Part 1 of this series discussed a tensegrity based approach to massage in those with shoulder pain while Part 2 introduced a potential theory on why the tensegrity based approach worked for the shoulder treatment – applying pressure in one area may influence or lead to changes in a remote area of the body. Part 3 will offer some concepts proposed by Stecco and thoughts around using this approach in treatment.
There are multiple ways of looking at how things are connected and Thomas Myers has done a great job taking concepts from rolfing and ideas around fascial connections and popularizing them, bringing them to the masses, and even teaching practitioners not in the bodywork or therapy fields (Ex., strength coaches, personal trainers, yoga practitioners, etc) how to apply these ideas to their practice.
More recently, Luigi Stecco’s Fascial Manipulation approach has gained popularity. I have read both of Stecco’s books – Book 1 & Book 2. I find the books to be interesting and there is, like most things, a lot of cross-over in terms of where certain points are on the body to Travell/Simons Trigger Point charts and to accupuncture points.
In selecting the points to be treated the therapist must first consider the Myofascial Units responsible for moving the joint in anyone of six directions: 2 movements in the sagital plane (flexion and extension), 2 movements in frontal plane (abduction and adduction), and 2 movements in the transverse plane (internal and external rotation). Once the Myofascial Units are determined there are two key points that one should be aware of:
- Center of Perception – The area where traction is exerted by the Myofascial Unit on the joint capsule, tendons, or ligaments, causing pain and/or aberrant joint movement.
- Center of Coordination - The point where all forces of a Myofascial Unit converge, which is thought to play a role in coordinating the motor units of the given Myofascial Unit. (Note: There are also Centers of Fusion discussed in the text but I will leave those out of the discussion for now).
In a nutshell, the center of perception is where things are going wrong or where the person’s chief complaint is located and the center of coordination is where one would consider treatment if they were to attempt to influence the Myofascial Unit hypothesized to be the culprit in the individual’s chief complaint.
Treating Patellar Tendinopathy with Fascial Manipulation
Pedrelli, Stecco, & Day (2009) evaluated the outcome of Fascial Manipulation on 18 patients with patellar tendiopathy. The subjects rated their pain using a visual analog scale and prior to treatment an assessment was performed so that the therapist could understand which myofascial units were “dysfunctional” (either causing pain, weakness, or lacking range of motion). In order to do this the subjects performed an assessment protocol that evaluated how the knee moved through all three planes of motion, thus evaluating the 6 potential Myofascial Units that could be involved. The Myofascial Unit Tests were as follows:
- Sagital Plane – Lunging with the painful knee forward and standing on the non-painful side and performing knee flexion on the painful side
- Frontal Plane – Standing hip abduction into manual resistance at the ankle (below the knee) and standing hip adduction
- Transverse Plane – Squatting down and then standing back up as a way of evaluating rotation at the knee
Additionally, there were two functional tasks that were assessed:
- Descending down a 30m step bearing weight on the painful side
- A jump squat
Treatment of the center of coordination for the Anterior Genu was used in all 18 cases. This point is located halfway between the patella and inguinal ligament, just lateral to the rectus femoris, between the vastus lateralis and rectus femoris with pressure being exerted down towards the vastus intermedius. The point was treated with friction for ~5min until their was a decrease in tissue tone/density, which the authors felt indicated better fascial sliding, and the patient reported decreased pain, sensitivity, and/or referral. The subjects were re-tested following treatment and were asked to report pain sensation on their visual analog scale. All subjects were asked to refrain from their sporting activities for four days after treatment to prevent further damage. Subjects were re-assessed at a one month follow up.
In all cases there was a significant decrease in pain immediately following treatment with two of the subjects indicating a complete regression of pain, which was also maintained at the one month follow up. Four of the patients had good outcomes post treatment and at one month follow up had no pain. Nine subjects had further reduction in pain compared to immediately post treatment at the one month follow up. At the one month follow up three patients saw their pain perception rise back up from the result immediately following treatment; however, not as painful as their pre-treatment levels.
Again we see this concept of tensegrity in the treatment approach. Treat an area remote to the site of pain and get a favorable response. In Part 2 we looked at the tensegrity approach and measuring areas distal to treatment with mechanomyography and electromyography. Additionally, in the comments section of that article, Erson Religioso offered the following thoughts:
“Patrick, I use this reference in my courses. Other than the peripheral explanations, another reason may be that the limb’s representation virtually in the CNS is also affected because the neuron that represent them are adjacent. Just to be sure, I say why does it have to be one or the other, it’s probably a bit of both.”
I like where Erson is going here. I think that being open to all possibilities of why something works is important because there is so much stuff we don’t really know – maybe all we do is just administer a placebo response? In any event, for whatever reason, global treatments seem to have an impact.
It is unfortunate that there was no control group in this study. Hopefully there will be more studies looking at this treatment method to better understand its application. For 5min of work the results were pretty good (even at the one month follow up)
On to the method itself….
I have played with the method for the past 2yrs or so (maybe just under 2yrs). Like most treatment methods it is not the be all, end all, but it does have its place. I do like that there is so much crossover between other methods as well. I don’t know that friction needs to be the exclusive method of treatment. I have tried a number of different approaches to treating the centers of coordination in addition to friction – compression, pin and stretch, skin stretching, gua sha, cups, pin and active movement, and positional release (and I suppose if you have the license to dry needle someone you could do that on the centers of coordination as well). The authors contend that the reason for friction being the preferred treatment method is that friction helps to improve the slide of fascial layers and achieve the result you are looking for. If we accept this as the only way to obtain a physiological change then maybe friction would be the only method, however, can we truly manipulate fascia? As Erson stated, the results people see probably come from multiple effects on the body and we cannot discount the brain and the client’s perception of the treatment being applied to them. I think whichever treatment method you choose should be up to you and what you feel most comfortable with as well as whatever gets the result you are looking for. I can tell you that doing 5min of friction on a very tender spot on an individual who is sympathetically dominant usually leads to an unfavorable response the next day – lots of soreness.
What about for those not in pain?
The interesting thing for me to think about is how can we use this treatment approach to influence how someone moves based on information we gather from them – movement assessment, table assessment, assessment during sport movements, and assessment during warm ups? The approach aims very much at treating those in pain; however, I have utilized some of the connections (myofascial sequences) throughout the body in treatment during recovery sessions and prior to workouts. The information needs to be specifically based on the assessment and, as I indicated in Parts 1 & 2 of this series, the areas that you treat may change on the information you gather that day.
What assessment should you use?
This is entirely up to the therapist. When using massage in these situations I evaluate some general movements first and then perform a table assessment to evaluate passive joint movements, end feel, and palpation of various muscles.
- The movement assessment approach comes out of the FMS/SFMA as a means of evaluating how the person functions in space. If we are doing work prior to or during a part of the workout (usually the beginning of the session) the movement assessment may just be watching the individual warm up and move around and gathering feedback from them.
- For the table assessment I typically will evaluate passive ROM of areas identified as being predominately mobile in the joint-by-joint approach: Ankles, Hips, T-spine, Upper Cervical. The muscles and structures I choose to palpate during the assessment are based on two things – areas that may negatively influence the mobile regions I just assessed and structures that may be highly involved in the individual’s sport (Ex. the shoulder of an overhead athlete or the lower body of someone who runs).
From these assessments I then try and formulate a treatment plan keeping in the back of my head all the potential things that may negatively influence areas that I assessed to be “not normal” for that individual. Again, as I stated in Parts 1 & 2, because things change with athletes as they train and compete the continual assessment helps build new and novel treatments that provide constantly varied stimuli to the body.
Whatever approach, treatment, or assessment you use just keep in mind that there is no one “right way” to do things and being open to all possibilities allows you to be aware of many different angles to look at the human body.
Pedrelli A, Stecco C, Day JA. Treating Patellar Tendinopathy with Fascial Manipulation. J Body Work Movement Thera 2009; 13: 73-80.
Stecco C, Stecco A. Fascial Manipulation. In: Schleip R, et al. Fascia: The Tensional Network of the Human Body. Churchill Livingstone. 2012.
Stecco L. Fascial Manipulation for Musculoskeletal Pain. Piccin. 2004.