Fascial Manipulation-Stecco® (FM)

(This page is a combination of a series of posts 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.

How Does FM Work?
Can Problems in the Fascia be Changed?
What Conditions Can Be Treated with FM?
Do You Have to Keep Retreating the Same Places?
Are There Articles & Research That Show FM is Effective?
Is FM Something New?
Who Uses FM?

How Does FM Work?

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.

History

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.

FM like a funnel — The FM approach can be viewed as a funnel comprised of these elements. Moving through this process narrows down information and possible influences on a problem until a site can be determined for treatment. Image from Amazon.

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.

Inspection revealing hives and bunions — Visually inspecting the body can provide clues as to where the tissues are struggling, and where treatment may be needed. On the left this 21 year old had recurrent hives in her legs whenever exposed to heat. She also harbored fascial densifications in the same hip and ankle. In the picture on the right this gentleman was subject to right low back pain and recurrent kidney stones. The severity of the bunion on the right was manifestation of extreme fascial densifications throughout the right lower limb. Photos by Colleen Whiteford.

Movement

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. In assessment, 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.

Various movement tests — Movement can be assessed in multiple manners. Straight plane movements such as trunk extension, flexion, and hip rotation are easy to administer. Gestures such as pulling a bow or climbing into bed can be used if they are what reproduce symptoms. A squat is also a nice method of globally assessing the lower body. We are looking for pain, restriction, or weakness and noting change in this with treatment. Photos by Colleen Whiteford.

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 (see Hypermobility brochure). Ultimately if a faulty movement cannot be identified then I simply move on to the next step in the funnel: palpation.

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).

CC & CF in lower leg — Here the centers of coordination (CC) and centers of fusion (CF) are shown on the lower leg and foot. The continuation of one color of dots into the next segment depicts the seamless nature of the fascia, and how these points relate to each other in movement. Courtesy of the Fascial Manipulation Association.

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.

The FM method divides the body into 14 segments. Movement and palpation are based on these segments, and consider not just the joints but also the muscles, fascia, vessels, and organs. Courtesy of the Fascial Manipulation Association.

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 an old 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 to address in that sequence. 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.

Myofascial sequences connecting centers of coordination from one segment to the next — Depiction of the myofascial sequences – the lines “connecting the dots” between centers of coordination (CC) of the same plane. This reflects how the fascia relates from one segment to the next to coordinate movement and function. This depiction nicely reinforces that the fascia is continuous from head to toe, right to left, and front to back. Courtesy of the Fascial Manipulation Association.

Can Problems in the Fascia be Changed?

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!

Combining compression and shear force to reach and alter a fascial densification — To reach a densification in the deep fascia, sufficient compression must be applied perpendicular to the tissue surface. Then, while maintaining this, a shear force (tangential friction) is applied in the direction of most restriction. While there are tools that can apply compression, there is no tool that can apply simultaneous compression and shear (friction) except a clinician. Courtesy of the Fascial Manipulation Association.

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 being performed on a neck, leg, and hip — FM can be utilized on multiple areas and for a wide variety of issues. The simultaneous application of compression and shear force to the site serves to restore normal tissue slide. Photos by Colleen Whiteford.

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 post. 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.

Treatment tools - percussion, dry needling, cupping — The right tool in the right location can be a huge help in treatment. A percussion gun (far left) can prep a densification so it does not require so much manual work for the clinician and is less painful for the patient. Dry needling (center) can also aid in removing pro-inflammatory biochemicals in an area. Cupping (right) is wonderful for breaking up painful thickening in the hypodermis. Photos by Colleen Whiteford.

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.

The Fascial Manipulation-Stecco® logo. The motto is in Latin so as to be universal, and is translated “A Knowledgeable Hand is Powerful.” Courtesy of the Fascial Manipulation Association.

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, in addition to the abundance of orthopedic problems I’ve treated for ages (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.

Many diagnoses treated with FM — ***FM can be utilized to treat an incredible array of conditions as depicted here. Image from rawpixel.***

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 must 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.

Brochures on ADL/ANL and Footwear — Examples of two of our brochures. These brochures are not purchased off the internet, but created specifically by us at Appalachian Physical Therapy to provide information reflecting current research as well as our clinical experience. Sometimes our perspective runs counter to information found on the internet – imagine that. Available at www.aptfc.com.

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

The optimal tissue plane/diagonal and optimal sites (CC/CF) in that plane/diagonal are chosen.
The sites chosen are adequately resolved.
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 a 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.

Hula hooping is a great form of exercise for working on the trunk core and it’s fun! Forget the sets and reps, just do it. One of the great aspects of my job is getting to join in on the fun! Photos by Colleen Whiteford.

Are There Articles & Research That Show FM is Effective?

Absolutely. More are being added to the compilation every day, I’ll stop at 10 articles. Some of these can be found in the articles section of the resources tab. Because that section deals with more than just FM articles, I’ll share the ones specific to FM here with a short synopsis. If the article is provided under open access and I can link to it I will. Otherwise I can only give the reference, out of respect for copyright and keeping myself out of trouble.

Application of Fascial Manipulation^© technique in chronic shoulder pain—Anatomical basis and clinical implications. Day J, Stecco C, Stecco A. 28 subjects with chronic shoulder pain experienced significant improvement in pain, mobility, and function after treatment with FM. These improvements were sustained at 3 month follow-up.

Fascial Manipulation Associated With Standard Care Compared to Only Standard Post-surgical Care for Total Hip Arthroplasty: A Randomized Controlled Trial. Busato Massimo, et al. American Academy of Physical Medicine and Rehabilitation
http://dx.doi.org/10.1016/j.pmrj.2016.04.007. 51 post-total hip arthroplasty patients were seen for daily sessions of active exercise. They were randomly assigned to one of two groups: one doing only the active exercise, and the other doing the active exercise for all but two sessions which were replaced by treatment with FM. Statistically significant differences were observed between the two groups, with the FM group demonstrating greater improvement in hip range of motion, strength, pain, and function.

Fascial Manipulation® for chronic aspecific low back pain: a single blinded randomized controlled trial. Mirco Branchini et al. doi:10.12688/f1000research.6890.2. 24 subjects with chronic aspecific low back pain were randomized into two groups, with both receiving eight treatments over 4 weeks. Outcomes of pain and function were measured at baseline, at the end of therapy and at a 1 month and a 3 months follow-up. Patients receiving FM® showed statistically and clinically significant improvements at the end of care for all outcomes.

Fascial Manipulation for persistent knee pain following ACL and meniscus repair.
Rajasekar S, Aure´lie Marie Marchand A. Journal of Bodywork & Movement Therapies (2016), http://dx.doi.org/10.1016/j.jbmt.2016.08.014. Case report of a 32 year old male experiencing persistent knee pain and limitations after knee surgery and extensive rehabilitation. Four treatments of FM were administered over the course of a month, and the patient experienced significant improvement in pain and dysfunction which was sustained at periodic follow-ups extending two years.

Fascial Manipulation in the Management of Carpal Tunnel Syndrome. Kannabiran B, Thamarai Selvi T, Nagarani R. EC Orthopaedics 4.2 (2016): 473-482. 10 subjects with findings of carpal tunnel syndrome were treated with FM and sustained significant improvement in pain.

Fascial manipulation vs. standard physical therapy practice for low back pain diagnoses: A pragmatic study. Harper B, Steinbeck L, Aron A. Journal of Bodywork & Movement Therapies (2019) Volume 23, Issue 1, pages 115-121. 102 patients with low back pain (LBP) associated with a wide variety of diagnoses were divided into two groups which were similar for gender, age and chronicity of LBP. Both groups received thermal and/or electrical modalities and general exercises. One group, called the standard physical therapy group (SPT) received general soft tissue work, joint mobilization/manipulation, and/or traction. The second group, called the FM group, received FM. Participants completed a number of outcome measures to track progress. Data analysis revealed statistically significant differences between SPT and FM, with the FM group accomplishing much greater improvement in pain and disability. These improvements were noted with fewer visits and a shorter time than the SPT group.

Treatment of Chronic Pelvic Pain with Fascial Manipulation®. Pasini A, Sfriso M, Stecco C. Pelviperineology 2015; 35: 13-16 http://www.pelviperineology.org. A nice report on two cases of pelvic pain using FM. The first was a 17 year old girl suffering with dysmenorrhea (dysfunction related to menstruation such as pain and heavy bleeding) as well as knee pain. She was seen for one session of FM, and reported 80% improvement in the status of both her knee and pelvic pain, which were sustained at one year follow-up. The second case involved a 38 year old male with a chronic history of severe pelvic pain, urinary urgency and frequency, low back pain, and a sense of heaviness in the legs. He reported significant improvement after one treatment with FM, and was symptom free a year later as reported in follow-up.

Myofascial Pain of the Jaw Muscles: Comparison of Short-Term Effectiveness of Botulinum Toxin Injections and Fascial Manipulation Technique. Guarda-Nardini L, Stecco A, Stecco C, Masiero S, Manfredini D. This was a randomized controlled trial comparing the short-term effectiveness of botulinum toxin injections versus FM in 30 patients with temporomandibular dysfunction (often called “TMJ”). Both treatment protocols provided significant improvement over time for pain symptoms as well as jaw range of motion, with improvements sustained at three months. (Note from CMW: FM may be considered superior in that it is non-invasive, is typically covered by insurance, and does not involve the use of a toxin to which the body develops antibodies.)

T1ρ‐Mapping for Musculoskeletal Pain Diagnosis: Case Series of Variation of Water Bound Glycosaminoglycans Quantification before and after Fascial Manipulation® in Subjects with Elbow Pain. Menon R, Oswald S, Raghavan P, Regatte R, Stecco A. Int. J. Environ. Res. Public Health 2020, 17, 708; doi:10.3390/ijerph17030708. Patients with elbow pain were evaluated with an innovative form of MRI called T1ρ (pronounced T-row), with imaging done both before and after three treatments with FM. Images showed a significant improvement in the water uptake of the connective tissue in the region of the painful elbow after treatment. (Inability of the connective tissue to bind with water is thought to be a major source of the pain and dysfunction experienced with many musculoskeletal syndromes.) Subjects also experienced improvement in pain and disability.

The influence of Fascial Manipulation on Function, Ankle Dorsiflexion Range of Motion and Postural sway in individuals with Chronic Ankle Instability. Kamani NC, Poojari S, Prabu Raja G. Journal of Bodywork & Movement Therapies. https://doi.org/10.1016/
j.jbmt.2021.03.024. This study looked at 13 recreational athletes ages 18-40 with a history of ankle sprain and recurrent issues in the ankle. Initial measurements included pain, range of motion, and postural sway. These showed significant improvement after treatment using FM, making this intervention recommended as part of an ankle rehabilitation program.

Is FM Something New?

Well, new to some! But it dates back to the late 1970’s, and began in Italy with Luigi Stecco, an Italian physiotherapist (in the US we’re known as physical therapists, same thing). He was dissatisfied with the poor outcomes typically accomplished in physical therapy as well as health care in general, and felt something was being missed. He studied anatomy and movement intensely, and proposed new constructs for approaching movement and dysfunction in the body. For a whirlwind explanation of it all you can watch this video.

Luigi Stecco teaching and 2 of his early books — Luigi Stecco, Italian physiotherapist, sharing his original concepts on FM many years ago. Today we still follow this original pattern of gathering a history, performing movement (not shown here) and palpation verification, and recording results. Pictured here are two of his earliest publications. Photos courtesy of the Fascial Manipulation Association.

He published his first book in 1987 exploring how muscles that move a body part in a certain direction relate to each other through their insertions onto the fascia. Here he related his concepts on movement, neuro-myo-fascial sequences and acupuncture meridians in his book that became very popular in China. His next book in 1990 further expanded his hypotheses of fascial involvement in proprioception (position sense), the physiology of fascia, and its relationship with pain. He began collaborating with Julie Ann Day, an Australian trained physiotherapist, who was instrumental in translating his books into English. Taught by Luigi, Julie went on to train many other teachers including Larry Steinbeck, my main FM instructor and mentor.

2020 first FM course in English, Thiene, Italy — In 2010 Thiene, Italy was the site for the first FM course in the world taught in English. The instructor was Julie Ann Day, (front row second from left). My instructor, Larry Steinbeck, was part of this group as well (second row, to the right, behind the baby). Many of these participants went on to become FM instructors. Photo courtesy of Larry Steinbeck.

It’s amazing that years before it was ever proven with high-powered microscopic magnification and staining that Luigi was proposing the fascia is innervated, plays a major role in governing movement, and could be a source of pain. This was the very same tissue that we were getting out of the way in our anatomy dissection labs so we could see the “important stuff.” It’s interesting to me how little our appreciation of the fascia has changed since then, even with all the science pointing us toward it. While change is slow, fortunately it is coming.

In 1997 Luigi began collaborating with his daughter, Carla, an MD, who joined him in researching his theories with much work done at the University of Padova in Padova, Italy. She became one of the first to identify and publish on the innervation of the fascia. His son Antonio, also an MD, PhD, later teamed up with them to contribute much to the literature expanding our understanding of the fascia. Over the years they have published an astounding compilation of books, research articles, and literature reviews. Luigi, Carla, and Antonio continue to present their work at events all over the world to practitioners from all disciplines, and have done much to catapult the discussion on fascia.

Luigi, Carla, and Antonio Stecco — Luigi Stecco, father of the FM method, with his children Carla and Antonio. These three have contributed much to the literature pool related to fascia and FM, and heightened awareness and appreciation of this vital yet overlooked structure. Photo courtesy of Fascial Manipulation Association.

In 2008 they founded the Fascial Manipulation Association (FMA) with the intent of promoting fascial research, investigating diagnostic tools and interventions for working with fascia, and expanding knowledge of the FM method. Since then courses have expanded and are currently taught all over the world by an elite group of teachers of which I am honored to be one. (A comprehensive listing of courses can be found on the FMA website under the education tab.) In 2017 the FMA introduced the specialist certification for recognizing clinicians who completed training in FM levels 1, 2, and 3 and also passed a written, oral, and practical examination. Practitioners from all over the world travel to Italy for this certification which is offered yearly. (A listing of these practitioners can be found on the FMA website, with other non-certified clinicians found in my Find a Provider section.)

Colleen with Luigi wearing FM certified specialist shirt — I call this the most expensive shirt I own! Here I am with Luigi on the happy day in Italy in 2018 when I was awarded my certification as an FM specialist, with the shirt presented to us as well. It’s hard to explain the effort and sacrifice behind this, and I only wear this shirt on special occasions. Thanks to my husband, Bill, for supporting me all the way. Photo by unknown attendee.

Celebrating the new FM instructors in 2019 — The Fascial Manipulation Institute in 2019 was the site of a toast with Prosecco (in true Italian form) for the three newly certified FM instructors. There we are in the front row – on my right is Christina from Austria, and Ferdinand from Spain is on my left. Behind me over my left shoulder is Luigi Stecco, surrounded by the FM instructors who were our examiners. Nothing quite rivals having an Italian emphatically grilling you for the right answer! Photo courtesy of the Fascial Manipulation Association.

To say FM has changed my life would be an understatement. I happened upon it at a time when I was, maybe like Luigi, getting a bit burnt out on physical therapy. I would work hard with patients, doing everything everyone told me was best practice, but it still fell short. I felt like we were never really getting to the root cause of problems, but just rehabilitating them after they had done their damage. Conversely for myself as a patient with lots of musculoskeletal and internal organ function issues, I was also getting discouraged at ever getting better.

Then mostly out of obligation to a colleague (thanks Brent!) I attended a weekend FM introductory course taught by Larry Steinbeck, and I began using the method. Even with my minimal understanding of it I was still getting results! Impressed and excited, I signed up for the full course. Later Brent and Larry were sorry to inform me that out of that introductory group I was the only one who signed up, so there would be no course. At that time (2014) there were very few courses offered in the US, and going to Italy was not an option for me. So we did the next best thing and held our own private course for the therapists in all our clinics! Since then we have continued to develop our skill in using this amazing method in the treatment of an incredible variety of diagnoses. It’s not easy to learn and apply correctly, perhaps owing to why there are not more clinicians utilizing it. But based on the changes I have seen it make for my patients as well as what I have felt it do for me, I could never go back to practicing without it.

On the left is one of our Appalachian PT courses taught by Larry (far left) and attended by many fine clinicians (acupuncturists, chiropractor, physical therapists, neuromuscular therapist), including our dogs. On the right we are learning where centers of coordination are located. Photos by Colleen Whiteford.

I will be forever indebted to Larry for all I have learned from him. He was one of the very few physical therapists who recognized the potential of this method years ago and acted on it. He has worked diligently to promote FM and a much needed change in our perspective as health care providers. He patiently mentored me as I moved through this whole process from student to teacher. He continues to provide wisdom, insight, and direction as we work to promote FM – sometimes like salmons swimming upstream! Many patients and clinicians are much better today because of his diligence and passion, which never seem to diminish.

Larry Steinbeck PT FM instructor — ***Larry Steinbeck, PT, from Georgia. Larry was the first PT in the US to become an FM instructor and has been my primary teacher and mentor over the years. Photo from Larry.***

Who Uses FM?

I’m embarrassed to confess that I used to be a snot about practitioners. As a PT I was very biased toward believing that the best clinician for handling patients for a multitude of diagnoses was a PT. Maybe if we’re honest we all start out that way. But maturity and experience have shown me otherwise, from two perspectives.

PT patch for lab coat — ***The old patch I used to wear on my lab coat. I haven’t seen one of these in years, and am very thankful we are not so rigid about wearing a uniform with a patch. Photo by Colleen Whiteford.***

First, I hear stories from patients I have followed behind other PT’s whose treatment of their patients was not very impressive. PT’s have the reputation, perhaps rightly earned, of counting on exercises as a pillar of their care. As a result, PT patients often end up with a hopelessly long list of exercises they eventually abandon, and it’s the patient’s fault they didn’t get or stay better because they didn’t do their exercises. Something about that has just never sat right with me, especially when I have been the patient. I would diligently work with my prescribed exercises, but I never felt they accomplished what I hoped for. Suffice it to say PT is like many other professions: some clinicians are passionate about going all out to help their patients, and some just don’t care as much. This is true for hairdressers, auto mechanics, dentists, and cashiers.

Secondly, I have met clinicians from a multitude of other professions that wowed my socks off. Their dedication to their patients, searching out the cause of a problem, and working hard to help their patients is heroic. This is the kind of clinician I want to be, and the kind of clinician I want treating me, my family, or anyone who asks me for a referral to a good clinician. Maybe this helps you understand why it’s so hard to confidently refer, and why I made the Find a Provider section of this website. When I can find this kind of person quite frankly I don’t really care as much what the letters are after their name. Sure, there are cases where those letters absolutely matter. But I’ll reiterate what put in my section on Fascia Facts:

Knowledgeable hands do not necessarily go with lots of letters after one’s name, nor do knowledgeable hands always accompany a particular health care field or license. To my way of thinking, knowledgeable hands are developed by a person who:

Uses their hands regularly and frequently for palpation in assessment and treatment
Is open-minded and seeking, even when it means they need to revise their paradigm, which is very demanding
Embraces a life-long path of learning
Is willing to give all they can to each patient, and is also passionate about helping people recover and thrive

So I celebrate anyone who does all this, regardless of their professional silo or which approach(es) they utilize.

FM Level 3 Las Vegas 2016 — I was excited and privileged to attend the first FM Level 3 course held in the US. Level 3 covers internal dysfunction and the relationship of the musculoskeletal system to the internal organs. There is also a lot of information on the autonomic nervous system. As you can imagine the course was pretty deep and complex, not at all easy to digest (no pun intended). Those attending came from all over the country and represented a wide variety of professional silos. I love gatherings like this where everyone lays aside their professional letters and comes together to learn. I wore a bright orange shirt that day so I would be easy to spot. Just kidding, I don’t plan that well.

As mentioned earlier, FM is used all over the world by a variety of clinicians. These include medical doctors, osteopaths, chiropractors, acupuncturists, massage therapists/bodyworkers, nurses, athletic trainers, and, of course, physical therapists. Many incredible professionals have stepped out from the comfort zone their professional silo affords to explore the possibilities FM offers, all in an effort to accomplish better results and get to the root cause of the problems our patients manifest. They all have my respect, whether I share the same professional title with them or not. I have undergone a major paradigm shift in my prior bias, and as it stands now I would rather refer to a clinician who is well versed in FM – regardless of the letters after their name – than one who does not use it, including a PT.

Who uses FM? A host of dedicated clinicians from a variety of disciplines. And now I can say that even five-year-olds use it!

5 year old doing FM — Here I am, a child prodigy at age five. Even then I saw the value of FM. Just kidding. This is the five year old granddaughter of a patient. She came along on treatment day and really wanted to help. I started her out by having her hold the percussion gun on the site to prep the area while I worked on the opposite side with FM. I turned my back to put up the percussion gun and the little FM’er jumped right in and starting treating her grandmother just like she saw me doing (yes, it’s an-la-ta). Too cute to pass up without capturing a picture. Photo by Colleen Whiteford.