www.terrarosa.com.au Open information for Bodyworkers No. 19, December 2016
Photo by Patty Kousaleos
Sciatic Pain, Changing your Story, The Thoracis Spine.. The Silent Saboteur, Does Cupping Enhance Sports Performance?, Experience in Rio 2016, Growing Hands with Myofascial Therapy, The Walking Cycle and Its Relationship to the Pelvis, Iliotibial Band, An Interview with Christopher-Marc Gordon, Myofascial Self-Help Therapy with a Mini Foot Roller, Sacral Neurons Reassigned to Sympathetic
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Terra Rosa E-magazine, Issue No. 19, December 2016.
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ontents Cover: Taso Lambridis. Photo by Patty Kousaleos
Sciatic Pain—Til Luchau Changing Your Story—Walt Fritz The Thoracic Spine... The Silent Saboteur— Joe Muscolino Does Cupping Enhance Sports Performance?— Romy Lauche My Experience in Rio 2016 Olympics — Ali Rubie Growing Hands with Myofascial Therapy The Walking/Gait Cycle and Its Relationship to the Pelvis—John Gibbons Iliotibial Band– A piece of the body from a body in pieces A Clinical Anatomists View —John Sharkey An Interview with Christopher-Marc Gordon Myofascial Self-Help Therapy with a Mini Foot Roller: A Plantar Fascia Study—Christopher-Marc Gordon et al. Sacral neurons reassigned to sympathetic Comments by Til Luchau & David Lesondak Research Highlights Six Questions to Taso Lambridis Six Questions to John Gibbons
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Sciatic Pain by Til Luchau
Figure 1. The origins of the sciatic nerveâ&#x20AC;&#x201D;the largest and longest nerve in the body. Pain results when its nerve roots are compressed where they exit the lumbar spine (axial sciatica) or when it is entrapped distally by other structures (appendicular sciatica). The dura (aqua color), psoas (green), and piriformis (red) are some of the structures that can contribute to sciatic pain. Image courtesy Primal Pictures, used by permission.
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Sciatica is a real pain in the rear—not just for the individuals who experience it, but collectively, for society as a whole . Although estimates vary, studies indicate that up to 43 percent of people experience sciatic pain at some point in their lives . Sciatica can also be a pain for manual therapy practitioners. Sometimes, sciatic pain responds quickly; other times, it seems intractable, and it can even worsen in response to handson work. As a practitioner, how do you determine which approaches are most likely to be helpful? In this article, we will take a look at straightforward and relatively reliable assessments for differentiating between the two types of sciatic pain; we will discuss important considerations for working with the axial type; and also will look at some techniques used for relieving the second appendicular type. Much of sciatica’s ubiquity and variability comes from the broadness of the term. Originally derived from “ischialgia,” meaning pelvic or ischium pain, sciatica has come to mean any pain involving the lower back or buttocks that radiates down the posterior leg. Sciatica is a symptom, not a diagnosis; there are many possible causes of sciatic pain, and knowing how to distinguish between its different types will allow you to be far more effective in your work (and it will help you know when to refer to a specialist). One thing is common to all sciatic pain: it is nerve pain, and so it can be radiating, shooting, sharp, tingling, or numb. Sciatic pain involves an irritating mechanical force on a nerve, usually somewhere along the neurons (nerve cells) that make up the sciatic nerve (usually because irritation of the other nerves can sometimes radiate to the sciatic nerve distribution area as well).
Assessing Sciatic Pain Sciatic pain can be described as one of two types, as outlined in Table 1: Axial sciatica arises from compression on the
nerve roots at the intervertebral foramina of
Figure 2. Protruding or degenerated intervertebral discs (green) or the dura (aqua color) can impinge the nerve roots where they exit the spinal canal, resulting in axial sciatic pain. Image courtesy Primal Pictures, used by permission .
nerves L1–S3 . Appendicular sciatica is pain from nerve entrap-
ment distal to the nerve roots. The first type, axial sciatica, involves narrowing of the foramina (the openings between the vertebra where the peripheral nerves exit the spinal canal; Fig. 2). This narrowing can result from: Postural or positional issues—for example, the
postural strain of later-term pregnancy, sacral instability, or spondylolisthesis (the instability and anterior shift of a vertebra on the one below Terra Rosa E-mag No. 19
Table 1. The 2 types of Sciatica pain.
I. Axial Sciatica Also known as...
II. Appendicular Sciatica
Type II, “Pseudosciatica”, Piriformis Syndrome, etc.
Distal to nerve roots
Bone-to-bone or disc-to-bone compression
Myofascial compression or neurofascial tethering
Low back pain
Posterior thigh and/or buttock pain
Pain distal to knee
it, narrowing their intervertebral foramen); Articular disc degeneration, herniation, or bulg-
ing into the foraminal space; or Stenosis (bony deposits in the foramen or spinal
canal). These mechanisms involve compression of the nerve roots between the adjacent vertebrae (boneto-bone compression) or between a disc and vertebra (disc-to-bone). There are also reports of small accessory muscles being found within the foramen parallel to the nerves, as well as dural tube adhesions at the nerve roots—either of which could conceivably cause axial sciatic pain. Infections, tumors, cancer, or trauma at the nerve roots (or elsewhere along the nerve) can also cause sciatic pain, and they are the reasons why referral to a specialist is prudent when sciatic pain is persistent, unresponsive, or severe. Axial sciatica will show one or more of these signs: Pain in the low back along with buttock or thigh
pain, usually without pain below the knee (unless there are also appendicular contributors). “Sciatic scoliosis”: a reluctance to put weight on
the affected side, resulting in leaning away from the affected side in order to minimize pain. A positive (i.e., painful) result when performing
the Straight Leg Test.
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Straight Leg Test The Straight Leg Test (SLT) or the Lasè gue Test is a common and reasonably reliable assessment for identifying lumbar nerve root compression. With your client seated at the front edge of a chair, ask him or her to raise a straightened leg at the hip (that is, with his or her knee extended straight). The straight leg test is positive (meaning that it indicates likely nerve root compression) if sciatic pain is reproduced with the motions listed in the caption of Fig. 3. Pain in the opposite (supporting) leg can be due to more severe disc herniation, and is clear cause for referral. Why do ankle dorsiflexion, slumping, or neck flexion increase sciatic pain in the SLT when a nerve root is compressed? All three of these movements stretch the nerve tissues further, putting a little more tension on any entrapment. Slumping and neck flexion also pull upwards (caudally) on the dural tube within the spinal canal. The dural tube’s projections surround the nerve roots and line each foramen (Fig. 2), so restrictions here can be a cause of axial sciatic pain. If this is the case, the slump test itself can be a helpful self-treatment, gently stretching the dural adhesions. Clients should be instructed not to over-do the stretching, or do too many repetitions, so as to avoid aggravating the already inflamed nerve roots. The SLT can also be performed passively, or with your client supine instead of sitting. Including these
Figure 3. The Straight Leg Test (SLT) indicates probable nerve root compression if: 1) sciatic pain is reproduced between 30° and 70° of hip flexion (70° is pictured); 2) pain worsens with ankle dorsiflexion, slumping, or neck flexion (dropping the head forward); or 3) pain is relieved by knee flexion of the raised leg.
variations may increase the accuracy of your findings. Supine testing does not allow for the slump test, but it does make it easier to add the bowstring variation of the SLT (described later in this chapter), which can help determine if there is appendicular involvement in addition to axial sciatic nerve entrapment. When performed and interpreted correctly, the SLT has a high statistical sensitivity (91 percent of correct positive results), but a lower statistical specificity (26 percent of correct negative results) . In other words, the SLT is quite reliable at indicating compression of the sciatic nerve roots (about nine out of ten positive results will accurately indicate nerve root involvement). However, the SLT is less reliable at determining when there is not nerve root compression (in other words, among those who have nerve root compression—as verified by other
Figure 4 . The Piriformis Test. An increase in sciatic symptoms when the flexed leg is brought across the body (adduction) indicates probable piriformis or rotator involvement. This can also be performed passively or with the client supine.
clinical means—three out of four will test negative with the SLT). Said another way, the SLT is fairly good at ruling in nerve root compression, but it is fairly bad at ruling it out. Of course, you should keep in mind that unless your training and licensing specifically permit you to diagnose conditions like disc issues, it is inappropriate to offer your client a diagnosis, or even suggest an interpretation of the SLT, for a variety of good reasons. Even if you are a physician or other licensed professional whose scope of practice does include diagnosis, telling someone with a positive SLT that they have a nine in ten chance of having a nerve root entrapment is a loaded and potentially complex conversation, with the potential for inadvertent harm as well as good. For most manual therapists, a positive SLT is reason to refer the client to a specialist for further evaluation, or to conTerra Rosa E-mag No. 19
firm that your client is already under a specialist’s care. Even in these cases, knowing and using the SLT will allow you to strategize your own work appropriately.
Working with Axial Sciatica Since they involve different entrapment sites and mechanisms, axial and appendicular sciatica are approached in different ways. Because many of the causes of axial sciatic pain involve instability, boneto-bone, or whole-body patterns, direct myofascial work with axial sciatica can be quite tricky. Although there are very effective manual therapy approaches which address the lumbar causes of axial sciatic pain, they often involve skilled discernment and judicious application by an experienced practitioner. While deep lumbar work can sometimes be quite helpful for someone with axial sciatic symptoms; however, if it is performed unskilfully, deep or overly-focused work (including trigger point work, active release, deep massage, structural work, or direct myofascial release) can in some cases worsen the symptoms of lumber disc issues by inadvertently releasing the adaptations and compensations that are providing stability to an unstable spine. For this reason, many of the actual techniques for working with axial sciatica are probably beyond the scope of a written instructional text like this one, and are best learned in an in-person training environment, followed by engaging in cautious practice while having access to experienced supervision and advice. However, even without specialized in-person training, there is a tremendous amount of benefit that manual therapy can provide. These pointers will help increase your effectiveness while minimizing risk to your clients who show signs of axial sciatica: The safest, most universally helpful intentions
for manual therapists when dealing with axial sciatica are to gently ease the effects of unnecessary splinting and guarding, and to relieve the overall tension and stress of dealing with pain. Relaxing and calming approaches, such as mas6 Terra Rosa E-mag No. 19
Figure 5 . A peripheral nerve’s connective tissue includes the inner perineurium (light tan), which encloses bundles of axons (dark beige) and the epineurium (green); and the outer wrapping of the nerve, which contains the nerve’s internal blood supply (red and blue). Image courtesy Primal Pictures, used by permission .
sage therapy, as well as work around the lateral hips, shoulders, and neck, are especially helpful. Work slowly. If you do deep work, proceed very
gradually, noting your client’s response between sessions. If there is a persistent increase in pain after your session, work less deeply next session, and/or in different places. Techniques that feel good on the table may worsen the symptoms when upright so, if possible, ask your client to sit or stand partway through your session to check in about pain level, and adjust or redirect your work accordingly. Employ your client’s own gentle active move-
ments, rather than passive moving, stretching, or positioning. Use your client’s comfort as a guide. Painful work is not helpful with inflammatory conditions such as sciatica, so your clients should be instructed not to push through their pain. Find a level of depth and pressure that allows your client to relax into the work.
Figure 6. The sciatic nerve pathway, from above. Originating from spinal nerves L4–S3, which pass through and lie posterior to the psoas muscle, the sciatic nerve emerges from the pelvis and passes between the structures of the hip and posterior thigh. Impingement anywhere along its pathway can lead to the symptoms of sciatica. Image courtesy Primal Pictures, used by permission .
Especially in cases of sciatica and other nerve
issues, the point of greatest pain is often the place that is least in need of direct, deep pressure. Because tissues are already inflamed or unstable where they are most painful, direct work may worsen the symptoms later. Instead, ease the body around the most painful areas. Avoid any techniques that apply longitudinal
compression or shearing forces (listhesis) to the spine, such as downward pressure in a prone position, and some seated techniques or passive stretches. Also, use caution with positions or techniques that twist the spine, which can narrow the foremen around an already crowded nerve root (twists can sometimes also relieve compression, but use them cautiously). It is a good idea for your client with acute axial
sciatic signs to be under the care of a spine specialist such as an orthopaedist, chiropractor, physiotherapist, or other rehabilitation specialist. If you suspect undiagnosed lumbar disc issues (for example, if your client feels a worsening of sciatic symptoms with the Straight Leg Test), be sure to refer your client to a qualified medical specialist for evaluation and possible rehabilitative work. Do not hesitate to get supervision or advice from a mentor as well. Even with this long list of cautions, do not be discouraged. Remember that your work can dramatically help someone with axial sciatic pain. Relaxing and calming are always helpful, and easing the overall patterns of guarding and stress from chronic pain can be a godsend for someone with unrelenting sciatic pain. Terra Rosa E-mag No. 19
Assessing Appendicular Sciatica Whether or not the SLT indicates possible nerve root compression, you will want to check for distal contributions to sciatic pain to further narrow down your choice of possible techniques. Often, axial sciatica is accompanied by appendicular sciatica as well. In contrast to the bone-to-bone or disc-to-bone compression of axial sciatica, appendicular sciatica entrapment is typically related to the soft tissues, which often respond very readily to direct manual therapy. We will describe three ways of assessing appendicular sciatica: the Bowstring Variation of the SLT, the Piriformis Test, and the Sciatic Nerve Glide Test. The Bowstring Test The Bowstring Test is a variation of the SLT. Once you have performed the SLT and found positive (painful) results, support your clientâ&#x20AC;&#x2122;s hip at the angle of maximum sciatic symptoms. Slightly flexing the knee in this position usually relieves sciatic symptoms, since it slackens the tension on the sciatic nerve and its roots. To check for peripheral sciatic nerve involvement (appendicular sciatica), apply gentle but firm pressure with your thumbs or fingers into the popliteal space, with a slight distal traction on the tissue around the nerve. Since the sciatic nerve is here at the back of the knee, pain with pressure or traction indicates peripheral sciatic nerve involvement due to localized stretch of the nerve and nerve sheath. The Piriformis Test Nerve entrapment by the piriformis muscle is the most common cause of appendicular sciatica, probably accounting for about 70 percent of all nonlumbar sciatic pain , so this test will help identify the most probable cause of appendicular sciatic pain. To perform this test, ask your seated or supine client to pull the knee of the affected leg to his or her chest (Fig. 4). Once the hip is flexed in this way, if actively bringing the knee across the midline of the body (adduction with flexion) increases sciatic pain, 8 Terra Rosa E-mag No. 19
Figure 7. The sciatic nerve pathway, from above. Originating from spinal nerves L4â&#x20AC;&#x201C;S3, which pass through and lie posterior to the psoas muscle, the sciatic nerve emerges from the pelvis and passes between the structures of the hip and posterior thigh. Impingement anywhere along its pathway can lead to the symptoms of sciatica. Image courtesy Primal Pictures, used by permission .
this indicates probable piriformis or hamstring entrapment of the sciatic nerve.
Assessing Sciatic Nerve Glide As described above, sciatic pain arises from either axial origins (typically at the spinal nerve roots) or from appendicular causes (distal entrapments in the buttocks, hip, or leg). Before we move on to assessing and addressing more appendicular impingements, let us take a look at nerve entrapment. Understanding Nerve Entrapment In order to understand sciatic nerve entrapment, it is helpful to review some important features about nerves in general, and the sciatic nerve in particular. The neurons that make up the sciatic nerve are the longest in the body—originating in the spinal cord and extending to the hip, leg, and foot. Like all peripheral nerves, these neurons are wrapped and bundled within various layers of connective tissue, the outermost layer being the epineurium (Fig. 5), which is a continuation of the arachnoid and dural layers surrounding the central nervous system. The connective tissues of a nerve function to: 1. help maintain its internal electrochemical environment; 2. carry the nerve’s intrinsic blood vessels and sensory nerves; and 3. give the nerve its structure, tensile resilience, and elasticity. Impingement (compression or tension) on the nerve impairs all three of these functions, causing internal inflammation of the nerve, reducing its blood flow, and diminishing its ability to glide and stretch. The third quality, elastic glide, is particularly relevant to our work. In an average sized adult, the long neurons within the sciatic nerve stretch an additional 9 to 12 cm (3.5–5 inches) with normal hip, knee, and ankle motions . This causes a significant amount of gliding movement between the epineurium and the surrounding intermuscular septa, muscle sheathes, and supporting fascias. A nerve gliding within these surrounding connective tissues can be compared to a tendon’s movement within its
surrounding bursa. As with other fascia and connective tissues, the epineurium sheath around a nerve may itself become adhered or tethered to surrounding structures (loosing differentiation); it may also become hardened and thickened from strain or injury (loosing elasticity). Since this protective sheath contains blood vessels that supply the nerve (Fig. 5), adhesions or hardening of the epineurium can choke the nerve’s circulation, worsening the internal inflammation. Impingements on the nerve sheath may also cause pain directly; the sheath itself is highly enervated by smaller sensory nerve filaments (the nervi nervorum) that are thought to be responsible for many cases of neuropathic pain (pain related to dysfunction of the nerve tissues themselves) . Most importantly for manual therapists, remember that you cannot rub nerve inflammation away. This is the key point to remember for effective work with sciatica (and other nerve pain). Since sciatic nerve inflammation is caused by pressure, applying more pressure will not usually help. With this in mind, it is typically best to avoid exerting direct manual pressure on the sciatic nerve; instead, our goal is to increase “nerve glide”: decompress the nerve’s passageways, and release nerve sheathes from their adjoining structures to restore normal neural movement, freedom, and elastic sliding.
Sciatic Nerve Glide Test Appendicular sciatica can be related to sciatic nerve entrapment at any of these sites: • Under, over, through, or around the piriformis muscle or other external hip rotators (as discussed below); • Between the quadratus femoris and gluteus maximus; and • In the intermuscular septum between the biceps femoris and the adductor magnus in the posterior thigh. These entrapment sites can be assessed with the Sciatic Glide Test. To perform the test, have your Terra Rosa E-mag No. 19
Figure 8. Given that the sciatic nerve stretches as much as 12 cm with lower-limb movements, the Sciatic Nerve Glide Test can help locate sciatic nerve entrapment sites. If knee extension and ankle dorsiflexion increase sciatic symptoms, nerve tethering in the hip or leg is likely, usually at the site of pain, or at a place proximal to it along the nerve’s pathway.
client lie supine with the hip and knee flexed on the affected side (Fig. 8). Direct your client to actively straighten the bent knee of his or her raised leg (Fig. 9). Extending just the knee from 90 degrees to fully straight stretches the sciatic nerve by about 4 to 5 cm (1.5–2.5 inches); adding ankle dorsiflexion (as pictured) typically adds another half-inch of stretch . Thus, if straightening the affected leg increases sciatic symptoms, nerve tethering in the hip or leg is a likely contributor to the sciatic pain. You can get even more specific about where to begin your work by asking your client to compare the sensations of straightening the affected and unaffected legs, and to direct you to any sites of increased pain or sensitivity. Nerve pain typically radiates distally, so the entrapment causing the pain resulting from this test is usually at the site of pain, or proximal to it, so it makes sense to start at the site of reported pain, and to work the nerve pathway proximally from there, retesting to track for 10 Terra Rosa E-mag No. 19
any changes. Here are two variations to the Sciatic Nerve Glide Test (not pictured): 1. If the client experiences increased sciatic pain when bringing the straightened leg across the body (hip flexion and adduction with knee extension), this can indicate piriformis involvement. 2. Placing the sole of the passive leg on the table by raising the knee can help differentiate between lumbar and non-lumbar tethering. Since the kneeup position decreases lumbar extension, suspect tethering at the lumbars (axial sciatica) if raising the knee on the passive side decreases the Glide Test’s sciatic pain. (Axial sciatica is discussed earlier in this chapter.) Use what you learn from performing the Sciatic Glide Test to choose where to work next. Myofascial techniques (such as those described below), as well
as stretching the rotators, gluteus, or hamstrings, are often particularly effective ways to release the neural sheath adhesions or myofascial restrictions that you have discovered with the Sciatic Glide Test. The Sciatic Glide Test itself can also be helpful as a take-home client exercise to mobilize a tethered nerve. Clients should be cautioned not to do too many repetitions at one time, or to repeat the maneuver more than once per day, so as to avoid continually irritating an already inflamed sciatic nerve.
Other Causes of Appendicular Sciatic Pain In addition to the soft-tissue impingements listed above, the following issues can also contribute to appendicular sciatic pain: • Prolonged sitting, either from direct pressure on the sciatic nerve from wallets, bucket seats, and so on; or from postural strain resulting from hip flexion contracture or posterior pelvic rolling (slumping). • Driving can increase leg tightness from pressing on the gas pedal, as well as from sitting (driving
is also a risk factor for disc issues). • Hypertrophy (overdevelopment and enlargement) of the piriformis, rotators, or hamstrings, especially when combined with repetitive motions (as in prolonged exercise). • Structural and tissue changes associated with pregnancy and postpartum. • Direct trauma to the sciatic nerve, tumours or infections, or scarring or thickening of adjacent soft tissues. Some of the causes noted above suggest their own solutions, which often involve changes in activities or ergonomics. Since appendicular sciatic entrapments are most often soft-tissue restrictions, these types of entrapments frequently respond quite well to focused and thorough hands-on myofascial work. I will describe hands-on techniques for working with the appendicular sciatic nerve entrapments that you identified with the Sciatic Nerve Glide test.
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Figure 10-11 The Rotator Technique: use static pressure on the piriformis attachments on the greater trochanter, combined with femur rotation.
Working with Appendicular Sciatica A brief review of some important points: because axial sciatica can be associated with spinal instability (which can be worsened by indiscriminate deep work), the safest approach to this type of sciatica is easing the whole-body guarding and stress that accompany chronic pain, rather than performing deep, focused work on the lumbar nerve roots themselves. Persistent axial sciatic symptoms (as described above) can be a reason for referral to a rehabilitation specialist, such as a physical therapist, chiropractor, or orthopaedist. By contrast, with appendicular sciatica, our approach is different. Appendicular sciatica is characterized by increased pain from sitting; stepping up stairs or inclines; from the direct pressure of sexual intercourse in women; or with resisted active external rotation of the femur. Appendicular sciatica can be just as painful as axial sciatica, but it is generally 12 Terra Rosa E-mag No. 19
more amenable and responsive to soft-tissue work. This is because in appendicular sciatica, it is usually soft tissue itself that entraps the sciatic nerve, as opposed to the bony or fibro-cartilaginous entrapments that are typical in axial sciatica. Our intention when working with appendicular sciatica is to facilitate normal nerve glide by releasing any tethering or compressing myofascial entrapments. These entrapment sites can often be identified using the Sciatic Nerve Glide Test described above; here are three techniques that serve as examples of ways to safely and effectively ease the most common appendicular sciatic nerve entrapments.
Rotator (Piriformis) Technique Sciatic nerve entrapment by the piriformis (â&#x20AC;&#x153;pearshapedâ&#x20AC;?) muscle is probably the most common cause of appendicular sciatica (as mentioned ear-
lier, the piriformis accounts for about 70 percent of all non-lumbar sciatic pain, according to one largescale study ). “Piriformis Syndrome” was first described in 1928, and its causes have been well studied and debated in the years since. It is also known as “pseudosciatica,” or Type II Sciatica in chiropractic terminology. Anatomical variations in the sciatic nerve’s pathway in relation to the piriformis have long been thought to be the cause of piriformis-related sciatic pain. In most people, the sciatic nerve passes deep to the piriformis (as it does in Figs 7 & 8), but 15–30 percent of people have variations in this arrangement, which can include: •
the nerve passing superficial to the piriformis;
• the nerve passing through the split belly of the muscle; and • the split nerve passing in two parts around the piriformis. However, some researchers question whether these anatomical variations have any significant bearing
on sciatic symptoms, as they correlate poorly with actual sciatic symptoms . In a manual therapy setting, these variations are probably more interesting as anatomical trivia than as clinically useful information, since it is questionable whether variations in the piriformis/sciatic nerve arrangement— even if they were known—would change one’s hands-on therapeutic approach. In other words, whatever the anatomy, the most practical strategy is usually to do some work and see how the symptoms respond, then adjust your approach accordingly. Piriformis entrapment does not occur without reason or cause. Some of the other structural and functional factors that may trigger piriformis-related sciatic pain include: • Internal rotation of the hip or leg, since during gait the piriformis may contract to counteract tendencies towards internal rotation. Internal hip rotation, in turn, can be related to ankle pronation or myofascial imbalances (for example, tightness or fascial binding of the anterolateral fascia lata, the medial hamstrings, or the posterior adductors). Terra Rosa E-mag No. 19
• Sacral position and movement restrictions (since the piriformis acts on the sacrum), such as will be seen when there are sacroiliac joint issues, leg length differences, or ilia mobility imbalances. Whatever the cause of piriformis entrapment, the Rotator Technique is an efficient and effective way to assess and release any local nerve impingement related to the piriformis, as well as the other external rotators (such as the quadratus femoris) that can have a bearing on sciatic nerve health. To perform the technique, start with your client prone and the knee of the affected leg flexed. Use the lower leg to slowly roll the femur into internal and external rotation (Figs. 10 & 11). With the soft fist of your other hand, gently apply firm, static pressure to various aspects of the greater trochanter, which is the distal attachment of the piriformis and other rotators. Use both hands; with the hand moving your client’s leg, feel through the client’s structure for the resistance of your static hand on the rotators. Once you feel a change in the tissue’s resilience, release your pressure, move your soft fist to another location, and slowly roll the femur again, feeling for restrictions in the new location. Be thorough; use this technique throughout the buttock and rotator region, but avoid putting direct pressure on the sciatic nerve itself. (The nerve runs midway between the trochanter and lateral edge of the sacrum, and pressure on it will be felt by your client as tenderness or an electric sensation.) Rather than indiscriminately mashing the nerve and tissues here, imagine freeing the nerve by releasing and separating any inelastic or adhered structures that surround it. As its name suggests, the superior gluteal nerve is in the superior portion of this gluteal region (visible superior to the piriformis in Figs. 6 & 7). Although considerably smaller than the sciatic nerve, it can be a source of sciatic-like pain in the upper buttock and lower back. If your client experiences pain here, you can use the Rotator Technique to release the tissues around this nerve as well. 14 Terra Rosa E-mag No. 19
Further techniques can be found in Advanced Myofascial Techniques Vol. 2 by Til Luchau (Handspring Publishing, 2016) and Sciatica DVD.
References  Konstantinou K, Dunn KM. Sciatica: review of epidemiological studies and prevalence estimates. Spine, Oct 15 2008; 33(22):2464-72.  Valat JP et al. Sciatica: Best Practices. Res Clinical Rheumatology 2010 Apr; 24(2):241-52.  Devillé WL et al. The test of Lasègue: Systematic review of the accuracy in diagnosing herniated discs. Spine, 2000; 25 (9): 1140–7.  Researchers at Cedars-Sinai Medical Center; the University of California, Los Angeles; and the Institute for Nerve Medicine in Los Angeles examined 2239 sciatic patients (using magnetic resonance neurography) who hadn’t improved with lumbar disc treatment. Results of the study confirmed that 69 percent had piriformis syndrome, while the remaining 31 percent had a combination of other nerve, SI joint or muscle conditions. From: Filler A, Haynes J, Jordan S, et al. Journal of Neurosurgery: Spine, 2005; 2(2):99-115  Belth, Iain D. et al. “An assessment of the adaptive mechanisms within and surrounding the peripheral nervous system, during changes in nerve bed length resulting from underlying joint movement.” From: Moving in on Pain: Conference Proceedings - April 1995 ButterworthHeinemann; 1 edition (December 27, 1995) 194-196.  Asbury AK, Fields HL. Pain due to peripheral nerve damage: an hypothesis. Neurology 1984; 34:1587-1590.  Belth, Iain D et al. Ibid.  Filler A, Haynes J, Jordan S, et al. Journal of Neurosurgery: Spine, 2005; 2(2):99-115.  Benzon HT et al (2003). "Piriformis syndrome: anatomic considerations, a new injection technique, and a review of the literature". Anesthesiology 98 (6): 1442–8.
New Books & DVD
Advanced Myofascial Techniques, by Til Luchau , two beautiful, information-packed guides to highly effective manual therapy techniques. Vol. 1 focuses on conditions of the shoulder, pelvis, leg & foot, while Vol. 2 on neck, head, spine and ribs. They providesa variety of tools for addressing some of the most commonly encountered complaints. With clear step-by-step instructions and spectacular illustrations, each volume is a valuable collection of hands-on approaches for restoring function, refining proprioception, and decreasing pain. Invaluable for practitioners, teachers, and students of hands-on manual therapies.
Advanced Myofascial techniques for Sciatica & Disc Issues This DVD shows the complete way to learn advanced myofascial techniques that dramatically improve your ability to work safely and effectively with Sciatica, Pseudo-sciatica, and sciatic pain; Hamstring Syndrome, Piriformis Syndrome, related lumbar disc issues; and more.
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Changing Your Story By Walt Fritz, PT
What if I asked you to strip away the story you tell when describing your modality? Is it possible to be a myofascial release (MFR) therapist without believing the work primarily engages/ involves fascia? Is it possible to teach myofascial release without using a fascia-based explanatory narrative? I believe the answer is yes to both of these questions. Some in the USA have branded me a heretic for such statements and beliefs, but if we define heretic as, ”one who dissents from an accepted belief or doctrine” , then count me in, as I am a fascial-narrative heretic. Why do I disbelieve? My moving away from what may seem like reams of fascial and myofascial release proof was prompted by many factors, one of which I include below in a blog post I recently made on my Myofascial Release Blog. The article covers just one small part of what became my MFR Conversion. I still use MFR every day and teach it to MTs, PTs, and SLPs, but I believe vastly different “things” are occurring under my hands than what was originally taught to me. I still call my work MFR as it is what I’ve done with my hands for the past 25 years. To me, MFR can be about the physical actions we perform with our hands and bodies without needing to adhere to a rigid set of MFR rules and beliefs. As I teach this work I am amazed at the wide breadth of explanations therapists use to describe and explain their 16 Terra Rosa E-mag No. 19
MFR work, so much so that the lack of a uniform brand identity makes me feel even more comfortable with my neurologically-explained model of MFR. Fascia purists may take issue with what I have to say, but that is how we learn and adapt; through cognitive dissonance and debate. I think it is outright silly to believe that we can grab hold, or poke at a person’s skin and state that we are primarily affecting shortened/restricted fascia (or all of the other dozens of things manual therapists believe they are impacting). Is it possible? Certainly, but can all of the claims made by therapists be possible as well? Most are improbable. What if I asked you to strip away the story you tell when describing your modality? Could you describe the actions of your hands without the jargon inherent in the story of your modality? It might be pretty hard to do, as it may be hard to separate actual plausible science, anatomy, and physiology from what you were taught as the science that supports the work you use. You have to say something that sounds science-like, but what if you had to change your story? Could you do it and would you even wish to try? You would need something to explain your work, though my explanation seems to get simpler by the year.
Figure 1. Walt Fritz performing the sequence formerly known as the thoracic outlet release. Photo property Walt Fritz, PT
Changing one’s story is often viewed as shifty or even indecisive, as if you cannot decide or are trying to cover up something. I disagree. I’ve written extensively about how I moved from a narrative (story) of myofascial release in the traditional, folkloric sense, which credits so-called fascial restrictions as being the cause of most pain as well as the key to the remediation of pain into a story of simplicity and plausibility. Apparently my story was so compelling it garnered a request to tell it earlier this year at the Registered Massage Therapists of British Columbia Manual Therapy 2016 Conference. The story I now tell and teach is a simple one, one deconstructed from the stories of fascial fantasies. But as a therapist (PT) with over 30 years in practice, I’ve heard literally hundreds of stories on how we are creating change in the body as well as the cautions as to what will happen if we do not follow the recipe set forth in that line of training’s rulebook. The story told by most manual therapy trainings might be called inherited narratives (Thanks to Phil
Greenfield for this term) in that the beliefs and explanatory models have been passed down over time. While new science might be sprinkled in for good effect, most of these narratives have remained unchanged for long periods of time. The narrative I was taught in my initial myofascial release training was certainly an inherited one, as the concepts of MFR (and its explanatory model) stem from osteopathic literature from the early 1900’s. I have begun to use the term folklore to describe the way MFR is taught; as many therapists repeat the inherited narrative verbatim without questioning its validity or authenticity. But this is true for much of the work that we all do. If I attempted to deconstruct most of what I was taught in physical therapy school and eliminate all that was not fully vetted as scientifically valid, I may have little to do with my days. Though I’ve allowed the MFR story I was taught to gradually slip away , initially it served me well and I questioned little of its truth. Over time, as I moved away from my MFR roots, the inherited narrative of Terra Rosa E-mag No. 19
MFR seemed to matter less and less. I also learned drastically conflicting stories from other people. Recognizing that my biases clouded my abilities to see real truth, I began to embrace the concept of attempting to be less wrong. Saying that I am less wrong, when it comes to explaining my work, may sound condescending or superior, but I believe that it comes from a place of humility. With a broadbased education, credible continuing education, and critical thinking, I do think we can be less wrong about the work we do. I do not mean to criticize those who believe differently and certainly not those who taught me these concepts. Science moves forward and I thank those in my past. Many different influences caused me to change my story, though the need to do so was not due to a lack of efficacy, as I think the MFR work I did has always been effective. But the story I was taught way back in the early 1990s always bothered me a bit. I found Figure 2. The Facial nerve. From Henry Gray (1918) Anatomy of it a bit far-fetched that such important concepts of the Human Body (public domain). anatomical structure and physiological properties were not taught to other health professions, physicians included, but were being taught to me in a vidual muscles and can refer into far-reaching areas continuing education seminar. But I like a good of the body (By then I told that story really well!). story, so I played alongâ&#x20AC;Ś just to hear the ending. Most patients would just nod or grunt in apparent One key point of the MFR work I was taught was the understanding, but I started to notice concept that fascial restrictions go beyond the orihow frequently I heard these reports. This was surgins and insertions of individual muscles, which was prising, since it was the belief that fascial restricsaid to explain why patients feel far-reaching symptions were unique to each individual, based on their toms while we are treating them. Such far-reaching history of physical (and emotional) trauma. Why sensations were a key aspect of explaining MFR were so many people telling me nearly the identical from a fascial perspective, and I used this explanareferral pattern? I filed it away for future worrying tion with my patients for many years, as well as (I do that a lot. Why waste good time worrying teaching it in the early days of my Foundations in about such things when there were more pressing Myofascial Release Seminars. It was a good story things to worry about? I tend to compile worry totold by some pretty good storytellers and I had no do lists). It seemed that with a sustained hold in the better story to explain the phenomenon, until I above mentioned (and previously pictured) selearned one. Let me tell you about that new story. quence, symptoms improved not only in the area of treatment, but also into the referral patterns Frequent feedback I heard when performing a techthrough the face. Seeds of scepticism were planted. nique that is termed a thoracic outlet release are reports of sensation or referral of familiar symptoms throughout the face. When my patients told me this, I repeated the story I had been taught explaining the concept of fascial restrictions and how they reach beyond the origins and insertions of indi18 Terra Rosa E-mag No. 19
Fast forward to a DermoNeuroModulation class I took from Diane Jacobs, PT. She speaks a decidedly non-fascial language and at a certain place in her lecture she displayed a PowerPoint slide regarding the anatomy and distribution of the facial nerve. She
had spoken at-length about neurodynamic technique principles, exposing me to some pretty new and interesting perspectives on evaluation and treatment. She spoke about the potential for engaging a nerve anywhere along its length and having the possibility of impacting and allowing change anywhere along the nerve path. In essence, grab hold of a nerve anywhere and you have the potential to impact the entire distribution of that nerve. Figure 1 shows me performing the sequence formerly known as the thoracic outlet release (I have different names for technique sequences today…but that’s another story). If you can imagine where my patient is feeling a stretch or engagement, a wide range of response is plausible, including the front of the neck and upper chest region.
Sitting in Diane’s class and seeing the facial nerve in an enlarged image allowed me to immediately see that old, folkloric story of so-called fascial referral patterns in an entirely new light. Does this mean that fascial restrictions do not explain this phenomenon? Not definitively, but when faced with a decision to choose one explanation over another, I now choose the one that is less wrong. I choose the one that science supports without needing to tell a story.
Now consider the anatomy in Figure 2. It is a Grey’s Anatomy plate showing the distribution of the facial nerve. The facial nerve is the seventh cranial nerve and “controls the muscles of facial expression, and functions in the conveyance of taste sensations from the anterior two-thirds of the tongue and oral cavity. It also supplies preganglionic parasympathetic fibers to several head and neck ganglia.” The facial nerve functions as a motor nerve as well as sensory and parasympathetic nerve and supplies the exact areas that my patients were reporting all in all those instances of so-called fascial referral. What might explain this phenomenon?
Stories have their place, but they should be told as either fact or fiction. When stories blur I do not believe they belong in the treatment room, where we give skilled care to patients in pain and dysfunction. Try to be less wrong. Change your story. What about you? Has your story changed?
Walt Fritz, PT Foundations in Myofascial Release Seminars
You can make comments to the original blog post, which is titled. “More Mental Floss for the MFR Brain: Changing Your Story” here, at my Myofascial Release Blog.  http://www.merriam-webster.com/dictionary/
Take a close look at the anatomy plate in Figure 2 and you will see that the cervical branch of the facial nerve runs down through the upper and middle anterior lateral neck regions. When I engage my patients in the stretch shown above in the photo, I believe that I am lightly engaging the cervical branch of the facial nerve. I believe that I am providing neurodynamic technique-like engagement to the cervical branch of the facial nerve, potentially affecting the entire facial nerve. I believe that I am allowing my patients to feel effect into their faces and potentially providing treatment to the facial region from this sequence, not from a fuzzy science explanation of fascial restriction, but from a biologically plausible model of nerve mobilization. Terra Rosa E-mag No. 19
The Thoracic Spineâ&#x20AC;Ś The Silent Saboteur By Joe Muscolino, DC
There is an old saying that no posture is bad unless you get stuck in it. The problem is that people often do get stuck in bad postures. And this is especially true for the thoracic spine. A further problem is that postural distortion of the thoracic spine, even when advanced, is often asymptomatic and therefore ignored by the client, but can be a major cause of other postural distortion and pain patterns in the body. In this way, the thoracic spine could be viewed as a silent saboteur of our health. The client may not even mention the thoracic region when describing their problem, but we need to always consider and assess the thoracic spine when evaluating our clientâ&#x20AC;&#x2122;s health.
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Figure 1. A, healthy natural kyphosis of the thoracic spine measures approximately 40 degrees. B, hypokyphotic thoracic spine. C, Hyperkyphotic thoracic spine. Reproduced with permission from Joseph E. Muscolino. Artwork by Giovanni Rimasti.
Rounded Back A healthy thoracic spine should have a natural kyphotic curve that measures approximately 40 degrees (Figure 1A). Although it is possible for this curve to be abnormally decreased, in other words, hypokyphotic (Figure 1B); by far the more common postural distortional pattern is for the thoracic spine to become hyperkyphotic (Figure 1C). In lay terms, this is often described as rounded back. A kyphotic curve is effectively a curve of flexion. So it makes sense that assuming forward flexed postures on a regular basis would lead to a hyperkyphotic, in other words hyperflexed, rounded thoracic posture. And in our modern world, most everything that we do is down in front of us, whether it is tending to a baby, cleaning a counter, cutting vegetables, doing paperwork, or working with a laptop, tablet, or smart phone (Figure 2). Indeed, working down in front of our body is not new, but with the tremendous proliferation of digital devices, the number of hours that people spend hunched forward into flexion has grown exponentially. Indeed, it seems that hyperkyphosis of the thoracic spine is becoming more and more prevalent, and may now be the most common and problematic postural dis-
tortion pattern that manual and movement therapists encounter. Like any postural distortion pattern, the longer we assume a rounded back posture, the more the soft tissues adapt to the distortional pattern. With a rounded thoracic spine, the anterior pectoral musculature ends up shortening and tightening and the posterior spinal extensor musculature ends up lengthening and tightens in response (See LockedShort/Locked-Long). Further, the anteriorly located fascial/ligamentous tissue shortens and becomes taut and the posterior fascial/ligamentous tissue lengthens and “weakens”, thereby losing the tautness/tone to oppose the forward flexion. As the fascial tissue weakens, this increases the burden on the extensor musculature, which becomes further overwhelmed and dysfunctional in its attempt to prevent the forward progression. And as we move further into flexion, our centre of weight moves anteriorly, increasing the leverage force of gravity, which furthers the force toward a forward flexed posture. Additionally, staying stuck in a rounded back posture also allows the build-up of fascial adhesions (often described as “fuzz” by educator Gil Hedley) that further resist the body from moving back into extension. And when exTerra Rosa E-mag No. 19
Figure 2. Working down in front of our body tends to promote a hyperflexed (hyperkyphotic) rounded thoracic spine. Reproduced with permission from Joseph E. Muscolino. Artwork by Giovanni Rimasti. Originally published in the massage therapy journal.
tremely long standing, for years or decades, even the bones remodel. The anterior aspects of the vertebral bodies narrow in height in response to the increased weight-bearing compression force anteriorly. All these factors add up to a postural distortional pattern that, once set in motion, tends to become a vicious cycle that feeds upon itself, steadily and progressively worsening. So what begins as a seemingly innocuous voluntary forward posture that we pay little attention to, often transitions into a stubborn, rigid dysfunctional pattern in which we become stuck, that alters the health of the thoracic spine, and indeed, much of the rest of the upper body.
Upper Crossed Syndrome (UCS) A rounded thoracic spine does not exist in isolation. Rather, it is usually part of a larger dysfunctional 22 Terra Rosa E-mag No. 19
Figure 3. Upper Crossed Syndrome. Reproduced with permission from Joseph E. Muscolino. Kinesiology: The Skeletal System and Muscle Function, 2ed. Artwork by Giovanni Rimasti.
pattern that involves the neck, head, shoulder girdles, and arms. This larger pattern is often described as upper crossed syndrome (UCS) and is so named because a cross (X) can be placed across the upper body. One arm of the cross represents overly facilitated (“locked-short”) musculature; the other arm represents overly inhibited (“locked-long”) musculature. The effect of the imbalanced asymmetrical pulls of the musculature results in the characteristic UCS posture which involves hyperkyphosis of the thoracic spine, hypolordosis of the lower cervical spine, hyperlordosis of the upper cervical spine, forward head carriage, protraction of the shoulder girdles, and medial/internal rotation of the arms at the glenohumeral joints (Figure 3). Even though each of these postural distortions can be
Locked Short/Locked Long When evaluating postural distortional patterns, opposing muscle groups at a joint were classically described as being tight and weak. The assumption was that tight muscles were strong and weak muscles were loose, so the imbalance of bony posture at a joint was described as being caused by strong/ tight muscles on one side of the joint overpowering weak/loose muscles on the other side. It is now understood this description does not fully and accurately describe the state of the relationship of these muscles groups to neuro-myo-fascio-skeletal posture and function. Current wisdom favours the use of the terms overly facilitated and overly inhibited muscles. These terms incorporate the role of the nervous system (NS) in recruiting musculature to contract for postural patterns. Overly facilitated muscles are excessively favoured by the NS to contract; and overly inhibited muscles are under recruited by the NS to contract. The facilitated muscles end up overly concentrically contracted and short; and the inhibited muscles are overpowered by the facilitated muscles and end up being pulled long. This results in the imbalanced pull across a joint and the resultant altered posture. Certainly, the overly facilitated muscles can be described as tight. But it is not accurate to describe the inhibited muscles as loose. Ironically, because of the constant pull by the overly facilitated musculature, the overly inhibited musculature must increase its tone in an attempt to counter the overly facilitated musculature, and ends up being, in a sense, overly facilitated itself and tight as well. Hence we have two opposing muscle groups, the “facilitated” muscles tight and short, in other words locked-short; and the “inhibited” muscles tight and long, in other words locked-long.
And because the length-tension relationship of muscle strength demonstrates that a muscle is strongest at resting length, and weaker when it is longer or shorter; we can say that both groups of muscles across the joint are overly weak. The inhibited musculature might be relatively weaker than the facilitated musculature, but in reality, both groups are weak. Effectively we have tight and weak musculature on both sides of the joint. A classic example of this would be the anterior pectoral musculature (locked-short; tight and weak) and the posterior shoulder girdle retractor and thoracic spinal extensor musculature (locked-long, tight and weak). When applying this knowledge to manual therapy, we see that it is valuable to work the overly facilitated and the overly inhibited musculature because both groups are dysfunctionally tight and weak and are therefore likely to develop myofascial trigger points and fascial adhesions. This is important to recognize because there are many manual therapists that assert that only the locked short musculature should be worked, likely because they feel that the opposing “long” musculature is already weak and would become even weaker if it were to be massaged and stretched. This is a fallacy. Manual therapy applied to any dysfunctional musculature, locked-short or locked-long, helps to restore the proper health and functioning of the musculature. Granted that the locked-long facilitated musculature should receive the lion’s share of the work, but it is only when both groups are healthy and in balance that these postural distortional patterns can truly be improved.
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ing the likelihood of facet irritation and degenerative osteoarthritic changes. These conditions, in turn, increase the likelihood of nerve compression in the intervertebral foramina.
Effect upon Forward Head Carriage This altered cervical posture also results in a forward head carriage in which the centre of weight of the head is located anterior to the trunk, over thin air (see Figure 4). This imbalanced posture requires the posterior soft tissues to work harder to keep the head from falling into flexion due to gravity, resulting in tighter posterior, extensor cervicocranial musculature, likely causing neck pain, myofascial trigger point referral pain, and tension headaches.
Effect upon Shoulder Posture Figure 4. Effect of a rounded thoracic spine on the posture of the neck and head. Note hypolordosis of the lower cervical spine, hyperlordosis of the upper cervical spine, and the forward head posture. Reproduced with permission from Joseph E. Muscolino. Artwork by Giovanni Rimasti.
Further, once the thoracic spine rounds forward, the shoulder girdles cannot maintain a posterior
viewed as a separate entity, in reality each one tends to increase the dysfunction of the others. But the rounded back thoracic hyperkyphosis is most fundamentally the root cause of the UCS pattern.
Effect upon the Cervical Spine Once we flex the thoracic spine forward, the cervical spine must begin its posture on the superior aspect of the body of T1 that is now more vertically oriented. This projects the lower neck anteriorly, continuing the path of the upper thoracic spine, causing the lower cervical spine to be hypolordotic. As a necessary compensation, the upper cervical spine must become hyperlordotic to bring the eyes and inner ears lever for proprioception (Figure 4). These dysfunctional cervical postures alter the balance of weight bearing through the cervical spinal joints. Hypolordosis/flexion of the lower cervical spine increases weight bearing through the discs, increasing the likelihood of disc pathology. Hyperlordosis/extension of the upper cervical spine increases weight bearing through the facets, increas24 Terra Rosa E-mag No. 19
Figure 5. Rounded thoracic spine also leads to protracted scapulae and medially rotated humeri. Reproduced with permission from Joseph E. Muscolino. Artwork by Giovanni Rimasti.
Figure 6. A rigid thoracic spine that is stuck in flexion places a greater demand on the lumber spine to extend when extension of the trunk is required. Reproduced with permission from Joseph E. Muscolino. Artwork by Giovanni Rimasti.
posture and therefore fall into protraction; and the arms follow suit by falling into medial/internal rotation (Figure 5). These upper extremity distortional postures often result in increased stress upon the muscles, resulting in tightness, pain, trigger point formation (along with referral of pain) and fascial adhesions. Further, a medially rotated humerus decreases abduction and flexion range of motion of the arm. To experience this, try abducting and/or flexing your arm with the arm first medially rotated. Then repeat the motion with the arm laterally rotated, and note the difference in range of motion. A medially rotated arm also increases the likelihood of shoulder impingement syndrome of the supraspina-
tus tendon and subacromial bursa (due to the approximation of the greater tubercle against the acromion process of the scapula above).
Effect upon Thoracic Outlet Syndrome And if this were not enough, UCS also increases the likelihood of all three myofascial forms of thoracic outlet syndrome: pectoralis minor syndrome, costoclavicular syndrome, and anterior scalene syndrome. Pectoralis minor syndrome due to the locked-short pectoralis minor; costoclavicular syndrome due to the collapsed posture of the clavicle against the first rib; and anterior scalene syndrome due to the adaptive shortening of the scalene musculature. Terra Rosa E-mag No. 19
Effect upon Breathing UCS even inhibits our ability to breathe. This is easy to demonstrate. Flex your thoracic spine, protract your shoulder girdles, and medially rotate your arms, and try to take in a deep breath. It is difficult, correct? Now open up your body by extending your thoracic spine, retracting your shoulder girdles, and laterally rotating your arms, and take in a deep breath, and notice how much more easily you can breathe deeply. A flexed/protracted/medially rotated posture inhibits the ability of the thoracic cavity to expand, limiting our ability to intake air, thereby limiting our ability to oxygenate our blood, thereby limiting our ability to oxygenate all the tissues of our body.
Effect upon the Lumbar Spine Effects of a rounded thoracic spine can even be felt inferiorly at the lumbar spine. By early middle age, a hyperkyphotic thoracic spine tends to become rigid, thereby limiting thoracic extension (as well as other ranges of motion). This places a greater demand on the lumbar spine to extend (Figure 6). This, in turn, results in increased compression force upon the lumbar facet joints, likely resulting in facet irritation, osteoarthritic degenerative changes (as well as possible foraminal encroachment and nerve impingement), joint dysfunction, and low back pain. Low back pain often then results in protective spasming of the nearby paraspinal extensor musculature, causing further joint dysfunction and low back pain. It is important to note that rigidity of the thoracic spine also impacts the cervical spine by similarly requiring the cervical spine to increase its range of motion to compensate for the rigid hypomobile thoracic spine. This places an increased stress upon the musculature and joints of the cervical spine, resulting in further pain and dysfunction there as well.
Lower Crossed Syndrome and the Thoracic Spine Rounded back thoracic hyperkyphosis is often caused by and accompanied by a general rounding of the entire spine, including the lumbar region (see Figure 2). In these cases, the lumbar spine reverses its lordosis to become kyphotic and the thoracic spine continues this kyphosis, resulting in rounded posture of the entire thoracolumbar spine. However, even a hyperlordotic lumbar spine can result in a rounded hyperkyphotic thoracic posture. Lumbar hyperlordosis is a prominent feature of the postural distortional pattern that is known as lower crossed syndrome (LCS â&#x20AC;&#x201C; see Figure 3). The hallmark feature of LCS is an excessively anteriorly tilted pelvis, which then results in a hyperlordotic (in other words, hyperextended) lumbar spine. With LCS, because the lumbar spine is hyperextended, the center of weight of the trunk moves posteriorly. As a compensation to bring the trunkâ&#x20AC;&#x2122;s center of gravity back anteriorly, the thoracic spine must increase its flexion (kyphosis), thereby resulting in an excessively rounded thoracic spine (with all of its sequelae described in this article). Figure - Reproduced with permission from Joseph E. Muscolino. Artwork by Giovanni Rimasti. Originally published in the massage therapy journal..
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Figure 7. Motion palpation assessment of the thoracic spine into extension. Reproduced with permission from Joseph E. Muscolino.
Assessment of Rounded Back Assessment of a rounded back posture is straightforward. Simply observe the client from the side and assess the degree of thoracic kyphotic curve. This should be followed by palpation of the pectoral musculature, as well as palpation of the extensor musculature of the thoracic spine and retractor musculature of the shoulder girdle. Because chronic rounded back posture results in rigidity of the spine being stuck in flexion, gentle but firm motion palpation of the thoracic spinal joints should be done by challenging these joints to move into extension. This is accomplished by pressing (gently but firmly) directly midline on the thoracic spine of the prone client with the palm of the hand; placing the spinous processes in the intereminential groove (the groove between the thenar and hypothenar eminences) and feeling for the end-feel motion of the joints
(Figure 7). A healthy joint has a firm but slightly elastic springy bounce at end-feel. If instead the end -feel is rigid, like hitting a concrete wall, then the joints being assessed are locked/hypomobile, likely due to intrinsic muscular spasming and fascial contractions. Because thoracic rigidity can cause dysfunctional compensations elsewhere, if thoracic hypomobility is identified, it is important to then assess for all of the possible related conditions.
Treatment of Rounded Back All effective clinical orthopedic manual therapy treatment should be directed at the fundamental underlying biomechanical and neurologic mechanisms that are causing the condition. With thoracic rounded back, the underlying mechanism is a chronic hyperflexed posture of the thoracic spine that then creates locked-short pectoral musculature Terra Rosa E-mag No. 19
Figure 8. Using a gym ball to stretch and open the thoracic spine into extension. Reproduced with permission from Joseph E. Muscolino. Artwork by Giovanni Rimasti.
anteriorly, locked-long thoracic musculature posteriorly, and hypomobile thoracic joints.
Treating MyofascialTissue Treatment of myofascial tissue should be directed toward loosening the anterior musculature, and loosening and strengthening the posterior musculature. Therefore the targets muscles to which treatment must be directed are the pectoral muscles anteriorly (pectoralis major, pectoralis minor, and the subclavius), and the posterior muscles of thoracic spinal extension (erector spinae and transversospinalis), shoulder girdle retraction (rhomboids and trapezius, especially middle trapezius), and humeral medial rotation (subscapularis, teres major, latissimus dorsi, anterior deltoid, and pectoralis major). There is no one magical soft tissue technique for loosening musculature, but a general approach is to use moist heat, followed by deep tissue massage, followed by stretching. If it is within your scope of practice, it is important to recommend to the client to strengthen the musculature of thoracic extension, shoulder girdle retraction, and humeral lateral rotation.
Treating the Thoracic Joints All of this wonderful myofascial work will be ineffective if the clientâ&#x20AC;&#x2122;s thoracic spinal joints are rigid and stuck in flexion. For these clients, it is imperative that Grade IV joint mobilization is performed, 28 Terra Rosa E-mag No. 19
especially directed toward extension. Grade IV joint mobilization involves repeated gentle but firm oscillations directed toward moving the joint into the ranges of motion that are decreased. These oscillations are usually repeated for approximately 15-30 seconds. For extension joint mobilization, the therapist simply directs the force from posterior to anterior midline on the spine of the prone client. In other words, it is performed in an identical manner to motion palpation assessment technique (see Figure 7). If this treatment technique is not within your scope, then the client should be referred to a softtissue oriented chiropractor or osteopath for adjunctive care. Note: Be aware that joint mobilization is contraindicated if the client has any hypermobility/instability of tissue locally where the treatment is being rendered (for example, osteoporosis/ osteopenia).
Self-Care Recommendations Homecare consisting of hot shower (or other form of moist heat) followed by foam rolling or working with therapeutic balls for work into the myofascial tissue. Following moist heat application with stretching is also extremely valuable. One easy and excellent way to stretch the thoracic spine into extension is to use a gym ball (Figure 8). And strengthening exercises for spinal extension, shoulder girdle retraction, and glenohumeral lateral rotation should also be done on a regular basis.
Addressing Posture Finally, given that the root cause of thoracic spinal hyperkyphosis is chronically assuming a rounded forward posture into flexion, it is imperative that the client begins to make lifestyle changes that eliminate these postures. For this reason, it is important to counsel the client about a wide range of postures including postures when using a desktop, laptop, tablet, smart phone, postures when writing or reading a book, postures when driving, and any other posture that might involve working down in front of their body.
Treating the Sequelae Given that a rounded thoracic postural distortion pattern can spin off and create other secondary problems, it is important to not only assess for these secondary conditions but to also treat them as needed. Often, when the initial primary cause of a secondary condition is removed, the secondary condition resolves on its own without needed treatment. However, when the secondary condition is allowed to be present for a long period of time (months, years, or even decades), it becomes entrenched in the body. In these cases, it is usually not enough to simply remove the initial cause; rather, the secondary conditions must be individually targeted and treated.
Motivations for Treatment The two most common signs/symptoms that direct a client toward seeking manual therapy treatment are pain and stiffness. Pain usually indicates that tissue damage is occurring, and is probably the primary reason that clients seek manual therapy. Stiffness (in other words, loss of range of motion), which usually indicates taut soft tissues is far less powerful toward compelling a client toward seeking care. Decreased range of motion is often ignored or not even noticed, especially when it occurs in small increments over long periods of time. This, unfortunately, is the circumstance with rounded back posture. Because the progressively greater thoracic kyphosis occurs so insidiously, often over months,
years, or even decades, the client pays little or no attention to it. Even becoming self-aware of the distortional posture is not that noticeable to the client because looking in the mirror affords the client an anterior view, which does not show well the condition; a lateral view is usually needed to appreciate the extent of the rounded posture that is occurring.
Conclusions The major reason that rounded back posture does not motivate the client to seek care is that the ensuing rigidity of the thoracic spine rarely causes pain. As a result, by the time that the client notices a problem, it is usually years and decades chronic and now much more firmly entrenched. And by this point in time, it has set in motion the other postural distortional sequelae of the cervical spine, head, shoulder girdles, arms, and lumbar spine. Ironically, it is often the pain in these other regions that initially motivates the client to seek manual therapy care. At that point in time, while direct manual therapy is needed for these other regions of the body for immediate alleviation of their symptoms, manual therapy to the asymptomatic thoracic region is crucially important for long-term relief. For example, when a clients come in with neck pain, I often like to tell them that if they want their neck to feel better today, I will work the neck today; but if they want their neck to feel better six months from now, I need to work their thoracic spine. It is simply not possible for a neck to be functional and healthy if the thoracic spine is hyperkyphotic! The same concept often holds true for the shoulders or low back. For all these regions, the thoracic spine is truly a silent saboteur that must be considered and addressed when performing clinical orthopedic manual therapy care with our clients. Joe Muscolino, DC, has been a massage therapy educator for more than 25 years and is the author of numerous textbooks on manual therapy, including The Muscle and Bone Palpation Manual (Elsevier, 2016), Kinesiology (Elsevier, 2016), The Muscular System Manual (Elsevier, 2016),.He teaches continuing education workshops around the world, including a certification in Clinical Orthopedic Manual Therapy (COMT).
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Terra Rosa E-mag No. 19
Does Cupping Enhance Sports Performance? By Romy Lauche PhD When Michael Phelps won the gold medal at the Rio Olympics, the whole world psyched out - about those mysterious purple marks on his body. Purple dots or blotches, giant â&#x20AC;&#x2DC;love bitesâ&#x20AC;&#x2122;, bruises, mysterious purple circles made the headlines, and cupping might again become a must-do. Manual therapists are probably familiar with Cupping, but this attracted media and social media uproar, with comments such as: fads, pseudoscience, superstitious, and load of hot air.
So what is cupping and how does it work? Cupping is probably as old as mankind. In ancient times, when medicine as we know it now was not invented yet, cupping was used to cure many ailments. The traditional cupping was a bloody business as the skin was punctured or cut before the actual cupping. It was literately used to suck out the toxins that made men sick. The modern (dry) cupping however is not nearly as archaic as it once was, and most cupping procedures do not involve the bloodletting anymore. One can even say that cupping has become a wellness intervention rather than a therapy, at least in the Western world. In Muslim cultures where cupping is part of the Prophetic Medicine the traditional bloody cupping is preferred still. 32 Terra Rosa E-mag No. 19
Cupping marks [CC BY 2.0 (http://creativecommons.org/ licenses/by/2.0)], via Wikimedia Commons
Cupping itself works with suction, and pretty much anything can be used, from special cupping devices to simple tea cups. The vacuum is created by fire or a mechanical pump, and the negative pressure will pull the skin into the cup. What happens than, has rarely been examined, but a few studies have shed some light into the hidden secrets of cupping. The application of the cupping glasses will suppress microcirculation as deep as 3 cm into the skin and tissues (Emerich et al., 2014). First evidence of that has been reported in 1827 already, when Martin
Cupping [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons
Barry examined the effects of subcutaneous poisoning in rabbits. When he applied the cupping glasses after subcutaneous arsenic injections nothing happened, but within moments after releasing the cups those poor animals would die of the poison (Chirali 2007). This indicates that microcirculation comes to a complete stop at the cupping site. When microcirculation is suppressed the tissue will be deprived of adequate oxygen supply, and this oxygen deficiency has been shown to increase lactate levels during and for up to several hours after cupping (Emerich et al., 2014). Such over-acidification bears the potential to damage nerves and tissues. As a result the body tries to resolve this state by dilating blood vessels to increase blood flow and oxygen supply (Modin et al., 2011; Hattori et al., 2002; Davis et al., 2011). This process is further amplified when small amounts of blood are forced to escape the capillaries and ‘leak’ into the surface tissues leaving the typical purple
cupping marks. Blood clots in the surface tissues will initiate a ‘clean-up campaign’ of the body, as they need to be evacuated to avoid further cell damage.
What is the evidence? There is only little evidence that dry cupping has beneficial effects. Small studies (Lauche et al., 2011, 2012, 2013; Kim et al., 2012; Cramer et al., 2011; Akbarzadeh et al., 2014; Markowski et al., 2014) found for example that cupping might help to improve neck and back pain, but the evidence is far from conclusive. At the current stage, there is also the possibility that the effects seen in those studies are largely driven by unspecific effects, known as placebo effects. A recent study has indeed found that the effects produced by cupping were comparable between the real intervention and the sham intervention in a sample of fibromyalgia patients (Lauche et al., 2015), however more Terra Rosa E-mag No. 19
studies are needed for conclusive judgement. As for the effects of cupping in athletes there is literally no data available at all. So while Russian TV likens cupping therapy to doping (https:// www.youtube.com/watch?v=V83CoTILr58) I fear it will not really improve athletes’ performance. It is even unclear if it can improve recovery from training, or muscle function. Nevertheless, the absence of evidence does not indicate ineffectiveness of cupping rather than little research interest in that topic so far. Let us hope that those celebrity situations help to spike interest in this widespread therapy to provide users and the critics with definite answers.
A word of caution! Notwithstanding the above, cupping therapy might come with a risk. It is important that cupping is not (or only under close supervision) to be used for people who have bleeding disorders, or take blood thinning medication, on infected skin, wounds or in the presence of certain skin conditions. Cupping with fire requires extra caution, and bleeding cupping implies special consideration regarding hygienic standards. Thus the application of cupping by experienced and qualified personnel is vital for a safe and effective treatment. Romy Lauche is a Chancellor’s post-doctoral research fellow at the Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), University of Technology Sydney. Romy has a background and qualifications in psychology (MSc), and received her PhD in medical sciences.
References Akbarzadeh M, Ghaemmaghami M, Yazdanpanahi Z, Zare N, Azizi A, Mohagheghzadeh A. The Effect Dry Cupping Therapy at Acupoint BL23 on the Intensity of Postpartum Low Back Pain in Primiparous Women Based on Two Types of Questionnaires, 2012; A Randomized Clinical Trial. Int J Community Based Nurs Midwifery. 2014; 2(2): 112-20. Chirali, I. Traditional Chinese Medicine Cupping Therapy. 2nd edition. Philadelphia, PA: Elsevier Churchill Livingston, 2007.
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Cramer H, Lauche R, Hohmann C, Choi KE, Rampp T, Musial F, Langhorst J, Dobos G. Randomized controlled trial of pulsating cupping (pneumatic pulsation therapy) for chronic neck pain. Forsch Komplementmed. 2011; 18(6): 327-34. Davis MJ, Hill M A, Kuo L. 2011. Local Regulation of Microvascular Perfusion. Comprehensive Physiology. 161–284. Emerich M, Braeunig M, Clement HW, Lüdtke R, Huber R. Mode of action of cupping--local metabolism and pain thresholds in neck pain patients and healthy subjects. Complement Ther Med. 2014; 22(1):148-58. Hattori K, Tsuchida S, Tsukahara H, Mayumi M, Tanaka T, Zhang L, Taniguchi T, Muramatsu I. Augmentation of NO-mediated vasodilation in metabolic acidosis. Life Sci. 2002; 71(12): 143947. Kim TH, Kang JW, Kim KH, Lee MH, Kim JE, Kim JH, Lee S, Shin MS, Jung SY, Kim AR, Park HJ, Hong KE. Cupping for treating neck pain in video display terminal (VDT) users: a randomized controlled pilot trial. J Occup Health. 2012; 54(6): 416-26. Lauche R, Cramer H, Choi KE, Rampp T, Saha FJ, Dobos GJ, Musial F. The influence of a series of five dry cupping treatments on pain and mechanical thresholds in patients with chronic non-specific neck pain--a randomised controlled pilot study. BMC Complement Altern Med. 2011; 11: 63. Lauche R, Cramer H, Hohmann C, Choi KE, Rampp T, Saha FJ, Musial F, Langhorst J, Dobos G. The effect of traditional cupping on pain and mechanical thresholds in patients with chronic nonspecific neck pain: a randomised controlled pilot study. Evid Based Complement Alternat Med. 2012; 2012: 429718. Lauche R, Materdey S, Cramer H, Haller H, Stange R, Dobos G, Rampp T. Effectiveness of home-based cupping massage compared to progressive muscle relaxation in patients with chronic neck pain--a randomized controlled trial. PLoS One, 2013; 8(6): e65378. Lauche R, Schwahn B, Spitzer J, Cramer H, Ostermann T, Bernardy K, Dobos G, Langhorst J. Efficacy of cupping therapy in patients with the fibromyalgia syndrome – a randomized shamcontrolled controlled trial. Integrative Medicine Research, 2015, 4(1): 20. Markowski A, Sanford S, Pikowski J, Fauvell D, Cimino D, Caplan S. A pilot study analyzing the effects of Chinese cupping as an adjunct treatment for patients with subacute low back pain on relieving pain, improving range of motion, and improving function. J Altern Complement Med. 2014; 20(2): 113-7. Modin A, Björne H, Herulf M, Alving K, Weitzberg E, Lundberg JO. Nitrite-derived nitric oxide: a possible mediator of 'acidicmetabolic' vasodilation. Acta Physiol Scand. 2001; 171(1): 9-16.
My Experience in Rio 2016 By Ali Rubie
“In the Olympics, as in life, it’s not the victory that matters most, but the struggle, the taking part” - Pierre du Combertin. The word ‘struggle’ broken down in Greek simply means to agonise. Embracing the agony actually is the victory. Olympic athletes speak about their race as being the most brutal, the most intense they have experienced, and they usually can’t wait to do it again! An Olympic cycle has come to a close, and the journey for all involved – athletes, families, officials, volunteers, and spectators has been full of joys, and ups and downs. Rio de Janeiro, cidade maravilhoso (the marvellous city), lived up to it’s promise to provide a wonderful location for a safe and memorable games. We were lucky enough to be there to cheer our daughter on in Athletics, in the 400m individual where she raced the world’s best reaching
the semifinal, and the 4 x 400m relay where they made the Olympic final. As with any previous Olympics, (except for London perhaps), the lead up was full of negative stories in the media of what to expect. Generally these were overstated, but there were some issues to contend with. The rooms in the Athletes village were very small, and with the budget cuts the food in the athletes’ food hall was unvaried and sometimes not sufficient. There were weather challenges – this being the first summer games held entirely in the winter! (The rowers certainly experienced the August winds springing up!) And crucially, there were less team support staff allowed in the village, including physios and massage therapists, owing to space and Terra Rosa E-mag No. 19
accreditation restrictions, than any games previously. However, any sporting event has it’s own challenges and it is part of the planning process to anticipate and prepare for those factors that can be controlled, and accept and try to mitigate those that can’t.
What is it like to be an Olympic athlete’s parent? It is such an emotional time – it can be overwhelming even for the general audience, seeing the competition between the finely tuned athletes at their physical peak. The intensity of the emotions a parent feels comes from years of watching their child’s dream develop and from supporting them throughout. As a family, everyone makes a contribution, from transporting them to training in the early years, or practical help like doing their laundry during busy times, to only having nutritious food in the house – no ‘snack food’, and keeping quiet at times to allow the athlete much needed sleep. Advice is given when needed, or soft tissue treatment (in my case), and occasionally we have had to help pick up the pieces when hopes shatter after a disappointing result. The joy of seeing them on the Olympic stage, their goals achieved, marvelling at their accomplishments in the face of such pressure, involves all these memories.
What advice can I pass on? It is a 4 year Olympic cycle and the planning starts now for the next one. Over 4 years, an athlete will train for around 7000 hours. Peaking for competition is a science, but the art is in the daily decisions made. Recovery, including massage, is often the missing ingredient. It is during recovery however, that the adaptation to the training stimulus occurs. During the competitive season, Cathy Freeman would have a daily massage to help her body maintain high performance. Michael Johnson’s massage therapist would also assess his tissue condition daily with treatment before training began so his session could be modified if necessary. In the weeks/ days before major races, it is not the time to try something new, whether on the track, in the gym, or in the clinic. If daily treatment in an intensive competition period is the goal, allow the athlete’s body to become used to receiving this frequency of treatment, so performance is not affected. This applies to key training sessions as well. Ideally the therapist and athlete have worked together before the major event so the therapist knows how the athlete’s body responds, enabling efficiency 36 Terra Rosa E-mag No. 19
with minimal treatment. If not, generally the athlete knows what they need to best prepare them for the next round. Don’t let niggles develop at any time – treat them immediately. Educate your athlete about body awareness – they are very reluctant to reduce training loads for what seems to be a small concern. A modification of a session or a little more rest for 2 or 3 days can save 2 or 3 weeks forced rest later. Injury most often occurs in the connective tissue – look after the fascia with training and soft tissue treatment that targets it for an injury-proof, resilient athlete. I thoroughly recommend George Kousaleos’ CORE Myofascial Therapy. And above all, enjoy the event – there’s nothing else quite like the Olympics. It really is something to celebrate!
CORE MYOFASCIAL THERAPY with George Kousaleos Sydney, October 2017 "George Kousaleos was one of the most influential people in the manual therapy profession on my career and my success. His amazing CORE Myofascial Therapy training should be the foundation of every manual therapist's practice. His incredible knowledge of the human body, his compassion, and his kind heart, make him one of my greatest mentors in the manual therapy” - James Waslaski LMT; Author & International Lecturer Integrated Manual Therapy & Orthopedic Massage
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Sydney CORE Myofascial Therapy 1: 20,21,22 October 2017 CORE Myofascial Therapy 2: 23,24,25 November 2016 An intermediate to advanced, six-day workshop designed to give practicing massage therapists in-depth knowledge and hands-on experience in full-body myofascial treatment protocols. With this knowledge and skill, you will be able to improve your clients’ structural body alignment and increase their physical performance.
This 3-day seminar will examine the basic styles of performance inherent in all athletic disciplines. Utilizing structural integration and myofascial therapy theories and techniques that are appropriate for each style of performance, we will focus on developing training and event protocols for endurance, sprint, power, and multi-skilled athletes.
“Getting the basic Myofascial Spreading done on my first day resulted in a dramatic improvement of my body alignment “ Mic, Townsville
George Kousaleos, LMT is the founder and director of the Core Institute, a school of massage therapy and structural bodywork in Tallahassee, FL. He is a graduate of Harvard University, and has practiced and taught Structural Integration, Myofascial Therapy and Sports Bodywork for the past 30 years. George has served as a member of the Florida Board of Massage Therapy and was Co-Director of the International Sports Massage Team for the 2004 Athens Olympics.
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Terra Rosa E-mag No. 19
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Growing Hands With Myofascial Therapy George Kousaleos helped a football player grows his hand size by half an inch.
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The size of one’s hand appears to be an important criterion set by the US National Footbal League (NFL) teams for selecting their next player. The minimum benchmark hand size for a quarterback is 9 inches (or 23 cm) measured from the tip of the thumb to the tip of the little finger with fingers spread apart. A larger hand can supposedly make a player easier to handle the ball, and better grip on the ball in rainy weather. Brandon Allen, a quarterback from the University of Arkansas, entered the NFL draft or selection process early in 2016, came up short of NFL standards with hand size measured at 8½ inches. Conventional wisdom would establish that Brandon’s hand size could not be increased, and his place in the NFL draft would be compromised. However, Brandon wouldn't accept that. At the XPE training facility in Boca Raton, Florida, he met George Kousaleos (Read about the XPE training with George in the last issue of our e-magazine). George had an idea, in George Kousaleos with his signature Velvet Glove and Myo2015 he used his signature CORE myofascial therfascial Spreading of the hand. apy to increase the foot and ankle mobility of Jameis Winston, Florida State University’s star the Jacksonville Jaguars in the 6th round of the NFL quarterback and also the first player selected in the Draft. 2015 NFL draft. George Kousaleos, utilised myofascial spreading techniques, worked on hands muscles and joints, was able to increase Brandon Allen’s hand size to 8 7/8 inches, an increase of three-eighths of an inch (or 9.5 mm) in about a month. This raised eyebrows in the media, with news headline such as “Size matters? QB Brandon Allen trying to make his hands bigger”, “Arkansas QB Brandon Allen actually grew his hands for the NFL Draft Combine”, “Brandon Allen using therapy to increase hand measurement”. Brandon Allen explained his “hand growing treatment” in an article in Sports Illustrated: Basically, all these muscles in my hand are very tight. So George is working out these muscles so that my hand kind of opens up a little more when I stretch it. Allen also has to do plenty of stretching home work. With continued hand exercises given by George , Brandon achieved the 9 inches mark. He was drafted by
Spreading Your Fingers can make you swim faster Researchers found that spreading the fingers 10 degree can make free-style swimming up to five per cent more efficient than keeping the fingers together. The study from the Eindhoven University of Technology found that spreading fingers increases the drag of the hand through the water. The team used 3D-printed plastic hand and arm models and measured the impact of five different conditions of finger spread at various degree in which the thumb remained in a fixed position. They found that the model with its fingers spread 10° created the most drag because a slight opening between the fingers obstructed air flow. The greater the drag, the better the hand is at generating thrust in the water . The researchers calculated that a finger spread of 10° could boost a swimmer’s speed by 2.5% compared with swimming with fingers held together. This translates into several tenths of a second over a 50-meter freestyle race, which could make a difference in elite swimming competitions.
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The Walking/Gait Cycle and Its Relationship to the Pelvis John Gibbons Most of us, I would say, take walking for grantedâ&#x20AC;&#x201D;it is something that we just do without understanding what exactly is going on â&#x20AC;Ś until we suffer pain somewhere in our body, and then the simple action of walking becomes very painful. What I would like to do in this chapter is examine in detail what exactly takes place when we walk (you might want to go through some of the movements yourself as they are described) and the relationship of the gait cycle to both the pelvis and the kinetic chain.
The gait cycle is divided into two main phases: the stance phase and the swing phase. Each cycle begins at initial contact (also known as heel-strike) of the leading leg in a stance phase, proceeds through a swing phase, and ends with the next contact of the ground with that same leg. The stance phase is subdivided into heel-strike, mid-stance, and propulsion phases.
Human gait is a very complicated, coordinated series of movements. An easier way of thinking about the gait cycle is to break it down into phases. The stance Gait Cycle phase is the weight-bearing component of each cyDefinition: A gait cycle is a sequence of events in cle; it is initiated by heel-strike and ends with toe-off walking or running, beginning when one foot confrom the same foot. The swing phase is initiated with tacts the ground and ending when the same foot con- toe-off and ends with heel-strike. It has been estitacts the ground again. mated that the stance phase accounts for approxi-
Figure 1. Stance and swing phases of the gait cycle.
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Figure 2. The position of the leg just before heel-strike.
mately 60% of a single gait cycle, and the swing phase for approximately 40%, as shown in Figure 1.
Figure 3. A person walking, with the posterior (deep) longitudinal sling muscles highlighted.
Heel-strike Mid-stance Stance phase Swing phase Propulsion Figure 1. Stance and swing phases of the gait cycle.
As a result of the ankle and foot being in a position of dorsiflexion and supination, the tibialis anterior (which is the main muscle responsible for this anatomical position, with an insertion on the medial cuHeel-Strike neiform and 1st metatarsal on the foot) is now part If you think about the position of your body just be- of a link system that we will call a myofascial sling fore you contact the ground with your right leg dur- (see Chapter 3 of the Functional Anatomy of the Peling the contact phase of the stance phase, the right vis and the Sacroiliac Joint). This sling, starting from hip is in a position of flexion, the knee is extended, the initial origin of the tibialis anterior, continues as the ankle is dorsiflexed, and the foot is in a position the insertion of the peroneus longus (onto the 1st of supination, as shown in Figure 2. The tibialis ante- metatarsal and medial cuneiform, as in the case of rior muscle, with the help of the tibialis posterior, the tibialis anterior) to its muscular origin on the works to maintain the ankle/foot in a position of lateral side and head of the fibula. This bony landdorsiflexion and inversion (inversion is one part of mark is also where the biceps femoris muscle inthe motion referred to as supination). serts. In normal gait, the foot strikes the ground at the beginning of the heel-strike in a supinated position of approximately 2 degrees. A normal foot will then move through 5–6 degrees of pronation at the subtalar joint (STJ) to a position of approximately 3–4 degrees of pronation, as this will allow the foot to function as a “mobile adaptor.
The sling now continues as the biceps femoris muscle toward its origin on the ischial tuberosity, where the muscle attaches to the tuberosity via the sacrotuberous ligament; often the biceps femoris directly attaches to this ligament rather than to the ischial tuberosity, and some authors have mentioned that potentially 30% or more of the biceps femoris atTerra Rosa E-mag No. 19
Figure 4a. Right ilium in posterior rotation—sacrotuberous ligament tensioned. Figure 4c. Right ilium in posterior rotation—left ilium in anterior rotation and sacrum rotated on the L-on-L axis.
spinae, which continue to the base of the occipital bone. This myofascial sling is known as the posterior longitudinal sling (PLS) or the deep longitudinal sling (DLS), as shown in Figure 3.
Figure 4b. Position of the leg just before heel-strike, with the biceps femoris and sacrotuberous ligament tensioned.
taches directly to the ILA of the sacrum. Vleeming et al. (1989a) found that in 50% of subjects, part of the sacrotuberous ligament was continuous with the tendon of the long head of the biceps femoris. The sling then carries on as the sacrotuberous ligament, which attaches to the inferior aspect of the sacrum at the ILA and fascially connects to the contralateral (opposite side) multifidi and to the erector 42 Terra Rosa E-mag No. 19
Even before you initiate the contact to the ground through heel-strike, dorsiflexion of the ankle (by the contraction of the tibialis anterior) initiates a coactivation of the biceps femoris and peroneus longus just prior to heel-strike. Studies have shown that the biceps femoris communicates with the peroneus longus at the fibular head, transmitting approximately 18% of the contraction force of the biceps femoris through the fascial system into the peroneus longus muscle. This co-contraction therefore serves to “wind up” the thoracolumbar fascia mechanism as a means of stabilizing the lower extremity; this results in the storage of the necessary kinetic energy that will subsequently be released during the propulsive phase of the gait cycle. The posterior (deep) longitudinal sling as described is being fascially tensioned; the increased tension is focused on the sacrotuberous ligament via the attachment of the biceps femoris, as shown in Figure 4b. This connection will assist the force closure mechanism process of the SIJ; in simple terms, this creates a self-locking and stable pelvis for the initia-
tion of the weight-bearing gait cycle. You may also notice that the right ilium (see Figure 4aâ&#x20AC;&#x201C;c) undergoes posterior rotation during the swing phase, which will assist the force closure of the SIJ because of the increased tension in the sacrotuberous ligament. You can also see from Figure 4c , that there is now tension developing within the right sacrotuberous ligament because of the contraction of the biceps femoris as well as the posterior rotation of the right innominate; at the same time, the left innominate is rotating anteriorly and the sacrum has rotated on the left oblique axis (L-on-L). This specific motion of the lumbopelvic hip complex occurs all at the same time as the right heel-strike. For the next phase, you might want to stand and slowly go through the following movements so that you can get a sense of what happens with your body in the normal walking cycle. As explained above, just before the heel-strike phase your hip will be flexed, your knee extended, and your ankle dorsiflexed with the foot supinated. The tibialis anterior and tibialis posterior maintain this position of the ankle and foot, and as you contact the ground, these two muscles are responsible for controlling the rate of pronation through the STJ by contracting eccentrically. As your right leg moves from heel-strike to toe-off (stance phase), your body weight begins to move over your right leg, causing your pelvis to shift laterally to the right. As the movement continues toward toe-off, your right pelvic innominate bone begins to rotate anteriorly while your left innominate bone begins to rotate posteriorly. As you proceed through the gait cycle, you now enter the mid-stance phase of gait. This is where the hamstrings should reduce their tension because of the natural anterior rotation of the pelvis and the slackening of the sacrotuberous ligament. Form closure at this point is gradually lost during the latter part of the stance phase, so that stability at this point is chiefly maintained through force closure. This is the point during the mid-stance phase where the Gmax on the right side should take the role of
Figure 5. A person running, with the posterior oblique sling muscles highlighted.
the continued movement of lower limb extension, as well as working in concert with the contralateral latissimus dorsi (left side). The active contraction of these two muscles increases the tension in the thoracolumbar fascia (posterior oblique sling), thus providing the necessary force closure stability to the right SIJ during the mid-stance phase of gait. I would like to elaborate a little more on this process. Phasic contraction of the Gmax occurs in the mid-stance phase; the Gmax simultaneously contracts with the contralateral latissimus dorsiâ&#x20AC;&#x201D;it is this muscle that will extend the arm through what is known as counter-rotation, to assist in propulsion. The thoracolumbar fascia, which is a sheet of connective tissue, is located between the Gmax and the contralateral latissimus dorsi; this fascial structure is forced to increase its tension because of the contractions of the Gmax and latissimus dorsi. This increased tension will assist in stabilizing the SIJ of the stance leg through the force closure mechanism. Terra Rosa E-mag No. 19
Figure 6b. Sacral rotation and lumbar counter-rotation superimposed on the pelvic girdle.
component (consisting of the continuations of the Gmax), which acts to increase the tension of the iliotibial band (ITB); this helps to stabilize the knee during the stance phase of gait. Figure 6a. Sacral rotation and lumbar counter-rotation.
As we progress from the mid-stance phase to heellift and propulsion, the foot begins to re-supinate and passes through a neutral position when the proIn Figure 5 you can see that just before heel-strike, pulsive phase begins; the foot continues in supinathe Gmax will reach maximum stretch as the latistion through toe-off. As a result of the foot supinating simus dorsi is being stretched by the forward swing during the mid-stance propulsive period, the foot is of the opposite arm. Heel-strike signifies a transition converted from a “mobile adaptor” (which is what it to the propulsive phase of gait, at which time the is during the contact period) to a “rigid lever” as the Gmax contraction is superimposed on that of the mid-tarsal joint locks into a supinated position. With hamstrings. the foot functioning as a rigid lever (as a result of the As explained in the previous paragraphs, activation locked mid-tarsal joint) during the time immediately of the Gmax occurs in concert with contraction of the preceding toe-off, the weight of the body is propelled contralateral latissimus dorsi, which is now extend- more efficiently. ing the arm in unison with the propelling leg. The synergistic contraction of the Gmax and the contra- Pelvis and SIJ Motion lateral latissimus dorsi creates a state of tension Next we will take a look at the pelvis and how it within the thoracolumbar fascia, which will be refunctions during the mid-stance phase of the walking leased in a surge of energy that will assist the muscycle. As the right innominate bone starts to rotate cles of locomotion. This stored energy within the anteriorly from an initial posteriorly rotated posithoracolumbar fascia helps to reduce the overall ention, the tension of the right sacrotuberous ligament ergy expenditure of the gait cycle. Janda (1992, is reduced, and the sacrum will be forced to move 1996) mentions that poor Gmax strength and activa(passively) into a right torsion on the right oblique tion is postulated to decrease the efficiency of gait. axis (R-on-R). In other words, the sacrum rotates to The posterior oblique sling also contains a lower 44 Terra Rosa E-mag No. 19
the right and side bends to the left, because the left sacral base moves into an anterior nutation position (this is also known as Type I spinal mechanics, as the rotation and side bending are coupled to opposite sides); the motion is illustrated in Figure 6a. We also need to mention and consider that, as the left side of the sacrum moves forward into nutation, the right side of the sacral base will move backward into counter-nutation (R-on-R); this is mainly because of the slackening of the right sacrotuberous ligament and the continual anterior rotational movement of the right innominate bone during midstance. Owing to the kinematics of the sacrum, the lumbar spine rotates left (opposite to the sacrum) and side bends to the right (Type I mechanics), as shown is Figure 6b. The thoracic spine rotates right (same as the sacrum) and side bends to the left, and the cervical spine rotates right and side bends to the right. The cervical spine coupling is opposite to that of the other vertebrae, since its specific spinal motion is classified as Type II spinal mechanics (Type II means that rotation and side bending are coupled to the same side).
Figure 7. A person running, with anterior oblique sling muscles highlighted.
As the left leg moves from weight bearing to toe-off, the left innominate, the sacrum, and the lumbar and thoracic vertebrae undergo sacral torsion, rotation, and side bending in a similar manner to that described above, but with movements in the opposite directions.
the cycle of adductor activity in gait, Basmajan and De Luca (1979) found that both sets of muscles (obliques and adductors) contribute to stability at the initiation of the stance phase of the gait cycle, as well as to the rotation of the pelvis and the action of pulling the leg through during the swing phase of The anterior oblique also works in conjunction with gait. (This was also demonstrated by Inman et al. the stance leg adductors, ipsilateral internal oblique, (1981).) As the speed of walking increases to runand contralateral external oblique muscles, as shown ning and sprinting speeds, the activation of the antein Figure 4.7. These integrated muscle contractions rior oblique system becomes more prominent as well as a necessity. help stabilize the body on top of the stance leg and assist in rotating the pelvis forward for optimum The swing phase of gait utilizes the lateral sling syspropulsion in preparation for the ensuing heeltem, as we have now entered the single-leg stance strike. position. This sling connects the Gmed and Gmin of The abdominal oblique muscles, as well as the adductor muscle group, serve to provide stability and mobility during the gait cycle. When looking at the EMG recordings of the oblique abdominals during gait and superimposing them on
the stance leg, and the ipsilateral (same side) adductors, with the contralateral (opposite) QL. Contraction of the left Gmed and adductors stabilizes the pelvis, and activation of the contralateral QL will assist in elevation of the pelvis; this will allow enough lift of the pelvis to permit the leg to go through the Terra Rosa E-mag No. 19
The way our axial skeletal system alternately undulates in side bending and rotation as we walk is very interesting and extremely important to our overall well-being. It is a movement that is reminiscent of the undulating action of a snake as it slithers through the grass. The big difference between a snake and a human, of course, is that our snakelike spine has ended up being given two legs on which to walk.
Summary of the Sacrum and the Gait Cycle To summarize the gait cycle and the specific motion of the sacral spine, the sacrum is capable of left rotation on the left oblique axis (L-on-L), from which it then returns to a neutral position. From this neutral Figure 8. An example of the swing phase of gait, with lateral position the sacrum then rotates to the right on the sling muscles highlighted on the single-stance leg. right oblique axis (R-on-R) and again returns to neuswing phase of gait. The lateral sling plays a critical tral. The movement of the sacrum is anterior in its nature as it undergoes the earlier-described motion role, as it assists in stabilizing the spine and hip of nutation. The forward nutational movement durjoints in the frontal plane and is a necessary coning walking is anterior on one side, followed by a tributor to the overall stability of the pelvis and return to the neutral position; anterior nutation then trunk. occurs on the opposite side, before the sacrum again Not only does the lateral sling system provide stabil- returns to neutral. This process is continually reity that protects the working spinal and hip joints, peated. According to various studies, the motion of but it is also a necessary contributor to the overall posterior nutation (counter-nutation) does not apstability of the pelvis and trunk. Should the trunk pear to extend past the neutral position during the become unstable, the diminished stability will com- normal walking/gait cycle. promise oneâ&#x20AC;&#x2122;s ability to generate the forces necessary for moving the swing leg quickly, as required in many work and sports environments. Attempts to This is an extract from the book Functional Anatomy move the swing leg, or to generate force with the of the Pelvis and the Sacroiliac Joint: A Practical Guide stance leg during gait and other functional activities, by John Gibbons, Lotus Publishing. Reproduced with can easily disrupt the SIJs and symphysis pubis and permission. cause kinetic dysfunction in joints throughout the Read also 6 Questions to John Gibbons on Page 65. entire kinetic chain. Maitland (2001) mentions that proper body movement while walking is influenced by the ability of the sacrum to cope with left torsion on the left oblique axis (L-on-L) and right torsion on the right oblique axis (R-on-R). Since most walking is accomplished with the vertebral column relatively upright and vertical, for the purpose of this discussion we will assume that your spine and sacrum are in neutral while you walk. 46 Terra Rosa E-mag No. 19
Author and respected bodywork specialist, John Gibbons, looks at one of the most important areas of the body: the pelvis and the sacroiliac joint. He takes readers on a fascinating journey of enlightenment, teaching us to recognize pain and dysfunctional patterns that arise from the pelvic girdle. Gibbons addresses key issues such as: The walking/gait cycle and its relationship to the pelvis Leg length discrepancy and its relationship to the kinetic chain and the pelvis The laws of spinal mechanics The relationship of the hip joint, gluteal muscles, lumbar spine to the pelvis Sacroiliac joint screening
Available now at www.terrarosa.com.au Terra Rosa E-mag No. 19
Iliotibial BandA piece of the body from a body in pieces A Clinical Anatomists View John Sharkey
Clinical Anatomist, Exercise Physiologist, Neuromuscular Therapist. MSc., Department of Clinical Sciences, University of Chester/NTC, Dublin , Ireland
Figure 1. This is a section of the Iliotibial band. No amount of pulling will lengthen it. I would caution that this ITB is outside the body and therefore outside its natural environment, alone, with no innervation and no life force. (Image: Sharkey, J 2010).
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Figure 2. A microvacuole can change shape (adapt) by stretching, widening, or shortening, and still be able to return to its initial shape. These changes occur simultaneously and in synchrony with the movements of the fibrillar system to return to its initial shape. (60 × magnifications). From Guimberteau, 2016, Handspring Publishing). (Note from John Sharkey: I would substitute the word “stretching” and replace it with “lengthening”)
This short article is in response to the excellent comments provided by a host of respected bodywork therapists reported in the Terra Rosa e-Mag (Issue 18) regarding research concerning the Iliotibial band (ITB). While I agree with much of the comment provided by the various authors I am compelled (wearing my Biotensegrity-Anatomy for the 21st century hat) to encourage a new view of human connective tissue. My supposition is that the wrong language and the wrong scientific methodology are currently being used. My proposition is that living connective tissue should not be, and does not respond well to being, stretched. Also human architecture does not allow for “Sliding” of tissues only “Gliding”. The use of these words, in my humble opinion, needs careful consideration to support a new paradigm. Tissues deeper to the skin move relative to each other, that is, they glide (not slide) relative to each other. Finally in human anatomy we need a new vision regarding what it is we are researching. I believe we are researching biological soft matter.
Following the excellent comments by various leading authorities it was interesting to find, in the same edition, the short interview with Dr Jean-Claude Guimberteau. It is worth taking time to view the photographs that supported that interview as they represent the first of such recorded images of living connective tissue (Figure 2). These historical images provided by Dr Guimberteau demonstrate a new vision of anatomy, one that could never have been imagined as a result of traditional cadaveric investigation until the development of Thiel soft fixed cadavers. Dr Guimberteau and myself have begun exploring the tissues of Thiel cadavers with endoscopic investigation. Even in living tissues once atmospheric air comes into contact with connective tissues beneath the skin we immediately encounter changes as emergent properties. These emerging properties change the consistency, texture and response of living tissues so that caution must be encouraged regarding scientific findings or assumptions based on such evidence. Once tissue has been cut out and removed from the body it has no Terra Rosa E-mag No. 19
frain from using the term however I want to encourage a move away from this term to “lengthening”. Unfortunately, scientists make the assumption that muscles and fascia are Hookean materials and therefore follow Hooke’s Law. Hooke’s law relates to the amount a material changes in length (the strain) being directly proportional to the applied force (the stress). In solid materials this is a linear relationship but in soft matter (such as fascia and muscle fibers which are themselves fascia) the relationship creates a very different curve called the “J curve”.
Figure 3. Dr. Jean Claude Guimberteau and Clinical Anatomist John Sharkey. Both presented at the Biotensegrity informed Dissection course in June 2016. This dissection course is an annual event held in Dundee University, Scotland (Details: http://www.ntc.ie/course/uk-courses/ human-anatomy-dissection-seminar-dundee )
This is a shortcoming in scientific investigations/ research into living architecture. If we applied Hooke’s law to biological systems, such as human beings, we would have much heavier, limited and less resilient systems. In Hookean material Young’s Modulus is a constant, and the resultant Poisson’s Ratio is a constant. When a connective tissue “lengthens” (as when we are,what we currently call, “stretching") what, in fact, is happening is the tissue is lengthening through its physiological range. This physiological range can be restricted by neural activity and adhesions and it may well benefit from soft tissue hands on therapeutic interventions to restore normal range. However you do not want to “stretch” living tissues as to do so will have negative consequences. I believe that when therapists use the term “stretching” they, in fact, mean “lengthening”. Is it too late or too much to expect that we can change our vocabulary in an effort to be more scientifically correct?
nervous system, no breath, no life force and no connection with the whole. A connection of continuity it would have enjoyed for a lifetime is removed. Every anatomy and biomechanics book describes knee cartilage tissue as a “shock absorber” and we The initial revelation coming out of the excellent reaccept that notion even though we also know that search by Falvey et al (2010) is that it is virtually running or other high impact activities result in impossible to stretch the Iliotibial band. The point I forces up to 12 times our body weight crushing wish to make to all bodywork and movement theradown on our joints. In vivo, cartilage tissue has the pists is that it is not possible to stretch any living consistency of boiled egg white. Biotensegrity strucconnective tissue without causing damage, much of tures dissipate stress in a non-linear manner mainwhich is irreversible. There is currency in Til Lutaining the integrity of the joint space and ensuring chau’s comment when he suggests “our methods still the cartilage is not compressed. It would not make get results; it’s our explanations that need updating”. sense that in healthy joints the bones would move In both bodywork and movement therapies the term closer together at the knee thus compressing the me“stretching” is widely used but wrongly used. I real- niscus tissue. Yet we accept this theory as fact. ize it would be fruitless to ask practitioners to re50 Terra Rosa E-mag No. 19
Figure 4. The splash down effect.
The term “stretching” reflects a dynamic of forces per unit area acting on a solid material causing it to elongate within its elastic limits. All connective tissues operate under continuous tension that is self generated and described as “pre-stress”. The heart of the problem is that there are several assumptions made in research regarding biologic tissues that are not valid. Biologic tissues, including muscles, bones and fascia, have nonlinear stress/strain curves.
Figure 5. Magic Putty stiffens and bounces on impact with a hard floor while slow sustained compression causes the putty to yield and conform to the shape of a thumb.
To take it a step further, Muscle and fascia (here I include the Iliotibial Band) are not isotropic, linear This means that there is no valid Young’s modulus, elastic material. They are anisotropic, and should not as the Young’s modulus is dependent on the slope of be expected to behave as isotropic matter does. They that curve, and since it is constantly changing, so is more closely resemble polymer foams such as Silly Young’s modulus. Poisson’s ratio is directly dependPuttyTM and Green Slime that children love to play ent on Young’s modulus and, if you cannot depend with. As my mentor Dr Stephen Levin says “You are on Young’s modulus, you cannot depend on Poisthe froth on your morning cappuccino”. Connective son’s ratio. tissues may even have auxetic material properties, The ear offers a perfect tactile example for readers to expanding or contracting in all directions and getting experience a nonlinear stress/strain curve. Place the thicker and longer at the same time. This can be seen in the so-called “muscular hydrostats", including spatula of your thumbs behind your ear lobes and frogs tongues, elephant’s trunks, and others (Kier, clasp them with your third finger while you place 2012. Kier et al 1985. Vogal, 2003). your second finger into your ear in front of the tragus cartilage (Fig. 4). Now gently pull your ear lobes Hooke’s Law, Young’s Modulus and Poisson’s Ratio, out and down. The tissue will lengthen and go are physical properties that apply to “Hard Matter” through its physiological range before you feel it stable solids that are isotropic linear elastic. Biologic reaching a point beyond which it is impossible to tissues such as the Iliotibial Band are “soft matter”. lengthen. No matter how hard you pull the tissue it Take some magic putty and roll it into a ball. Now will not lengthen unless you use sufficient force to drop the ball from your hand to a hard floor (Fig 4). result in tissue damage. This slowing down and reThe ball will stiffen on impact with the floor and sistance to further elongation is known as the bounce back up towards your hand returning stored “splash down effect”. energy. Now place the ball of putty on a table and Terra Rosa E-mag No. 19
slowly allow your thumb or other digit to sink into the putty. You will notice the putty conforms to the shape of your thumb or digit. Connective tissues behave and respond in a similar manner such as on heel strike when walking. Connective tissues stiffen in response to high intensity impacts but conform and yield to low intensity, slow compression and force. To quote Oxford University Condensed Soft Matter Physics Lab, “Biology is soft matter come alive”. Soft matter has its own set of physics rules and cannot, nor should not, be bound by hard matter physics rules any more than gases or liquids are stuck with those rules. John Sharkey, Clinical Anatomist, Exercise Physiologist, Neuromuscular Therapist. MSc., Department of Clinical Sciences, University of Chester/NTC, Dublin , Ireland. E-mail address: firstname.lastname@example.org www.johnsharkeyevents.com
Robert Schleip’s comment Following on the discussion of Falvey et al.’s paper, Robert Schleip PhD commented: "Stimulating mechanosensory nerve endings in the IT band could very well trigger resulting downstream effects in the tonus of related muscle portions (gluteus maximus, tensor fascia latae, vastus lateralis) as well as in the blood/ lymph supply to this band. In addition the inherent fibroblasts in this tissue may react via changes in their metabolism and cytokine expression during subsequent hours. See currently fashionable concepts about manual therapy, which usually include neuromyofascial reflexes and autonomic responses, etc. Of course you will miss these potential responses in a cadaver study.“
4. Sharkey, J. 2008 Concise Book of Neuromuscular Therapy. A Trigger Point Manual. Lotus Publishing and North Atlantic Press.
References 1. Levin, S. M., 1982. Continuous tension, discontinuous compression, a model for biomechanical support of the body. Bulletin of Structural Integration, Rolf Institute, Bolder:31-33. 2. Ingber DE. 2008. Tensegrity-based mechanosensing from macro to micro. Prog Biophys Mol Biol. 97(6 -3):163-179. 3. Scarr, G. M., 2014. Biotensegrity, The Structural Basis of Life. Handspring Publishing Ltd. ISBN: 9781909141216.
5. Avison, J. 2015. YOGA Fascia, Anatomy and Move- ment. Handspring Publishing Ltd. 6. Falvey, E. C., R. A. Clark, A. Franklyn- Miller, A. L. Bryant, C. Briggs, and P. R. McCrory. "Iliotibial band syn- drome: an examination of the evidence behind a number of treatment options." Scandinavian Journal of Medicine & Science in Sports 20, 4 (2010): 580-587.
A major development in the safe and effective treatment of myofascial trigger points and myofascial pain, this book is a concise, comprehensive, and well-illustrated reference on dry needling. John Sharkey—an international authority on myofascial trigger points, myofascial pain, myofascial trigger point dry needling, and neuromuscular therapy as well as an accredited clinical anatomist—draws on his thirty years of experience in bodywork and movement therapy to provide accurate and essential criteria for the identification and subsequent treatment of myofascial trigger points through the exclusive use of a fine, filiform needle. This book describes the origin, etiology, and pathophysiology of the myofascial trigger point as well as indications and contraindications for myofascial trigger point dry needling. Available at www.terrarosa.com.au
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An Interview with Christopher-Marc Gordon Can you tell us a bit about yourself? I'm a state-registered British Physiotherapist, Myofascial Osteopath, as well as a state-registered German Naturopathic Physician. At our Clinic we have a lot of experience treating myofascial tissues, with a particular emphasis on the psycho-physiological connection on how our autonomic nervous system reacts to pain and vice-versa, or how it affects the myofascial-skeletal system.
silience training courses using the Fascia-ReleaZer for the general public. I also teach this approach in the corporate industries.
How did you come up with the idea of the Fascia-ReleaZer?
The idea was conceived in September 2011 when conducting a pilot investigation on myofascial shoulder pain. We learned from systematically studying the biomechanical stiffness in shoulder tissues that I have a Clinic and research institute called the Cen- pain could significantly reduce the tissue’s elasticity, ter for Integrative Therapy (CIT) Research in Stutt- thereby markedly restricting the range of movement. gart, Germany, which collaborates with the Universi- We presented our findings from this pilot study, ties of Ulm, Dr. Robert Schleip; Tübingen, Prof. Niels "Assessment of Myofascial Trigger Point Release Birbaumer; Memphis, Prof. Frank Andrasik (USA); with a Novel Myometer (MyotonPRO)”, at the Fascia Alliant California, Prof. Richard Gevirtz (USA), and Research Congress in Vancouver in 2012. The Palma de Mallorca, Prof. Pedro Montoya (Spain). MyotonPRO served as our main measurement device Thus, we have five different academic institutions because it is non-invasive and relatively quickly is lending their support to us. Our group is particularly able to provide highly reliable measures of the viscointerested in the subjects of pain and stress, leading elastic and biomechanical behaviour of tissue. us to focus intently on the autonomic nervous sysWhile working on the shoulder pain study, we saw tem. that we could actually objectify the measurement of We are based in Stuttgart and since our opening, in tensional tissue, and learned that we were able to 1990, we have worked with over a hundred thoureduce stiffness and enhance the elasticity of tissue sand patients, employing a large team of 9 to 10 by using a special sequence of manual grips. I sudtherapists, in the intervening 26 years. Since 1998, I denly realized the power and potential impact it have been teaching myofascial therapeutic osteocould have if we could develop an instrument that pathic courses, which have been the focus of our would enable patients to apply our techniques by work. Most recently I have begun to teach fascia reTerra Rosa E-mag No. 19
What was the study presented at the 2015 Fascia Congress? We actually performed two related studies—one was with 111 break dancers, the other was a followup -study with 30 of the break dancers. Break dancers in Germany are viewed as athletes; they are typically very fit and enthusiastic young university students. One of my leading research colleagues is an avid break dancer, and she was able to round up the needed volunteers. The 111 break dancers were randomly assigned to an intervention or a control condition. The intervention group performed a self-help Various prototypes of Fascia-ReleaZer (photo courtesy of Christreatment using the Fascia-ReleaZer® only on the topher Gordon). right leg, focusing on the quadriceps muscle and the iliotibial band. After eight minutes of Fasciathemselves, whenever and wherever they needed ReleaZer® intervention, we observed that the help, with minimal instruction required. At that mo- treated leg had marked reductions in stiffness, inment, the idea of Fascia-ReleaZer was hatched. creased elasticity, and increased local temperature. In the follow up study, we were able to measure tisWe then began developing and testing a series of desue hydration using a bioimpedance method, and we vices, searching for the optimal model. We started were pleased to see that the Fascia-ReleaZer® also with a copper prototype, which was quite short, helped the tissues to become more hydrated. Thus, about 30 centimeters long, and quickly realized that we were able to demonstrate that using the Fasciawe needed a longer device to provide further leverReleaZer® had multiple positive outcomes: deage. We went from copper to wood, and over a pecreased tissue stiffness, increased elasticity, inriod of 3 years (2012-2014), 15 prototypes were decreased local temperature, and enhanced hydration. veloped and tested in about 8,000 treatment sessions. In 2014, and thereafter, we developed the first Does hydration reduce the stiffness of tismodel of the Fascia-ReleaZer with a vibrating oscilsues? lation, and subsequently filed an International patent application for this device—the FasciaWe cannot say it is a direct cause and effect, but we ReleaZer®. Some of the prototypes developed along do know that you can reduce the stiffness in the tisthe way are pictured above. sue very quickly by using the Fascia-ReleaZer®. One From 2014-2015 we implemented several biomechanical pilot studies looking at viscoelastic changes in tissue, temperature, mobility, hydration, pain sensitivity and other sensations when applying the Fascia-ReleaZer®. In September 2015, I presented a randomized, controlled study on the use of the Fascia-ReleaZer® with 111 athletes at the Fascia Research Congress in Washington DC. Our team was honoured to receive the third prize for the best scientific poster presentation. Fascia-ReleaZer® was released on the market in Germany just before Christmas last year (2015). 54 Terra Rosa E-mag No. 19
does not always obtain a significant change in elasticity, but sizeable changes in stiffness typically occur very quickly. This is highly important for professionals in clinical work because it is known that when tissues become stiff, pain becomes more prevalent. After we completed the study with the 111 breakdancers, we realised that we needed to examine hydration of tissue as well, and thus the follow up study with 30 further break dancers was initiated.
What is the difference between the Fascia -ReleaZer and a foam-roller? Rollers and the Fascia-ReleaZer® create two different types of biomechanical impulse. Rolling involves a continuum of pressure, while the Fascia-ReleaZer creates a specific directional shearing force. However, the Fascia-ReleaZer has a very important further function in relation to self-regulation. The core training and focus of our course on this consists of heart rate variability training which helps reduce pain and stress symptoms by stimulating the vagal nerve. This form of training reduces the negative effects of stress hormones—cortisol and adrenaline— and stimulates “happy” hormones, like DHEA. This training function is built into the Fascia-ReleaZer, however, it often requires further training so that it is fully understood. Forthcoming training courses will be offered in Australia soon.
How do you see the role of the brain in the treatment of chronic pain? I view it from at least two sides. I see that the pain patient can develop a pain memory and yet can also develop an imbalance in the autonomic nervous system. This can create hypersensitive tissues as they become stiff and hard. We should take both (soft tissue and nervous system) into consideration when dealing with people with chronic pain—the muscle trigger point and the nervous system are both important issues to address. When treating a patient
Science Award for Fascia-ReleaZer Study at The International Fascia Research Congress held in Washington, DC on September 18 – 20, 2015. The study of the Fascia-ReleaZer was awarded one of the best poster awards out of about 120 studies. Photo courtesy of Christopher Gordon.
who has pain, a body therapist should not look just at the soft tissues; rather the function of the autonomic nervous system also needs attention.
How about cellulite? Cellulite, of course, is related to genetic predisposition, but we should also understand that cellulite is consequently more prevalent in women because of the structure of the tissues. Studies have shown that cellulite depression is associated with the presence of the underlying thick fibrous septae, which are perpendicular to the skin surface and mostly ramified. But even then, women who have increased amounts of cellulite will have a lot of oxidative stress and
Fascia Releazer for treatment of the leg. Photo Copyright Christopher-Marc Gordon, CIT .
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Fascia Releazer for treatment of lower back. Photo Copyright Christopher-Marc Gordon, CIT .
changes in the pH level of the tissues, which means it In Summary, the Fascia-ReleaZer is a self regulation can be affected by lifestyles, such as stress and diet. tool for the reduction of pain and stress symptoms. It has been born out of a clinical research setting of Oxidative stress and deficiencies in lymphatic drainInterdisciplinary Fascia Therapy tradition with the age and microvascular circulation also promote celintention to empower the patient and the therapist lulite. If one uses the Fascia-ReleaZerÂŽ, it helps dealike. As such it has a unique and large variety of crease tissue stiffness and increases its elasticity, uses and indications. which indicates a loosening of the adhesions of the underlying ramified, thick, fibrous, myofascial septa. For further information on training courses please This in turn stimulates metabolism. Because we have contact Terra Rosa at www.terrarosa.com.au or a leveraged instrument that vibrates and contains a Christopher-Marc Gordon at Center fĂźr Integrative sharp edge we are able to biomechanically ease the Therapie, email@example.com , Web: oxidative stress and change the bio-mechanicals of www.center-gordon.de , www.fascia-releazer.com, the tissues, and that is my hypothesis. www.facebook.com/FasciaReleaZer/
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Myofascial Self-Help Therapy with a Mini Foot Roller: A Plantar Fascia Study Christopher-Marc Gordon1, Carmen Graf1, Pedro Montoya2,3, Frank Andrasik4 1 Center for Integrative Therapy, Germany 2 Institute of Medical Psychology and Behavioral Neurobiology, University of Tübingen, Germany 3 Research Institute on Health Sciences (IUNICS), University of Balearic Islands, Palma, Spain 4 Department of Psychology, University of Memphis, USA
BACKGROUND Self-help therapy with a mini foot roller was performed on the foot fascia. The aim of this pilot-study was to explore the effectiveness of selftherapy on psycho-physiological states through a tool assisted tissue manipulation.
roller was used to work on the plantar fascia using body weight and leverage. All participants treated the plantar fascia of each foot for five minutes twice a day for three weeks.
states of the participants in the parameters physical condition, general pain, feelings of stress, circulation, metabolism, mood change, as well as feelings of general energy.
The questionnaire collects states Statistical analysis included the of life quality, pain, stiffness, mobil- paired t-test, Wilcoxon signed rank ity, flexibility, coordination, stress test and Cohen’s d-test behaviour and changes in mood. RESULTS METHODS A follow-up questionnaire was conA significant reduction (p<0.05) in ducted four weeks after the inter37 post office workers were rethe psychological states of dizzicruited randomly, to perform a self vention period. The objectives of ness, sorrow and in the physical -help therapy trial for three weeks the retrospective questionnaire states of restriction of life quality, were to evaluate and to determine with a small foam roller, the as well as the feeling of stiffness BLACKROLL® MINI. The mini foot a change in psycho-physiological
Figure 1. The effect of self myofascial release of plantar fascia using a mini roller on the psycho-physiological states of 37 subjects. Terra Rosa E-mag No. 19
ACKNOWLEDGEMENTS Center for Integrative Therapy: Josip Sibenik REFERENCES Curran PF, Fiore RD, Crisco JJ. A comparison of the pressure exerted on soft tissue by 2 myofascial rollers. Journal of sport rehabilitation, 17.4 (2008): 432. Figure 2. The follow-up questionnaire on the effect of self myofascial release of plantar fascia .
and physical suffering were indicated. The parameters of the follow-up questionnaire relating to physical condition, general pain, feelings of stress, metabolism, mood change and feelings of general energy improved and stabilised to the average of 40% to 60% four weeks after the self-treatment. Parameters of momentary psychological and physiological states, using a modified mind-body questionnaire including the Proof of Mood States (POMS), were selected before and after the three weeks of self-
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treatment. CONCLUSIONS A self-help therapy with a mini foot roller, if applied for ten minutes twice a day, may positively affect physiological and psychological states and can remain stable for a period of four weeks after the selftreatment. DISCLOSURE This study was undertaken in accordance with the Declaration of Helsinki and was financed through patient donations and BLACKROLLÂŽ.
Healey KC, Hatfield DL, Blanpied P, Dorfman LR, Riebe D. The effects of myofascial release with foam rolling on performance. The Journal of Strength & Conditioning Research 28.1 (2014): 61-68.
Not just Foam Rollers BLACKROLL® delivers unsurpassed German Engineering giving you premium tools for myofascial release
“"I have to confess that I firstly underestimated the efficacy of myofascial self treatments with BLACKROLL® products. Today I suppose that a rather big part of the documented successes can be accredited to the concept of self-efficacy. The patient is not passively lying down waiting for his or her treatment but is put into an active role. In many cases this is very important in terms of a sustainable success." Dr. ROBERT SCHLEIP
Available at www.terrarosa.com.au
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Sacral neurons reassigned to sympathetic The autonomic nervous system regulates the function of internal organs such as the gut. It is divided into sympathetic and parasympathetic subdivisions, the yin and yang control mechanism for stress responses (fight or flight) and homeostasis (rest and digest). The parasympathetic and sympathetic tend to work antagonistically. Sacral autonomic outflow are traditionally assigned to the parasympathetic division of the visceral nervous system—as part of the “cranio-sacral outflow” In a recent publication in Science, Isabel Espinosa– Medina and colleagues from France used anatomical and modern molecular analyses to show that the autonomic motor neurons in the sacral cord share similar characteristics with the sympathetic motor neurons in the thoracic cord and not with the parasympathetic motor neurons in the hindbrain. Dr Peggy Mason, a Professor of Neurobiology at University of Chicago wrote on her blog : “The crux of the change implied by reclassifying sacral autonomic motor neurons as sympathetic is that Traditional diagram of sympathetic (red) and parasympathetic two functions, hitherto classified as parasympa(blue) nervous system. From: Gray’s Anatomy (Public Domain) thetic, are in fact sympathetically controlled: Voiding (both urine and feces), and Sexual arousal (including erection in males) Current model: Craniosacral division (parasympathetic outflow) In sum, spinal autonomic outflow belongs to a single Thoracolumbar division (sympathetic outflow) branch of the autonomic nervous system, that which we call sympathetic. The functions of this unified New model: sympathetic aka spinal autonomic system are many Cranial division (parasympathetic outflow) “f”-s: fleeing , freezing, fighting, f-cking (excuse me), Spinal division (sympathetic outflow).” and two “p”-s: peeing and pooping.” Kevin Patton, from the A&P Professor website, wrote: “In a nutshell, the new model stipulates that the outflow (efferent pathways) are divided into a cranial division and spinal division— NOT the craniosacral and thoracolumbar divisions that we learned (and that exist in all A&P textbooks):
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References Espinosa-Medina, I., Saha, O., Boismoreau, F., Chettouh, Z., Rossi, F., Richardson, W.D. and Brunet, J.F., 2016. The sacral autonomic outflow is sympathetic. Science, 354(6314), pp.893-897. Peggy Mason, Fight or flight gets joined by f—, pee, & poop. https://thebrainissocool.com/2016/11/25/fight-or-flight-getsjoined-by-f-pee-poop/
Comments by Til Luchau
any evidence that the actual effects were considered, just their origin and structure. But as Peggy Mason We were totally wrong: the sacral autonomic outsuggests in her fun video, it seems that the neurons' flow is sympathetic. We all learned that the sacral function wasn’t the main way these structures were plexus were the second major centre of parasympa- classified as sympathetic or parasympathetic in the thetic neuron concentration (after the vagus nerve), first place; that it was always anatomy, rather than but a paper by published in the Nov 18, 2016 issue of function, that gave them their classification . Here is Science has me fairly convinced that’s not the case. the YouTube short from Prof. Peggy Mason https:// youtu.be/uV0RRlazx-Y If true, this reclassification means a lot of our ideas about the role of sacral approaches to calming the autonomic nervous system (ANS) may need fairly major revisions. This has implication on approaches Comments by David Lesondak that include Ida Rolf's pelvic lift technique, cranioOverall, I think it's great that we can still find out sacral therapy, and trauma-informed approaches such as TRE and Porges' Polyvagal Theory, to name a that we got something so basic so wrong, and for so many years. few. (And, the last chapter of my second Advanced Myofascial Techniques book. Darn; it just came out. It gives me great hope that this discovery will open But it’s still a cool discovery.) more minds to question the dogmas of science, The Big Question: Does this change how we should work? I’ll leave the details of the reclassification to the sources below, but as other newly emerging disruptive explanations (such as the changing views of pain and nociception; the debates about the importance or unimportance of biomechanics, the questions about the plausibility of tissue change explanations for the results we see), the key question is, how does this change what we do in the practice room?
which can sometimes close the door to innovation. And frankly it makes a kind of sense, for example I could never wrap my head around the idea that sexual arousal and responses were parasympathetic activities. And I am sure that we will discover part of what's al at play here will also involve the enteric nervous system.
Or so they say. But since we're all prone to look for the results we expect to see, I wonder what will happen if we start imagining that we're affecting sympathetic function (instead of parasympathetic function) with our pelvic lifts, sacral holds, etc.? Are there new possibilities that this shift opens up? For instance, can we up-regulate via a pelvic lift, as well as downregulate?
tals and so anything else seemed intrusive and unnecessary. And omitting it didn't seem to have any effect on the outcome. Now when I do psoas treatments I usually do lumbar traction for the sake of reciprocal stimulation, but that's about it these days.
As far as my practice and treatment is concerned, this discovery isn't going to effect it. It was drilled into me for years that you end every treatment with If we could correct for confirmation bias (and we can't, at least not by ourselves), we could say that if subocciptal work, followed by a series of "pelvic lifts" (essentially long, slow traction along the lumthe old methods work, then maybe we just need to bar spine, with your patient supine and your hand explain them differently. If people seem to get calmer with a pelvic lift technique, for instance, then underneath). This was stimulate a parasympathetic it is presumably doing what we want it to, even if we response. need to update our theory about why it seems to I stopped doing that years ago. No more pelvic lifts. work. A rose by any other name, after all, smells just No specific reason, except people seemed quite suffias sweet. ciently mellowed out after treating their suboccipi-
So, in summary, I am quite glad the science has now given me a rationale for something I quit doing years ago!
The only little niggle I still have is that it seems the reclassification done by genetic and phenotyping, rather than by observing the actual functional effects of the neurons involved. In other words, I don't see Terra Rosa E-mag No. 19
Research Highlights Massage Therapy for Pain Relief There is growing evidence for the efficacy of massage therapy against pain. A new review, published in the July to September 2016 issues of Pain Medicine journal said that pain is recognized as the most compelling reason for an individual to seek medical attention. Three systematic reviews demonstrate good evidence for massage in the management of musculoskeletal pain, cancer-associated pain, and surgical pain. The researchers searched databases of medical studies to find research that investigated massage for the treatment of pain. They included 60 high-quality studies and seven low-quality studies which tested massage for muscle and bone pain, headaches, deep internal pain, chronic pain like fibromyalgia and spinal cord pain. Three of four studies involving a total of 245 people with muscle and bone pain showed that compared to no therapy, massage had a very significant effect on pain. The authors made a strong recommendation: when properly delivered by certified massage therapists, massage can be effective for the treatment of pain in these populations. Despite this evidence, it will be difficult to get the attention, time, and resources for widespread delivery of massage for pain. Full acceptance by conventional care providers remains a barrier. The lack of financial drivers undercuts other activities such as research, education, and training and systems integration, which are all needed to determine how we might implement massage for pain treatment in an integrative manner. The authors of the study wrote that “As clinicians, it is our duty to help our patients with pain as quickly, as safely, and as effectively as possible.” Reference: Crawford, C., Boyd, C., Paat, C.F., Price, A., Xenakis, L., Yang, E. and Zhang, W., 2016. The impact of massage therapy on function in pain populations—A systematic review and metaanalysis of randomized controlled trials. Pain Medicine
Massage Therapy for Anxiety A new study finds that massage can help people with anxiety and other mental health disorders, like depression, due to their ability to reduce cortisol and anxiety symptoms. Researchers from Emory University School of Medicine in Atlanta, Georgia, USA conducted a randomized study on patients who had generalized anxiety disorder (GAD). People with GAD experience constant anxiety, with fearful and worrisome thoughts clouding their mind at all hours of the day — often for weeks or months on end. This constant anxiety often lead to fatigue, or develop long-term stomach pain or muscle tension. GAD is typically treated with antidepressants, and the researchers investigated the effect of touch. In the study, the participants were divided into two groups. One was given Swedish massage therapy twice a week, and the other was given light touch therapy twice a week, all over the course of six weeks. Each therapy session was 45 minutes long, and were carried out in the same room conditions. Before and after the session, the participants selfreported on how they felt. The results showed that Swedish massage therapy is the most effective in reducing anxiety and depressive symptoms. Light touch therapy didn’t show as much of an effect on the participants’ anxiety levels. Reference: Rapaport M, Schettler P, Larson E, Edwards S, Dunlop B, Rakofsky J, Kinkead B. Acute swedish massage monotherapy successfully remediates symptoms of generalized anxiety disorder: A proof-of-concept, randomized controlled study. The Journal of Clinical Psychiatry, 2016.
Running Barefoot Improves Working Memory Working memory, our ability to recall and process
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Research Highlights information, is used throughout our life. And researchers from the University of North Florida (UNF) tested if running barefoot can improve the working memory. 72 participants between the ages of 18 and 44, who ran both barefoot and wore shoes at a comfortable, self-selected pace for approximately 16 minutes. Working memory was measured before and after running. The results of this research, published in Perceptual and Motor Skills journal, found a significant increaseâ&#x20AC;&#x201D;approximately 16 percentâ&#x20AC;&#x201D;in working memory performance in the barefoot-running condition. There was no significant increase in working memory when running with shoes. When running barefoot, one often has to avoid stepping on potentially hurtful objects by using precise foot placement. It is possible that the barefoot condition required a more intensive use of working memory because of the extra tactile and proprioceptive demands associated with barefoot running, which may account for the working memory gains. Reference: R. G. Alloway, T. P. Alloway, P. M. Magyari, S. Floyd. An exploratory study investigating the effects of barefoot running on working memory. perceptual and motor skills, 2016; 122 (2): 432.
The cross-over effect of stretching It is known that stretching can have a crossover or non-local effects. Stretching a left shoulder can increase the range of motion of the right shoulder. However, there is little known if stretching the upper body can have a cross-over effect over the lower body, and vice versa. Scientists from Canada and Brazil conducted a study evaluate whether static (SS) and dynamic (DS) stretching of the shoulders would affect hip flexor range of motion (ROM) and performance and vice versa. A randomized crossover study was designed. Experimental sessions included upper and lower body control tests, upper body (shoulder horizontal abduction) SS and lower body (hip abduction) SS, upper body (shoulder horizontal abduction and adduction) DS and lower body DS (hip abduction and adduction). Results showed that there were significant shoulder ROM increases following lower body Static and Dynamic Stretching (8-9 %). There was a significant hip flexor ROM increase following upper body Static Strtching (5% increase). There were no significant main effects or interactions for dynamic ROM or
muscle force and activation variables. The authors concluded that the lack of stretch-induced force and fatigue changes suggests that rather than a mechanical or neural drive mechanism, the improved ROM was due to an enhanced stretch tolerance. Reference: Behm, D.G., Cavanaugh, T., Quigley, P., Reid, J.C., Nardi, P.S.M. and Marchetti, P.H., 2016. Acute bouts of upper and lower body static and dynamic stretching increase nonlocal joint range of motion. European journal of applied physiology, 116(1), pp.241-249.
Connecting (T)issues: How Research in Fascia Biology Can Impact Integrative Oncology Helene Langevin, Robert Schleip and colleagues published an article in the Journal Cancer Research highlighting the importance of fascial biology and thus manual therapy on Cancer treatment. Complementary and integrative treatments, such as massage, acupuncture, and yoga, are used by increasing numbers of cancer patients to manage symptoms and improve their quality of life. In addition, such treatments may have other important and currently overlooked benefits by reducing tissue stiffness and improving mobility. Recent advances in cancer biology are underscoring the importance of connective tissue in the local tumour environment. Inflammation and fibrosis are wellrecognized contributors to cancer, and connective tissue stiffness is emerging as a driving factor in tumor growth. There is an increasing evidence indicates that the physical and mechanical environment can regulate cell behaviour and tumour progression at a cellular level. It is likewise clear that many patients benefit from physical manipulation of connective tissue, but it is not clear what happens at the cellular and molecular level when these manipulations occur. Thus, a large disconnect exists between the cell and connective tissue biology and integrative medicine approaches. Advancing this field will require a coordinated effort combining epidemiology with cancer cellular and extracellular matrix biology. Both basic and clinical research are needed to understand the full impact of integrative oncology on cancer biology as well as whole person health. Reference: Langevin, H.M., Keely, P., Mao, J., Hodge, L.M., Schleip, R., Deng, G., Hinz, B., Swartz, M.A., de Valois, B.A., Zick, S. and Findley, T., 2016. Connecting (T) issues: How Research in Fascia Biology Can Impact Integrative Oncology. Cancer Research, 76(21), pp.6159-6162.
Massage and post-exercise recovery: the science is emerging Terra Rosa E-mag No. 19
Research Highlights Massage as a post-exercise recovery for athletes is not new. And now scientific findings support this, according to Thomas Best from University of Miami and Scott Crawford from University of Nebraska in an editorial published in the October 2016 issue of British Journal of Sports Medicine.
studies showing that the sustained effects of massage on tissue stiffness reduction over multiple days were not as great compared to the immediate (premassage to post-massage) effects.
Although there appears to be increasing evidence that molecular changes occur within skeletal muscle The scientific literature on post-exercise massage in following massage, the effects of these changes on the last decade has provided a plausible biological clinical markers of performance are less clear. The explanation. Clinical studies have shown that maseffects of multiple bouts of massage, either daily or sage mediates leucocyte migration and attenuates at regular intervals over the course of an athletic the inflammatory response to exercise, as well as season, still need to be investigated. The training decreases pain, muscle tone, and hyperactivity. level of the athlete may also play a role in determinResearch studies have shown that massage mediates ing the effectiveness of post-exercise massage as a molecular processes linked to inflammation, specifi- recovery modality. cally by decreasing nuclear factor κβ (NF-κβ), various pro-inflammatory cytokines and tumour necroSpecific and cross-over effects of foam rolling sis factor-α. The demargination (process of neutrophils entering the peripheral circulation or circulat- Self-myofascial release using foam rolling (FR) increase flexibility acutely but how long such increases ing pool from marginating pools) of leucocytes is hypothesised due to increased peripheral blood flow in range of motion (ROM) last is unclear. Static stretching (SS) also increases flexibility acutely and and blood perfusion. Animal studies also showed produces a cross-over effect to contralateral limbs. significant improvements in peak isometric torque recovery from intense eccentric exercise following Researchers from Birmingham and London in the UK four consecutive days of massage. It has also been explored the potential cross-over effect of foam rollshown that massage initiated immediately after ex- ing . They investigating the effects of ercise and massage delayed by 48 hours were both a foam rolling treatment on the ipsilateral limb of 3 effective in reducing muscle oedema and decreasing bouts of 30 seconds on changes in ipsilateral and the number of damaged muscle fibres compared to contralateral ankle dorsi flexion ROM and to assess exercised, non-massaged controls. These investiga- the time-course of those effects up to 20 minutes tions suggest that the reduction in inflammatory post-treatment. 26 subjects, allocated into FR (n=13) cells and pro-inflammatory cytokines by massage and control (CON, n=13) groups. can mitigate secondary injury associated with intense exercise, thereby reducing tissue damage and The researchers found that Foam Rolling improves ankle dorsi flexion ROM for accelerating recovery. at least 20 minutes in the ipsilateral limb and up to Animal studies have addressed important questions 10 minutes in the contralateral limb, indicating regarding the dosage and timing of massage on the that foam rolling produces a cross-over effect into recovery of muscle contractile properties, indicating the contralateral limb. The mechanism producing that recovery is dependent on the magnitude of com- these cross-over effects is unclear but may involve pressive force and frequency of the massage. This increased stretch tolerance, as observed following a dose-dependent response has not been investigated static stretch. in human studies, although some findings report difReference: Kelly, S. and Beardsley, C., 2016. International journal ferences in resting muscle activity (as measured by of sports physical therapy, 11(4), p.544. surface electromyography) with different pressure levels. Poppendieck et al. (2016) noted that shorter sessions of massage (5–12 min) were most beneficial in improving performance measures. This is consistent with animal studies where no difference was observed in the recovery of muscle active properties between 15 or 30 min of massage. Moreover, postexercise massage may be more beneficial in acute short-term recovery (5–10 min postmassage) compared to longer recovery periods (>1–6 hour postmassage).This hypothesis is consistent with animal 64 Terra Rosa E-mag No. 19
1. When and how did you decide to become a bodyworker? I have been qualified as a Physiotherapist for over 20 years but it was while focusing more on treating the spine and pelvis some 15 years ago that I started developing the skills as a bodywork therapist. Over the past 10 years I have consolidated my skills & knowledge on the fascial system, learnt about other manual therapy methods and approaches and now I do consider what I provide patients with treatment as bodywork therapy . I’ve always been interested in the human body with respect to anatomy, human movement, so for me it was a natural process to go into a profession that allowed me to explore my interest areas. I like the term bodywork therapy as it encapsulates it a more integrated way my treatment approach and I’m not restricted by what traditional Physiotherapy has to offer in terms of manual therapy. 2. What do you find most exciting about bodywork therapy? What is so exciting is the fundamental changes you can to someone’s own perspective of their own bodies, how it feels and how it moves differently after manual therapy. Yes, some problems are very chronic but it is surprising how quickly a change can be made, the challenge is to sustain this and make further progress. This is such a broad field with a wide variety of manual therapy techniques and methods that you can draw on but as a Physiotherapist I’m also interested on the rehabilitation side of things. Recently there has been a growing focus on not only the ‘release’ side of things but also adapting fascia, the so-called ‘strength hardening’ aspect of rehabilitation that is proving very exciting to the field of bodywork therapy. 3. What are your favourite bodywork books? 1. Fascia: The Tensional Network of the Human Body which provides the most comprehensive approach to the amazing structure of fascia. It has numerous contributors which covers key aspects of the structure, function, histology but also integrates this knowledge into practical applications. If you really want an in-depth understanding of fascia then you need to work your way through this one.
cal application of bodywork methods with sufficient theory and background to give the most systematic approach. This material resonates with my approach to bodywork. 3. The Anatomy Trains by Thomas Myers is another good text which most bodywork practitioners are likely to encounter at some stage and it is a fairly easy read and provides a clear representation of the various fascial lines by providing a good overview of the structural integrated fascial system. It has so much useful information on the functional anatomy and offers a very integrated perspective on human movement. Each edition is an improvement on the previous one so get the latest one. 4. What is the most challenging part of your work? There will always be more challenging cases but I see this as an opportunity to learn more. It’s often from difficult, challenging patient presentations that I’ve learnt something new or it has forced me to try a different approach. I think it is these clinical challenges that push me to strive to improve as a clinician rather than become stale & complacent. 5. What advice you can give to fresh manual therapists who wish to make a career out of it? Never stop the thirst for knowledge. Learn the basics well and then keep adding to them. Try & learn from more experienced practitioners so finding yourself in a clinic set-up that you can learn from others is always great. The main thing is to really be excited about this life-long journey that you’re embarking on. 6. How do you see the future of manual therapy? I’m very excited about the field of many therapy because of the diversity that I see. Coming initially from Physiotherapy, I had the perspective that there was only a single approach to manual therapy but by learning from a wide range of approaches, schools of thoughts and been able interact with a range of different practitioners has given me a more in-depth insight into the world of manual therapy. I think there is a revolution of sorts going on currently in the field of health and it is been recognised what a key role manual therapy has for a wide range of health issues, as manual therapist we are all well placed for providing this work.
2. Fascial and Membrane Technique by Peter Schwind is my favourite clinical book as it combines both the practiTerra Rosa E-mag No. 19
1. When and how did you decide to become a bodyworker? I was actually a serving soldier in the British Army when I initially trained as a physical therapist and when I left the Army after 12 years I was inspired to do further training and subsequently qualified as an Osteopath. 2. What do you find most exciting about bodywork therapy? These days I do a lot more lecturing and writing and the most exciting thing is meeting therapists that are passionate about helping others. 3. What are your favourite bodywork books? Apart from my own of course....I like books that easily describe the subject matter rather than making it to complex!! I am currently reading Malalignment syndrome by Wolf Schamberger. 4. What is the most challenging part of your work? To truly teach a subject you have to know the subject inside and out, this sometimes becomes a real challenge to myself, especially when I am teaching therapists that attend my courses at Oxford University as everybody has a completely different ability as well as their underpinning knowledge of the subject matter. I now have the task of lecturing a course whereby I hope that every participant will get something from it, it is not that easy as it sounds and to me personally, that's the main challenge!!
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5. What advice you can give to fresh manual therapists who wish to make a career out of it? Try and work along side someone who is experienced and who is also willing to pass their knowledge and expertise to you as that will be invaluable. Keep reading up on functional anatomy and I suggest attending therapy courses that are taught by the true professionals in their field. 6. How do you see the future of manual therapy? It is unbelievable what therapists can now be trained in compared to when I started studying manual therapy. Everybody I meet on my courses or at conferences are trained in all aspects of physical therapy and I think that is brilliant. I personally see a very bright future for all therapists as it is such a rewarding career choice!!
John Gibbons is a registered osteopath with the General Osteopathic Council, specialising 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 for over 12 years, John delivers advanced therapy training to qualified professionals within the Premiership football and rugby sectors. He has written many articles on various aspects of physical therapy, which have been published through the Federation of Holistic Therapists and the Sports Injury Bulletin.