Terra Rosa

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No. 22, Dec 2019

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Principles of Assessment
Cover Photo by Patty Kousaleos

—Bob McAtee 10
10 Notes from Fascia Research Congress and Pain Science
Summit —Til Luchau
17 Fascia can actively contract and thereby influence
musculoskeletal dynamics
18 Exercise attenuates fibrosis to the multifidus muscle
associated with intervertebral disc degeneration
19 Manual Therapy as a Treatment for Overuse Injures
20 Josephine Key talks about Freedom to Move
22 Til Luchau on Scoliosis: Working from Inside Out 22
32 Differential diagnosis of shoulder pathology
— John Gibbons
38 Assessment of Fascial Dysfunction
— Doreen Killens
46 Ligamentous Articular Strain Technique:
A Reconceptualization and Revitalization of a
Classical Osteopathic Manual Technique
— Robert Libbey
52 Research Highlights

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Terra Rosa E-mag No. 22 1

 Principles
of Assessment
by Bob McAtee
Accurate assessment is vital for properly treating soft tissue injuries. The goal of the assessment pro-
cess is to locate the structure or structures responsible for the client’s pain. Although massage thera-
pists are not legally qualified to diagnose a condition or injury, the profession’s scope of practice in-
cludes the right to assess a client to determine whether massage therapy is appropriate treatment for
her condition or whether the client needs to be referred to another practitioner.
This article serves as a thorough introduction to the principles of assessment for the therapist who
may not have studied the topic during their initial training as a sports massage therapist.

2 Terra Rosa E-mag No. 22

HOPS Method
Thorough evaluation includes several steps that can be
summarized by the acronym HOPS: history, observation,
palpation, and special tests. Table 1 contains examples of
the types of information collected in each category, but it
is by no means a comprehensive list. The HOPS process
provides the practitioner with a systematic, repeatable
method for evaluating injuries.
History
An accurate history of the problem presented by the ath-
lete is essential for determining a proper course of treat-
ment. Some conditions have a characteristic pattern of
onset and symptoms that can be ascertained from the
history. For instance, if an athlete reporting a knee injury
describes hearing a pop in his knee at the time of injury,
accompanied by the knee giving way, this combination is
characteristic of a meniscal or ligament injury, or both.
Taking a thorough history is the beginning of the deduc-
tive process that eventually leads to a working hypothesis
of what the injury may be and whether it’s a condition
that would benefit from sports massage therapy. The in-
formation acquired in the history helps direct the next
steps in the HOPS evaluation.
The history should include, but is not limited to, these
questions:
Gathering background information on the injury or com-
plaint
• What happened? Where? When?
• Do you have a previous history of this injury or issues
with this body part?
• Did you hear anything (e.g., popping, grinding)?
• Did you feel anything (e.g., popping, burning, joint giv-
ing way, numbness)?
Gathering information about the primary complaint
• What symptoms or complaint brought you in today?
• What symptoms are bothering you the most today?
• What were the symptoms at the time of injury?
• How would you describe the pain today (e.g., achy,
sharp, burning, throbbing)?
• How would you rate today’s pain on a scale from 0 to
10?
• What makes your symptoms worse?
• What makes your symptoms better?
Gathering information about previous diagnosis and treat-
ment
Learning about a previous diagnosis and any previous
treatment and its outcome helps a practitioner design a
treatment plan with a greater chance of success.
• Has there been a previous diagnosis? If so, who made
the diagnosis and what was it?
• Has there been previous treatment? If so, what was
done and by whom?
• What were the results of the treatment?
Observation
Observation is generally limited to what the practitioner
can see, feel, or hear, as opposed to what the client re-
ports subjectively. When possible, quantifying the finding
in some way is valuable for documenting results. For in-
stance, a swollen ankle could be noted as mild, moderate,
or severe. Even better, one could measure the ankle cir-
cumference (comparing to the uninjured side). After
treatment, changes can be documented to show the
effectiveness of the treatment administered.
During observation, look for the following:
• Swelling or atrophy
• Abnormal colour (bruising, redness, paleness)
• Postural issues such as an antalgic position, holding,
guarding
• Altered gait mechanics, for example limping
• Heat or cold (note colour changes in the skin due to
heat or cold)
• The sound of crepitus or grinding
• Facial expressions that could indicate pain
Palpation
The palpatory examination is guided by the findings gath-
ered from the history and observation. Palpation is per-
formed on the uninjured side first (to obtain a benchmark
for normal) and then proceeds cautiously on the injured
side.
The palpation portion of the HOPS evaluation is the dis-
crete use of the fingers, thumbs, or back of the hand to
help determine the quality of the soft tissues. Palpation is
performed to identify the feel and quality of the injured
area, with special attention to previous observations such
as swelling and temperature changes, as well as to muscle
Terra Rosa E-mag No. 22 3
spasm, crepitus, and significant point tenderness. Palpa-
tion may also include passive ROM to get a sense of the
condition of the movement quality of joint (e.g., spongy,
springy, etc.). Later in the assessment process, palpation
will play a key role in determining exactly where massage
and additional techniques, such as stretching, will be ad-
ministered.
Special Tests
In general, this portion of the assessment examines pas-
sive and active joint range of motion and muscle activa-
tion. The aim of accurate evaluation is to locate the struc-
ture responsible for the athlete’s pain. This is accom-
plished using a variety of tests to stress the suspected
tissues. Healthy tissue is expected to function without
pain or weakness. When injured tissue is placed under
stress, pain will increase (especially the pain that brought
the athlete in for evaluation) or the tissue will be weak, or
both.
Assessing Active, Passive, and Resisted
Motion
Evaluation protocols that test active, passive, and resisted
movements are intended to investigate the soft tissues
that could be the source of the client’s pain. These assess-
ments, with the potential findings for each, are summa-
rized in Table 2 and then described in detail. As with all
tests, assessment begins with the non-involved side first,
then moves to the injured side, at the joint closest to the
client’s pain symptoms. Depending on initial findings, test-
ing may need to progress more globally to rule out injury
above or below the suspected joint, especially if referred
pain is suspected.
TABLE 2 Joint Motion Assessment Summary. Adapted from J.H. Cynax and P.J. Cynax, Cynax’s Illustrated Manual of
Orthopaedic Medicine (Oxford, OK: Butterworths, 1983), and other sources.
4 Terra Rosa E-mag No. 22
From a sports massage perspective, these assessments
are concerned primarily with two types of soft tissue: con-
tractile and noncontractile (also called inert tissues).
The active, passive, and resisted motion tests engage
these tissues in different ways to help narrow the search
for the cause of the athlete’s symptoms.
Contractile tissues
Contractile tissues include muscles, tendons, and associat-
ed fascial bands. The muscle–tendon units are evaluated
globally during active ROM testing and more specifically
by using resisted (isometric) muscle tests. These tests
load the muscle and tendon fibres, while minimizing
stress on other structures. An increase in pain or weak-
ness, or both, is considered a positive finding and indi-
cates muscle strain or tendon issues in the tested muscle–
tendon unit. Injuries in contractile tissues respond well to
the massage techniques featured in the Sports Massage
for Injury book.
Noncontractile tissues
Ligaments, nerves, joint capsules, and bursae are consid-
ered to be noncontractile tissues. These tissues are evalu-
ated globally during active ROM testing and more specifi-
cally by using passive movements that test the integrity of
the tissue without involving the contractile tissues. Posi-
tive findings in these tests indicate that one or more of
these tissues is the site of the pain-causing lesion.
Ligament sprains respond well to specific massage tech-
niques, such as deep transverse friction. In nerve entrap-
ment conditions, sports massage directed at the tissues
that contribute to the entrapment is valuable. For the
most part, injuries to bursae and capsules do not benefit
from the direct application of sports massage.

The following assessments are typically performed to help
determine which structures to investigate with a more
detailed palpatory examination. All assessments are per-
formed on the unaffected side first to document a base-
line for their normal motion and to help allay any fears
that testing the affected side will be painful.
Assessment Using Active Motion
Active motion tests all the structures around the joint. It’s
a general test to determine whether the search for the
injury site is beginning in the right place. As the name im-
plies, the client performs active motion, with no assis-
tance from the therapist. Active motion is used to com-
pare and document the ROM and quality of movement
between the unaffected and the affected sides. Active
motion on the unaffected side is expected to be within
normal range for the joints being tested, and the move-
ment quality is expected to appear smooth and easy. Ac-
tive motion on the affected side is observed and docu-
mented, noting any limitations in ROM, any parts of the
motion that appear difficult, or that activate compensato-
ry movements, and where in the motion the athlete feels
pain.
For example, when an athlete complains of shoulder pain,
active motion can be used to evaluate the shoulder com-
plex, especially the rotator cuff. Figures 1-4 illustrate ac-
tive flexion, extension, abduction, adduction, internal and
external rotation, and horizontal abduction and adduc-
tion. The practitioner directs the client to perform these
movements, starting with the uninjured side to get a
sense of and document the quality and range of normal
FIGURE 1 Normal ranges
of active motion of the
shoulder girdle: (a) neu-
tral, (b) flexion, and
(c) extension.
movement for this client. This normal is then used as the
comparison when documenting active movement on the
injured side. It’s important to note that restrictions in
ROM on the affected side could be caused by a variety of
issues, other than a painful lesion. These include, but are
not limited to, hypertrophy, hypertonicity, weakness, soft
tissue scarring, the client being fearful of performing the
active movement, or nerve damage preventing the mus-
cle from contracting.
If active testing proves to be completely pain free, this
usually indicates that the source of pain is elsewhere, and
the client is experiencing referred pain. Occasionally, ac-
tive motion assessment will be pain free, even though
further tests will elicit the pain, especially if the injury is in
contractile tissue. This is because active motion often re-
quires less force than subsequent specific tests that re-
quire the recruitment of more muscle fibres and involve
the injured area enough to generate the symptoms.
Assessment Using Passive Motion
Passive motion is performed by the therapist, with no
assistance from the client. Normal passive range of mo-
tion is usually greater than active range and is done bilat-
erally to compare the unaffected and affected sides. Con-
tinuing with the example of complaints of shoulder pain,
the practitioner repeats the same set of movement tests
as in the active tests, encouraging the client not to help so
as to get a true reading of the quality and range of pain-
free passive movement available.
Passive motion on the unaffected side is expected to be
within normal range for the joints being tested, and the
Terra Rosa E-mag No. 22 5
FIGURE 2 Normal ranges of active motion of the shoulder girdle: (a) neutral, (b) abduction, and (c) adduction.

FIGURE 3 Normal ranges of active motion of the shoulder girdle: (a) neutral, (b) external rotation, and (c) internal rota-
tion.

movement quality is expected to feel smooth and easy.

6 Terra Rosa E-mag No. 22
Passive motion on the affected side is performed and doc-
FIGURE 4 Normal ranges of active motion of the shoulder girdle: (a) horizontal abduction and (b) horizontal adduc-
tion.
umented, noting any limitations in ROM, any parts of the
motion that appear difficult, or that activate compensato-
ry movements, and where in the motion the athlete feels
pain. Figure 5 illustrates a few passive motion assess-
ments.
Passive motion assesses the noncontractile tissues with-
out engaging the contractile tissues. Increased pain dur-
ing passive testing but not during resisted tests (the next
step) usually indicates that noncontractile tissue is in-
jured. However, at or near the ends of range, passive mo-
tion may cause pain by stretching injured contractile tis-
sue or by pinching it against bone.
Assessment Using Manual Resistive Tests
Resisted motion is used to specifically assess contractile
tissues (muscle, tendon, and associated fascial bands).
This isometric assessment is conducted by asking the cli-
ent to perform a strong isometric contraction that iso-
lates and loads the muscle–tendon unit while the thera-
pist holds the joint in neutral to avoid stressing the non-
contractile tissues around the joint.
A finding of weakness or an increase in pain (as the client
came in with some pain already) are positive for the tissue
tested and indicate muscle strain or tendon issues, or
both. To perform a manual resistive test and properly as-
sess the contractile tissue around a joint, follow these
steps:
1. Position the limb so the joint is at midrange (neutral).
Manual resistive testing done at or near a joint’s end of
range could also stress the noncontractile tissues, provid-
ing unclear results. Proper positioning isolates the specific
muscle–tendon unit to be tested.
2. Provide matching resistance as the client isometrically
contracts the muscle being tested, starting gradually and
building to a full contraction. Continuing with shoulder
assessment; if ROM tests indicate rotator cuff injury, the
manual resistive tests are used to isolate and assess each
of the four rotator cuff muscles. To test the supraspinatus
(the most commonly injured cuff muscle), the practitioner
positions the client with the arm hanging at the side. The
practitioner then stabilizes the arm at the elbow and di-
rects the client to slowly attempt to abduct the arm while
the practitioner provides matching resistance to prevent
the arm from moving (see Figure 6).
One of the following results should occur:
a. If the muscle tested is strong and pain free, there is no
overt injury. Continue testing other suspected muscles.
Even if no overt injury is found through testing, a subclini-
cal condition may be discovered when performing the
palpation assessment.
b. If the pain the client is complaining of increases, stop
the test. The lesion is probably contained in that muscle or
Terra Rosa E-mag No. 22 7
 tendon. Additional pain symp-
toms may arise during these
tests. These additional symp-
toms may be indicative of other
issues in conjunction with the
primary complaint. Make a note
of them and continue testing
for the presenting complaint.
c. If the muscle is weak but pain
free, there may be a possible
nerve conduction problem,
which should be evaluated by a
qualified physician.
3. If the test causes increased
pain, begin the palpation assess-
ment of the tested muscle–
tendon unit for the exact site of
the injury, using pain reports
from the client and tissue as-
sessment to guide the exam.
Pain will be the greatest at the
exact site of the lesion.

It’s important to note that

sports injuries often involve
both contractile and noncon-
tractile tissues. If an increase in
pain occurs with both passive
motion tests and resisted mo-
tion tests, then it may be that
both noncontractile and con-
tractile tissue is injured. It may
also mean that the noncontrac-
tile tissue is healthy, but the
contractile elements are swol-
len and inflamed and being
pinched during the passive test.

Additional Tests
Once the preliminary movement
assessments have been per-
formed, it may be useful to in-
clude additional, more specific
orthopaedic tests to further
pinpoint the injury site. These
are specialized to focus on the
joint being examined and can be
categorized as orthopaedic or
as neural tests.

FIGURE 5 Selected passive

movement assessments of the
shoulder complex: (a) flexion,
(b) extension, (c) external ro-
tation, (d) internal rotation.

8 Terra Rosa E-mag No. 22


FIGURE 3.6 Manual resistive test for the supraspinatus.
Assess End Feel
Quality of motion, especially at the end of the range, is
assessed through the application of mild overpressure at
or near the end of passive motion. This is called end feel.
Every joint has a normal end feel. Abnormal end feel, or
normal end feel at the wrong place in the ROM, indicates
injury or pathology. The ability to assess end feel im-
proves with practice and experience.
James Cyriax, a British orthopaedic physician, pioneered
the discussion of end feel, and many other experts have
since described different types of end feel. Cyriax wrote,
“The significance of the end-feel is thus the degree to
which it corresponds to or differs from what the end-feel
would be if the joint were normal. Different types of end-
feel imply different disorders” (Cyriax and Cyriax 1983,
p.8). The following are common examples of end feel:
• Boggy: This is a soft and mushy feel that occurs because
of joint effusion or oedema. This may indicate acute swell-
ing and inflammation. A good example would be a moder-
ate to severe ankle inversion sprain.
• Bony: This is a hard stop when two bones touch each
other. Elbow extension is a good example of the normal
end feel being bone to bone. If the end feel of an elbow
extension were not a hard stop, this would be an abnor-
mal finding.
• Capsular (often extended to include ligamentous): This
is typically described as a “firm but leathery” stop. Normal
capsular end feel occurs when the joint capsule is the pri-
mary limiter of the end range, such as with external rota-
tion of the shoulder.
• Empty: This category is used when the practitioner is
unable to reach the end feel because the client stops the
test due to pain or anticipated pain. In this case, there is
no physical restriction to the movement, but the client is
purposefully preventing movement through the full ROM.
A good example of this occurs with shoulder impinge-
ment conditions, where soft tissue pain occurs before
normal end feel can be achieved.
• Muscle stretch: The motion stops as a result of the tis-
sue reaching the end of its stretch. This feels rubbery or
slightly springy, like stretching a bicycle tire inner tube. A
good example of this end feel occurs when the hip is
flexed while the knee is held in extension and motion is
stopped by the hamstrings.
A client with extremely tight hamstrings may have a nor-
mal end feel but is well short of a normal ROM. This would
indicate a condition to be treated.
• Soft tissue approximation: The motion stops when two
masses of tissue (muscle, fat) press against each other,
such as calf muscles pressing against hamstrings during
knee flexion.
• Spasm: The movement ends abruptly, short of normal
end range, and is accompanied by pain or anticipated
pain. Spasm has a springy, rebound end feel that repre-
sents protective muscle guarding.
• Springy block: The motion stops short of normal, ac-
companied by a bouncy sensation, like when compressing
a spring. This indicates that a loose body may be blocking
the motion; it is commonly felt in the knee when a piece
of floating cartilage or a torn meniscus limits knee exten-
sion.
Summary
The ability to correctly assess the condition causing the
symptoms an athlete is complaining of can be the differ-
ence between success or failure in the treatment of that
athlete. This chapter has provided a framework for the
systematic assessment of soft tissue injuries (HOPS meth-
od), as well as reminders to evaluate perpetuating factors
that may prolong the recovery from injury. These assess-
ment protocols are developed more thoroughly in the
chapters that cover specific injuries commonly seen in the
sports massage therapy setting.
This article is excerpted from Sports Massage for Injury
Care by Robert E. McAtee, LMT, BCTMB, CSCS, with per-
mission from Human Kinetics. In Australia or New Zea-
land, order from www.terrarosa.com.au;
in the U.S., visit us.humankinetics.com
Terra Rosa E-mag No. 22 9
 Notes from
Fascia Research Congress
and Pain Science Summit
Til Luchau
Til Luchau recently wrote up his impressions from 2 large conferences he attended:
the Fifth International Fascia Research Congress (FRC5) in Berlin, Germany 14-15 November 2018,
and the 2019 San Diego Pain Summit in California, USA, 19 - 24 Feb 2019.

While it’s tempting to compare the two events, as they re-
flect two influential (and sometimes polarized) points of
view within our field, the two meetings were quite different
in purpose. Luchau writes that “the FRC5 aimed to show-
case the latest fascia research and to promote understand-
ing and collaboration among scientists working in fascia
research and the clinical professionals whose work address-
es fascia,” while “the purpose of the San Diego Summit is
not research (nor manual therapy) per se. Instead, the Pain
Summit’s role has been bringing people together to share
their application and continuing refinement of existing con-
cepts.”
Excerpts from each of Til Luchau’s reports are below.
The Fifth International Fascia Research
Congress
My colleagues and I joined more than 1,000 diverse pro-
fessionals from all over the world: manual therapy, move-
ment, sports, and rehabilitation practitioners; academics
and researchers; writers; teachers; and more. In standing-
room-only crowds, and afterward in the surrounding
cafes, river boats, and off-campus events, we listened,
learned, socialized, debated, and digested several days of
presentations, workshops, panels, art events, screenings,
and talks.
I am sharing here some of the most personally interesting
aspects of what I learned.

10 Terra Rosa E-mag No. 22


Carla Stecco, MD
Looking for explanations for why myofascial pain and fas-
cial disorders are more common in women than men (and
why they vary over women’s lifespans), fascial researcher
and orthopedic surgeon Carla Stecco, MD, presented her
group’s recent research into sex hormones’ role in fascial
remodeling. They see potential implications for better
understanding of fascial properties, healing, and nocicep-
tor sensitization.
Stecco also presented the histological evidence behind
her group’s proposed redesignation of a class of round
fibroblasts as fasciacytes. These “new” cells appear to
regulate hyaluronic acid (or HA, which is involved in fascial
gliding and elasticity), and in her analysis, have several key
differences from other fibroblasts.1
Stecco also shared evidence that endocannabinoid (CB2)
receptors in fascia seem to inhibit collagen formation in
inflammation, which suggests to me that when these re-
ceptors are activated, they may help regulate fibrosis in
injury recovery and scarring, but may also imply slower
tissue recovery and remodeling.
Paul Hodges, PhD
I was particularly looking forward to Paul Hodges’s
presentations on inflammation, pain, and motor control.
Paul is a Professor of Spinal Pain, Injury, and Health at Uni-
versity of Queensland. A few highlights from my lengthy
notes:
Multifidus inflammation was seen after experimentally
Dr Paul Hodges from University of Queensland. Used by permission.
induced spinal disk injury in pigs, and curiously, in muscles
far from the injured disk. This raises questions (for me at
least) about the mechanisms of inflammatory triggering
and spreading: was the remote inflammation due to bio-
mechanical, circulatory, neurological, or other factors? Or,
all of the above?
Most interestingly, people with chronic sciatic pain have
an increased representation of the back and leg in their
motor cortexes (not just their sensory cortexes, as I’d
expect). This adds a neurological rationale to the practice
of using active movement to help resolve inflammation
and pain.
Daniel Lieberman, PhD
In his opening plenary, “The Evolution of Human Walking
and Running and the Cases of the IT Band and the Plantar
Fascia,” Harvard paleoanthropologist Daniel Lieberman
(whose work was popularized in Chris McDougall’s best-
selling Born to Run) described fascial features in evolu-
tionary biology. One example: great apes’ iliotibial bands
are only one-third as thick as humans’ and have insertions
from only one-third the number of muscles. This is pre-
sumably related to apes’ knuckle-walking depending less
on lateral stabilization than humans’ bipedal stride. From
his evolutionary perspective, Lieberman’s view is that
many of our musculoskeletal problems come from adap-
tations (e.g., shoes) to unnatural situations (e.g., pave-
ment).
Instertitium and Fluid Dynamics
When physician and pathology researcher Neil Theise,
MD, co-authored a paper about the interstitium earlier
this year,2 the popular press touted him as the
“discoverer” of a new organ. Osteopaths, Rolfers, and
fascial anatomists (such as Jean-Claude Guimberteau and
Gil Hedley) were quick to point out that they’d already
been talking about the same tissues, layers, and struc-
tures (as the loose connective tissues) for many years.
Theise’s recent work, however, has emphasized and clari-
fied these layers’ fluid flows, as well as their interconnec-
tions with lymphatic flows. This new view of loose con-
nective tissue (such as superficial fascia) has implications
that extend to cancer, immune function, and inflamma-
Dr Meldody Schwarts on interstitum and fluid dynamics. Used by permis-
sion.
Terra Rosa E-mag No. 22 11

Dr Frank Willard on myofascial and low back pain.
tion.
Molecular bioengineering researcher Melody A.
Schwartz’s presentation expounded on these interstitial/
lymphatic connections, and among other remarkable ide-
as, I learned that interstitial pressures are lower in
lymphedema (tissue swelling), rather than higher as I
might have assumed. This, she says, is due to loss of tissue
Several members of the Advanced-Trainings.com faculty attended the FRC5. From left: Larry Koliha, Bethany Ward, Til Luchau, Ramona Peoples, and Bibiana
Badenes. Image courtesy www.Advanced-Trainings.com.
12 Terra Rosa E-mag No. 22
elasticity; and since interstitial fluid flows are fundamental
to inflammatory resolution, tissue elasticity has possible
implications for non-resolving inflammatory and autoim-
mune conditions, such as adult-onset psoriasis.
Frank Willard, PhD
Neurobiologist and anatomist Frank Willard from the Uni-
versity of New England, College of Osteopathic Medicine,
in Portland, Maine, presented gorgeous anatomical imag-
es of little-known innervation of the intervertebral disks
and facet joints, and shared the results of his review of
back-pain literature. He estimates myofascia and liga-
ments are the source of nociception in 70 percent of back
pain, while disk-relegated pain accounts for an estimated
4 percent.
Watch Til talked about FRC5 here https://youtu.be/
dz1nUpe9qFg
Clinical Relevance
“Clinical relevance” is the litmus test that many of us will
use when evaluating fascial (or other) research. Of
course, each of our ideas of “relevance” depends on our
favoured therapeutic narratives. Those friendly to fascia
will find much in the FRC5 proceedings that has practical
relevance to their work. In other circles, and especially on
social media, the therapeutic relevance of fascia is some-
times hotly debated, and those who have already been
put off by the hype, exaggeration, speciousness, and fad-
dishness unfortunately associated with many fascial ap-
proaches are unlikely to change their opinions based on
one Congress’s proceedings alone.
From my own point of view, as someone with a range of
passions that include fascial science, somatic psychology,
pain science, biopsychosocial applications (and most re-
cently, inflammation), I was heartened by the FRC5’s tone
of cross-disciplinary curiosity, openness, learning, and From neuroscientist Antonio Damasio’s keynote address: “Our minds are
discourse. Both in our society, and within our field, we can constructed in partnership between the brain and the body: the brain reports
on the outside world, the body reports on the inside world, and the nervous
use all the bridges across that chasms between us that we
system is the broker between these two.” Image courtesy San Diego Pain
can get.
Summit, used by permission.
Still, as practitioners, our main question is most often “So,
how does all this translate into hands-on practice?” The The brain shapes this bodily emotion into mental feelings
full answer is that it will take time to tell. Though I doubt by assigning valence: the mental valuing that determines
it’ll take the medical average of 17 years for new research meaning and preference. “Feelings,” Damasio says,
to appear in clinical practice5, new ideas need validation, “occur after we become aware in our brain of [emotion’s]
debate, integration, and of course application. physical changes; only then do we experience the feeling
of fear.”4 “And pain,” he says, “needs to be treated as a
Personally, however, since the FRC5, I’m already:
feeling,” implying a deep role for the mind in the pain ex-
- Re-mapping my narratives of what happens under my perience. (For more, see Damasio’s book Descartes’ Error,
hands to include even more about fluids and flows, and or his TED talk at http://bit.ly/2Jx4QoG).
even less about fibres and fascia per se;
• When Maxi Miciak, PT, PhD, was writing her doctoral
- Experimenting with the idea that active movement thesis about how the practitioner/patient relationship
affects cortical maps of inflammation and pain (as does influences the effectiveness of physical therapy, she
sensory experience, like touch); found almost no existing research and very little formal
study into the therapeutic relationship in any field.5 What
- Keeping in mind that there is no one-size-fits-all for any
research she found, she says, showed (unsurprisingly)
of these approaches.
that the quality of the practitioner/patient relationship is
Though we’re learning more all the time about how pain, linked to better patient satisfaction, and to better thera-
tissues, fluids, and the nervous system all interact and peutic outcomes. Her own research into the question
play a part in hands-on work, each person and each situa- (using an interpretive description qualitative method, fol-
tion is distinct, and needs an adaptable approach from us lowed by quantitative analysis) led to her model of the
as practitioners. The more options and the broader our conditions of engagement necessary for therapeutic
view, then, the more versatile and responsive we become. effectiveness . One of her practical suggestions: since lis-
tening can be a powerful therapeutic intervention itself,
practice making room for your client’s story and try wait-
2019 San Diego Pain Summit ing for eight seconds after the patient speaks before re-
sponding.
About a dozen presenters spoke about pain-science–
• Australian physical therapist Mark Bishop, PhD, shared
related topics, ranging from the neurology of body/brain
his thought-provoking research into how patient/client
interactions, therapeutic relationships, and compassion to
expectations influence the outcomes of manual therapy,
brain imaging, the role of patient/client expectations, and
and his thoughts on placebo mechanisms.
more. Here are some of my personal favorites.
Bishop says that placebo has a “branding problem” be-
• Neuroscientist Antonio Damasio, PhD, has written ex-
cause “people think placebo is nothing; a sugar pill. Place-
tensively on the ways the body informs the mind. To help
bo mechanisms, however, are far from nothing,” since the
explain this interaction, Damasio makes a neurological
mechanisms behind placebo responses are physical, hor-
distinction between feelings and emotions. Emotions, in
monal, endocrine, and neurotransmitter changes in the
this model, are bodily reactions that serve to maintain
body. Bishop emphasized that placebo effects are always
homeostasis: physical reaction, retraction, and move-
present in our treatments, whether we consciously use
ment. For example, Damasio says, “When we are afraid of
them or not. “We always provide care within a context,”
something, our hearts begin to race, our mouths become
Bishop says. “I’ve never walked into a black room, in a
dry, our skin turns pale and our muscles contract. This
dark spandex suit, to treat someone lying on a table
emotional reaction occurs automatically and unconscious-
who’s blindfolded, with earplugs, and asleep.”
ly.”

Terra Rosa E-mag No. 22 13

In Maxi Miciak’s Safe Therapeutic Container model, her five Conditions of Engagement are visualized as a box, with the floor and walls representing two corner-
stone conditions, “present” and “receptive.” “Committed” and “genuine” are more variable, and so are represented by the mobile lids of the container. Image
courtesy Dr. Miciak, used by permission.

But it was his findings on client and practitioner expecta-
tions I found most interesting:
• In a 400-person comparative study of spinal manipula-
tion versus spinal mobilization effectiveness for back pain,
therapeutic touch (or TT, in which therapists simply
“place their hands on or near their patient’s body with the
intention to help or heal”) was used as sham treatment
(i.e., as a placebo comparison, intended to reveal the di-
rect effects of the spinal methods). In a surprise to the
researchers, at the end of the six-year study, TT was the
most desired treatment by the participants, and the treat-
ment they most expected to help their pain.6
• In another comparative study, massage therapy was the
neck pain treatment that study participants most ex-
pected would help (Image 3).7
• In studies of cervical, shoulder, and lumbar complaints,
patients’ general expectation of recovery have been re-
peatedly found to be the strongest predictor of recovery;
stronger than the therapeutic method used, practitioner
experience, or other factors.8 Given this, Bishop says, our
skills at building an alliance and keeping clients engaged
are probably more important to pain recovery than any
particular method or therapy.
• And perhaps most importantly, Bishop’s research
showed that method does matter, but on the provid-
ers’ (rather than clients’) side: when practitioners had a
strong preference for a particular treatment, that treat-
ment had better results, no matter what that treatment
was.9
Is Pain Science Passé?
14 Terra Rosa E-mag No. 22
This was the fifth San Diego Pain Summit, and with 111
participants in attendance, this Summit was a bit smaller
than in previous years. Does this dip in size mean that in-
terest in pain science is waning? There are signs elsewhere
that perhaps the initial gush of enthusiasm about biopsy-
chosocial approaches might be fading: in the manual ther-
apy blogs and podcasts that I follow, “pain” is much less
frequently a topic than it was just a couple years ago; and,
on one (formerly?) pain-science-friendly podcast, the
hosts audibly snickered when “pain science” was men-
tioned amongst the list of trendy topics that are no longer
in the fore.
Or could it be that biopsychosocial perspectives on pain
have by now percolated deeply enough into our field that
they are no longer quite so radical or new? No idea stays
on the cutting edge indefinitely; at some point, a novel
view either fades away, or becomes part of the main-
stream. Though some would argue that pain science has-
n’t penetrated deeply enough into massage and body-
work yet, its influence on our field is well-established, and
maturing. After all, these ideas have been around for
some time now: many PT’s trace pain science ideas to Da-
vid Butler’s neurodynamic work in the 1990’s; or MT’s, to
Diane Jacob’s Dermoneuromodulating approach, which
she developed in the last decade. But biopsychosocial
concepts have parallels in earlier concepts of mind/body
holism, including Feldenkrais’ work from the 1970’s, and
many other early influences on massage and bodywork.
Here at Advanced-Trainings.com, it’s been about six years
since we offered our first pain science-focused course;
and it’s not an exaggeration to say our entire in-person
PT and researcher Mark Bishop, PhD, on the influence of patients’ and practitioners’ expectations on therapeutic outcomes. Chart: Study participants’ expecta-
tions of neck pain benefit from common interventions for “this episode of neck pain,” ranked by level of agreement (blue bar) with “I believe [the intervention]
will significantly help improve this episode of my neck pain.” From the left (most agreement): Massage; Manipulation; Strengthening; ROM; Aerobic; Traction;
Rest; Modalities; Medication; Surgery (least agreement). Image courtesy Advanced-Trainings.com; chart slide courtesy Dr. Bishop, used by permission.

curriculum has been accordingly revised in the years since.
We are not alone in this: several of my esteemed continu-
ing education colleagues (such as Whitney Lowe, Ruth
Werner, Erik Dalton, Walt Fritz, and others) have also in-
corporated pain science or biopsychosocial concepts into
their approaches. And to be fair, the purpose of the San
Diego Summits is not research (nor manual therapy) per
se; none of the presenters at this year’s summit claimed
to be presenting radical new pain research; or novel,
game-changing ideas--instead, the Pain Summits’ role
have been bringing people together to share their applica-
tion and continuing refinement of existing concepts.
A question I heard several times while there was, “Why
don’t more massage therapists and bodyworkers attend
the Summit?” According to the event’s organizer, Rajam
Roose, most of the summit’s attendees are physical thera-
pists or physical therapy students. Massage therapists are
indeed a minority (though interestingly, about half of the
MTs in attendance travelled from a single Canadian prov-
ince, British Columbia, where, I was told, pain science ide-
as have a strong following amongst massage therapists).
But the BC exception aside, we saw this same phenome-
non when Advanced-Trainings.com cosponsored an
“Explain Pain” training (from the Australian NOI Group)
here in Colorado in 2015: most attendees were physical
therapists, with only a few Rolfers, structural integrators,
and even fewer massage therapists attending.
Could it be that the “science” emphasis in pain science
isn’t appealing to as many MTs as PTs? Though massage
therapy is moving towards greater science literacy, none
of the presenters at the Summit were massage therapists
or bodyworkers. There were no hands-on manual therapy
pre-conference workshops; and only one presenter identi-
fied himself as a manual therapist (physical therapist Mark
Bishop). Or perhaps, as I also heard several times in my
conversations there, it’s not always obvious to massage
therapists how they might apply pain science’s education-
or rehabilitation-focused material within their skillset and
scope of practice (which where my educator-colleagues
and I come in).
Watch Til talking about the Pain Summit here https://
youtu.be/QIWD8ilAVLw
Next Year’ Pain Summit
With about 60% of this year’s attendees being first-time
Summit-goers, Roose is optimistic about next year’s at-
tendance. She says that her focus in 2020 “is going to be
more on the ‘psych’ in biopsychosocial (BPS).” As she
sees it, “There is this pervasive idea that things like moti-
vational interviewing (MI) or acceptance and commitment
therapy (ACT) are out of scope for the clinician, which
really isn't true. It's not out of scope for us to understand
how to communicate with our patients/clients and give
them a sense of self-efficacy… There's also going to be a
presentation on the limitations of the BPS model, which I
think will be really interesting!”
Whether you think the pain science trend in our field is the
Terra Rosa E-mag No. 22 15
next big thing; already passé; or, maturing into an integral
part of our field’s way thinking, there’s still plenty to learn
together about pain, and the many ways to work with it,
both on and off the table.
Special thanks to Ruth Werner for her contributions and
collaboration.
Til Luchau is the author of Advanced Myofascial Techniques
(Handspring Publishing, 2016), a Certified Advanced Rolfer,
and a member of the Advanced-Trainings.com faculty,
which offers online learning and in-person seminars
throughout the United States and abroad. He invites ques-
tions or comments via info@advanced-trainings.com and
Advanced-Trainings.com’s Facebook page.
Notes
1. C. Stecco et al., “The Fasciacytes: A New Cell Devoted to Fascial Gliding
Robert Schleip, Ph.D., (center) played a key leadership role in current and past Fascia Research Congresses. Along with Rachelle L. Clauson and Gary Carter (seen
here admiring a specimen of the fascia cruris, inset), Schleip also co-coordinated the Fascial Net Plastination. Project. Image courtesy Alison Slater.
16 Terra Rosa E-mag No. 22
Regulation,” Clinical Anatomy 31(5) (July 2018):667–676. doi: 10.1002/
ca.23072.
2. P. C. Benias et al., “Structure and Distribution of an Unrecognized
Interstitium in Human Tissues,” Scientific Reports 8, no. 1 (2018): 4947.
3. Z. S. Morris, S. Wooding, and J. Grant, “The Answer is 17 Years, What
is the Question:
Understanding Time Lags in Translational Research,” Journal of the
Royal Society of Medicine, 104, no. 12 (2011): 510–20.
4. Antonio Damasio, quoted in Lenzen, Manuela, “Feeling Our Emo-
tions,” Scientific American Mind 16, no. 1 (April 2005): 14–15, https://
doi.org/10.1038/scientificamericanmind0405-14.
5. M. Miciak et al., “The Necessary Conditions of Engagement for the
Therapeutic Relationship in Physiotherapy: An Interpretive Description
Study,” Archives of Physiotherapy 8 (2018): 3, https://doi.org/10.1186/
s40945-018-0044-1.
6. M. D. Bishop, “What Effect Can Manual Therapy Have on a Patient’s
Pain Experience?” Pain Management 5, no. 6 (November 2015): 455–64,
https://doi.org/10.2217/pmt.15.39.
7. M. D. Bishop, “Patient Expectations of Benefit from Interventions for
Neck Pain and Resulting Influence on Outcomes,” Journal of Orthopae-
dic & Sports Physical Therapy 43, no. 7 (July 2013): 457–65, https://
doi.org/10.2519/jospt.2013.4492.
Fascia can actively contract and thereby
influence musculoskeletal dynamics
Plastination of fascia of the thigh . Photo courtesy of Rachelle Clauson
Fascia is a biological fabric that enmeshes all structures in our
body. While there is a research interest in the role of fascia as a
force transmitter in muscular dynamics, fascia is often regarded
as a passive contributor to biomechanical behaviour.
There have been several studies that indicated the active role of
fascia which has an inherent ability to contract actively. These
indications include the reported phenomenon of “ligament con-
traction” of human lumbar fascia in response to repeated iso-
metric strain application. There is also evidence of fascial tissues
can shorten over several days in certain pathologies, such as
Palmar fibromatosis, hypertrophic scars, and similar fascial fi-
brotic conditions. This tissue shortening is mostly due to the
presence of myofibroblasts (a type of cell responsible for wound
healing and tissue repair). The resulting tissue contracture is due
to an incremental combination of cellular contraction, collagen
cross-linking and matrix remodelling.
Robert Schleip and colleagues from Ulm University has been
interested in finding out whether normal fascia may possess the
capacity for cellular contraction which, in turn, could play an
active role in musculoskeletal mechanics.
In a new study published in Frontiers of Physiology, they studied
human and rat fascial specimens from different body sites for
the presence of myofibroblasts using immunohistochemical
staining for α-smooth muscle actin (n= 31 donors, n=20 animals).
Also, mechanographic force registrations were performed on
isolated rat fascial tissues which were exposed to pharmacologi-
cal stimulants to measure contracting force.
The study found that:
• the density of myofibroblasts is larger in the human lumbar
fascia in comparison to fasciae from the two other regions
examined in this study: fascia lata and plantar fascia.
• Fascial tissues contract when exposed to different pharma-
cological substances: fetal bovine serum, the thromboxane
A2 analog U46619, TGF-β1, and mepyramine.
• Botulinum toxin type C3–used as a Rho kinase inhibitor–
provoked relaxation.
• In contrast, fascial tissues were insensitive to angiotensin II
and caffeine.
• There is a positive correlation between myofibroblast densi-
ty and contractile response.
The calculation of potential contractile forces of fascia predicts a
force range that seems insufficient for exerting a direct short-
term effect (i.e., occurring within minutes to hours) on mechani-
cal joint stability of the human spine. The short-term contractile
forces of fascial tissues are at least two orders of magnitude
below that of muscle tissue and may have no significant effect
on spinal stability or other important aspects of human biome-
chanics.
Nevertheless, the predicted fascial contraction forces in the
human lumbar region are above the much lower threshold for
influencing mechanosensation. They are strong enough to alter
motoneuronal coordination in the lumbar region. The authors
suggest that a local and/or temporal increase in fascial contrac-
tility might contribute to long-term tissue contracture, which
includes matrix remodelling.
Based on the known signalling influence of the sympathetic
nervous system on TGF-β1 expression, they suggest that their
findings tend to support the hypothesis of a close connection
between fascial stiffness and chronic sympathetic activation. In
the light of the large contribution of psychosocial factors in low
back pain, they suggest further studies to explore possible inter-
actions between emotional stress, fascial stiffness, and low back
pain.
The authors concluded that the tension of myofascial tissue is
actively regulated by myofibroblasts with the potential to im-
pact active musculoskeletal dynamics.
Reference:
Schleip, R., Gabbiani, G., Wilke, J., Naylor, I., Hinz, B., Zorn, A., Jäger, H., Schreiner,
S. and Klingler, W., 2019. Fascia is able to actively contract and thereby influence
musculoskeletal dynamics: a histochemical and mechanographic investiga-
tion. Frontiers in physiology, 10, p.336.
Terra Rosa E-mag No. 22 17
Exercise attenuates fibrosis to the multifidus
muscle associated with intervertebral disc
The International Society for the Study of the Lumbar Spine re-
cently awarded the ISSLS Prize in Basic Science 2019 to a paper
by G. James, Paul Hodges and colleagues from the University of
Queensland. The study, published in the European Spine Journal,
found that Intervertebral disc degeneration is associated with
fibrosis in the multifidus muscle and exercise attenuates that
fibrosis
Chronic low back pain is usually accompanied by structural re-
modelling and inflammation of muscles around the spine, in
particular, the multifidus muscle. Studies have found an in-
creased cross-sectional area of connective tissue and expression
of collagen in the multifidus during early chronic LBP. These
changes are characteristic of tissue fibrosis. However, the extent
and mechanisms underlying the increased fibrotic activity in the
multifidus are unknown.
It is also known that physical activity can modify connective tis-
sue in skeletal muscles. Short-term exercise stimulates both
collagen synthesis and degradation which assist in its remodel-
ling. Long-term exercise prevents aging-dependent fibrosis. A
past study found that physical activity reduces local inflamma-
tion that precedes multifidus fibrosis during intervertebral disc
degeneration (IDD).
Inflammation can happened peripherally or centrally. When
there’s an inflammation, white blood cells released certain
chemicals to protect against foreign substances. These chemi-
cals in the tissue create a kind of “inflammatory soup”, which
can excite and sensitize neurons, making them more responsive
than under normal conditions. Inflammation can generate and
modify pain response. It can lead to central sensitization, periph-
eral sensitization, tissue effects, and neuroimmune reactions.
This new study evaluated the development of fibrosis and its
underlying genetic network during IDD and the impact of physi-
cal activity.
• Physical activity attenuated the IDD-dependent increased
connective tissue thickness and reduced the expression of
collagen-I, fibronectin, CTGF, substance P, MMP2 and TIMP2
in mice.
The authors concluded that the fibrotic networks that promote
fibrosis in the multifidus muscle during chronic IDD. Further-
more, physical activity is shown to reduce fibrosis and regulate
the fibrotic gene network.
Comments by Til Luchau:
Some degree of connective tissue fibrosity is a normal result of
inflammatory reactions to injury—scar tissue is one example.
But when inflammatory reactions are extreme or prolonged,
excessive fibrosity and pathological, painful scarring play into a
vicious cycle of less movement; more sensitivity and pain; and
more inflammatory response.
Our field is in the midst of a debate between differing points of
view about tissue and pain. Is it tissue density that causes pain
(the conventional working assumption behind many manual
therapies)? Or is it that tissue fibrosity is an unrelated by-product
of pain-induced stasis?
However, there is widespread agreement, across many points of
view and therapeutic disciplines, that movement often helps
with injury recovery: especially active, moderate and regular
movement. This recent study confirms that (at least in SPARC-
null mice, which are genetically prone to disc injuries) there are
indeed biological, tissue-based differences, and better healing,
that result from voluntary active movement after an injury. But
far from confirming whether fibrosity is the injury-chicken or the
pain-egg, it reveals the intrinsic interconnection between our
tissues, our activities, and healing from an injury.

The study used mice that were either sedentary or housed with
a running wheel, to allow voluntary physical activity. At 12
months of age, IDD was assessed with MRI, and multifidus mus-
cle samples were harvested from L2 to L6.

The study found:

• Fibrosis (i.e., increased thickness of the connective tissue

between the multifidus and longissimus muscles) in muscle
that crossed a degenerated disc.

• Fibrotic gene network (CTGF, SP, TIMP1, and TIMP2) was

dysregulated in multifidus crossing a degenerated disc and
correlated with changes in Extra Cellular Matrix (ECM) gene
expression

18 Terra Rosa E-mag No. 22

Manual Therapy as a Treatment for
Overuse Injures
Chronic repetitive motion and overuse injuries made up a large
proportion of musculoskeletal and nerve disorders. These con-
ditions are often called repetitive motion disorder or repetitive
strain injuries. Painful and disabling musculoskeletal disorders
remain prevalent and manual therapy has been used to treat
such issues. However the actual neural mechanism of how man-
ual therapy work is still unclear.
To find out the neural mechanism of manual therapy, Geoffrey
Bove and colleagues University of New England College of Os-
teopathic Medicine conducted a study on rats. The rats were
trained to perform repetitive tasks leading to signs and dys-
function similar to those in humans. The authors then tested
whether manual therapy would prevent the development of
the pathologies and symptoms.
The researchers collected behavioral, electrophysiological, and
histological data from control rats, rats that trained for 5 weeks
before performing a high repetition high force task (HRHF) for
3 weeks untreated, and trained rats that performed the task for
3 weeks while being treated 3 times per week using modeled
manual therapy to the forearm. The modelled manual therapy
included bilateral mobilization, skin rolling, and long axis stretch- inflammation, which is usually painful. The authors suggested
ing of the entire upper limb. that regarding overuse injuries, if manual therapy were adminis-
tered early, before pathological changes occur, then medical
Results showed that rats that performed a repetitive task expenses for treatments that are often ineffective might be
showed decreased performance of the given task and showed avoided.
increased discomfort-related behaviours, starting after training.
Comment by Joe Muscolino
Those strained rats that were treated with manual therapy
showed improved task performance and decreased discomfort This is another in a long line of studies that show the effective-
related behaviours compared to untreated rats. Subsets of rats ness of manual therapy. In this case, that early manual therapy
were assayed for presence or absence of ongoing activity in C- might avoid much pain and expense in the future. Wouldn’t it be
and slow Aδ- neurons in their median nerves. Neurons from wonderful if manual therapy could become the norm in people’s
strained rats had a heightened proportion of ongoing activity lives instead of an occasional treat or perhaps not existing at all.
and altered conduction velocities compared to control and man- I am such a believer in the power and benefit of manual and
ual-treated rats. Median nerve branches in strained rats con- movement therapies!
tained increased numbers of CD68+ macrophages and degraded
The three major keys to musculoskeletal (neuro-myo-fascio-
myelin basic protein, and showed increased extraneural collagen
skeletal) health…
deposition, compared to the other groups.
The authors concluded that the performance of the task for • Strength of musculature
three weeks leads to increased ongoing activity in nociceptors • Flexibility of soft tissues
(pain receptors), in parallel with behavioural and histological
signs of neuritis and nerve injury. Manual therapy: • Proper neural control

• prevents functional declines

• improves task performance
• prevents discomfort
• reduces neural inflammation
• reduces myelin degradation
• reduces extraneural fibrosis.
This study confirms that a repetitive task can cause body struc-
tures to be overloaded and injured. If the task is repeated with-
out enough time for healing, the inflammation becomes persis-
tent because it is reinforced during each task session. The nor-
mal response of the body is to heal the injury, which starts with

Terra Rosa E-mag No. 22 19

Josephine Key talks about
Freedom to Move
Can you tell us a bit about yourself?
I’ve been a practicing physiotherapist for over 45 years, the ma-
jority of which have been devoted to seeking a better under-
standing of the spine in both its health and dis-ease. I have de-
veloped a model of care which combines manual therapy and
complimentary movement therapy which more specifically ad-
dresses the client’s actual neuro-myo-fascial and joint dysfunc-
tions and helps restore more healthy patterns of spinal control
for optimal function.
I’ve called this model the Key Approach. Its evolution is the re-
sult of evaluating and integrating the available movement, fas-
cial and neuroscience; the ample evidence gleaned from clinical
practice; the exploration and evaluation of various movement
disciplines – for what they offer in terms of healthy spinal con-
trol – or otherwise.
I am increasingly exploring the felt sense of movement and the
ability to exploit neuroplastic change – “retraining our brain” to
organise healthier movement patterns and better biomechanics.
I have had a number of academic papers published in the inter-
national peer reviewed Journal of Bodywork and Movement
Therapy. (See www.keyapproach.com.au/publications). My pa-
per “The Core: Understanding it and retraining its dysfunc-
tion” was one of the journal’s five most downloaded papers in
2014.
My first book, BACK PAIN: A movement problem. A clinical ap-
proach incorporating relevant research and practice was pub-
lished by Elsevier in 2010.
My latest book FREEDOM TO MOVE: movement therapy for
spinal pain and injuries has just been published by Handspring
Publishing.
I have presented at national and international congresses and
conduct workshops both in Australia and overseas for physio-
therapists, and interdisciplinary manual and movement thera-
pists.
What made you write Freedom to Move?
My first book “Back Pain: A movement problem” offered the
reader an in-depth treatise on healthy and ‘dysfunctional’ spinal
posturo-movement control found in people with a whole spec-
trum of spinal pain disorders. It proffered a combined, compli-
mentary manual therapy and movement therapy approach to
redress these joint and myofascial movement disorders – and so,
ease the clients’ pain.
I consider that one of the short falls of the book was inadequate
coverage of the particular exercise and movement therapy advo-
cated if one is to more effectively rehabilitate most spinal pain
disorders. I have been increasingly interested in the aspect of
therapeutic movement for spinal pain and continue to further
develop and refine the Key Moves® for spinal rehabilitation.
Sarena Wolfaard published my first book and was keen for me to
write another which bore the fruits of the further development
of my work over the past 8 years. I was eventually ready to do
so. I wanted this to be an informative yet accessible, clinically
20 Terra Rosa E-mag No. 22
useful practical manual for the
multidisciplinary movement ther-
apist treating spinal pain –
Freedom to Move is the result.
What is The Key Moves®
Programme?
Spinal pain research is increasingly demonstrating the im-
portance of the deep sensori-motor system in healthy postural
and movement control of the trunk. When this deep muscle
system is lazy and weak, the body compensates by over-
engaging some of the large more superficial trunk muscles for
the job – and that is where problems start to occur for the spine
and pelvis. This substandard control is not only likely to lead to
spinal pain but also to many other ‘injuries’, pains, tightness and
stiffness etc.
Unfortunately a number of therapeutic, strength, fitness, and
‘core stabilisation’ training programmes don’t pay enough atten-
tion to deep system control in the trunk. Instead, the tendency is
to overly work the large muscles, thereby contributing to the
development of many pains and ‘injuries’ – and the need to ‘use
the roller’ and stretch all the time.
The Key Moves® are a system of embodied natural movement
explorations. They reintegrate physiological movements that
develop during the process of motor development but which
become diminished or absent in people with spinal pain disor-
ders.
In essence, the Key Moves® rely a lot upon ‘deep myofascial
system’ activity and so provide the opportunity to retrain and re-
condition the ‘deep’ postural muscle system and help re-
establish the important, ‘key’ basic (fundamental) patterns of
movement control in the spine and proximal limb girdles neces-
sary for a more healthy, fit, strong and robust musculo-skeletal
system.
Re-establishing the ‘fundamental patterns’ are central to the
approach as they provide the basic building blocks of spinal con-
trol. These are particularly deep system dependent and are a key
element to restore in movement. When they become better
established, they are further integrated into more challenging
exercises and functional movement patterns
The Key Moves® is a sensori-motor re-learning programme
which focuses a lot on mindfulness in movement, and refining
the senses of interoception, proprioception – sensing ‘how’ a
posture or movement feels – and being able to make discreet
adjustments. Through sensory enrichment we can tap into the
neuroplasticity of the central nervous system and facilitate
changed movement behaviour. The movements are akin to
‘brain exercises’ which aim for more refined patterns of func-
tional movement control
The programme also address.es the freer sliding and fitness of
the fascial system to further improve whole body flexibility and
movement ease.
 What is the relevance of the current fascia research instructed and mindfully, these are safe, enjoyable and thera-
findings? peutic as they help re-establish the natural foundations of
healthy spinal control. For clarity and ease of access, these are
The fascial system has been largely ignored until relatively re- presented in a recipe book format – instructions on the left hand
cently – yet it provides the basic building blocks of functional page and illustrated on the right.
anatomy, posture, and movement. ‘Fascia’ is enlarging our un-
The first section of the book (Chapters 1-4) is a reference section
derstanding of musculo-skeletal pain and ‘how’ we move.
to support and aid the understanding of the major practical sec-
Research into the fascial system shows that it influences and is tion (Chapters 5-10) in the second part of the book
affected by the nervous system, fluid dynamics and mechanical
loading. Structural support, joint loading and movement are not What is your current project?
only affected by the local myofascial tissues but by the whole Having a restful respite! – practising what I preach and devoting
fascial ‘bio-tensegrity’ system. In a tensegrity system, force more time to myself! One forgets the work involved in writing a
transmission is nonlinear; in other words, forces applied to it are book – particularly after submitting the manuscript! – added to
also transmitted tangentially and in all directions across the ma- which the past eighteen months have been particularly eventful.
trix. However I continue to explore and develop the Key Moves® and
Appreciating the functional body as a bio-tensegrity system despite saying to myself that Freedom to Move is my last book I
helps the movement therapist understand how and why a move- nonetheless find myself thinking of a sequel: ‘More Key
ment initiated in one part of the body will create changes in ten- Moves®’!
sion (not only locally but also regionally and in other, often quite
distant, parts) that contribute directly or indirectly to movement
and/or stability.
This “whole system involvement” means the neuromuscular
system doesn’t need to work too hard to produce a given pos-
ture and movement, thus greatly reducing the energy and effort
required in functional movementyet enabling movement diversi-
ty.
By initiating movements from ‘key points of control’ we can
influence the architecture of the whole fascial-tensegrity sys-
tem, improve spinal flexibility and control while also accessing
stiff regions and restrictions in the axial and limb tissues. The
effect is to promote better tissue elasticity and easier move-
ment. This differs from the traditional approach of static stretch-
ing, which often does little to change the tensegrity of the
whole fascial matrix – and often bothers the spine.
And how do you reconcile fascia and neuroplasticity?
The fascial system is richly innervated possessing an exceptional-
ly high density of mechanoreceptors and free nerve endings
which contribute to our senses of interoception and propriocep-
tion which play an important role in the central nervous system’s
(CNS) integration and control of posture and movement. Intero- Freedom to Move, Movement Therapy for Spinal Pain and Inju-
ception is the ability to sense and monitor our inner landscape. It ries is Available now at terrarosa.com.au
is a vital tool in accessing improved deep myofascial system ac-
tivity and changing movement behaviour
The plentiful innervation in fascia also contributes to nociception
if the fascia becomes ‘bound’ and free nerve endings are activat-
ed
Fascia can thus be both a source of pain and disturbed afference
to the CNS – which in turn leads to adverse (neuroplastic) chang-
es in the CNS – evidenced by altered control of posture and
movement – and musculoskeletal pain.
However there is an upside to neuroplasticity: by restoring fas-
cial slide, fluid dynamics and elasticity through appropriate man-
ual and movement therapy we can exploit the CNS ability for
more positive ‘neuroplastic change’ and improve neuro-myo-
fascial function and movement control, joint loading and protec-
tion and functional wellbeing.

Which part of the book do you like most?

I’d have to say Chapter 7. This offers a suite of 60 exercises for
the benefit of patients and practitioners alike. When executed as

Terra Rosa E-mag No. 22 21

 Til Luchau on Scoliosis:
Working from Inside Out
Til Luchau, director of Advanced-Trainings.com, discusses scoliosis in a wide-ranging interview that covers his
influences, orientation toward working with scoliotic clients, working with teenagers, expectations, conven-
tional treatments, and changing understanding of scoliosis towards a three-dimensional model. This interview
was conducted by Ann Hoff (Certified Advaned Rolfer® and Editor-in-Chief of ‘Structural Integration: The
Journal of the Rolf Institute™,’ where a longer version of this article originally appeared.

“Image Bryan Christi Design, used under license to Advanced-Trainings.com”

22 Terra Rosa E-mag No. 22

Working with Scoliosis to make people straight often make them less comfortable.
AH: I'm curious, did you study about scoliosis first and Often people hurt more after we just try to lengthen their
then apply it in your work and teaching, or did clients shorter erectors, or whatever we think will help them be
drive you towards the study and the development of what straighter. Being straightened isn't always more comforta-
you now teach? Or a bit of both? ble. Then, it's teasing apart the context of why someone is
coming to us. If it's just to look different, there may be
Til: My first serious scoliosis client was hitchhiking some reframing or alternatives to explore.
around the USA in a wheelchair. She showed up at a re-
treat I was teaching in New Mexico, just to visit the place, Pain is interesting, because we often assume that if some-
and was in a lot of pain. I had graduated from the Rolf In- one has an “off” shape, they must feel off too. That doesn't
stitute just two years before. Her scoliosis was a real puz- seem to be the case with scoliosis. People with scoliosis
zle to me. I took some of the things that I remembered and don't have any higher incidence of back pain than the gen-
learned in my basic Rolfing training and started working eral population. That’s important: just because someone
with her. At some point, she just gave a big smile and re- has a different shape, doesn't mean they hurt or will hurt.
laxed, and felt a lot better. Later, people with scoliosis be- There is some evidence that says when people with scolio-
gan appearing more and more in my practice. The biggest sis do have back pain; it tends to be worse, or more in-
influence within the Rolf Institute was probably Robert tense. But they don't have it more often. It's not like a
Schleip, a mentor of mine, who had also spent a lot of time crooked spine equals back pain. A crooked spine, in and of
puzzling out scoliosis. His ideas had a lot of influence on itself, is not necessailry a problem to fix from a pain per-
the way I was thinking about scoliosis and still do, as did spective.
[Rolfing instructor] Jan Sultan’s, though at this point, I’m What Causes Scoliosis?
doing much of it differently than I learned it from either of AH: So the woman in the wheelchair, was she in the chair
them. because of mobility issues or pain or any sort of degrada-
The other big Rolfing influence that comes to mind was tion of her condition that was causing pain?
Emmett Hutchins (one of Ida Rolf’s original Advanced TL: Which came first? I don't know. There is a point at
Rolfing instructors). He said, "When I'm working with sco- which spinal curves are a serious biological issue, often a
liosis, I'm helping the client move around a line, not neces- compromise to organ function. Then at some point, having
sarily stand around a line," which I found interesting. It a sideways spine starts to affect the nerve roots and things
was one of those koans he would toss out, that we would like that where you have pretty clear mechanical effects.
have to ponder and wonder about. But “moving versus The standard medical cutoff point – the point at which
standing around a line” was a real clue that started my medical issues are more likely to happen – is somewhere
inquiry and probably still informs the way that I’m work- around 40º; that’s where people are told they need to take
ing with scoliosis to this day. some aggressive measures to stop the progression. In
AH: That points to something important: we're not going most cases, 40º is an obvious and strong scoliosis. Most of
to make somebody straight. If you're lucky, there may be our clients don't have that much curve and so are a differ-
some change in those curvatures, but we're not trying to ent category of intervention, where the most useful goals
get a platonic ideal of the spine. are about mobility, comfort, staying proprioceptively re-
TL: We're trying to make the person happier, like that fined, and less about intervention on their shape.
woman in the wheelchair. I think we're all driven to help AH: Let's go bigger picture. What do you understand
people. That's why we're in this profession, and there's about potential causes of scoliosis?
where human compassion arises. Here are people who TL: It's a puzzle really. Rather than try to answer the puz-
may or may not have pain, may or may not have re- zle, what I do is ask how I can help people. ‘Idiopathic’ sco-
strictions in their movement; if we can support them as liosis, which is the most widely studied form of scoliosis,
Emmett was indicating, in helping them in living with means it has an ‘unknown cause’ or is even ‘without ap-
more ease and moving in a way that works better, they're parent cause.’ Honestly, anybody who says they know why
going to be happier and feel better. it's being caused is going in the face of the consensus view.
One thing is, when people walk in and say, "I've been told There are lots of pieces to the scoliosis puzzle. There is
I'm crooked. I want to be straight," that asks for a reality- some thought about cerebrospinal fluid flow having turbu-
check conversation. There are certainly miracle cases. lence, that being associated with foetal development.
There are plenty of pictures around of people who were There are bizarre little facts like there's almost no adoles-
dramatically, visibly different after getting hands-on work. cent idiopathic scoliosis in people that are deaf. Animals,
But I think most people would agree, those are the excep- quadrupeds, don't get adolescent idiopathic scoliosis.
tions more than the rule. Most people aren't walking out There are some interesting puzzles there that point to bi-
of their Rolfing or any other kind of session perfectly pedalism, that point to perceptual issues, that point to de-
straight, after coming in with scoliosis. And attempts to try velopmental things.

Terra Rosa E-mag No. 22 23

Some say it’s visceral; other say it’s a top-down phenome- bly with that story I told you and with Emmett's teaching,
non that relates to the way you're perceiving; or, a bottom and my time assisting and learning from Robert Schleip.
-up phenomenon, related to the way you're supporting His perspective is interesting and his stories were influen-
yourself. Those are just a few pointers toward possible tial. For example, he relates that realized at some point
causation, but causation is complex, and what counts in that he was doing the biomechanics exactly opposite of
the practice room is a strategy. The causative theories are Fryette's laws; but changing his strateguy to to the
probably better thought about as strategic narratives that ‘correct’ coupling of sidebending and rotation didn’t really
get the practitioner thinking about how to go about work- get much different results, maybe 10% better. So when he
ing with it, more than they explain how it got there. got the laws ‘right’, there weren’t necessarily dramatic
Adult-onset scoliosis is a lot more common than adoles- improvements.
cent scoliosis. By the time we're seventy years old, about AH: Interesting. Perhaps even when he didn't have
70% of us have observable scoliosis. It appears progres- Fryette's law right in his mind, he was still working the
sively through our lives, and it's overwhelmingly asympto- soft tissue correctly, if not the joints.
matic, not correlated with back pain or other symptoms TL: I wonder. I bet he would argue, and I would too, that
(although, sometimes it can result from osteoporosis or ‘correctly,’ at least in terms of external measures like left/
facet issues, things like that, which can have their own right etc., becomes less relevant. It might be the act of get-
symptoms). So a whole lot of elderly people have scoliosis, ting worked, and the act of moving, and the act of finding
and it's not necessarily a problem. Strategically, if there's movement into new places. Whether you did it as an open-
back pain, or if there's a movement restriction, we work fixed or closed-fixed direction, in either case, you can
with those issues like we do any back pain or movement make a huge difference. From one point of view, most of
restriction. That's a little different maybe than a strict the effect we have as practitioners comes from the client
structural integration perspective. The perspective we receiving work, as opposed to the actual strategy being
take in my trainings is to ask, “Are there options for move- employed. Increasing body awareness, increasing mobili-
ment needed?” – And those include the option of stillness ty, providing a powerful intervention in the context of
and support. And, “How can we help refine propriocep- movement, therapeutic ritual, all those things seem to be
tion, so the person can feel body sensations more accu- valuable.
rately, and in a more nuanced way?” In other words, can
they have greater body awareness? So that's probably been the biggest change. I'm not think-
ing any more about things like which direction is right, or
AH: Has the way you work with scoliosis changed over how do I want the body to be ‘corrected’. In most cases,
time? I'm thinking more about how to increase options for mo-
TL: Has it changed over the thirty-three years since I met bility so that the body can do what it needs to; and I’m
that woman in the wheelchair? Absolutely. It began proba- thinking about refining proprioception so that my client

Lewis Albert Sayre (1820–1900), one of the founding fathers of orthopaedic surgery in the United States, demonstrating his traction-casting of scoliosis, a tech-
nique which has not survived him. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2493005/"

24 Terra Rosa E-mag No. 22

Scoliosis by Angela C. https://www.flickr.com/photos/_twiggy/3345890702

can respond to what they’re feeling. And typically, I want primary motivator. It's a tall order to have someone lie
to do that in a way that's not noxious, because pain is un- passively on the table for an hour, even ten or twelve
refined, overwhelming proprioception. times, and walk away permanently changed in their very
Therapeutic Goals structure. Movement and awareness are probably much
more malleable that tissue, and arguably, have a bigger
AH: Okay. Somebody comes in with scoliosis, what are impact on client’s subjective experience.
your own goals and aims, and how do you work with
whatever the client's expectations are? Do people come in So if the person says, “In my wedding picture I noticed my
with realistic expectations, or do you have to downgrade right shoulder was higher than the left,” I might explore
their expectations? what that’s like from the inside. I might ask, “Can you tell
you have a shoulder higher without looking at your wed-
TL: I'm always assuming that the reason that they're com- ding picture? If you can tell, what happens to you when
ing in has an element of false promise to it. I probably you ‘correct’ it? Is that an expansive experience for you
don't think about it as downgrading, but more reframing. inside, or a diminishing experience? Where do you want to
Often, it's an upgrade of what they imagine could be possi- be in that continuum? How much adapting do you want to
ble; often, it's a shift of their criteria in terms of what de- do inside to accommodate what you think you should look
fines success – especially scoliosis, probably more than like from outside?”
other conditions. Often the client’s perspective is like,
“Yeah, I notice in my wedding picture, my right shoulder AH: I feel the enticement of that myself, but I know there's
was higher than my left. I want to fix that.” Dramatic visual a lot of people who don't want to go there. They don't
changes can happen, but it's complicated when that's the want to go in. For some people that means going into a lot

Terra Rosa E-mag No. 22 25

of experiences that are difficult. What rate of engagement
do you get with people, when you invite them in like that?
TL: 99%. Because I'm just talking about feeling your
shoulder. Most all of us have access to plesant, expansive
internal experiences, in addition to any diffult ones. For
some people, sensation is a whole pathway into an inner
world that's really rich and they can't resist exploring.
Maybe for others, that's not so interesting. It might even
be something they've worked hard to stay out of. There's
culturally not a lot of encouragement or support for our
interior life. If that’s the case, I might ask, “But, I was talk-
ing about feeling your shoulder, just on the level of sensa-
tion: can you tell your shoulder's higher or lower? If you
can't, what about if I put my hands here? If you can tell,
does it even matter to you? Now go ahead and let's look
into the mirror together and hold your shoulders straight.
What's that like to hold? Would you want to feel like that,
or, is there a way with your breath you might find some-
thing that's gentler, more expansive?” As you see, it's often
grounded in a language of sensation. It has lots of implica-
tions into other realms, but it's super tangible with some
people. It's baby steps. Many more people than I expect
really take off. I'm looking for whatever lights their fire,
honestly. For example, a girl scoliosis, sent to me by her
parents to “correct” her scoliosis– she might not even no-
tice any inner experience of scoliosis, or care. But she
might get interested if she noticed her sit-ups were asym-
metrical; if that’s where she got interested, that’d be the
thread we’d follow.
AH: Is your goal first to find what interests them?
TL: Yes. I think I want to find the essence of what interests
them. That's at least one layer deeper than the presenting
problem. There is something they want; identifying that
and staying connected to that is my therapeutic goal.
That's a moment-by-moment thing, where you look to see
what's interesting to someone, where their energy goes up
or goes down, how does that breath get more expansive,
how can they have awareness in a part of their body that
they haven't before. Those are all types of positive feed-
back.
Structural vs Functional Scoliosis
AH: Say something about structural and functional scolio-
sis and different approaches based on that.
TL: Classically, structural scoliosis would be thought to be
related to the bone shape, like osteoporosis that's causing
vertebrae to go wedge-shaped; something like that could
sidebend the spine as well as causing it to rotate. Some
definitions include the ligaments; those points of view see
ligamentous and articular relationships in the spine as
structural components that can make a spine passively
stiff. The definition is if it's passively stiff in one direction,
it's a structural issue. If it’s passively mobile but the client
can’t actively move it, then it's a functional issue. It's an
interesting distinction. Though it probably has a lot of
26 Terra Rosa E-mag No. 22
stragic usefulness in helping us know which intervention
to start with, it's probably at its core a false dichotomy. Ida
Rolf's big revolutionary statement is that all structure is
plastic. Way before neuroplasticity, she was saying there's
fascial plasticity. This gave people a sense of possibility
about what could change, right down to the level of what
we're made of. There's something useful in that point of
view. Even if collagen molecules turn out not to literally
stretch, or if glide becomes a more useful tissue goal than
length, there's something very useful in the sense that my
body is changeable.
I don't limit myself to working just functionally or just
structurally. We do tests in our treatment protocols that
help me, and the client feel: does this segment resist pas-
sive motion? – in which case, I might start with a structur-
al intervention. Or can it respond passively? – then it's
probably more functional. And they we see how it re-
sponds; if we don’t get the movement or awareness we’re
looking for, we’ll try the opposite strategy. Often, we end
up working with those two cases similarly, or at least we
have similar ultimate goals. We want more options for
movement. We want it to move in ways it doesn't now. We
want someone to be able to feel it in a less noxious or
more refined way, and feel it in context to the whole body.
Homework
AH: How important is it, with working with scoliosis cli-
ents, that they are doing something on their own, either
some form of movement practice or some exercises that
will give support the manual therapy.
TL: It would depend on their identified goals. But let's say
there's somebody who's getting close to that 40˚curve and
trying to avoid surgery. They want to do whatever they
can. Then, yeah, a multidisciplinary approach is super-
important. Scoliosis often isn't just a fascial thing. It isn't
just a visceral thing. It isn't just a strength and condition-
ing thing. All those are factors. When people do strength
and conditioning, they have fewer problems with their
scoliosis. Scoliosis can also measurably change from hands
on work. There are some decent studies of people doing
just myofascial work on scoliosis, and showing a change in
curves. All of these are pieces. For some people, there are
balance differences, or more postural sway. Especially for
adult-onset cases, being active physically seems to help.
AH: Do you refer people in any particular directions or it
all depends on that client and what their interests are?
TL: I encourage people to be physically active in a way
that they're likely to do. There's a window of opportunity
too, with kids right around puberty. There are some pretty
specific ways that a primary care provider can tell if a kid
is within that window using x-rays to stage growth plates.
For our purposes, within a couple of years of puberty,
that's a key time when there does seem to be an argument
for aggressive and preventative work, even if there are no
presenting problems with pain. That includes bracing or
After scoliosis surgery (ventral fusion). Weiss HR, Goodall D. Scoliosis. 2008 Aug 5;3:9. PMID: 18681956. doi:10.1186/1748-7161-3-9 . https://commons.wikimedia.org/wiki/
File:Surgical_result_after_ventral_fusion_of_scoliosis.jpg

surgery if the threat was severe enough. And in kids ap- member what I did right? Just think it through on the oth-
proaching that degree of severity, I would encourage eve- er side.” In his model it was all neurological, it was all
rything I could. Some physical activities, some balance about learning. Once you learned it, you got it. He wasn't
sports or balance activities, hands-on work, refined pro- thinking of the stuff we're made of, the hardware, as much
prioception body awareness. Whatever that means for the as the operating system.
kid. In our training we're teaching people how to work asym-
Working Symmetrically, or Not metrically. But that’s not the point. The point is to leave
AH: Here's a question about working symmetrically and people feeling like they have balanced options for move-
asymmetrically. In Rolfing sessions, we work differently ment. If someone comes in with an asymmetrical pattern,
on the two sides of the body according to what we find. My that often means working asymmetrically. Then again, it's
experience is that many trainers and yoga teachers want not to try to make them symmetrical, but to help them do
people to work very symmetrically. If you do this exercise something like Emmett was referring to, which is to be
or stretch, do it equally on both sides. My sense has always able to move in a way that feels supported, balanced, in all
been that if someone has scoliosis, or any identifiable directions.
asymmetrical pattern, and they can sense that from the AH: If they're going to go out and do yoga as part of their
inside or understand it from the inside, it’s intelligent to program of being active, would you encourage them to
take an asymmetrical approach into conditioning or yoga explore being more asymmetrical in how they do it?
or stretching. I'm curious for your thoughts. TL: I want to be careful about my prescriptions to them.
TL: Massage therapists are the other group that might get It's not like, “You should now do asymmetrical yoga, to
stuck in symmetrical thinking. Entry-level massage thera- ‘correct’ your imbalance.” My only prescription is, “What
pists are often taught to do the same thing left and right. would it be like if you explored movement in both direc-
The intention behind that is probably good: it's to try to tions? Can you have as rich a sense of flexible body in this
keep things balanced, so to speak. You don't want to in- direction, as in that direction? Can you expand in each di-
duce some sort of difference. Again, it's a simplistic way to rection?”
stay safe, but it gets translated into dogma. Probably the Clients with Rods and Fusions
least dogmatic person that I can think of in that point of
view was Moshe Feldenkrais, who was famous for work- AH: Let's talk about scoliosis and surgery. Are Harrington
ing just one side of the body and leaving his clients asking Rods still current or is it different what's used now?
for the other side. His answer was well, just, “No. You re- In the past, Harrington Rods were the most common sur-

Terra Rosa E-mag No. 22 27

gical intervention used for scoliosis. These days, they are movement that’s being asked at the ends of the rods that
one of about five different rods that are being used now.. seem to be contributing to that joint problems.
Lots of people trying experimental things too. But a lot of Parts and the Whole
people will come with Harrington Rods that they got years
ago. Honestly, the principles are still the same: I'm still AH: Talk a bit about the content of your courses. How long
helping them find options for movement and refined pro- they are and what kind of material you cover, the scoliosis
prioception. Now, I'm not trying to bend the rod, obvious- courses in particular.
ly. You can get a sense of movement and refine proprio- TL: We have a series of modular seminars and online
ception even in the fused zone of a spine. courses. The in-person versions are typically two- or three
Newer rods have lots of variation, and many of them flex. -day workshops. I have a new DVD, all about scoliosis. And
Many of them attach to the ribs instead of the spine, or are we have a specialized live workshop about scoliosis, but
adjustable, so they grow with the kid as she ages. Most of it's really the culmination of our five principle courses,
them now are three dimensional. Harrington Rods were which cover the whole body. That’s because scoliosis is a
straight; that came from a two-dimensional view that sco- whole-body phenomenon. Even though we have two days
liosis was an S, not a three-dimensional spiral, which that we dedicate to scoliosis , in practice, it means pulling
probably is attributable to the fact that x-rays were the in perspectives and ideas for working the entire body.
main way that they were studied – that we perceived sco- AH: You're working from the holistic perspective, obvi-
liosis as a flat situation because we were looking at flat ously.
pictures (even though some of the early people were TL: Trying to all the time. We try to play that balance be-
working with scoliosis with stereoscopic x-rays – in the tween really tangible, sometimes joint-specific, tests and
early twentieth century, there were clinicians who would techniques, while staying connected to the whole-body,
take two x-rays and wear stereoscopic glasses to try to see whole-person picture.
the three dimensional curves in scoliosis.) The classical
AH: Which is something we didn't talk much about, but
measure of scoliosis, the Cobb angle, is measured in two
obviously when we’re working with clients who have sco-
dimensions. The rod became a straight rod to try and
liosis, we're not just looking at their thorax, their spine,
straighten it out. They're getting more sophisticated, the
we're looking at the whole body too, and how the pattern
rods are now three dimensional, flexible, and adjustable.
plays out through the limbs, through the head, through the
But people can move, even with a rod. That's a major in-
cranial system.
sider discovery for people that have a rigid rod. Even the
mental concept of having a rod stiffens people up. Finding TL: Absolutely. The muscles of the spine aren't strong
that they can actually feel breath, even gently bend and enough to curve the spine in the way that we see in scolio-
twist and move in the zones where they have a rod, can be sis – there are some bizarre machines they use to test
a healing insight. spines’ passive stiffness. The idea that scoliosis is due to
spinal muscular contraction doesn't hold up, and as
AH: It makes me think of a client in her twenties who had
Schleip’s later research showed us, any force provided by
the Harrington rod surgery as a teenager. She was fine,
fascial contractability is very weak and slow. But conven-
completely adapted to it. She could play soccer, pretty
tionally, a practitioner with a tissue-based view would
much do whatever she wanted to do, no issues. Then she
look at someone with a sidebend and think, “Oh, those
was in a car accident and that homeostasis of comfort
erectors, or the thoracolumbar fasciae, are tight on that
from having adapted to and been supported by this sur-
concave side.” You’d think of the bowstring model, that
gery was disrupted and she was suddenly getting all sorts
you’ve got to go loosen the tight tissue and straighten it
of radiating pain. She perhaps had less adaptability and
out. Well, refining awareness and getting more movement
that made it a little harder to go back to the old homeosta-
possibility in the concave side can be really useful, but it
sis or to find a new one.
turns out that those things also help on the convex side.
TL: That sounds feasible. People with rods also have a And there often won't usually be dramatic muscle tonus or
higher statistical incidence of arthritis at the ends of the fascial texture differences between the concave and con-
rods. In general, people with scoliosis don't have more vex sides. It's probably not the case that the erectors or
back pain than people without scoliosis, but people with thoracolumbar fascia are ‘pulling’ the spine into a bend,
rods have more facet joint issues at the end of the rods and so that’s why ‘lengthening’ the erectors doesn’t usual-
over time –decades later usually. That's information we ly straighten it out.
need to be careful with because it could be a self-fulfilling
The girdles, however, are a somewhat different matter.
prophecy. Most of rod patients have heard it anyways.
That’s because myofascial structures crossing the girdles
They're worried about it already. We can get good results
and going out into the limbs are bigger, stronger, and have
by getting movement in the other facet joints, the ones
different line of pull so that they can exert more force on
that aren't in the section where there are limits or where
the spine than the spinal muscles themselves. So just in
there's a rod. The results come from relieving the extra
terms of biomechanics, there are better arguments for
28 Terra Rosa E-mag No. 22
working with the girdles and limbs than with the spine
per se. But even then, there are problems with the idea
that tissue shortness here causes scoliosis, as the limbs,
especially the shoulders, are typically not fixed points than
could pull the spine towards them.
PSOAS
AH: What about the psoas?
TL: For a long time, the psoas was considered a key mus-
cle in scoliosis. If you look at lumbar scoliosis or even low-
er thoracic scoliosis, it looks like the concave side psoas
has got to be “short” – one psoas could look like it was
pulling the spine into that pattern. That led to a common
surgical release where an orthopaedic surgeon would ac-
tually sever the psoas tendon on the ‘short’ side, to try and
correct scoliosis and prevent it worsening. This quite com-
monly done up until the 1950s, when outcome studies
showed that people that had psoas release surgery were
no better off than people that didn't have the surgery.
AH: They were minus the psoas.
TL: Yeah, they were minus one of their psoas. It called into
question the role – the causative role, you could say – of
the psoas too. People’s scoliosis wasn't getting better with
one psoas cut. Even still, the movement possibilities and
preceptive function that myofascial structures provide
seem to be important. The bowstring model probably
doesn't have a lot of basis in actual physics, and even less
Source: http://en.wikipedia.org/wiki/Image:Wiki_pre-op.jpg
so in what seems actually to help; the tissue-tightness
model is probably more conceptual than empirical.
When we see mild curves, especially in an otherwise
AH: The three-dimensionality really implies that the healthy person, it's more helpful to reassure them and
whole biomechanical structure is going to be involved; ease their concerns about having a disease that they’re
trying to figure out one or two places to work is not going afraid is going to cause them to degenerate or degrade or
to be a model that is that helpful, ultimately. twist up in a funny way. That’s not to say we want to en-
TL: That's right. In our trainings, we start our scoliosis courage complacence: fear is a powerful motivator, so
protocol with the arms, legs, shoulder girdle, and pelvic when we reduce it, we want to help the client replace it
girdle. We also have a lot of tools for direct work with the with something else.
spine, thorax, abdomen, sacrum, and the neck. But then we AH: That's a good point. I can think of so many clients
finish with the limbs and girdles, back to where we start- who've come in and announced that their chiropractor or
ed. another practitioner has said they have scoliosis. I look at
AH: If somebody wants to learn from you, they should them and feel, “You've been scared for no reason.”
move through the sequencing of your classes to get the TL: It gets complex when they've been scared by another
whole worldview. practitioner. That gets into the ethical quandaries around
TL: Yeah. It's a whole-body phenomenon. But people can interprofessional relationships. Often clients are relieved
jump into our series of short workshops at any point, and by an approach that’s more like, “I'm going to help you
move through them in whatever order. move comfortably in every direction. And I'm going to
help you refine your body awareness, in every direction.”
Pathologizing of Scoliosis
That seems to help everyone.
AH: Anything else you'd like to share?
AH: Thank you very much, Til!
TL: One thing – the deep pathologizing of scoliosis. People
will come in having been told that they have scoliosis and
that they should urgently do something about it. If they're
in that adolescent window, like I said, there're very good
arguments for doing ambitious preventative work. But so
many people have spinal curves that are asymptomatic.

Terra Rosa E-mag No. 22 29

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Terra Rosa E-mag No. 22 31
Differential diagnosis
of shoulder pathology
John Gibbons
When I teach the shoulder joint masterclass at my clinic
within the University of Oxford, it is to students from all
the corners of the earth, a fact that makes me feel truly
honored. Nevertheless, when, during the course of the
class, I discuss differential diagnosis of shoulder pain and
upper limb pain, I have often found it disappointing how
little knowledge many physical therapists have regarding
other bodily structures and vital organs (viscera or viscus)
32 Terra Rosa E-mag No. 22
that can be the underlying causative factor for the pa-
tient’s presenting symptoms (or at least contribute to it).
Medically trained personnel, whose initial training is gener-
ally longer, may have greater knowledge but hopefully, this
article will be of interest to all readers and serve as a re-
minder of the specific pathologies that can cause shoulder
or upper limb pain. It is very important that pain from a
musculoskeletal origin can be differentiated from a visceral
pathology because they can easily mimic each other in
terms of how they present, as we will read shortly.
An article I wrote many years ago discussed five individual
patients that presented to my clinic with shoulder pain.
What was of particular interest was that they all had some-
thing in common. Each was asked to place their arm by
their side and to perform a movement of shoulder abduc-
tion as far as they could comfortably reach and to try to
raise their arm over their head to the normal range of mo-
tion (typically classified as 180 degrees). All were aware
that something was ‘not quite right’ during the movement:
three of them had actual pain on motion during abduction
of their arm.
The first patient was a 75-year-old male who had fallen off a
ladder onto his right shoulder, and when he presented to
the clinic, he was not able to even initiate abduction active-
ly, even though I could take his arm to 180 degrees passive-
ly without any pain. The second patient was a 34-year-old
female painter and decorator, and she presented with pain
only between 60 and 110 degrees of abduction (after a
weekend of painting ceilings) – this is typically called a
painful arc. The third patient was a 24-year-old rugby play-
er. He had sustained an injury to the top of his shoulder
when he was tackled in a game, and he had pain towards
the end of the range of motion for abduction. The fourth
Figure 1: Abduction of 0–180 degrees and the five specific conditions
patient was a 55-year-old female. She had started to notice
her shoulder was getting stiffer since doing a fitness class 6
weeks ago and now had limited movement of the shoulder
Regarding the five case studies above (see also Figure 1),
joint and could not even lift the arm to 60 degrees without
the first patient had what I believed to be a full thickness
feeling restriction and subsequent pain. The fifth person
tear (rupture) of the supraspinatus, the second an impinge-
was a 45-year-old male. He could not abduct his shoulder
ment syndrome of the subacromial bursa and/ or a su-
past 20 degrees (but could initiate), and this had happened
praspinatus tendinopathy. The third patient, who present-
after doing some push-ups in the morning when he woke
ed with pain at the end range for abduction, sustained an
up. The patient could lift his arm to 20 degrees but could
acromioclavicular joint (AC joint) sprain, the fourth I diag-
go no further without some pain and weakness and it ap-
nosed with a chronic frozen shoulder (adhesive capsulitis)
peared that the deltoid muscle was not working. At the
and the last I considered to have an axillary nerve palsy due
time I considered this was due to a potential muscle weak-
to the inability to activate the deltoid muscle during abduc-
ness of some sort or possibly caused by a neurological
tion (axillary nerve, which originates from the cervical
problem.
nerve root level of C5 and specifically innervates the del-
My personal belief about treatment of the shoulder com- toid and teres minor muscles).
plex tends to chime with a methodology that was taught
Regarding the last case study, many therapists with a good
to me many years ago when I was a student of manual
knowledge base might say it could be a C5 nerve root prob-
therapy. It is known as the K.I.S.S. principle (Keep it simple
lem that is potentially causing the weakness with shoulder
stupid!), or the keep it simple principle. I always say to my
abduction, and that is perfectly correct because the person
therapy students that if a patient presents with what they
had weakness abducting their arm. However, the C5 myo-
believe to be an ‘actual shoulder’ or upper limb problem
tome also innervates the motion of elbow flexion, and in
and they are having an issue in terms of pain or restriction
this case, the patient tested strong for the contraction of
during abduction or even flexion of their shoulder to 180
the biceps muscle. Also, there was no weakness to other
degrees, it is probably a localized shoulder complex issue
C5 innervated muscles like the supraspinatus or infraspina-
or pathology that would need addressing through hands-
tus. In this case, therefore, it cannot be a C5 nerve root
on physical therapy, whether that is considered to be the
issue.
right or wrong approach. This approach currently seems to
work well for me with my patients and athletes. I used to be a vehicle electrician when I was in the military,

Terra Rosa E-mag No. 22 33

 scapulohumeral rhythm and the structures involved to al-
low this motion to happen? Simply lifting the arm above
the head requires the precise interaction of the GH, ST, AC
and SC joints, as well as the integration of all of the soft
tissues and nerve innervations. There are multitude of rea-
sons why patients or athletes present with shoulder pain
and below I would like to discuss some of those conditions.

CASE STUDY
A lady in her mid-40s presented to the clinic, with pain gen-
erally located to the top of her right shoulder and upper
trapezius muscle. This has been present for many months
with no obvious cause. During the day the lady was not
aware of her pain, but at night, while she was sleeping, the
right shoulder was noticeably worse to the point she
would wake up, take some medication and eventually fall
back to sleep. The lady also mentioned something was not
quite right with her middle to lower thoracic spine, but she
said her shoulder pain was the priority. On examination, I
asked the lady to abduct her shoulder as far as she felt
comfortable, and to my surprise, she could easily reach a
full range of motion to 180 degrees. It was the same when
she was asked to flex the shoulder and also managed to
reach the full 180 degrees of motion with no issues. Be-
cause the lady could abduct and flex the shoulder to full
and I consider the axillary nerve to be similar to a sidelight range, I considered that there could not be any underlying
or indicator on your car: if the bulb has blown or the wire musculoskeletal issue present directly related to the region
has been cut (open circuit) then the light will cease to func- of the shoulder complex. This next sentence or two might
tion. For the axillary nerve, if the little wire (nerve) that sound a bit strange as I asked the patient the following:
supplies the deltoid and teres minor have been damaged, ‘When you go to the toilet for a number two (defecation),
this can subsequently cause the nerve to switch off (the have you noticed that your stool has a tendency to float on
muscle now becomes inhibited and/, or the light bulb goes the surface, rather than sinking to the bottom of the
off or dims). As a result, the muscles in question will test bowl?’ Unsurprisingly, the lady looked a little startled but
weak and will start to atrophy (waste) very quickly. Howev- responded by saying ‘funny you should ask that question,
er, everything else in the body (or car) will work as normal, but yes, my stool does seem to float when I go to the toi-
and initially you might not notice a problem. It will not be let.’ Before I continue with the case study, ask yourself why
long, though, before you are aware of the underlying issue. I asked this particular question – what do you think was
So, the next time someone walks into your clinic with going through my thought processes?
shoulder pain, if you bear in mind what I have said regard- Before I answer this question, I want to mention some-
ing the motion of abduction, I am sure it will help you come thing that was taught to me when I was studying osteopa-
to a diagnosis or a hypothesis of localized pathology or thy. One particular lecture that I found of great interest
not. and remembered was on ‘differential diagnosis of musculo-
To recap, if a patient is standing and is asked to abduct skeletal pain in physical therapy.’ The tutor had talked
their arm to 180 degrees and the person is aware of some- about a female patient that presented to him with right-
thing during this motion (e.g., pain, restriction, weakness) sided shoulder pain who surprisingly had a full range of
then there is a good likelihood that this patient has some motion (ROM) without any pain in all the tested move-
dysfunction present that requires further investigation. ments. The tutor proceeded to discuss something known
However, if the patient in question can fully abduct as well as the four ‘F’s – female, fair, fat and forty. You can proba-
as to flex their shoulder to 180 degrees, without mention- bly guess that it relates to an overweight lady with fair col-
ing anything, and the movement is fluid and pain-free, then ouring who is in early middle age. The patient in the case
one needs to consider the following: does this patient have study certainly fitted this picture. Basically, the tutor had
an underlying pathology with the shoulder complex? said if a patient comes to your clinic with right-sided shoul-
Remember what was discussed earlier concerning the der pain and fits the criteria of the four Fs then one needs
to consider that the gall bladder might be the underlying
34 Terra Rosa E-mag No. 22
Figure 2: a. Gall bladder and its relationship to the phrenic nerve, b. The dermatomes of the upper limb
causative factor for their presenting symptoms of pain lo-
cated to the right shoulder.
Common pathologies that occur with the gall bladder are
inflammation of the gall bladder (cholecystitis) and gall-
stones (cholelithiasis). I am hoping at this point that I have
whet your appetite enough for you to want to gain more
underpinning knowledge of the subject matter and hope-
fully you are now trying to work out in your head the fol-
lowing: so how does the organ of the gall bladder cause
right-sided shoulder pain? As far as I understand it there
are two possible processes at work: one process is related
to embryology and it is considered that when you are a
foetus growing in your mother’s womb, the gall bladder
initially originates from the area near to the right shoulder
and as you develop, the gall bladder naturally descends to
its resting position underneath the lower rib cage located
Terra Rosa E-mag No. 22 35
 upper trapezius muscle, and it can be exacerbated when
the patient coughs, sneezes, or deep breathes. What I am
saying is this: if you have a pathological issue with your gall
bladder then the chances of having right shoulder pain is
increased because the pain signals are transmitted back to
the cervical spine and the sensory input is then transported
to the peripheral nerve and subsequent dermatomes.
One could look at this as a referred pattern of pain. Let me
give you an example: someone is having a myocardial in-
farction (heart attack). The person will naturally feel in-
tense pain in the area of the central chest; however, most
patients describe feeling other areas of pain or sensations,
and these can be felt in the mid-thoracic spine, left arm and
hand, and even towards the left side of face and jaw.
What I want to do now is give an analogy for this process.
Imagine you are travelling to London by train on a Monday
morning at rush hour, arriving at, say, Paddington station.
Hundreds of people will get off the train at the same time.
Figure 3: Palpation for rebound tenderness of gall bladder The conductor directs them through the normal gates
pathology – Murphy’s sign (relate this to chest pain). Nevertheless, because so many
people are getting off the train, a queue forms and now
the conductor diverts some people to alternative gates
on the right side of the body. This means that if you have
(left side of face and jaw), and if they also become busy, to
an inflamed gall bladder, or even gallstones, in some way
another gate, which might be a few extra minutes walk
the gall bladder remembers its original position from when
away (arm and hand). I hope that this analogy makes some
it was forming inside of you as a foetus, and subsequently
sense to you. To put it simply, if the gall bladder is inflamed
pain is now present in the right shoulder.
then this organ can refer to the right shoulder via the
The second process, which I am more inclined to believe, is phrenic nerve as well as to the area of the mid-lower tho-
the proximity of a nerve called the phrenic nerve and its racic spine. This is due to the sympathetic nerve celiac gan-
relationship to the gall bladder. The phrenic nerve inner- glia innervation of the gall bladder and because of the
vates the central component of the respiratory muscle of proximity of the gall bladder to the abdomen the patient
the diaphragm (it is a musculotendinous structure and not could perceive pain to the right lower costal margin, which
a viscus). This nerve originates from C3, C4, and C5 and is located to the upper right quadrant of the abdomen.
there is a simple mnemonic that states C3, 4, 5 keep the
diaphragm alive. This relates to spinal cord trauma, in that
if you damage the spinal cord below the level of C5, then Conclusion
you should be able to breathe for yourself unassisted; how-
Regarding the lady from the above case study, I mentioned
ever, if you damage the spinal cord above this level, then
to her that I thought it was the gall bladder that was re-
you might need to have artificial respiration. However, the
sponsible for her pain to her right shoulder as well as dis-
peripheral part of the diaphragm is innervated by the lower
comfort in the mid-lower thoracic spine. I discussed with
six intercostal nerves and subsequently, does not refer
her the function of the gall bladder in terms of breaking
pain to the shoulder complex.
down fatty foods, etc., that and if this organ does not func-
Let us now look at the scenario of an inflamed gall bladder. tion correctly, then the stool tends to float. I also discussed
Because of its proximity to the diaphragm and the phrenic through anatomical books and diagrams how the gall blad-
nerve (figure 2a), there is a stimulus that excites the neuro- der caused pain to her right shoulder via the phrenic nerve.
logical system, and subsequently, a signal is relayed back to There is also a small area under the lower right costal mar-
the origins of the nerve that is located to the area of the gin (rib) that when palpated (especially with the patient
cervical spine from levels C3–5. If you look at a map of the breathing in), may cause a rebound tenderness (figure 3).
neurological dermatomes, you will notice that C3–5 covers
This is known as Murphy’s sign and is a positive finding for
the area of the upper limb and in particular, the area of the
an inflamed gall bladder, especially if the same procedure is
shoulder region (figure 2b). Pain that is referred from the
performed on the left side of the abdomen with no per-
diaphragm is typically felt near the superior angle of the
ceived pain from the patient. I wrote a letter to my pa-
scapula, along the suprascapular fossa and even along the
tient’s GP, explaining my findings and she had a meeting
36 Terra Rosa E-mag No. 22
with a gastrointestinal consultant who confirmed it was
pathology with the gall bladder and removed it a few
weeks later. The patient in question had a follow-up ap-
pointment a few weeks after the surgery, and I was
pleased to see that her shoulder and thoracic pain had dis-
appeared.
This type of condition is what is described as a visceral-
somatic dysfunction because the organ (viscera) is the un-
derlying causative factor for the pain to present itself to
the somatic/soma region (body), in this case pain the right
shoulder.
Regarding pathology of the gall bladder, patients can also
present with upper right abdominal pain, as well as nausea
and vomiting, after eating fatty meals. They might also pre-
sent with jaundice, low-grade fever, and weight loss, espe-
cially if there is a cancer present.
In the Vital Shoulder book, I discussed other pathologies
that can refer pain to the shoulder, including spleen, liver,
lung carcinoma, stomach, pancreas, and others.
My focus here is to try and make you aware of how the
viscera refer pain to other structures within the musculo-
skeletal framework and especially to the region of the
shoulder complex. With the correct questioning during the
initial consultation and the appropriate orthopaedic testing
protocols, we can hopefully eliminate the musculoskeletal This article is excerpted from The Vital Shoulder Complex,
tissues as a source of a patient’s presenting symptoms, An Illustrated Guide To Assessment, Treatment, and Reha-
especially if the practitioner cannot reproduce their symp- bilitation By John Gibbons, with permission from Lotus
toms during the physical therapy examination. It is time Publishing. Order at terrarosa.com.au
then to consider that the symptoms the patients are pre-
senting with might be referred from the pathology of the
viscera rather than being musculoskeletal in origin.

John Gibbons is a registered sports osteopath, multi-

published author and lecturer for the Bodymaster Method ®.
He specializes in the assessment, treatment and rehabilita-
tion of sport-related injuries, specifically for the University of
Oxford sports teams. Having lectured in the field of sports
medicine and physical therapy since 1999, John delivers ad-
vanced therapy training to qualified professionals through-
out the UK and internationally. He has written over 45 arti-
cles on various aspects of physical therapy, which have been
published through companies like SportEx, Federation of
Holistic Therapies, Massage World, Positive Health and
Sports Injury Bulletin.

Terra Rosa E-mag No. 22 37

Assessment of Fascial
Dysfunction
Doreen Killens FCAMT

You have probably read articles about how to treat fas- Subjective Assessment
cia-related problems; however, do you know how to Geoffrey Maitland, one of the grandfathers of manual
identify if fascial dysfunction is the cause of your pa- physiotherapy, had a significant global impact on the pro-
tient’s symptoms? fession. One of the most important messages he conveyed
This article is the missing link and provides all you need to physiotherapists was the importance of a thorough sub-
jective evaluation.
to know to diagnose fascial dysfunction or to make a
differential diagnosis. Making the correct diagnosis is “Not only will a thorough subjective exam tell you what
the first step to providing the right treatment for your the problem(s) are,” he would say, “but also how to treat
patient’s problems to achieve long-term results. them.”
This is true for all cases of musculoskeletal pain: it is partic-
ularly important for cases of fascial dysfunction. The typical
This article has been extracted from the author’s book Mo- questions asked in a good subjective evaluation include the
bilizing the Myofascial System: A clinical guide to assess- following topics:
ment and treatment of myofascial dysfunctions.
• areas of pain and their relationship to each other
• complaints of paraesthesia, numbness or other neuro-
logical symptoms
38 Terra Rosa E-mag No. 22
• previous history of the complaint • The patient has difficulty maintaining an optimal pos-
• previous medical history, including medications taken ture.
• medical tests performed and their results
• previous treatments tried and their effects
• behaviour of pain throughout the day/ night THE OBJECTIVE EXAM
• factors that provoke and ease symptoms The objective exam involves several aspects, which, along
• functional difficulties with their common findings, are described below.
• patient’s goals for treatment.
A patient with fascial dysfunction may present with the Observation
following additional subjective complaints. Positional faults are noted in observing the patient’s pos-
“My skin is too small for my muscles.” ture, but testing the accessory movements of the joints
only gives a partial explanation for this positional fault.
“I feel tension in my leg overall, as if I were wearing a twist-
ed pair of tights.” For example, ideally, when assessing the position of the
femoral head relative to the pelvis, the therapist is hoping
“I know that other therapists and doctors have told me to find a centered femoral head, a key requirement for op-
that my right leg and arm symptoms are separate prob- timal biomechanics of the hip. An example of a positional
lems, but that’s not how it feels to me.” fault is one in which the femoral head is positioned anteri-
Other characteristics of myofascial pain include the follow- orly in relation to the ilium. If the therapist thinks only of
ing symptoms. articular factors, they will presume that the capsule of the
hip joint is the cause of this positional fault. However, opti-
• Pain is dull, aching, and often deep. mal biomechanics requires not only normal capsular mobili-
• Pain may be low-grade to severe in intensity. ty around the hip joint but also balanced activation of all
• There are frequently many areas of local tenderness. muscle and fascial vectors.
• There are disturbed sleeping patterns with morning
stiffness. Active Range of Motion
• Pain does not follow dermatomal, myotomal or sclero- The area in question may demonstrate normal, or near-
tomal patterns. normal, range of motion (ROM), but the range may be de-
Does this last category of symptoms not sound suspicious- creased if the body is positioned differently. For example, if
ly like fibromyalgia? Clinically, I have found that clients with the Superficial Back Line of fascia is tight, testing active
this condition tend to manage their symptoms well with a cervical flexion in sitting may be more restricted than if it is
combination of active exercise, dry needling, craniosacral tested in standing.
techniques, and fascial techniques as well as appropriate
medication, such as pregabalin, to tone down the nervous Active ROM may or may not produce pain, but the patient
system. frequently reports a sense of ‘stiffness’ or ‘pulling’.

Patients with fascial dysfunction are rarely able to identify Testing of individual joint mobility or muscle length is with-
specific provocative movements that consistently repro-
duce their symptoms unless the activity adds tension to a
tight fascial line [eg. low back pain brought on by walking
or standing for a while if the Deep Front Line (DFL) of fas-
cia is restricted]. We must, however, rule out other dys-
functions that can reproduce these symptoms such as hy-
pomobility or hypermobility of the facet joints, poor mobili-
ty, and/or dynamic control of the foot, knee, hip, lumbar
spine, pelvis or thorax that may contribute to the low back
pain. Given the connectivity and relationship between body
regions, every region of the body can contribute to low
back pain.
There can be other clues that we may be dealing with the
dysfunction of the fascial system:
• The patient has difficulty maintaining the effects of
treatment despite good results obtained during treat-
ment.
• The patient has difficulty maintaining the effects of
treatment despite being diligent in doing recommend-
ed flexibility, postural or stabilisation exercises.
• There has been a recent growth spurt in adolescence.
in normal limits (or, at times, hypermobile), but a re-
striction is noted with combined, functional movements.
Muscle Length Tests
These are often within normal limits. If a muscle is restrict-
ed and treatment is targeted to the local muscle, both the
patient and the therapist may feel that results from treat-
ment are short-lived, and the muscle soon tends to stiffen
up again.
Joint Mobility
Testing joint mobility includes both passive physiological
movements and passive accessory movements. Passive
physiological movements are movements in which the
practitioner produces the motion while supporting the
limb or spine. The technique is chosen in order to assess
the joint with the muscle in a relaxed position. Accessory or
joint play movements are joint movements that cannot be
performed by the individual. These accessory movements,
including roll, spin, and slide, accompany the physiological
movements of a joint. Manual therapists have been taught
that when assessing passive physiological or passive acces-
sory movements of a joint, attention must be paid to the

Terra Rosa E-mag No. 22 39

sensation throughout the whole movement and not simply If the load and listen test points to an articular restriction,
the end feel of the movement. the therapist will feel that the accessory glide may be stiff
with a relatively harder, capsular end feel. Upon the re-
All joints have ROM divided into two zones:
lease of the accessory glide, a small amplitude movement
1. A neutral zone (NZ) in which no resistance is felt. The NZ occurs to allow the joint to re-establish a more neutral posi-
ends once the beginning of the first resistance to move- tion.
ment is perceived (R1).
If the load and listen test points to a myofascial restriction,
2. An elastic zone (EZ) in which the first resistance to move- the therapist feels the resistance to the accessory move-
ment (R1) gradually increases until firm resistance is felt ment, but the end feel will not be as hard. More important-
(R2) at the end of range. In a normal joint, it is considered ly, upon release of the glide, there will be a vector of pull
that R2 is due to tension in the ligaments and capsule of towards the area that is ‘tugging’ on the joint. This myofas-
the joint (Chapter 4 ‘Principles of treatment with Mobilisa- cial restriction may be a combination of neuromuscular
tion of the Myofascial System’ of the author’s book Mobi- vectors (increased tone in muscles due to increased neural
lizing the Myofascial System discusses this in more detail). drive), visceral vectors, muscular and fascial vectors. (Keep
in mind that fascia surrounds all of these systems.)
A normal accessory movement for a joint, although small in
amplitude (usually a few millimetres of glide or roll), will This test may be used as a ‘before’ and ‘after’ test when
have a small NZ, where no resistance is felt at the start of using any release technique. It is particularly useful to use
the movement, and a gradually increasing EZ until R2 is before and after a mobilisation of the myofascial system
felt. Training is required to determine a normal or abnor- (MMS) technique. It guides the therapist as to which myo-
mal feel for an accessory movement of a joint. fascial vector(s) have the most impact on a particular joint
and encourages exploration of that myofascial vector. Re-
When there is a myofascial restriction, accessory move-
lease can be done both locally to the involved muscle and
ments of the joints have a ‘bouncy’ or ‘rubberlike’ end feel
also along its myofascial line (based on Anatomy Trains
as opposed to the end feel of a fibrotic or stiff joint, which
myofascial meridians). (Chapter 11 of the author’s book
is crisper and harder.
‘The lower extremity’ outlines the load and listen test for
Several levels in the lumbar spine may exhibit stiffness with the hip joint.)
PIVM (passive intervertebral movement) testing for flex-
The same concepts for the load and listen test apply to
ion, for example. If a fascial line is restricted, mobilising
other joints. For example, if the glenohumeral (GH) joint is
these joints often results in only partial release.
positioned anteriorly in relation to the acromion, on the
The patient’s joints may have a tendency to be hypermo- load and listen test we may find some limitation in the pos-
bile, but they still present with decreased ROM when ac- terior glide of the GH joint (the loading aspect of the test):
tive ROM is tested. but upon the release of the anteroposterior (AP) glide (the
listening aspect of the test), we may feel a vector that pulls
Vector Analysis: Load and Listen Test the humeral head caudally toward the biceps if the Superfi-
This test derives from listening courses developed by Gail cial Front Arm Line is shortened. It is then appropriate to
Wexler for the Barral Institute. These listening techniques check the myofascial tissues of the Superficial Front Line.
differentiate active and passive listening. ‘Load and listen’ (Chapter 13 ‘The upper extremity’ outlines the load and
encompasses both aspects of listening. I find it invaluable listen test for the GH joint.)
in helping to detect the primary myofascial vectors that
Dynamic Stability Tests
may be impacting a joint. When an accessory movement
for a joint is assessed, not only is the resistance of this ac- Dynamic instability may be defined as a patient exhibiting a
cessory movement noted but, in this test, particular atten- failed load transfer when performing functional tasks such
tion is paid to the release component of the accessory as the half squat or OLS (one-leg stand) test. The failed
glide. In other words, when you let go of a correction, load transfer in these functional tests may present in one
where does it pull you? This is what is termed ‘vector analy- or several areas(1):
sis’.
The pelvis: ‘unlocking’ of the pelvis may occur. In this situa-
Vector analysis in the Integrated Systems Model (ISM) ap- tion, the sacroiliac joint fails to maintain a position of sacral
proach has taken the ‘load and listen’ concept of the Barral nutation in relation to the ilium (the position of optimal
visceral approach and applied it to the musculoskeletal stability for the sacroiliac joint). The therapist may perceive
system to help identify the underlying system impairment this as the ilium moving into anterior rotation (relative
that is creating suboptimal alignment, biomechanics and/or counternutation of the sacrum) when doing a half squat or
control of a body region. OLS test.
In a healthy hip, when the therapist glides the femoral The hip: ideally the femoral head should stay centered in
head posteriorly, it floats back up to the surface, much like relation to the pelvis throughout an OLS or a squat ma-
the type of ‘soap on a rope’ that pops back up to the sur- noeuvre. A common clinical pattern of dysfunction is a fem-
face of the water after it has been pushed down (Diane oral head that glides anteriorly and/or internally rotates
Lee, personal communication). instead of staying centralized.
40 Terra Rosa E-mag No. 22
The foot: the foot should be able to maintain its neutral posterior, which is at the tail end of this line (see Chapter 5
position, with the talus directly under the tibia, the fore- ‘The cervical spine’ for details).
foot in a neutral position in relation to the hindfoot.
To explore the Lateral Line the therapist may position the
The thorax: no lateral shift of the thoracic rings should oc- client in side-lying, stabilise the mid-cervical spine with an
cur with functional tests of OLS and squat (1). Patients with AP mobilisation and explore the intercostal fascia on the
fascial dysfunction frequently exhibit signs of dynamic in- side of the trunk (see Chapter 5 ‘The cervical spine’ for de-
stability, especially in the area of fascial tightness. Recruit- tails).
ing muscles that help in motor control is often a frustrating
experience for both the therapist and the client, as fascial
How Does the Therapist Know when a Particular Line
tension is frequently a factor that inhibits these stabiliser of Fascia is Restricted?
muscles from ‘kicking in’. The therapist will feel an almost immediate increase in ten-
ASSESSMENT OF THE FASCIAL SYSTEM sion of the stabilising hand (in this case, the AP mobilisa-
tion of the C4) as he/ she applies a gentle pressure on the
Testing for Fascial Restriction with Recurring Joint Dys- anterior aspect of the sternum with the exploratory hand
function (for a SFL restriction). It is normal to feel a certain re-
If a joint restriction is recurrent despite good effects with sistance between the two areas at the end of a caudal
previous treatment, good compliance with mobility and pressure on the sternum. Still, it is not normal to feel this
stability exercises, and awareness of posture, it may be resistance at the very start of the manoeuvre being per-
that the fascial component to the restriction needs to be formed by the exploratory hand. There should be (in Geoff
addressed. For example, if anteroposterior (AP) mobilisa- Maitland’s terms) a ‘toe region’ where there is little re-
tions of the C4 and C5 levels are chronically stiff despite sistance at the beginning of the movement (discussed fur-
good release with treatment, we may consider whether ther in Chapter 4 ‘Principles of treatment with Mobilization
this dysfunction is perhaps connected elsewhere along a of the Myofascial System’). When the fascial line is restrict-
fascial line and whether this may possibly be a contributing ed, this toe region is absent or quite limited and early re-
factor toward its recurrence. If the therapist suspects that sistance between the two hands of the therapist will be
fascia may be a factor in movement restriction, he/she can felt. The patient may perceive this as the therapist pushing
then explore which line of tension is most problematic. harder on the level being stabilised (in this case, C4) when
in reality, the therapist is simply preventing the fascial tis-
The MMS techniques described in this text have two com- sues at C4 from gliding caudally.
ponents:
Using the Star Concept
1. The therapist stabilises an area of recurrent dysfunction
with one hand stabilising either an accessory movement of The star concept implies that the therapist must not think
a joint or a recurring myofascial trigger point. along the lines of an articular glide but rather explore mul-
tiple directions: somewhat like the shape of a star. The aim
2. The therapist’s other hand becomes the hand that ex- is to discover where there is most tension between the
plores and mobilises lines of fascia, always using the ‘star stabilising hand and the fascial tissues anterior to the ster-
concept’ (described below). num (for this example of a problem with the Superficial
Continuing with the same example of the restricted AP Front Line). The therapist ‘corrals’ the myofascial tissue,
mobilisation at C4, the C4 level can be stabilised with an AP ‘sniffing out’ the vector where most tension between the
mobilisation angled cranially and then the following consid- two hands is felt. In the example above, the caudal pres-
ered. sure on the tissues anterior to the sternum may be done in
a straight caudal direction, caudal to the right of the pa-
To explore the SFL the therapist may add: tient, caudal to the left of the patient, or perhaps in a me-
– an AP mobilisation to the ipsilateral or contralateral scap- dial/ lateral direction or even in a clockwise/anticlockwise
ula direction. Restriction may be felt in several directions.
Treatment begins by using the most restricted direction
– an AP pressure directed caudally to the tissue anterior to and, once released, exploring and releasing the other re-
the sternum stricted directions in that fascial line.
– the rest of this line may then be explored with an AP Exploring Lines of Fascia
pressure directed caudally to the rectus abdominis area
and/or the symphysis pubis (see Chapter 5 for details). Tom Myers’s Anatomy Trains lines, although very pertinent
to MMS, are not the only way a therapist can explore the
To explore the DFL the therapist may add: fascia. The Anatomy Trains is simply a map of the ‘grain’ in
– an AP mobilisation directed caudally to the tissue posteri- the myofascial fabric, and so, like most maps, only an indi-
or to the sternum (pericardium) cation of a good place to look (2).
– an AP mobilisation directed caudally to the right and/or The nervous system may also be used as a guideline (see
left diaphragm – active dorsiflexion/eversion of the ankles the femoral nerve fascial technique in Chapter 9 ‘The lum-
to pre-tense the DFL by putting a stretch on the tibialis bar/pelvic region’ as an example).

Terra Rosa E-mag No. 22 41

The patient’s functional problems may also give us a clue
as to what to explore. Refer to Chapter 5 (Anterior cervical
in relation to glenohumeral movements) for an example
where the patient complains of arm pain with reaching
forward as opposed to reaching sideways with abduction.
“It hurts right here.” The location of the patient’s main
complaint of pain may also be a good place to start, stabi-
lising that area and exploring fascial lines that may be
‘tethered’ to that painful area. The area of pain is frequent-
ly a ‘victim’ of another dysfunction nearby (e.g., the lower
lumbar area may become symptomatic during standing or
walking if it is compensating for an extension dysfunction
in the upper lumbar area, and/ or poor hip extension).
However, the symptomatic area may also be tethered by a
tight fascial line, and this may also play a role in its recur-
rence.
Reposition and Test
then adding dorsiflexion/eversion will cause an immediate
increase in tension in the hand that is stabilising C4 in an AP
glide (see Chapter 5 for MMS technique).
Testing for Fascial Restriction with a Recurring Mus-
cle Trigger Point
Myofascial tension may tend to recur if the following fac-
tors are not addressed:
• optimising balance between muscle groups in the area
(i.e., stretching tight muscles, strengthening weak
ones)
• using dry needling or IMS techniques to de-facilitate
muscles that are hypertonic secondary to increased
neural drive
• considering other areas of the body that may be im-
pacting the symptomatic area (ISM concept of drivers)

Another way to help differentiate an accessory joint move- • last but not least, considering that there may be a myo-
ment restricted by the joint capsule from one restricted by fascial component to the restriction that needs to be
myofascial vectors is to repeat an accessory movement addressed.
with other regions of the body under tension. For example, The following paragraph describes an example of this last
an AP mobilisation of the C4 level in the mid-cervical region concept using MMS.
may be compared to the same mobilisation (same grade of
movement) with the ipsilateral arm in 70° of abduction. If Recurrent tension in the upper fibres of trapezius (UFT)
the AP at C4 is stiffer (which may or may not reproduce may be due to tension of the Superficial Back Arm Line
pain), then it implies that fascia may be a factor in this re- (SBAL), which needs to be addressed to get optimal re-
current restriction. The fascia may be related to the muscu- sults. In this example, the therapist ‘stabilises’ the recur-
lar system (e.g. scalenes), the clavicle, the neural system rent myofascial trigger point in the UFT by pinching it in an
(e.g. median nerve), the visceral system (e.g. pericardium) AP direction. If there is tension in the SBAL, the therapist
or perhaps a combination of all four areas. will feel an immediate increase in tension of the ‘stabilising’
hand on the UFT as soon as he/she adds a component of
Another example is to explore the DFL of fascia in relation the passive wrist and finger flexion. Keep in mind that the
to recurrent C4 dysfunction. This is done by stabilising C4 wrist and finger extensors are at the tail end of the SBAL
as above and simply adding active (or passive) combined (see Chapter 2 ‘A summary of Tom Myers’s Anatomy Trains
dorsiflexion/eversion of the ankles to see if this affects C4. fascial lines and clinical implications’). Using oscillatory
(Keep in mind that tibialis posterior is at the tail end of Tom movements of wrist flexion while maintaining the pinch on
Myers’s DFL, so adding dorsiflexion/eversion puts it under the trigger point will help to release this line of tension
tension). If there is abnormal tension in the DFL of fascia, (see Chapter 5 for MMS technique).

CASE REPORT – MICHAEL’S STORY

This case hits close to home as it involves my son Michael, who is presently 25 years old. When he was 14 years old, he fell skate-
boarding and sustained a severe fracture of his left clavicle – it had fractured into three pieces, with the middle portion angled verti-
cally. He was initially placed in a sling and told to go home – the assumption was that the bone would heal on its own. Lyn Watson, a
shoulder specialist in Melbourne, Australia, whom I consulted, stated that, in Australia, they would operate on such a case. Needless
to say, I made sure to go with Michael to his follow-up appointment. I had a number of concerns about the long-term function of his
shoulder girdle, including the possibility that it would heal in a shortened position and forever impact his upper quadrant function.
Unfortunately, I could not convince the chief orthopaedic doctor to perform surgery. He assured me that healing was coming along
and I should just allow nature to take its course. Knowing that bone was essentially dense fascia, I proceeded to remodel the clavicu-
lar fascia, initially with a listening approach and later, as healing progressed, with a more directive, MMS mobilisation approach. The
clavicle fascia was tight in a number of directions (see techniques above), particularly in relation to the Superficial Front Line
(clavicle in relation to the pectoral muscles and rectus abdominis) and the anterior functional line of fascia (left clavicle with right
ilium). The intraclavicular fascia also was remodelled to encourage healing in the most lengthened position possible. This work was
followed up with a strengthening programme to his scapular upward rotators. Initial treatment was performed weekly, and then
periodically over the next year, as bone (and fascia) remodelling took place. Throughout his growth spurt, Michael could feel the
need for more fascial release and periodically through the years, as his system adjusted to a new gym programme. Today, he is fully
functional and grateful that his mother is a physiotherapist with skills in MMS!

42 Terra Rosa E-mag No. 22


Testing for Fascial Restriction with a Neural Mobili-
ty Test
In order to address problems of decreased mobility of a
particular nerve, the usual approach in manual therapy is
to mobilise the interfaces of the nerve in question. The
median nerve, for example, may involve positioning the
arm in some degree of shoulder abduction, external rota-
tion, elbow extension, and wrist and finger extension
(depending on irritability of the tissues and where first
resistance is felt when doing the median nerve mobility
test) and then adding AP mobilisations or lateral shear
movements at C5, C6, and C7. As well, the nerve mobility
test itself may be used as a treatment technique, either as
a sliding technique or a tensioning technique. If, however,
the tension of the nervous system persists despite this
approach to treatment, it is suggested that the therapist
explore a little more broadly than the usual interfaces of
the nerves. For example, the therapist may use a mobilis-
ing technique in the anterior cervical spine with the arm in
abduction, external rotation, wrist and finger extension to
pre-tense the median nerve and then explore the SFL of
the trunk. Or the therapist may also explore other regions
of the cervical spine, frequently as high as C1 or C2, that
may have an impact on the mobility of the median nerve
(see Chapter 5 for MMS techniques).
Indications/Contraindications to MMS Treatment
The contraindications to treatment with MMS are similar
to the contraindications for manual therapy in general.
CNS, spinal cord or cauda equina disease and injury are an
obvious contraindication to any manual therapy, but there
are also other conditions to consider such as vascular is-
sues and metabolic and systemic contraindications. MMS
is particularly indicated for subacute or chronic condi-
tions. If the condition is acute, the therapist may work
either proximally or distally (craniocaudally) to the symp-
tomatic region, following Myers’s fascial lines of tension.
When first working with tissues that are in the subacute
phase of healing, it is wise to use ‘listening techniques’
rather than be too directive until such time that the body
gives you a green light to go ahead (see Chapter 4 for
principles of treatment with MMS). Recent fractures must
be given time to heal before using fascial techniques di-
rectly on the fracture site, but areas above and below the
fracture may be explored and treated.
THE AUTHOR
Doreen Killens FCAMT is an orthopaedic
musculoskeletal physiotherapist with
40 years of clinical experience. For 25
years, she was an instructor for the
Canadian Orthopaedic Manipulative
Division of the Canadian Physiotherapy
Association, teaching manual therapy
courses across Canada. In addition, she
was an Examiner and former Chief Examiner for the same
association. She is presently in private practice in Montre-
al and has a particular interest in the field of headaches
and myofascial dysfunction. She is the developer of a
physiotherapy approach to the treatment of the myofas-
cial body called Mobilization of the Myofascial System
(MMS) (Upper Quadrant, Lower Quadrant and Advanced
Integration). Also, she teaches a two-level course system
entitled Manual Therapy for the Cranium, courses she
teaches across Canada and Europe, both in English and in
French. Email: Doreen.Killens@gmail.com
KEY POINTS
• A thorough subjective exam is crucial for the correct
analysis and treatment of fascial dysfunction.
• Some symptoms of myofascial pain can sound like the
symptoms of fibromyalgia.
• It is often difficult for fascial dysfunction patients to
identify specific movements that reproduce their
symptoms.
• Difficulty in maintaining good treatment results with
conventional manual therapy approaches can indicate
fascial dysfunction.
• A cornerstone of the objective exam is to test whether
joint position is balanced during functional movements
that are relevant to the subjective complaint.
• The end feel of accessory movements of the joint is
‘bouncy’ when fascial restriction is present.
• Mobilisation of the myofascial system (MMS) tech-
niques are also useful for testing fascial restriction. n
MMS is particularly indicated for subacute or chronic
conditions.
• ‘What the therapist perceives as recurring joint stiff-
ness may actually have a component of fascial dys-
function – a myofascial vector that pulls on the joint
making it more difficult for the patient to obtain opti-
mal biomechanics. This recurrent ‘joint stiffness’ will
remain until the appropriate myofascial vectors are
examined and treated.’
References
1. Lee L-J, Lee D. Techniques and tools for addressing bar-
riers in the lumbopelvic–hip complex. In Lee D (ed.), The
pelvic girdle: an integration of clinical expertise and re-
search, 4th edn. Elsevier 2011.
2. Myers T. Anatomy trains: Myofascial meridians for man-
ual and movement therapists, 3rd edn. Churchill Living-
stone 2013.
Terra Rosa E-mag No. 22 43
We know now that fascia plays an important role in
health, wellbeing and mobility. It transmits the power of
the muscles, communicates with the nervous system and
serves as a sense organ. However, many manual thera-
pists are still unfamiliar with fascia and continue to think
of it as the ‘dead packing material’.
Mobilization of the Myofascial System (MMS) outlines the
theory and pathophysiology of fascial dysfunctions. A full
description of the MMS assessment and treatment ap-
proach is given as well as guidance on ways in which it
may be integrated into the other methods normally used
by manual therapists. Subsequent chapters offer full de-
scriptions and colour photos of the MMS techniques. The
chapters are organised into various anatomical regions
simply to facilitate learning. These divisions are, of course,
artificial, as fascia is a continuum, from the top of the
head, down to the toes.
Mobilization of the Myofascial System is primarily intend-
ed for physical therapists who have been trained in manu-
Available at : terrarosa.com.au
al therapy, but it will also be valuable for osteopaths, chi-
ropractors, massage therapists, structural integrators and
other body workers who are seeking an alternative way to
work with this important and fascinating tissue.

44 Terra Rosa E-mag No. 22

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Ligamentous Articular Strain
Technique
A Reconceptualization and
Revitalization of a Classical
Osteopathic Manual Technique
By Robert Libbey, RMT

Today’s global Massage Therapy profession is com- manage our patients.

mitted to utilizing techniques informed from re-
Therapists must rationally integrate this new infor-
search and evidence. As science and medicine have
mation into their clinical reasoning, keeping the best
advanced, our understanding of human complexities
interests and goals of their patients in mind at all
has evolved. Advances in our understanding of anat-
times. Practicing in this manner has the potential to
omy, physiology, neurology, psychosocial factors,
transform your practice and improve the quality of
pain science, the role of fascial tissues and regenera-
life of your patients, as I know it has for mine. In this
tive therapies demands that we adapt the narratives
first of two articles, I will explore the research sup-
of our manual therapy applications and how we
46 Terra Rosa E-mag No. 22
porting the theory for Ligamentous Articular Strain
Technique (LAST) In the second article of this series,
I’ll provide a case study documenting the use of
LAST in treatment.
A Brief History of LAST
At the beginning of my career, I began searching for
a more precise and specific technique that targeted
ligamentous and joint capsule tissues. My journey
lead me to Andrew Taylor Still DO. Ligamentous Ar-
ticular Strain Techniques originated in the late 1800s.
The majority of the techniques initially developed
were called traction methods, known as “Indirect
Techniques.” Several of these were Ligamentous
Articular Strain Techniques and various myofascial
techniques. 22 Throughout the years, William Suther-
land DO, Rolin Becker DO and the Dallas Osteopathic
Study Group continued to innovate and instruct
these techniques. 34
It has been a passion of mine to research and ad-
vance LAST, incorporating today’s research on struc-
ture, function and neurophysiology. New research
directly affects our understanding of all tissues not
just the ligamentous articular tissues. My aim is to
educate Therapists on a safe, ethical and effective
treatment technique, for the treatment of injured
ligaments and the surrounding fascial tissues, by
providing education congruent with current evi-
dence informed research.
I instruct LAST as a reconceptualization and revitali-
zation of a classical Osteopathic Manual Technique.
In these courses, therapists learn to apply Ligamen-
tous Articular Strain Techniques with a biotensegral
and Biopsychosocial (BPS) perspective.
What we know now…
For many years we have been taught that ligaments
and muscles were separate structures. Many anato-
my texts portray ligaments, cartilage, joint capsules
and muscles as separate tissues, which are not con-
nected to the surrounding tissues. However, liga-
ments are in fact continuous with the fascial connec-
tive tissue web that extends throughout the body.
Ligaments are highly dynamic and non-stationary
organs. In 2009, Jaap van der Wal stated that liga-
ments are mostly arranged in series with the mus-
cles, not parallel. There is a joint stability system, in
which muscular tissue and regular dense collagenous
connective tissue (ligaments/joint capsules) inter-
weave and function mainly in an “in series” situation
rather than an “in parallel” situation. 37 Periarticular
connective tissues are loaded and stretched during
both concentric and eccentric muscular contrac-
tions, like the reins on a horse, constantly assisting
the stabilization of a joint, no matter what its posi-
tion
Afferent mechanoreceptors in ligaments/joint cap-
sules of the extremities and in the spine (responsible
for kinesthetic and proprioceptive sensation) trigger
a ligamentomuscular reflex activation of associated
muscles. Muscular activity elicited by this reflex al-
lows muscles and ligaments to work together as a
unit, inhibiting muscles that destabilize the joint and
increasing antagonist co-activation to maintain joint
stability 26, 33
In his articles on fascial plasticity, Dr. Schleip discuss-
es how fascia and the autonomic nervous system are
connected and communicate via mechanoreceptors
afferent input.29, 30 Research from Schleip & Pelletier
recommend that therapists’ change their perspec-
tive of treatment from a purely mechanical perspec-
tive to one that also is inclusive of nervous system
modulation strategies. 23, 24, 29, 30
Fibrous continuities between different tissues enable
reciprocal feedback to occur over multiple path-
ways. Both mechanical and neural pathways provide
the central nervous system (CNS) with significant
input about dynamic joint positional sense, contrib-
uting to the synergistic activation of muscles and
providing proprioceptive sensation.22, 29, 30, 33
Understanding Injuries
Injuries or influences to the joint’s soft tissues can
happen abruptly as in the case of an ankle inversion
event, or may occur slowly over a lifetime as with
postural changes or diseases such as Rheumatoid
Arthritis. The abrupt event can have dysfunctional
ramifications that are immediate and recognizable
while the long-term dysfunctional influences may be
more difficult to perceive. Regardless of either state,
autonomic nervous system responses create ineffi-
Terra Rosa E-mag No. 22 47
cient compensatory patterns in order to maintain
the joint stability system’s and function.
Within several hours after an injury, acute inflamma-
tion sets in and can last from several weeks to 12
months. If the injured tissues are not allowed to rest,
recover and heal, chronic inflammation progresses.
33
Even after 2 years, ligamentous healing does not
regenerate a normal ligament, but creates scar tis-
sue that has an inferior tissue quality, with changes
in biochemical and histologic properties. Permanent
disabilities occur when chronic inflammation causes
degeneration of the collagen matrix, tissue atrophy
and weak and non-functional ligaments. 3, 33, 36
The long-term ramifications of not effectively and
immediately managing these injuries are potential
damage to capsule, cartilage and tendons, nearby
nerves and blood vessels, discs and further potential
damage to the ligaments themselves. Full recovery
has never been reported when the chronic stage of
an injury is left to develop. 33 Chronic instabilities and
dysfunctions are known to drastically modify the
intra-articular pressure and the muscular activity
around the joint, resulting in early onset of osteoar-
thritis, pain, disability and eventually the need for
joint replacement surgery. 2, 36
Injuries to the soft tissues of peripheral joints, play a
part in chronic neuromuscular adaptations due in
part to a loss of effective messaging from mechano-
receptors to the CNS.12, 19, 21, 33, 37 Peripheral joint inju-
ries disrupt the generation and transmission of ade-
quate proprioceptive input from mechanoreceptors,
which can lead to significant joint sensorimotor im-
pairment.9, 11, 12, 19, 21, 31, 33, 40 These dysfunctions influ-
ence “executive functions” such as processing of
somatosensory information by the prefrontal cortex,
causing reorganization of the central nervous sys-
tem at both the cortical and spinal levels, effecting
neural plasticity.9, 11, 21, 23, 24, 40 Neuroplastic changes
may help to explain, in part, the transition from
acute to chronic conditions.21, 24
Tissue damage is real, and pain/discomfort arising
from it is real and complex. How a patient perceives
their injury/condition and how therapists communi-
cate with a patient has the potential to affect the
rehabilitation process. The more emotionally the
brain reacts to the initial injury, the more likely some
patients will continue to experience pain after the
injury has healed, no structural cause can be deter-
mined, and why some patients fail to respond to
conservative interventions. 7, 21, 23, 24
48 Terra Rosa E-mag No. 22
A common Patient perception is that certain activi-
ties may potentially cause further tissue damage to
their injury/condition extending their recovery pro-
cess. Dysfunctional changes in a patients bioten-
segral plasticity, stability and their neuropsychophys-
iology create the experience of pain, discomfort,
impaired interoception, tissue guarding, sensory mo-
tor impairment and structural instability. 27, 28 Pa-
tients can suffer from dysfunctional thoughts, be-
liefs, behaviors, emotional factors such as depres-
sion, anxiety and take part in fewer healthy social
interactions. These catastrophizing behaviors and
thoughts can contribute to the production of pro-
inflammatory cytokines which have been shown to
worsen the injury/condition and slow the rehabilita-
tion process. 1, 18, 19, 20, 25
The therapeutic relationship between a Therapist
and patient has the potential to positively or nega-
tively impact the rehabilitation process. Therapists
must recognize that communication utilizing nocebo
terminology (having a detrimental effect on health
produced by psychological or psychosomatic factors
such as negative expectations of treatment or prog-
nosis) can also contribute to the production of pro-
inflammatory cytokines within their patients. Thera-
pists may unknowingly contribute to and or amplify
dysfunctional thoughts, beliefs, behaviors and
chronic psychological stress of their patients, con-
tributing to the chronicity of injuries and extending
the rehabilitation process. 8, 10
Ligamentous/fascial injuries are no longer seen as
just simple local musculoskeletal peripheral joint inju-
ries, but as systemic dysfunctions influencing all as-
pects of their life; from the smallest properties of
their physiology to their neuropsychophysiology.
Why Focus on Mechanoreceptor Specific Tech-
niques?
LAST affects the connective tissues of the body,
mainly ligaments, joint capsules, fascia, muscles, ten-
dons and indirectly, lymphatic and blood flow and
the autonomic nervous system.
Manual techniques that target mechanoreceptors
have been proven to affect autonomic functions
such as lowering sympathetic nervous system activi-
ty, increase local proprioceptive attention, cause a
decrease in active muscle tone and affect both the
local blood supply and the local tissue viscosity. 6, 29,
30, 31, 32
In a study presented at the Third International Fascia
Research Congress, Viklund et al. concluded that
specific myofascial receptor techniques might not
only improve ROM but also have a longer lasting
effect than classical (Swedish) massage techniques.
They suggested that “therapists might be encour-
aged to aim their soft tissue techniques to a lesser
area where there is known to be high density of
mechanoreceptors”. 39
Langevin et al. proposed that therapies which briefly
stretch tissues beyond the habitual range of motion
(massage) locally inhibit new collagen formation for
several days, and thus, prevent and/or ameliorate
soft tissue adhesions. Manual Therapy has been
shown to affect the fibrosis and densification of fas-
cia by changing its tensile status and sliding compo-
nents. 13,14, 15, 16, 17
Therapists who utilize both bottom-up influences
(manual therapy) and top-down influences include
cognitive based therapy techniques (positive narra-
tive explanations, Patient education, cognitive-
behavioral therapy, mindfulness meditation) can
stimulate CNS neuroplastic changes. 23 Treatment
approaches that incorporate mechanoreceptor spe-
cific techniques have both local and systemic effects
on our physiological environment. Therapists have
the opportunity not only influence the neuropsycho-
physiology (thoughts, beliefs and behaviors) of a
patient but also modulate the ligamentous/fascial
physiology, alter the pain/discomfort perception,
improve biotensegral stability, improve interocep-
tion and sensory motor function. 17, 29, 30, 35, 38
In the next article in this series, I will present a case
study, which incorporates LAST and evidence-
informed research into practice.
For more information about Ligamentous Articular
Strain Techniques please go to www.lastsite.ca
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50 Terra Rosa E-mag No. 22

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Terra Rosa E-mag No. 22 51

Research
Highlights
The energy expenditure of massage therapists
Massage therapy can be considered hard work, as per-
forming massage requires lots of energy. However, there
is no objective measure yet on how many calories are
used in a course of treatment. Researchers from Poland
evaluated the intensity of the effort and energy expendi-
ture in the course of performing selected classical mas-
sage techniques.
Thirteen massage therapists (age: 22±1.9 years old, aver-
age 76±11 kg) were recruited. The stress test consisted of
performing selected classical massage techniques in the
following order: stroking, kneading, shaking, beating, rub-
bing, and direct vibration, during which the cardio-
respiratory responses were measured.
The results indicated that the intensity of performing mas-
sage was:
• 47% in terms of % VO2max (maximal oxygen consump-
tion)
• 75% in terms of % HRmax (maximal heart rate)
• 48% in terms of % HRR (heart rate reserve) during the
whole procedure. While performing the classical massage
techniques, the energy expenditure was:
• net energy expenditure (EE) 5.6±0.9 kcal per minute
• metabolic equivalent of task (MET) was 5.6±0.2.
• Rubbing was the highest intensity exercise.
Based on the data, the researchers calculated that the
average energy expenditure of a therapist performing a
session of massage is 336 ± 56 kcal per hour. This amount
of energy is equivalent to running for half an hour or a
distance of 5 km. For a therapist working five hours per
day, this is about 1700 kcal per day. This work is classified
as hard work according to a classification of work intensi-
ty.
Weekly massage effective in reducing pain from
knee osteoarthritis
Massage is a safe and effective complement option to
manage knee osteoarthritis. Researchers from Duke Uni-
versity Medical Centre conducted a study to examine the
effects of whole-body massage on knee osteoarthritis.
52 Terra Rosa E-mag No. 22
The study which involved more than 200 participants was
published in the Journal of General Internal Medicine. The
study was a randomised control trial conducted at multi-
ple sites where massage was compared to light-touch and
usual care in adults with knee osteoarthritis. The treat-
ment was a 60-minute full-body massage following a
standard protocol or light-touch. There were 222 adults
with knee osteoarthritis enrolled in the program, 200
completed 8-week assessments, and 175 completed 52-
week assessments. Participants in massage or light-touch
groups received eight weekly treatments, then were ran-
domised to biweekly intervention or usual care to week
52. The original usual care group continued to week 24.
Assessments were at baseline and weeks 8, 16, 24, 36, and
52.
At eight weeks, massage significantly improved pain
score, called Western Ontario and McMaster Universities
Arthritis Index (WOMAC), compared to light-touch and
usual care. Massage also improved pain, stiffness, and
physical function of WOMAC scores compared to light-
touch and usual care. At 52 weeks, there was no signifi-
cant difference in change across groups. Adverse events
were minimal. The authors concluded that weekly mas-
sage is effective as a symptom relief, which makes it an
attractive short-term treatment option for knee osteoar-
thritis. Longer-term biweekly dose maintained improve-
ment but did not provide additional benefit beyond the
usual care post-8-week treatment.
Massage therapy for managing depression: Restor-
ing impaired interoceptive functioning
Massage therapy is known to induce relaxation and pro-
vide emotional support for people suffering from depres-
sion. There is also an increasing amount of studies that
show that massage therapy could significantly alleviate
 Research Highlights
symptoms of depression. However, the mechanism of the
anti-depression effect is still unclear. Concurrently, man-
ual therapists now recognise the importance of intero-
ception, an individual’s sense of the physiological condi-
tion of his/her entire body. It comprises the sensation,
interpretation, and integration of signals arising from
within the body.
Researchers from Ulm University, Germany, proposed
a mechanism linking the anti-depressive effects to a mas-
sage-induced modulation of interoceptive states. The
study was published in Medical Hypotheses. The research-
ers looked at affective massage therapy, which is massage
therapies aiming to influence affective states rather than
targeting muscles or manipulating fascial tissues. The
type of massage techniques commonly used long strokes
and caress-like touches such as effleurage. Affective mas-
sage therapy applies slow, rhythmic, and caress-like
touch that stimulates C tactile (CT) afferents in the non-
glabrous (without hair) skin.
Non-glabrous skin contains numerous mechanosensitive
receptors, which give rise to perceived pleasantness in
response to slow, rhythmic, and caress-like touch. CT me-
diated touch elicits responses in interoceptive brain areas
(e.g., the insular cortex) that have been associated with
abnormal interoceptive representations in people
suffering depression.
Thus, the authors hypothesised that the anti-depressive
effects of massage therapy are mediated by the restora-
tion of the impaired interoceptive functioning through
the stimulation of CT afferents or related interoceptive
structures. This hypothesised mechanism supports that
massage is probably one of the most ancient interocep-
tive treatments.
Foam rolling increases range of motion without al-
tering muscles’ morphology
Foam rolling is an effective tool for improving the
range of motion (ROM). Many studies have shown foam
rolling could increase ROM of the hip, knee, and ankle
without impairing muscular strength. Theoretically, pres-
sure stimulation is expected to change the morphology
of the muscle and fascia (i.e., reducing thickness, adhe-
sion, and tension). Some studies reported a 24 per cent
decrease in stiffness in the anterior thigh tissues and a 42
per cent increase in the thoracolumbar fascia mobility
after foam rolling. Thus, it was hypothesised that foam
rolling might increase ROM because of changes in fasci-
cle length and aponeurosis displacement.
Robert Schleip and colleagues investigated this hypothe-
sis in a study published in Journal of Strength and Condi-
tioning Research. A crossover study, involving 22 male
university students, compared foam rolling on the gas-
trocnemius muscle with a control. The foam rolling group
performed three sets of 1-minute foam rolling with a 30-
second rest between each set targeting the right medial
head of the gastrocnemius muscle.
Results showed that foam rolling significantly in-
creased ROM of both dorsiflexion and plantar flexion.
However, there is no observed changes in fascicle length
and aponeurosis displacement. The mean perception of
pain of foam rolling was ‘slightly uncomfortable’, implying
that foam rolling could increase ankle ROM without caus-
ing uncomfortable and excessive pain. The authors hy-
pothesised that the increase in ROM may be due to the
autonomic nervous system response. Schleip reported
that Ruffini bodies exist within the connective tissue,
which could be activated by stimulation combining tan-
gential forces and stretch. As a result, the phenomenon
led to a more parasympathetic state as well as a lowering
sympathetic activity, alteration in muscle tones, tissue
viscosity, and reduction of intrafascial smooth muscle
cells.
Interestingly, plantar flexion and dorsiflexion ROM
improved, although the foam rolling was on the triceps
surae muscle, which is an agonist muscle of ankle
plantarflexion. It was speculated that this effect is due to
the neurological modulation, which is commonly called
the crossover effect. The authors questioned that foam
rolling is called self ‘myofascial release’ as it does not
affect myofascia morphology. They concluded that future
work will need to consider the neurophysiological mecha-
nism.
PEACE and LOVE for Soft Tissue Injury
We are familiar with RICE for handling soft tissue injury.
Rest, Ice, Compression, and Elevation are suggested as
the first treatment of injuries. Over time, other acronyms
have been suggested and added: PRICE, POLICE, MICE,
including ‘Avoid HARM’ (Heat, Alcohol, Reinjury, Mas-
sage). Blaise Dubois and Jean-Francois Esculier from Cana-
da mentioned that RICE and other similar treatments only
focus on acute management but ignore chronic stages of
tissue healing. They proposed two new acronyms for the
rehabilitation of soft tissue injury:
PEACE for immediate care and LOVE for subsequent man-
agement.
P for Protect: avoid activities that can increase pain during
the first few days after injury. Rest should be minimised as
prolonged rest can compromise tissue strength and quali-
ty.
E for Elevate: the limb higher than the heart to promote
interstitial fluid flow out of the tissue.
A for Avoid: anti-inflammatory medications.
C for Compress: external mechanical pressure using tap-
ing or bandages helps to limit intra-articular oedema and
tissue haemorrhage.
E for Educate: therapists should educate patients on the
benefits of an active approach to recovery.
Terra Rosa E-mag No. 22 53
 Research Highlights
After the first days have passed, soft tissues need LOVE: chains:
L for Load: an active approach with movement and exer- • the ventral arm chain (pectoralis major, brachial fascia/
cise benefits most patients with musculoskeletal disorders. biceps brachii, flexor carpi ulnaris/brachioradialis/
supinator, based on five studies);
O for Optimism: the brain plays a key role in rehabilitation
interventions; therapists should encourage optimism on • the lateral arm chain (trapezius, deltoideus, lateral inter-
optimal recovery. muscular septum/brachialis, brachioradialis, four studies);
V for Vascularisation: pain-free physical activity that in- and
cludes cardiovascular components should be started a few • the dorsal arm chain (latissiumus dorsi/ teres minor/
days after injury to boost motivation and increase blood infraspinatus, triceps brachii, anconeus, extensor carpi
flow to the injured structures. ulnaris, six studies).
E for Exercise: to restore mobility, strength, and proprio- There is good evidence for direct serial tissue continuity
ception early after injury. extending from the neck and shoulder region to the fore-
arm.
The authors concluded that despite this intriguing finding,
Effects of myofascial release of the diaphragm on
which could have implications for health professionals and
acid reflux condition the treatment of musculoskeletal disorders, further re-
Gastroesophageal reflux disease (GERD), also known as search is needed to establish the mechanical relevance
acid reflux or heartburn, is a digestive disorder, where of the identified myofascial chains.
stomach acid frequently flows back into the oesophagus,
the tube that connects the mouth and stomach. Current
standard medical treatment includes the administration of
proton pump inhibitor drug (PPIs). Long-term consump-
tion of PPIs can have negative side effects.
A study from Spain looked at the effect of myofascial re-
lease (MFR) of the diaphragm protocol on patients with
acid reflux condition. The study involved 30 patients with
GERD who were randomised into an MFR group or a sham
group. The MFR group received a myofascial release of the
diaphragm protocol consisting of four 25 minute sessions
(twice a week for two weeks).
Results showed that at week 4, patients receiving MFR
showed significant improvements in symptomatology,
gastrointestinal quality of life, and decrease in PPI use
when compared to the sham group. The authors hypothe-
sised that MFR improves diaphragmatic mobility and vis-
ceral fascial mobility. Considering that optimal phreno-
esophageal membrane slip is necessary for correct anti-
reflux barrier function, applying MFR treatment may im-
prove the function of the crura of the diaphragm–
oesophagus sliding component.

Evidence of myofascial chains of the upper limb

Myofascial chains or myofascial meridians describe the
continuity between skeletal muscles and myofascial in-
series. Their presence has been confirmed via scientific
evidence in the trunk and lower extremity. Researchers
Jan Wikle and colleagues try to see if the research litera-
ture has identified the myofascial chain in the upper limb
or shoulder-arm region. The study was published in Clini-
cal Anatomy journal.
The researchers looked through peer-reviewed anatomical
dissection studies reporting myofascial in-series continui-
ty in the upper extremity and found 13 studies. Analysis of
these papers led to the identification of three myofascial

54 Terra Rosa E-mag No. 22