Fascia Manipulation for Internal Dysfunction® (FMID) Part II

This post is part of a series on FMID. 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 as well as FASCIAL MANIPULATION

Now let’s talk about what can be done for internal dysfunction.  As you can imagine, my go-to approach is using the FM® model, in this case expanded to consider not just the musculoskeletal system but also the internal organs. 

It begins with getting a history, which is no different for a problem in the back, bowel, or bladder.  Surgeries that have altered the anatomy in any way are important – meaning all surgeries matter.  Even a childhood appendectomy or tonsillectomy can be exerting an influence years later on the myofascial network as well as organ function.  Traumas such as a broken bone, ankle sprain, or a bad fall off a bike can impact tissue mobility for years.  Chronology matters a great deal, and I am very interested in someone’s oldest problems:  old is gold!  Sometimes including this historical region of the body in a treatment plan makes the difference between improvement/resolution versus living with it.  It’s also important to quantify the problem and establish a baseline status so we know if change is occurring, especially as it pertains to internal organ function.  Yes, I really do want to know if you have a bowel movement on a daily basis, how many times do you get up at night to use the bathroom, how severe is your menstrual pain, do you have daily reflux symptoms even on medication, and so on.  Then as these parameters improve I know we’re on the right track, and if they aren’t changing then I modify the approach.  Observing the structure of the anatomy such as skin alterations, posture, joint enlargement, and bony deformities is part of getting the history and often correlates with it. Visible anatomical changes can provide clues as to where the body is compensating and needs attention.    

Visible anatomical changes in the body give direction to dysfunction.
Global inspection of the body can reveal clues as to where dysfunction is manifesting. In the photo on the far left the third metacarpal phalangeal (MCP ) joint is enlarged and painful. While diagnosed with rheumatoid arthritis, I also found her to have fascial densifications in the fascia of the hand and forearm. The middle photo highlights a low back held in excessive lumbar lordosis, or an exaggerated curve. This is often associated with fascial densifcations in various locations of the lower back, causing over-active back muscles, while the abdominal muscles seem to have checked out. The photo on the right clearly demonstrates pronounced bunion formation in the right foot. Each of these anatomical anamolies related to the primary problem for which the person sought help.

Next is movement assessment, much like in the FM musculoskeletal evaluation.  The difference with FMID may be the absence of any movement deficits, although the opposite may occur:  multiple deficits in multiple directions in several segments of the body.  Sometimes people get so locked up they can hardly move.  Perhaps you’re now thinking, “She’s talking about me!”  Conversely, many people also present with hypermobility, the term for too much movement (we call it too much of a good thing – a whole separate post.  Until that’s written you can see our brochure on Hypermobility).  Either way I like to check body parts reflecting any old injury/trauma sites as well as segments potentially related to the ID.  By this I mean that if the problem involves organ function in the lower half of the body (constipation, urinary incontinence) I am going to move segments related to the lower half of the body.  This could mean the low back, assessing trunk forward/backward/side bending and rotation.  Hips are easy to assess as they have (or should have) much mobility in three planes of motion.  It’s amazing how many people accept loss of range of motion in the hips as a normal part of aging, when it may simply be a reversible loss of slide in the tissue layers.  Research also supports the correlation between musculoskeletal problems and internal dysfunction, such as back pain and urinary incontinence.  I like using a squat to quickly assess mobility and ability related to the lower half of the body.  It’s rather remarkable how many people have significant deficits in their squat.  For problems in the upper half of the body (reflux, mastitis, dysphagia or swallowing difficulties) I may move the shoulder and/or neck, which makes perfect sense.   

Hip mobility deficits relate to internal dysfunction
It’s easy to see the hip range of motion deficit this young woman presents with in left hip external rotation, pictured in the photo on the right. This would be easy to brush off as unimportant since it was not associated with an active complaint of hip pain. Yet a significant mobility deficit such as this WILL have an impact, even if it’s not causing pain. Consider too the proximity of the hip to many internal organs, and the fact that the fascia surrounding the hip is continuous with the fascia of the abdomen, pelvic floor, and low back.

Now we come to palpation.  Feeling tissues is key to identifying specific sites of fascial dysfunction where the fascia has lost slide between layers.  People often ask, “Can you really feel where there’s a problem?”  I try not to laugh at that as I give my brilliant response of “Yep!”  Experience helps, and having begun palpating in 1984 as a green but eager new PT has given me lots of practice.  Any practitioner who uses their hands with any consistency will attest that it’s one of our most powerful tools and definitely gets better with experience.  The skill set is open and available to anyone who chooses to cultivate it, and completely dormant in those who don’t.  It’s very true for this conversation:  if you don’t use it you lose it (or never develop it). It’s certainly easier to palpate some people than others.  Many people think that it’s easier to palpate a skinny person but that’s not always the case.  Sometimes they are so wiry (not sure of a better word) that it’s really hard to be sure if what you’re feeling is a dysfunction or just normal skinny tissue.  Hard to explain, but I know what I mean.  Certainly there is a point where an abundance of adipose tissue can also pose a challenge. 

The internal dysfunction model often involves palpation of the abdomen and calves.
Palpation in the internal dysfunction (ID) model follows patterns according to the dysfunction related. Many dysfunctions, such as constipation and urinary incontinence, involve palpation of the abdomen and the calf as seen here. This facilitates identification of a predominant dysfunctional tissue line which is a good starting point for treatment.

I palpate with my knuckle or elbow (I’m told my elbow has a reputation….) the CC and CF points of the FM model in an effort to identify a dominant problematic tissue line that manifests in the trunk and the limbs.  I’m looking for a recurrent theme, a pattern of dysfunction. To me this is the most difficult part of this whole process.  It’s not that one tissue line is responsible for everything, but starting here will likely yield the biggest change.  Often there is a predictable pattern of a dysfunctional tissue line according to the problems reported.  For instance, issues involving the urinary apparatus often present with densifications on the back side of the body closer to mid-line.  Anatomically this makes sense as these organs are oriented more central and posterior, and there is a strong relationship between the musculoskeletal system of the lower back and organs participating in urination such as the kidneys and bladder.  Conversely, the organs of digestion are located more toward the anterior or front aspect of the body, with many attaching along the lines of our “6 pack” or rectus abdominis muscle.  So densifications in these points can have a strong influence on digestive issues such as constipation and IBS.  However, it does not always line up this perfectly and there are exceptions.  I wish “always” applied here as it would make my job easier.  Since it doesn’t we have to check all the CC and CF with an open mind.  Sometimes I get it right the first time and hit a home run.  Sometimes I don’t, which frustrates me.  As my dear husband, Bill, likes to remind me, all I can do is my very best based on the knowledge and information available to me at that moment in time.  I do find that the longer I practice the better I get at it.  Likely true for all of us.  I also like to say a prayer at the start of each session for wisdom and discernment – sometimes to myself, sometimes with the person in the room with me.  I need all the help I can get.   

Centers of Coordinatio and Centers of Fusion in the trunk
Here we see the Centers of Coordination (CC) and Centers of Fusion (CF) found in the trunk. Densification in one or more of these points can impact the underlying organs by two possible mechanisms. First, the point may be where an internal organ has its fascial attachment to the trunk wall. Second, densification in any of these points compromises the elasticity of the trunk to accommodate volumetric changes in the organs. Pictures courtesy of the Fascial Manipulation Association.

In the case of internal dysfunction (ID) we pay close attention to the upper and lower limbs (UL, LL) because they serve as the tensors, as mentioned earlier.  It’s quite remarkable how often there is an old injury in a limb – an ankle sprain, broken wrist, surgery, plantar fasciitis, carpal tunnel, shoulder pain just to name a few possibilities.  Sometimes people don’t remember these things because they were long ago and seemed to heal.  Ankle sprains in high school are a classic example.  The acute swelling and pain eventually subside, and mobility improves.  Since there’s no pain or obvious limitation it’s easy to assume all is well and everything is fully resolved.  But what may be missing is restoration of slide between the fascial layers – densifications.  This chronic phase with loss of slide doesn’t necessarily cause pain, so we can be completely unaware of its presence.  But remember that these tissues are highly innervated, especially at the ankle, where nerves that give us position sense (called proprioceptors) are numerous.  So fascial densifications here can greatly interfere with our perception of constantly knowing where the ankle is in space, and that we just stepped on a rock and need to adjust the ankle position or it will turn.  Sometimes this happens again, and again, and again.  A popular explanation for this is that the ankle is “weak,” but there is evidence running contrary to this assumption.  Densifications can manifest anywhere in the body where tissues are overloaded – and we tax our tissues all the time with trauma/injury, repetitive motions, and immobilization.  The FM® method suggests that densifications occurring at specific points are more impactful on musculoskeletal movement and organ motility. 

Fascial points of the lower and upper limbs
Depicted here are the CCs and CFs of the lower and upper limbs. These points are based on movement, force vectors, muscle and fascia physiology, and meticulous anatomical dissections. Palpation of these areas along with the CCs and CFs of the trunk helps identify a dysfunctional tissue line. The FM® approach gives us a road-map of sorts to follow. Drawings courtesy of the Fascial Manipulation Association.

So once I determine which tissue line is the most dysfunctional – demonstrates the most significant densifications in at least two segments – then I go at it.  I strategically choose the points that seem to have the most potential for making a positive change and begin manipulating them to restore slide to the tissue layers.  I use my knuckle (only when I must), my elbow (really, it’s not that bad….), or some of the wonderful tools available to help prep the tissues so it doesn’t hurt the patient so bad and I don’t have to work sooooo hard (a future post on Tools).  With musculoskeletal dysfunction we typically retest the problem movements after treatment to confirm a change.  But ID can be a little different:  we likely can’t know immediately if constipation, incontinence, or dysmenorrhea are better.  I am hopeful for a change that becomes apparent over the course of the following week or maybe weeks.  Depending on the person it might sound like this:  reducing the night-time bathroom trips down from 4 to 2 (0-1 is ideal); having a daily bowel movement without straining;  only needing to change a urinary incontinence pad once as opposed to multiple times; eating spaghetti sauce (or whatever) without being up all night with reflux.  Such changes are possible by addressing the dysfunctional fascial environment surrounding the organ.     

Treatment of fascial densifications in the trunk and extremites
Treatment of the chosen points along the tissue line determined to be the most dysfunctional in the trunk and limbs. The middle picture shows a vibration roller being used to prep the densified fascia of the torso making it quicker, easier, and less painful to address. Photos by Colleen Whiteford.

Another key element to ID, as with any issue, is addressing the other components of the problem.  Health issues are multifaceted, and a successful approach to addressing them should also be.  Nutrition, daily activities, and stress are just three examples of additional factors that have a profound impact on the body, especially the function of our internal organs.  If perpetuating and confounding influences are not addressed then the best care may be ineffective.  At the same time, I think it’s extremely unfair to blame a lack of response to treatment on the patient or their external circumstances.   Perhaps it’s the treatment approach that is the problem, as much as we clinicians may not like to admit that.  It’s easy to blame the patient as it gets us clinicians off the hook.  I exhaust many options when working with someone before I go there.  I also find that people are suffering from a pitiful lack of information, direction, and options so I do a LOT of educating in addition to treatment (hence this website) to address the pervasive gaps there are in quality information.  Dr. Google and Dr. Oz can be helpful but I don’t always agree with what they propose (shocking, I know).   Sometimes I am surprised at the debatable and outdated information many prestigious websites present on health issues.  I go to them curious as to their perspective but am often disappointed by the same old yada yada. 

Various aspects feeding into pain
I like this wheel of sorts, put out in 2009 by the International Association for the Study of Pain. I think it nicely depicts the construct that pain – as well as many other symptoms – is a multifaceted phenomenon consisting of past and present influences. For every individual some aspects carry more influence than others, like direct trauma or pathology. The impact of these elements can also vary at different times in life. When too many of the inputs exert a negative impact on an individual then problems arise. This supports the need for a balanced approach to problems, and that crediting all dysfunction to one aspect (such as emotional state) is incomplete. I believe that focusing on changing what is changeable (movement patterns, daily activities, attitudes & beliefs) then maybe those things we can’t change (genetics, previous experience) won’t be as noticeable and troublesome.

I hope this perhaps broadens your awareness of the impact the fascia can have.  It’s mind boggling to appreciate how many problems can stem from fascial dysfunction.  Equally amazing is how many of them can be changed by addressing the root cause instead of just mitigating the symptoms.      

Wishing you health and joy!

Published by Colleen Murphy Whiteford

I am a physiotherapist, graduate of Saint Louis University Class of 1984. I married my best friend and business partner, Bill, who is also a physiotherapist, in 1988. We have worked together all these years - an example of God's grace! Together we started Appalachian Physical Therapy which continues to thrive. I am a big believer in the power of touch, the manual therapies, and treating holistically. There are many alternatives to medications, surgeries, and testing, but people are often uninformed. My perspective emphasizes the role of the connective tissues including the fascia. Lack of attention to this structure is the source of many physical ailments - our bodies are truly fearfully and wonderfully made (Psalm 139)! I am passionate about helping people of all ages and diagnoses maximize their health, and empowering them to understand their role in management and prevention of problems.

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