques, as well as your own skills2. I should point out that though it's quite reasonable to expect that increasing confidence would likely result in more clients and more satisfaction overall, our survey showed only correlation, not cause. In other words, it’s also possible that some of the confidence/practice size correlations were due to a lower number of clients causing practitioners to doubt their skills. However, even when this might be the case, increasing one’s skill and confidence clearly brings direct benefits when a practice is smaller than desired, including self-fulfillment, a sense of purpose, client satisfaction, and higher efficacy; all worthy aims, no matter how satisfied or unsatisfied we are with the size and nature of our practices.

An abridged version of this article was first published in Massage & Bodywork magazine. Thanks to expert advisors Anne Williams, Cherie Sohnen-Moe, Drew Freedman, Eric Brown, and Irene Diamond; and to in-kind contributors including Advanced-Trainings.com, ABMP, and the World Massage Conference.

Assess Your Confidence Want to know how confidence compares?

Take a quick self-assessment of key confidence indicators, or the entire full-practice survey, at http://www.a-t.tv/ abmp-full-practice-survey 40 Terra Rosa E-mag No. 21

3. Invest in quality training, or additional credentials you value. Without enough of those to believe in your own possibilities, you’re wasting the time and money you’ve already put in. 4.

Search for a mentor who believes in you.

5. Find a coach, accountability buddy, or goals-group to stay on track. 6. Get even better at providing the results your clients want. Supervision or a good training will help. 7. Collect, share and celebrate your successes, both small and large, with friends, family, peers, social media, your website. (Get a website.) 8.

Trade with peers; ask for feedback.

Ask for specific feedback from your clients.

10.

Just do it, even if you’re afraid. Action counts.

11.

Get help with self-compassion. We all need it.

12.

Lighten up. Enjoy what you do.

Til Luchau is the author of Advanced Myofascial Techniques (Handspring Publishing, 2016), a Certified Advanced Rolfer, practice coach, and a member of the AdvancedTrainings.com faculty, which offers online learning and inperson seminars throughout the world. He invites questions or comments via info@advanced-trainings.com and Advanced-Trainings.com’s Facebook page. Notes

1. ABMP. (n.d.). Massage Profession Metrics. In massagetherapy.com. Retrieved Aug. 2018, from http:// www.massagetherapy.com/media/ metrics_massage_therapists.php. 2. RH Gracely, R Dubner, WR Deeter, PJ Wolskee (1985) Clinicians' expectations influence placebo analgesia. The Lancet, 1985.

Altered patterns of pelvic bone motion determined in subjects with posterior pelvic pain A summary of the study by Barbara Hungerford, Wendy Gilleard, Diane Lee. Published in Clinical Biomechanics (2004)

In our daily practice, we all encounter patients presenting with low back pain, and there is no doubt that on-going low back pain results in a significant financial and economic burden to the health care system and society in general. In many instances low back pain is still poorly understood and not well managed, this is partly due to the medical professions obsession with costly imaging such as MRI scans and with an over-emphasis on only looking at the structure of the lumbar spine when addressing low back pain. The spine instead should be considered as a fully integrated structure rather than only examining or treating the sensitive region and what better place to start than at the base, in other words at the pelvis. The pelvis should be considered as a fundamental corner stone of the body encasing and surrounding vital organs but also constituting an important part of the spine and skeletal structure of the body. Outside of the mainstream medical profession, there is a recognition of the importance of the pelvis and sacroiliac joints, but at the same time, there is also a lot of unnecessary confusion about how best to assess and treat the pelvis. Without a clear understanding of the anatomy as well as the biomechanics of the sacroiliac joints that contribute to pelvic stability, treatment of this area has in the past utilized methods that are unsubstantiated and are not supported by the research. There is now quite a substantial body of work that has in recent years helped to clarify many of the mysteries surrounding the sacroiliac joint. A study by Barbara Hungerford, Wendy Gilleard, Diane Lee, published in Clinical Biomechanics (2004) aimed to determine altered patterns of pelvic bone motion in subjects with posterior pelvic pain using skin markers. Lumbar spine and pelvis A primary function of the lumbar spine and pelvis is to transfer the loads generated by body weight and gravity during standing, walking and sitting. During weight bearing activities, control of intra-pelvic motion is required for the transference of loads between the spine and the lower limbs. According to Panjabi (1992) stability is achieved when the passive, active and control systems work together to produce an approximation of the joint surfaces. The ability to effectively transfer load through the pelvis is dy-

namic and therefore depends on:

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Optimal function of the bones, joints, and ligaments,

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Optimal function of the muscles and fascia, and

â&#x20AC;˘

Appropriate neural function.

For every joint, there is a position called the self-braced (closepacked) position in which there is a maximum congruence of the articular surfaces and maximum tension on major ligaments. In this position, the joint is under significant compression, and the ability to resist shear forces is enhanced by tensioning of the passive structures and increased friction between the articular surfaces. The self-braced position of the SIJ is nutation of the sacrum or posterior rotation of the innominate. The study The study by Hungerford et al. determined whether the pattern of pelvic bone motion, determined by skin markers, differs between control subjects and subjects with posterior pelvic pain.

Design. A cross-sectional study of three-dimensional angular and translational motion of the innominate relative to the sacrum in two subject groups. Methods. Fourteen males with posterior pelvic pain and healthy age and height matched against fourteen controls were studied. Fifteen lightweights highly reflective 15 mm diameter balls were used to define the bony landmarks of each innominate, femoral segments, and the sacrum. A 6-camera motion analysis system was used to determine 3D angular and translational motion of pelvic skin markers during standing hip flexion. Terra Rosa E-mag No. 21

Results During the hip flexion component of the standing hip flexion movement, there was no significant difference in the patterning of translational motion between groups on the side of hip flexion. Posterior rotation of the innominate occurred with hip flexion in control subjects and pelvic pain subjects as previously reported in the literature. However, on the side of single leg support: a significant difference in the pattern of translational motion of the innominate between controls and symptomatic subjects was determined. In the control group, posterior rotation of the weight bearing innominate occurred on the side of single leg support. However, in the posterior pelvic pain group, anterior rotation occurred on the symptomatic side. In summary, on the supporting leg, the innominate rotated posteriorly in controls and anteriorly in symptomatic subjects. Conclusion

Each subject in the posterior pelvic pain group reported unilateral pain over the posterior pelvic/SI region for greater than two months and no pain above the lumbosacral junction. The pain was consistently and predictably aggravated by activities that vertically loaded the pelvis (walking, standing or sitting). Positive results on the side of posterior pelvic pain in clinical tests for impaired lumbopelvic stabilisation. These tests included: Active straight leg raise test: A positive test was indicated when the pelvis failed to remain in neutral alignment, and the subject reported difficulty or inability to elevate a straight leg in supine. Standing hip flexion test: During a left standing hip flexion test, the subject stands on their right leg and flexes the left hip towards 90â °. The left innominate should posteriorly rotate relative to the sacrum. A positive test was indicated when the superior motion of the posterior superior iliac spine (PSIS) was palpated relative to the sacrum. Neutral zone analysis test (joint play): this test was used to evaluate motion in the neutral zone of the SIJ. All symptomatic subjects demonstrated asymmetric stiffness of the SIJ when the innominate was glided relative to the sacrum (analysis of the neutral zone).

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Posterior rotation of the innominate, as measured using skin markers during weight bearing in controls may reflect activation of optimal lumbo-pelvic stabilisation strategies for load transfer. Anterior rotation occurred in symptomatic subjects, suggesting a failure to stabilise intra-pelvic motion for load transfer. Counternutation of the sacrum, or anterior rotation of the innominate, is thought to be a relatively less stable position for the SIJ. The findings from this study support the self-braced position of the SIJ as one that relies on nutation of the sacrum or posterior rotation of the innominate. Relevance This study found that posterior rotation of the innominate occurred during weight bearing in controls. This movement pattern is thought to optimise stability of the pelvic girdle during increased loading. Conversely, anterior rotation occurred in symptomatic subjects during weight bearing. This is a nonoptimal pattern and may indicate abnormal articular or neuromyofascial function during increased vertical loading through the pelvis.

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Demystifying the SIJ & Pelvis with Taso Lambridis Sydney, 17-18 November 2018 Why another SIJ and pelvic course? Over the past 15 years there has been a continued interest and research into this often complex region however there are still many unanswered questions regarding the fundamental function and role of the SIJ. There is an ongoing debate on what if any role the SIJ plays in the cause of low back pain as well as continued controversy about how best to treat SIJ or pelvic problems. Taso has been running his SIJ series of courses since 2010 and presents a comprehensive 2 day course aimed at enhancing your understanding of this key region of the body.

Over the 2days participants will have the opportunity to explore the biomechanics and fundamentals of pelvic stability responsible for optimal function of the SIJ and pelvic region. The course is designed around the small group learning experience so that you can benefit from the individual attention.

The course material is underpinned by current knowledge of the anatomy and biomechanics and provides an evidence approach to treating SIJ dysfunction that will challenge previously acquired misconceptions about the cause of SIJ dysfunction and ultimately lumbo -pelvic pain.

Taso Lambridis is a highly skilled Physiotherapist from South Africa with over 20 years experience treating musculoskeletal and sporting injuries. He has gained extensive experience having worked internationally and his clinical area of expertise is treating complex lumbar spine and pelvic injuries. Taso has a post-graduate MSc Sports Medicine degree from the UK and has worked in elite physiotherapy and sports clinics in London where he treated professional rugby players, English Premiership football players, elite triathlete and runners as well as dancers from Londonâ&#x20AC;&#x2122;s leading West End theatre shows, dance academies and schools for the performing arts.

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For more information & Registration Terra Rosa E-mag No. 21 Visit www.terrarosa.com.au

The Efficacy of Vibrating Rollers Foam rollers has become a popular a self-myofascial release gizmo among health and fitness professionals. Studies have shown that foam rollers can enhance joint range of motion (ROM). Recently vibrating foam rollers were introduced allowing a combination of vibration therapy and foam rolling. A few studies have confirmed its efficacy. On Range of Motion and Pressure Pain Threshold A study headed by Dr. Scott Cheatham from California State University compared the effectiveness of a vibrating roller and a conventional roller intervention on knee flexion range of motion (ROM) and pressure pain thresholds (PPT) of the quadriceps. The study, published in Journal of Sport Rehabilitation, recruited 45 recreationally active adults, whom were randomly allocated to one of three groups: vibrating roller, non-vibrating roller, and control. The results showed that vibrating roller had the greatest increase in PPT (180 kPa), followed by the non-vibrating roller (112kPa), and control (61 kPa). A high value indicates the participant can withstand higher amount of pressure pain. For knee ROM, the vibrating roller demonstrated the greatest increase in ROM (7 degrees), followed by the non-vibrating roller (5 degrees), and control (2 degrees). The authors suggested that a vibrating roller may increase an individualâ&#x20AC;&#x2122;s tolerance to pain greater than a nonvibrating roller. Part of Warm-up Routine

Another study from Taiwan published in Journal of Sports Science investigated that the immediate effects of foam rolling, vibration rolling, and static stretching as a part of a warm-up regimen in young adults. Compared with the pre-intervention, vibration rolling induced the range of motion of knee flexion and extension significantly increased by 2.5% and 6%, respectively, and isokinetic peak torque and dynamic balance for muscle strength and dynamic balance increased by 33%-35% and 1.5%, respectively. In the three conditions, most outcomes 44 Terra Rosa E-mag No. 21

between vibration rolling and regular rolling were comparable; however, the participants had a significantly higher knee joint reposition error after non-vibration rolling, indicating that foam rolling could have a knee joint proprioception hampering effect. Compared with static stretching, vibration rolling significantly increased the quadriceps muscle strength by 2-fold and dynamic balance by 1.8-fold. The authors suggested that these findings could inform athletic professionals to consider vibration rolling for designing more efficient and effective pre-performance routine. Cross-education Effect A study from Spain explored further the effects of the application of a foam roller on the ankle dorsiflexion mobility. It also examined the effect of vibrating foam roller applied to the ankle plantar flexors muscles. Thirty-eight undergraduate students participated in the study (19 males and 19 females). The participants were allocated to each of the three treatments (3 sets of 20 s) in random order: 1) foam roller, 2) vibrating foam roller, and 3) no foam roller or vibration (Control). All treatments were applied to the dominant leg, separated by at least 48 hours and were conducted at the same time of day. Ankle dorsiflexion ROM and plantar flexor were measured in both legs before and immediately after the treatment. The results showed that foam rolling caused an increase in ankle dorsiflexion ROM in the treated and contralateral untreated limb. Ankle mobility was increased 6-7% with the application of either Roller or vibrating roller. However, maximum voluntary IC was not affected by foam roller. The addition of the vibration stimulus with foam rolling did not further increase ROM compared to foam rolling alone. The authors concluded that foam rolling with and without vibration increase ankle mobility and produced a crosseducation effect.

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“"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 selfefficacy. 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. 21

Research Highlights Stretching Reduces Tumour Growth in a Mouse Breast Cancer Model There is growing interest in developing nonpharmacological treatments that could boost natural defences against cancer and contribute to cancer prevention. Recent studies from Osher Center for Integrative Medicine at Harvard Medical School have shown that gentle daily stretching for 10 minutes can reduce local connective tissue inflammation and fibrosis.

As mechanical factors within the stroma can influence the tumour microenvironment, the researchers investigated whether stretching would reduce the growth of tumours implanted within locally stretched tissues. They tested this hypothesis on mice. Female FVB mice (N = 66) were injected with mammary tumour cells. Mice were randomized to stretch vs. no stretch, and treated for 10 minutes once a day, for four weeks. The animals are held by the tail and gently lifted, allowing their front paws to grasp a bar, as a stretching treatment. Tumour volume at end-point was 52% smaller in the stretch group, compared to the no-stretch group in the absence of any other treatment. Cytotoxic immune responses were activated, and levels of Specialized ProResolving Mediators were elevated in the stretch group. The results suggest a link between immune exhaustion, inflammation resolution and tumour growth. However, the researchers still donâ&#x20AC;&#x2122;t understand the mechanism how stretching reduces tumour growth. The authors suggested that stretching is a gentle intervention that could become an important component of cancer treatment. They also caution that this preclinical research on mice does not suggests that cancer patients should stretch instead of receiving cancer treatment.

Injured an arm? Train the other arm to gain strength The concept of contralateral effects can be very important when rehabbing after an injury. If a limb in injured, the immobilization necessary to allow time for it to heal, can result in muscle atrophy in that limb, resulting in decreased size and strength. 46 Terra Rosa E-mag No. 21

It is known that stretching one side of the body can influence the flexibility of the contralateral, unstretched side of the body. This effect is also observed in strength training in which unilateral training of a limb enhances performance of the contralateral untrained limb. A study published in the April 2018 issue of the Journal of Applied Physiology, investigated if exercising muscles of a healthy, uninjured limb can prevent atrophy of the muscles of the contralateral immobilized limb. The nondominant forearm of 16 participants was immobilized with a cast. Participants were then randomly assigned to a resistance-training group in which the uncasted limb was trained (eccentric wrist flexion contraction, 3 times/week), or a control group that had no resistance training. The period of the study was one month. In the control group, the wrist flexor musculature of the immobilized casted limb was, on average, more than 20 percent weaker; and those muscles had also shrunk in size, dropping approximately three percent of their mass. In comparison, the resistance-training group showed strength preservation of the wrist flexor musculature of the immobilized limb that was not trained (as well as increased wrist flexor strength of the non-immobilized limb that was directly trained). Strength preservation was nonspecific to contraction type (strength preservation was found for all three types of muscle contractions: concentric, eccentric, and isometric). But strength preservation was specific to the wrist flexor musculature that was trained in the other limb. In other words, strength loss was found in the other muscle groups of the immobilized limb in the resistance-training group. These findings suggest that eccentric training of the nonimmobilized limb can preserve size of the immobilized contralateral homologous musculature (musculature that had the same functional joint action).

Research Highlights The Effect of Massage Therapy on Blood Pressure in Prehypertensive Women Prehypertension, also known as high normal blood pressure, is a condition when a person’s blood pressure is elevated above ideal normal, but not to the level considered hypertension. Lowering the risk of prehypertension developing into hypertension is therefore essential. A study from University of Isfahan in Iran investigated the long-term effect of massage therapy on blood pressure in prehypertensive women. A single-blind clinical trial study was conducted on 50 prehypertensive women during a 6-month period. Participants were randomly selected to receive treatment or control. The treatment group (25 patients) received massage for 10-15 min, three times a week for 10 sessions. The control group was relaxed in the same environment but with no massage. The results indicated that the mean systolic and diastolic blood pressures in the massage group were significantly lower in comparison with the control group. The results also showed that the lowered blood pressure was still observed 72 hours after the treatment, and there was still a significant difference between the test and control groups. The control group did not show changes in blood pressure. However, at the two-week point after the study, there was no significant difference in the blood pressure between the two groups. The study suggests that blood pressure lowering effects of massage is temporary and lasts between 3-14 days after the massage therapy treatment.

Does text neck exist? Text neck is referred to as neck pain caused by the head posture during reading and texting on a smart phone. While it is of a concern, some called that there is no such thing as a text neck. A recent study from Brazil recruited 150 students between 18 and 21 years old from a public high school in Rio de Janeiro to investigate whether there is an association between text neck and neck pain. The results showed that the majority of the participants (77%) reported more than 4h of mobile phone use per day. The physiotherapists’ judged 40% of the participants’ posture as text neck, while 85% self-reported text neck. Based on the data, the authors found that text neck was not associated with either neck pain or the frequency of neck pain. The authors concluded that their results conflict with the idea that the mechanical stress caused by poor posture due to mobile phone use is a threat to cervical spine integrity and challenge the belief that inappropriate neck posture during mobile phone texting is the leading cause of the growing prevalence of neck pain. The Chartered Society of Physiotherapy supported it with a statement that the use of phones is likely to be 'incidental' to the development of neck pain, the use of phone is the same as reading a book, which we have done

for centuries. Dr Joe Muscolino commented that indeed there is nothing new in “texting neck” posture. The forward flexed posture can be found while one is reading a news paper or book. The difference, is the tremendous increase in time spent in this texting posture. Digital devices are not the enemy, it is the tremendous amount of time that we spend in the forward flexed craniocervical poor posture using them that is the enemy. Pain is often the result of long-standing repetitive overuse. Just as it is unlikely that a young adult who smokes cigarettes would experience lung cancer or any of the other deleterious effects of smoking when still young, it is also unlikely that a young adult would experience any of the deleterious effects of postural distortion patterns. So, can we say that there is no link between texting neck posture and neck pain in young adults? Yes. But can we say that texting neck posture is therefore healthy? NO! Mechanics do matter, that forces into tissues do matter, then there will have to be some price to pay, somewhere down the road, for the increased chronic repetitive asymmetrical forces into our soft and hard tissues. Even if the price is not direct pain, it will be in tissue adaption dysfunction.

Massage is the Best Post-exercise Recovery Techniques Training in athletes frequently involve repeated eccentric contractions and tissue vibrations that can lead to muscle damage (i.e., the disruption of structural proteins in muscle fibres and/or connective tissues), subsequent tissue inflammation, delayed onset muscle soreness (DOMS), and increased perceived fatigue. These conditions can lead to a temporary reduction in muscular force and an increased risk of injury. Thus it is important for sports physician to optimize the recovery period in order to manage muscle damage and alleviate DOMS, inflammation, and fatigue. Researchers from France attempted to provide an evidence-based approach for choosing post-exercise recovery techniques. They also looked at studies that measured changes in the blood concentrations of muscle damage indicators [i.e., creatine kinase (CK)] and inflammatory biomarkers [C-reactive protein (CRP) and interleukin-6 (IL6)] that are observed after exercise and are associated with the occurrence of DOMS. The study published in Frontiers in Physiology conducted a meta-analysis by searching through 3 scientific databases and found 99 studies that were related to the topic. The literature showed that active recovery, massage, compression garments, immersion, contrast water therapy, and cryotherapy induced a small to large decrease in the magnitude of DOMS, while there was no change for the other methods (e.g. stretching). Massage was found to be the most powerful technique for recovering from DOMS and fatigue. In terms of muscle damage and inflammatory markers, the review observed an overall moderate decrease in creatine kinase and overall small decreases in interleukin-6 Terra Rosa E-mag No. 21

Research Highlights and C-reactive protein. The most powerful techniques for reducing inflammation were massage and cold exposure.

outcome was relative muscle activation amplitude between research and control subjects.

The authors concluded that Massage appears to be the most effective method for reducing DOMS and perceived fatigue. Water immersion and the use of compression garments also have a significant positive impact but with a less pronounced effect. Perceived fatigue can be effectively managed using compression techniques, such as compression garments, massage, or water immersion. Furthermore, the most powerful techniques that provide recovery from inflammation are massage and cold exposure, such as water immersion and cryotherapy.

The results of the experiment showed muscle activation along the superficial back line was observed during distal movement (plantar flexion or neck extension). LBP patients showed significant lower muscle activation in the erector spine of lower back region compared with the control group during active plantar flexion and active neck extension. Healthy controls were able to recruit more proximal muscle along the myofascial chain with greater power. Lower muscle activation in other regions (gastrocnemius, hamstrings, erector spine level T6) was observed in the research group but the difference is not statistically significant.

The authors added that in this meta-analysis, only one recovery session was examined. Further research needs to confirm if similar outcomes can be obtained when the same recovery technique is used on a regular basis after exercise.

Massage Therapy Improves Training of Elite ParaAthletes Researchers from South Carolina examined the effect of massage therapy on the performance goals on the bike, as well as the quality of life off the bike, in elite paracycling athletes (para-athletes). The study published in the journal BMJ Open Sport and Exercise Medicine, involved one team, with nine paracycling participants, during their training from January 2015 until the Rio Olympics in 2016. Onehour massage sessions were scheduled one time per week for 4 weeks, and then every other week for the duration of the time the athlete was on the team and/or in the study. The results showed that massage therapy afforded significant improvement for sleep, muscle tone (tightness), and recovery from workout while in training for paracyclists.

The authors concluded that LBP may causes or result in a lower muscle activation of the muscles along the superficial back line. The implication of this study is that therapists should treat the patient in more holistically along the myofascial line and not to only focus on muscles at certain regions.

Massage Promotes Muscle Regrowth Even on Opposite Leg A recent study published in The Journal of Physiology hypothesized that the mechanical activity associated with massage induces an anabolic (growth) effect in skeletal muscle undergoing regrowth after a period of atrophy.

The experiment used rats, where they were randomly assigned into four groups: weight bearing (control group with no muscle atrophy), hind limb suspended for 14 days, hind limb suspended for 14 days followed by recovery for 7 days, and suspended limb followed by recovery for 7 days of weight bearing and movement supplemented with masThe authors concluded that this real-world study provides sage as a 30-minute cyclic compressive loading applied to new information to support massage therapy as a valuable the right gastrocnemius every other day for 4 rounds of treatment approach for physical improvement during treatment. training and recovery after training in elite paracyclists. The outcomes show that the average muscle fibre of gastrocnemius after immobilization was decreased by 38%. Muscle fibre cross-sectional area was enhanced by 18% Decreased muscle activation along the back myofascial with massage performed during the 7-day recovery period, line in subjects with low back pain compared to 7-day recovery period without massage. This The myofascial chain or myofascial continuity concept sug- is due to improvement in the making of protein in cells. gests that muscles activate along kinematic chains with The surprising outcome is that the contralateral, noncommon fascial coverings. Researchers from Haifa, Israel massaged limb in the massage treatment group exhibited examined muscle activations along the superficial back line a comparable 17% higher muscle fibre size. in LBP patients compared to healthy controls. The study was published in Journal of Back and Musculoskeletal Re- The authors hypothesised that massage acts through the activation of the sympathetic nervous system to cause the habilitation anabolic cross-over effect through direct neural mechaThe study recruited 20 males with chronic LBP and 17 nisms as well as endocrine-like processes. Alternatively, healthy controls. All subjects underwent five test condimassage can cause the release of factors from muscle tions: Conditions 1-3 involved passive movement, active (such as myokines) that can influence muscles or other movement and active movement against maximum isoorgans at distant sites. metric resistance of the right gastrocnemius muscle. ConThe authors conclude that massage in the form of cyclic ditions 4 and 5 involved neck extension without and with compressive loading induces an anabolic response in musisometric resistance from the prone position. The main cles regrowing after a period of inactivity. Muscle loss can 48 Terra Rosa E-mag No. 21

Research Highlights be rapid during periods of immobilization, such as during bed rest, and it is extremely difficult to grow back, especially in older people.

Do longus capitis and colli stabilise the cervical spine? The longus colli and longus capitis are two small muscles spanning multiple cervical motion segments and located deep in the anterior neck, lying against the cervical spine’s anterior bodies and transverse processes. These muscles are often termed the ‘deep cervical flexors’, and are proposed to play a role in stabilizing the cervical spine. Dysfunction of these muscles has been shown in whiplash and chronic neck pain utilizing the cranio-cervical flexion test (CCFT).

Lumbodorsal fascia as a potential source of low back pain In the past few years, the lumbodorsal (thoracolumbar) fascia has been proposed as one of possible sources of “idiopathic low back pain” (pain that is stated as having no known cause). Authors Jan Wilke, Robert Schleip, Werner Klinger, and Carla Stecco wrote a review in Biomed Research International investigating the possible role of the lumbodorsal fascia in patients with low back pain, with special focus on combining findings from histological studies and experimental research. The authors proposed three possible mechanisms for fascia-mediated low back pain sensations: microinjuries irritating nociceptive nerve endings in the lumbodorsal fascia may directly induce back pain

Researchers from University of Otago in New Zealand published a study in Musculoskeletal Science and Practice which describes the fascicular morphology of the longus capitis and colli, and estimates their peak force generating capabilities across the individual cervical motion segments.

tissue restructuring, for example following immobility, chronic overloading, or microinjury, may compromise proprioceptive signalling, which by itself could decrease the pain threshold by means of an activity-dependent sensitization of wide dynamic range neurons

The study used a cadaveric dissection to reveal the architecture and morphology of longus capitis and colli; magnetic resonance imaging (MRI) of these muscles in healthy volunteers to measure in vivo muscle volumes, and finally biomechanical mathematical calculationof the peak.

nociceptive input from other tissues innervated by the same spinal segmental levels could elicit an increased sensitivity in the lumbodorsal fascia (Figure 2).

The authors highlight the complex anatomy and small force capacity of longus capitis and colli, and have implications for the efficacy of their function. In particular, they found a small peak compression forces indicate that these muscles have a limited capacity to contribute to cervical stability via traditional mechanisms. This implies that the mechanism(s) by which cervicocranial flexion exercises produce clinical benefits is worth exploring further.

All too often, the medical world ignores the contribution of extra-articular myofascial tissues to low back and other pain and dysfunction syndromes. Consequently, if no osseous structural damage is found on radiographic examination (x-ray) and no annular disc damage is seen on MRI examination, the patient’s / client’s pain is often described as idiopathic, in other words pain from an unknown origin (the word root “idio” comes from the same origin as the word “idiot”). Dr Robert Schleip added its implication for manual therapists:

Massage therapist and Educator Til Luchau commented that, though conventional approaches often conflate stability with strength, there may be metrics other than strength that can improve our therapeutic outcomes. For instance, what if the neck structures involved contribute more than just brute force? The deep muscles of the anterior cervical spine, like the psoas on the anterior lumbar spine, are extremely sensitive; could it be that they act as length-variable sensors, contributing to stability and adaptability via their rich mechanoreceptor capabilities, maybe even more than they contribute as prime movers? And, what if stabilization itself is also a function of refined perception and variable adaptability, as much (or more) than it is a function of raw contractile power (which is what the study measures)? The authors’ inviting conclusion leaves a door open: Refined proprioception and more options for subtle adaptability are two such areas that many of us are actively exploring in our practices every day.

And, of course, various combinations of these three processes are possible.

“For manual therapists this article supports the long-held assumption that at least some cases of low back pain may originate from the lumbar fascia. The reduced shearing mobility of the lumbar fascia seems to play a central role in these cases. Since this will tend to reduce proprioceptive signalling from the lumbar fascia, it should be beneficial to include manual techniques in the treatment of low back pain patients which involve horizontal tissue traction (parallel to the skin) rather than only vertical compression. Another conclusion for many low back pain cases will be that a myofascial treatment focus on superficial tissue layers may often be more efficient that a focus on deeper tissues. Working with the patient in a prayer position (child’s position in yoga) or similar, in case that is easily possible, can be good way to direct the manual deformation mainly towards the then pre-stretched lumbar fasciae on the surface, while having the deeper muscle fibres in a relatively relaxed state. No wonder that this position is frequently included in most fascia oriented yoga styles, but also in the Rolfing method of myofascial integration. “

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