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