I had the opportunity to take Fascial Manipulation Part 2 recently in Dallas, Texas. I thank Drs. Antonio Stecco and Warren Hammer for sharing their time and expertise in this method, as well as Part 1 in Newark, NJ in April. Fascial Manipulation© (FM) is a technique developed by Luigi Stecco, PT over 30 years and now carried forward by his children, Carla and Antonio Stecco, who are both MDs by training. While Luigi developed this fabulous system of analysis and treatment, his children have taken on the task of further evaluating the anatomy and principles behind Fascial Manipulation©. Their efforts are clear with a quick search of pubmed which produced almost 100 articles during my recent search. New techniques are often copyrighted and taught, but rarely do we see this level of effort go into supporting and explaining the methods. Carla will also again be presenting at the 2012 Fascial Congress.
What is Fascial Manipulation©???
Let’s start with what we know from other sources…. the body moves in complex patterns and the brain activates movements, not individual muscles. We are seeing this concept more readily adopted in the areas of functional assessment and functional training, but have not seen it to any great extent in the soft tissue world. Many techniques are still teaching treatment of individual muscles. (One notable exception is FAKTR.) With the concept of movement patterns in mind Stecco’s Fascial Manipulation teaches movement verification (MoVe) through assessing movements based in each plane of the body (sagittal, frontal, transverse). Dysfunction in these planes is detected and then narrowed to a particular region by limiting the number of regions involved in the MoVe. (This assessment method reminds me of the SFMA breakouts.) Planes are dedicated an abbrevaited as follows: (Sagittal Plane: an-Ante, re-Retro; Frontal/Coronal Plane: le-Latero, me-Medio; Transverse/Horizontal Plane: ex-Extra, and in-Intra). The ‘sequences’ of points drawn through these planes/lines are similar to the lines drawn in Anatomy Trains by Tom Myers, however the detail and clinical application in Fascial Manipulation: Practical Part is much more detailed and clinically oriented.
Fascial Manipulation also simplifies anatomy for us and creates a common language for practitioners around the globe to speak. For example: Any point in the head is known as Caput, abbreviated, cp. Any point in the neck is Collum, cl. (Arm=Humerus=hu; Forearm=Cubitus=cu; Lumbar=Lumbi=lu; Pelvic=Pelvi=pv; Coccyx=cx; etc). There is no differentiation of individual muscles, ligaments, or tendons although reference to these familiar anatomical structures are used to help practitioners learn the Centers of Coordination (cc) which are points of possible densified tissue to be evaluated by palpation and possibly treated and Centers of Perception (cp) which are the areas where symptoms are reported. For example finding the cc or cp referred to as Anterio-Collum (an-cl). [While a bit confusing at first the language becomes second nature quickly.... finding the points on the other hand takes a bit longer.] Finding these points through palpation is the second step in FM. Step 1: MoVe. Step 2: Palpatory Verification (PaVe). The most densified, most painful, or points with the most radiation are compared to MoVe and treated.
In Part 2 of Fascial Manipulation Centers of Fusion (CF) are introduced. From the Fascial Manipulation Workshops website: “While CC points regulate unidirectional muscle fibers of a single mf unit, CF coordinates intermediate muscle fibers, activated during movements between mf units. Luigi Stecco realized that it was necessary to coordinate two or three myofascial units involved in complex global movements where the forces of myofascial units converged. CF will be taught to be used for single segments, along myofascial diagonal and myofascial spirals.”
After MoVe and PaVe assessment, the results of the 2 are compared. Points are selected along the most significant plane. Typically several points (perhaps 3-5) are treated in each session. While the majority of these points will come from the most significant plane, a point or two from the antagonist sequence is also treated, and any relevant CF points can be treated as well. The ultimate goal is balance of the fascial system which is designed to reduce altered stress and strain on joints, reduce symptoms, and improve fascial proprioception contributing to faulty movements.
Intro to Stecco’s Fascial manipulation (youtube video 1min 39sec)
Antonio Stecco – Shoulder Tx (FM Assessment & Treatment with Antonio & Carla 12min 31sec)
Interview with Drs. Warren Hammer & Antonio Stecco (6min 49sec)
An incomplete technique:
Despite the many significant connections, the incorporation of movement patterns analysis in evaluation, and the authenticity of a system that requires test and retest improvement within the same visit (like McKenzie or the Clinical Audit Process), Fascial Manipulation© is an incomplete system. I say this not to detract from the exceptional work of the Stecco family, or to lessen the value Dr. Warren Hammer added by bringing this work to the U.S., but to acknowledge that for many with soft tissue dysfunction FM can serve as a starting point, but not an end point.
Concepts significantly lacking from FM include movement pattern training and failure tolerance. There is an interplay or overlap of these 2 concepts, as you will see below. Research has shown presence of proprioceptors within fascia and it is hypothesized that this plays a significant feedback role in controlling and coordinating movements and I believe it does. However, we fail to acknowledge that movement patterns come in 2 forms; inborn pure patterns and those developed from habit and repetition. Despite removal of densifications in fascia and associated improvement proprioceptive feedback the system does not retrain faulty movement patterns, which are programmed in the CNS, nor does it reactivate the natural inborn movement patterns (see DNS for how this can be done). Allowing someone to continue operating with faulty mechanics will lead to accumulation of stress/strain, eventual crossing of a tissue’s failure tolerance, and then reinjury. Without addressing this component FM is in my opinion an incomplete system. Further, we know that failure tolerance can be increased through appropriately loading of tissue (see Stuart McGill’s work or research on eccentric loading of tendons). Proper levels of strain can increase tissue strength and resilience which alters failure tolerance. Failure to address this component in a previously injured tissue also detracts from the outcomes of FM treatment. A final note on tissue tolerance; incorporation of microbreaks during prolonged or repetitive activities have been shown to have significant impact on how quickly a tissue reaches its failure point. Instruction and education in this principle would also be a nice addition during a course of FM treatment.
For those looking for ways to teach/train appropriate functional movement patterns, to appropriately engage stabilizing musculature, and for patient review of microbreaks you may wish to check out, www.myrehabexercise.com. In addition to instruction, this site can help reduce the time and effort needed to reinforce your in-session training with proper home instruction for your patients. (I had the opportunity to spend some time with the sites creator, Dr. Phillip Snell, during breaks at the Fascial Manipulation 2 seminar, and believe he and I see eye to eye on the addition of these principles to the FM technique.)
To reinforce the concepts above, I present the following analogy. Imagine playing soccer on a field atop a hill. Now let’s imagine that the field shrinks to the size of a basketball court, or indoor soccer pitch if you prefer, or perhaps even smaller. Imagine the challenge of keeping the ball on top of the field and keeping the game going. In FM we are thinking of balancing forward movement (an) with backward movement (re) as well as lateral movement (la) with medial movement (me). The same is true in the oblique directions (ir, ex). If we balance our movements with each plane, like kicking the soccer ball around our small field, it will remain atop the hill and we can continue to play and enjoy our game. When the balance is disrupted, for example too many kicks to one side, the game stops as the ball rolls down the hill. The stoppage of our game would be similar to crossing a tissues failure tolerance or suffering an injury. With FM treatment we can restore balance and get the ball back into the middle of the field, but what prevents this from occurring again? (Remember we’re playing on a small field.) Teaching movement pattern training would be analogous to teaching the players of this soccer game better ball control (they are less likely to have uncontrolled forces or unexpected vectors on their kicks) and the ball will likely stay atop the hill. Therapeutic exercise (such as stability training or eccentric loading) can increase the failure tolerance of tissues, this would be analogous to taking our small field and expanding it back to the dimensions of a standard field (allowing more margin for error and greater forces within the game). By doing either of these we increase the likelihood that the game continues. To review my obscure analogy, the goal of FM is to balance tissue tension, like trying to keep our ball in the center of the field. This technique is well-developed, with emerging research, and clinically applicable concepts. However, trying to keep our ball in the center of the field, without giving significant consideration to training ball control, and ignoring the fact that the field size could be increased, creates a situation where recurrence/reinjury is more likely.
For more information on learning Fascial Manipulation© visitwww.fascialmanipulationworkshops.com