Can Problems in the Fascia be Changed?

This post is part of a series on Fascial Manipulation (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. 

Without getting into a scientific debate on materials and form, suffice it to say that fascia and the surrounding connective tissues are both plastic and malleable, which means they can be modified without damage – maybe something like play dough.  This is the very characteristic that causes dysfunction in response to overload (trauma/injury, repetitive movements, and immobilization).  Considering that we encounter overload every day and all day to varying degrees, it’s no wonder we get into trouble.  Yet it’s not all bad news. The attributes of plasticity and malleability that allow tissues to become deformed in response to overload are also the attributes we can exploit to restore normal form and function, or at least as close to normal as possible. Hooray!

FM involves the application of simultaneous compression and friction (shear force) to a densification in order to restore normal space and slide.  It is not known whether the restoration of slide is due to the reversion of the modified HA in the vicinity of the densification back to its original state, and/or if the altered HA is simply replaced by new HA.  What is known is the compression and shear forces stimulate a controlled dose of inflammation at the application site.  HA, among other biochemicals, is a component of the inflammatory process.  Contrary to popular belief, inflammation is not inherently evil; rather, it is a normal physiologic process that can actually kick-start healing.  So in this case, once the inflammatory process has moved through approximately 24—48 hours post treatment, then there can be improvement in symptoms associated with treatment as well as the primary complaints being addressed.  For this reason it is advisable to limit anti-inflammatory measures (ice, medication) immediately post treatment as much as possible so as to allow this process to run its course and potentially optimize the therapeutic effect. 

FM is typically performed manually with an elbow or knuckle at the site of the densification.  The clinician identifies the sites to be addressed and applies sufficient pressure to reach the deep fascia, and then administers a shear force in the direction of greatest restriction.  A knuckle is typically used on smaller body parts, while the elbow works well on deeper structures such as around the hip.  Tissue density, body type, and adipose all play a role in determining the amount of compression and shear needed to resolve the densification. 

FM is incredibly effective. FM is also intense.  While the elbow and knuckle are unsurpassed as FM tools, I find that other devices can help.  There is an absolute smorgasbord of soft tissue tools on the market, and my plan is to address these in a future blog.  Percussion and vibration devices, heat, laser, dry needling, cupping, and a host of other tools can be helpful.  They prep the tissue leaving less work to be done manually by the clinician, and also seem to reduce the pain associated with resolving a densification. 

But even so, there still seems to be a need for the application of simultaneous compression and shear to the deep fascia, and there is no other tool that can do this except for a clinician.  As they say, a knowledgeable hand (or elbow) is powerful!  Ultimately it is not as critical which tool is used for therapeutic intervention, but more importantly to identify the tissue being targeted and formulate a strategy for where to apply a therapeutic intervention.  This is where the FM model shines in giving the clinician a method to approach the person from a total body perspective.  FM certainly cannot cure all problems 100%. But I like to say that by changing what we can change we may diminish the impact of what we can’t change.

What Conditions Can Be Treated with FM?

Bringing FM into my “jewel box” of care has enabled me to embrace diagnoses I never imagined I’d be addressing:  constipation, urinary incontinence, flatus, endometriosis, dysmenorrhea, and a host of orthopedic problems as well (knee, back, neck, shoulder, foot, temporomandibular, etc.). I made the below diagram for a lecture years ago attempting to illustrate the slew of diagnoses I treat in practice with FM as it’s absolutely mind-boggling and challenging to communicate this to other clinicians.  Over the years I’ve added to it to the point that there is not much space left!  I’m sure I’ve left some diagnoses out, and may add to it further as space allows. 

Quite a mix of issues, isn’t it?  I like how this blends the specialties and eradicates barriers, grouping problems together in the body by location. The torso or trunk is especially crowded, but rightly so.  Many of our major organs are housed here, but also the low back structures which are among the most commonly implicated orthopedic issues.  Note how the bladder is included too, and studies show that many people with low back pain also have urinary issues.  For others it may be constipation and hip pain.  It merits consideration that perhaps the link between them is the fascia.  The same construct applies to the temporomandibular joint and the vestibular mechanism – they share the same space in the segment of the head, and dysfunction of the fascia in the head can lead to temporomandibular dysfunction and/or vertigo, not to mention headaches – even migraines.   

The body knows nothing of our compartmentalizing by specialty; there is no anatomical basis for it. Body parts and functions depend on each other and relate to each other through the seamless connective tissue network that includes the fascia.  Our tendency in healthcare to create divisions is an effort to simplify the complexity of our fearfully and wonderfully made bodies!  While specialization and intense focus on one body region or function has a role, optimal wellness also requires consideration of how these elements relate to each other in function and especially in dysfunction.   

This is not to imply that FM completely cures all these issues – no method does.  But I find that applying this methodology from a total body perspective often helps the multiple widespread issues that people battle on several levels:

• Approaching the body globally with consideration of all problems
• Going beyond temporarily diminishing symptoms and searching for root causes of problems
• Addressing biomechanical (movement) problems to maximize mobility and minimize pain
• Reducing/eliminating the need for medications and surgery
• Preventing disease and dysfunction from occurring or advancing

Do You Have to Keep Retreating the Same Places?

The answer to this question lies in understanding why the densification(s) occurred in the first place.  I may treat the shoulder of a pitcher and do an excellent job, but if she keeps overusing the arm then it’s likely the densifications will return.  I may change someone’s calf cramps by addressing densifications in the lower limb, but if they keep wearing non-supportive shoes then it’s possible the problem will return.  The segment of the pelvis is especially challenged in sitting.  So those who present with pelvic problems and do prolonged or excessive sitting have got to explore options for breaking it up.  

All of us are subject to overload of our tissues every day, some days more than others and some people more than others.  The more we understand about the factors that subject us to overload, the better equipped we are to consider modifications that may keep us out of trouble.  I like to say that shoes are the most important piece of clothing on your body, and the bed is the most important piece of furniture in your home.  Choose them wisely.  To that end I have created several brochures that are available.  The two that speak most directly to this conversation are the ones on activities of daily/nightly living and Footwear. 

So in an ideal world densifications should resolve nicely if certain criteria are met:

1. The optimal tissue plane/diagonal and optimal sites (CC/CF) in that plane/diagonal are chosen.
2. The sites chosen are adequately resolved.
3. Any perpetuating factors that are feeding into the problem are reduced or eliminated.

But things aren’t always ideal.  Sigh.  I used to think that if I chose the best points and treated them adequately then I should never have to return to that site.  Experience is teaching me not to be so rigid in that mindset.  I will say that if the same points keep presenting as densified after multiple treatments, then common sense says we need to do something different or they will just keep needing repeat treatment.  My first thought in the case of a recurrent densification is “How did they respond to treatment here the first time?”  If it was a favorable response to treatment, and the person has had chronic (long) history then the same site may simply need more work – some densifications just don’t go down without a fight.  It may also be that I need to take a look at a densified point in the same tissue line above or below the one I worked on.  It could be that the antagonist (the one that exerts a counter-force) may need attention.  It could be that I need to revise my original hypothesis and consider that something else is driving the problem – maybe another body part that the person forgot to tell me about in their history.  Maybe I need to try a different tissue line.  Maybe they are doing something in their daily or nightly activities that keeps perpetuating the problem.  Ultimately as long as all elements are being addressed then it should make a change without needing recurrent treatment to the same points.  Sometimes having people use their own home tools and follow through with further treatment to stubborn points can help.  I plan to talk more on this in future postings on self-care and maintenance.  

Sometimes what is needed to maintain gains and changes is a simple exercise. I am not a believer in giving people a long list of stretching and strengthening exercises as often happens in physical therapy. Studies show that people typically are not compliant with these anyway, maybe in part because they are boring. But sometimes a few key ones can complement the other treatment interventions. The person who has been sitting too much may be able to keep recurrent densifications from forming in the front of the pelvis by doing a simple lunge stretch. Breathing retraining and work with blowing up a balloon may benefit a shoulder and upper back problem. Whatever the exercise, I believe it should have a clear purpose and be suited to that individual’s needs and abilities. But keep it short, make it fun, and people are much more likely to comply! And that can go a long way in deterring the need for recurrent treatment.

I’ll continue in this series on the FM method next time. Until then wishing you health and joy!