Fascial Manipulation

Today’s guest post is written by Larry Steinbeck, PT.  Larry and I have been talking about Stecco and his Fascial Manipulation book for some time now.  I have both books and must say they are fascinating.  It is a great way to look at the body and to combine the thought process of the kinetic chain and manual therapy.  For those familiar with Anatomy Trains, this is pretty similar.  I find that Anatomy Trains is a bit more geared to the clinical application side, while these books are geared more towards deeper understanding of fascia.  If you have read and enjoyed Anatomy Trains, this is the recommended next book for you.

imageA month ago I had the opportunity to participate in a course presented by the Fascial Manipulation Association in Italy. They present coursework based on the studies and research of Luigi Stecco, PT. This was the first time that the full course was presented in English. Over the past several years this group has presented twice at the the Fascia Research Congress, 2007 in Boston and 2009 in Amsterdam. They have published on fascial research, histology and treatment with 35 indexed articles. I stumbled on their research while continuing my studies on trigger points and myofascial sources of pain. 6 months or so ago I contacted Mike to see if he had read any of Fascial Manipulation. The book describes a unique biomechanical model for movement assessment and treatment of dysfunction.

 

The Myofascial Unit

imageTheir theoretical concepts have moved away from a strictly muscle insertion and origin viewpoint where a muscle moves a bone/joint, towards a function of a myofascial unit. A myofascial unit is described as group of motor units that activate mono and biarticular fibers that can move a body segment in a specific direction. This includes the joint moved, the nerves and circulatory system and the fascia that connect it all. They look at fascia as more than just a containment vessel, but looking at past and present research, fascia has a role in movement perception and force transmission.

As an example, they cite studies that show that up to 40% of force generated by a muscle contraction is not directed toward the origin and insertion of the muscle, but rather is transmitted to agonistic and antagonistic muscles through endo-, epi- and perimysium. It has been speculated that this force transmission coordinates motor function by stimulation of muscle spindles. Stecco has postulated that the force transmission through the fascia has centers of coordination, where vector forces converge in a given movement pattern. Through his practice and study he noted that many of these centers have commonality with myofascial trigger points as described by Travell, as well as, correlation to acupuncture points.

 

Fascial Manipulation

clip_image004This method presents an evidence based framework for symptoms associated with myofascial pain, as well as, developing an assessment based on myofascial continuity and centers of coordination.

The assessment and treatment are quite thorough and logically based, and are quite unique. The past several years we have read in PT literature about “regional interdependence”. This model takes that concept to the next level. Movement is looked at locally as well as globally with each assessment. They have demonstrated in their studies the fascial continuity between upper limbs, trunk and lower limbs in a way unique to them. Whether it was their original intent or not, I see how other concept/model can be explained even deeper through the eyes of fascial manipulation biomechanical model-this includes my experience with studying Travell, Elvey/Butler, Lewit/Janda, Mulligan and Knott/Voss. The concepts may take a while to understand and conceptualize. It is definitely worth a look at their texts, articles or even one of their courses. As for me, I am looking forward to be heading back to Italy in September for the second of three courses in the series.

 

Case Studies

I would like to present 2 recent cases that hopefully will give a more practical representation of the theories presented by Stecco and the Fascial Manipulation Association.

The Fascial Manipulation Association places a great deal of emphasis on history taking. This will include present site of pain, any other present pain (things that I normally would brush off like a patient who comes to the clinic with a diagnosis of cervical arthritis, but also notes knee pain on their intake form). History taking also ask about historical injury/pain-pain that may not be at present, but may have occurred in the past and may have not healed in a normal physiologic time frame,( i.e. a sprained ankle “took months to get over”). There is interest in movements that cause the present pain. History will be taking on past surgeries-anywhere, past fractures, visceral problems, and any parasthesias. (A headache might be considered a parasthesia.) They use this history to develop a hypothesis for segments/myofascial units that might be involved and to establish movement assessment that needs to be undertaken. Below are two recent cases in our clinic that were previously treated in other clinics with no resolution of symptoms.

Case Study 1 – Hip Causing Neck Pain

imageFemale, age in the mid 40′s with 6 month duration right sided cervical pain.  She had received 7 visits over 4 weeks of PT consisting of moist heat, electrical stimulations, cervical, and thoracic manipulations. Symptoms overall had not changed. Primary complained of pain while talking on the phone and turning head to look out rear window in the car. Limitation with cervical sidebend and rotation to the right, but some symptoms to the left as well. No other present pain reported at this time. She had a history of L hip “bursitis” that persisted for 6 months prior to resolution.  Prior treatment had included 2 injections and 6 PT visits. No other history reported.

Fascial manipulation in this case would be directed to look at 2 segments – cervical and hip. Assessment will be made through all planes in both segments. In this case there was a limitation in strength and mobility of the left hip abductors only. The assessment leads one to believe that there is consistent limitation in mobility, either strength or range of movement, in the frontal plane. Based on this finding, treatment would be directed to the myofascial units involved in hip abduction and cervical side bending to the right.  The theory would be that the older injury can quite possibly cause compensation in other areas of the fascia system, and that these compensations may lead to pain/dysfunction. For this reason, the hip was addressed first. Treatment to the hip myofascial units for abduction, resulted in 75% decrease in pain during right cervical sidebend.

Treatment was next direct to the cervical segment for sidebend right. This resulted in 90% decrease in pain with right sidebend.  One week later symptoms were still 75% improved. Each visit a new assessment was made to determine segment and the unit to be treated. Visits were planned for 1 week apart. After 3 visits there was a 95% improvement. Limitation persisted with”tightness” for looking out the car rear window, but no pain with activities.

 

Case Study 2 – Ankle Cramps and Back Pain

72 year old female with 3 year history of bilateral leg pain,”sciatica”, with a diagnosis of lumbar degenerative disc disease and spinal stenosis. She had been treated medically with NSAIDs, and an epidural injection, as well as traction and HVLA manipulation from a local chiropractor. Primary complaints pain worse at night, “cramps in both my calves.” Also has pain in central lumbar/sacral junction, and in right buttock. Pain is reported as intermittent, worse with activity, primarily with ascending stairs. No other concomitant pain noted. No history of surgeries or fractures.

Based on movements that patient reported as painful and the body areas reported as painful, hypothesis was made to look individually at the lumbar spine, pelvis and both ankles (lower leg). Movement assessment was made for three planes of movement in each segment. Calf pain and low back pain were reproduced with movement test for the posterior myofascial units of the calves.  Low back pain was reproduced with the test for posterior myofascial units. These movements were on the same plane, so treatment was directed to the posterior components. The patient thought that she had the “cramps” in both her calves “years” before she ever had any low back pain.

Treatment was directed to the calves first. Movement assessment following the treatment to the claves resulted in no symptoms present in the lumbar region or pelvis and no pain with the movement reassessment.  The patient was given a home program. At the one week follow up visit, she reported no cramps since initial visit, but still had 1/10 low back pain. No change in ability to ascend stairs without increasing low back pain. Reassessment demonstrated continued problem in the post myofascial unit in the lumbar region, but also in the anterior hip myofascial unit. Treatment was directed toward the posterior lumbar and anterior hip components (the same planes of movement). No symptoms in lumbar region following treatment.

During the follow up one week later, no pain in lumbar region with general activity was noted, no further occurrence of night cramps, but still has pain with ascending stairs. Reassessment revealed limitation in ant hip myofascial unit. Treatment directed here along with progression of home exercises. One week later, no symptoms reported with ascending stairs, no low back pain with general activity, and no night cramps.

With this patient’s history and diagnosis, I would have previously most likely considered traction and unweighted gait training, lumbar “stabilization” program, and maybe another attempt at HVLA manipulation or graded joint mobilization.

 

More Information

This method provided another means to assess dysfunction through a logical, well thought out, and reproducible method. If this method piques your interest, I would recommend reading both of Luigi Stecco’s books, Fascial Manipulation for Musculoskeletal Pain and Myofascial Manipulation: Practical Part,

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About the Author: Lawrence (Larry) Steinbeck, PT is a physical therapist at the Atlanta Falcons Physical Therapy Center in Jasper, GA.

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19 Responses to “Fascial Manipulation”

  1. Do you have a valid and reliable method for discovering and identifying fascial restrictions or adhesions? I assume you are aware of the extensive research existing in the literature demonstrating the poor reliability and questionable validity of spinal motion palpation/manual spinal diagnosis.

    if indeed a soft tissue contracture can be identified, can the forces provided by manual therapy or exercise be of sufficient force, duration, and direction to change the tissue, given what we know of human physiology? I would refer you to Threlkeld's excellent article in 1992 in the journal "Physical Therapy" for the background on the basic science of this issue.

  2. Anony – I see it in one of two ways – you can avoid things that we don't really understand or you can listen to the patients and do what works. My goal is to blend both to be as effective and safe as possible. I'm as evidence based as you get – I practice, teach, and contribute to evidence based medicine, but I also realize that we really don't have all the answers and probably never will. We don't truly understand the human body, as much as sometimes think we do, just my opinion. Remember the world used the be flat, that wasn't that long ago, who knows maybe its not round either!

    What does everyone else think?

  3. Mike
    I'm with you on this one. Science lags behind practice–we would never progress if all we practiced were the handful of proven things. This bothers me with EBM that practitioners can be so handcuffed by research that they fail to see whats sitting in front of them. We will probably never be able to understand or study the body fully or even the variability in the body's systems–our own biases interfere.
    I've taught gross anatomy and, you're right, the one thing we thought we know (the body) we really don't know. Some recent publications on fascia have really reinforced my views on how we are put together, and changed my views on what fascia is made of. I don't think there is a neat compartmentalized way to assess this (and then study it and call it valid). Individuals will all carry different patterns and the clinical judgment and observation skills are your friend.

  4. Great blog today, Mike. Thanks to Larry for sharing his case studies.

    I agree that we don't have all the answers and probably never will.

    If clients (I'll say clients and not patients since I am not a PT) come in and receive this kind of work and get better does it matter what we call it? I can tell you that the client doesn't care one bit! Perhaps nothing happens with regard to the fascia when we impose these techniques on people. Perhaps the big change happens in their brain, as the preceive a positive change, and this makes them feel bette (think baby skinning their knee on the ground and mommy kissing the boo-boo and the pain goes away and the kid stops crying). Some of Schleip's (sp?) research looks at these things with regard to fascia and developing hypotheses for why manual soft tissue therapy works based on what we currently know about physiology.

    Patrick

  5. I'm not disputing the outcomes. With the research identified above, It is unlikely we are able to inflict a structural change to underlying tissues, considering our first point of contact, skin.

    I agree along the line of Patrick's reasoning, where we are most likely influencing the nervous system to make these dramatic effects. Think Neuromatrix.

  6. Anony- Palpation is a skill, and I think it's a bit like throwing the baby out with the bathwater if we say that we should discount or ignore motion or static palpation completely based on the current literature.

    Most of the studies designed to determine whether or not palpation is reliable, really only truly tested the reliability of those practitioners who were performing the palpation in the study. I haven't read any study that stated how often the testers actually utilized palpation in clinical practice. For all we know, they could have been researchers who haven't laid hands on a patient for years. Like any other skill, palpation takes time to develop.

    Palpation is also just a piece of the diagnostic puzzle, we can't simply rely on palpation alone to find a restriction, we have to watch the patient move, and understand how the body compensates around or through those restrictions to truly understand their dysfunction and how to properly apply treatment.

    I don't discount the fact that the nervous system has a profound influence on patient response, but I find it hard to believe that the nervous system has exclusive governance over the response to a given treatment.

    I would have to say positive patient outcomes are a combination of dysfunction reduction, the nervous system's response to the intervention and the patient's belief that they are receiving something that will get them well.

  7. Anonymous
    Thanks for your comments. What gained my interest in this area of study is the fresh look that Stecco has applied to fascia and it's roll in treatment. He did not take an esoteric concept of fascial treatment, but has used a scientific approach from the fields of physiology and physical therapy to expand his hypotheses. There has been plenty of research of late that shows that fascia play a part in pain mediation. Whether you look at the work of Langevin and her studies on fibroblast changes following a needle insertion-intramuscular manual therapy or the work of Huijing on the role of fascia in proprioception. Also, present research at the Univ of New Jersey (unpublished) has demonstrated that with deep pressure there is an increase in hylaronic acid found in the extracellular matrix between the deep fascia and the epimysium. HA presence allows for gliding between the tissues. One of Stecco's hypotheses is we are changing the relationship between the fascia and the underlying muscle to permit normal gliding and thus restore proprioception. Just some quick thoughts, there is a lot of room for discussion on fascia's role in pain causation and our role in rectifying it.

  8. "fascia's role in pain causation and our role in rectifying it."

    I can only suppose that you have not been made aware of the neuromatrix model as it relates to pain? Melzack's model.
    At this moment the most important tissue in the "causation" of pain is the human brain where the experience of pain is created. Fascia can at best play a small role in the peripheral triggering or inhibition of possible nociception (the existence of which by itself is hard to prove in a clinical practice).
    Any gentle manual technique is likely to provide relief. Outcomes are not an issue here. The explanatory model is.
    Anonymous 2

  9. Agree with the above Anonymous. Here's a link to a must read for anyone jumping on the latest bandwagon of manual approaches, neglecting to consider the nervous system.

    http://www.somasimple.com/forums/showthread.php?p=95314&posted=1#post95314

    In fact, this whole forum is worth some lonely Saturday nights of reading through various posts and literature references. Disclaimer, I am not affiliated with the aforementioned link, nor am I the author of the post.

    Anonymous 1

  10. Great discussion, even with a couple of Anony's! Personally, I think we are being really short sighted to not consider the role of various structures in pain, function, etc. The research that is slowly coming out on fascia sure is interesting.

    I'm not a huge fan of myofasical release, and i can see the skepticism, however the Fascial Manipulation and Anatomy Trains concepts make nothing but sense.

    I have used these concepts to help understand how various parts of the body influence another. I seldom "treat the fascia" but realize that when I stretch, strengthen, manipulate, massage, etc a certain area it is going to have an impact on tissue elsewhere.

    I have a bigger question to ask the group, why resist? I'll agree with @Chris, who nicely stated that it is all in our own individual skills. Try it, if it doesn't work for you, move on. But why resist? I call it avoid treatment tunnel vision. It's all about making patients/clients/athlete feel better and get back to living, right?

  11. Some great discussion, I hope because I was off internet for a few days, that my comments aren't missed out by those that have already made some great points.

    Mike, first interesting thing about the world being round. Actually it was probably discovered more than 3,000 years ago by the Persian's or Babylonia's and most people in Hellenistic Greece saw the world as a sphere. Interesting how misconceptions can persist beyond when science has proven otherwise. Just like the spinal subluxation theory, science has shown this doesn't happen – yet many still believe in it. So sometimes science doesn't lag behind practice, but practice lags behind science.

    Patrick, if they get better does it matter what we call it? Well we might be calling it placebo and then question is should someone pay for that? I agree that mauch of the change may be happening in the brain.

    Chris, I agree we need to be careful not to throw the baby out with the bathwater. But what if there is no baby in the bathwater? We have to remember placebo is something we have to consider. Palpation is a skill, but is it possible we deceive ourselves as well with palpation into thinking we are feeling a "baby" when it might not even be there, or maybe isn't that important and may be normal? I'm not agreeing or disagreeing, just saying it may be something we need to consider to stay objective and critical in our thinking. But I do think the nervous system does have goverenance over everything we do. I've yet to see a muscle contract or a joint move without nervous input. Unless your brain brings nociception into consciousness, you won't feel pain. That is why I have worked in the yard and cut my hand and did not notice it until later when I saw the blood. I'm sure the tissues sent nociceptive input but my brain and nervous system did not see it as a threat so it was not brought to my consciouness until my eyes (actually the optic nerve) brought the info to my brain. So I do believe the nervous system governs everything, I will need some proof or examples that it doesn't.

    Larry, you make some interesting points and I will need to investigate those more. The one hurdle I run into is that I can't touch fascia. I can touch skin and know I am stretching skin. But I can only guess what is happening, if anything, is actually going on underneath the skin. I have yet to peel off anyone's skin and work on fascia directly. That is why I have been more interested in dermoneuromodulation as a better explaination to what might be happening.

    I hope the discussion continues, because according to our code of ethics as PTs we need to make sure we are not making claims to patients that could be false.
    2C. Physical therapists shall provide the information necessary to allow patients or their surrogates to make informed decisions
    about physical therapy care or participation in clinical research.
    4A. Physical therapists shall provide truthful, accurate, and relevant information and shall not make misleading representations.

    So even if techniques work we need to be careful how we are presenting the info to our patients as theory, evidence based, science based or just our best guess.

  12. "I don't discount the fact that the nervous system has a profound influence on patient response, but I find it hard to believe that the nervous system has exclusive governance over the response to a given treatment."

    Actually, it does. This is why an individual who has had chronic pain can report 10/10 pain with gentle palpation and a person who has their arm stuck in a rock can saw their arm off with a pocket knife…

  13. Not that mechanical factors or various anatomical structures do not influence of affect the onset, development, or resolution of pain. But, pain is always a nervous system dysfunction. Granted in this forum, we are usually talking about athletes which most likely have a truer, but not totally, tissue damage, nocicpetive cause of pain. But, that doesn't mean their response to treatment is dependent upon the tissues we "think" we are targeting, stretching, moving, or affecting.

    Especially with manual therapy, no matter what you call it we are ALWAYS affecting the nervous system, it is relatively unknown what we are doing to other tissues…

    [And yes, it absolutely does matter what we call it...]

    The neuromatrix model of pain and pain neuroscience and phsyiologic research always need to be considered when considering pain and pt. response to pain.

    A great blog dealing with pain science and research: http://bodyinmind.com.au/

    [Not the author, not affiliated]

  14. "Science lags behind practice–we would never progress if all we practiced were the handful of proven things."

    Practice also lags WAY behind science/latest research…by about 7-12 YEARS. Further, most clinical practice guidelines (in both medicine and PT) are not routinely followed. Take low back pain as example (from either a physician or PT standpoint).

    So, there seems to be a disconnect between the everyday clinician and the scientist/researcher and the literature…

  15. I do really think that pain is in the brain.
    I agree that "the most important tissue in the "causation" of pain is the human brain, where the experience of pain is created".

    But the role of Fascia in pain, I think, is another one.
    As we know from recent research, the Fascia is the tissue of the body richer in nociceptors and propioceptors.
    In addition, recent investigations have shown the role of connective tissue in the coordination of movement (of course, under supervision of the Nervous System).

    So, let's try to normalice the Fascia, just try to leave noci/propioceptors carry out their work properly, let's try to normalize the tension in the joints, and then, let the brain decide if he will project pain or not.

    As PTs, I think this is a possibility of work: to normalize the body's structures in order to turn off noxiousness ("nocivity" I think doesn't exist in english) signals to the brain.
    In my experience, working on the fascia, and in particular with Fascial Manipulation can be an interesting option to achieve this goal, given the histological composition, biomechanical properties, and continuity of this tissue over all structures of the body.

  16. @ Kory – great contribution and lots of great points. Your thoughts on the neurological contribution certainly make sense and can't be ignored.

    @ Kyle – thanks for all your comments, you make excellent points regarding the neuro influence, you are right!

    @ Miguel – you do bring up a good point regarding all the pain receptors within the fascia, these have to be related and an issue with some chronic pain perceptions.

  17. Phillip Snell, DC Reply March 16, 2011 at 11:43 pm

    For those interested, Luigi’s son, Antonio Stecco, MD is now teaching this technique in the US. Info at FascialManipulationWorkshops.com and there’s also an interview with Warren Hammer on YouTube.

  18. Dr. Tim Jackson, DPT Reply June 16, 2011 at 6:12 pm

    No Anony., research mostly serves to elucidate the mechanisms behind what we are doing in the clinic. Success leaves clues. Look at NFL teams with unlimited budgets for healthcare providers. Do they choose neuromatrix providers? Nope, they almost always look for ART certified providers. Because IT WORKS! And yes there is research to support fascial manipulation. Is it in the APTA journals? Of course not, it’s in the histology journals, cell and molecular bio. journals and chiro journals. Besides who are we to argue with Dr. Reinold, one of the most influential DPTs of our time.

  19. The author states:

    “I see how other concept/model can be explained even deeper through the eyes of fascial manipulation biomechanical model-this includes my experience with studying Travell, Elvey/Butler, Lewit/Janda, Mulligan and Knott/Voss.”

    Does anyone know what he means by this especially as it relates to Mulligans work?

    Second question is on the two Stecco books, if you are buying just one then which is better for a clinician?

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