Terra rosa E magazine issue 15

Terra Rosa E-magazine Open information for Bodyworkers

www.terrarosa.com.au

Terra Rosa E-Magazine, No. 15, December 2014

contents

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Fascial Training for Soccer Players , An interview with Markus Rossman

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Interoception—Some Suggestions for Manual and Movement Therapies—Robert Schleip

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Report from the 2014 Fascia Summer School— Alison Slater

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FFT Case Study: Exposed Leg Fractures—Ron Alexander

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Plantar Fasciitis: High loading strength training improves outcome - Michael Rathleff

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Comments on Plantar Fasciitis—Joe Muscolino

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Treatment of Plantar Fasciitis—Judah Lyons

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Comments on Plantar Fasciitis—Art Riggs

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Comments on Plantar Fasciitis—Til Luchau

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Touch is Everything—Art Riggs

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Fascia: A Body wide Organ — Paolo Tozzi

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CORE Myofascial Therapy— George Kousaleos

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Workshop Report: CORE Myofascial Therapy & CORE Sports and Performance Bodywork

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Research Highlights

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6 Questions to Paolo Tozzi

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Featured Front Cover: 6 Questions to Jo Phee

Front Cover: Jo Phee

52 Published and made freely available by: Terra Rosa www.terrarosa.com.au www.massage-research.com

Disclaimer: All material provided in this e-magazine should be used as a guide only.

This information should not be took or used as a substitute for professional or medical advice. The publisher of this e-magazine disclaims any responsibility and liability for loss or damage that may result from articles in this publication.

Fascial Training for Soccer Players An interview with Markus Rossmann Are there still power reserves remaining unused by elite athletes? Markus Rossmann says there are. He teaches soccer coaches how to train their fascia.

Frank Aschoff spoke with him.

Golf Roll: Typical for the fascial training: The athlete is given a basic exercise and then discovers his optimal individual position, which lets him actively stretch the areas that need stretching. At first, this might seem like an unfamiliar procedure. The shown exercise is used by professional golfers (amongst others) to get ready for a tournament. However, it could be an interesting, effective and new idea for the warm-up program of a soccer player as well.

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Fascial Fitness for Soccer Flamingo I Goal: flexibility of the complete back of the upper leg, while including the fascial net of the whole body

What made you pick soccer players as your target group for fascial training?

I’m an athlete myself. I’ve played basketball in the regional league and in the second division, and I have been a youth coach for many years. I have known for a long time that a special training of the fasciae can boost an athlete’s capacity and prevent injuries. It can also be used for rehabilitation.

Bring body weight over the leg, feel the tension.

This well-known exercise now gets a twist: the game with different motion vectors begins. You can look for new, unfamiliar tension. Once you find a position, you should bounce lightly three or four times, and then move on to a new position.

The boosted capacity can be explained easily: An elastic fascial network results in a smaller consumption of energy while moving, this can set aside power reserves that a soccer player might need in the defining last ten minutes of a game. A second important aspect that I have experienced is that the fascial training improves the presence on the field.

Players talked about a better sense of direction, being able to comprehend faster where were their teammates and opponents, and more precise passes and shots.

How can this be explained?

A very big part of someone’s own body perception, their proprioception, is influenced by the fascial system—more than the well-known receptors near the joint which fire when the joint is at the end-range position. This is how you can explain the observed effects on the field. The fascial network is our largest sensing organ, so it is only logical to train it.

Currently, a lot of attention is drawn to this subject and many reports refer to the well-known international fascia researcher, Dr. Robert Schleip.

In what way are you working with him?

It is very important to remember the playful aspect of this (“Everything is allowed”): for example, changing the position of the leg or the torso, changing the position of the arm, or changing the position of the head.

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Everyone can discover where one feels the tension.

He is a Rolfing instructor and was the one that trained me as well. He also let me be a part of his practice quite soon. I knew that he was doing a lot of research, and then he asked me if I wanted to work with him on a new concept for moving that lets you actively train your fascia. In the beginning, there were five or six of us that worked closely together. My job is to

Fascial Fitness for Soccer Flamingo II Goal: flexibility of the complete back of the upper leg, while including the fascial net of the whole body, but unlike the Flamingo I, more focus on the torso or the thoracolumbar fascia

turn their latest scientific discoveries into actual moves. It’s a fact that people have always been training both muscles and fascia. Obviously they cannot be separated. We are moving the focus on the fascia. While people train, we let them move in a way that activates more of the fascial component, and therefore makes them need fewer muscles. This way of moving is well known to a lot of people, and yet it is somehow new to them.

So research results are continuously put into practice ?

Yes, we are very lucky that Dr. Robert Schleip is close to the source and that he regularly keeps us informed on the latest research findings.

What have you done with the soccer players so far?

Another well-known exercise, but with a slight modification: bounce lightly, again a change of vectors (directions), look for a different position, as shown: turn to your side.

Alternate with feet pointing towards each other.

So far, I mainly provided training for trainers, especially at the soccer association of WĂźrttemberg, at the Bavarian soccer association, but also at the federation of German soccertrainers. Those are the ones with the highest trainer certification. However, I am not only involved in soccer, but in many other sports like golf, triathlon and long-distance track. On an occasion, I was also a trainer at a summer camp for Norwegian biathletes.

What do you offer to soccer trainers?

First, I offer some theoretical basics particularly concerning soccer. Soon, we focus on practicing. The course participants do a lot of exercises. This way, the trainer can feel the effects for themselves, which is important! It then becomes clear to them: We can change how we move in a way that activates our fascial network more.

Point feet to the inside, combine with turning sideways.

Feet turned to the outside.

It is no secret that many soccer players are not that flexible and often suffer from pulled or torn muscles.

This is why I bring up the fascia roll in courses. After the trainers have worked with the roll for 15 minutes, they usually feel like they are able to move a lot more easily. Also, they notice very quickly that the finger to

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Fascial Fitness for Soccer floor distance is reduced by a lot.

They say, “I can reach further down now!” Every soccer player has areas of struggles. Often, we can take active measures to prevent problems, or help with a looming pulled muscle.

I have been told various times by the players that they were able to go back to training the very next day.

Straight Jump Goal: Improving the catapult capability of the Achilles tendon and at the same time preventing injuries

Another important aspect is the “fascial stretch” which offers threedimensionality. When doing so called “correct axial stretches”, we only stretch a small part of the neglected parts. There’s no impulse. It is essential, not only for soccer players, to move on to a change of vectors (directions). The athlete can discover for himself: Where do I feel the pull?

Where do I feel this exercise? That’s something no trainer can tell him, everyone has to feel it for himself.

So, no more one-dimensionality. It’s time to move on to threedimensional stretching with many changes of vectors.

You know, each person is an individual. Everyone has a different bone structure, different muscles, different fascia, and, most of all, a different everyday life. While one person sits behind his or her desk all day, another works physically in the construction business. Their bodies are being formed individually. However, when it comes to sports, everyone is told to do the same stretches in the same positions. It just doesn’t make sense.

Swing movements

Jump

Only once the athlete starts looking for better ways, when he tries various vectors changes, he will be able to activate a wide range of fasciae and muscles, and he will be prepared for bigger athletic challenges.

You are talking about a playful element as well.

Definitely. A basic exercise is given, and then everyone can find the area where he or she feels the pull: “I have potential there, I can work on that.”

And then they are allowed to do continuous, soft and bouncy movements in that specific direction – exactly

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Land like a “ninja”, meaning bounce silently and softly, while changing the position of your legs. For this exercise, one’s feet should point to the inside.

Land with feet turned to the outside.

Fascial Fitness for Soccer Power Leg Goal: Using the catapult effect for better movements when shooting

what we were told not to do for thirty years.

How do you explain this new attitude towards bouncy movements to the trainers?

Initial position with lead and trail leg

First bouncing phase: “whiplash motion“, meaning a maximum of prestretching.

While the trail leg is moving back to its initial position, your upper body and pelvis should already be moving forward.

Well, the goal is a tear-resistant, elastic fascial network. With examples such as the Achilles’ tendon, science has clearly shown that there can only be an impulse with bouncy movements. Normal stretching, without bouncing or pre-stretching, is not enough for an impulse! You can look at the tendon like a rubber band. It can conserve energy or give it off. To get low energy consumption, it needs optimal elastic characteristics. To train the Achilles’ tendon to have this elastic quality, you don’t have to do any extra training. All it takes is the inclusion of this knowledge in the normal training. For instance, a good exercise to improve the catapult effect of the Achilles’ tendon are bouncy, teetering movements when going up the stairs –of course, after pre-stretching.

What are the typical areas a soccer player struggles with?

Mainly the calf muscle, hamstrings, quadriceps, but obviously, the lumbopelvic and hip area.

Groin problems are fairly common, too. What about those?

There is still need for more research.

If we’re lucky, we will have new insights soon.

How do the athletes react to the new exercises?

Second bouncing phase

After swinging forward, you move right on to using your own body weight for the next movement cycle.

The majority of the prescribed exercises receive positive feedbacks, because the soccer players can feel the improvement straight away. Also, it is diverse and entertaining. The area of the Sensory Refinements, or the proprioception exercises, takes sometime to get used to by many players.

Often, they smile at me oddly when I asked them to turn around on the floor and “toll”. However, once they gave it a try, they quickly realized that it does a lot for them, especially

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Fascial Fitness for Soccer Starfish Goal: Improvement of the body perception, mainly of the contralateral movements, which are extremely important when it comes to running and shooting.

Start movement

Initial position

Initiate a turn to the left, bring your left elbow and your right knee closer together, and at the same time stretch the entire right side of your body.

once they’re out on the field again.

The new insights about fascial training are not being used to their full potential yet, especially in male sports. Luckily, as an athlete, I know how to “sell” these exercises. I know that I don’t need fancy instructions, so I don’t use instructions such as “Imagine you are a starfish…” that were meant to stimulate the imagination.

Mr. Rossmann, what is your next goal?

The plan is to include the positive effects of fascial training in many different sports. I’m highlighting the word “include” here, because it is extremely important for us to make clear that fascial training is just another tool in the “training and ther-

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As soon as the centre of the body weight lies on the left side, you change positions into the relaxed “embryo position”. Don’t remain in this position for too long, but instead move on to the opposite, contrasting movement. To enjoy the full potential of this exercise, continue doing those flowing motions for three to four minutes.

apy” tool box. When used correctly as a part of training and therapy, I promise a bigger capacity, faster healing and a lower risk of injuries.

Another big goal has to be the inclusion of fascial training in mass sports.

It is simply a fact that it allows you to do more for your health in less time – and this is a trend that fits our modern lives perfectly.

IMAGES All photographs by Mira Hampel for the Fascial Fitness Association INTERNET RESOURCES Webpage of the Fascial Fitness Association www.fascial-fitness.com Fascia Research Group

Last but not least, there is a byproduct of fascial training we should not forget about: it encourages creativity and self-responsibility. Two things that we don’t get too often in our working life or in the society.

Thank you for this interview!

www.fasciaresearch.de Webpage of Markus Rossmann: www.concept-rossmann.com Webpage of the European Rolfing Association: www.rolfing.org

Basic principles of Fascial Fitness Fascial Stretch Playful, creative whole-body fascia and muscle stretching can stimulate the fascial network perfectly. A multidirectional, bouncy stretching prepares the soccer player (athlete) specifically for the extreme, three-dimensional, and physical pressure during a competition or practice.

Rebound Elasticity Only by pre-stretching the fascial network, the maximum of physical strength can be achieved. This training boosts the so-called “catapult effect”. It supports the process where motions can be done with less muscle energy, which leads to fewer tendon and ligament injuries.

Fascial Release Fascial Release is a self-treatment method using a fascia roll. It lets you dissolve adhesions and soften the tissue. This results in more flexibility and better physical ease that you can feel right away. Fascial Release should be done before (fast rolling) and after (slow rolling) practice and competitions.

Sensory Refinement Considering that the fascial network is our largest sense organ, the fascial system should be stimulated to its maximum capacity when thinking about our body perception. At times, this makes delicate, sensual exercises necessary.

The better the body perception, the closer to perfect will be the motion sequences. In the case of a soccer player, this equals more precise passes and shots, as well as a more economical running style.

(See www.fascial-fitness.com)

Markus Rossmann Markus Roßmann Dipl.-Sportl. Univ., a Certified Rolfer, MAT/EAP certification, fascial trainer, many years of experience as the director of motion and health seminars, member of the European Rolfing Association.

In 1992 graduated from the Technical University Munich as a sport scientist (rehabilitation/ prevention). After working as a ski instructor in Canada, he became the head of medical training therapies of several ambulant rehabilitation centres in Germany. Searching for new, more efficient and sustainable approaches, he came across the Rolfing method. After completing his training in Munich in December of 2004, he started working in Munich and Erding.

Contact: markus.rossman@fascial-fitness.com

This article is an English translation of: Aschoff F. 2014. Fasziales Training mit Fußballern. Im Gespräch: Markus Roßmann. Z. f. Physiotherapeuten 66, 6: 14-22.

Copyright: Richard Pflaum Verlag GmbH & Co. KG, Lazarettstr. 4, 80636 München, Germany

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Interoception Some Suggestions for Manual and Movement Therapies

By Robert Schleip

The discovery of interoceptive receptors in human skin.

The established view is that touch is mediated by largediameter, fast-conducting peripheral nerves and there are areas in the body that are more densely innervated and more cortically represented such as the finger tips and the lips. However recent findings showed that there is another purpose to touch that is more interoceptive than exteroceptive. Beside the well known cutaneous receptors for haptic perception human skin contains interoceptive C-fibre endings which trigger a general sense of well being. The connections of these slowly conducting receptors do not follow the usual pathway of the pyramidal tract towards the proprioceptive areas in the brain.

They rather project to the insular cortex, a key player in the regulation of interoception. This was recently discovered through experiments with patients lacking myelinated afferents. Whenever their skin was gently stroked, they responded with an increased sense of general wellbeing, although they were unable to detect the direction of stroking. Subsequent brain imaging studies revealed that the touch activated their insular cortex, while no activation was seen in proprioceptive brain areas. It is concluded that human skin contains special touch receptors, with a slow conduction velocity, which are part of a neurobiological system for social touch.

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Interoception

Body Image

Insula

Thalamus

Body Awareness Interoception

Proprioception

Figure 1. Body Image, Body Awareness, Proprioception & Interoception. Body awareness includes proprioception and interoception, whereas body image includes to some extent information on what our body looks like when observed from without (From Mosely 2011).

In manual and movement therapies, we have discussed the importance of proprioception, our sixth sense, the ability of our body to sense our relative position in space, be aware of its surroundings, and the sense in movement, the sense of effort, force, and heaviness. The awareness or how we perceive our own body can be quite variable (Figure 1). It is mostly linked to the ‘external’ signals to the body, such as how we look or touch our bodies or how our body acts in terms of biomechanical parameters. But body awareness can also be perceived by how we feel our body as a dynamic physiological organism from the inside. Recently a ‘new’ concept of interoception has been proposed.

Body awareness relies on the representation of both exteroceptive, proprioceptive and interoceptive signals.

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So what is interoception?

The current concepts describe interoception as a sense of the physiological condition of the body, an ubiquitous information network used to represent one’s body from within. It is the ability to detect subtle changes in bodily systems, including muscles, skin, joints, and viscera (Dunn et al.

2010). It includes a range of physiological sensations, including: warmth, coolness, pain, tickle, itch, hunger, thirst, air hunger, sexual arousal, muscular activity, heartbeat, vasomotor activity, distension of bladder, distension of stomach, rectum or oesophagus, wine tasting (in sommeliers), and sensual touch.

These sensations are triggered by stimulation of unmyelinated sensory nerve endings (free nerve endings) that project to the insular cortex rather than to the primary somato-

Prebrachial nucleus

Lamina I of spinal cord

Free nerve endings Figure 2. A novel short-cut route for interoception in primates. In mammals, the main pathway of interoception starts with free nerve endings, which project to the lamina I of the spinal cord. From here they project to the prebrachial nucleus in the brainstem, and it is only from there that they are further projected to the insular cortex via the thalamus. In primates, however, there are additionally direct projections from lamina I to the insula via the thalamus. Primates therefore possess – as a novel phylogenetic acquisition – a more direct route between the afferent region for interoceptive sensations in the spinal cord and the insular cortex (red arrow).

sensory cortex which is usually considered as the main target of proprioceptive sensations (Figure 2) (Berlucchi & Aglioti 2010). Feelings from these sensations not only have a sensory, but also an affective, motivational aspect and are always related to the homeostatic needs of the body. They are associated with behavioural motivations that are essential for the maintenance of physiological body integrity.

Interoception Table 1. Properties of Primary Sensory Afferents Innervating Human Skin (After McGlone et al., 2014).

Sensory Afferent Nerves Receptor Type Aβ Fibre Group Low-threshold mechanoreceptors Aδ Fibre Group Nociceptors Cool receptors C Fibre Group Nociceptors Warm and cool receptors Itch receptors Low-threshold mechanoreceptors (CT)

Modality

Axonal Diameter

Conduction Velocity

Discriminative touch

10 μm

60 m/s

Pain Temperature

2.5 μm –

12 m/s –

Pain Temperature Itch Affective Touch

1 μm 1 μm 1 μm 1 μm

<2 m/s <2 m/s <1 m/s <2 m/s

Distressed interoception and altered insular processing is associated with conditions such as irritable bowel syndrome, eating disorders, anxiety, depression, alexythymia (emotional blindness), schizophrenic disorders, Post-Traumatic Stress Disorder (PTSD), and possibly fibromyalgia. It has been proposed that the neural pathways associated with interoception may be considered as a potential correlate for consciousness (Craig 2009). The sensory receptors for interoception are free nerve endings, most of which are located in fascial tissues throughout the human body.

It is helpful to understand that proprioception and interoception are organized differently in the human brain and that very different afferent pathways are involved in them. Figure 3 shows some conditions that tend to be affected by distressed proprioception and interoception.

work better for some conditions and a more interoceptive oriented approach for others.

If applied with an open minded and careful attitude, it is an appealing thought that a more proprioceptive oriented therapeutic stimulation may

Based on the innervation of primate skin and on subsequent studies with other patients it was concluded that there is dual tactile innervation of the

Affective Touch A recent and surprising addition to the list of interoceptive sensations is the sense of affective, sensual or pleasant touch. This discovery was triggered by examinations of a unique patient lacking myelinated afferents, slow stroking of the skin with a soft brush triggered a faint and obscure sensation of pleasant touch, although the patient was unable to recognize any stroking direction. Functional magnetic imaging showed that this vague sensation was accompanied by a clear activation of the insular cortex, while no activation was seen in the primary somatosensory cortex (Olausson et al. 2010).

human hairy skin: in addition to fastconducting myelinated afferent fibres, there is a system of slowconducting unmyelinated C tactile (CT) afferents that respond to gentle touch (Table 1). The C tactile afferents are a distinct type of unmyelinated, low-threshold mechanoreceptive receptors that are connected with neural interoceptive pathways.

Those afferents have a slow conduction velocity (half to a second delay from stimulus to arrival in the brain).

Since these receptors types have never been found in the glaburous skin (areas with lack of hair, mainly at palm of the hand and plantar of the foot) despite numerous micro neurographic recordings, it is assumed that they are only present in hairy skin.

The cells are stimulated by gentle pressure on the skin and respond preferentially to gentle caressing stroke. C tactile afferents are connected to specific areas of the brain: the insular cortex, the posterior superior temporal sulcus, the medial prefrontal cortex and the dorsoanterior cingulate cortex, which are known to

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Interoception

PROPRIO-CEPTION

INTERO-CEPTION

Lower back pain

Irritable bowel syndrome

Phantom pain

Eating disorders

ADHS

Anxiety, depression

Complex Regional Pain Syndrome

Alexythymia (emotional blindness)

Scoliosis

Schizophrenic disorder

Whiplash

Post Traumatic Stress Disorder

Other myofascial pain syndromes?

Fibromyalgia?

Figure 3. Conditions that tend to be affected by distressed proprioception and interoception.

be activated by affective touch (McGlone et al. 2014). It is concluded that primate skin contains particular touch receptors which form a system for social touch that may underlie emotional, hormonal (for example oxytocin) and affiliative responses to caress-like, skin-to-skin contact between individuals (Figure 2). The profound importance of such a system for human health and well-being has long been indicated (Montague 1971), at least since the classical study of Harlow (1958) with baby rhesus monkeys that express affection for a surrogate mother in response to tactile comfort. This is reiterated by McGlone et al. (2014) who suggested the “affective touch hypothesis”: the essential role of the CT system is to provide a peripheral mechanism for signalling pleasant skin-to-skin contact in humans, thereby promoting interpersonal touch and affiliative behavior.

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Fascia as an Interoceptive Organ In musculoskeletal tissues only a small amount of the sensory nerve endings are myelinated mechanoreceptors which are related to proprioception, such as muscle spindles, Golgi receptors, Pacini corpuscles or Ruffini endings. Predominantly, approximately 80% of afferent nerves, terminates in free nerve endings (Schleip 2003). Termed ‘interstitial muscle receptors’ they are located in fascial tissues such as the endomysium or perimysium and are connected with either unmyelinated afferent neurons (then called type IV or C-fibres) or myelinated axons (type III or Ad fibres). Indeed 90% of these free nerve endings belong to the first group, to the slowly conducting Cfibre neurons. Functional magnetic imaging studies by Olausson et al.

(2008) revealed that stimulation of these C-fibre neurons results in acti-

vation of the insular cortex (which indicates a clear interoceptive role of these receptors) and not of the primary somatosensory cortex which is usually activated by proprioceptive input.

A surprising conclusion from this is that the number of interoceptive receptors in muscular tissues by far outnumbers the amount of proprioceptive endings. Quantitatively, one could estimate that for every proprioceptive nerve ending in these tissues there are more than 7 endings which could be interoceptive receptors.

While some of these free nerve endings are thermoreceptors, chemoreceptors, or have multimodal functions, the majority of them do in fact function as mechanoreceptors, which means they are responsive to mechanical tension, pressure or shear deformation. While some of these receptors are high threshold recep-

Interoception tors, it has been shown that a significant portion (approximately 40%) can be classified as low threshold receptors, which are responsive to light touch, even to touch as light as “with a painter’s brush” (Mitchell & Schmidt 1977). Most likely they are responsive to the gentle myofascial stretch by therapists.

Pain and Interoception Camila Valenzuela-Moguillansky (2012) recently reviewed the relationship between chronic pain and body awareness. She presented evidences that showed the relationship between pain and exteroceptive body awareness is bidirectional: not only does pain change the body perception, but modifications in one’s perception of the body can modulate pain. In addition, she suggested that in order to give a full account of the relationship between chronic pain and body awareness it might be necessary to include the interoceptive sensorimotor system. While augmented attentive interoceptive sensitivity seems to be associated with increased myofascial pain perception, a mindfulness based interoceptive training can be helpful in the treatment of somato-emotional disorders such as anxiety or depression (Fjorback et al. 2013).

Pollatos et al. (2012) in an article published in Pain evaluated the relationship between interoception sensitivity and pain perception. This study was based on the idea that enhanced sensitivity to autonomic state is often accompanied by increased autonomic reactivity. As pain is made up of both sensory and emotional components, the authors investigated the relationship between pain and the ability to perceive physiological changes.

To evaluate interoception sensitivity, 60 healthy participants were asked to

count their own heartbeat rate and compared it to actual heart rate count. Based on the data, participants were split into two groups: higher interoceptive sensitivity more accurate heart rate estimation) and low interoceptive sensitivity (more error in estimation). Then the participants were subjected to pain stimuli, using an algometer, cutaneous pressure pain was applied to the thenar eminence of the participants. Subjective pain intensity and unpleasantness was assessed along with heart rate variability and respiratory activity.

They observed significant relationship between heightened interoceptive sensitivity and enhanced sensitivity and decreased tolerance to pain.

In other words, high interoceptive sensitive participants had lower pain threshold and tolerance than low interoceptive sensitive participants, they also rated threshold level stimuli as significantly more unpleasant.

These effects were accompanied by a more pronounced parasympathetic decrease and a change in sympathovagal balance during pain assessment in the high, compared to the low, interoceptively sensitive group. The authors concluded that “better detection of internal signals and evoked bodily changes seems to increase pain perception for pressure pain”.

Manual Therapy and Interoception Manual therapists when treating muscular tissues issues are mostly concerned with direct biomechanical effects on non-neural tissues or with the stimulation of specific proprioceptive nerve endings, such as muscle spindles, Golgi receptors, etc.

However, based on the above information, manual therapists could target the interoceptive receptors and

thus can trigger their related upstream effects much more effectively than what is commonly practiced.

Some of the interoceptive nerve endings in muscle tissues have been classified as ergoreceptors; they inform the insula about the work load of local muscle portions. Their mechanical stimulation has been shown to lead to changes in sympathetic output which increases the local blood flow. Stimulation of other interoceptive nerve endings has been shown to result in an increased matrix hydration, via an augmentation of plasma extravasation, i.e. the extrusion of plasma from tiny blood vessels into the interstitial matrix (Schleip 2003).

It would be really useful for the therapist to pay attention to the autonomic responses at each moment and to the limbic-emotional (or insular) response of the client, while monitoring the touch direction (plus its speed and magnitude) in such a manner that a profound change in local tissue hydration as well as other autonomic effects can be achieved. It would also be worthwhile to encourage a perceptual refinement and some verbal feedback from the client regarding his/her interoceptive perceptions. While proprioceptive sensations may be in the foreground during the application of strokes, those finer interoceptive sensations are usually easier to perceive in periods of at least several seconds of rest between different manipulative strokes. Subjective sensations of warmness, lightness/heaviness, spaciousness, density/fluidity, nausea, streaming, pulsation, spontaneous affection or a general sense of well being may be such interoceptive sensations that can be triggered by myofascial tissue manipulation. From the therapist’s perspective subtle changes in the client - such as an in-

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Interoception

PROPRIO-CEPTION

INTERO-CEPTION

Dance training (classical/modern, etc.)

Continuum Movement, Body Mind Centering

Feldenkrais method of ‘Awareness through

Somatic Experiencing

movement’ Iyengar yoga (if done with emphasis on

Yoga style with emphasis on physiological

biomechanical precision)

tingling, temperature, streaming sensations

Classical Pilates approaches

Visceral and cranial osteopathy

F.M. Alexander work

Energy work (with emphasis on subjective

streaming sensations) Rolf Movement Education

Biodynamic bodywork (e.g. Reichian bodywork, Boyesen work, etc.)

Postural re-education methods

Gentle affective massage methods

Figure 4. Therapeutic approaches primarily focused on refinement of proprioception and interoception.

creased local tissue hydration, changes in temperature, in skin colour, in breathing, micro movements of the limbs, pupil dilation and facial expression can serve as valuable signals for physiological effects related to interoceptive processes.

Therapists which apply mechanical stimulation to visceral tissues, such as visceral osteopaths, should also profit from a larger recognition of interoception and related physiological as well as psycho-emotional effects. Recent discoveries concerning the richness of the enteric nervous system have taught us that our ‘belly brain’ contains more than 100 million neurons (Gershon 1999). Most of these are located either in the con-

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nective tissue zone between the inner and outer layers of the muscularis externa (Auerbach’s plexus) or in the dense connective tissue layer of the sub mucosa (Meissner’s plexus).

Many of these visceral nerve endings are directly concerned with interoception and are connected via the “lamina 1-spinothalamocortical pathway” with the cortical insula, as described above. Considering that several complex disorders such as irritable bowel syndrome are associated with a disrupted modulation of insular responses to visceral stimuli, it is conceivable that a slow and careful application of manual forces to visceral tissues, if accompanied by a sense of safety and mindfulness of the client, could be useful if not ideal

approaches for enhancing a healthy interoceptive self regulation.

Myofascial as well as visceral therapists should also not be surprised when encountering psychoemotional responses or emotional release which may include changes in internal body perception, in selfawareness or affective emotions.

These may be triggered by their stimulation of interoceptive free nerve endings in the skin, in visceral connective tissues as well as in muscular tissues.

Movement Therapies and Interoception In competitive sports, the attention is often focused on achieving an exter-

Interoception nal goal, and often it also focused on overriding internal sensations of discomfort, tiredness, etc. In contrast, complementary or alternative practices, such as Yoga, Tai Chi, Qi Gong, Pilates, Feldenkrais, Body Mind Centering or Continuum Movement, usually encourage a perceptual emphasis on finer sensations in one’s own body. However, depending on the focus of the individual teacher or respective school, the internal perception is sometimes directed almost entirely towards proprioceptive refinement. For example, a student of such training approaches may learn to feel minute movements of individual vertebrae or to control their lumbar lordosis within a multitude of loading situations. Nevertheless they may remain an ‘interoceptive moron’, e.g. unable to differentiate visceral sensations from signs of an empty stomach, of stage fright oriented ‘butterflies’, of empathy driven ‘gut feelings’ about another person’s dilemma, which may simply be an acute gastritis.

In contrast some teachers of these practices also include a skilled finetuning the student’s perception for interoceptive sensations (see Figure 4). This may include emphasizing sensations such as a subtle tingling under the skin, sensation of a general or localized warming, a subjective sense of internal spaciousness, a feeling of aliveness, an inner silence, an emotional ‘home coming’, or a meditation like change in general self awareness. For example gravity oriented changes in body positions, such as some upside-down postures in yoga practices, could easily trigger new and interesting (and hopefully unthreatening) sensations in visceral ligaments, which can foster interoceptive refinement. Given the recent research indications for a close corre-

lation between disrupted interoception with many psycho-emotional disorders, such as irritable bowel syndrome, anxiety or post-traumatic stress disorder, it is plausible that some of these movement practices may have a strong therapeutic potential. Typically these therapeutic practices foster an attitude of inner mindfulness, of refining ‘internal listening skills’, and they frequently alternate brief periods of active motor attention with subsequent periods of rest where the students pay attention to small interoceptive sensations within their body. Not surprisingly, some studies already indicate a positive health enhancing effect of such mindfulness-based therapies for a large number of common clinical conditions (Astin et al. 2003).

References Astin JA, Shapiro SL, Eisenberg DM, Forys KL (2003) Mind-body medicine: state of the science, implications for practice. J Am Board Fam Pract 16: 131 -147.

Berlucchi G, Aglioti SM (2010) The body in the brain revisited. Exp Brain Res 200: 25-35 Craig AD (2002) How do you feel?

Interoception: the sense of the physiological condition of the body.

Nat Rev Neurosci 3: 655-66 Craig AD (2003) Interoception: the sense of the physiologically condition of the body. Curr Opin Neurobiol. 13: 500-505.

Craig AD (2009) How do you feelnow? The anterior insula and human awareness. Nat Rev Neurosci 10: 59– 70

P (2013) Mindfulness therapy for somatization disorder and functional somatic syndromes: randomized trial with one-year follow-up. J Psychosom Res 74(1): 31-40.

Gershon MD (1999) The second brain.

Harper Perennial, New York.

Harlow HF (1958) The nature of love.

Am Psych 13: 673-689.

Montague A. (1971) Touch: The Human Significance of the Skin. Harper & Row, New York McGlone, Francis, Johan Wessberg, and Håkan Olausson (2014) Discriminative and Affective Touch: Sensing and Feeling. Neuron 82.4 : 737-755.

Mosely, L. How should we measure body awareness? Body In Mind. http://www.bodyinmind.org/howshould-we-measure-body-awareness/ Olausson HW, Cole J, Vallbo A, McGlone F, Elam M, Krämer HH, Rylander K, Wessberg J, Bushnell MC (2008) Unmyelinated tactile afferents have opposite effects on insular and somatosensory cortical processing.

Neurosci Lett 436: 128-132.

Olausson H, Wessberg J, Morrison I, McGlone F, Vallbo A (2010) The neurophysiology of unmyelinated tactile afferents. Neurosci Biobehav Rev. 34: 185-191 Pollatos, O., Füstös, J., & Critchley, H. D. (2012). On the generalised embodiment of pain: How interoceptive sensitivity modulates cutaneous pain perception. Pain, 153(8), 1680-1686.

Schleip R (2003) Fascial plasticity – a new neurobiological explanation.

Part 1. J Bodyw Movem Ther 7: 11-19 Valenzuela-Moguillansky, C. (2012) Chronic pain disturbances in body awareness. Chilean Journal of Neuropsychology, 7(1) 26-38.

Dunn BD, Galton HC, Morgan R, et al.

(2010). Listening to your heart. How interoception shapes emotion experience and intuitive decision making.

Psychol Sci 21 (12): 1835–1844.

Fjorback L, Arendt M, Ornbøl E, Walach H, Rehfeld E, Schröder A, Fink

Terra Rosa E-mag 15

Yoga & Fascia with Daniela Meinl

Explore an interesting Fusion of Bhakti Vinyasa Yoga and latest Fascial Training and Fascia Research in an experiential Workshop to dive deep into your tissues.

Sydney Jan 29, 2015. (9 amâ&#x20AC;&#x201D;5 pm ) More info at www.terrarosa.com.au E: terrarosa@gmail.com

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Clinical Orthopedic Manual Therapy with Dr. Joe Muscolino Sydney, November 2015 www.terrarosa.com.au

This workshop covers the major clinical orthopedic assessment and treatment techniques for the thoracic spine and ribcage.

31 Oct, 1 Nov 2015, Sydney

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.

2 & 3 November 2015, Sydney

Terra Rosa e-magazine, No. 11 (December 2012)

"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 body-worker. I, E-mag 17 G, North 17 myself, can't wait for the nextTerra one!"Rosa Zuzana Sydney.

Report from The 2014 Fascia Summer School

By Alison Slater It was my pleasure and privilege to attend the recent Fascia Summer School in Germany, held at the esteemed Ulm University. A biennial event, it offered a mouth-watering array of internationally-renowned presenters. Part of a small (60 or so) group, the likes of Andry Vleeming, Carla Stecco, William Fourie, Siegfried Mense and Robert Schleip were easily accessible and open to questions. The program was well considered but in such company, there was a tendency to want to see and participate in everything on the agenda! Meeting at the charming and historic Villa Eberheim, we were allocated groups depending on our pre-conference preferences to attend different breakout sessions , and given an opportunity to meet the other attendees who had gathered from all over the world. It was fascinating to appreciate the range of professions from which they all hailed â&#x20AC;&#x201C; physiotherapists (like myself), soft tissue and movement therapists, yoga and Pilates aficionados! They were all represented.

We opened with an inspiring address by Carla Stecco, who is soon to put to print the worldâ&#x20AC;&#x2122;s first anatomy atlas with the emphasis on fascia! In her relentless quest for answers and countless dissections, Carla always comes up with something fresh and exciting. On this occasion, she outlined and showed us the role of paratenon, and how this structure in the Achilles area is strongly integrated with the crural fascia and that it is this continuity of paratenon and the deep fascia which splits around each tendon to create separate compartments. (Note: paratenon is the fatty areolar tissue filling the interstices of the fascial compartment in which a tendon is situated according to Dorland's Medical Dictionary for Health Consumers). The differentiation of paratenon, epitenon and endotenon was highlighted, and we were reminded of the role of these structures and the deep fascia in force transmission. The

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disease process of paratendinitis involves myofibroblastic activity, thickening of the paratenon, the increase in type I and type II collagen fibres and obliteration of blood vessels. Normalisation of fascial tensions in the early stages could avoid damage to the tendon but chronic inflammation will dramatically alter the glide characteristics of the tissue with devastating functional consequences; surgical repair must aim to preserve the paratenon to nourish further repair. Preservation of the gliding between different layers must be our aim when working on the soft tissue, and foam rollers were lauded as a means to accentuate this. She also touched upon more recent research that

suggests that antibiotics can increase the likelihood of ruptures of the tendo-Achilles.

Her second lecture, delivered later that same morning, concerned the difference between densification and fibrosis of fascia. Both represent pathologic changes to deep fascia which may be responsible for causing pain within deep fascia when nociceptors become enmeshed.

Differentiating between the two and understanding the connective tissue matrix will guide treatment choice to alleviate chronic pain syndromes. The causes of densification include low pH, low temperature, dehydration and accumulation of waste products. Alkalisation is not a problem – increased acidity causes increased viscosity of loose connective tissue. We were introduced to the concept of “functional failure” if collagen is deposited between the fascial layers and that stretching the fibroblasts increases collagen turnover. And that the fascia of a newborn is homogeneous, and that movement dictates line-of -force creation as the child begins to load-bear. There was general agreement that there is urgent need to standardise the terminology we’re using internationally to differentiate the fascial layers, and this was highlighted repeatedly during the week’s presentations.

Boris Hinz joined us via a Skype link from the Laboratory of Tissue Repair and Regeneration at the University of Toronto. His presentation concerned the mechanics of healing, including truly amazing time-lapse footage of integrans allowing TGF-β1 from the extracellular matrix to facilitate the transformation of a fibroblast into a differentiated myofibroblast. This process is inhibited by mechanical stress and reduced oxygen levels in the blood.

William Fourie gave two excellent presentations on the importance of working with scar tissue. This gracious and empathetic man told of his work with paralympians and breast cancer survivors alike, and was at pains to point out the critical aspect of respecting the emotional aspect

of a scar and what it represents in terms of loss. His painstaking dissections demonstrated just how devastating adhesions can be, not just in the immediate vicinity of the scar but over vast areas of the body – think kinetic chains/ anatomy trains, with the inevitable ramifications for functional movement.

Uwe Schütz gave a fascinating insight and account into the lives of ultra marathon runners. He and his team followed the participants in the 2009 Trans Europe Footrace covering a staggering 4487 km! He drove a pantechnicon containing an MRI scanner to monitor the inflammatory profiles of the runners. While some had to withdraw from the race, others actually ran themselves back to health through a process of adaptation. These individuals were found to have a higher cold pain tolerance than controls.

Heike Jäger walked us through the myriad of tensional loading receptors within fascia that support our true sixth sense, proprioception, an ideal first introduced by Andrew T Still in 1899. Martina Zügel then spoke of her work into how sex hormones promote skeletal muscle regeneration.

Scott Wearing, a fellow Aussie, spoke of his work into defining the heel pad behaviour during barefoot running.

He devised an ingenious method of applying ultrasound to a heel during impact. The findings of his study suggest that wearing shoes decreases the vibrational loading in the heel but significantly increases the loading within the Achilles.

Siegfried Mense whose work we are all familiar with, over many years, Nat Padihar, Andry Farasyn, Rainer Wirtz and Tom Findlay all gave their insights into their current research. Dr Findlay with his myriad of knowledge and experience was on hand to offer tips and guidance for those wishing to undertake research. Given his prolific output over many years, who could ignore his wisdom?

We were all treated to a couple of sessions in the anat-

Terra Rosa E-mag 19

omy labs where barely-fixed specimens were available as we observed Hanno Steinke demonstrating various fascial connections and the overall integrity of the body. There were a number of plastinated models as well, a methodology first developed by Gunther von Hagens in 1977. This allowed the models to be handled with ease and safety (both of the model and the handler!). The sections through the trunk, about 2 cm thick allowed for easy appreciation of the layering effect that the superficial and deep fascia affords the tissue be it muscle, an organ or a cavity. A small group of us had the honour of a private tutorial with Dr. Stecco who demonstrated the three distinct layers of the thoracolumbar fascia as it envelops and divides the trunk.

Amongst the break-out sessions, Daniele-Claude Martin offered a fascinating practical insight into biotensegrity, something I’m sure as practitioners we’ll hear a lot more about it in the future. As well as giving a keynote address, Andry Vleeming demonstrated the accepted tests for differentiating pelvic girdle pain, imploring all to recognise and adequately address the long dorsal ligament as a common source of so much of the pain emanating from this area. He was adamant that piriformis syndrome is exceedingly rare other than in athletes. Instead, Gluteus Maximus is believed to be hypertonic, even if it is atrophic.

Divo Müller (aka Mrs. Schleip) was on hand to demonstrate the methodology of Fascial Fitness. She also provided welcome relief from long hours of sitting (the natural enemy of the clinician!) with intermittent bursts of fascial stretching and bouncing between lectures! William Fourie expounded the practical approach to scar management to avoid the pitfalls he had so graphically demonstrated in his lectures. He is apparently touring Australia at the end of 2015 so keep an eye out for that. I can per-

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sonally recommend his presentations. Wilbour Kelsick who has worked on and associated with the likes of Usain Bolt, taught us how to run, fascially, which was fun and instructional!

I hope I’ve at least given readers an insight into what was a thought-provoking and fascinating week. One I hope to repeat when it rolls around in another 2 years!

About the Author Alison Slater is a highly accredited Physiotherapist, offering 28 years of Australian and international training and practical clinical experience. A graduate of The University of New South Wales and Cumberland College of Health Sciences , Alison has also undertaken significant postgraduate study, including a Master of Manual Therapy from the University of Western Australia. Upon graduation, Alison was invited to join the University as an Adjunct Teaching Fellow, a position she has retained since.

Alison’s areas of special interest are fascia and fascial manipulation, and the spine, specifically, the sacrum/pelvis.

She has undertaken numerous advanced courses and taught extensively throughout Australia and the United Kingdom in Muscle Energy Technique. She has presented at Soft Tissue Conferences both here and abroad. Alison also has extensive experience in Craniosacral Therapy, Dry Needling, Myofascial Release, Mulligan Technique and manual therapy assessment and treatment; and is committed to being totally ‘hands-on’. She balances her holistic approach with the latest clinical research findings from around the world.

bodybliss is a movement program developed by Divo G. Müller and incorporates latest scientific knowledge on fascial connectivity and neurobiology of movement. Special Focus will be on the concept of embodiment - the experience of the body as a moving flow and the sensual unfolding into the fluid dynamics of muscles, bones, fascia and the fluid systems.

Sydney bodybliss Part I: 22-23 Jan 2015, bodybliss Part II: 24-25 Jan 2015 “Daniela Meinl is a dedicated and gifted Bodybliss Trainer. She embodies strength, fluidity and sensitivity and is able to share her knowledge with a clear mind, an open heart and a kind spirit. All aspects which are providing an opening in the field to encourage participants to explore and discover new, yet unknown movement potentials. I highly encourage you to get introduced in bodybliss and deepen your experience in the Courses offered in Australia by her.” Divo Müller

DANIELA MEINL Fascial Fitness Master Trainer, Yoga Teacher, Advanced Pilates and bodybliss Trainer, Meditation Facilitator, Alternative Practitioner for body-oriented Psychotherapy (HPG) Trained as a movement teacher, bodyworker and meditation facilitator I have been exploring movement and personal growth for the past 10 years. I have been trained in Aerobics, Back Health and Pilates, Certified Bhakti Vinyasa Flow Yoga Teacher .

“My strength in teaching is in imparting knowledge in a structured way while always keeping the practical relevance of the content in mind. I like to allow participants to explore the new aspects of movement and to experience this directly in their own bodies. I am passionate about how movement can bring back life and connection to oneself and each other in peoples lives. I´d love to share this with you soon in one of my classes.”

More Info at www.terrarosa.com.au

Terra Rosa E-mag 21

Advanced Myofascial Techniques with Til Luchau, Advanced-Trainings.com

Sciatica and Disc Issues: Special 1-day course Friday, May 22, 2015, Sydney Pelvis, Hip and Sacrum: Parts I & II Sat-Sun, May 23-24, 2015, Sydney

More Info at: www.terrarosa.com.au 22 Terra Rosa E-mag

FFT Case Study: Exposed Leg Fractures

By Ron Alexander At the Functional Fascial taping (FFT) Workshop in Rio de Janerio, one of the participants, Julio Cesar, a Physiotherapist, suffered 5 exposed fractures as a result of being hit by a truck whilst riding a motorbike 21 years ago. After the accident he was placed in a leg device to lengthen the leg, he then had a surgical fascial release of the Tendo Achilles and the Plantar Fascia.

Before FFT treatment he had a Visual Analogue Scale (VAS) score of 8/10 pain whilst standing and whilst sitting putting weight on the leg and foot.

After FFT his VAS score was 2/10. The following day he had no pain standing and walking. He still had limited dorsiflexion which still resulted in a limp, however his gate was better than he had for years. We don't think dorsiflexion will return to normal due to the amount of damage and surgical procedures. Over subsequent weeks and months Julio self administered FFT less frequently and then only sporadically. Now, he no longer requires FFT. Julio’s quality of life has improved dramatically as a result of the tape.

At the 12 month follow up he reported that he had returned to doing martial arts including competitive fighting, this is after 21 yrs of being unable to participate in any sport due to pain. His surgeon was impressed by this but was unable to explain how

the taping could bring about this change. In Julio’s case we were not able to achieve much of an improvement to his range of motion, apart from putting his foot flat on the floor, which was completely achieved the following day. However, this was already a major improvement, his function was much better with significant reduction in pain and he felt optimistic about change in his condition.

The surgeon’s inability to identify how change occurred is a question that still remains unanswered. There are numerous reasons why we experience pain. In Julio’s case, for the first couple of years we can understand it as his condition involved massive trauma, mechanical repair, ongoing mechanical disruption by the process of the lengthening and healing bones and soft tissues, followed by ongoing disrupted biological repair. He followed the standard rehabilitation procedures for someone with this type of injury. This is a complicated pathology that would have many contributing factors, however, in the end he continued to have pain and it is the residual pain that I viewed from a neuro-fascial perspective.

The application of FFT involves stretching the skin and underlying tissues in a pain-specific direction.

One plausible explanation is that the

application of rigid tape with tension on the skin could stimulate largediameter afferent fibres and then modulate nociceptor input (gate control mechanism). In addition to this, stretching the skin in a pain-specific direction with FFT may affect pain perception or it may alter local tissue internal architecture (Ingber 2008) as well as stimulate cutaneous Mechanoreceptors (Grigg 2002). If we view the body from a Biotensegrity principle where living tissue and cells are constructed by discontinuous compression columns (bones) supported and balanced by tension elements (fasciae and connective tissues) resulting in continuous tension (Fuller 1961, Ingber 1998) then FFT may be offering a strong sustained load by tightening components of the mechanical scaffolding of the body. The external force from the tape on the skin may transfer to the underlying tissue and cause multi-laminal sliding movements under the skin, and that could convert into an internal force to evoke different levels and types of mechanoreceptor firing (Chen 2012#).

In a practical sense once the tape is applied to the body this potentially creates sustained altered load, the patient is then assisting the treatment by actively moving the affected area and thereby increasing the load provided by the tape . This is custom made for each patient/athlete for an

Terra Rosa E-mag 23

FFT on Exposed Leg Fractures (a)

(b)

(c)

(a) Medial side of foot. Pre-test position with limited range of motion. (b) Medial side of foot after taping. Julio is taught h ow to re-apply the tape himself. (c) Lateral side of foot after taping and shoe on. The tape directions stayed consistent throughout the treatment.

extended and pre-determined period of time. By removing the pain via FFT and having the patient go about normal activity, we are potentially assisting proprioceptively by encouraging muscle firing and restoring normal movement patterns. The patient can now move into this new range, pain free which may assist with the apprehension of pain, elevate mood and reeducate the neuro-muscular system through rehabilitation. In Julio’s case FFT, walking, normal activity and then martial arts was all that was required to reduce his pain, possibly due to the limited dorsiflexion.

We conducted a randomised double blind placebo controlled study on FFT for a non-acute non-specific low back pain that demonstrated a significant effect on pain and function with FFT. Although this was conducted on the low back, the same hypothesis of how change occurred can translate to other areas of the body (Chen 2012). This is the process that I used when treating Julio’s condition. FFT

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has a relative simple objective assessment procedure and tape application that can be fast to do (not in this case study) and is used by any therapist treating neuro-musculoskeletal conditions.

References

Ron Alexander. Functional Fascial Taping Practitioner [FFTP]. Director/ Founder of the Functional Fascial Taping Institute Melbourne, Australia. Co-Investigator Randomised Double Blind Placebo Controlled Trial of FFT for Non-Specific Low Back Pain [PhD] Deakin University Melbourne, Australia. Awarded the Lady Southey Scholarship for Excellence from the Australian Ballet Foundation. Presented FFT to the International Olympic Committee World Congress, the Royal College of Surgeons UK. Fifth, Sixth and Eighth Interdisciplinary World Congress on Low Back & Pelvic Pain and the Fascia Research Congress 2007 including an FFT workshop at the FRC in 2012.

Macgregor K, Gerlach S, Mellor R, et al.

2005. Cutaneous stimulationfrom patella tape causes a differential increase in vasti muscle activity in people with patellofemoral pain. J Orthopaed Res; 23: 351– 358.

Ingber DE. 2008. Tensegrity-based mechanosensing from macro to micro. Prog Biophys Mol Biol; 97: 163–179.

Grigg P and Del Prete Z. 2002.Stretch sensitivity of cutaneous afferent neurons.

Behav Brain Res; 135: 35–41.

Chen SM, Alexander R, Sing KL,Cook J. 2012. Efficacy of Functional Fascial Taping on Pain and Function in Patients with Non -Specific Low Back Pain: A Randomised Controlled Trial. Pub Clin Re-hab Oct 2012 Vol 26, No. 10. 924-933. #Chen SM. 2012. FFT Thesis. Neurophysiology of the Cutaneous Mechanoreceptors.

Deakin University, Supervised by Professor Jill Cook.

Alexander R. 2014. Functional Fascial Taping and Research. Terra Rosa e-magazine, No. 14.July. pp 24-29.

Functional Fascial Taping with Ron Alexander

“Evidence-Based Pain Relief” This workshop teaches a fast and simple way for clinicians to reduce pain, improve function, encourage normal movement patterns and rehabilitation of musculoskeletal pathologies in a pain-free environment.

FFT has been shown to have a significant effect on Non-Specific Low Back Pain in a randomised double-blind PhD study. FFT is a noninvasive, immediate, functional and an objective way to decrease musculoskeletal pain.

Presenter: Ron Alexander—

A great way to encourage treatments to hold longer

STT [Musculoskeletal], FFT Founder and Teacher

Sydney, 14-15 March 2015 Melbourne ,21-22 March 2015 Wodonga, 28-29 March 2015 Register Now at: www.terrarosa.com.au

Terra Rosa E-mag 25

Plantar Fasciitis High loading strength training improves outcome

By Michael Rathleff Most of us who have experienced plantar fasciitis know first hand how debilitating and frustrating it can be. Every morning resembles being forced to walk on broken glass and you quickly become grumpy and dissatisfied. The prevalence in the general population is estimated to range from 3.6% to 7% [1, 2], and may account for as much as 8% of all running-related injuries [3, 4]. The life time prevalence may be as high as 10% which means that quite a big proportion of us will at some point be affected by plantar fasciitis or see these patients in the clinic.

Most previous treatment studies on plantar fasciitis have used a combination of orthotics, plantar specific stretching or similar non-exercise intervention. These interventions have proven successful to some degree and we know they are superior to placebo treatment. However a large proportion of patients still have symptoms two years after the initial diagnosis. Most clinicians who see these patients in the clinic will agree that they can be quite the challenge â&#x20AC;&#x201C; especially if they have a long symptom duration. So we definitely need to start thinking about new effective treatments. An interesting thing is that we are starting to realise that there are some similarities between plantar fasciitis and tendinopathy. We know from the literature that high-load strength training appears to be effective in the treatment of tendinopathy [5].

A similar approach to plantar fasciitis therefore seems to be relevant to test. We recently completed a study where we investigated the effect of a high-load strength-training program compared to a standard plantar specific stretching program in the treatment of plantar fasciitis.[6]

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Our main question before initiating the trial was how we could induce high tensile forces across the plantar fascia to resemble the loads induced to the patella tendon during e.g. single leg squat. Our approach was to exploit the windlass mechanism during single-leg calf-raises by using a towel to dorsal flex the toes. In theory, the windlass-mechanism would cause a tightening of the plantar fascia during dorsal flexion of the metatarsophalangeal joints while high -loading of the Achilles tendon is transferred to the plantar fascia because of their close anatomical connection [7-9].

We recruited 48 patients with ultrasonography verified plantar fasciitis. They were randomised to either high-load strength training or plantar specific stretching. In addition both groups received a short patient information sheet and gel heel-inserts. The patient information sheet covered information on plantar fasciitis, advice on pain man-

Table 1. Advice given to the patients.

agement; information on how to modify physical activity; how to return slowly to sports and information on how to use the gel heel-inserts. On a side note, I think that one of the key things in successful management of plantar fasciitis is to educate the patient. The advice we used can be seen below in Table 1.

The plantar-specific stretching protocol was identical to that of DiGiovanni (2003) [10]. Patients were instructed to perform this exercise whilst sitting by crossing the affected leg over the contralateral leg (Figure 1). Then, while using the hand on the affected side, they were instructed to place the fingers across the base of the toes on the bottom of the foot (distal to the metatarsophalangeal joints) and pull the toes back toward the shin until they felt a stretch in the arch of the foot. They were instructed to palpate the plantar fascia during stretching to ensure tension in the plantar fascia. As in DiGiovanni, patients were instructed to perform the stretch 10 times, for 10 seconds, three times per day [10].

High-load strength training consisted of unilateral heelraises with a towel inserted under the toes to further activate the windlass-mechanism (Figure 2). The towel was individualised, ensuring that the patients had their toes

â&#x20AC;&#x153;A key clinical point is that the calf-raises need to be done slowly to decrease the risk of symptom flaring.â&#x20AC;? maximally dorsal flexed at the top of the heel-rise. The patients were instructed to perform the exercises every second day for three months. Every heel-rise consisted of a three second concentric phase (going up) and a three second eccentric phase (coming down) with a 2 second isometric phase (pause at the top of the exercise). The highload strength training was slowly progressed throughout the trial as previously reported by Kongsgaard et al. [11].

They started at 12 repetition maximum (RM) for three sets.

After two weeks, they increased the load by using a backpack with books and reduced the number of repetitions to 10RM, simultaneously increasing the number of sets to four. After four weeks, they were instructed to perform 8RM and perform five sets. They were instructed to keep adding books to the backpack as they became stronger.

We used the Foot Function Index as our primary outcome after three months but also did follow-ups after 1,6 and 12

Terra Rosa E-mag 27

Figure 1. Plantar-specific stretching.

months. At our 3 months follow-up we saw that patients randomised to high load strength training had a 29 points lower Foot Function Index.

This is far greater than the minimal relevant difference and suggests a superior effect of high-load strength training compared to plantar specific stretching. An important aspect is that we saw no difference between groups at 6 and 12 months indicating no superior longterm effect. However, if you ask patients to choose between two treatments that have similar long-term effect but one will give you a quicker reduction in pain, I am certain that all patients would choose the treatment, which provides them with the quickest reduction in pain.

There are still lots of unanswered questions about why high-load strength training may work in the treatment of plantar fasciitis. One explanation could be that high-load strength training may stimulate increased collagen synthesis which help normalise tendon structure, increase load tolerability of the plantar fascia and thereby improve patient outcomes. Another explanation may be that the exercise help improve ankle dorsal flexion range of motion as well as improving intrinsic foot strength and ankle dorsal flexion strength. When I completed the high-load strength training program as part of our pilot studies I developed good DOMS in the intrinsics which suggest

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they are active during the exercise. The questions are many and hopefully other researchers will take a critical look at our findings and confirm or contradict our findings.

The loading paradigm for treatment of plantar fasciitis is by no means a miracle treatment. However, it does provide us with the first evidence that high-load strength training may be the road towards more effective treatments for plantar fasciitis. The key message to the patients is that they need to perform the exercises (otherwise they are unlikely to work) and they need to be performed slowly (3s up, 2s pause at the top and 3s down) to decrease risk of symptom flaring and with enough load starting by 12RM for three sets and working their way down to 8RM for five sets.

This article was originally published in RunningPhysio.com.

Dr. Michael Rathleff is a researcher at Department of Clinical Medicine, Aarhus University, Denmark. His research interest is in Patellofemoral Pain among adolescents and how new technology can measure adherence and quality of unsupervised home-exercises . Follow his tweeter https://twitter.com/MichaelRathleff

Figure 2. High-load strength training.

References

Scand J Med Sci Spor 2014:n/a-n/a doi: 10.1111/sms.12313.

1. Hill CL, Gill TK, Menz HB, Taylor AW. Prevalence and correlates of foot pain in a population-based study: the North West Adelaide health study. J Foot Ankle Res 2008;1(1):2 doi: 10.1186/1757-1146-12.

7. Stecco C, Corradin M, Macchi V, et al. Plantar fascia anatomy and its relationship with Achilles tendon and paratenon. Journal of anatomy 2013;223(6):665-76 doi: 10.1111/joa.12111.

2. Dunn JE, Link CL, Felson DT, Crincoli MG, Keysor JJ, McKinlay JB. Prevalence of foot and ankle conditions in a multiethnic community sample of older adults. Am J Epidemiol 2004;159(5):491-8.

3. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2002;36(2):95-101.

4. Lysholm J, Wiklander J. Injuries in runners. Am J Sports Med 1987;15(2):168-71.

5. Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med 2013;43(4):267-86 doi: 10.1007/s40279-013-0019-z.

6. Rathleff MS, Mølgaard CM, Fredberg U, et al. High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up.

8. Cheung JT, Zhang M, An KN. Effect of Achilles tendon loading on plantar fascia tension in the standing foot. Clin Biomech (Bristol, Avon) 2006;21(2):194-203 doi: 10.1016/ j.clinbiomech.2005.09.016.

9. Carlson RE, Fleming LL, Hutton WC. The biomechanical relationship between the tendoachilles, plantar fascia and metatarsophalangeal joint dorsiflexion angle. Foot Ankle Int 2000;21(1):1825 10. DiGiovanni BF, Nawoczenski DA, Lintal ME, et al. Tissuespecific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study.

J Bone Joint Surg Am 2003;85-A(7):1270-7 11. Kongsgaard M, Kovanen V, Aagaard P, et al. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports 2009;19(6):790-802 doi: 10.1111/j.1600-0838.2009.00949.x.

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Comments on the Plantar Fasciitis study

By Joe Muscolino The research study and subsequent guest blog (reprinted here) on the effectiveness of the treatment of plantar fasciitis with high-load strength training was nicely laid out and clearly explained. And the conclusion was quite straightforward: High-load strength training is an effective treatment paradigm for plantar fasciitis, and a viable alternative to the classic plantar stretching protocol. In fact, as pointed out, high-load strength in this study was shown to be more effective in the short run, three months from the outset of the treatment program, than the plantar stretching approach.

The blog was so clearly written and explained that I do not feel that I have any enlightening conclusions to make regarding the topic of the study itself. Instead, I would like to use the opportunity to comment on this study to make a general observation regarding the value of biomechanics compared to research.

I am a great proponent of research. At its core, research is simply the ability to reproduce a stated result. If someone claims that a particular treatment approach is effective because it works in his or her practice, and as we so often hear in the world of manual and movement therapy, that it is a miraculous new technique that will cure the world; a research study puts this claim to the test. And if done well, the study is “double blind” and therefore without bias.

However, in this age in which the trend is swinging harder and harder toward all care being evidence-based, there are times when I fear that the pendulum is swinging too far and that we are replacing critical thinking with the need for a research study to tell us what to think. Although I greatly respect research being applied to neuromyo-fascio-skeletal treatment, I never want it to blindly replace critical thinking that comes about from a fundamental understanding of biomechanics, in other words, kinesiology.

It is probably not fair that I bring this up in response to this particular research study because it actually was prompted by critical thought. The author of the study/ blog noticed that high-load strength training was effective with the treatment of tendinopathies, and rightly made the correlation that plantar fascia is similarly consti-

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tuted of the same connective tissue. Therefore, it seemed prudent that whatever treatment protocol was effective with one fibrous fascia would be effective with another fibrous fascia. After all, it is the mechanics that determine the efficacy of a “mechanical” treatment approach. And I am very glad that this particular research study was done and proved this to be true.

It just scares me sometimes when I hear people repeat a research study result without critically thinking through the biomechanics of why the study’s results turned out as they did. Or often just as bad, someone discredits a treatment approach simply because a study has not yet been conducted proving it to be true, without trying to reason through the reasonableness/logic of the approach.

I often like to joke that a research study showed that 2 dogs + 2 dogs = 4 dogs; and another study showed that 2 cows + 2 cows = 4 cows; and yet another study showed that 2 tigers + 2 tigers = 4 tigers; and then someone proposes that we should do another research study to examine the question of whether 2 cats + 2 cats = 4 cats. What I believe is most important when determining the efficacy of manual therapy treatment is to understand, and then extrapolate and apply the principles of kinesiology!

Perhaps I unfairly used the opportunity of commenting on this study to make my plea to not lose the idea of critical thinking based on kinesiology to work through the likely value of our neuro-myo-fascio-skeletal assessment and treatment approaches. I very much enjoyed this study and applaud the authors for undertaking it. The concept of loading the plantar fascia from both ends by extending (dorsiflexing) the metatarsophalangeal joints (for the windlass effect) and engaging ankle joint plantarflexion musculature (for its connection to the plantar fascia via the superficial back line myofascial meridian) was an extremely creative and effective approach… and quite in keeping with critical thinking based on concepts of kinesiology!

Dr. Joe Muscolino is a global lecturer and author, and has been a manual therapy educator for more than 25 years. His website is http://www.learnmuscles.com/

Treatment of the Plantar Fasciitis

By Judah Lyons Plantar Fasciitis has been one of the five major complaints that seem to have hobbled through my practice door in the last 25 years as a Rolfer and Craniosacral therapist. Up until this point, no one has needed the surgery to repair the inflammatory condition. Although, if the client has been plagued by the condition for any length of time, and they have made it to my table as a last resort having exhausted other approaches, I will ask them if they have had an x-ray to determine whether or not they have a bone spur that has been laid down due to excessive tension at the attachments. Because if they do have a large bone spur, its out of the scope of our practice. (I only encountered this condition once in my practice). But, if they are free of any spurs, then as I have said, I have been totally successful with my myofascial approach.

Stretching the plantar fascia, image from Plantar Fasciitis DVD by Judah Lyons.

Once I ask the tell tale question, “ is it very painful when you first get out of bed in the morning"?. And the answer is a definite yes, my strategy is a simple one, and I won’t bore you by naming every anatomical structure in the lower leg and foot. But, in order to take tension off of the attachments of the foot, including the plantar fascia, we need to loosen everything below the knee including the retinaculum. Once that has been accomplished, the muscles of the bottom of the foot, the quadratus plantae, abductor hallucis, abductor digiti minimi, flexor digiroum brevis, lumbricals, flexor hallucis brevis can be attended to with various “tools” that we can employ from our own anatomy.

Essentially the protocol is to loosen planes of tissue that have been tightened due to wide assortment of activities.

Imagine a trampoline that has been tightened down too much! The springs need to be “let out”, loosened to remove some of the tension. Once that has been accomplished, the pain is usually gone. That may take some time of course, and I send them home with lacrosse and golf balls to work the tissue themselves as instructed for 5 to 10 minutes a day to continue the lengthening process. It has never failed. Once they feel like the pain has diminished to 70-80% of the original condition, I will have them do calf raises in a very specific manner, and only if it doesn’t create a return of the inflammatory process. I also highly recommend epsom salt baths as hot as possible daily.

Judah Lyons is a certified Rolfer and Craniosacral therapist, practising in Charlottesville. He is also a graduate of the British Sports Institute concentrating on sports injuries. Judah shared his knowledge, passion and experience with many students over the years. His website is http://www.lyonsinstitute.com/

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Comments on the Plantar Fasciitis study

By Art Riggs depth comment.

First, the original article about the high load strength training as a treatment for plantar fasciitis. Like Joe, I found the study well conducted and worthwhile, but also think that for bodyworkers, its importance is extremely important in broader perspective for growing a successful therapeutic practice. An early teacher often quoted, “You give a man a hammer, and the whole world becomes a nail.” As therapists we do our most effective work with freeing adhesions and lengthening short muscles and fascia. However, many of the problems we treat can be greatly helped by strengthening, movement work, and educating with home programs. I will go into detail in the next section, but must say that for most all conditions and injuries, adding a well-informed knowledge of other strategies will be of tremendous help for your clients and for separating yourself from the competition. So many of my clients have commented that the suggestions for other strategies are the icing on the cake and it has been a huge referral resource.

First, I want to applaud Terra Rosa for its continuing efforts to offer such informative and thought provoking articles. I was quite intrigued with the recent articles about plantar fasciitis and feel that their importance transcends just that condition and has general applications to all of our practices for both our efficacy in treatment and for a successful practice. To understand my comments, it will be necessary to revisit the original articles.

As an ex-runner (knees) who treats both athletes and sedentary clients with plantar fasciitis, I feel it is almost an epidemic, and am sure that any therapist could be seeing 20 people a week for shorter sessions with a little advertising and communication with podiatrists and athletic shoe stores. Like Judah Lyons, I’ve found that soft tissue techniques are extremely helpful—most clients commenting that it was the key to their recovery and more useful than a lot of the more conventional treatments offered by physicians or podiatrists. I was also grateful to Joe Mucolino for his philosophy about how to interpret clinical studies with critical thought and think it is worth an in-

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I do concur that the high load exercises would be very helpful for many people who suffer from plantar fasciitis, especially those in which stability and lack of strength is a factor, but do feel that the condition is extremely complex and that there are many other helpful tools, particularly stretching, so putting all your eggs in the strengthening basket is not the best approach. In comparing the strengthening to the stretching in the article, I sensed an “either/or” mentality that is often seen in such studies (albeit necessary to control factors) and would hope that a multi faceted approach would be used by anyone treating plantar fasciitis.

The author of the study also writes a full guest blog article on this (reprinted here) that illustrates the importance of taking the time to read the complete study rather than relying upon quick summaries. Doing this will stimulate the critical thinking that Joe Muscolino argues for in his excellent reply. The original has very helpful photographs that demonstrate both the stretching used in the control group and the specific high load exercises so one could properly instruct clients.

What grabbed me in the photographs (Figure 2, page 29) was that the exercises are not just training concentric high load muscle function, and are a perfect example of the difficulty in isolating factors, possibly leading to incorrect conclusions. Although the protocol only speaks to “heel raises,” since the exercises require both dipping the heel far down below the forefoot with the toes supported by a towel, they also perform a significant stretch of the plantar fascia and mobilization of the transverse arch.

Possibly more important is that in lowering the heel in preparation for the concentric contraction, the patient is performing a slow, non-explosive eccentric contraction of the posterior compartment as well as a good stretch.

Many studies indicate that eccentric muscle strength is an important factor in strengthening, especially in Achilles injuries, and this may be a large factor that is ignored in the statistics claiming benefit from the high load heel raises.

Again, I think the article is very worthwhile and certainly would recommend the exercises as part of a more comprehensive treatment plan, especially including the soft tissue techniques that Judah Lyons covers.

To me, Joe’s comments about statistics on controlled studies may be more important than the specifics of the original article. Like Joe, I am highly in favor of such studies, but think he is astute in pointing out the risks of kneejerk acceptance that may shut off the all-important critical thinking to apply to our treatments.

I want to point out a few brief points in connection with Joe’s thoughts and possibly go into more detail in a later article covering treatment options. Most important is the fact that that plantar fasciitis. is a very complex condition, and although the study is well constructed to attempt to isolate treatment factors, it is impossible to isolate the multi-faceted causes of the condition some of which are actually conflicting and would require very different treatment.  Hypermobility: A high percentage of plantar fasciitis. is a result of hypermobility (and not just in the foot, but also knees and hips). If this is the primary cause, then by all means, stabilization and strengthening will probably be of the most benefit. This stabilization can be accomplished by proper shoes or orthotics, which have been shown to be quite helpful. And strengthening as demonstrated in the article would also be very beneficial.  Hypomobility: I actually see more clients suffering

from plantar fasciitis. having a high arched rigid foot structure or from having shoes that immobilize the foot having both biomechanical effects with gait, and preventing the plantar fascia from normal stretching in activities so it becomes short and fibrosed. A lot of new literature, including the well known “Born to Run” touts the benefits of less shoe stability so the foot can move through the range of motion that it is built for. For such people, strengthening may be less effective and techniques mentioned by Judah to increase mobility would probably be more helpful.  Body Structure: In addition to the arches of the foot and the all important talo-tibial joint that Judah treats by freeing the retinaculum, one must consider a multitude of factors, including, forefoot mechanics, hip function, IT band tension causing rotational strain, valgus or varus knees, weight and general health of the client.  Causative Activities: Any treatment should consider the activities that seem to be causative. Is the person sedentary? Are athletic activities primarily straight ahead running or more mobile, as in sports requiring a lot of lateral mobility and quick explosive starting and stopping.

In varying degrees, these difficult to control factors may influence the outcome of studies as much as a particular technique. So the danger of any sampling is to jump to

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different needs as mentioned above) are equally important.

The one exception I’d offer concerns heel spurs. So often I’ve had people with quite new plantar fasciitis. say that an x-ray showed a heel spur and that the doctor said that was the cause. My feeling is that the heel spur has probably been there for years, and although it may be involved, until the flare up it was also there and it should not be given as the “cause.” I have excellent results working to soften tissue around the spur along with the other areas I treat.

I also spend a great deal of time stretching and softening the posterior compartment of the lower leg, with particular attention to determining if the gastroc or soleus is more tight and working with lateral/medial balance since tightness in one of the two gastroc heads can cause torsional forces on the foot. I also agree that freeing the ankle retinaculum is extremely useful to have the foot track in a straight line. Dealing with rotational forces all the way up the leg is also helpful. I also always check both the navicular and cuboid bones for mobility, often finding that the cuboid needs mobilizing.

conclusions about the efficacy of treatments. This may create an either/or myopic approach and have therapy exclude possibly benefits from other strategies or even utilize a strategy that may be counter-productive. For example, if a large sample were to show minimal differences in results for stretching, or for strengthening, or for orthotics, one might conclude that choice of treatment really isn’t much of a factor. In reality, the sample may include very different causes such as previously mention hyper/ hypo mobility, weakness, tight muscles and fascia. A result showing strengthening as more beneficial may actually be that the sample included a higher number of people with weakness or hypermobility as their causative factor, and conversely, an apparent larger benefit from stretching, might actually be a higher number of people with hypomobility as a cause. The skill of the therapist lies in tailoring the treatment to the relevant factors

I have a whole basket of golf balls I give out to clients, telling them to use several times a day, but never to the point of pain. For stubborn cases, a night splint to move the foot into dorsiflexion can be very helpful. Interestingly, I also find that calf stretches, both with knee straight and flexed are often the key to lasting recovery, even after symptoms abate. I’m always very clear to clients that just because the pain abates, they can’t forget about keeping the area working properly with stretching and possible tune up work.

Lastly, I strongly suggest that therapists study proper function of the foot to understand the complexity of lateral and medial arches, the transverse arch and the differences in how the foot responds to proximal forces such as knees and hips. The old “shin bone connected to the knee bone” definitely applies. I’m extremely impressed with James Earls’ new book Born to Walk. If you want to really understand how the foot works and the tremendous importance of how it distributes gravity through the body, affecting all the major joints through the skull, this book will change Lastly, a few comments about Judah’s thoughts on plantar the way you approach bodywork. fasciitis. I totally agree with the importance of his treatments of specific foot muscles and also am glad that he gives his clients home treatment options. It is unrealistic Art Riggs is a Certified Advanced Rolfer® and massage therato think that we can “cure” such complex issues with a pist who has been teaching bodywork since 1988. His webtreatment every week or two. Most of my clients love the site is http://www.deeptissuemassagemanual.com/ work but say that the home programs I offer (tailored to

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Comments on the Plantar Fasciitis study

By Til Luchau

Like Joe Muscolino, I appreciated the study’s (and the subsequent guest blog reprinted in this issue) clarity and reasoned approach. I also noted that the authors included the plantar fascia’s larger-picture relationship to the Achilles tendon in their exercise design, and their measurements of plantar fascia tendon thickness changes, both of which have potential relevance to the hands-on myofascial approaches I practice and teach.

pain despite my best efforts to further her gains over the following weeks.

Because she was also working with a physical therapist who had given her exercises for her plantar fascia pain, I gave her a copy of the study and suggested she share it with her PT. He added the study’s heel-raise exercise to her routine. Six weeks later, she now reports no plantar fascia pain.

Of course, her case represents just one data point. It was also impossible to tell if the heel-raises alone made the difference: she continued to see me for myofascial work during this time, as well as an orthopedist who administered four sessions of shock wave therapy (which is thought to trigger tissue healing by inducing microtrauma to the painful tissues). However, it was gratifying to see her find a combination of approaches that gave her the relief she had been seeking.

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Foot Function Index

This study, published in the Scandinavian Journal of Medicine & Science in Sports, compared a plantar fascia stretching routine with a strengthening exercise (heel raises), measuring the two approaches’ relative effectiveness in reducing foot pain and disability in those with plantar fasciitis symptoms.

Previous studies showed degenerative changes in such patients in the connective tissue of plantar fascia where it attaches the bone. Because similar connective tissue degeneration of the patellar and Achilles tendons has been improved by high-load strength training, the authors of this study reasoned that such strength training of the plantar fascia might also improve plantar fasciitis outcomes.

It is noteworthy that although the Rathleff et al. study showed the most dramatic advantage to strengthening vs. stretching after 3 months (see Figure 1), no significant differences in improvement were seen at 1, 6, or 12 months when comparing the strengthening and stretching groups, suggesting that there is value in stretching as well. Of course, our patients and clients will appreciate the most rapid relief possible; having multiple approaches and tools to employ will only increase our effectiveness and versatility.

Til Luchau, Advanced-Trainings.com, is a Certified Advanced Rolfer and the originator of the Advanced Myofascial Techniques series.

Shoe insert & stretching Shoe insert & strength training

80 70 60

At the time I read this study, I was see50 ing a 66-year-old client with a history of plantar fascia pain secondary to 40 trauma. Like many other fascial practi30 tioners, I usually see clear and lasting 20 improvement of plantar fascia pain in 10 my clients. However, the improvements in this client’s plantar fasciitis 0 pain seemed to have plateaued. She Baseline 1 month 3 months 6 months 12 months had experienced dramatic relief in her first sessions with me, but even though Figure 1. Foot function index at baseline and at 1, 3, 6, and 12 months from the study by Rathleff et these improvements had lasted to al. (2014). FFI is is a self-report questionnaire that assesses multiple dimensions of foot function. some degree, she continued to experi- Score of 0 reflecting no pain, disability, or activity limitations. ence a certain amount of plantar fascia

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Le Massage au Hamam by Edouard Debat-Ponsan (1883) 36 Terra Rosa E-mag

Touch is Everything (Well.. At least really important)

By Art Riggs It’s more than just techniques I remember in workshops I’ve taken through the Rolf Institute and elsewhere that when trading with different partners attempting the same techniques demonstrated by instructors. With some practitioners I felt profound change in my body, while with others, very little happened. I also notice this in workshops that I teach; some people have had extensive training in protocols but just don’t seem to relate well to the tissue and don’t get the results that they and their clients hope for. I often mention, “A stroke without intention is an empty gesture.” To accomplish our goals, we need to have a clear intention of what we want to happen in the body (not just doing strokes, routines, or even protocols) and we need to work with the tissue in a way that it releases to accomplish our goals. This requires a two-way communication of listening to what the body tells us and responding, rather than just inputting our direction.

Most massage trainings mention the “gel-sol” transformation of connective tissue when skilfully applied pressure in bodywork can actually change the stiff, short and hard “gel” state to a more fluid and adaptable “sol” state allowing for hydration of cells

and actual re-alignment of collagen for muscles to work better both by lengthening short tissue and by releasing strain patters that prevent muscles from contracting in an efficient line to help joints work properly. In more simple terms, this softening and re-alignment, along with voluntary relaxation by the client is the magic “melt” that we look for in release. If we work too fast, too hard, at the wrong angle, it may feel good, but without the melt, we often lose the lasting benefits of massage and elicit the frequently heard complaint, “It felt good for an hour or so, but then returned to the same state.”

From most of our anatomy texts we get a simplified and incorrect image of our muscles being ropes pulling our bones in a straight line as levers of perfect Newtonian physics. In reality, our muscles look nothing like that, and are impacted by countless “insults” of injury, overuse, underuse, poor posture, or repetitive strain that create adhesions. Compare what the posterior knee looks like in “real” life (Figure 1). Can you envision finding strain and restrictions with slow and precise work with your fingers?

If someone is complaining of knee pain, can you imagine the lost opportunity of careful and precise freeing of restrictions if one simply per-

Figure 1. Muscles of the popliteal fossa.

Can you envision finding strain and restrictions with slow and precise work with your fingers? Image from Traité complet de l'anatomie de l'homme .

formed fast paced and broad strokes sliding over the tissue using lots of lubrication in prescribed directions?

To really restore balance and release adhesions and tension, you would have to slow down, sink into fibrous restrictions and patiently wait for the melt while thinking of proper joint function.

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Figure 2. A sheet that is pulled tight, we see the subtle straight lines of the fabric all going in one direction.

How can we all continually improve our touch, not with new tricks, but a sensitive intention and feeling for physical change in the tissue we work with?

Working in the non-neutral position In this example using a sheet that is pulled tight (Figure 2), we see the subtle straight lines of the fabric all going in one direction as depicted by most anatomy drawings, but complicated by a hypothetical strain pattern from any number of potential restrictions, possibly fascial, adhesions in muscle tissue, or even voluntary holding patterns. To work with pain or dysfunction in this “muscle”, it is necessary to release the conflicting pulls from different tangents that interfere with proper muscle contraction rather than just trying to simply compress tissue or just stretch tissue in a straight line.

I find that challenging restrictions in the non-neutral position has many advantages. By stretching muscles to the end range of easy motion I can find opposing strain patterns that don’t show up in neutral relaxed mus-

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cle length. It is easy to find the angle of pull that is disrupting proper function and at the same time give a lasting release as the restriction releases and lengthens with thoughtful intention.

Different strokes for different restrictions I love lessons from everyday life that I can apply to bodywork. A few days ago I was working in my garden in my perpetual battle with encroaching weeds, trying to pull up the weed with the entire root system so they wouldn’t grow back. I found that there was no simple routine that worked for all weeds. Take a look at the beautiful drawing I’ve rendered to make my point imagining the complex variables that exist in the human body (Figure 3).

Notice that there are multiple restrictive factors impacting the extraction.

What I found was that with some weeds, I could simply pull straight out of the ground and the whole root system would easily come out. This would be analogous to simple lengthening strokes in a massage. However

Figure 3. An illustration of a weed and its root system.

when the weed resisted, if I “muscled” and pulled straight out of the ground, I might just as easily leave lingering roots to grow into more weeds. Depending upon the soil composition (what is the general texture of the muscles you work with?), the depth of moisture (are restrictions deep or superficial?), and especially the tangential angles of restriction that may prevent “freeing” the plant; I had to approach each plant differently.

With some weeds, I could pull right out; with others I might need to use a fair amount of force very slowly releasing the horizontal feeder roots first. My suggestion with bodywork is to try the direct and simplest approach first and see how the body reacts and how successful you are.

Don’t waste time making release more complicated than it needs to be. With the weeds, I might rock back and forth between pulling vertically or horizontally, twisting, or any number of strategies. If the soil was too hard, I had to give up and water (the equivalent of warm up work to tangential areas). Of particular impor-

tance was the speed and force at which I worked. If working too fast (in bodywork this is forcing tissue and causes pain and resistance), I might break off the stem and have to wait for the roots to regenerate so I could start all over. With the body, you may need to free tangential restrictions and strain patterns first before the primary restriction releases. For example, if someone is experiencing rhomboid tightness and pain, it might be advisable to first free restrictions in the lateral scapular area from subscapularis, the teres muscles, latissimus, and lateral fascial pull (Figure 4).

My point is that, in spite of advertisements touting universal protocols as the panacea for all ills, there is no magic formula for releasing restrictions. Some are fascial, some muscular, tendinous or ligamental; some are protective neurological holding that you must retrain to give lasting freedom. Inventive experimentation is not only very effective, but also makes our work a lot more fun.

Speed and direction of intentions I like the image of achieving the melt by visualizing pushing a heavy boat from a dock. You certainly would not get a running start and suddenly apply all your force at the beginning. You first need to conquer inertia by slow steady pressure until you feel the boat begin to move.

When that happens, instead of applying more pressure with too much intention or control, this is the time to con- Figure 4. Freeing restrictions in the lateral scapular area from tinue to apply easy pressure, but possibly releasing inten- subscapularis, the teres muscles, latissimus, and lateral fascial pull. tion and letting the body tell you which direction to go.

With the boat, once it starts moving, you would continue pressure, possibly lightening up and let the boat tell you years of practice and experimentation. I work less hard how it wants to move, reacting to currents in the water, and accomplish more and have fun. My touch has evolved the wind and the shape of the hull and keel. Although we more in the last two or three years than in any time in my sometimes do need to butt heads with resistance, having practice. My work has never stagnated and I look forward voluntary cooperation if almost always the best way to to each client as a new learning experience. leave a lasting lesson.

How do you achieve these skills? We all learn differently: some visually oriented people are able to just view good work being done, while others who are more kinaesthetic need to experience the melt in their own bodies. I go to my fabulous teacher Michael Salveson to receive work, not only for the benefits to my body, but to experience his magical touch. At times, when working after these sessions, I feel his hands working through mine like a muse, albeit with some loss in translation.

Happy learning!

I can say that one of the joys of doing this work is that I continue to refine and improve my touch after over 25

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Picture courtesy of Robert Schleip

Fascia: A Body wide Organ

By Paolo Tozzi, MSc Ost, DO, PT Despite some current/old trends to distinguish fascial tissue in its bits and pieces, as if it is a death tissue to be dissected and named in its components (Stecco, 2014), nowadays fascia is always more intended from different profession as a body wide structure that permeates, supports, suspends and connects the entire organism. The old view of fascia consisting of different superimposed layered, gliding on each other, is now gradually being replaced by a broader perspective that considers this ‘fascinating’ tissue in the light of the interaction of its structure and function; as a body wide organ at different depths of differentiation; as a single architecture at various levels of form and complexity (Guimbertau, 2012). In other terms, fascia is finally starting to be intended as it truly is and has always been in nature: an ubiquitous, living, dynamic, pulsating and coherent whole.

As suggested by the work of Blechschmidt and Gasser (2012), each constituent of the connective tissue in the body presents a functional and anatomical continuity, due to the common embryologic origin from the mesoderm.

However, loading demands acting through and upon tissues, may determine their differentiation, influencing fi-

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bres arrangement, length, and density. Nevertheless, despite tissues seem to specialize in response to mechanical forces, their structural and functional interconnection is always maintained at each stage of embryological and foetal development. This requires an alternative architectural view of the body, than the traditional division of muscles, ligaments and bones.

By investing each tissue at all levels, fascia displays a three -dimensional arrangement that shapes and moulds every body constituent, being as such referred to as an ‘organ of form’ (Varela and Frenk, 1987). In fact, it embodies the element of structural interconnectedness in the organism, by surrounding, pervading, and connecting all body constituents, and yet allowing sliding and gliding motions at the same time. Interestingly, due to its phenomenological dimension of ‘in between’ the ‘outer’ (skin) and the ‘inner’ (visceral endothelium) boundaries of the body, it has also been referred to as the ‘organ of innerness’ (Van der Wal, 2014). Such body wide organ raises from the structural continuum between the musculoskeletal and connective tissue being arranged in series, rather than by separated entities in parallel as traditionally proposed

Picture courtesy of Robert Schleip

(Van der Wal, 2009).

This concept of intrinsic multi-tissue continuity has been advanced by various authors, who highlighted the structural and functional interrelationship between muscular, fascial, ligamentous, capsular and articular components.

Such whole-body connection has been referred to as ‘ectoskeleton’ (Wood Jones, 1944), ‘ligamentous complex system’ (Willard, 1997), ‘dynament’ (Van der Wal, 2009), ‘supertendon’ (Benjamin, 2009) , with subtle differences despite the same basic principle. As shown in cadaveric experiments and computer simulations, this ‘superstructure’ is capable to elaborate information at a macroscopic scale without requiring neural processes. It appears to play a ‘switching function of a logic gate’, by distributing forces in a non-linear fashion independently from neural control (Valero-Cuevas et al., 2007).

to any force introduced anywhere in the system. Thanks to its hierarchical organization, any applying force can influence any part of the whole, from cellular to the entire body and vice versa, through a non-linear distribution of forces.

Even at a cellular level, fascia displays an interconnected tensegritive arrangement, through an extensively reticular network that has found to be formed by soft tissue fibroblasts, via their cytoplasmic expansions permeating the all body (Langevin et al., 2004). Furthermore, each fibroblast’s cytoskeleton is structurally connected to the external environment, either directly with contiguous cells or through the extracellular matrix (ECM) constituents (Fletcher and Mullins, 2010). The entirety of this system may indeed represent a body-wide signalling network (Langevin, 2006), expressing through the interdependence between cells and surrounding matrix. Signals from the ECM are transferred through trans-membrane mechanoreThe whole fascial body network can be intended as a three ceptors to the cell nuclei, while being transduced into -dimensional viscoelastic matrix, balanced by an integrated chemical information, so playing an impact on various assystem of compression-tensional forces in dynamic equilibpects of cell behaviour and metabolism via modulation of rium (Ingber, 2008). In this vision, bones are the nongenes expression (Wang et al., 2009). touching rods, that play the role of compression struts, embedded in a continuous connecting system (the tension Fascia appears to respond to various physical and chemical system), that is the myo-fascio-ligamentous continuum forces, as a single structural continuum interacting with a (Levin and Martin, 2012). This exhibits a balanced tension multitude of regulatory functional properties. In health as as well as a three-dimensional and dynamic ability to adapt well as in disease, it plays different roles, such as those

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related to joint stability, general movement coordination, gross and fine movement control, transmission and distribution of mechanical forces; body wide proprioception, nociception and autonomic activity, constantly interacting with the central nervous system, cortical organization, including cognitive and affective components; hydraulic pumping and fluids flow; piezoelectricity and other forms of energy transmission; diffusion of various chemicals and nutrients; immune, hormonal, cellular, genetic and epigenetic responses, together with a potential role in many connective tissue pathologies, wound healing and tissue repair (Tozzi, 2014). Such multi-potential system provides the anatomical and physiological basis for a fasciagenic unifying theory on the different mechanisms underlying body function and dysfunction.

This network may certainly represents a body wide sensory organ (Schleip et al., 2014), and even more, a metasystem (Langevin, 2006) that coherently influences structure and function of the whole organism and the interaction between its constituents. Its vital function is so crucial that “by its action we live and by its failure we shrink, or swell and die” (Still, 1899).

Paolo Tozzi has a degree in Physiotherapy, Doctor in Posturology and Master in Osteopathy. He is the Founder of the First Italian School of Veterinary Osteopathy, former Vice-Principal of the Italian Association of Posturologists, former Treasurer of the Osteopathic European Academic Network (OsEAN), and former Vice Principal of the school of Osteopathy CROMON, Rome. He lectures widely on osteopathy, biomechanics and manual therapy, and he is a member of the Fascia Science and Clinical Applications Advisory Board of the Journal of Bodywork and Movement Therapies, in which he has published several articles about fascial tissue. He can be contacted at pt_osteopathy@yahoo.it

Guimbertau, JC. 2012. [Is the multifibrillar system the structuring architecture of the extracellular matrix?]. [Article in French].

Ann. Chir. Plast. Esthet. 57(5):502-6.

Ingber, DE., 2008. Tensegrity and mechanotransduction. J. Bodyw. Mov. Ther. 12(3):198-200.

Langevin, HM., Cornbrooks, CJ., Taatjes, DJ., 2004. Fibroblasts form a body-wide cellular network. Histochem. Cell Biol. 122(1):715.

Langevin, HM., 2006. Connective tissue: a body-wide signalling network? Med. Hypotheses 66(6):1074-7.

Levin, S., Martin, D., 2012. Biotensegrity the mechanics of fascia.

In: Schleip, R., Findley, T., Chaitow, L., Huijing, P. (Eds.), Fascia: the tensional network of the human body. Churchill Livingstone, Elsevier, Edinburgh. pp. 137-42.

Schleip, R., Mechsner, F., Zorn, A., et al., 2014. The bodywide fascial network as a sensory organ for haptic perception. J. Mot. Behav. 46(3):191-3.

Stecco, C., 2014. Why are there so many discussions about the nomenclature of fasciae? J. Bodyw. Mov. Ther. 18(3):441-2.

Still, AT., 1899. Philosophy of Osteopathy. A.T. Still, Kirksville, MO. pp. 164.

Tozzi, P., 2014. A fasciagenic model of somatic dysfunction - underlying mechanisms and treatment - A unifying model. J. Bodyw. Mov. Ther. under revision.

Valero-Cuevas, FJ.,Yi, JW., Brown, D., et al. 2007. The tendon network of the fingers performs anatomical computation at a macroscopic scale. IEEE Trans. Biomed. Eng. 54(6 Pt 2):1161-6.

Van der Wal, J., 2014. The fascia as the organ of innerness – An holistic approach based upon a phenomenological embryology und morphology. In: Torsten, L., Tozzi, P., Chila, A. (Eds.), Fascia in the osteopathic field. Handspring Publishing, Edinburgh. In preparation.

Van der Wal, J., 2009. The architecture of the connective tissue in the musculoskeletal system-an often overlooked functional parameter as to proprioception in the locomotor apparatus. Int. J. Ther. Massage Bodywork. 7;2(4):9-23.

Read 6 Questions to Paolo on page 55.

Varela, FJ., Frenk, S., 1987. The organ of form: towards a theory of biological shape. J. Soc. Biol. Struct. 10(1):73-83.

References

Wang, N., Tytell, JD., Ingber, DE., 2009. Mechanotransduction at a distance: mechanically coupling the extracellular matrix with the nucleus. Nat. Rev. Mol. Cell Biol. 10(1):75-82.

Benjamin, M., 2009. The fascia of the limbs and back--a review. J. Anat. 214(1):1-18.

Blechschmidt, E., Gasser, RF., 2012. Biokinetics and biodynamics of human differentiation: principles and applications. North Atlantic Books, Berkeley.

Fletcher, DA,, Mullins, RD., 2010. Cell mechanics and the cytoskeleton. Nature 28;463(7280):485-92.

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Willard, FH., 1997. The muscular, ligamentous and neural structure of the low back and its relation to back pain. In: Vleeming, A., Mooney, V., Snijders, CJ., et al. (Eds), Movement, stability and low back pain: the essential role of the pelvis. Churchill Livingstone, Edinburgh.

Wood Jones, F., 1944. Structure and function as seen in the foot.

Baillière, Tindall and Cox, London.

CORE Myofascial Therapy

By George Kousaleos, LMT Every workshop that I have taught for the past 30 years has dealt with creating an appreciation for the fascial tissues that surround, support, connect, and in many ways, defend the other soft and osseous tissues of the human body. This concern stems from a myofascial approach to structural integration that forms the foundation of my work. Like most massage therapists, I was trained at the entry level to primarily consider that my palpatory skills were focused on the musculature of the body. While I was taught that my strokes would also improve lymphatic, venous return, and neurological issues, I still found myself thinking, ‘What muscle is this, and how can I improve its tonicity?’ It wasn't until I began my advanced structural training that I was introduced to the importance of the fascia and its integrative role with other systems. My advanced training focused on techniques that improved the relationship between structure and function. The idea of taking the fascial tissues through a thixotropic phase change implied that these tissues were paramount in releasing muscle tension, improving both venous and lymphatic flow, reducing neurosensory excitability, and balancing structure and posture.

My experience tells me that chronic pain resides in these fascial tissues, especially in the deep fascia that surrounds the body and the epimysium that surrounds the extrinsic musculature. Over the years I have refined the foundational technique that I use to prepare the myofascial tissues for deeper and more specific work. This technique is called CORE Myofascial Spreading. It approaches the fascial tissues at a 45 degree angle and uses a minimum amount of lubrication to increase tissue temperature. The technique is applied slowly with the broad surfaces of the palm, finger pads, or fist. This technique has allowed me to more easily ‘feel’ the improvement of thickened or adhered fascial tissues. My experience seems to suggest that if more effort is made in working in a full-body ap-

Figure 1. Langer’s Lines

proach with these two outer layers of myofascia, an improvement in related systems is achieved and more easily maintained. Application of any myofascial technique should take into consideration the layout of the sensory nervous system on the outermost layers of fascia. CORE Myofascial Spreading follows the primarily horizontal layout of Langer's Lines (Figure 1), so that a minimum amount of nerve stimulation can be maintained during slow, but forceful strokes. This organization of stroke delivery is crucial to a balanced application of full-body sessions that promote fascial improvement.

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Workshop Report: CORE Myofascial Therapy & CORE Sports and Performance Bodywork Sydney, September - October 2014.

CORE Myofascial Therapy is a 6-day certification course taught directly by George P. Kousaleos, founder of the CORE Institute, from Tallahassee, Florida. The workshop was held in a nice location tucked away in the busy Newtown area in 26 September until 1 October 2014.

The first day, George presented information on the theory and history of structural integration, the anatomy and physiology of fascia, body reading strategies, and specific benefits of myofascial and structural therapies. He also discussed the Intrinsic Spiral Theory, where most of a person’s structural contour has a unique circular pattern that often resembles a clockwise spiral. Then he described the Neurosomatic Awareness, taught the 5-Point Standing Awareness exercise, and full-body application of the myofascial spreading techniques. The second day George introduced arthrokinetic joint techniques, and CORE myofascial therapy from a side-lying position. The final day George detailed cervical, cranial, and facial techniques, and strategies for stimulating the parasympathetic nervous system while improving neurosomatic awareness.

Mic Mueller-Coons, a massage therapist and Iron Man Champions from Townsville wrote: “Getting the basic Myofascial Spreading done on my first day resulted in a dramatic improvement of my body alignment and this is without focusing on any area of special discomfort or pain. They worked only the front and back of my body. The results were astounding! Much greater improvement of range of motion and Breathing freeness were achieved on the 2nd day while working in side posture on the lateral side of the body and the inside of the legs. Supporting the work with moderate stretching and twisting again produced even more astonishing results.”

We then continued to the next level, CORE Myo 2 where George presented information on somatic psychology, client-education strategies, and specific techniques for

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intrinsic layers of fascia and musculature. George taught clinical protocols, include the “Back Specific”, a deeper treatment plan for the paraspinal, scapula, sacrum, and iliofemoral regions. The “CORE Release” was presented to work with the pelvic floor, sacrotuberous ligament, and related ligaments of the lumbar, thoracic, and cervical spine. Also included is the “Foot Specific”, a treatment protocol for the fascia and musculature of the foot and ankle.

One of the participants’ comment: “I love the systematic way of being able to assess body type, pain areas and probable response to treatment and then be able to help in a clear and precise manner with profound bodywork that I would be confident to use.”

Everyone is impressed with George’s approach, clear instruction and stories. Comments from the CORE Myofascial participants are a testament to the quality of the educational experience: ” I enjoyed George’s knowledge (and stories). I love it all.

The whole course made me felt very flexible while covering a lot of content” Linda, Brisbane.

“George was very eloquent and articulate in explaining the techniques and the reasoning behind them. His anecdotal

stories were great. He was approachable, patient, and funny.” Leanne, Brisbane.

“Thank you so much for your CORE workshops, they were fantastic! I learnt so much and my clients are really benefitting from your techniques.” Dani, Newcastle.

“One of the best workshops I have been” Leigh-Ann, Perth.

The CORE Sports and Performance Bodywork is the next in the workshop series. George has lots of experiences working with elite athletes. He was the General Manager for the 1995-96 British Olympic Association Preparation Camp Sports Massage Team, and was the Co-Director of the Athens 2004 International Sports Massage Team. George also currently leads the CORE Sports Bodywork team that works with the Florida State University National Champion Football Team.

In this workshop, George introduced myofascial therapy theories and techniques that are appropriate for each style of sport. George showed how the Myofascial system relates to sport. He further introduced the primary concepts of the physical and psychological demands of training and performance for different athletes. A breakdown of somatotypes and their inherent strengths and challenges was used to discuss the development of bodywork protocols for the endurance, sprint, power, and multiskilled athlete. George then demonstrated myofascial techniques for legs, pelvis, and back.

The second day of the workshop, George showed advanced strategies including working with intrinsic myofascial tissues of the axial and apendicular regions and strategies to balance autonomic nervous system. Advanced protocols for the arms, shoulders, chest, neck, and head were also taught.

The final day focused on the integration of the CORE myofascial techniques. In the afternoon, George organised elite athletes for us to work-on in a 90 minute session. The athletes include medal-winner runner, surfer, marathon runner, swimmer, football player, and boxer.

work very well and I averaged 13 seconds faster than any of my previous training sessions in Australia while doing 1k intervals two days after the massage. I had experienced stiffness in my legs during my time here, but after the treatment my muscles felt much more relaxed and flexible.”

“Thank you again for this amazing seminar, I felt welcome and I learnt heaps. The most beneficial outcome from my side as a therapist is that I haven't been using my thumbs as much as in the past and my back and neck certainly like this kind of work. My clients have commented on how "light" they feel after the massage.” - Myriame (Canberra).

“Since I've been back at my practice I performed 95% of my work with CORE Myofascial therapy. I had great and some amazing results.” - Mic (Townsville)

Finally, Taso Lambridis, BSc (Physiotherapy) MSc (Sports Medicine), Sydney wrote: “Having recently attended the CORE Myofascial workshops with George Kousaleos I would highly recommend this course to all manual therapists who are keen to understand and explore the amazing world of fascia. As a physiotherapist I found the material invaluable and a great add-on to what I am already using. George was highly informative and has so much experience to give you great insight into this fantastic treatment method. This is one course not to be missed and I look forward to attend any further training with him next year.“

Kip Hobson, swimming athlete, and Ranell, Masters Championship winner and athlete trainer commented: “Both Ranell and I really enjoyed the massage immensely – Even coming from myself who is an avid hater of them, I found it to be wonderful and would gladly book in for regular ones if a suitable location was found close to home.”

Robert Alexandersson, a marathon athlete from Sweden who experienced the massage wrote: “The treatment

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Maximise Oxygenation

CORE MYOFASCIAL THERAPY with George Kousaleos Sydney, Brisbane Sept-Oct 2015 "George Kousaleos was one of the most influential people in the manual therapy profession on my career and my success.

His amazing CORE Myofascial Therapy training should be the foundation of every manual therapist's practice. His incredible knowledge of the human body, his compassion, and his kind heart, make him one of my greatest mentors in the manual therapy” - James Waslaski LMT; Author & International Lecturer Integrated Manual Therapy & Orthopedic Massage

CORE Myofascial Therapy Certification

CORE Myofascial Therapy for the Back & Neck

Sydney (Venue: 5 Forbes St, Newtown)

Sydney 3, 4 October 2015

CORE Myofascial Therapy 1: 25, 26,27 September 2015 CORE Myofascial Therapy 2: 28, 29,30 September 2015

This 2-day seminar will focus on CORE myofascial treatment Back Specific and Chest Neck & Head protocols.

An intermediate to advanced, six-day workshop designed to give practicing massage therapists in-depth knowledge and hands-on experience in full-body myofascial treatment protocols. With this knowledge and skill, you will be able to improve your clients’ structural body alignment and increase their physical performance.

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

CORE Sports and Performance Bodywork Brisbane 9,10,11 October 2015 (venue 41 Anzac Av. Redcliffe) This 3-day seminar will examine the basic styles of performance inherent in all athletic disciplines. Utilizing structural integration and myofascial therapy theories and techniques that are appropriate for each style of performance, we will focus on developing training and event protocols for endurance, sprint, power, and multi-skilled athletes.

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

Terra Rosa 46 Terra Rosa E-mag Your Source for Massage Information AMT Approved CEU Points, ATMS Approved CPE

For more information & Registration Visit www.terrarosa.com.au E: terrarosa@gmail.com

Research Highlights Compiled By Jeff Tan Myofascial Trigger Point-focused Head and Neck Massage for Recurrent Tension-type Headache Myofascial trigger points (MTrPs) are focal disruptions in skeletal muscle that can refer pain to the head and reproduce the pain patterns of tension-type headache (TTH).

Researchers Albert Moraska and colleagues from University of Colorado at Denver studied massage focused on MTrPs on subjects with tension-type headache in a placebo-controlled, clinical trial to assess efficacy on reducing headache pain.

Fifty-six subjects with TTH were randomized to receive 12 massage or placebo (detuned ultrasound) sessions over six weeks, or to wait-list. Trigger point release (TPR) massage focused on MTrPs in cervical musculature. Headache pain (frequency, intensity and duration) was recorded in a daily headache diary. Additional outcome measures included self-report of perceived clinical change in headache pain and pressure-pain threshold (PPT) at MTrPs in the upper trapezius and sub-occipital muscles.

The results from diary recordings showed differences in headache frequency between treatment groups across time , but not for intensity or duration. Post hoc analysis indicated headache frequency decreased from baseline for both massage and placebo. However no difference was detected between massage and placebo. Nevertheless, subject report of perceived clinical change was a greater reduction in headache pain for massage than placebo or wait-list groups. Pressure-pain threshold improved in all muscles tested for massage only.

The authors wrote: Two findings from this study are apparent: (1) MTrPs are important components in the treatment of TTH, and (2) TTH, like other chronic conditions, is responsive to placebo. Clinical trials on headache that do not include a placebo group are at risk for overestimating the specific contribution from the active intervention.

Kinesio Taping to generate skin convolutions is not better than sham taping for people with chronic non-specific low back pain Researchers from Universidade Cidade de São Paulo, Brazil asked the question “For people with chronic low back pain, does Kinesio Taping, applied according to the treatment manual to create skin convolutions, reduce pain and disability more than a simple application without convolutions?”

The researchers conducted a randomised trial with concealed allocation, intention-to-treat analysis and blinded assessment of some outcomes. 148 participants with chronic non-specific low back pain were recruited. Experimental group participants received eight sessions (over four weeks) of Kinesio Taping applied according to the Kinesio Taping Method treatment manual (i.e., 10 to 15% tension applied in flexion to create skin convolutions in neutral). Control group participants received eight sessions (over four weeks) of Kinesio Taping with no tension, creating no convolutions.

The primary outcome measures were pain intensity and disability after the four-week intervention. Secondary outcomes were pain intensity and disability 12 weeks after randomisation, and global perceived effect at both four and 12 weeks after randomisation.

The results showed that applying Kinesio Tape to create convolutions in the skin did not significantly change its effect on pain (MD-0.4 points, 95% CI-1.3 to 0.4) or disability (MD-0.3 points, 95% CI-1.9 to 1.3) at four weeks. There was a small difference in favour of the experimental group for the secondary outcome of global perceived effect (MD 1.4 points, 95% CI 0.3 to 2.5) at four weeks. However no significant between-group differences were observed for the other secondary outcomes.

The authors concluded that Kinesio Taping applied with stretch to generate convolutions in the skin was no more effective than simple application of the tape without ten-

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Research Highlights sion for the outcomes measured. These results challenge the proposed mechanism of action of this therapy.

Reference: Parreira PCS, Costa LCM, Takahashi R, Hespanhol Junior LC, da Luz Junior MA, da Silva TM, Costa LOP (2014) Kinesio Taping to generate skin convolutions is not better than sham taping for people with chronic nonspecific low back pain: a randomised trial. Journal of Physiotherapy 60: 90-96.

Evidence-Based Sexual Positions for Back Pain A lack of evidence-based guidelines on how to avoid triggering back pain during sex prompted the research, says co-author Professor Stuart McGill, professor of spine biomechanics at the University of Waterloo, Ontario. The findings were published in Spine jouranl.

Stuart McGill and PhD student Natalie Sidorkewicz set out to build an evidence-based and practical atlas matching sexual positions and styles with possible back pain triggers.

They recruited ten healthy couples who were filmed using motion capture and infra-red technology while they had sex. The researchers were in a separate booth where they could hear, but not see, the participants. Electrodes were used to record muscle activity in certain parts of the body to get an idea of force.

Their results showed that the 'spooning' position for sex was actually one of the worst positions for individuals with flexion-intolerant back pain—back pain that is worsened by bending over forward or by sitting for long periods of time.

“I'm assuming because people lay on their side, someone thought the spine would be supported and this was good for people, but it turned out not to be true,” McGill says. For men with that particular back pain trigger, the study suggested doggy-style sex was far less likely to aggravate the back problem. In general, the researchers found that the person on top—whether male or female— is most responsible for motion.

For individuals with back pain triggered by movement, the researchers suggested there was no position that would avoid pain, and advised instead that they should try to move more using their hips than their back.

"The more the hinging takes place at their hip, the less the hinging takes place in their spine, the better off [their back is]," McGill says.

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Researchers were also able to measure the impact of orgasm on the body, which yielded some surprises. "I had no idea of the range; how it's basically a non-event in some people, through to really substantial muscle contraction in others, and you could see that if they were out of position, they would hurt themselves," says McGill.

From ABC Science.

Golden Goose Award: Massages for baby rats lead to better outcomes for premature infants What could we possibly learn from massaging baby rat?

The answer is, a lot. Just ask the millions of families whose prematurely born infants have survived and thrived on account of that research.

That's why the researchers behind this work – Saul Schanberg, Tiffany Martini Field, Cynthia Kuhn and Gary Evoniuk – receiveed the Golden Goose Award September 18 at a ceremony at the Library of Congress in Washington, D.C. The Golden Goose Award honours scientists whose federally funded research may not have seemed to have significant practical applications at the time it was conducted but has resulted in major economic and other benefits to society. In this case, the impact of the researchers' collective work has been momentous. The key discovery – that touch, in the form of infant massage, can vastly improve the outcome for babies born prematurely. And it began when researchers studying infant rats decided to rub their backs with a tiny brush.

In 1979 Schanberg, a Duke University neuroscientist, Kuhn, a graduate student, and Evoniuk, a lab technician, were working with rat pups to study factors influencing two key growth markers, ornithine decarboxylase and growth hormone. To conduct their work, which was funded by the National Institutes of Health, they needed to separate the pups from their mothers. However, they quickly found that the pups, though being fed and kept warm, were failing to thrive and their levels of the key growth markers were declining.

A series of experiments ruled out factors such as nutrition, body temperature and maternal pheromones. The researchers then made the key observation: the rat mothers spent a great deal of time grooming and vigorously licking their pups. Wondering whether the act of stimulation through licking was making the difference, the researchers simulated the mother's tongue with a small brush and stroked up and down the rats' tiny backbone.

This was the missing link. Enzyme and growth hormone

Research Highlights levels rose and the rat pups thrived again.

foam rolling, and control groups.

Field, a psychologist at the University of Miami Medical School who was conducting her own research on how to help premature infants survive and grow, learned of Schanberg’s groundbreaking work and wondered whether it had implications for human infants. In 1986, Field published her own landmark study drawing from Schanberg, Kuhn and Evoniuk’s work with rat pups. Funded by the National Institute of Mental Health, Field’s study demonstrated that using similar tactile stimulation in preterm human infants had immediate positive effects. Premature infants who were massaged for 15 minutes three times a day gained weight 47 percent faster than others left alone in their incubators (standard practice at the time), were more alert and responsive, and were released from the hospital an average of six days sooner than the premature babies who were not massaged.

The authors concluded that: The results support the use of a foam roller in combination with a static stretching protocol. If time allows and maximal gains in hip flexion ROM are desired, foam rolling the hamstring muscle group prior to static stretching would be appropriate in non-injured patients who have less than 90° of hamstring ROM.

flexion ROM from the pre-measure on day 1 to the post measure on day 6.

Reference: Williams, Christopher M., et al. Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial. The Lancet (2014).

Reference: Mohr, A. R., Long, B. C., & Goad, C. L. (2014).

Foam Rolling and Static Stretching on Passive Hip Flexion Range of Motion. Journal of sport rehabilitation.

Paracetamol doesn’t help back pain

Paracetamol, a painkiller universally recommended to treat people with acute low back pain, does not speed recovery or reduce pain from the condition, according to the results of a large trial. Panadol sells a product that is dedicated to back and neck pain, containing 500g paracetamol. The study published in The Lancet medical journal Foam Rolling as Effective as Stretching? found that the popular pain medicine was no better than Many athletes report that foam rollers help release tension placebo, for hastening recovery from acute bouts of low in their muscles thus resulting in greater range of motion back pain or easing pain levels, function, sleep or quality of (ROM) when used prior to stretching. To date, no investilife. gators have examined foam rollers and static stretching.

In this trial, 1,652 people from Sydney with acute low back Thus a study was conducted by researchers from Dept of Sport Sciences, Iowa Western Community College to deter- pain were randomly assigned to receive up to four weeks of paracetamol, either in regular doses three times a day, mine if foam rolling prior to static stretching produces a or as needed, or to receive placebos. All those involved significant change in passive hip flexion range of motion. received advice and reassurance and were followed up for The study is a Controlled laboratory study. Forty subjects three months. with less than 90° of passive hip flexion ROM and no lower The results showed no difference in the number of days to extremity injury 6 months prior to data collection particirecovery between the treatment groups - with the average pated. time to recovery coming out at 17 days for each of the During each of 6 sessions, subjects passive hip flexion groups given paracetamol, and at 16 days for the placebo range of motion was measured prior to and immediately group. following: static stretching, foam rolling and static stretching, foam rolling, or nothing (control). To minimize acces- Paracetamol had no effect on short-term pain levels, disability, function, sleep quality, or quality of life, the resory movement of the hip and contralateral leg, subjects lay supine with a one strap placed across their hip and an- searchers said, and the number of patients reporting negaother strap located over the uninvolved leg just superior to tive side effects was similar in all groups. the patella. A bubble inclinometer was then aligned on the This study indicates is that the mechanisms of back pain thigh of the involved leg where subjects then performed are likely to be different from other pain conditions. This hip flexion. study would suggest that probably the most important thing a patient does is to resume normal activities.

The main outcome measure is the change in passive hip

The results showed that there was a significant change in passive hip flexion ROM regardless of treatment. Subjects receiving foam roll and static stretch had a greater change in passive hip flexion ROM compared to the static stretch,

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Research Highlights Constantly looking down at your phone can cause a 27 kg force on your neck Erik Dalton once wrote that your head could weigh 42 Pound (or 19 kg) if you have a forward heard posture, moving 3 inches (or 76 mm) of the head forward will bear a 19 kg forge against gravity.

Kenneth Hansraj, chief spinal and orthopaedic surgeon at the New York Spine Surgery and Rehabilitation Medicine in the US, used a 3D computer model of the human spine to calculate the effect of constantly bending our heads down to check our phones. Because our heads are pretty heavy - weighing up to 5.5 kg, or 12 pounds - when we are frequently looking down for extended periods, we’re increasing the gravitational pull on them.

And, as it turns out, this force is pretty huge.

“As the head tilts forward, the forces seen by the neck surge to 27 pounds (12 kg) at 15 degrees, 40 pounds (18 kg) at 30 degrees, 49 pounds (22 kg) at 45 degrees and 60 pounds (27 kg) at 60 degrees,” Hansraj reports his finding in the journal Surgical Technology International. "The weight seen by the spine dramatically increases when flexing the head forward at varying degrees.

These stresses may lead to early wear, tear, and degeneration, and possibly surgeries.”

Ultrasonography in myofascial neck pain Antonio Stecco and colleagues from Padova University recently studied the possible role of the deep fasciae in Chronic Neck Pain and test the utility of the ultrasonography in the diagnosis of myofascial neck pain. This is because a definitive diagnosis of chronic neck pain (CNP) is sometimes not possible. The study was published in Surgical and Radiologic Anatomy.

The ultrasound morphometric and clinical data of 25 healthy subjects and 28 patients with CNP were compared. For all subjects, the active and passive cervical range of motion (ROM) was analyzed and the neck pain disability questionnaire (NDPQ) was administered. The fascial thickness of the sternal ending of the sternocleidomastoid and medial scalene muscles was also analyzed by ultrasonography.

The results showed that there were significant differences between healthy subjects and patients with CNP in the thickness of the upper side of the sternocleidomastoid fascia and the lower and upper sides of the right scalene fascia both at the end of treatment as during follow-up. A significant decrease in pain and thickness of the fasciae were found. Analysis of the thickness of the sub-layers showed a significant decrease in loose connective tissue, both at the end of treatment and during follow-up.

The data support the hypothesis that the loose connective tissue On average, we’re spending up to four hours a day looking down inside the fasciae may plays a significant role in the pathogenesis to read something or check our phones. This equates to 1,400 of CNP. In particular, the value of 0.15 cm of the SCM fascia was hours every year of extra stress on our cervical spines - the part in considered as a cut-off value which allows the clinician to make a our necks just above our shoulders. diagnosis of myofascial disease in a subject with CNP. The variation of thickness of the fascia correlated with the increase in quantity of the loose connective tissue but not with dense connective tissue.

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6 Questions to Paolo Tozzi 1. When and how did you decide to become a bodyworker?

therefore, in turn, its clinical application.

At the end of my high school, I was fascinated from the idea of working with my own hands on living bodies for relieving pain and promoting health. At that time, I was already a Reiki practitioner, so that I had some little experience in that sense and I definitely wanted to grow in that direction. In 1996, I started my degree physiotherapy at the A. Gemelli University of Rome. It took me three years to graduate and to understand that it wasn’t exactly what I was looking for. I felt the need to develop something different: the ability ‘to feel’ the tissues beyond just the skills ‘to work on’ them. Because of that, I moved in the U.K. to study osteopathy at the European School of Osteopathy in Maidstone. Finally, I found the dimension I was searching and the profession I was born for.

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

2. What do you find most exciting about bodywork therapy?

The most exciting part about it is that you never know what is going to happen…when treating a person, and when engaging a tissue in particular, is like starting an adventure. Despite the intention remains always the same – to promote the healing process – each patient will take his/her own path, own direction and modality. Each time is different; each way is unpredictable.

It can only be followed and we can just offer a fulcrum around which the healing may occur. The wisdom within, between and around tissues will do the rest. The most exciting part is being an ‘actively passive’ witness of this extraordinary healing process, rising from an instant of emptiness and stillness up to the branching into its full development in the patient’s life.

3. What is your favourite bodywork book?

Each patient is an outstanding ‘book’ to read and discover at each continuing phase of its life-lasting ‘writing’. Every time I look at any patient of mine, I remind to myself to be looking at an ongoing ‘phenomenon’, at a wonderful universe, being unique in its nature, form, behaviour and development, instant by instant. I am still searching for a book that can teach me more than a patient in my practice.

4. What is the most challenging part of your work?

I would say to remain always ‘intellectually questioning’ and ‘manually perceptive’ at the same time. To keep always alive the intimate dialogue between the “thinking” and the “feeling” process in each treatment session. We should avoid exceeding in any of these two directions, since the optimal therapeutic state occurs when the dynamic interaction between these two elements is in balance. I believe also each bodywork profession should reflect this equilibrium: keep its philosophy and manual application pure and free, while the knowledge coming from appropriate research should support its understanding and

If you wish to make a career out of it, change job. This is not like going to the office every day. We deal with human being, we take care of living person suffering of various conditions, emotional states, mental processes, social contexts. We hold a huge responsibility for each of them. We should guide them towards autonomy, independency, wellness, happiness; finding their own way to reach this ultimate goal; helping the solution within to become fully expressed; by supporting without conditioning; promoting without imposing. This is not an ordinary job; I would call it a vocation instead.

6. How do you see the future of manual therapy?

I see two directions. The first one is dominated by business. I have seen many lecturers willing to create disciples instead of colleagues; many courses where ‘fishes’ were given, rather than ‘fishing’ being taught. At the same time, I have noticed many manual approaches being basically very similar and yet distinguished and protected by trademarks and copyrights. Some of them have even named their application with words of common use in the clinical and research field…so that we are not even free to use those words without being legally prosecuted. I believe this is just ridiculous, especially if we consider that most of these people who claim to have ‘invented’ something have just ‘re-discovered’ and ‘re-named’ old methods of manual intervention instead. This direction leads to separation, division, selfprotection, self-referencing, self-maintenance and a leadercentred medicine.

The second direction is dominated by passion. Thousands of bodyworkers in the world do their job with devotion, every day on every patient, in both a clinical and research field. I hold a huge respect for each of them. I believe the future for this direction will be a structured and dynamic interdisciplinary approach for every patient. We are coming to a day when we are finally seeing the multi-dimensional reality of each patient, the multifactorial etiology of each condition, therefore the need of a multidisciplinary intervention. We are on the edge of a radical change leading to a shift of paradigm. Clinicians and scientists from different fields are gathering and sharing always more their opinions, evidences, competences and experiences. Communication of knowledge and sharing of clinical experience, under a common scientific language, amongst different professions, will be the foundation for this bright future. This direction is based on and will lead to participation, sharing, inter-collaboration, holism and a person-centred medicine. So my only question is: which direction do YOU want to go?

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6 Questions to Jo Phee 1. When and how did you decide to become a yoga teacher?

More than a decade ago, I held a corporate job as an Event Manager and was very stressed from the corporate work. I would visit the gym daily to unwind and one day, I saw a yoga class taking place and I stepped in to try. I was appalled by my inflexibility, given that I was still young and active then. That was possibly the most painful class I had ever attended and it was pivotal to what spiked my interest in yoga since.

In late 2000, I migrated to Sydney and, as yoga was already very popular in Australia. there was an abundance of teachers, studios and styles to choose from. I wanted to study yoga more in-depth beyond the physical stretching, so I enrolled into a 3-year Diploma course with the Satyananda Yoga Academy in Mangrove (The Bihar School of Yoga). This school offers one of the most rigorous and extensive training programs in the world and, while I was not sure I was going to become a teacher, I am glad I made that choice simply out of my interest for yoga.

3. What are your most favourite yoga books?

Asana, Pranayama, Mudras and Bandhas by Swami Satyananda, and The Complete Guide to Yin Yoga by Bernie Clark.

4. What is the most challenging part of your work?

I find not knowing how each student will react to the practice is what is most challenging but also fascinating in teaching yoga. No matter how much analysis or study a teacher may have, the real textbook is the student in front of you. And each time just when I am sure I was correct, I am pleasantly stoked to have a student that will prove me wrong. It just goes to show that teaching yoga (just like teaching all other movement modalities) is a continuous, lifelong learning journey. You can never finish learning what is to come because each individual human being is so different in their anatomy.

5. What advise you can give to fresh yoga teachers who wish to make a career out of it?

Upon graduation and coming back to Singapore, becoming a teacher seemed the natural way to progress in my practice.

Be authentic and teach sincerely from the heart. Teach because you want to share and give, not because you want to make a career out of yoga. If you are passionate about teaching, the professional aspects will take care of themselves.

2. What do you find most exciting about yoga?

6. How do you see the future of yoga?

Yoga challenges the body on all aspects of its being. The stretching opens up areas of the body that are stuck from immobility. The breathing exercises enhance the energetic body and improve the circulation of stagnant blood and energy flow. The meditation trains the mental body to focus and become present with the very moment and allows us to reconfigure the mind at will, so that we may learn to weather and cope with the oscillations of everyday life. With that mindfulness training, we become a more aware being and we acquire insight in polishing and refining our interactions with our inner environment, as well as the people around us. It is truly a profound bodymind-heart practice.

It is promising to see more people practicing yoga these days. I think yoga will continue to be mainstream like running and swimming and it will become part of our daily exercise needs.

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Jo Phee is a senior Yin Yoga teacher trainer, specializing in Anatomy and Fascia studies, as well as Chinese Medicine.

She is based in Singapore but travels around the world to conduct Yin Yoga Teacher Training programs. She will be teaching in Melbourne, 6 - 9 March. For more info on her trainings, visit www.yinspiration.org

The Heskiers OneTool™ The All-in-one Bodywork Tool—The One Tool You Need An ergonomically designed myofascial release tool that offers potentially effective and precise bodywork treatments for bodywork professionals. The Heskiers OneTool™ can be used in combination with your existing bodywork techniques . Practitioners can use the Heskiers OneTool to open the muscles in preparation for their respective treatments. The Heskiers OneTool™ can assist your hands by minimizing the pressure needed to give effective deep tissue treatments and may protect you from work related injuries to your hands, arms and shoulders.

Available at www.terrarosa.com.au

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