Fascial Manipulation for Internal Dysfunction® (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. 

Internal dysfunction (let’s abbreviate it ID) is a heavy term for a heavy topic.  What are we actually talking about?  It refers to stuff that’s not working right related to our internal organ function, causing problems such as constipation, tachycardia, bloating, urinary or fecal incontinence/frequency/urgency, kidney stones, UTI, dysmenorrhea (abnormal menstruation), and gastroesophageal reflux disease (GERD) just to name a few.  If you’re wondering about your problem that I didn’t name here it’s likely included.  (My plan is to address these individually in future posts.)  A staggering number of people grapple with one or more of these issues.  Odds are the majority of those reading this are suffering, or know someone who is (although they may not talk about it).  While easily relegated to the fate of the elderly, brushing these off as a factor of aging doesn’t work for multiple reasons:

  1. Children manifest these symptoms as well (constipated kids keep Miralax in business).
  2. Young adults suffer too, maybe those same children whose problems were never alleviated
  3. Not all older adults struggle with these issues – some are remarkably free
  4. ID can respond to proper intervention.

These are problems many people are embarrassed to discuss, and rightly so.  When I encounter someone who is shouting across the clinic or dinner table about their ID issues I have to wonder…….  While these folks are out there, the majority of people are not so vocal.  Some are embarrassed but manage to discuss their problems with a practitioner.  For some this leads to rounds of tests that may or may not yield information that directs treatment toward resolution.  Others resort to prescription, over-the-counter, and/or herbal aids that may or may not provide some relief.  Many people simply suffer in heartbreaking silence and shame, enduring their issues.  It can be frustrating as well as life-altering.  Urinary incontinence can keep a grandmother from traveling to her granddaughter’s wedding.  Dysmenorrhea has caused many a female to curl up in pain, bleed all over her clothing, and miss school, work, and social events.  Constipation can make people dread going to the bathroom.  Bloating, and gas can force people into incredibly restrictive diets.  People spend a fortune on medications, probiotics, incontinence pads, and even surgical procedures that may yield disappointing results.  Why is the fix so elusive?  Perhaps it’s because many of these interventions focus on managing symptoms but are not addressing the root cause of the problem. 

Pills, tests, surgery
Our healthcare system has no shortage of tests, pills, and procedures designed to help internal dysfunction symptoms. Unfortunately for many people they do nothing to alleviate the problem. Photos accessed at rawpixel.com.

Sometimes there is an actual disease or dysfunction of the organ.  Such diseases are what medical tests are searching for and are typically spot-on with identifying, directing necessary and sometimes life-saving care.  Yet in other cases the tests are negative and reveal nothing.  While it can be disappointing to not have an answer, a negative report from these tests is desirable.  It’s good to appreciate that a negative test does not mean there is nothing wrong; it just means the problem or disease the test is designed to detect is not present.  Sadly, at this point many people are sort of directionless:  there’s no clear identifiable problem, so no real solution can be pursued.  Some are labeled with diagnostic labels that read something like this:  “The cause of {yada yada} isn’t well understood. A diagnosis is often made based on symptoms and lack of other findings.” When tests are negative but problems persist, logic dictates something else is driving the problem.  By the same token, when problems recur for no apparent reason over and over and over again (urinary tract infections, kidney stones, reflux) it’s time to expand the search for a cause.

My training and experience support that it’s often not the organ (bladder, stomach, colon, uterus, esophagus, kidneys, etc.) at fault but the fascial environment in which these structures are trying to function.  That’s why tests studying the organ are often negative or inconclusive.  They are looking at the organ itself, but this may not be where the problem resides.   In contrast, the fascial environment refers to the fascia surrounding and going into the organs (investing fascia) and the fascia that attaches the organs to the trunk walls (insertional fascia).  I like to explain it this way:  think about the organs in your torso – stomach, liver, spleen, intestines, and bladder.  They are arranged in a pretty consistent manner for all of us, with differences according to male/female anatomy.  When you lie on your side, bounce around in an airplane, or turn a cartwheel those organs don’t get shaken up and rearranged like a snow globe – that’s not sustainable to life.  They are held in place by fascia that connects them to each other and to the trunk walls.  Anyone who has ever butchered a hog or dissected a rabbit has seen this internal fascial structure.

Depiction of fascia, nerves, and stomach
The relationship of the fascia, autonomic nervous system, and internal organs is extremely complex. Here the stomach is depicted with its associated fascia that penetrates into the walls lining the stomach. The nerves embedded in this fascia orchestrate the precise timing of the movement of food to different parts of the stomach as it is processed. The integrity of this timing depends on the associated fascia functioning normally. Used with permission from Dr. Antonio Stecco.

The fascial connections between organs allows them to synchronize their function and know what’s going on with other organs relevant to their function.  For instance the fascia of the stomach is continuous with the fascia of the colon – that’s because they share the responsibility of moving food along the digestive tract.  The fascia of the kidneys is continuous with the fascia of the bladder – this makes sense as these organs must synchronize the filtering of toxins from the blood to be eliminated from the bladder as urine.  The fascia of the uterus is continuous with the fascia of the ovaries for obvious reasons.  In this manner organs that have roles to play that depend on other organs can perceive what’s going on throughout the process.   Such communication is possible because of the rich innervation of the fascia.  So problems develop when the internal fascia becomes densified, much like in the musculoskeletal system.  Whereas densification in the thigh can cause knee pain and degeneration of the joint, similarly densification in the trunk can cause bowel and/or bladder issues.  I like to compare these organ-trunk fascial attachments to Goldilocks:  very picky.  They can’t be too loose, or organs will not be supported properly.  But they can’t be too tight, or organs will not have the vital space and freedom to move (termed motility) which are required to function normally – kind of like being in a straight-jacket or constrained by duck tape.  Movement is life, whether we’re talking about the back, bowel, or bladder. 

This is a great example of rigidity in the trunk fascia affecting the underlying organ. Imagine that this water balloon depicts the bladder. Certainly the volume of fluid in the bladder varies greatly. Ordinarily the bladder can accommodate such fluctuation as long as the fascia investing into it and inserting it to the trunk wall is elastic. But in the presence of a loss of slide in the fascial layers, as depicted by the rubber band around the balloon, the bladder will not be free to vary in volume without generating an abnormal signal – like frequency, urgency, incontinence, or even infection. Used with permission of Dr. Carla Stecco.

In the FMID® model, when key sites (centers of coordination {CC} and centers of fusion {CF}) become densified they can exert an impact on the function of the underlying organs.  Some of these sites relate to the fascial attachment of the organ to the trunk wall, but not all.  Yet even when they are not over a site of organ attachment, they can still exert an impact on organ function simply by causing a loss of elasticity in the trunk.  Think about it this way:  the volume of hollow organs such as the stomach, bladder, uterus, and colon changes as the content of the organ changes.  As long as the trunk connective tissue layers have elasticity and slide, then they can accommodate such volumetric fluctuations.  But when this elasticity is compromised, the trunk cannot accommodate fluctuations in the volume of the organ.  Organs do not like being restricted and get very crabby.  Such loss of motility can manifest as pain, constipation, incontinence, gas, dysmenorrhea, and much more.  This is why tests targeting the organ itself can be negative even when there are symptoms that seem to be arising from the organ.  It’s not the organ that is at fault, but the fascial environment associated with that organ.   

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. Images courtesy of the Fascial Manipulation Association.

Another element in the FMID® approach is what’s known as a tensor.  This refers to the upper limb (UL) and lower limb (LL), which are key components to normalizing fascial tension in the trunk and preserving vital organ space.  I like to compare the body to a canopy.  The roof of the canopy is like the trunk.  The ropes are synonymous with the arms, legs, and neck.  The stakes driving it in the ground represent the hands, head, and feet.  All it takes is for one element in this structure to be pulling too much or not pulling enough and it will impact the integrity of the entire structure – because it’s all connected.

Perhaps a more sophisticated and scientific way to visualize this is from an engineering perspective, as applied to a bridge.  In this model the trunk is compared to the deck of the bridge, and cars on the bridge are like our internal organs.  The support cables correlate with our abdominal musculature.  The upright pylons supporting the cables are like our pelvic and shoulder girdles.  But by themselves the pylons are not enough to support the deck or the cables, and the bridge would collapse under the weight of the cars.  This is where the tensors come into play. 

In the FMID® model the trunk can be compared to a bridge.  In the picture on the left, this incomplete bridge would collapse under the weight of the cars.  The upright pylons need more support, as in the bridge on the right.  Such support comes from the tensors, which equate to the upper and lower limbs.  All concepts and photos used with permission from Dr. Carla Stecco

The tensors serve to sustain the correct tension in the main support cable, also termed a catenary.  Without going too deep into physics and geometry, a catenary is the curve that an idealized hanging chain or cable assumes under its own weight when supported only at its ends. In the case of the trunk, it’s actually an inverted catenary, as it doesn’t sag in like on the bridge but rather out (and for some this outward sag is more apparent than others!).  So the body is an engineering masterpiece when all the elements are perfectly balanced, and, when considering the fascia, all the layers are free to slide and transmit proper tension and force. 

Applying these engineering concepts to the body allows us to see how important the extremities are for maintaining healthy internal organ function. All concepts and photos used with permission from Dr. Carla Stecco. 

Earlier I mentioned that elasticity is vital in the trunk so as to accommodate the variations in volume of the underlying organs. But this is not the case in the upper and lower limbs.  The function of the upper and lower limb requires more stability and less elasticity than the fascia of the trunk.  They are designed more for force transmission.  So it’s conceivable that alteration of the fascia in the trunk could be communicated into the extremity.  Conversely, alteration of the fascia of the lower limb can be communicated to the trunk. Certainly people can have alteration in the fascia of a limb and not be dealing with internal dysfunction of the organs – not everyone with knee pain has constipation.  But it is very unlikely that someone dealing with internal dysfunction does not have some element of dysfunction in the limbs.  Perhaps for those with problems in a limb yet no internal issues it’s just a matter of time until the internal dysfunction manifests.  Perhaps with early attention we might even prevent things moving into internal dysfunction.  I find it fascinating that when I am working with someone with internal dysfunction in the lower half of the body I always find issues with the fascia of the lower limb.  Internal dysfunction in the upper half of the body always seems to have an element in the upper limb.  Yet our traditional medical model does not typically consider this relationship.  Perhaps this is why so many internal disorders and dysfunctions with the yada yada diagnosis are unresponsive to standard care. 

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. Photos by Colleen Whiteford.

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. Photos by Colleen Whiteford.

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. Photos by Colleen Whiteford.

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. Images 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. Images 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.