Category Archives: Soft Tissue Therapy and Recovery

Trigger Points Revisited: Implications For Sport

It has been over 5 years since I wrote my Trigger Point 101 article, which offered a basic explanation of trigger points for strength and conditioning coaches. The article is still one of the most popular on the site and in a recent discussion with Dr. Phil Snell, regarding Trigger Points, I figured I’d circle back around and revisit the topic.

Questions About Trigger Points

Trigger points are still a hotly debated topic and my aim is not to get into a name convention about what we should call them (I’ll let the researchers sort that one out). What we do know is that there are two main kinds of trigger points we may be dealing with:

  • Active Trigger Points – These are trigger points that are currently referring their characteristic pain response. For example, you have some pain in the anterior shoulder and when I push on your infraspinatus it refers the pain you are currently feeling and after some time that pain dissipates and goes away.
  • Latent Trigger Points – These are the trigger points that only produce pain when they are provoked. Using the above example, you would not be experiencing any anterior shoulder irritation, however, if I started to massage your infraspinatus you end up feeling a referral pain in your anterior shoulder, which dissipates after treatment.

One thought that Dr. Snell raised in our discussion was centered around the idea that maybe trigger points don’t ever go away. Perhaps they just modulate between being latent and being active based on activities that we perform in our daily lives.

This is certainly an interesting hypothesis and it has been shown in a number of studies that latent trigger points are very common in asymptomatic subjects (Fernandez-de-Las-Penas C, Dommerholt J. 2014.). The more that I think about it, the more I think that maybe trigger points are a potential ramification of being upright. After all, we do tend to see a lot of the same muscles develop trigger points and these are often the same muscles that we need to hold us up against gravity (Upper Traps, Gastroc, Erectors, etc). Additionally, many of the muscles that commonly develop trigger points are those that Janda suggested had the tendency for hypertonicity:

triggerpointsrevisited

Thinking more about Dr. Snell’s assumption and the idea that trigger points may be related to us being upright I believe there are some important applications regarding sport and sports preparation.

Implications For Sport

Training for sport is brutal. Athlete’s log long hours in the gym and long hours on the field/court/track, day after day, month after month, and year after year. On top of that the movements tend to be rather repetitive in nature, in order to develop specific skills and technique, leading to overuse injuries and unique strain patterns.

The Integrated Hypothesis of Trigger Points (McPartland JM, Simons DG. 2006.) encompasses multiple physiological components:

“The ‘integrated hypothesis’ regarding the etiology of myofascial trigger points states that each trigger point has a sensory component, a motor component, and an autonomic component.  The hypothesis encompasses local myofascial tissue, the CNS, and systemic biomechanical factors.”

This hypothesis allows us a to paint a very broad picture of how an athlete’s soft tissue may react to the stresses that we place upon them in training and competition as well as how their daily lives may impact soft tissue structures. If trigger points don’t ever go away but rather just modulate from latent to active based on activity, as Dr. Snell suggested, and if they are a product of being upright, perhaps the goal of soft tissue therapy in sport should be to aid in supporting the physiological system to prevent increased trigger point activity (Note: Of course this is not just specific to soft tissue therapy but the program as a whole. Because trigger points can be influenced by multiple factors – nutrition, hydration, overuse, repetitive strain, psycho-emotional stress, etc – it is important to manage all stressors within the training program.).

The concept of latent trigger points is an interesting one. While trigger points may not actively be referring a pain pattern it has been suggested that their presence may disturb motor function leading to issues such as muscle weakness, inhibition, increased motor irritability, muscle cramps, or altered muscle recruitment patterns (Fernandez-de-Las-Penas C, Dommerholt J. 2014.Shah, 2008.,Ibarra, 2011). Recently, it has been suggested that trigger points may play a roll in central sensitization (Fernandez-de-Las-Penas C, Dommerholt J. 2014.) due to their ability to activate and maintain sensitization of central pathways. This may happen through ongoing sensitization of previously silent dorsal horn neurons brought about by various neuropeptides and inflammatory compounds, such as, bradykinin, CGRP, substance P, TNF-a, IL-6, etc. (Shah, 2008.). Thus, because everyone posses latent trigger points, because latent trigger points can become active trigger points, and because latent trigger points may negatively influence motor function and increase inflammatory compounds that can make an athlete more adverse to changes in their dorsal horn neurons, managing soft tissue health and treating latent trigger points to help manage their activity and prevent them, as best as possible, from becoming active may be a good strategy.

Treatment of Latent Trigger Points in Healthy Subjects

A recent study by Grieve and colleagues (2013) set out to evaluate the immediate effect of restricted ankle joint dorsiflexion ROM after a single treatment of latent trigger points in recreational runners. The twenty-two runners in the study were tested to have restricted ankle dorsiflexion with both a straight knee (gastroc) and knee bent to 90 degrees (soleus). The presence of trigger points were confirmed with a palpatory assessment. The subjects served as their own control and were randomly assigned to either an intervention or control session, 1 week apart.

Intervention Session

  • Lewit’s barrier release concept was applied to trigger points in the gastroc and/or soleus (which were marked on the client during the palpatory assessment to ensure accuracy). The Lewit barrier release concept is performed by applying increased thumb pressure over the marked trigger point until the first barrier of tissue resistance is felt. This barrier was perceived to be ‘tender’ but not ‘painful’ to the subject. The pressure is maintained until the therapist felt a release in muscle tension.
  • Following the release of muscle tension a 10sec passive stretch was applied to the treated muscle.
  • This sequence of treatment and stretch were performed for a 10min treatment period.

Control Session

  • During the control session, subjects performed a 10min supervised rest period.

Measurements

  • Ankle dorsiflexion was measured at baseline and post 10min treatment/rest period for both groups.

Findings & Relevance

Post treatment measurements of dorsiflexion revealed a 4 degree and 3 degree increase in soleus and gastroc dorsiflexion, respectively. Both findings were clinically and statistically significant.

This paper confirms a few of the concepts discussed above:

  • First, latent trigger points, while not referring pain, may negatively influence motor function and range of motion.
  • Second, a small amount of time (10min) was required in order to see clinically relevant improvements in ankle dorsiflexion in asymptomatic recreational runners.

Treatment of soft tissue structures as part of the training process may be beneficial for keeping tissue healthy and keeping the athlete training. Perhaps some of the ROM benefits in this study can be had with the FOAM ROLLING that athletes perform prior to warm up and training.

Wrapping Up

Soft tissue treatment has an important place within a structured training program and the idea that we should be treating latent trigger points in athletes as a means of preventing them from becoming active, enhancing joint function, and decreasing tissue tension is an interesting one. Latent trigger points may be a product of being upright as well as the tasks the athlete commonly performs. Understanding the sport and the soft tissue structures which are stressed in that sport may be helpful when planning a treatment session. Treatment can be performed via hands on therapy, dry needling techniques, or foam rolling. As indicated in the paper above by Grieve and colleagues, treatment does not need to be overly painful or aggressive. The Lewit barrier concept takes the tissue to the first barrier of resistance and works within the individual’s level of discomfort. I typically use a 1-10 scale and ask the client to not let me get over a 7 >> Some may refer to this as a “good hurt” and treatment of trigger points has been shown to bring about a favorable shift in the autonomic nervous system (Delany JP, 2002.). Many of the trigger points line up with the Stecco centers of coordination and treatment to those regions, with either compression (as in the Lewit barrier concept) or friction (as in the Stecco treatment approach) may be beneficial. It is common to follow treatment of a trigger point, once there has been a decrease in tissue tension and a decrease in client sensation, with some form of stretch, as used in the study by Grieve and colleagues above. The types of stretches I commonly apply are Muscle Energy Techniques, some form of active isolated stretch, a low grade passive stretch (as indicated in the Grieve study), or some type of pin and stretch technique. Finally, it is important to educate the athlete on self-care strategies and remember that trigger points are multifaceted and things such as nutrition, hydration, sleep, stress, etc, all play a roll in their expression.

Interview with Dr. Andreo Spina

I am extremely excited to have Dr. Andreo Spina coming to Portland in March to present his Lower Extremity Functional Anatomic Palpation & Treatment Course. For registration information CLICK HERE (NOTE: Early Bird Discount ends January 1!). This is a course you wont want to miss and it isn’t often that Dr. Spina comes up to the Northwest.

I truly believe this is one of the best con ed courses out there for chiropractors, physical therapists, and massage therapists. You can read my review of the course HERE.

Despite Dr. Spina’s crazy schedule of traveling, teaching, studying, and, lets not forget, being a clinician, I was fortunate enough to snag a bit of his time so that we could do a short interview for the site discussing some of his thoughts on soft tissue treatment.

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1) Thanks for taking the time out of your busy clinical and teaching schedule to do this interview, Dr. Spina. Can you please give the readers a short overview of your background??

Sure thing…

I studied Kinesiology at McMaster University in Hamilton, Ontario, Canada.  I later graduated with summa cum laude and clinic honors from the Canadian Memorial Chiropractic College as a Doctor of Chiropractic and subsequently completed the two-year post-graduate fellowship in sports sciences. During my time studying Chiropractic, I became the first pre-graduate student to tutor in the cadaver laboratory in the department of Human Anatomy, a position that continued throughout my post-graduate fellowship program.

Stemming from my passion of studying and teaching anatomy, in 2006 I created Functional Anatomic Palpation Systems (F.A.P.)™ which is a systematic approach to soft tissue assessment and palpation.  Following the success of F.A.P. seminars, I later created a follow up system of soft tissue release and rehabilitation called Functional Range Release (F.R.)® technique which is now being utilized by manual practitioners around the world including the medical staffs of various professional sports organizations.  I then combined the scientific knowledge gained during my studies with my 29 years of martial arts training in various disciplines to create the third installment of my curriculum, Functional Range Conditioning (FRC)™, which is a system of mobility conditioning and joint strengthening.

Aside from my work teaching seminars, I also own a sports centre in Toronto, Ontario where I practice and train clients.  I am a published researcher, and I have authored chapters in various sports medicine textbooks.

2) You approach to soft tissue therapy is extremely comprehensive and, after having attending one of your courses before, it is obvious that you have spent a lot of time reading research in order to develop your thought processes and theories about what may be taking place when we apply contact to another person’s body. The fascial system is a big part of your approach and the concept of the fascial system and how the body is connected has gained a lot of popularity in recent years. Can you please explain your approach and this concept you refer to as “Bioflow Anatomy”?

To say that the Functional Range Release system has a sole focus on fascia is not entirely accurate actually, although it might have been in the not so distant past.  Further examination of literature has led/forced me to be more inclusive of other tissues, which together constitute the most abundant type of tissue in the human body, namely Connective Tissue (CT).  Examples of other tissues inclusive in CT other than fascia include bone, cartilage, tendons, ligaments, blood vessels, lymphatic tissues…and even 80% of nerve structure.  When contemplating the effects of manual therapy ‘inputs,’ or even training inputs for that matter, we must be inclusive of all of these tissue types as each of them will equally adapt to applied inputs.  To say that with a particular soft tissue technique application I am affecting one tissue vs. another is as inaccurate as claiming that any particular exercise targets a single tissue, which is in fact impossible.  This line of thought stems from literature examining the effects of load inputs on cellular/subcellular processes…a topic that we dive into deeply in the FR Release curriculum.

There has indeed been an increased focus on the ‘body is connected’ concept mostly stemming from a renewed interest in fascia.  This has led to the concept of myofascial slings/trains for example which speaks to the idea that tissues of the body blend into one another rather than existing/acting as independent structures.  This concept has progressed our view of live anatomy immensely at a gross tissue level.  However in my opinion it also contradicts its own premise.  Namely, that all tissues are connected.  If all tissues are indeed connected, then to distinguish specific lines in the body is to fall into the original trap of structure individualization.

I believe that the next ‘evolution’ of how we think about the anatomic continuum must occur not at the gross tissue level, but at the microscopic level, as this is where its true nature is observed.  The fact of the matter is that all of the tissues listed above under the broader label of connective tissue represent a continuum whose boarders are difficult to delineate even with the help of a microscope.  In other words, it is difficult, and unrealistic to distinctly separate these tissue forms as they simply represent changes in composition of identical elements – namely cells, fibers, and ground substance.

If I were to show you a magnified tissue slide of a tendon ‘inserting’ into a bone and asked you to draw a line distinguishing where the change occurs you would not be able to do so.  You would simply be able to say that on one side of the slide the composition of cells, fibers, and ground substance looks more “tendon-like,” while on the other side it looks more “bone-like.”  Thus the distinction between the two exists as a gradual progression/change in composition.  In this light, ALL body tissues are not only connected…they are actually all different expressions of the same substances.

We get into much more detail in the FR curriculum regarding this topic as I feel that we must consider the affects of our assessments, treatments, and even training applications at a histological level, vs. the gross tissue level, which is the norm.
Getting back to your original question regarding BioFlow anatomy, it can be generally defined as a term used to describe, and conceptualize the extent of continuity found in human tissue at the microscopic level.  Part of the FR curriculum is dedicated to creating a detailed understanding of how tissue exists in the living body.  Specifically how tissues seemingly ‘flows’ from one form to another.  This concept vastly alters not only ones perception of anatomy, but also their understanding of tissue assessment, treatment, rehabilitation, and training.

3) Your courses all start with a very comprehensive palpation class. I feel this is not only important but also incredibly helpful. A lot of therapists or clinicians say, “I don’t need to start with the palpation course. I already know how to palpation”. Can you please tell us why you feel the need to start there and why specific palpation is so important? I feel like your course does one of the best jobs in teaching this than any I have ever taken.?

It’s a common occurrence that some practitioners enter the seminars with the belief that the palpation portion will serve simply as a review, as it is there belief that their palpation skills are adequate.  I enjoy seeing the ‘ah-ha’ moments when they realize that they are palpating many of the structures that they have been ‘treating’ for years…for the very first time.  In fact, I had many, many of these moments during the creation of the palpation system that is taught at FR seminars – Functional Anatomic Palpation Systems.

In my opinion palpation forms the backbone of manual therapy practice…or at least it should. Although many of us are taught to rely on orthopedic testing, such tests can only provide general information regarding the location of an injury.  The reason is that orthopedic tests are developed (and for that matter are only useful for) is for the localization and diagnosis of what I refer to as ‘macro’ tissue injury, which can be defined as damage on a gross tissue level.  Examples of this type of injury include osseous fractures, overt muscle or ligament tears, neural tissue damage, etc.  As manual therapists however, the majority of the cases that we deal with are ‘micro’ tissue injuries such as feelings of ‘tightness,’ poorly defined aches/pains, movement errors, etc.  For such conditions, ‘macro’ tissue diagnostic procedures help very little in generating a useful manual medical diagnosis, and even less in guiding the creation of a subsequent manual therapeutic treatment plan.

As an example, tests confirming a diagnosis of “Sub-acromial impingement” only serve to inform us of the area of pain; namely the sub-acromial space.  However this diagnosis can represent pathology in several different structures and can comprise of several different histological processes – Supraspinatus Insertional tendonopathy, Biceps tendonitis/opathy/osis/tenosynovitis, Internal impingement (Posterior superior Glenohumeral joint impingement), sub-acromial bursitis, etc., are all possible under this ‘umbrella’ diagnosis.  While this diagnosis may be suitable for a medical doctor, for a manual therapist it is of very little use, as it does not allow us to select the appropriate treatment intervention(s).  Say for example this diagnosis represents a bursitis and the therapist decides to try Graston for example.  Being an inflammatory condition, this would lead to a worsening of symptoms.  Or say the diagnosis represents a tendonosis of the Supraspinatus muscle and the therapist decides to apply ultrasound & ice.  In this case the literature dictates that the selected treatments will have little to no effect.

The reality of manual practice is that aside from a good clinical history, which is by far the most important aspect of assessment, it is the palpatory findings that are ultimately used to both define pathologic tissue, and subsequently to guide decision making when selecting a treatment approach.  This is a concept that I learned very early in my career by shadowing various manual medical practitioners.  Following any and all diagnostic procedures, it always came down to the therapist actually palpating the area….and subsequently, during the application of manual care, it is ones ability to palpate that guides our decisions moment by moment.

In light of this, I always found it odd that so little effort was dedicated to perfecting the art of palpation, and as I began to teach practitioners of several disciplines all around the world I soon learned that this problem was not solely found in my profession, nor was it localized to North America.

With any skill, be it in sport, art, etc., the perfection of the skill cannot simply be obtained via brief introduction…it requires training.  No martial artist has ever had confidence in using a technique in competition simply by observing it on a few occasions.  They require hours and hours of mindful, repetitive practice before they can demonstrate proficiency.  Contrary to how it is taught, I believe palpation requires the same dedicated practice.  Thus, in Functional Range Release curriculum, a large percentage of time is dedicated to learning a systematic approach to the palpation of soft tissue structures.

This includes not only instruction regarding the localization of structure (which by it self is insufficient) but also in the interpretation of palpatory findings.  When I confront a group of practitioners with the simple question of “what are we palpating for,” I am always surprised by the large variety of conflicting answers.  I am even more surprised to hear that almost all of the offered answers represent on scientific ‘analogies.’  Some common examples include:

  • “Knots” – which obviously do not occur in any literal sense.
  • “Scar” tissue/“adhesions” – which simply represents disorganization of connective tissue amounting to fibers being laid down in the wrong direction…fibers which are nanometers in size and are thus un-palpable.
  • “Rope-y-ness” – which is inevitable as all muscles are encased and are thus shaped like ropes.
  • “Tightness” – This can refer to ‘mechanical’ tightness caused by an area of aberrant fibrosis…OR it can refer to ‘neruologically-induced” tightness/spasm.  Thus it does not defined the pathology enough to decide on clinical interventions.
  • “Range of motion” – which is generally not a good clinicical outcome measure as per the literature.  Further, soft tissue application is not intended to induce permanent improvements to range of motion as that is generally known to require progressive stretching/strengthening procedures over a period of time.
  • “Pain” – which can normally be found in various areas of everyone’s body during palpation.
  • “Bumps” – which likely represent the small pockets of adipose tissue which sit in the sub-dermal fibrous scaffolding known as the fascia Superficialis.
  • …and the most common, “I don’t know…but I know it when I feel it,” which can be loosely translated as “I don’t really know.”

If a practitioner cannot define what they are feeling for in any realistic, scientific manner, then what is the outcome measures guiding their treatment?  By this I don’t mean the outcome measure used to define success in the eyes of patients such as pain or range of motion.  I mean what is the tactile finding that, on a moment-by-moment basis, guidance the practitioners treatment?  How does one know when soft tissue ‘release’ procedures are appropriate vs. passive modalities?  How does one know the needed amplitude and direction of force to apply?  How does one know when the treatment is over?  These and many other questions require that the practitioner is able to palpably distinguish between normal and abnormal anatomic structure, and further that they have a working definition/understanding of what they are looking for.

Of course at this point I expect many readers to be thinking that they did indeed have instruction in palpation during their education…to them I encourage them to find a certified FR practitioner and ask them to describe the level of palpation specificity that was taught to them at the certification seminar….its far more powerful to hear it from them then from the person teaching the courses.

4) There are many systems of soft tissue release or fascial release out there. One question that always comes up is, “How is your course different than the others?” Can you please address that for the readers??

I think the best way to answer that question is to describe both why, and how I developed the FR Release system.  When I was a student studying manual therapy, I made it a point to both exposed myself to, and understand the premise of as many approaches as I could.  By doing so I soon realized the following:

  1. The development of most soft tissue treatment systems have historically been done in a trial and error fashion.  Supporting scientific evidence was then sought out retrospectively to justify the various approaches.  If none was to be found, it seldom led to any significant changes.  Further, it would be commonly claimed that there is no literature available to guide manual care in an evidence-based manner.
  2. Many ‘new’ systems simply represented a re-packaging of older systems approach.
  3. None of the currently available systems gave any focus to either assessment, or rehabilitative procedures.
  4. Most systems, when given enough time, began to lag behind in terms of current scientific knowledge.

The development of the FR system came out of a desire to create an approach to soft tissue injury management OUT OF the most current scientific literature.  As I read more and more I soon realized that there is indeed ample scientific knowledge available that can be used to develop a ‘best-approach’ to the management of soft tissue injury and/or dysfunction.  The key was that I had to dive more deeply into topics seldom studied in the context of manual therapy such as cellular/sub-cellular biology, tissue morphogenesis, and cellular biophysics.  In this literature one can learn of tissue responses to load application at the cellular level.  Because the application of manual care at the base level is concerned with controlled load application (be it via externally applied load such as soft tissue ‘release’ procedures, or internal loading via rehabilitative procedures) a logical, evidence-guided approach can be made for both soft tissue treatment application and rehabilitative procedures utilizing this knowledge, which forms the basis for the FR Release system.  I believe this to be a major way that the system sets itself apart from others.  We not only take a logical, evidence-guided approach, but we insist that each participant be thoroughly exposed to these concepts.  To do so we provide several mandatory online lectures, to be studied prior to the seminar that walk participants through the through process and supporting evidence for its creation and utilization.  These lectures cover topics ranging from how to interpret palpatory findings, to BioFlow Anatomy (described earlier), to progressive tissue adaptation mechanisms.

Further, as is noted above, much of the seminar is dedicated to learning our specific system of soft tissue palpation and assessment.  We are not concerned with simply teaching treatment “protocols.” Rather we teach a complete system of assessment, treatment, and rehabilitation, thus preparing participants to apply FR to any and all potential musculoskeletal diagnosis’.  We are less concerned with changing what one thinks than we are with how one thinks.

5) You mentioned in your bio that various professional sports organizations medical teams have begun using the FR Release system.  Can you tell us more about that?  

Sure.  Thus far we have certified the staffs of the Arizona Diamondbacks (MLB), and Houston Rockets (NBA).  We also currently have seminars lined up with the staffs from the Chicago Cubs, Seattle Mariners, San Diego Padres, and the Philadelphia Phillies MLB teams.  We are also working with the NCAA staff of Texas A&M University.

Our feedback thus far has been outstanding with regards to the effectiveness of the system on their players for injury treatment, rehabilitation, and prevention.

6)  What would one expect if they choose to attend a certification seminar?

The FR curriculum is divided into 3 sections – Upper Limb, Lower Limb, & Spine.  Each section consists of a 3-day practical seminar along with a significant preparatory online lecture component (9 lectures in total).

Each seminar begins with training in the Functional Anatomic Palpation Systems (FAP) for the body region.  FAP is a systematic approach to soft tissue palpation and assessment looking to improve the practitioner’s ability to both locate tissue, as well as interpret their palpatory findings for assessment purposes.

Following that we teach the FR Release component, which includes manual treatment/release procedures as well as an original rehabilitative approach including the PAILs & RAILs systems (Progressive & Regressive Angular Isometric Loading).

Once successfully completed, participants receive certification for the particular body region (FR  is a registered trademarked system).  This automatically includes them in our websites find a provider function, and allows them access to our social media groups, as well as our members only online site where we are constantly providing new ideas, techniques, concepts, cases, etc, related to the FR system.  This allows us to omit the need for “recertification’s.”

7)  You also teach a mobility conditioning seminar called Functional Range Conditioning, or FRC.   Perhaps you can give us a brief overview of that system?

FRC is a system of mobility training based in scientific principals and research. Mobility, defined as flexibility plus strength, refers to the amount of USABLE motion that one possesses across a particular articulation (joint). The more mobile a person is, the more they are able to maximize their movement potential safely, efficiently, and effectively. FRC Seminars teach participants, ranging from manual therapists, to personal trainers and strength and conditioning specialists, how to improve mobility in both their clients, as well as themselves.  In the process, the system also builds articular strength and neurological control, which translates into injury prevention. More importantly, workshops explain the scientific basis behind this new and invaluable system. Participants come away not with a simple list of exercises, but a greater understanding of the musculoskeletal system, and the tools needed to implement FRC methodology in the training/ rehabilitation programs of patients, clients, or themselves.

8) Thank you for your time today, Dr. Spina. Can you please tell the readers where they can find more information about your courses as you have several coming to the United States in the upcoming months and through 2014, including one that we will be hosting in Portland.

For more information regarding seminars including dates and locations you can visit FunctionalAnatomySeminars.com.  I am also one who shares lots of information on social media including a frequently updated blog – FunctionalAnatomyBLOG.com, Twitter feed – @DrAndreoSpina, and Facebook page – FunctionalAnatomySeminars.

Functional Anatomical Palpation and Functional Range Release Seminar Coming to Portland, OR!

I’m excited to announce that Dr. Andreo Spina will be coming to Portland, OR, March 21-13, to offer the Lower Extremity Course of the Functional Anatomy Seminar Series.

The course is a 3 day course covering both anatomical palpation and Functional Range Release treatment to the lower extremity. In addition to this, 2-weeks prior to the course, attendees will receive log in information to the Functional Anatomy Seminars website where they can watch several pre-course videos on the system and treatment method that Dr. Spina has created.

I am extremely excited to be bringing this course to Portland as Dr. Spina is starting to present more in the United States and I believe he has some great stuff to offer. A year ago I attended the Functional Anatomical Palpation course for the lower extremity and it was one of the best soft tissue therapy courses I have ever attended. My review of the course can be found HERE. The course is excellent for chiropractors, physical therapists, and massage therapists and one of the things I like best about the course is that Dr. Spina doesn’t teach a bunch of techniques, rather, he presents an entire system and the reasons behind why he does what he does in treatment.

I’ll have an interview with Dr. Spina up in the coming weeks but in the meantime I encourage you to check out his BLOG, which is loaded with great content regarding soft tissue and movement therapies.

If you are interested in signing up for the course you can do so HERE. There is an early bird discount and I expect that this course will fill up fast.

Tensegrity Principles & Massage Therapy Part 3: Stecco & Fascial Connections

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:

  1. 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.
  2. 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.

My Comments

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.

References

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.

Tensegrity Principles & Massage Therapy Part 2: Mechanomyography

Movement involves the transmission of forces between various body segments, between body tissues, and across multiple joints. The tensegrity principle would indicate that forces in one area of the body need to be balanced by forces in another area of the body. Because elastic deformation of muscle can influence the structural relationship of soft tissue elements (fascia, muscle, tendon, ligament) it may be possible that massage treatment in one area of the body may influence structures distant to the area of treatment.

Along this line of thinking, two weeks ago I wrote an article about tensegrity and massage, Tensegrity Principles & Massage Therapy Part 1: Shoulder Treatment. The article found that those in the tensegrity massage group saw the same improvements in shoulder pain as those in the local massage group, however, only the tensegrity massage group saw significant improvements for passive and active range of motion in shoulder flexion and abduction.

A previous article by the same researcher (Kassolik, 2009) used EMG and MMG to evaluate the effect of massage on muscles lying distance from but indirectly connected to the treated muscle.

Treatment

Thirty-three healthy men participated in the study. The two areas of treatment were the peroneals and the brachioradialis. Three seconds of petrissage was performed on each of the muscles and that treatment was repeated three times with three minutes of rest between each treatment. When the brachioradialis was receiving treatment the middle deltoid of the same arm was evaluated with EMG and MMG and when the peroneal muscle was being treated the TFL of the same leg was evaluated with EMG and MMG.

Results

Mechanomyography (MMG), which reflects oscillations in muscle movement and pressure, was found to be increased in both the middle deltoid and TFL with both treatments while EMG increases were found to be significant in the TFL and insignificant in the middle deltoid.

Comments

These findings are inline with the tensegrity principle and may indicate that when we apply pressure or contact to one area of the body its influence can be felt in other areas. The EMG changes in the TFL only are interesting and the researchers offered a few potential reasons for this. One potential reason is just electrical noise in both readings (since the middle deltoid did have some EMG changes but they were not significant). The other possible reason is that it is hypothesized that the physiological tone of the TFL is higher than the middle deltoid so we may be seeing that in the EMG reading. The changes in MMG in both muscles makes me think about the potential influence we can have on structures we don’t even touch without our treatment:

  • In an acute injury setting when certain muscles have a large amount of swelling and inflammation perhaps more distant treatment can produce a favorable response.
  • In treatment for recovery purposes, when we are looking to develop novel treatment approaches that prevent the athlete from adapting to the same stimuli.
  • In treatment for improving movement capacity by looking at long chains of muscles and the sport movement and trying to understand how things influence each other.
  • In warm ups, when trying to influence muscle tone/tension and influence an athletes mechanics.

In order to make this approach work one must develop an assessment process that is holistic in nature. This assessment approach may take into account several things such as:

  • General/Basic Movement
  • Sports Movement/Skill
  • Joint Range of Motion >> Active and Passive
  • Muscle Length and Strength
  • Palpation >> Tone, Tenderness, Tension

Hopefully more research will push forward into how this tensegrity approach can be used in massage therapy. I believe there is tremendous value in touch therapies and a full understanding of the ramifications is exciting as the more we know the more we can begin to evolve treatments to come up with something highly specific for the individual.

Reference

Kassolik K, et al. Tensegrity principle in massage demonstrated by electro- and mechanomyography. J Body Work Movement Thera 2009; 13: 164-170.