Terra Rosa E-magazine No 22

Terra Rosa E-magazine

ISSN 2652-0060

terrarosa.com.au Open information for Bodyworkers No. 22, Dec 2019

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ISSN 2652-0060

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ontents

Principles of Assessment —Bob McAtee

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Cover Photo by Patty Kousaleos

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Notes from Fascia Research Congress and Pain Science Summit —Til Luchau

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Fascia can actively contract and thereby influence musculoskeletal dynamics

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Exercise attenuates fibrosis to the multifidus muscle associated with intervertebral disc degeneration

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Manual Therapy as a Treatment for Overuse Injures

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Josephine Key talks about Freedom to Move

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Til Luchau on Scoliosis: Working from Inside Out

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Differential diagnosis of shoulder pathology

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— John Gibbons 38

Assessment of Fascial Dysfunction — Doreen Killens

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Ligamentous Articular Strain Technique: A Reconceptualization and Revitalization of a Classical Osteopathic Manual Technique — Robert Libbey

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Research Highlights

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Principles of Assessment

by Bob McAtee Accurate assessment is vital for properly treating soft tissue injuries. The goal of the assessment process is to locate the structure or structures responsible for the client’s pain. Although massage therapists are not legally qualified to diagnose a condition or injury, the profession’s scope of practice includes the right to assess a client to determine whether massage therapy is appropriate treatment for her condition or whether the client needs to be referred to another practitioner.

This article serves as a thorough introduction to the principles of assessment for the therapist who may not have studied the topic during their initial training as a sports massage therapist.

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HOPS Method Thorough evaluation includes several steps that can be summarized by the acronym HOPS: history, observation, palpation, and special tests. Table 1 contains examples of the types of information collected in each category, but it is by no means a comprehensive list. The HOPS process provides the practitioner with a systematic, repeatable method for evaluating injuries.

History An accurate history of the problem presented by the athlete is essential for determining a proper course of treatment. Some conditions have a characteristic pattern of onset and symptoms that can be ascertained from the history. For instance, if an athlete reporting a knee injury describes hearing a pop in his knee at the time of injury, accompanied by the knee giving way, this combination is characteristic of a meniscal or ligament injury, or both.

Taking a thorough history is the beginning of the deductive process that eventually leads to a working hypothesis of what the injury may be and whether it’s a condition that would benefit from sports massage therapy. The information acquired in the history helps direct the next steps in the HOPS evaluation.

The history should include, but is not limited to, these questions: Gathering background information on the injury or complaint • What happened? Where? When?

• Do you have a previous history of this injury or issues with this body part?

• Did you hear anything (e.g., popping, grinding)?

• Did you feel anything (e.g., popping, burning, joint giving way, numbness)?

Gathering information about the primary complaint • What symptoms or complaint brought you in today?

• What symptoms are bothering you the most today?

• What were the symptoms at the time of injury?

• How would you describe the pain today (e.g., achy, sharp, burning, throbbing)?

• How would you rate today’s pain on a scale from 0 to 10?

• What makes your symptoms worse?

• What makes your symptoms better?

Gathering information about previous diagnosis and treatment Learning about a previous diagnosis and any previous treatment and its outcome helps a practitioner design a treatment plan with a greater chance of success.

• Has there been a previous diagnosis? If so, who made the diagnosis and what was it?

• Has there been previous treatment? If so, what was done and by whom?

• What were the results of the treatment?

Observation Observation is generally limited to what the practitioner can see, feel, or hear, as opposed to what the client reports subjectively. When possible, quantifying the finding in some way is valuable for documenting results. For instance, a swollen ankle could be noted as mild, moderate, or severe. Even better, one could measure the ankle circumference (comparing to the uninjured side). After treatment, changes can be documented to show the effectiveness of the treatment administered.

During observation, look for the following: • Swelling or atrophy • Abnormal colour (bruising, redness, paleness) • Postural issues such as an antalgic position, holding, guarding • Altered gait mechanics, for example limping • Heat or cold (note colour changes in the skin due to heat or cold) • The sound of crepitus or grinding • Facial expressions that could indicate pain

Palpation The palpatory examination is guided by the findings gathered from the history and observation. Palpation is performed on the uninjured side first (to obtain a benchmark for normal) and then proceeds cautiously on the injured side.

The palpation portion of the HOPS evaluation is the discrete use of the fingers, thumbs, or back of the hand to help determine the quality of the soft tissues. Palpation is performed to identify the feel and quality of the injured area, with special attention to previous observations such as swelling and temperature changes, as well as to muscle

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spasm, crepitus, and significant point tenderness. Palpation may also include passive ROM to get a sense of the condition of the movement quality of joint (e.g., spongy, springy, etc.). Later in the assessment process, palpation will play a key role in determining exactly where massage and additional techniques, such as stretching, will be administered.

Special Tests In general, this portion of the assessment examines passive and active joint range of motion and muscle activation. The aim of accurate evaluation is to locate the structure responsible for the athlete’s pain. This is accomplished using a variety of tests to stress the suspected tissues. Healthy tissue is expected to function without pain or weakness. When injured tissue is placed under stress, pain will increase (especially the pain that brought the athlete in for evaluation) or the tissue will be weak, or both.

Assessing Active, Passive, and Resisted Motion Evaluation protocols that test active, passive, and resisted movements are intended to investigate the soft tissues that could be the source of the client’s pain. These assessments, with the potential findings for each, are summarized in Table 2 and then described in detail. As with all tests, assessment begins with the non-involved side first, then moves to the injured side, at the joint closest to the client’s pain symptoms. Depending on initial findings, testing may need to progress more globally to rule out injury above or below the suspected joint, especially if referred pain is suspected.

From a sports massage perspective, these assessments are concerned primarily with two types of soft tissue: contractile and noncontractile (also called inert tissues).

The active, passive, and resisted motion tests engage these tissues in different ways to help narrow the search for the cause of the athlete’s symptoms.

Contractile tissues Contractile tissues include muscles, tendons, and associated fascial bands. The muscle–tendon units are evaluated globally during active ROM testing and more specifically by using resisted (isometric) muscle tests. These tests load the muscle and tendon fibres, while minimizing stress on other structures. An increase in pain or weakness, or both, is considered a positive finding and indicates muscle strain or tendon issues in the tested muscle– tendon unit. Injuries in contractile tissues respond well to the massage techniques featured in the Sports Massage for Injury book.

Noncontractile tissues Ligaments, nerves, joint capsules, and bursae are considered to be noncontractile tissues. These tissues are evaluated globally during active ROM testing and more specifically by using passive movements that test the integrity of the tissue without involving the contractile tissues. Positive findings in these tests indicate that one or more of these tissues is the site of the pain-causing lesion.

Ligament sprains respond well to specific massage techniques, such as deep transverse friction. In nerve entrapment conditions, sports massage directed at the tissues that contribute to the entrapment is valuable. For the most part, injuries to bursae and capsules do not benefit from the direct application of sports massage.

TABLE 2 Joint Motion Assessment Summary. Adapted from J.H. Cynax and P.J. Cynax, Cynax’s Illustrated Manual of Orthopaedic Medicine (Oxford, OK: Butterworths, 1983), and other sources.

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FIGURE 1 Normal ranges of active motion of the shoulder girdle: (a) neutral, (b) flexion, and (c) extension.

The following assessments are typically performed to help determine which structures to investigate with a more detailed palpatory examination. All assessments are performed on the unaffected side first to document a baseline for their normal motion and to help allay any fears that testing the affected side will be painful.

Assessment Using Active Motion Active motion tests all the structures around the joint. It’s a general test to determine whether the search for the injury site is beginning in the right place. As the name implies, the client performs active motion, with no assistance from the therapist. Active motion is used to compare and document the ROM and quality of movement between the unaffected and the affected sides. Active motion on the unaffected side is expected to be within normal range for the joints being tested, and the movement quality is expected to appear smooth and easy. Active motion on the affected side is observed and documented, noting any limitations in ROM, any parts of the motion that appear difficult, or that activate compensatory movements, and where in the motion the athlete feels pain.

For example, when an athlete complains of shoulder pain, active motion can be used to evaluate the shoulder complex, especially the rotator cuff. Figures 1-4 illustrate active flexion, extension, abduction, adduction, internal and external rotation, and horizontal abduction and adduction. The practitioner directs the client to perform these movements, starting with the uninjured side to get a sense of and document the quality and range of normal

movement for this client. This normal is then used as the comparison when documenting active movement on the injured side. It’s important to note that restrictions in ROM on the affected side could be caused by a variety of issues, other than a painful lesion. These include, but are not limited to, hypertrophy, hypertonicity, weakness, soft tissue scarring, the client being fearful of performing the active movement, or nerve damage preventing the muscle from contracting.

If active testing proves to be completely pain free, this usually indicates that the source of pain is elsewhere, and the client is experiencing referred pain. Occasionally, active motion assessment will be pain free, even though further tests will elicit the pain, especially if the injury is in contractile tissue. This is because active motion often requires less force than subsequent specific tests that require the recruitment of more muscle fibres and involve the injured area enough to generate the symptoms.

Assessment Using Passive Motion Passive motion is performed by the therapist, with no assistance from the client. Normal passive range of motion is usually greater than active range and is done bilaterally to compare the unaffected and affected sides. Continuing with the example of complaints of shoulder pain, the practitioner repeats the same set of movement tests as in the active tests, encouraging the client not to help so as to get a true reading of the quality and range of painfree passive movement available.

Passive motion on the unaffected side is expected to be within normal range for the joints being tested, and the Terra Rosa E-mag No. 22

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FIGURE 2 Normal ranges of active motion of the shoulder girdle: (a) neutral, (b) abduction, and (c) adduction.

FIGURE 3 Normal ranges of active motion of the shoulder girdle: (a) neutral, (b) external rotation, and (c) internal rotation. movement quality is expected to feel smooth and easy.

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Passive motion on the affected side is performed and doc-

FIGURE 4 Normal ranges of active motion of the shoulder girdle: (a) horizontal abduction and (b) horizontal adduction. umented, noting any limitations in ROM, any parts of the motion that appear difficult, or that activate compensatory movements, and where in the motion the athlete feels pain. Figure 5 illustrates a few passive motion assessments.

Passive motion assesses the noncontractile tissues without engaging the contractile tissues. Increased pain during passive testing but not during resisted tests (the next step) usually indicates that noncontractile tissue is injured. However, at or near the ends of range, passive motion may cause pain by stretching injured contractile tissue or by pinching it against bone.

Assessment Using Manual Resistive Tests Resisted motion is used to specifically assess contractile tissues (muscle, tendon, and associated fascial bands).

This isometric assessment is conducted by asking the client to perform a strong isometric contraction that isolates and loads the muscle–tendon unit while the therapist holds the joint in neutral to avoid stressing the noncontractile tissues around the joint.

A finding of weakness or an increase in pain (as the client came in with some pain already) are positive for the tissue tested and indicate muscle strain or tendon issues, or both. To perform a manual resistive test and properly assess the contractile tissue around a joint, follow these

steps: 1. Position the limb so the joint is at midrange (neutral).

Manual resistive testing done at or near a joint’s end of range could also stress the noncontractile tissues, providing unclear results. Proper positioning isolates the specific muscle–tendon unit to be tested.

2. Provide matching resistance as the client isometrically contracts the muscle being tested, starting gradually and building to a full contraction. Continuing with shoulder assessment; if ROM tests indicate rotator cuff injury, the manual resistive tests are used to isolate and assess each of the four rotator cuff muscles. To test the supraspinatus (the most commonly injured cuff muscle), the practitioner positions the client with the arm hanging at the side. The practitioner then stabilizes the arm at the elbow and directs the client to slowly attempt to abduct the arm while the practitioner provides matching resistance to prevent the arm from moving (see Figure 6).

One of the following results should occur: a. If the muscle tested is strong and pain free, there is no overt injury. Continue testing other suspected muscles.

Even if no overt injury is found through testing, a subclinical condition may be discovered when performing the palpation assessment. b. If the pain the client is complaining of increases, stop the test. The lesion is probably contained in that muscle or Terra Rosa E-mag No. 22

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tendon. Additional pain symptoms may arise during these tests. These additional symptoms may be indicative of other issues in conjunction with the primary complaint. Make a note of them and continue testing for the presenting complaint. c. If the muscle is weak but pain free, there may be a possible nerve conduction problem, which should be evaluated by a qualified physician.

3. If the test causes increased pain, begin the palpation assessment of the tested muscle– tendon unit for the exact site of the injury, using pain reports from the client and tissue assessment to guide the exam.

Pain will be the greatest at the exact site of the lesion.

It’s important to note that sports injuries often involve both contractile and noncontractile tissues. If an increase in pain occurs with both passive motion tests and resisted motion tests, then it may be that both noncontractile and contractile tissue is injured. It may also mean that the noncontractile tissue is healthy, but the contractile elements are swollen and inflamed and being pinched during the passive test.

Additional Tests Once the preliminary movement assessments have been performed, it may be useful to include additional, more specific orthopaedic tests to further pinpoint the injury site. These are specialized to focus on the joint being examined and can be categorized as orthopaedic or as neural tests.

FIGURE 5 Selected passive movement assessments of the shoulder complex: (a) flexion, (b) extension, (c) external rotation, (d) internal rotation.

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FIGURE 3.6 Manual resistive test for the supraspinatus.

Assess End Feel Quality of motion, especially at the end of the range, is assessed through the application of mild overpressure at or near the end of passive motion. This is called end feel.

Every joint has a normal end feel. Abnormal end feel, or normal end feel at the wrong place in the ROM, indicates injury or pathology. The ability to assess end feel improves with practice and experience.

James Cyriax, a British orthopaedic physician, pioneered the discussion of end feel, and many other experts have since described different types of end feel. Cyriax wrote, “The significance of the end-feel is thus the degree to which it corresponds to or differs from what the end-feel would be if the joint were normal. Different types of endfeel imply different disorders” (Cyriax and Cyriax 1983, p.8). The following are common examples of end feel: • Boggy: This is a soft and mushy feel that occurs because of joint effusion or oedema. This may indicate acute swelling and inflammation. A good example would be a moderate to severe ankle inversion sprain.

• Bony: This is a hard stop when two bones touch each other. Elbow extension is a good example of the normal end feel being bone to bone. If the end feel of an elbow

extension were not a hard stop, this would be an abnormal finding.

• Capsular (often extended to include ligamentous): This is typically described as a “firm but leathery” stop. Normal capsular end feel occurs when the joint capsule is the primary limiter of the end range, such as with external rotation of the shoulder.

• Empty: This category is used when the practitioner is unable to reach the end feel because the client stops the test due to pain or anticipated pain. In this case, there is no physical restriction to the movement, but the client is purposefully preventing movement through the full ROM. A good example of this occurs with shoulder impingement conditions, where soft tissue pain occurs before normal end feel can be achieved.

• Muscle stretch: The motion stops as a result of the tissue reaching the end of its stretch. This feels rubbery or slightly springy, like stretching a bicycle tire inner tube. A good example of this end feel occurs when the hip is flexed while the knee is held in extension and motion is stopped by the hamstrings.

A client with extremely tight hamstrings may have a normal end feel but is well short of a normal ROM. This would indicate a condition to be treated.

• Soft tissue approximation: The motion stops when two masses of tissue (muscle, fat) press against each other, such as calf muscles pressing against hamstrings during knee flexion.

• Spasm: The movement ends abruptly, short of normal end range, and is accompanied by pain or anticipated pain. Spasm has a springy, rebound end feel that represents protective muscle guarding.

• Springy block: The motion stops short of normal, accompanied by a bouncy sensation, like when compressing a spring. This indicates that a loose body may be blocking the motion; it is commonly felt in the knee when a piece of floating cartilage or a torn meniscus limits knee extension.

Summary The ability to correctly assess the condition causing the symptoms an athlete is complaining of can be the difference between success or failure in the treatment of that athlete. This chapter has provided a framework for the systematic assessment of soft tissue injuries (HOPS method), as well as reminders to evaluate perpetuating factors that may prolong the recovery from injury. These assessment protocols are developed more thoroughly in the chapters that cover specific injuries commonly seen in the sports massage therapy setting.

This article is excerpted from Sports Massage for Injury Care by Robert E. McAtee, LMT, BCTMB, CSCS, with permission from Human Kinetics. In Australia or New Zealand, order from www.terrarosa.com.au; in the U.S., visit us.humankinetics.com Terra Rosa E-mag No. 22

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Notes from Fascia Research Congress and Pain Science Summit Til Luchau Til Luchau recently wrote up his impressions from 2 large conferences he attended: the Fifth International Fascia Research Congress (FRC5) in Berlin, Germany 14-15 November 2018, and the 2019 San Diego Pain Summit in California, USA, 19 - 24 Feb 2019.

While it’s tempting to compare the two events, as they reflect two influential (and sometimes polarized) points of view within our field, the two meetings were quite different in purpose. Luchau writes that “the FRC5 aimed to showcase the latest fascia research and to promote understanding and collaboration among scientists working in fascia research and the clinical professionals whose work addresses fascia,” while “the purpose of the San Diego Summit is not research (nor manual therapy) per se. Instead, the Pain Summit’s role has been bringing people together to share their application and continuing refinement of existing concepts.”

The Fifth International Fascia Research Congress

Excerpts from each of Til Luchau’s reports are below.

I am sharing here some of the most personally interesting aspects of what I learned.

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My colleagues and I joined more than 1,000 diverse professionals from all over the world: manual therapy, movement, sports, and rehabilitation practitioners; academics and researchers; writers; teachers; and more. In standingroom-only crowds, and afterward in the surrounding cafes, river boats, and off-campus events, we listened, learned, socialized, debated, and digested several days of presentations, workshops, panels, art events, screenings, and talks.

induced spinal disk injury in pigs, and curiously, in muscles far from the injured disk. This raises questions (for me at least) about the mechanisms of inflammatory triggering and spreading: was the remote inflammation due to biomechanical, circulatory, neurological, or other factors? Or, all of the above?

Most interestingly, people with chronic sciatic pain have an increased representation of the back and leg in their motor cortexes (not just their sensory cortexes, as I’d expect). This adds a neurological rationale to the practice of using active movement to help resolve inflammation and pain.

Carla Stecco, MD Looking for explanations for why myofascial pain and fascial disorders are more common in women than men (and why they vary over women’s lifespans), fascial researcher and orthopedic surgeon Carla Stecco, MD, presented her group’s recent research into sex hormones’ role in fascial remodeling. They see potential implications for better understanding of fascial properties, healing, and nociceptor sensitization.

Stecco also presented the histological evidence behind her group’s proposed redesignation of a class of round fibroblasts as fasciacytes. These “new” cells appear to regulate hyaluronic acid (or HA, which is involved in fascial gliding and elasticity), and in her analysis, have several key differences from other fibroblasts.1 Stecco also shared evidence that endocannabinoid (CB2) receptors in fascia seem to inhibit collagen formation in inflammation, which suggests to me that when these receptors are activated, they may help regulate fibrosis in injury recovery and scarring, but may also imply slower tissue recovery and remodeling.

Paul Hodges, PhD I was particularly looking forward to Paul Hodges’s presentations on inflammation, pain, and motor control.

Paul is a Professor of Spinal Pain, Injury, and Health at University of Queensland. A few highlights from my lengthy notes:

Daniel Lieberman, PhD In his opening plenary, “The Evolution of Human Walking and Running and the Cases of the IT Band and the Plantar Fascia,” Harvard paleoanthropologist Daniel Lieberman (whose work was popularized in Chris McDougall’s bestselling Born to Run) described fascial features in evolutionary biology. One example: great apes’ iliotibial bands are only one-third as thick as humans’ and have insertions from only one-third the number of muscles. This is presumably related to apes’ knuckle-walking depending less on lateral stabilization than humans’ bipedal stride. From his evolutionary perspective, Lieberman’s view is that many of our musculoskeletal problems come from adaptations (e.g., shoes) to unnatural situations (e.g., pavement).

Instertitium and Fluid Dynamics When physician and pathology researcher Neil Theise, MD, co-authored a paper about the interstitium earlier this year,2 the popular press touted him as the “discoverer” of a new organ. Osteopaths, Rolfers, and fascial anatomists (such as Jean-Claude Guimberteau and Gil Hedley) were quick to point out that they’d already been talking about the same tissues, layers, and structures (as the loose connective tissues) for many years.

Theise’s recent work, however, has emphasized and clarified these layers’ fluid flows, as well as their interconnections with lymphatic flows. This new view of loose connective tissue (such as superficial fascia) has implications that extend to cancer, immune function, and inflamma-

Multifidus inflammation was seen after experimentally

Dr Paul Hodges from University of Queensland. Used by permission.

Dr Meldody Schwarts on interstitum and fluid dynamics. Used by permission.

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elasticity; and since interstitial fluid flows are fundamental to inflammatory resolution, tissue elasticity has possible implications for non-resolving inflammatory and autoimmune conditions, such as adult-onset psoriasis.

Frank Willard, PhD

Dr Frank Willard on myofascial and low back pain.

Neurobiologist and anatomist Frank Willard from the University of New England, College of Osteopathic Medicine, in Portland, Maine, presented gorgeous anatomical images of little-known innervation of the intervertebral disks and facet joints, and shared the results of his review of back-pain literature. He estimates myofascia and ligaments are the source of nociception in 70 percent of back pain, while disk-relegated pain accounts for an estimated 4 percent.

Watch Til talked about FRC5 here https://youtu.be/ dz1nUpe9qFg

tion.

Molecular bioengineering researcher Melody A. Schwartz’s presentation expounded on these interstitial/ lymphatic connections, and among other remarkable ideas, I learned that interstitial pressures are lower in lymphedema (tissue swelling), rather than higher as I might have assumed. This, she says, is due to loss of tissue

Clinical Relevance “Clinical relevance” is the litmus test that many of us will use when evaluating fascial (or other) research. Of course, each of our ideas of “relevance” depends on our favoured therapeutic narratives. Those friendly to fascia

Several members of the Advanced-Trainings.com faculty attended the FRC5. From left: Larry Koliha, Bethany Ward, Til Luchau, Ramona Peoples, and Bibiana Badenes. Image courtesy www.Advanced-Trainings.com.

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will find much in the FRC5 proceedings that has practical relevance to their work. In other circles, and especially on social media, the therapeutic relevance of fascia is sometimes hotly debated, and those who have already been put off by the hype, exaggeration, speciousness, and faddishness unfortunately associated with many fascial approaches are unlikely to change their opinions based on one Congress’s proceedings alone.

From my own point of view, as someone with a range of passions that include fascial science, somatic psychology, pain science, biopsychosocial applications (and most recently, inflammation), I was heartened by the FRC5’s tone of cross-disciplinary curiosity, openness, learning, and discourse. Both in our society, and within our field, we can use all the bridges across that chasms between us that we can get.

Still, as practitioners, our main question is most often “So, how does all this translate into hands-on practice?” The full answer is that it will take time to tell. Though I doubt it’ll take the medical average of 17 years for new research to appear in clinical practice5, new ideas need validation, debate, integration, and of course application.

Personally, however, since the FRC5, I’m already: - Re-mapping my narratives of what happens under my hands to include even more about fluids and flows, and even less about fibres and fascia per se; - Experimenting with the idea that active movement affects cortical maps of inflammation and pain (as does sensory experience, like touch); - Keeping in mind that there is no one-size-fits-all for any of these approaches.

Though we’re learning more all the time about how pain, tissues, fluids, and the nervous system all interact and play a part in hands-on work, each person and each situation is distinct, and needs an adaptable approach from us as practitioners. The more options and the broader our view, then, the more versatile and responsive we become.

2019 San Diego Pain Summit About a dozen presenters spoke about pain-science– related topics, ranging from the neurology of body/brain interactions, therapeutic relationships, and compassion to brain imaging, the role of patient/client expectations, and more. Here are some of my personal favorites.

• Neuroscientist Antonio Damasio, PhD, has written extensively on the ways the body informs the mind. To help explain this interaction, Damasio makes a neurological distinction between feelings and emotions. Emotions, in this model, are bodily reactions that serve to maintain homeostasis: physical reaction, retraction, and movement. For example, Damasio says, “When we are afraid of something, our hearts begin to race, our mouths become dry, our skin turns pale and our muscles contract. This emotional reaction occurs automatically and unconsciously.”

From neuroscientist Antonio Damasio’s keynote address: “Our minds are constructed in partnership between the brain and the body: the brain reports on the outside world, the body reports on the inside world, and the nervous system is the broker between these two.” Image courtesy San Diego Pain Summit, used by permission.

The brain shapes this bodily emotion into mental feelings by assigning valence: the mental valuing that determines meaning and preference. “Feelings,” Damasio says, “occur after we become aware in our brain of [emotion’s] physical changes; only then do we experience the feeling of fear.”4 “And pain,” he says, “needs to be treated as a feeling,” implying a deep role for the mind in the pain experience. (For more, see Damasio’s book Descartes’ Error, or his TED talk at http://bit.ly/2Jx4QoG).

• When Maxi Miciak, PT, PhD, was writing her doctoral thesis about how the practitioner/patient relationship influences the effectiveness of physical therapy, she found almost no existing research and very little formal study into the therapeutic relationship in any field.5 What research she found, she says, showed (unsurprisingly) that the quality of the practitioner/patient relationship is linked to better patient satisfaction, and to better therapeutic outcomes. Her own research into the question (using an interpretive description qualitative method, followed by quantitative analysis) led to her model of the conditions of engagement necessary for therapeutic effectiveness . One of her practical suggestions: since listening can be a powerful therapeutic intervention itself, practice making room for your client’s story and try waiting for eight seconds after the patient speaks before responding.

• Australian physical therapist Mark Bishop, PhD, shared his thought-provoking research into how patient/client expectations influence the outcomes of manual therapy, and his thoughts on placebo mechanisms.

Bishop says that placebo has a “branding problem” because “people think placebo is nothing; a sugar pill. Placebo mechanisms, however, are far from nothing,” since the mechanisms behind placebo responses are physical, hormonal, endocrine, and neurotransmitter changes in the body. Bishop emphasized that placebo effects are always present in our treatments, whether we consciously use them or not. “We always provide care within a context,” Bishop says. “I’ve never walked into a black room, in a dark spandex suit, to treat someone lying on a table who’s blindfolded, with earplugs, and asleep.”

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In Maxi Miciak’s Safe Therapeutic Container model, her five Conditions of Engagement are visualized as a box, with the floor and walls representing two cornerstone conditions, “present” and “receptive.” “Committed” and “genuine” are more variable, and so are represented by the mobile lids of the container. Image courtesy Dr. Miciak, used by permission.

But it was his findings on client and practitioner expectations I found most interesting: • In a 400-person comparative study of spinal manipulation versus spinal mobilization effectiveness for back pain, therapeutic touch (or TT, in which therapists simply “place their hands on or near their patient’s body with the intention to help or heal”) was used as sham treatment (i.e., as a placebo comparison, intended to reveal the direct effects of the spinal methods). In a surprise to the researchers, at the end of the six-year study, TT was the most desired treatment by the participants, and the treatment they most expected to help their pain.6 • In another comparative study, massage therapy was the neck pain treatment that study participants most expected would help (Image 3).7 • In studies of cervical, shoulder, and lumbar complaints, patients’ general expectation of recovery have been repeatedly found to be the strongest predictor of recovery; stronger than the therapeutic method used, practitioner experience, or other factors.8 Given this, Bishop says, our skills at building an alliance and keeping clients engaged are probably more important to pain recovery than any particular method or therapy.

• And perhaps most importantly, Bishop’s research showed that method does matter, but on the providers’ (rather than clients’) side: when practitioners had a strong preference for a particular treatment, that treatment had better results, no matter what that treatment was.9

Is Pain Science Passé?

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This was the fifth San Diego Pain Summit, and with 111 participants in attendance, this Summit was a bit smaller than in previous years. Does this dip in size mean that interest in pain science is waning? There are signs elsewhere that perhaps the initial gush of enthusiasm about biopsychosocial approaches might be fading: in the manual therapy blogs and podcasts that I follow, “pain” is much less frequently a topic than it was just a couple years ago; and, on one (formerly?) pain-science-friendly podcast, the hosts audibly snickered when “pain science” was mentioned amongst the list of trendy topics that are no longer in the fore.

Or could it be that biopsychosocial perspectives on pain have by now percolated deeply enough into our field that they are no longer quite so radical or new? No idea stays on the cutting edge indefinitely; at some point, a novel view either fades away, or becomes part of the mainstream. Though some would argue that pain science hasn’t penetrated deeply enough into massage and bodywork yet, its influence on our field is well-established, and maturing. After all, these ideas have been around for some time now: many PT’s trace pain science ideas to David Butler’s neurodynamic work in the 1990’s; or MT’s, to Diane Jacob’s Dermoneuromodulating approach, which she developed in the last decade. But biopsychosocial concepts have parallels in earlier concepts of mind/body holism, including Feldenkrais’ work from the 1970’s, and many other early influences on massage and bodywork.

Here at Advanced-Trainings.com, it’s been about six years since we offered our first pain science-focused course; and it’s not an exaggeration to say our entire in-person

PT and researcher Mark Bishop, PhD, on the influence of patients’ and practitioners’ expectations on therapeutic outcomes. Chart: Study participants’ expectations of neck pain benefit from common interventions for “this episode of neck pain,” ranked by level of agreement (blue bar) with “I believe [the intervention] will significantly help improve this episode of my neck pain.” From the left (most agreement): Massage; Manipulation; Strengthening; ROM; Aerobic; Traction; Rest; Modalities; Medication; Surgery (least agreement). Image courtesy Advanced-Trainings.com; chart slide courtesy Dr. Bishop, used by permission.

curriculum has been accordingly revised in the years since.

We are not alone in this: several of my esteemed continuing education colleagues (such as Whitney Lowe, Ruth Werner, Erik Dalton, Walt Fritz, and others) have also incorporated pain science or biopsychosocial concepts into their approaches. And to be fair, the purpose of the San Diego Summits is not research (nor manual therapy) per se; none of the presenters at this year’s summit claimed to be presenting radical new pain research; or novel, game-changing ideas--instead, the Pain Summits’ role have been bringing people together to share their application and continuing refinement of existing concepts.

A question I heard several times while there was, “Why don’t more massage therapists and bodyworkers attend the Summit?” According to the event’s organizer, Rajam Roose, most of the summit’s attendees are physical therapists or physical therapy students. Massage therapists are indeed a minority (though interestingly, about half of the MTs in attendance travelled from a single Canadian province, British Columbia, where, I was told, pain science ideas have a strong following amongst massage therapists).

But the BC exception aside, we saw this same phenomenon when Advanced-Trainings.com cosponsored an “Explain Pain” training (from the Australian NOI Group) here in Colorado in 2015: most attendees were physical therapists, with only a few Rolfers, structural integrators, and even fewer massage therapists attending.

Could it be that the “science” emphasis in pain science isn’t appealing to as many MTs as PTs? Though massage

therapy is moving towards greater science literacy, none of the presenters at the Summit were massage therapists or bodyworkers. There were no hands-on manual therapy pre-conference workshops; and only one presenter identified himself as a manual therapist (physical therapist Mark Bishop). Or perhaps, as I also heard several times in my conversations there, it’s not always obvious to massage therapists how they might apply pain science’s educationor rehabilitation-focused material within their skillset and scope of practice (which where my educator-colleagues and I come in).

Watch Til talking about the Pain Summit here https:// youtu.be/QIWD8ilAVLw

Next Year’ Pain Summit With about 60% of this year’s attendees being first-time Summit-goers, Roose is optimistic about next year’s attendance. She says that her focus in 2020 “is going to be more on the ‘psych’ in biopsychosocial (BPS).” As she sees it, “There is this pervasive idea that things like motivational interviewing (MI) or acceptance and commitment therapy (ACT) are out of scope for the clinician, which really isn't true. It's not out of scope for us to understand how to communicate with our patients/clients and give them a sense of self-efficacy… There's also going to be a presentation on the limitations of the BPS model, which I think will be really interesting!”

Whether you think the pain science trend in our field is the Terra Rosa E-mag No. 22

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next big thing; already passé; or, maturing into an integral part of our field’s way thinking, there’s still plenty to learn together about pain, and the many ways to work with it, both on and off the table.

Regulation,” Clinical Anatomy 31(5) (July 2018):667–676. doi: 10.1002/ ca.23072.

Special thanks to Ruth Werner for her contributions and collaboration.

3. Z. S. Morris, S. Wooding, and J. Grant, “The Answer is 17 Years, What is the Question:

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

Notes 1. C. Stecco et al., “The Fasciacytes: A New Cell Devoted to Fascial Gliding

2. P. C. Benias et al., “Structure and Distribution of an Unrecognized Interstitium in Human Tissues,” Scientific Reports 8, no. 1 (2018): 4947.

Understanding Time Lags in Translational Research,” Journal of the Royal Society of Medicine, 104, no. 12 (2011): 510–20.

4. Antonio Damasio, quoted in Lenzen, Manuela, “Feeling Our Emotions,” Scientific American Mind 16, no. 1 (April 2005): 14–15, https:// doi.org/10.1038/scientificamericanmind0405-14.

5. M. Miciak et al., “The Necessary Conditions of Engagement for the Therapeutic Relationship in Physiotherapy: An Interpretive Description Study,” Archives of Physiotherapy 8 (2018): 3, https://doi.org/10.1186/ s40945-018-0044-1.

6. M. D. Bishop, “What Effect Can Manual Therapy Have on a Patient’s Pain Experience?” Pain Management 5, no. 6 (November 2015): 455–64, https://doi.org/10.2217/pmt.15.39.

7. M. D. Bishop, “Patient Expectations of Benefit from Interventions for Neck Pain and Resulting Influence on Outcomes,” Journal of Orthopaedic & Sports Physical Therapy 43, no. 7 (July 2013): 457–65, https:// doi.org/10.2519/jospt.2013.4492.

Robert Schleip, Ph.D., (center) played a key leadership role in current and past Fascia Research Congresses. Along with Rachelle L. Clauson and Gary Carter (seen here admiring a specimen of the fascia cruris, inset), Schleip also co-coordinated the Fascial Net Plastination. Project. Image courtesy Alison Slater.

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Fascia can actively contract and thereby influence musculoskeletal dynamics The study found that:

• the density of myofibroblasts is larger in the human lumbar fascia in comparison to fasciae from the two other regions examined in this study: fascia lata and plantar fascia.

• Fascial tissues contract when exposed to different pharmacological substances: fetal bovine serum, the thromboxane A2 analog U46619, TGF-β1, and mepyramine.

• Botulinum toxin type C3–used as a Rho kinase inhibitor– provoked relaxation.

• In contrast, fascial tissues were insensitive to angiotensin II and caffeine.

• There is a positive correlation between myofibroblast density and contractile response.

Plastination of fascia of the thigh . Photo courtesy of Rachelle Clauson

Fascia is a biological fabric that enmeshes all structures in our body. While there is a research interest in the role of fascia as a force transmitter in muscular dynamics, fascia is often regarded as a passive contributor to biomechanical behaviour.

There have been several studies that indicated the active role of fascia which has an inherent ability to contract actively. These indications include the reported phenomenon of “ligament contraction” of human lumbar fascia in response to repeated isometric strain application. There is also evidence of fascial tissues can shorten over several days in certain pathologies, such as Palmar fibromatosis, hypertrophic scars, and similar fascial fibrotic conditions. This tissue shortening is mostly due to the presence of myofibroblasts (a type of cell responsible for wound healing and tissue repair). The resulting tissue contracture is due to an incremental combination of cellular contraction, collagen cross-linking and matrix remodelling.

Robert Schleip and colleagues from Ulm University has been interested in finding out whether normal fascia may possess the capacity for cellular contraction which, in turn, could play an active role in musculoskeletal mechanics.

In a new study published in Frontiers of Physiology, they studied human and rat fascial specimens from different body sites for the presence of myofibroblasts using immunohistochemical staining for α-smooth muscle actin (n= 31 donors, n=20 animals).

Also, mechanographic force registrations were performed on isolated rat fascial tissues which were exposed to pharmacological stimulants to measure contracting force.

The calculation of potential contractile forces of fascia predicts a force range that seems insufficient for exerting a direct shortterm effect (i.e., occurring within minutes to hours) on mechanical joint stability of the human spine. The short-term contractile forces of fascial tissues are at least two orders of magnitude below that of muscle tissue and may have no significant effect on spinal stability or other important aspects of human biomechanics.

Nevertheless, the predicted fascial contraction forces in the human lumbar region are above the much lower threshold for influencing mechanosensation. They are strong enough to alter motoneuronal coordination in the lumbar region. The authors suggest that a local and/or temporal increase in fascial contractility might contribute to long-term tissue contracture, which includes matrix remodelling.

Based on the known signalling influence of the sympathetic nervous system on TGF-β1 expression, they suggest that their findings tend to support the hypothesis of a close connection between fascial stiffness and chronic sympathetic activation. In the light of the large contribution of psychosocial factors in low back pain, they suggest further studies to explore possible interactions between emotional stress, fascial stiffness, and low back pain.

The authors concluded that the tension of myofascial tissue is actively regulated by myofibroblasts with the potential to impact active musculoskeletal dynamics.

Reference: Schleip, R., Gabbiani, G., Wilke, J., Naylor, I., Hinz, B., Zorn, A., Jäger, H., Schreiner, S. and Klingler, W., 2019. Fascia is able to actively contract and thereby influence musculoskeletal dynamics: a histochemical and mechanographic investigation. Frontiers in physiology, 10, p.336.

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Exercise attenuates fibrosis to the multifidus muscle associated with intervertebral disc The International Society for the Study of the Lumbar Spine recently awarded the ISSLS Prize in Basic Science 2019 to a paper

by G. James, Paul Hodges and colleagues from the University of Queensland. The study, published in the European Spine Journal, found that Intervertebral disc degeneration is associated with fibrosis in the multifidus muscle and exercise attenuates that fibrosis Chronic low back pain is usually accompanied by structural remodelling and inflammation of muscles around the spine, in particular, the multifidus muscle. Studies have found an increased cross-sectional area of connective tissue and expression of collagen in the multifidus during early chronic LBP. These changes are characteristic of tissue fibrosis. However, the extent and mechanisms underlying the increased fibrotic activity in the multifidus are unknown.

It is also known that physical activity can modify connective tissue in skeletal muscles. Short-term exercise stimulates both collagen synthesis and degradation which assist in its remodelling. Long-term exercise prevents aging-dependent fibrosis. A past study found that physical activity reduces local inflammation that precedes multifidus fibrosis during intervertebral disc degeneration (IDD).

Inflammation can happened peripherally or centrally. When there’s an inflammation, white blood cells released certain chemicals to protect against foreign substances. These chemicals in the tissue create a kind of “inflammatory soup”, which can excite and sensitize neurons, making them more responsive than under normal conditions. Inflammation can generate and modify pain response. It can lead to central sensitization, peripheral sensitization, tissue effects, and neuroimmune reactions.

This new study evaluated the development of fibrosis and its underlying genetic network during IDD and the impact of physical activity.

The study used mice that were either sedentary or housed with a running wheel, to allow voluntary physical activity. At 12 months of age, IDD was assessed with MRI, and multifidus muscle samples were harvested from L2 to L6.

The study found:

• Fibrosis (i.e., increased thickness of the connective tissue between the multifidus and longissimus muscles) in muscle that crossed a degenerated disc.

• Fibrotic gene network (CTGF, SP, TIMP1, and TIMP2) was dysregulated in multifidus crossing a degenerated disc and correlated with changes in Extra Cellular Matrix (ECM) gene expression 18 Terra Rosa E-mag No. 22

• Physical activity attenuated the IDD-dependent increased connective tissue thickness and reduced the expression of collagen-I, fibronectin, CTGF, substance P, MMP2 and TIMP2 in mice.

The authors concluded that the fibrotic networks that promote fibrosis in the multifidus muscle during chronic IDD. Furthermore, physical activity is shown to reduce fibrosis and regulate the fibrotic gene network.

Comments by Til Luchau: Some degree of connective tissue fibrosity is a normal result of inflammatory reactions to injury—scar tissue is one example.

But when inflammatory reactions are extreme or prolonged, excessive fibrosity and pathological, painful scarring play into a vicious cycle of less movement; more sensitivity and pain; and more inflammatory response.

Our field is in the midst of a debate between differing points of view about tissue and pain. Is it tissue density that causes pain (the conventional working assumption behind many manual therapies)? Or is it that tissue fibrosity is an unrelated by-product of pain-induced stasis?

However, there is widespread agreement, across many points of view and therapeutic disciplines, that movement often helps with injury recovery: especially active, moderate and regular movement. This recent study confirms that (at least in SPARCnull mice, which are genetically prone to disc injuries) there are indeed biological, tissue-based differences, and better healing, that result from voluntary active movement after an injury. But far from confirming whether fibrosity is the injury-chicken or the pain-egg, it reveals the intrinsic interconnection between our tissues, our activities, and healing from an injury.

Manual Therapy as a Treatment for Overuse Injures Chronic repetitive motion and overuse injuries made up a large proportion of musculoskeletal and nerve disorders. These conditions are often called repetitive motion disorder or repetitive strain injuries. Painful and disabling musculoskeletal disorders remain prevalent and manual therapy has been used to treat such issues. However the actual neural mechanism of how manual therapy work is still unclear.

To find out the neural mechanism of manual therapy, Geoffrey Bove and colleagues University of New England College of Osteopathic Medicine conducted a study on rats. The rats were trained to perform repetitive tasks leading to signs and dysfunction similar to those in humans. The authors then tested whether manual therapy would prevent the development of the pathologies and symptoms.

The researchers collected behavioral, electrophysiological, and histological data from control rats, rats that trained for 5 weeks before performing a high repetition high force task (HRHF) for 3 weeks untreated, and trained rats that performed the task for 3 weeks while being treated 3 times per week using modeled manual therapy to the forearm. The modelled manual therapy included bilateral mobilization, skin rolling, and long axis stretching of the entire upper limb.

Results showed that rats that performed a repetitive task showed decreased performance of the given task and showed increased discomfort-related behaviours, starting after training.

Those strained rats that were treated with manual therapy showed improved task performance and decreased discomfort related behaviours compared to untreated rats. Subsets of rats were assayed for presence or absence of ongoing activity in Cand slow Aδ- neurons in their median nerves. Neurons from strained rats had a heightened proportion of ongoing activity and altered conduction velocities compared to control and manual-treated rats. Median nerve branches in strained rats contained increased numbers of CD68+ macrophages and degraded myelin basic protein, and showed increased extraneural collagen deposition, compared to the other groups.

The authors concluded that the performance of the task for three weeks leads to increased ongoing activity in nociceptors (pain receptors), in parallel with behavioural and histological signs of neuritis and nerve injury. Manual therapy:

•

prevents functional declines

•

improves task performance

•

prevents discomfort

•

reduces neural inflammation

•

reduces myelin degradation

•

reduces extraneural fibrosis.

inflammation, which is usually painful. The authors suggested that regarding overuse injuries, if manual therapy were administered early, before pathological changes occur, then medical expenses for treatments that are often ineffective might be avoided.

Comment by Joe Muscolino This is another in a long line of studies that show the effectiveness of manual therapy. In this case, that early manual therapy might avoid much pain and expense in the future. Wouldn’t it be wonderful if manual therapy could become the norm in people’s lives instead of an occasional treat or perhaps not existing at all.

I am such a believer in the power and benefit of manual and movement therapies!

The three major keys to musculoskeletal (neuro-myo-fascioskeletal) health…

•

Strength of musculature

•

Flexibility of soft tissues

•

Proper neural control

This study confirms that a repetitive task can cause body structures to be overloaded and injured. If the task is repeated without enough time for healing, the inflammation becomes persistent because it is reinforced during each task session. The normal response of the body is to heal the injury, which starts with Terra Rosa E-mag No. 22

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Josephine Key talks about Freedom to Move Can you tell us a bit about yourself?

I’ve been a practicing physiotherapist for over 45 years, the majority of which have been devoted to seeking a better understanding of the spine in both its health and dis-ease. I have developed a model of care which combines manual therapy and complimentary movement therapy which more specifically addresses the client’s actual neuro-myo-fascial and joint dysfunctions and helps restore more healthy patterns of spinal control for optimal function.

I’ve called this model the Key Approach. Its evolution is the result of evaluating and integrating the available movement, fascial and neuroscience; the ample evidence gleaned from clinical practice; the exploration and evaluation of various movement disciplines – for what they offer in terms of healthy spinal control – or otherwise.

I am increasingly exploring the felt sense of movement and the ability to exploit neuroplastic change – “retraining our brain” to organise healthier movement patterns and better biomechanics.

I have had a number of academic papers published in the international peer reviewed Journal of Bodywork and Movement Therapy. (See www.keyapproach.com.au/publications). My paper “The Core: Understanding it and retraining its dysfunction” was one of the journal’s five most downloaded papers in 2014.

My first book, BACK PAIN: A movement problem. A clinical approach incorporating relevant research and practice was published by Elsevier in 2010.

My latest book FREEDOM TO MOVE: movement therapy for spinal pain and injuries has just been published by Handspring Publishing.

I have presented at national and international congresses and conduct workshops both in Australia and overseas for physiotherapists, and interdisciplinary manual and movement therapists.

What made you write Freedom to Move?

My first book “Back Pain: A movement problem” offered the reader an in-depth treatise on healthy and ‘dysfunctional’ spinal posturo-movement control found in people with a whole spectrum of spinal pain disorders. It proffered a combined, complimentary manual therapy and movement therapy approach to redress these joint and myofascial movement disorders – and so, ease the clients’ pain.

I consider that one of the short falls of the book was inadequate coverage of the particular exercise and movement therapy advocated if one is to more effectively rehabilitate most spinal pain disorders. I have been increasingly interested in the aspect of therapeutic movement for spinal pain and continue to further develop and refine the Key Moves® for spinal rehabilitation.

Sarena Wolfaard published my first book and was keen for me to write another which bore the fruits of the further development of my work over the past 8 years. I was eventually ready to do so. I wanted this to be an informative yet accessible, clinically 20 Terra Rosa E-mag No. 22

useful practical manual for the multidisciplinary movement therapist treating spinal pain – Freedom to Move is the result.

What is The Key Moves® Programme?

Spinal pain research is increasingly demonstrating the importance of the deep sensori-motor system in healthy postural and movement control of the trunk. When this deep muscle system is lazy and weak, the body compensates by overengaging some of the large more superficial trunk muscles for the job – and that is where problems start to occur for the spine and pelvis. This substandard control is not only likely to lead to spinal pain but also to many other ‘injuries’, pains, tightness and stiffness etc.

Unfortunately a number of therapeutic, strength, fitness, and ‘core stabilisation’ training programmes don’t pay enough attention to deep system control in the trunk. Instead, the tendency is to overly work the large muscles, thereby contributing to the development of many pains and ‘injuries’ – and the need to ‘use the roller’ and stretch all the time.

The Key Moves® are a system of embodied natural movement explorations. They reintegrate physiological movements that develop during the process of motor development but which become diminished or absent in people with spinal pain disorders.

In essence, the Key Moves® rely a lot upon ‘deep myofascial system’ activity and so provide the opportunity to retrain and recondition the ‘deep’ postural muscle system and help reestablish the important, ‘key’ basic (fundamental) patterns of movement control in the spine and proximal limb girdles necessary for a more healthy, fit, strong and robust musculo-skeletal system.

Re-establishing the ‘fundamental patterns’ are central to the approach as they provide the basic building blocks of spinal control. These are particularly deep system dependent and are a key element to restore in movement. When they become better established, they are further integrated into more challenging exercises and functional movement patterns The Key Moves® is a sensori-motor re-learning programme which focuses a lot on mindfulness in movement, and refining the senses of interoception, proprioception – sensing ‘how’ a posture or movement feels – and being able to make discreet adjustments. Through sensory enrichment we can tap into the neuroplasticity of the central nervous system and facilitate changed movement behaviour. The movements are akin to ‘brain exercises’ which aim for more refined patterns of functional movement control The programme also address.es the freer sliding and fitness of the fascial system to further improve whole body flexibility and movement ease.

What is the relevance of the current fascia research findings?

The fascial system has been largely ignored until relatively recently – yet it provides the basic building blocks of functional anatomy, posture, and movement. ‘Fascia’ is enlarging our understanding of musculo-skeletal pain and ‘how’ we move.

Research into the fascial system shows that it influences and is affected by the nervous system, fluid dynamics and mechanical loading. Structural support, joint loading and movement are not only affected by the local myofascial tissues but by the whole fascial ‘bio-tensegrity’ system. In a tensegrity system, force transmission is nonlinear; in other words, forces applied to it are also transmitted tangentially and in all directions across the matrix.

Appreciating the functional body as a bio-tensegrity system helps the movement therapist understand how and why a movement initiated in one part of the body will create changes in tension (not only locally but also regionally and in other, often quite distant, parts) that contribute directly or indirectly to movement and/or stability.

instructed and mindfully, these are safe, enjoyable and therapeutic as they help re-establish the natural foundations of healthy spinal control. For clarity and ease of access, these are presented in a recipe book format – instructions on the left hand page and illustrated on the right.

The first section of the book (Chapters 1-4) is a reference section to support and aid the understanding of the major practical section (Chapters 5-10) in the second part of the book

What is your current project?

Having a restful respite! – practising what I preach and devoting more time to myself! One forgets the work involved in writing a book – particularly after submitting the manuscript! – added to which the past eighteen months have been particularly eventful.

However I continue to explore and develop the Key Moves® and despite saying to myself that Freedom to Move is my last book I nonetheless find myself thinking of a sequel: ‘More Key Moves®’!

This “whole system involvement” means the neuromuscular system doesn’t need to work too hard to produce a given posture and movement, thus greatly reducing the energy and effort required in functional movementyet enabling movement diversity.

By initiating movements from ‘key points of control’ we can influence the architecture of the whole fascial-tensegrity system, improve spinal flexibility and control while also accessing stiff regions and restrictions in the axial and limb tissues. The effect is to promote better tissue elasticity and easier movement. This differs from the traditional approach of static stretching, which often does little to change the tensegrity of the whole fascial matrix – and often bothers the spine.

And how do you reconcile fascia and neuroplasticity?

The fascial system is richly innervated possessing an exceptionally high density of mechanoreceptors and free nerve endings which contribute to our senses of interoception and proprioception which play an important role in the central nervous system’s (CNS) integration and control of posture and movement. Interoception is the ability to sense and monitor our inner landscape. It is a vital tool in accessing improved deep myofascial system activity and changing movement behaviour

Freedom to Move, Movement Therapy for Spinal Pain and Injuries is Available now at terrarosa.com.au

The plentiful innervation in fascia also contributes to nociception if the fascia becomes ‘bound’ and free nerve endings are activated Fascia can thus be both a source of pain and disturbed afference to the CNS – which in turn leads to adverse (neuroplastic) changes in the CNS – evidenced by altered control of posture and movement – and musculoskeletal pain.

However there is an upside to neuroplasticity: by restoring fascial slide, fluid dynamics and elasticity through appropriate manual and movement therapy we can exploit the CNS ability for more positive ‘neuroplastic change’ and improve neuro-myofascial function and movement control, joint loading and protection and functional wellbeing.

Which part of the book do you like most?

I’d have to say Chapter 7. This offers a suite of 60 exercises for the benefit of patients and practitioners alike. When executed as Terra Rosa E-mag No. 22

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Til Luchau on Scoliosis: Working from Inside Out Til Luchau, director of Advanced-Trainings.com, discusses scoliosis in a wide-ranging interview that covers his influences, orientation toward working with scoliotic clients, working with teenagers, expectations, conventional treatments, and changing understanding of scoliosis towards a three-dimensional model. This interview was conducted by Ann Hoff (Certified Advaned Rolfer® and Editor-in-Chief of ‘Structural Integration: The Journal of the Rolf Institute™,’ where a longer version of this article originally appeared.

“Image Bryan Christi Design, used under license to Advanced-Trainings.com”

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Working with Scoliosis

to make people straight often make them less comfortable.

Often people hurt more after we just try to lengthen their AH: I'm curious, did you study about scoliosis first and shorter erectors, or whatever we think will help them be then apply it in your work and teaching, or did clients drive you towards the study and the development of what straighter. Being straightened isn't always more comfortable. Then, it's teasing apart the context of why someone is you now teach? Or a bit of both? coming to us. If it's just to look different, there may be Til: My first serious scoliosis client was hitchhiking some reframing or alternatives to explore. around the USA in a wheelchair. She showed up at a retreat I was teaching in New Mexico, just to visit the place, Pain is interesting, because we often assume that if someand was in a lot of pain. I had graduated from the Rolf In- one has an “off” shape, they must feel off too. That doesn't stitute just two years before. Her scoliosis was a real puz- seem to be the case with scoliosis. People with scoliosis zle to me. I took some of the things that I remembered and don't have any higher incidence of back pain than the general population. That’s important: just because someone learned in my basic Rolfing training and started working has a different shape, doesn't mean they hurt or will hurt. with her. At some point, she just gave a big smile and relaxed, and felt a lot better. Later, people with scoliosis be- There is some evidence that says when people with scoliogan appearing more and more in my practice. The biggest sis do have back pain; it tends to be worse, or more intense. But they don't have it more often. It's not like a influence within the Rolf Institute was probably Robert Schleip, a mentor of mine, who had also spent a lot of time crooked spine equals back pain. A crooked spine, in and of itself, is not necessailry a problem to fix from a pain perpuzzling out scoliosis. His ideas had a lot of influence on spective. the way I was thinking about scoliosis and still do, as did [Rolfing instructor] Jan Sultan’s, though at this point, I’m What Causes Scoliosis? doing much of it differently than I learned it from either of AH: So the woman in the wheelchair, was she in the chair them. because of mobility issues or pain or any sort of degradaThe other big Rolfing influence that comes to mind was Emmett Hutchins (one of Ida Rolf’s original Advanced Rolfing instructors). He said, "When I'm working with scoliosis, I'm helping the client move around a line, not necessarily stand around a line," which I found interesting. It was one of those koans he would toss out, that we would have to ponder and wonder about. But “moving versus standing around a line” was a real clue that started my inquiry and probably still informs the way that I’m working with scoliosis to this day.

AH: That points to something important: we're not going to make somebody straight. If you're lucky, there may be some change in those curvatures, but we're not trying to get a platonic ideal of the spine.

TL: We're trying to make the person happier, like that woman in the wheelchair. I think we're all driven to help people. That's why we're in this profession, and there's where human compassion arises. Here are people who may or may not have pain, may or may not have restrictions in their movement; if we can support them as Emmett was indicating, in helping them in living with more ease and moving in a way that works better, they're going to be happier and feel better.

tion of her condition that was causing pain?

TL: Which came first? I don't know. There is a point at which spinal curves are a serious biological issue, often a compromise to organ function. Then at some point, having a sideways spine starts to affect the nerve roots and things like that where you have pretty clear mechanical effects.

The standard medical cutoff point – the point at which medical issues are more likely to happen – is somewhere around 40º; that’s where people are told they need to take some aggressive measures to stop the progression. In most cases, 40º is an obvious and strong scoliosis. Most of our clients don't have that much curve and so are a different category of intervention, where the most useful goals are about mobility, comfort, staying proprioceptively refined, and less about intervention on their shape.

AH: Let's go bigger picture. What do you understand about potential causes of scoliosis?

TL: It's a puzzle really. Rather than try to answer the puzzle, what I do is ask how I can help people. ‘Idiopathic’ scoliosis, which is the most widely studied form of scoliosis, means it has an ‘unknown cause’ or is even ‘without apparent cause.’ Honestly, anybody who says they know why it's being caused is going in the face of the consensus view.

One thing is, when people walk in and say, "I've been told There are lots of pieces to the scoliosis puzzle. There is I'm crooked. I want to be straight," that asks for a reality- some thought about cerebrospinal fluid flow having turbucheck conversation. There are certainly miracle cases. lence, that being associated with foetal development.

There are plenty of pictures around of people who were There are bizarre little facts like there's almost no adolesdramatically, visibly different after getting hands-on work. cent idiopathic scoliosis in people that are deaf. Animals, But I think most people would agree, those are the excep- quadrupeds, don't get adolescent idiopathic scoliosis. tions more than the rule. Most people aren't walking out There are some interesting puzzles there that point to biof their Rolfing or any other kind of session perfectly pedalism, that point to perceptual issues, that point to destraight, after coming in with scoliosis. And attempts to try velopmental things.

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Some say it’s visceral; other say it’s a top-down phenomenon that relates to the way you're perceiving; or, a bottom -up phenomenon, related to the way you're supporting yourself. Those are just a few pointers toward possible causation, but causation is complex, and what counts in the practice room is a strategy. The causative theories are probably better thought about as strategic narratives that get the practitioner thinking about how to go about working with it, more than they explain how it got there.

Adult-onset scoliosis is a lot more common than adolescent scoliosis. By the time we're seventy years old, about 70% of us have observable scoliosis. It appears progressively through our lives, and it's overwhelmingly asymptomatic, not correlated with back pain or other symptoms (although, sometimes it can result from osteoporosis or facet issues, things like that, which can have their own symptoms). So a whole lot of elderly people have scoliosis, and it's not necessarily a problem. Strategically, if there's back pain, or if there's a movement restriction, we work with those issues like we do any back pain or movement restriction. That's a little different maybe than a strict structural integration perspective. The perspective we take in my trainings is to ask, “Are there options for movement needed?” – And those include the option of stillness and support. And, “How can we help refine proprioception, so the person can feel body sensations more accurately, and in a more nuanced way?” In other words, can they have greater body awareness?

bly with that story I told you and with Emmett's teaching, and my time assisting and learning from Robert Schleip.

His perspective is interesting and his stories were influential. For example, he relates that realized at some point that he was doing the biomechanics exactly opposite of Fryette's laws; but changing his strateguy to to the ‘correct’ coupling of sidebending and rotation didn’t really get much different results, maybe 10% better. So when he got the laws ‘right’, there weren’t necessarily dramatic improvements.

AH: Interesting. Perhaps even when he didn't have Fryette's law right in his mind, he was still working the soft tissue correctly, if not the joints.

TL: I wonder. I bet he would argue, and I would too, that ‘correctly,’ at least in terms of external measures like left/ right etc., becomes less relevant. It might be the act of getting worked, and the act of moving, and the act of finding movement into new places. Whether you did it as an openfixed or closed-fixed direction, in either case, you can make a huge difference. From one point of view, most of the effect we have as practitioners comes from the client receiving work, as opposed to the actual strategy being employed. Increasing body awareness, increasing mobility, providing a powerful intervention in the context of movement, therapeutic ritual, all those things seem to be valuable.

So that's probably been the biggest change. I'm not thinking any more about things like which direction is right, or AH: Has the way you work with scoliosis changed over how do I want the body to be ‘corrected’. In most cases, time?

I'm thinking more about how to increase options for moTL: Has it changed over the thirty-three years since I met bility so that the body can do what it needs to; and I’m that woman in the wheelchair? Absolutely. It began proba- thinking about refining proprioception so that my client

Lewis Albert Sayre (1820–1900), one of the founding fathers of orthopaedic surgery in the United States, demonstrating his traction-casting of scoliosis, a technique which has not survived him. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2493005/"

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Scoliosis by Angela C. https://www.flickr.com/photos/_twiggy/3345890702

can respond to what they’re feeling. And typically, I want to do that in a way that's not noxious, because pain is unrefined, overwhelming proprioception.

Therapeutic Goals

primary motivator. It's a tall order to have someone lie passively on the table for an hour, even ten or twelve times, and walk away permanently changed in their very structure. Movement and awareness are probably much more malleable that tissue, and arguably, have a bigger impact on client’s subjective experience.

AH: Okay. Somebody comes in with scoliosis, what are your own goals and aims, and how do you work with whatever the client's expectations are? Do people come in So if the person says, “In my wedding picture I noticed my right shoulder was higher than the left,” I might explore with realistic expectations, or do you have to downgrade what that’s like from the inside. I might ask, “Can you tell their expectations? you have a shoulder higher without looking at your wedTL: I'm always assuming that the reason that they're com- ding picture? If you can tell, what happens to you when ing in has an element of false promise to it. I probably you ‘correct’ it? Is that an expansive experience for you don't think about it as downgrading, but more reframing. inside, or a diminishing experience? Where do you want to Often, it's an upgrade of what they imagine could be possi- be in that continuum? How much adapting do you want to ble; often, it's a shift of their criteria in terms of what dedo inside to accommodate what you think you should look fines success – especially scoliosis, probably more than like from outside?” other conditions. Often the client’s perspective is like, AH: I feel the enticement of that myself, but I know there's “Yeah, I notice in my wedding picture, my right shoulder was higher than my left. I want to fix that.” Dramatic visual a lot of people who don't want to go there. They don't changes can happen, but it's complicated when that's the want to go in. For some people that means going into a lot Terra Rosa E-mag No. 22

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of experiences that are difficult. What rate of engagement do you get with people, when you invite them in like that?

TL: 99%. Because I'm just talking about feeling your shoulder. Most all of us have access to plesant, expansive internal experiences, in addition to any diffult ones. For some people, sensation is a whole pathway into an inner world that's really rich and they can't resist exploring.

Maybe for others, that's not so interesting. It might even be something they've worked hard to stay out of. There's culturally not a lot of encouragement or support for our interior life. If that’s the case, I might ask, “But, I was talking about feeling your shoulder, just on the level of sensation: can you tell your shoulder's higher or lower? If you can't, what about if I put my hands here? If you can tell, does it even matter to you? Now go ahead and let's look into the mirror together and hold your shoulders straight.

What's that like to hold? Would you want to feel like that, or, is there a way with your breath you might find something that's gentler, more expansive?” As you see, it's often grounded in a language of sensation. It has lots of implications into other realms, but it's super tangible with some people. It's baby steps. Many more people than I expect really take off. I'm looking for whatever lights their fire, honestly. For example, a girl scoliosis, sent to me by her parents to “correct” her scoliosis– she might not even notice any inner experience of scoliosis, or care. But she might get interested if she noticed her sit-ups were asymmetrical; if that’s where she got interested, that’d be the thread we’d follow.

AH: Is your goal first to find what interests them?

TL: Yes. I think I want to find the essence of what interests them. That's at least one layer deeper than the presenting problem. There is something they want; identifying that and staying connected to that is my therapeutic goal.

That's a moment-by-moment thing, where you look to see what's interesting to someone, where their energy goes up or goes down, how does that breath get more expansive, how can they have awareness in a part of their body that they haven't before. Those are all types of positive feedback.

Structural vs Functional Scoliosis AH: Say something about structural and functional scoliosis and different approaches based on that.

TL: Classically, structural scoliosis would be thought to be related to the bone shape, like osteoporosis that's causing vertebrae to go wedge-shaped; something like that could sidebend the spine as well as causing it to rotate. Some definitions include the ligaments; those points of view see ligamentous and articular relationships in the spine as structural components that can make a spine passively stiff. The definition is if it's passively stiff in one direction, it's a structural issue. If it’s passively mobile but the client can’t actively move it, then it's a functional issue. It's an interesting distinction. Though it probably has a lot of 26 Terra Rosa E-mag No. 22

stragic usefulness in helping us know which intervention to start with, it's probably at its core a false dichotomy. Ida Rolf's big revolutionary statement is that all structure is plastic. Way before neuroplasticity, she was saying there's fascial plasticity. This gave people a sense of possibility about what could change, right down to the level of what we're made of. There's something useful in that point of view. Even if collagen molecules turn out not to literally stretch, or if glide becomes a more useful tissue goal than length, there's something very useful in the sense that my body is changeable.

I don't limit myself to working just functionally or just structurally. We do tests in our treatment protocols that help me, and the client feel: does this segment resist passive motion? – in which case, I might start with a structural intervention. Or can it respond passively? – then it's probably more functional. And they we see how it responds; if we don’t get the movement or awareness we’re looking for, we’ll try the opposite strategy. Often, we end up working with those two cases similarly, or at least we have similar ultimate goals. We want more options for movement. We want it to move in ways it doesn't now. We want someone to be able to feel it in a less noxious or more refined way, and feel it in context to the whole body.

Homework AH: How important is it, with working with scoliosis clients, that they are doing something on their own, either some form of movement practice or some exercises that will give support the manual therapy.

TL: It would depend on their identified goals. But let's say there's somebody who's getting close to that 40˚curve and trying to avoid surgery. They want to do whatever they can. Then, yeah, a multidisciplinary approach is superimportant. Scoliosis often isn't just a fascial thing. It isn't just a visceral thing. It isn't just a strength and conditioning thing. All those are factors. When people do strength and conditioning, they have fewer problems with their scoliosis. Scoliosis can also measurably change from hands on work. There are some decent studies of people doing just myofascial work on scoliosis, and showing a change in curves. All of these are pieces. For some people, there are balance differences, or more postural sway. Especially for adult-onset cases, being active physically seems to help.

AH: Do you refer people in any particular directions or it all depends on that client and what their interests are?

TL: I encourage people to be physically active in a way that they're likely to do. There's a window of opportunity too, with kids right around puberty. There are some pretty specific ways that a primary care provider can tell if a kid is within that window using x-rays to stage growth plates.

For our purposes, within a couple of years of puberty, that's a key time when there does seem to be an argument for aggressive and preventative work, even if there are no presenting problems with pain. That includes bracing or

After scoliosis surgery (ventral fusion). Weiss HR, Goodall D. Scoliosis. 2008 Aug 5;3:9. PMID: 18681956. doi:10.1186/1748-7161-3-9 . https://commons.wikimedia.org/wiki/ File:Surgical_result_after_ventral_fusion_of_scoliosis.jpg

surgery if the threat was severe enough. And in kids approaching that degree of severity, I would encourage everything I could. Some physical activities, some balance sports or balance activities, hands-on work, refined proprioception body awareness. Whatever that means for the kid.

member what I did right? Just think it through on the other side.” In his model it was all neurological, it was all about learning. Once you learned it, you got it. He wasn't thinking of the stuff we're made of, the hardware, as much as the operating system.

In our training we're teaching people how to work asymmetrically. But that’s not the point. The point is to leave people feeling like they have balanced options for moveAH: Here's a question about working symmetrically and ment. If someone comes in with an asymmetrical pattern, asymmetrically. In Rolfing sessions, we work differently on the two sides of the body according to what we find. My that often means working asymmetrically. Then again, it's not to try to make them symmetrical, but to help them do experience is that many trainers and yoga teachers want people to work very symmetrically. If you do this exercise something like Emmett was referring to, which is to be or stretch, do it equally on both sides. My sense has always able to move in a way that feels supported, balanced, in all directions. been that if someone has scoliosis, or any identifiable Working Symmetrically, or Not

asymmetrical pattern, and they can sense that from the inside or understand it from the inside, it’s intelligent to take an asymmetrical approach into conditioning or yoga or stretching. I'm curious for your thoughts.

TL: Massage therapists are the other group that might get stuck in symmetrical thinking. Entry-level massage therapists are often taught to do the same thing left and right.

The intention behind that is probably good: it's to try to keep things balanced, so to speak. You don't want to induce some sort of difference. Again, it's a simplistic way to stay safe, but it gets translated into dogma. Probably the least dogmatic person that I can think of in that point of view was Moshe Feldenkrais, who was famous for working just one side of the body and leaving his clients asking for the other side. His answer was well, just, “No. You re-

AH: If they're going to go out and do yoga as part of their program of being active, would you encourage them to explore being more asymmetrical in how they do it?

TL: I want to be careful about my prescriptions to them.

It's not like, “You should now do asymmetrical yoga, to ‘correct’ your imbalance.” My only prescription is, “What would it be like if you explored movement in both directions? Can you have as rich a sense of flexible body in this direction, as in that direction? Can you expand in each direction?”

Clients with Rods and Fusions AH: Let's talk about scoliosis and surgery. Are Harrington Rods still current or is it different what's used now?

In the past, Harrington Rods were the most common surTerra Rosa E-mag No. 22

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gical intervention used for scoliosis. These days, they are one of about five different rods that are being used now..

Lots of people trying experimental things too. But a lot of people will come with Harrington Rods that they got years ago. Honestly, the principles are still the same: I'm still helping them find options for movement and refined proprioception. Now, I'm not trying to bend the rod, obviously. You can get a sense of movement and refine proprioception even in the fused zone of a spine.

movement that’s being asked at the ends of the rods that seem to be contributing to that joint problems.

Parts and the Whole AH: Talk a bit about the content of your courses. How long they are and what kind of material you cover, the scoliosis courses in particular.

TL: We have a series of modular seminars and online courses. The in-person versions are typically two- or three Newer rods have lots of variation, and many of them flex. -day workshops. I have a new DVD, all about scoliosis. And Many of them attach to the ribs instead of the spine, or are we have a specialized live workshop about scoliosis, but adjustable, so they grow with the kid as she ages. Most of it's really the culmination of our five principle courses, which cover the whole body. That’s because scoliosis is a them now are three dimensional. Harrington Rods were straight; that came from a two-dimensional view that sco- whole-body phenomenon. Even though we have two days that we dedicate to scoliosis , in practice, it means pulling liosis was an S, not a three-dimensional spiral, which in perspectives and ideas for working the entire body. probably is attributable to the fact that x-rays were the main way that they were studied – that we perceived sco- AH: You're working from the holistic perspective, obviously. liosis as a flat situation because we were looking at flat pictures (even though some of the early people were TL: Trying to all the time. We try to play that balance beworking with scoliosis with stereoscopic x-rays – in the tween really tangible, sometimes joint-specific, tests and early twentieth century, there were clinicians who would techniques, while staying connected to the whole-body, take two x-rays and wear stereoscopic glasses to try to see whole-person picture. the three dimensional curves in scoliosis.) The classical AH: Which is something we didn't talk much about, but measure of scoliosis, the Cobb angle, is measured in two obviously when we’re working with clients who have scodimensions. The rod became a straight rod to try and liosis, we're not just looking at their thorax, their spine, straighten it out. They're getting more sophisticated, the we're looking at the whole body too, and how the pattern rods are now three dimensional, flexible, and adjustable. plays out through the limbs, through the head, through the But people can move, even with a rod. That's a major incranial system. sider discovery for people that have a rigid rod. Even the mental concept of having a rod stiffens people up. Finding TL: Absolutely. The muscles of the spine aren't strong enough to curve the spine in the way that we see in scoliothat they can actually feel breath, even gently bend and twist and move in the zones where they have a rod, can be sis – there are some bizarre machines they use to test spines’ passive stiffness. The idea that scoliosis is due to a healing insight. spinal muscular contraction doesn't hold up, and as AH: It makes me think of a client in her twenties who had Schleip’s later research showed us, any force provided by the Harrington rod surgery as a teenager. She was fine, fascial contractability is very weak and slow. But convencompletely adapted to it. She could play soccer, pretty tionally, a practitioner with a tissue-based view would much do whatever she wanted to do, no issues. Then she look at someone with a sidebend and think, “Oh, those was in a car accident and that homeostasis of comfort erectors, or the thoracolumbar fasciae, are tight on that from having adapted to and been supported by this surconcave side.” You’d think of the bowstring model, that gery was disrupted and she was suddenly getting all sorts you’ve got to go loosen the tight tissue and straighten it of radiating pain. She perhaps had less adaptability and out. Well, refining awareness and getting more movement that made it a little harder to go back to the old homeostapossibility in the concave side can be really useful, but it sis or to find a new one. turns out that those things also help on the convex side.

TL: That sounds feasible. People with rods also have a And there often won't usually be dramatic muscle tonus or higher statistical incidence of arthritis at the ends of the fascial texture differences between the concave and conrods. In general, people with scoliosis don't have more vex sides. It's probably not the case that the erectors or back pain than people without scoliosis, but people with thoracolumbar fascia are ‘pulling’ the spine into a bend, rods have more facet joint issues at the end of the rods and so that’s why ‘lengthening’ the erectors doesn’t usualover time –decades later usually. That's information we ly straighten it out. need to be careful with because it could be a self-fulfilling The girdles, however, are a somewhat different matter. prophecy. Most of rod patients have heard it anyways.

That’s because myofascial structures crossing the girdles They're worried about it already. We can get good results and going out into the limbs are bigger, stronger, and have by getting movement in the other facet joints, the ones different line of pull so that they can exert more force on that aren't in the section where there are limits or where the spine than the spinal muscles themselves. So just in there's a rod. The results come from relieving the extra terms of biomechanics, there are better arguments for 28 Terra Rosa E-mag No. 22

working with the girdles and limbs than with the spine per se. But even then, there are problems with the idea that tissue shortness here causes scoliosis, as the limbs, especially the shoulders, are typically not fixed points than could pull the spine towards them.

PSOAS AH: What about the psoas?

TL: For a long time, the psoas was considered a key muscle in scoliosis. If you look at lumbar scoliosis or even lower thoracic scoliosis, it looks like the concave side psoas has got to be “short” – one psoas could look like it was pulling the spine into that pattern. That led to a common surgical release where an orthopaedic surgeon would actually sever the psoas tendon on the ‘short’ side, to try and correct scoliosis and prevent it worsening. This quite commonly done up until the 1950s, when outcome studies showed that people that had psoas release surgery were no better off than people that didn't have the surgery.

AH: They were minus the psoas.

TL: Yeah, they were minus one of their psoas. It called into question the role – the causative role, you could say – of the psoas too. People’s scoliosis wasn't getting better with one psoas cut. Even still, the movement possibilities and preceptive function that myofascial structures provide seem to be important. The bowstring model probably doesn't have a lot of basis in actual physics, and even less so in what seems actually to help; the tissue-tightness model is probably more conceptual than empirical.

AH: The three-dimensionality really implies that the whole biomechanical structure is going to be involved; trying to figure out one or two places to work is not going to be a model that is that helpful, ultimately.

Source: http://en.wikipedia.org/wiki/Image:Wiki_pre-op.jpg

When we see mild curves, especially in an otherwise healthy person, it's more helpful to reassure them and ease their concerns about having a disease that they’re afraid is going to cause them to degenerate or degrade or twist up in a funny way. That’s not to say we want to encourage complacence: fear is a powerful motivator, so when we reduce it, we want to help the client replace it with something else.

TL: That's right. In our trainings, we start our scoliosis protocol with the arms, legs, shoulder girdle, and pelvic girdle. We also have a lot of tools for direct work with the spine, thorax, abdomen, sacrum, and the neck. But then we AH: That's a good point. I can think of so many clients finish with the limbs and girdles, back to where we start- who've come in and announced that their chiropractor or ed. another practitioner has said they have scoliosis. I look at them and feel, “You've been scared for no reason.”

AH: If somebody wants to learn from you, they should move through the sequencing of your classes to get the whole worldview.

TL: Yeah. It's a whole-body phenomenon. But people can jump into our series of short workshops at any point, and move through them in whatever order.

Pathologizing of Scoliosis AH: Anything else you'd like to share?

TL: One thing – the deep pathologizing of scoliosis. People will come in having been told that they have scoliosis and that they should urgently do something about it. If they're in that adolescent window, like I said, there're very good arguments for doing ambitious preventative work. But so many people have spinal curves that are asymptomatic.

TL: It gets complex when they've been scared by another practitioner. That gets into the ethical quandaries around interprofessional relationships. Often clients are relieved by an approach that’s more like, “I'm going to help you move comfortably in every direction. And I'm going to help you refine your body awareness, in every direction.”

That seems to help everyone.

AH: Thank you very much, Til!

Terra Rosa E-mag No. 22

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Info & Registration: terrarosa.com.au Terra Rosa E-mag No. 22

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Differential diagnosis of shoulder pathology John Gibbons

When I teach the shoulder joint masterclass at my clinic within the University of Oxford, it is to students from all the corners of the earth, a fact that makes me feel truly honored. Nevertheless, when, during the course of the class, I discuss differential diagnosis of shoulder pain and upper limb pain, I have often found it disappointing how little knowledge many physical therapists have regarding other bodily structures and vital organs (viscera or viscus) 32 Terra Rosa E-mag No. 22

that can be the underlying causative factor for the patient’s presenting symptoms (or at least contribute to it).

Medically trained personnel, whose initial training is generally longer, may have greater knowledge but hopefully, this article will be of interest to all readers and serve as a reminder of the specific pathologies that can cause shoulder or upper limb pain. It is very important that pain from a musculoskeletal origin can be differentiated from a visceral

pathology because they can easily mimic each other in terms of how they present, as we will read shortly.

An article I wrote many years ago discussed five individual patients that presented to my clinic with shoulder pain.

What was of particular interest was that they all had something in common. Each was asked to place their arm by their side and to perform a movement of shoulder abduction as far as they could comfortably reach and to try to raise their arm over their head to the normal range of motion (typically classified as 180 degrees). All were aware that something was ‘not quite right’ during the movement: three of them had actual pain on motion during abduction of their arm.

The first patient was a 75-year-old male who had fallen off a ladder onto his right shoulder, and when he presented to the clinic, he was not able to even initiate abduction actively, even though I could take his arm to 180 degrees passively without any pain. The second patient was a 34-year-old female painter and decorator, and she presented with pain only between 60 and 110 degrees of abduction (after a weekend of painting ceilings) – this is typically called a painful arc. The third patient was a 24-year-old rugby player. He had sustained an injury to the top of his shoulder when he was tackled in a game, and he had pain towards the end of the range of motion for abduction. The fourth patient was a 55-year-old female. She had started to notice her shoulder was getting stiffer since doing a fitness class 6 weeks ago and now had limited movement of the shoulder joint and could not even lift the arm to 60 degrees without feeling restriction and subsequent pain. The fifth person was a 45-year-old male. He could not abduct his shoulder past 20 degrees (but could initiate), and this had happened after doing some push-ups in the morning when he woke up. The patient could lift his arm to 20 degrees but could go no further without some pain and weakness and it appeared that the deltoid muscle was not working. At the time I considered this was due to a potential muscle weakness of some sort or possibly caused by a neurological problem.

My personal belief about treatment of the shoulder complex tends to chime with a methodology that was taught to me many years ago when I was a student of manual therapy. It is known as the K.I.S.S. principle (Keep it simple stupid!), or the keep it simple principle. I always say to my therapy students that if a patient presents with what they believe to be an ‘actual shoulder’ or upper limb problem and they are having an issue in terms of pain or restriction during abduction or even flexion of their shoulder to 180 degrees, it is probably a localized shoulder complex issue or pathology that would need addressing through handson physical therapy, whether that is considered to be the right or wrong approach. This approach currently seems to work well for me with my patients and athletes.

Figure 1: Abduction of 0–180 degrees and the five specific conditions

Regarding the five case studies above (see also Figure 1), the first patient had what I believed to be a full thickness tear (rupture) of the supraspinatus, the second an impingement syndrome of the subacromial bursa and/ or a supraspinatus tendinopathy. The third patient, who presented with pain at the end range for abduction, sustained an acromioclavicular joint (AC joint) sprain, the fourth I diagnosed with a chronic frozen shoulder (adhesive capsulitis) and the last I considered to have an axillary nerve palsy due to the inability to activate the deltoid muscle during abduction (axillary nerve, which originates from the cervical nerve root level of C5 and specifically innervates the deltoid and teres minor muscles).

Regarding the last case study, many therapists with a good knowledge base might say it could be a C5 nerve root problem that is potentially causing the weakness with shoulder abduction, and that is perfectly correct because the person had weakness abducting their arm. However, the C5 myotome also innervates the motion of elbow flexion, and in this case, the patient tested strong for the contraction of the biceps muscle. Also, there was no weakness to other C5 innervated muscles like the supraspinatus or infraspinatus. In this case, therefore, it cannot be a C5 nerve root issue.

I used to be a vehicle electrician when I was in the military, Terra Rosa E-mag No. 22

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scapulohumeral rhythm and the structures involved to allow this motion to happen? Simply lifting the arm above the head requires the precise interaction of the GH, ST, AC and SC joints, as well as the integration of all of the soft tissues and nerve innervations. There are multitude of reasons why patients or athletes present with shoulder pain and below I would like to discuss some of those conditions.

CASE STUDY

and I consider the axillary nerve to be similar to a sidelight or indicator on your car: if the bulb has blown or the wire has been cut (open circuit) then the light will cease to function. For the axillary nerve, if the little wire (nerve) that supplies the deltoid and teres minor have been damaged, this can subsequently cause the nerve to switch off (the muscle now becomes inhibited and/, or the light bulb goes off or dims). As a result, the muscles in question will test weak and will start to atrophy (waste) very quickly. However, everything else in the body (or car) will work as normal, and initially you might not notice a problem. It will not be long, though, before you are aware of the underlying issue.

So, the next time someone walks into your clinic with shoulder pain, if you bear in mind what I have said regarding the motion of abduction, I am sure it will help you come to a diagnosis or a hypothesis of localized pathology or not.

A lady in her mid-40s presented to the clinic, with pain generally located to the top of her right shoulder and upper trapezius muscle. This has been present for many months with no obvious cause. During the day the lady was not aware of her pain, but at night, while she was sleeping, the right shoulder was noticeably worse to the point she would wake up, take some medication and eventually fall back to sleep. The lady also mentioned something was not quite right with her middle to lower thoracic spine, but she said her shoulder pain was the priority. On examination, I asked the lady to abduct her shoulder as far as she felt comfortable, and to my surprise, she could easily reach a full range of motion to 180 degrees. It was the same when she was asked to flex the shoulder and also managed to reach the full 180 degrees of motion with no issues. Because the lady could abduct and flex the shoulder to full range, I considered that there could not be any underlying musculoskeletal issue present directly related to the region of the shoulder complex. This next sentence or two might sound a bit strange as I asked the patient the following: ‘When you go to the toilet for a number two (defecation), have you noticed that your stool has a tendency to float on the surface, rather than sinking to the bottom of the bowl?’ Unsurprisingly, the lady looked a little startled but responded by saying ‘funny you should ask that question, but yes, my stool does seem to float when I go to the toilet.’ Before I continue with the case study, ask yourself why I asked this particular question – what do you think was going through my thought processes?

Before I answer this question, I want to mention something that was taught to me when I was studying osteopathy. One particular lecture that I found of great interest and remembered was on ‘differential diagnosis of musculoTo recap, if a patient is standing and is asked to abduct skeletal pain in physical therapy.’ The tutor had talked their arm to 180 degrees and the person is aware of some- about a female patient that presented to him with rightthing during this motion (e.g., pain, restriction, weakness) sided shoulder pain who surprisingly had a full range of motion (ROM) without any pain in all the tested movethen there is a good likelihood that this patient has some ments. The tutor proceeded to discuss something known dysfunction present that requires further investigation.

However, if the patient in question can fully abduct as well as the four ‘F’s – female, fair, fat and forty. You can probaas to flex their shoulder to 180 degrees, without mention- bly guess that it relates to an overweight lady with fair coling anything, and the movement is fluid and pain-free, then ouring who is in early middle age. The patient in the case one needs to consider the following: does this patient have study certainly fitted this picture. Basically, the tutor had an underlying pathology with the shoulder complex? said if a patient comes to your clinic with right-sided shoulder pain and fits the criteria of the four Fs then one needs Remember what was discussed earlier concerning the to consider that the gall bladder might be the underlying 34 Terra Rosa E-mag No. 22

Figure 2: a. Gall bladder and its relationship to the phrenic nerve, b. The dermatomes of the upper limb

causative factor for their presenting symptoms of pain located to the right shoulder.

Common pathologies that occur with the gall bladder are inflammation of the gall bladder (cholecystitis) and gallstones (cholelithiasis). I am hoping at this point that I have whet your appetite enough for you to want to gain more underpinning knowledge of the subject matter and hopefully you are now trying to work out in your head the fol-

lowing: so how does the organ of the gall bladder cause right-sided shoulder pain? As far as I understand it there are two possible processes at work: one process is related to embryology and it is considered that when you are a foetus growing in your mother’s womb, the gall bladder initially originates from the area near to the right shoulder and as you develop, the gall bladder naturally descends to its resting position underneath the lower rib cage located Terra Rosa E-mag No. 22

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upper trapezius muscle, and it can be exacerbated when the patient coughs, sneezes, or deep breathes. What I am saying is this: if you have a pathological issue with your gall bladder then the chances of having right shoulder pain is increased because the pain signals are transmitted back to the cervical spine and the sensory input is then transported to the peripheral nerve and subsequent dermatomes.

One could look at this as a referred pattern of pain. Let me give you an example: someone is having a myocardial infarction (heart attack). The person will naturally feel intense pain in the area of the central chest; however, most patients describe feeling other areas of pain or sensations, and these can be felt in the mid-thoracic spine, left arm and hand, and even towards the left side of face and jaw.

What I want to do now is give an analogy for this process.

Imagine you are travelling to London by train on a Monday morning at rush hour, arriving at, say, Paddington station.

Hundreds of people will get off the train at the same time.

Figure 3: Palpation for rebound tenderness of gall bladder The conductor directs them through the normal gates pathology – Murphy’s sign (relate this to chest pain). Nevertheless, because so many people are getting off the train, a queue forms and now the conductor diverts some people to alternative gates on the right side of the body. This means that if you have (left side of face and jaw), and if they also become busy, to an inflamed gall bladder, or even gallstones, in some way another gate, which might be a few extra minutes walk the gall bladder remembers its original position from when away (arm and hand). I hope that this analogy makes some it was forming inside of you as a foetus, and subsequently sense to you. To put it simply, if the gall bladder is inflamed pain is now present in the right shoulder. then this organ can refer to the right shoulder via the The second process, which I am more inclined to believe, is phrenic nerve as well as to the area of the mid-lower thothe proximity of a nerve called the phrenic nerve and its racic spine. This is due to the sympathetic nerve celiac ganrelationship to the gall bladder. The phrenic nerve innerglia innervation of the gall bladder and because of the vates the central component of the respiratory muscle of proximity of the gall bladder to the abdomen the patient the diaphragm (it is a musculotendinous structure and not could perceive pain to the right lower costal margin, which a viscus). This nerve originates from C3, C4, and C5 and is located to the upper right quadrant of the abdomen. there is a simple mnemonic that states C3, 4, 5 keep the diaphragm alive. This relates to spinal cord trauma, in that if you damage the spinal cord below the level of C5, then Conclusion you should be able to breathe for yourself unassisted; howRegarding the lady from the above case study, I mentioned ever, if you damage the spinal cord above this level, then to her that I thought it was the gall bladder that was reyou might need to have artificial respiration. However, the sponsible for her pain to her right shoulder as well as disperipheral part of the diaphragm is innervated by the lower comfort in the mid-lower thoracic spine. I discussed with six intercostal nerves and subsequently, does not refer her the function of the gall bladder in terms of breaking pain to the shoulder complex. down fatty foods, etc., that and if this organ does not funcLet us now look at the scenario of an inflamed gall bladder. tion correctly, then the stool tends to float. I also discussed Because of its proximity to the diaphragm and the phrenic through anatomical books and diagrams how the gall bladnerve (figure 2a), there is a stimulus that excites the neuro- der caused pain to her right shoulder via the phrenic nerve. logical system, and subsequently, a signal is relayed back to There is also a small area under the lower right costal marthe origins of the nerve that is located to the area of the gin (rib) that when palpated (especially with the patient cervical spine from levels C3–5. If you look at a map of the breathing in), may cause a rebound tenderness (figure 3). neurological dermatomes, you will notice that C3–5 covers This is known as Murphy’s sign and is a positive finding for the area of the upper limb and in particular, the area of the an inflamed gall bladder, especially if the same procedure is shoulder region (figure 2b). Pain that is referred from the performed on the left side of the abdomen with no perdiaphragm is typically felt near the superior angle of the ceived pain from the patient. I wrote a letter to my pascapula, along the suprascapular fossa and even along the tient’s GP, explaining my findings and she had a meeting 36 Terra Rosa E-mag No. 22

with a gastrointestinal consultant who confirmed it was pathology with the gall bladder and removed it a few weeks later. The patient in question had a follow-up appointment a few weeks after the surgery, and I was pleased to see that her shoulder and thoracic pain had disappeared.

This type of condition is what is described as a visceralsomatic dysfunction because the organ (viscera) is the underlying causative factor for the pain to present itself to the somatic/soma region (body), in this case pain the right shoulder.

Regarding pathology of the gall bladder, patients can also present with upper right abdominal pain, as well as nausea and vomiting, after eating fatty meals. They might also present with jaundice, low-grade fever, and weight loss, especially if there is a cancer present.

In the Vital Shoulder book, I discussed other pathologies that can refer pain to the shoulder, including spleen, liver, lung carcinoma, stomach, pancreas, and others.

My focus here is to try and make you aware of how the viscera refer pain to other structures within the musculoskeletal framework and especially to the region of the shoulder complex. With the correct questioning during the initial consultation and the appropriate orthopaedic testing protocols, we can hopefully eliminate the musculoskeletal tissues as a source of a patient’s presenting symptoms, especially if the practitioner cannot reproduce their symptoms during the physical therapy examination. It is time then to consider that the symptoms the patients are presenting with might be referred from the pathology of the viscera rather than being musculoskeletal in origin.

This article is excerpted from The Vital Shoulder Complex, An Illustrated Guide To Assessment, Treatment, and Rehabilitation By John Gibbons, with permission from Lotus Publishing. Order at terrarosa.com.au

John Gibbons is a registered sports osteopath, multipublished author and lecturer for the Bodymaster Method ÂŽ.

He specializes in the assessment, treatment and rehabilitation of sport-related injuries, specifically for the University of Oxford sports teams. Having lectured in the field of sports medicine and physical therapy since 1999, John delivers advanced therapy training to qualified professionals throughout the UK and internationally. He has written over 45 articles on various aspects of physical therapy, which have been published through companies like SportEx, Federation of Holistic Therapies, Massage World, Positive Health and Sports Injury Bulletin.

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Assessment of Fascial Dysfunction Doreen Killens FCAMT

You have probably read articles about how to treat fascia-related problems; however, do you know how to identify if fascial dysfunction is the cause of your patient’s symptoms?

Subjective Assessment Geoffrey Maitland, one of the grandfathers of manual physiotherapy, had a significant global impact on the profession. One of the most important messages he conveyed to physiotherapists was the importance of a thorough subjective evaluation.

This article is the missing link and provides all you need to know to diagnose fascial dysfunction or to make a “Not only will a thorough subjective exam tell you what differential diagnosis. Making the correct diagnosis is the first step to providing the right treatment for your the problem(s) are,” he would say, “but also how to treat them.” patient’s problems to achieve long-term results.

This is true for all cases of musculoskeletal pain: it is particularly important for cases of fascial dysfunction. The typical This article has been extracted from the author’s book Mo- questions asked in a good subjective evaluation include the bilizing the Myofascial System: A clinical guide to assessfollowing topics: ment and treatment of myofascial dysfunctions.

• areas of pain and their relationship to each other • 38 Terra Rosa E-mag No. 22

complaints of paraesthesia, numbness or other neurological symptoms

• previous history of the complaint • previous medical history, including medications taken • medical tests performed and their results • previous treatments tried and their effects • behaviour of pain throughout the day/ night • factors that provoke and ease symptoms • functional difficulties • patient’s goals for treatment.

A patient with fascial dysfunction may present with the following additional subjective complaints.

“My skin is too small for my muscles.”

• The patient has difficulty maintaining an optimal posture.

THE OBJECTIVE EXAM The objective exam involves several aspects, which, along with their common findings, are described below.

Observation Positional faults are noted in observing the patient’s posture, but testing the accessory movements of the joints only gives a partial explanation for this positional fault.

“I feel tension in my leg overall, as if I were wearing a twistFor example, ideally, when assessing the position of the ed pair of tights.” femoral head relative to the pelvis, the therapist is hoping “I know that other therapists and doctors have told me to find a centered femoral head, a key requirement for opthat my right leg and arm symptoms are separate probtimal biomechanics of the hip. An example of a positional lems, but that’s not how it feels to me.” fault is one in which the femoral head is positioned anteriOther characteristics of myofascial pain include the follow- orly in relation to the ilium. If the therapist thinks only of articular factors, they will presume that the capsule of the ing symptoms. hip joint is the cause of this positional fault. However, opti• Pain is dull, aching, and often deep. mal biomechanics requires not only normal capsular mobili• Pain may be low-grade to severe in intensity. ty around the hip joint but also balanced activation of all • There are frequently many areas of local tenderness. muscle and fascial vectors.

• There are disturbed sleeping patterns with morning Active Range of Motion stiffness.

• Pain does not follow dermatomal, myotomal or sclero- The area in question may demonstrate normal, or neartomal patterns. normal, range of motion (ROM), but the range may be deDoes this last category of symptoms not sound suspicious- creased if the body is positioned differently. For example, if ly like fibromyalgia? Clinically, I have found that clients with the Superficial Back Line of fascia is tight, testing active this condition tend to manage their symptoms well with a cervical flexion in sitting may be more restricted than if it is combination of active exercise, dry needling, craniosacral tested in standing. techniques, and fascial techniques as well as appropriate medication, such as pregabalin, to tone down the nervous Active ROM may or may not produce pain, but the patient frequently reports a sense of ‘stiffness’ or ‘pulling’. system.

Patients with fascial dysfunction are rarely able to identify Testing of individual joint mobility or muscle length is within normal limits (or, at times, hypermobile), but a respecific provocative movements that consistently reprostriction is noted with combined, functional movements. duce their symptoms unless the activity adds tension to a tight fascial line [eg. low back pain brought on by walking or standing for a while if the Deep Front Line (DFL) of fascia is restricted]. We must, however, rule out other dysfunctions that can reproduce these symptoms such as hypomobility or hypermobility of the facet joints, poor mobility, and/or dynamic control of the foot, knee, hip, lumbar spine, pelvis or thorax that may contribute to the low back pain. Given the connectivity and relationship between body regions, every region of the body can contribute to low back pain.

There can be other clues that we may be dealing with the dysfunction of the fascial system: • The patient has difficulty maintaining the effects of treatment despite good results obtained during treatment.

• The patient has difficulty maintaining the effects of treatment despite being diligent in doing recommended flexibility, postural or stabilisation exercises.

• There has been a recent growth spurt in adolescence.

Muscle Length Tests These are often within normal limits. If a muscle is restricted and treatment is targeted to the local muscle, both the patient and the therapist may feel that results from treatment are short-lived, and the muscle soon tends to stiffen up again.

Joint Mobility Testing joint mobility includes both passive physiological movements and passive accessory movements. Passive physiological movements are movements in which the practitioner produces the motion while supporting the limb or spine. The technique is chosen in order to assess the joint with the muscle in a relaxed position. Accessory or joint play movements are joint movements that cannot be performed by the individual. These accessory movements, including roll, spin, and slide, accompany the physiological movements of a joint. Manual therapists have been taught that when assessing passive physiological or passive accessory movements of a joint, attention must be paid to the Terra Rosa E-mag No. 22

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sensation throughout the whole movement and not simply If the load and listen test points to an articular restriction, the end feel of the movement. the therapist will feel that the accessory glide may be stiff with a relatively harder, capsular end feel. Upon the reAll joints have ROM divided into two zones: lease of the accessory glide, a small amplitude movement 1. A neutral zone (NZ) in which no resistance is felt. The NZ occurs to allow the joint to re-establish a more neutral posiends once the beginning of the first resistance to movetion. ment is perceived (R1).

If the load and listen test points to a myofascial restriction, 2. An elastic zone (EZ) in which the first resistance to move- the therapist feels the resistance to the accessory movement (R1) gradually increases until firm resistance is felt ment, but the end feel will not be as hard. More important(R2) at the end of range. In a normal joint, it is considered ly, upon release of the glide, there will be a vector of pull that R2 is due to tension in the ligaments and capsule of towards the area that is ‘tugging’ on the joint. This myofasthe joint (Chapter 4 ‘Principles of treatment with Mobilisa- cial restriction may be a combination of neuromuscular tion of the Myofascial System’ of the author’s book Mobi- vectors (increased tone in muscles due to increased neural lizing the Myofascial System discusses this in more detail). drive), visceral vectors, muscular and fascial vectors. (Keep in mind that fascia surrounds all of these systems.)

A normal accessory movement for a joint, although small in amplitude (usually a few millimetres of glide or roll), will This test may be used as a ‘before’ and ‘after’ test when have a small NZ, where no resistance is felt at the start of using any release technique. It is particularly useful to use the movement, and a gradually increasing EZ until R2 is before and after a mobilisation of the myofascial system felt. Training is required to determine a normal or abnor(MMS) technique. It guides the therapist as to which myomal feel for an accessory movement of a joint. fascial vector(s) have the most impact on a particular joint and encourages exploration of that myofascial vector. ReWhen there is a myofascial restriction, accessory movelease can be done both locally to the involved muscle and ments of the joints have a ‘bouncy’ or ‘rubberlike’ end feel also along its myofascial line (based on Anatomy Trains as opposed to the end feel of a fibrotic or stiff joint, which myofascial meridians). (Chapter 11 of the author’s book is crisper and harder.

‘The lower extremity’ outlines the load and listen test for Several levels in the lumbar spine may exhibit stiffness with the hip joint.)

PIVM (passive intervertebral movement) testing for flexThe same concepts for the load and listen test apply to ion, for example. If a fascial line is restricted, mobilising other joints. For example, if the glenohumeral (GH) joint is these joints often results in only partial release. positioned anteriorly in relation to the acromion, on the The patient’s joints may have a tendency to be hypermoload and listen test we may find some limitation in the posbile, but they still present with decreased ROM when acterior glide of the GH joint (the loading aspect of the test): tive ROM is tested. but upon the release of the anteroposterior (AP) glide (the listening aspect of the test), we may feel a vector that pulls Vector Analysis: Load and Listen Test the humeral head caudally toward the biceps if the Superficial Front Arm Line is shortened. It is then appropriate to This test derives from listening courses developed by Gail Wexler for the Barral Institute. These listening techniques check the myofascial tissues of the Superficial Front Line. differentiate active and passive listening. ‘Load and listen’ (Chapter 13 ‘The upper extremity’ outlines the load and listen test for the GH joint.) encompasses both aspects of listening. I find it invaluable in helping to detect the primary myofascial vectors that Dynamic Stability Tests may be impacting a joint. When an accessory movement for a joint is assessed, not only is the resistance of this acDynamic instability may be defined as a patient exhibiting a cessory movement noted but, in this test, particular atten- failed load transfer when performing functional tasks such tion is paid to the release component of the accessory as the half squat or OLS (one-leg stand) test. The failed glide. In other words, when you let go of a correction, load transfer in these functional tests may present in one where does it pull you? This is what is termed ‘vector analy- or several areas(1): sis’.

The pelvis: ‘unlocking’ of the pelvis may occur. In this situaVector analysis in the Integrated Systems Model (ISM) ap- tion, the sacroiliac joint fails to maintain a position of sacral proach has taken the ‘load and listen’ concept of the Barral nutation in relation to the ilium (the position of optimal visceral approach and applied it to the musculoskeletal stability for the sacroiliac joint). The therapist may perceive system to help identify the underlying system impairment this as the ilium moving into anterior rotation (relative that is creating suboptimal alignment, biomechanics and/or counternutation of the sacrum) when doing a half squat or control of a body region.

OLS test.

In a healthy hip, when the therapist glides the femoral head posteriorly, it floats back up to the surface, much like the type of ‘soap on a rope’ that pops back up to the surface of the water after it has been pushed down (Diane Lee, personal communication).

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The hip: ideally the femoral head should stay centered in relation to the pelvis throughout an OLS or a squat manoeuvre. A common clinical pattern of dysfunction is a femoral head that glides anteriorly and/or internally rotates instead of staying centralized.

The foot: the foot should be able to maintain its neutral position, with the talus directly under the tibia, the forefoot in a neutral position in relation to the hindfoot.

The thorax: no lateral shift of the thoracic rings should occur with functional tests of OLS and squat (1). Patients with fascial dysfunction frequently exhibit signs of dynamic instability, especially in the area of fascial tightness. Recruiting muscles that help in motor control is often a frustrating experience for both the therapist and the client, as fascial tension is frequently a factor that inhibits these stabiliser muscles from ‘kicking in’.

posterior, which is at the tail end of this line (see Chapter 5 ‘The cervical spine’ for details).

To explore the Lateral Line the therapist may position the client in side-lying, stabilise the mid-cervical spine with an AP mobilisation and explore the intercostal fascia on the side of the trunk (see Chapter 5 ‘The cervical spine’ for details).

How Does the Therapist Know when a Particular Line of Fascia is Restricted?

The therapist will feel an almost immediate increase in tension of the stabilising hand (in this case, the AP mobilisaASSESSMENT OF THE FASCIAL SYSTEM tion of the C4) as he/ she applies a gentle pressure on the Testing for Fascial Restriction with Recurring Joint Dysanterior aspect of the sternum with the exploratory hand function (for a SFL restriction). It is normal to feel a certain resistance between the two areas at the end of a caudal If a joint restriction is recurrent despite good effects with pressure on the sternum. Still, it is not normal to feel this previous treatment, good compliance with mobility and resistance at the very start of the manoeuvre being perstability exercises, and awareness of posture, it may be formed by the exploratory hand. There should be (in Geoff that the fascial component to the restriction needs to be Maitland’s terms) a ‘toe region’ where there is little readdressed. For example, if anteroposterior (AP) mobilisasistance at the beginning of the movement (discussed furtions of the C4 and C5 levels are chronically stiff despite ther in Chapter 4 ‘Principles of treatment with Mobilization good release with treatment, we may consider whether of the Myofascial System’). When the fascial line is restrictthis dysfunction is perhaps connected elsewhere along a fascial line and whether this may possibly be a contributing ed, this toe region is absent or quite limited and early refactor toward its recurrence. If the therapist suspects that sistance between the two hands of the therapist will be fascia may be a factor in movement restriction, he/she can felt. The patient may perceive this as the therapist pushing harder on the level being stabilised (in this case, C4) when then explore which line of tension is most problematic. in reality, the therapist is simply preventing the fascial tisThe MMS techniques described in this text have two com- sues at C4 from gliding caudally. ponents:

Using the Star Concept

1. The therapist stabilises an area of recurrent dysfunction with one hand stabilising either an accessory movement of The star concept implies that the therapist must not think along the lines of an articular glide but rather explore mula joint or a recurring myofascial trigger point. tiple directions: somewhat like the shape of a star. The aim 2. The therapist’s other hand becomes the hand that exis to discover where there is most tension between the plores and mobilises lines of fascia, always using the ‘star stabilising hand and the fascial tissues anterior to the sterconcept’ (described below). num (for this example of a problem with the Superficial Front Line). The therapist ‘corrals’ the myofascial tissue, Continuing with the same example of the restricted AP mobilisation at C4, the C4 level can be stabilised with an AP ‘sniffing out’ the vector where most tension between the mobilisation angled cranially and then the following consid- two hands is felt. In the example above, the caudal pressure on the tissues anterior to the sternum may be done in ered. a straight caudal direction, caudal to the right of the paTo explore the SFL the therapist may add: tient, caudal to the left of the patient, or perhaps in a me– an AP mobilisation to the ipsilateral or contralateral scap- dial/ lateral direction or even in a clockwise/anticlockwise direction. Restriction may be felt in several directions. ula Treatment begins by using the most restricted direction – an AP pressure directed caudally to the tissue anterior to and, once released, exploring and releasing the other rethe sternum stricted directions in that fascial line.

– the rest of this line may then be explored with an AP pressure directed caudally to the rectus abdominis area and/or the symphysis pubis (see Chapter 5 for details).

Exploring Lines of Fascia

– an AP mobilisation directed caudally to the right and/or left diaphragm – active dorsiflexion/eversion of the ankles to pre-tense the DFL by putting a stretch on the tibialis

The nervous system may also be used as a guideline (see the femoral nerve fascial technique in Chapter 9 ‘The lumbar/pelvic region’ as an example).

Tom Myers’s Anatomy Trains lines, although very pertinent to MMS, are not the only way a therapist can explore the To explore the DFL the therapist may add: fascia. The Anatomy Trains is simply a map of the ‘grain’ in – an AP mobilisation directed caudally to the tissue posteri- the myofascial fabric, and so, like most maps, only an indication of a good place to look (2). or to the sternum (pericardium)

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The patient’s functional problems may also give us a clue as to what to explore. Refer to Chapter 5 (Anterior cervical in relation to glenohumeral movements) for an example where the patient complains of arm pain with reaching forward as opposed to reaching sideways with abduction.

“It hurts right here.” The location of the patient’s main complaint of pain may also be a good place to start, stabilising that area and exploring fascial lines that may be ‘tethered’ to that painful area. The area of pain is frequently a ‘victim’ of another dysfunction nearby (e.g., the lower lumbar area may become symptomatic during standing or walking if it is compensating for an extension dysfunction in the upper lumbar area, and/ or poor hip extension).

However, the symptomatic area may also be tethered by a tight fascial line, and this may also play a role in its recurrence.

Reposition and Test Another way to help differentiate an accessory joint movement restricted by the joint capsule from one restricted by myofascial vectors is to repeat an accessory movement with other regions of the body under tension. For example, an AP mobilisation of the C4 level in the mid-cervical region may be compared to the same mobilisation (same grade of movement) with the ipsilateral arm in 70° of abduction. If the AP at C4 is stiffer (which may or may not reproduce pain), then it implies that fascia may be a factor in this recurrent restriction. The fascia may be related to the muscular system (e.g. scalenes), the clavicle, the neural system (e.g. median nerve), the visceral system (e.g. pericardium) or perhaps a combination of all four areas.

then adding dorsiflexion/eversion will cause an immediate increase in tension in the hand that is stabilising C4 in an AP glide (see Chapter 5 for MMS technique).

Testing for Fascial Restriction with a Recurring Muscle Trigger Point Myofascial tension may tend to recur if the following factors are not addressed: • optimising balance between muscle groups in the area (i.e., stretching tight muscles, strengthening weak ones) • using dry needling or IMS techniques to de-facilitate muscles that are hypertonic secondary to increased neural drive • considering other areas of the body that may be impacting the symptomatic area (ISM concept of drivers) • last but not least, considering that there may be a myofascial component to the restriction that needs to be addressed.

The following paragraph describes an example of this last concept using MMS.

Recurrent tension in the upper fibres of trapezius (UFT) may be due to tension of the Superficial Back Arm Line (SBAL), which needs to be addressed to get optimal results. In this example, the therapist ‘stabilises’ the recurrent myofascial trigger point in the UFT by pinching it in an AP direction. If there is tension in the SBAL, the therapist will feel an immediate increase in tension of the ‘stabilising’ hand on the UFT as soon as he/she adds a component of Another example is to explore the DFL of fascia in relation the passive wrist and finger flexion. Keep in mind that the to recurrent C4 dysfunction. This is done by stabilising C4 wrist and finger extensors are at the tail end of the SBAL as above and simply adding active (or passive) combined (see Chapter 2 ‘A summary of Tom Myers’s Anatomy Trains dorsiflexion/eversion of the ankles to see if this affects C4. fascial lines and clinical implications’). Using oscillatory (Keep in mind that tibialis posterior is at the tail end of Tom movements of wrist flexion while maintaining the pinch on Myers’s DFL, so adding dorsiflexion/eversion puts it under the trigger point will help to release this line of tension tension). If there is abnormal tension in the DFL of fascia, (see Chapter 5 for MMS technique).

CASE REPORT – MICHAEL’S STORY This case hits close to home as it involves my son Michael, who is presently 25 years old. When he was 14 years old, he fell skateboarding and sustained a severe fracture of his left clavicle – it had fractured into three pieces, with the middle portion angled vertically. He was initially placed in a sling and told to go home – the assumption was that the bone would heal on its own. Lyn Watson, a shoulder specialist in Melbourne, Australia, whom I consulted, stated that, in Australia, they would operate on such a case. Needless to say, I made sure to go with Michael to his follow-up appointment. I had a number of concerns about the long-term function of his shoulder girdle, including the possibility that it would heal in a shortened position and forever impact his upper quadrant function.

Unfortunately, I could not convince the chief orthopaedic doctor to perform surgery. He assured me that healing was coming along and I should just allow nature to take its course. Knowing that bone was essentially dense fascia, I proceeded to remodel the clavicular fascia, initially with a listening approach and later, as healing progressed, with a more directive, MMS mobilisation approach. The clavicle fascia was tight in a number of directions (see techniques above), particularly in relation to the Superficial Front Line (clavicle in relation to the pectoral muscles and rectus abdominis) and the anterior functional line of fascia (left clavicle with right ilium). The intraclavicular fascia also was remodelled to encourage healing in the most lengthened position possible. This work was followed up with a strengthening programme to his scapular upward rotators. Initial treatment was performed weekly, and then periodically over the next year, as bone (and fascia) remodelling took place. Throughout his growth spurt, Michael could feel the need for more fascial release and periodically through the years, as his system adjusted to a new gym programme. Today, he is fully functional and grateful that his mother is a physiotherapist with skills in MMS! 42 Terra Rosa E-mag No. 22

Testing for Fascial Restriction with a Neural Mobility Test In order to address problems of decreased mobility of a particular nerve, the usual approach in manual therapy is to mobilise the interfaces of the nerve in question. The median nerve, for example, may involve positioning the arm in some degree of shoulder abduction, external rotation, elbow extension, and wrist and finger extension (depending on irritability of the tissues and where first resistance is felt when doing the median nerve mobility test) and then adding AP mobilisations or lateral shear movements at C5, C6, and C7. As well, the nerve mobility test itself may be used as a treatment technique, either as a sliding technique or a tensioning technique. If, however, the tension of the nervous system persists despite this approach to treatment, it is suggested that the therapist explore a little more broadly than the usual interfaces of the nerves. For example, the therapist may use a mobilising technique in the anterior cervical spine with the arm in abduction, external rotation, wrist and finger extension to pre-tense the median nerve and then explore the SFL of the trunk. Or the therapist may also explore other regions of the cervical spine, frequently as high as C1 or C2, that may have an impact on the mobility of the median nerve (see Chapter 5 for MMS techniques).

Indications/Contraindications to MMS Treatment The contraindications to treatment with MMS are similar to the contraindications for manual therapy in general.

CNS, spinal cord or cauda equina disease and injury are an obvious contraindication to any manual therapy, but there are also other conditions to consider such as vascular issues and metabolic and systemic contraindications. MMS is particularly indicated for subacute or chronic conditions. If the condition is acute, the therapist may work either proximally or distally (craniocaudally) to the symptomatic region, following Myers’s fascial lines of tension.

When first working with tissues that are in the subacute phase of healing, it is wise to use ‘listening techniques’ rather than be too directive until such time that the body gives you a green light to go ahead (see Chapter 4 for principles of treatment with MMS). Recent fractures must be given time to heal before using fascial techniques directly on the fracture site, but areas above and below the fracture may be explored and treated.

THE AUTHOR Doreen Killens FCAMT is an orthopaedic musculoskeletal physiotherapist with 40 years of clinical experience. For 25 years, she was an instructor for the Canadian Orthopaedic Manipulative Division of the Canadian Physiotherapy Association, teaching manual therapy courses across Canada. In addition, she

was an Examiner and former Chief Examiner for the same association. She is presently in private practice in Montreal and has a particular interest in the field of headaches and myofascial dysfunction. She is the developer of a physiotherapy approach to the treatment of the myofascial body called Mobilization of the Myofascial System (MMS) (Upper Quadrant, Lower Quadrant and Advanced Integration). Also, she teaches a two-level course system entitled Manual Therapy for the Cranium, courses she teaches across Canada and Europe, both in English and in French. Email: Doreen.Killens@gmail.com

KEY POINTS • A thorough subjective exam is crucial for the correct analysis and treatment of fascial dysfunction.

• Some symptoms of myofascial pain can sound like the symptoms of fibromyalgia.

• It is often difficult for fascial dysfunction patients to identify specific movements that reproduce their symptoms.

• Difficulty in maintaining good treatment results with conventional manual therapy approaches can indicate fascial dysfunction.

• A cornerstone of the objective exam is to test whether joint position is balanced during functional movements that are relevant to the subjective complaint.

• The end feel of accessory movements of the joint is ‘bouncy’ when fascial restriction is present.

• Mobilisation of the myofascial system (MMS) techniques are also useful for testing fascial restriction. n MMS is particularly indicated for subacute or chronic conditions.

• ‘What the therapist perceives as recurring joint stiffness may actually have a component of fascial dysfunction – a myofascial vector that pulls on the joint making it more difficult for the patient to obtain optimal biomechanics. This recurrent ‘joint stiffness’ will remain until the appropriate myofascial vectors are examined and treated.’

References 1. Lee L-J, Lee D. Techniques and tools for addressing barriers in the lumbopelvic–hip complex. In Lee D (ed.), The pelvic girdle: an integration of clinical expertise and research, 4th edn. Elsevier 2011.

2. Myers T. Anatomy trains: Myofascial meridians for manual and movement therapists, 3rd edn. Churchill Livingstone 2013.

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We know now that fascia plays an important role in health, wellbeing and mobility. It transmits the power of the muscles, communicates with the nervous system and serves as a sense organ. However, many manual therapists are still unfamiliar with fascia and continue to think of it as the ‘dead packing material’.

Mobilization of the Myofascial System (MMS) outlines the theory and pathophysiology of fascial dysfunctions. A full description of the MMS assessment and treatment approach is given as well as guidance on ways in which it may be integrated into the other methods normally used by manual therapists. Subsequent chapters offer full descriptions and colour photos of the MMS techniques. The chapters are organised into various anatomical regions simply to facilitate learning. These divisions are, of course, artificial, as fascia is a continuum, from the top of the head, down to the toes.

Mobilization of the Myofascial System is primarily intended for physical therapists who have been trained in manual therapy, but it will also be valuable for osteopaths, chiropractors, massage therapists, structural integrators and other body workers who are seeking an alternative way to work with this important and fascinating tissue.

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Ligamentous Articular Strain Technique A Reconceptualization and Revitalization of a Classical Osteopathic Manual Technique

By Robert Libbey, RMT

Today’s global Massage Therapy profession is committed to utilizing techniques informed from research and evidence. As science and medicine have advanced, our understanding of human complexities has evolved. Advances in our understanding of anatomy, physiology, neurology, psychosocial factors, pain science, the role of fascial tissues and regenerative therapies demands that we adapt the narratives of our manual therapy applications and how we 46 Terra Rosa E-mag No. 22

manage our patients.

Therapists must rationally integrate this new information into their clinical reasoning, keeping the best interests and goals of their patients in mind at all times. Practicing in this manner has the potential to transform your practice and improve the quality of life of your patients, as I know it has for mine. In this first of two articles, I will explore the research sup-

porting the theory for Ligamentous Articular Strain Technique (LAST) In the second article of this series, I’ll provide a case study documenting the use of LAST in treatment.

A Brief History of LAST At the beginning of my career, I began searching for a more precise and specific technique that targeted ligamentous and joint capsule tissues. My journey lead me to Andrew Taylor Still DO. Ligamentous Articular Strain Techniques originated in the late 1800s.

The majority of the techniques initially developed were called traction methods, known as “Indirect Techniques.” Several of these were Ligamentous Articular Strain Techniques and various myofascial techniques. 22 Throughout the years, William Sutherland DO, Rolin Becker DO and the Dallas Osteopathic Study Group continued to innovate and instruct these techniques. 34 It has been a passion of mine to research and advance LAST, incorporating today’s research on structure, function and neurophysiology. New research directly affects our understanding of all tissues not just the ligamentous articular tissues. My aim is to educate Therapists on a safe, ethical and effective treatment technique, for the treatment of injured ligaments and the surrounding fascial tissues, by providing education congruent with current evidence informed research.

I instruct LAST as a reconceptualization and revitalization of a classical Osteopathic Manual Technique.

In these courses, therapists learn to apply Ligamentous Articular Strain Techniques with a biotensegral and Biopsychosocial (BPS) perspective.

What we know now…

For many years we have been taught that ligaments and muscles were separate structures. Many anatomy texts portray ligaments, cartilage, joint capsules and muscles as separate tissues, which are not connected to the surrounding tissues. However, ligaments are in fact continuous with the fascial connective tissue web that extends throughout the body.

Ligaments are highly dynamic and non-stationary organs. In 2009, Jaap van der Wal stated that ligaments are mostly arranged in series with the muscles, not parallel. There is a joint stability system, in which muscular tissue and regular dense collagenous connective tissue (ligaments/joint capsules) interweave and function mainly in an “in series” situation rather than an “in parallel” situation. 37 Periarticular connective tissues are loaded and stretched during

both concentric and eccentric muscular contractions, like the reins on a horse, constantly assisting the stabilization of a joint, no matter what its position Afferent mechanoreceptors in ligaments/joint capsules of the extremities and in the spine (responsible for kinesthetic and proprioceptive sensation) trigger a ligamentomuscular reflex activation of associated muscles. Muscular activity elicited by this reflex allows muscles and ligaments to work together as a unit, inhibiting muscles that destabilize the joint and increasing antagonist co-activation to maintain joint stability 26, 33 In his articles on fascial plasticity, Dr. Schleip discusses how fascia and the autonomic nervous system are connected and communicate via mechanoreceptors afferent input.29, 30 Research from Schleip & Pelletier recommend that therapists’ change their perspective of treatment from a purely mechanical perspective to one that also is inclusive of nervous system modulation strategies. 23, 24, 29, 30 Fibrous continuities between different tissues enable reciprocal feedback to occur over multiple pathways. Both mechanical and neural pathways provide the central nervous system (CNS) with significant input about dynamic joint positional sense, contributing to the synergistic activation of muscles and providing proprioceptive sensation.22, 29, 30, 33

Understanding Injuries Injuries or influences to the joint’s soft tissues can happen abruptly as in the case of an ankle inversion event, or may occur slowly over a lifetime as with postural changes or diseases such as Rheumatoid Arthritis. The abrupt event can have dysfunctional ramifications that are immediate and recognizable while the long-term dysfunctional influences may be more difficult to perceive. Regardless of either state, autonomic nervous system responses create ineffiTerra Rosa E-mag No. 22

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cient compensatory patterns in order to maintain the joint stability system’s and function.

Within several hours after an injury, acute inflammation sets in and can last from several weeks to 12 months. If the injured tissues are not allowed to rest, recover and heal, chronic inflammation progresses.

33 Even after 2 years, ligamentous healing does not regenerate a normal ligament, but creates scar tissue that has an inferior tissue quality, with changes in biochemical and histologic properties. Permanent disabilities occur when chronic inflammation causes degeneration of the collagen matrix, tissue atrophy and weak and non-functional ligaments. 3, 33, 36 The long-term ramifications of not effectively and immediately managing these injuries are potential damage to capsule, cartilage and tendons, nearby nerves and blood vessels, discs and further potential damage to the ligaments themselves. Full recovery has never been reported when the chronic stage of an injury is left to develop. 33 Chronic instabilities and dysfunctions are known to drastically modify the intra-articular pressure and the muscular activity around the joint, resulting in early onset of osteoarthritis, pain, disability and eventually the need for joint replacement surgery. 2, 36 Injuries to the soft tissues of peripheral joints, play a part in chronic neuromuscular adaptations due in part to a loss of effective messaging from mechanoreceptors to the CNS.12, 19, 21, 33, 37 Peripheral joint injuries disrupt the generation and transmission of adequate proprioceptive input from mechanoreceptors, which can lead to significant joint sensorimotor impairment.9, 11, 12, 19, 21, 31, 33, 40 These dysfunctions influence “executive functions� such as processing of somatosensory information by the prefrontal cortex, causing reorganization of the central nervous system at both the cortical and spinal levels, effecting neural plasticity.9, 11, 21, 23, 24, 40 Neuroplastic changes may help to explain, in part, the transition from acute to chronic conditions.21, 24 Tissue damage is real, and pain/discomfort arising from it is real and complex. How a patient perceives their injury/condition and how therapists communicate with a patient has the potential to affect the rehabilitation process. The more emotionally the brain reacts to the initial injury, the more likely some patients will continue to experience pain after the injury has healed, no structural cause can be determined, and why some patients fail to respond to conservative interventions. 7, 21, 23, 24

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A common Patient perception is that certain activities may potentially cause further tissue damage to their injury/condition extending their recovery process. Dysfunctional changes in a patients biotensegral plasticity, stability and their neuropsychophysiology create the experience of pain, discomfort, impaired interoception, tissue guarding, sensory motor impairment and structural instability. 27, 28 Patients can suffer from dysfunctional thoughts, beliefs, behaviors, emotional factors such as depression, anxiety and take part in fewer healthy social interactions. These catastrophizing behaviors and thoughts can contribute to the production of proinflammatory cytokines which have been shown to worsen the injury/condition and slow the rehabilitation process. 1, 18, 19, 20, 25 The therapeutic relationship between a Therapist and patient has the potential to positively or negatively impact the rehabilitation process. Therapists must recognize that communication utilizing nocebo terminology (having a detrimental effect on health produced by psychological or psychosomatic factors such as negative expectations of treatment or prognosis) can also contribute to the production of proinflammatory cytokines within their patients. Therapists may unknowingly contribute to and or amplify dysfunctional thoughts, beliefs, behaviors and chronic psychological stress of their patients, contributing to the chronicity of injuries and extending the rehabilitation process. 8, 10 Ligamentous/fascial injuries are no longer seen as just simple local musculoskeletal peripheral joint injuries, but as systemic dysfunctions influencing all aspects of their life; from the smallest properties of their physiology to their neuropsychophysiology.

Why Focus on Mechanoreceptor Specific Techniques?

LAST affects the connective tissues of the body, mainly ligaments, joint capsules, fascia, muscles, tendons and indirectly, lymphatic and blood flow and the autonomic nervous system.

Manual techniques that target mechanoreceptors have been proven to affect autonomic functions such as lowering sympathetic nervous system activity, increase local proprioceptive attention, cause a decrease in active muscle tone and affect both the local blood supply and the local tissue viscosity. 6, 29, 30, 31, 32

In a study presented at the Third International Fascia Research Congress, Viklund et al. concluded that specific myofascial receptor techniques might not only improve ROM but also have a longer lasting effect than classical (Swedish) massage techniques.

They suggested that “therapists might be encouraged to aim their soft tissue techniques to a lesser area where there is known to be high density of mechanoreceptors”. 39 Langevin et al. proposed that therapies which briefly stretch tissues beyond the habitual range of motion (massage) locally inhibit new collagen formation for several days, and thus, prevent and/or ameliorate soft tissue adhesions. Manual Therapy has been shown to affect the fibrosis and densification of fascia by changing its tensile status and sliding components. 13,14, 15, 16, 17 Therapists who utilize both bottom-up influences (manual therapy) and top-down influences include cognitive based therapy techniques (positive narrative explanations, Patient education, cognitivebehavioral therapy, mindfulness meditation) can stimulate CNS neuroplastic changes. 23 Treatment approaches that incorporate mechanoreceptor specific techniques have both local and systemic effects on our physiological environment. Therapists have the opportunity not only influence the neuropsychophysiology (thoughts, beliefs and behaviors) of a patient but also modulate the ligamentous/fascial physiology, alter the pain/discomfort perception, improve biotensegral stability, improve interoception and sensory motor function. 17, 29, 30, 35, 38 In the next article in this series, I will present a case study, which incorporates LAST and evidenceinformed research into practice.

For more information about Ligamentous Articular Strain Techniques please go to www.lastsite.ca

References: 1. ANISMAN, H., & MERALI, Z. (2002). Cytokines, stress, and depressive illness. Brain, Behavior, and Immunity, 16(5), 513– 524. doi:10.1016/s0889-1591(02)00009-0 2. Blalock, D., Miller, A., Tilley, M., & Wang, J. (2015). Joint instability and osteoarthritis. Clinical medicine insights. Arthritis and musculoskeletal disorders, 8, 15–23. doi:10.4137/CMAMD.S22147 3. Bouffard NA, et al. (2008) Tissue stretch decreases soluble TGF ß1 and Type-1 pro-collagen in mouse subcutaneous connective tissue: evidence from ex vivo and in vivo models. Journal of Cellular Physiology. 2008;214: 389–395, 2008.

6. Coote JH, et al. The response of some sympathetic neurons to volleys in various afferent nerves. The Journal of Physiology.

1970;208(02): 261-278.

7. Farmer, M. A., Baliki, M. N., & Apkarian, A. V. (2012). A dynamic network perspective of chronic pain. Neuroscience Letters, 520 (2), 197–203. doi:10.1016/j.neulet.2012.05.001 8. Graham, J. E., Glaser, R., Loving, T. J., Malarkey, W. B., Stowell, J. R., & Kiecolt-Glaser, J. K. (2009). Cognitive word use during marital conflict and increases in proinflammatory cytokines.

Health Psychology, 28(5), 621–630. doi:10.1037/a0015208 9. Grooms et al. (2015) Neuroplasticity following anterior cruciate ligament injury: a framework for visual-motor training approaches in rehabilitation. J Orthop Sports Phys Ther. 2015 May;45(5):381-93.

10. Jensen, M. P., & Karoly, P. (1991). Motivation and expectancy factors in symptom perception: a laboratory study of the placebo effect. Psychosomatic Medicine, 53(2), 144– 152. doi:10.1097/00006842-199103000-00004 11. Kapreli et al. (2009) Anterior cruciate ligament deficiency causes brain plasticity: a functional MRI study. Am J Sports Med. 2009 Dec;37(12):2419-26.

12. Karagiannopoulos CKaragiannopoulos C1 (2016) Rehabilitation strategies for wrist sensorimotor control impairment: From theory to practice. J Hand Ther.J Hand Ther. 2016 Apr-Jun;29 (2):154-65. doi: 10.1016/j.jht.2015.12.003. Epub 2015 Dec 12.

13. Langevin HM, et al.(2002) Mechanical signaling through connective tissue: A mechanism for the therapeutic effect of acupuncture. FASEB J. 2001;15:2275–2282.

14. Langevin HM, et al. (2002) Evidence of connective tissue involvement in acupuncture. FASEB J. 2002;16:872–874.

15. Langevin HM, et al. (2005) Dynamic fibroblast cytoskeletal response to subcutaneous tissue stretch ex vivo and in vivo. AmJ Physiol Cell Physiol. 2005;288:C747–C756.

16. Langevin HM, et al. (2006) Subcutaneous tissue fibroblast cytoskeletal remodeling induced by acupuncture: evidence for a mechanotransduction-based mechanism. J Cell Physiol.

2006;207:767–774.

17. Langevin HM, et al. (2007) Pathophysiological model for chronic low back pain integrating connective tissue and nervous system mechanisms. Med Hypotheses. 2007;68:74–80.

18. Lu, Z. W., Hayley, S., Ravindran, A. V., Merali, Z., & Anisman, H. (1999). Influence of Psychosocial, Psychogenic and Neurogenic Stressors on Several Aspects of Immune Functioning in Mice.

Stress, 3(1), 55–70.doi:10.3109/10253899909001112

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19. Melnyk M Changes in stretch reflex excitability are related to "giving way" symptoms in patients with anterior cruciate ligament rupture. J Neurophysiol. 2007 Jan;97(1):474-80. Epub 2006 Aug 30.

20. Miller, G. E., Cohen, S., & Ritchey, A. K. (2002). Chronic psychological stress and the regulation of pro-inflammatory cytokines: A glucocorticoid-resistance model. Health Psychology, 21 (6), 531–541. doi:10.1037/0278-6133.21.6.531 21. Needle AR (2014) Neuromechanical coupling in the regulation of muscle tone and joint stiffness. Scand J Med Sci Sports. 2014 Oct;24(5):737-48.

22. The Osteopathic Cranial Association. (1953). Journal of the Osteopathic Cranial Association.

23. Pelletier et al. (2015) Addressing Neuroplastic Changes in Distributed Areas of the Nervous System Associated With Chronic Musculoskeletal Disorders. Phys Ther. 2015 Nov;95(11):1582-91 24. Pelletier et al. (2015) Is neuroplasticity in the central nervous system the missing link to our understanding of chronic musculoskeletal disorders? BMC Musculoskelet Disord. 2015 Feb 12;16:25 25. Ravindran, A. V., Griffiths, J., Waddell, C., & Anisman, H. (1995). Stressful life events and coping styles in relation to dysthymia and major depressive disorder: Variations associated with alleviation of symptoms following pharmacotherapy. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 19(4), 637–653.doi:10.1016/0278-5846(95)00108-8 26. Sakada S. (1974). Mechanoreceptors in fascia, periosteum and periodontal ligament. Bull Tokyo Med Dent Univ, 21 (Suppl.)

11-13.

27. Scarr, Graham. Biotensegrity:The Structural Basis of Life (p.

85). Handspring Pub Ltd. Kindle Edition.

28. Scarr, Graham. Biotensegrity: The Structural Basis of Life (p.

99). Handspring Pub Ltd. Kindle Edition.

29. Schleip R. (2003) Fascial plasticity – a new neurobiological explanation: Part 1. Journal of Bodywork and Movement Therapies, Volume 7, Issue 1, January 2003, Pages 11-19 30. Schleip R. (2003) Fascial plasticity – a new neurobiological explanation: Part 2. Journal of Bodywork and Movement Therapies.2Volume 7, Issue 2, April 2003, Pages 104-116 31. Schleip R. (2012) Dynamic Body: Exploring Human Form, Expanding Human Function Fascia as a Sensory Organ: A Target of Myofascial Manipulation.

32. Shockett, S., & Findley, T. (2018). Findings from the Frontiers of Fascia Research Insights into “Inner Space” and Implications for Health. Journal of Bodywork and Movement Therapies.doi:10.1016/j.jbmt.2018.12.001 33. Solomonow M. (2009) Ligaments: a source of musculoskeletal disorders. Journal of Bodywork and Movement Therapies, 2009;13(2):136-54. Retrieved from http://www.ncbi.nlm.nih.gov/ pubmed/19329050 34. Speece CA, et al. (2009). Ligamentous Articular Strain: Osteopathic Manipulative Techniques for the Body (Revised edition).

Seattle, WA: Eastland Press.

35. Stecco et al. (2014) Fibrosis and Densification: Anatomical vs Functional Alteration of the Fascia. Fourth International Fascia Research Congress: Basic Science and Implications for Conventional and Complementary Health Care. Munich, Germany: Else50 Terra Rosa E-mag No. 22

vier GmbH. 36. Stilwell D. (1957). Regional variations in the innervation of deep fasciae and aponeuroses. The Anatomical Record, 127(4), 635-653.41 37. 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. International Journal of Therapeutic Massage and Bodywork. 2009 Dec;2(4).

38. Vigotsky, A. D., & Bruhns, R. P. (2015). The Role of Descending Modulation in Manual Therapy and Its Analgesic Implications: A Narrative Review. Pain Research and Treatment, 2015, 1– 11.doi:10.1155/2015/292805 39. Viklund P. (2012) Comparison of ankle joint dorsiflexion after classical massage or specific myofascial receptor massage technique on the calf muscle. Third International Fascia Research Congress: Basic Science and Implications for Conventional and Complementary Health Care. Munich, Germany: Elsevier GmbH. 40. Ward et al. (2014) Neuromuscular deficits after peripheral joint injury: a neurophysiological hypothesis. Muscle Nerve. 2015 Mar;51(3):327-32

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Research Highlights The energy expenditure of massage therapists Massage therapy can be considered hard work, as performing massage requires lots of energy. However, there is no objective measure yet on how many calories are used in a course of treatment. Researchers from Poland evaluated the intensity of the effort and energy expenditure in the course of performing selected classical massage techniques.

Thirteen massage therapists (age: 22±1.9 years old, average 76±11 kg) were recruited. The stress test consisted of performing selected classical massage techniques in the following order: stroking, kneading, shaking, beating, rubbing, and direct vibration, during which the cardiorespiratory responses were measured.

The results indicated that the intensity of performing massage was: • 47% in terms of % VO2max (maximal oxygen consumption) • 75% in terms of % HRmax (maximal heart rate) • 48% in terms of % HRR (heart rate reserve) during the whole procedure. While performing the classical massage techniques, the energy expenditure was:

The study which involved more than 200 participants was published in the Journal of General Internal Medicine. The study was a randomised control trial conducted at multiple sites where massage was compared to light-touch and usual care in adults with knee osteoarthritis. The treatment was a 60-minute full-body massage following a standard protocol or light-touch. There were 222 adults with knee osteoarthritis enrolled in the program, 200 completed 8-week assessments, and 175 completed 52week assessments. Participants in massage or light-touch groups received eight weekly treatments, then were randomised to biweekly intervention or usual care to week 52. The original usual care group continued to week 24.

Assessments were at baseline and weeks 8, 16, 24, 36, and 52.

Based on the data, the researchers calculated that the average energy expenditure of a therapist performing a session of massage is 336 ± 56 kcal per hour. This amount of energy is equivalent to running for half an hour or a distance of 5 km. For a therapist working five hours per day, this is about 1700 kcal per day. This work is classified as hard work according to a classification of work intensity.

At eight weeks, massage significantly improved pain score, called Western Ontario and McMaster Universities Arthritis Index (WOMAC), compared to light-touch and usual care. Massage also improved pain, stiffness, and physical function of WOMAC scores compared to lighttouch and usual care. At 52 weeks, there was no significant difference in change across groups. Adverse events were minimal. The authors concluded that weekly massage is effective as a symptom relief, which makes it an attractive short-term treatment option for knee osteoarthritis. Longer-term biweekly dose maintained improvement but did not provide additional benefit beyond the usual care post-8-week treatment.

Weekly massage effective in reducing pain from knee osteoarthritis

Massage therapy for managing depression: Restoring impaired interoceptive functioning

Massage is a safe and effective complement option to manage knee osteoarthritis. Researchers from Duke University Medical Centre conducted a study to examine the effects of whole-body massage on knee osteoarthritis.

Massage therapy is known to induce relaxation and provide emotional support for people suffering from depression. There is also an increasing amount of studies that show that massage therapy could significantly alleviate

• net energy expenditure (EE) 5.6±0.9 kcal per minute • metabolic equivalent of task (MET) was 5.6±0.2.

• Rubbing was the highest intensity exercise.

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Research Highlights symptoms of depression. However, the mechanism of the anti-depression effect is still unclear. Concurrently, manual therapists now recognise the importance of interoception, an individual’s sense of the physiological condition of his/her entire body. It comprises the sensation, interpretation, and integration of signals arising from within the body.

Researchers from Ulm University, Germany, proposed a mechanism linking the anti-depressive effects to a massage-induced modulation of interoceptive states. The study was published in Medical Hypotheses. The researchers looked at affective massage therapy, which is massage therapies aiming to influence affective states rather than targeting muscles or manipulating fascial tissues. The type of massage techniques commonly used long strokes and caress-like touches such as effleurage. Affective massage therapy applies slow, rhythmic, and caress-like touch that stimulates C tactile (CT) afferents in the nonglabrous (without hair) skin.

Non-glabrous skin contains numerous mechanosensitive receptors, which give rise to perceived pleasantness in response to slow, rhythmic, and caress-like touch. CT mediated touch elicits responses in interoceptive brain areas (e.g., the insular cortex) that have been associated with abnormal interoceptive representations in people suffering depression.

Thus, the authors hypothesised that the anti-depressive effects of massage therapy are mediated by the restoration of the impaired interoceptive functioning through the stimulation of CT afferents or related interoceptive structures. This hypothesised mechanism supports that massage is probably one of the most ancient interoceptive treatments.

Foam rolling increases range of motion without altering muscles’ morphology Foam rolling is an effective tool for improving the range of motion (ROM). Many studies have shown foam rolling could increase ROM of the hip, knee, and ankle without impairing muscular strength. Theoretically, pressure stimulation is expected to change the morphology of the muscle and fascia (i.e., reducing thickness, adhesion, and tension). Some studies reported a 24 per cent decrease in stiffness in the anterior thigh tissues and a 42 per cent increase in the thoracolumbar fascia mobility after foam rolling. Thus, it was hypothesised that foam rolling might increase ROM because of changes in fascicle length and aponeurosis displacement.

Robert Schleip and colleagues investigated this hypothesis in a study published in Journal of Strength and Conditioning Research. A crossover study, involving 22 male university students, compared foam rolling on the gastrocnemius muscle with a control. The foam rolling group performed three sets of 1-minute foam rolling with a 30second rest between each set targeting the right medial head of the gastrocnemius muscle.

Results showed that foam rolling significantly increased ROM of both dorsiflexion and plantar flexion.

However, there is no observed changes in fascicle length and aponeurosis displacement. The mean perception of pain of foam rolling was ‘slightly uncomfortable’, implying that foam rolling could increase ankle ROM without causing uncomfortable and excessive pain. The authors hypothesised that the increase in ROM may be due to the autonomic nervous system response. Schleip reported that Ruffini bodies exist within the connective tissue, which could be activated by stimulation combining tangential forces and stretch. As a result, the phenomenon led to a more parasympathetic state as well as a lowering sympathetic activity, alteration in muscle tones, tissue viscosity, and reduction of intrafascial smooth muscle cells.

Interestingly, plantar flexion and dorsiflexion ROM improved, although the foam rolling was on the triceps surae muscle, which is an agonist muscle of ankle plantarflexion. It was speculated that this effect is due to the neurological modulation, which is commonly called the crossover effect. The authors questioned that foam rolling is called self ‘myofascial release’ as it does not affect myofascia morphology. They concluded that future work will need to consider the neurophysiological mechanism.

PEACE and LOVE for Soft Tissue Injury We are familiar with RICE for handling soft tissue injury.

Rest, Ice, Compression, and Elevation are suggested as the first treatment of injuries. Over time, other acronyms have been suggested and added: PRICE, POLICE, MICE, including ‘Avoid HARM’ (Heat, Alcohol, Reinjury, Massage). Blaise Dubois and Jean-Francois Esculier from Canada mentioned that RICE and other similar treatments only focus on acute management but ignore chronic stages of tissue healing. They proposed two new acronyms for the rehabilitation of soft tissue injury: PEACE for immediate care and LOVE for subsequent management.

P for Protect: avoid activities that can increase pain during the first few days after injury. Rest should be minimised as prolonged rest can compromise tissue strength and quality.

E for Elevate: the limb higher than the heart to promote interstitial fluid flow out of the tissue.

A for Avoid: anti-inflammatory medications.

C for Compress: external mechanical pressure using taping or bandages helps to limit intra-articular oedema and tissue haemorrhage.

E for Educate: therapists should educate patients on the benefits of an active approach to recovery.

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Research Highlights After the first days have passed, soft tissues need LOVE:

chains:

L for Load: an active approach with movement and exer• the ventral arm chain (pectoralis major, brachial fascia/ cise benefits most patients with musculoskeletal disorders. biceps brachii, flexor carpi ulnaris/brachioradialis/ supinator, based on five studies); O for Optimism: the brain plays a key role in rehabilitation interventions; therapists should encourage optimism on • the lateral arm chain (trapezius, deltoideus, lateral interoptimal recovery. muscular septum/brachialis, brachioradialis, four studies); and V for Vascularisation: pain-free physical activity that includes cardiovascular components should be started a few • the dorsal arm chain (latissiumus dorsi/ teres minor/ days after injury to boost motivation and increase blood infraspinatus, triceps brachii, anconeus, extensor carpi flow to the injured structures. ulnaris, six studies).

E for Exercise: to restore mobility, strength, and proprioception early after injury.

Effects of myofascial release of the diaphragm on acid reflux condition Gastroesophageal reflux disease (GERD), also known as acid reflux or heartburn, is a digestive disorder, where stomach acid frequently flows back into the oesophagus, the tube that connects the mouth and stomach. Current standard medical treatment includes the administration of proton pump inhibitor drug (PPIs). Long-term consumption of PPIs can have negative side effects.

A study from Spain looked at the effect of myofascial release (MFR) of the diaphragm protocol on patients with acid reflux condition. The study involved 30 patients with GERD who were randomised into an MFR group or a sham group. The MFR group received a myofascial release of the diaphragm protocol consisting of four 25 minute sessions (twice a week for two weeks).

Results showed that at week 4, patients receiving MFR showed significant improvements in symptomatology, gastrointestinal quality of life, and decrease in PPI use when compared to the sham group. The authors hypothesised that MFR improves diaphragmatic mobility and visceral fascial mobility. Considering that optimal phrenoesophageal membrane slip is necessary for correct antireflux barrier function, applying MFR treatment may improve the function of the crura of the diaphragm– oesophagus sliding component.

Evidence of myofascial chains of the upper limb Myofascial chains or myofascial meridians describe the continuity between skeletal muscles and myofascial inseries. Their presence has been confirmed via scientific evidence in the trunk and lower extremity. Researchers Jan Wikle and colleagues try to see if the research literature has identified the myofascial chain in the upper limb or shoulder-arm region. The study was published in Clinical Anatomy journal.

The researchers looked through peer-reviewed anatomical dissection studies reporting myofascial in-series continuity in the upper extremity and found 13 studies. Analysis of these papers led to the identification of three myofascial 54 Terra Rosa E-mag No. 22

There is good evidence for direct serial tissue continuity extending from the neck and shoulder region to the forearm.

The authors concluded that despite this intriguing finding, which could have implications for health professionals and the treatment of musculoskeletal disorders, further research is needed to establish the mechanical relevance of the identified myofascial chains.