This post is part of a series on FM. Any discussion on FM begins with having at least some understanding of the fascia. For this I would encourage you to first read FASCIA FACTS.
Just as there is a multitude of soft tissue tools, there is also a plethora of soft tissue techniques. I have training in some of them, certainly not all. Many provide some form of relief, even if only temporary. Perhaps some of the reason behind a return of symptoms is a lack of attention to correcting faulty biomechanics. FM encompasses normalizing biomechanics as much as possible, and uses movement to guide treatment. Many approaches target only the main complaint in treatment – a characteristic of our health care approach in general. Yet this symptom-focused mindset often falls short as it may overlook the actual cause of the complaint. FM respects that the site of pain / main complaint may not be the best place to intervene, and focus here may lead to sub-optimal or unsustainable results. Many techniques utilize elbows, knuckles, and tools – much like FM. So what makes FM any different? The answer lies in the methodology for determining where to treat. The best place to apply a therapeutic intervention may be quite remote to the main complaint.
I view FM like a big funnel encompassing history, movement, and palpation to determine where to treat. At the top of the funnel is the main complaint driving a person to seek help, as well as everything from their past: co-existing problems, old injuries, fractures, surgeries, and previous issues now seemingly resolved. Even if these are remote to the site of pain, everything and anything is fair game – musculoskeletal or internal organ. History is key in the FM method and leads to identifying remote areas that may be influencing the primary problem. This is especially true when the primary complaint is “idiopathic.” The body has a reason for doing everything. Like a detective we have to piece together the evidence to arrive at a reasonable hypothesis as to what is driving the problem. It’s even more challenging when people forget about portions of their history or have the mindset that their past history has nothing to do with their current complaint. Sometimes I feel like I’m pulling teeth (out of my scope of practice) just to get the history. There’s a saying in FM: old is gold. Old problems can be a factor in new complaints, especially when the new complaint is not responding to intervention and especially when the new complaint is idiopathic. The FM methodology is also very helpful when people seem to have every possible problem in every segment of the body. In these cases I think about eating an elephant one bite at a time (yuck) and narrow it down to beginning with their primary complaint and oldest problem. It doesn’t mean the other areas won’t be factored in, but it provides a starting point.
In some cases the complaints may include issues with internal organ function (notice I did not say the organ itself, but rather its function). A staggering number of people suffer with such maladies as constipation, urinary incontinence, pelvic pain, reflux, heartburn, and the list goes on. Often this is in addition to musculoskeletal complaints. Many times they have undergone testing that reveals no organ abnormality and they fall into that idiopathic category, called internal dysfunction. In these cases it should be considered that the problem may not be the organ, but rather the fascial environment in which the organ is trying to function. There’s a lot to say on this, and I’ll delve into this more at a later time.
In addition to history, visually inspecting the body can also provide clues as to what’s going on with a person. When I see hammer toes and bunions I know there’s abnormal tissue tension rearranging the anatomy of the foot. Legs that are always turned out or externally rotated may be getting pulled that way by densifications in the hips. Skin issues can also be an interesting roadmap leading to where the fascia is struggling and tell us where to treat.
Next in the FM method is the performance of movement tests. As with tools and methods, there is a smorgasbord of movement tests covering every part of the body. The shoulder alone has roughly 33 special tests for theoretically identifying rotator cuff pathology, impingement, labral tears, etc. I had to know all of these to sit the orthopedic specialty examination in 2000, but now I rarely use them as I find they are time consuming and yield little practical information that influences my therapy. The research on them supports this perspective as well, and recommends that even when clustered they should not be a predominant factor dictating care. Many treatment methods have specific active and/or passive movement tests they advocate using to direct treatment, and I say if that works for you then go for it. I like the KISS principle of keeping it simple (sweetheart) and doing very basic tri-planar movement. We live in a 3-D world and there are roughly 3 planes of movement, with variations and combinations in between. Body parts that can move in the sagittal (forward/backward), frontal (side to side), and horizontal (rotation) planes are moved in these directions, with restriction, pain, weakness, cracking, or any other abnormality noted. Even if the movement doesn’t cause pain, any abnormality signals a problem. (Consider that this is the time to intervene: before the movement becomes painful and wears out the joint.) Sometimes people have a gesture that is problematic, like reaching in the back seat of the car to break up a kid fight. I like using a squat to tell me about the lower half of the body, and measuring the difference between squatting with heels up versus down (highlights problems in the feet/calves). If the symptoms are reproducible, then they’re very often reducible.
Which body part(s) should be moved depends on the history. If the main complaint is in a body segment (foot, wrist, hip, pelvis, etc.) that is easy to move AND if the area of complaint is not in severe pain then I will move that part. If someone is limping then I won’t ask them to squat – that’s just mean. If their main complaint is in the shoulder but the shoulder moves fine, then I may move another area related to their history. Finding a problematic movement gives me a measure that I might use after treatment to confirm a change and support my hypothesis of what’s driving the main complaint. But sometimes there are no movements that are problematic. Sometimes the organ function is the problem, like with urinary incontinence or constipation, and there may not be a problematic movement to track. Having said that, many people have both musculoskeletal and internal organ issues. Sometimes people are hypermobile and move too much in every direction. Ultimately if a faulty movement cannot be identified then I simply move on to the next step in the funnel: palpation.
In the FM method palpation is the cornerstone for guiding treatment and is the most important and challenging step in this method. Palpation is not just focused on a joint, but also the muscles, of course the fascia, the skin, nerves, lymphatics, and vessels in the area. Initially I palpate superficially to get a sense of what’s going on in the hypodermis – the area below the skin but above the deep fascia. I feel for tissue temperature, moisture (or lack thereof), tenderness, and thickness that is asymmetrical compared to the other side as well as compared to normal. Next is palpation of the deep fascia. Even within just two or three body segments, palpation does not include every centimeter of the deep fascia but is targeted at specific sites. These points, termed centers of coordination (CC), are where force vectors converge to coordinate movement happening in a particular plane. This is logical considering that movement does not involve an all-or-none contraction of one muscle or another, but rather a coordinated series of contractions involving only portions of muscles needed to move in a certain direction and velocity. The fascia, by virtue of its location over the muscle bellies as well as its innervation, is perfectly suited to be the peripheral mechanism coordinating movement. Owing to the existence of complex movements involving multiple planes and directions of force, the fascia over the joints, tendons, and retinaculum near the joints is also theorized to direct these more complex movements. These points are called centers of fusion (CF).
What we are feeling for is thickness, density, and loss of slide at the CC and CF. This is called a densification, and is not a desirable situation. Such places are typically (but not always) painful to palpate. Sometimes and in some people sites are tender but not densified, and other times densifications are so chronic they are not tender which poses a challenge to the clinician. Paramount is what the clinician feels in terms of thickness and a loss of slide at the site, which is attributed to dysfunctional Hyaluronan (also called hyaluronic acid or HA). HA is believed to be key to supporting slide and space between the fascial layers. In response to tissue overload, HA is transformed from a space-creating lubricant in the extracellular matrix situated between the fascial layers to a space-occupying adherent.
Where to palpate is once again based on history. We want at least two body segments to palpate, which typically include the segment with the main complaint as well as one other segment relevant to the history. For instance, if someone has a main complaint of shoulder pain then I may palpate the segment of the shoulder. Their history may include a broken wrist, so I will palpate that segment also. Even if the wrist healed fine with no further complaints, or even if the wrist fracture was many years ago I may still palpate the segment of the forearm. Sometimes such injuries harbor “silent” points – densifications that may not be generating a symptom, but are still exerting an influence on movement and be part of the symptoms felt somewhere else. I’m feeling for densification in the tissue – that stuck place where the HA has morphed from a space creating lubricant to a space occupying adherent. This methodology reduces the areas needing to be palpated down to two or three body segments.
I explain to people it’s a scoring system of sorts, and I’m playing connect the dots. I’m trying to determine if there is a predominant theme of dysfunction in one segment that is echoed in another. If I find the yellow dots in the segment of the pelvis seem to be the most involved in terms of densification, and I find the yellow dots in the segment of the ankle, then I have more confidence that the sequence of intra-motion (IR) in the horizontal plane seems to be the predominant problem and I begin there. It doesn’t mean all their problems will be addressed by working on this tissue sequence, but it gives me a starting point that may have the biggest therapeutic impact. Once I determine the predominant tissue plane, then I palpate further to determine the most advantageous points in that sequence to address. This may be remote to the main complaint, but remember that where it hurts isn’t always where the source of the symptom is dwelling. I like to think of it this way: knee pain may be stemming not from the knee itself, but from fascial densifications above and below the joint. The joint (and organs) may just be caught in the middle of a connective tissue tug of war.
I’ll continue in this series on the FM method next time. Until then wishing you health and joy!