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2 Fascia and the Mind-Body Connection

—David Lesondak
6 Fascial Net Plastination Project – January, 2018
—Francesca Philip
9 There is a Third Layer of the ITB 20
11 Fascial tissue research in sports medicine
12 “Oh Baby – now that’s a scar!” Scar Release & C-sections
—Marjorie Brook, LMT
16 Can We Give Precisely Define Deep Tissue Massage?
20 Michael Phelps’ Forward Head Posture and
Swimmer’s Shoulder
24 Thoracic Hyperkyphosis –
The Critical Component of Upper Crossed Syndrome 28
— Joe Muscolino
28 A Cient-Centered Model of Manual Care
— Walt Fritz
32 Frozen Shoulder: The role of muscle guarding
33 Response from Clinical Anatomist John Sharkey
34 Fascial Manipulation® – Stecco® method:
The practitioner’s perspective
— Julie Ann Day
34
38 The Value of Confidence -Til Luchau
42 Altered patterns of pelvic bone motion determined in
subjects with posterior pelvic pain
44 The Efficacy of Vibrating Rollers
46 Research Highlights
Terra Rosa E-mag No. 21 1
 Fascia and the Mind-Body
Connection
by David Lesondak
2 Terra Rosa E-mag No. 21
T
hat there is a distinct relationship between brain all the way down to the ependyma, where the cere-
thought, emotion, and the body should be ap- brospinal fluid is produced.
parent to anyone involved in the realm of fascia
The individual collagen fibre direction in the pia are unidi-
-oriented bodywork. For some, the idea that we
rectional. Some think it capable of communicating tensile
are actually working with fascia is controversial but for
forces throughout the meningeal network4. And there’s
the purposes of the next 1,420 words let’s accept that we
another intriguing study indicating a relationship between
are doing just that. So what is it about fascia therapies
collagen laxity and anxiety5. This makes me wonder if
that have the potential to induce such strong emotional
there might be a natural level of pre-tension in the brain,
expressions? For as long as I can remember I have been
just as there is in the body.
fascinated by this relationship. And there’s a lot of inter-
esting things out there that begin to explain the pathways Speculation aside, a vital player in this game is a class of
of just how such a thing is possible. cell known as the glia. And the story of the glia has curi-
ous parallels to the story of fascia and the fascial net-
One of the most startling is the existence of the myodural
work6. And in terms of tension, glial cells also possess in-
bridge1,2. The myodural bridge is a literal connection – a
tegrins, the cell receptors that respond to pressure, vibra-
fascial, fibrous, physical connection between the dura
tion, and are linked to the collagen network.
mater and the sub occipital group. Further investigations
reveal the existence of proprioceptive nerve endings in A neurological outlier, glia cells outnumber the neurons
the myodural bridge and suggests both the regulation of nine to one in humans (animals have a lower ratio). They
dural tension and cerebrospinal fluid flow3. were ignored in the early days of neuroscience in favour
of the neuron which were less abundant but far larger. In
Someone, somewhere, said “What you don’t express, you
an interesting example of confirmation bias, in this case
repress.” Repression takes energy. Repression creates
that bigger is better, they were ignored in favour of the
tension. Think back to the last time you really wanted to
neurons. Glia were thought to be inert, mere structural
say something but were afraid, or really wanted give
support and scaffolding for the neurons. Sound familiar?
someone a piece of your mind but didn’t. Was it easy to
modulate your emotions in those circumstances? Did it That changed in the early 1990s when it discovered that
create a fair amount of tension in your body? If you’re not only are the glia not inert, but that they communicate
being honest, I would wager it did. to each other and to the neurons7. Put another way, the
cells previously thought to be the stuffing between the
So lets go into the extreme and think about the physiolo-
neurons are talking to each other. Since then there has
gy of the startle response, particularly the contraction of
been an explosion in glia research, with discoveries that
the neck muscles. And while it is possible, albeit difficult,
they can regulate synaptic activity8, may be essential to
to regulate the startle response, it is considered innate. So
the formation of muscle memory9, and play a role in
innate that it is referred to as the Moro Reflex in newborn
chronic pain10. In fact, prolonged exposure to opioids
babies. Fold in anxiety-induced startle response, PTSD,
cause glia to release pro inflammatory agents11. Glia are
and a dash of fear. We’ve all seen people like that. Is it any
also attributed, by their top researchers, to imbuing the
wonder that when that tension releases, however mo-
body with the ability to move and perform physical tasks
mentary or lasting, that there can be a concurrent expres-
with grace and ease. This too, has a familiar ring.
sion of emotion?
Most of the literature divides the glia into 4 types (though
I’m not suggesting a simple cause and effect here, release
some of the literature will refer to only 3) the one I want
the sub occipitals and release the trauma. If only if were
to focus our attention on is the Schwann cell, the only glia
that easy. We’d all just get a Stillpoint inducer, then Net-
cell to arise from the mesoderm, the same embryological
flix and chill as needed. Life and the body is a little more
layer as our connective tissue.
complicated than that. Let’s go back to the anatomy.
Schwann cells are found in the peripheral nervous system,
The dura mater is part and parcel of the fascial system,
and while there are at least 3 distinct types, the ones that
often specifically referred to as the meningeal fascia. The
hold my interest the most are the perisynaptic Schwann
meningeal fascia covers and interpenetrates the nerves. It
cells (PSCs). PSCs live in the neuromuscular junctions,
includes the dura, arachnoid, and the pia mater. The pia is
where the motor commands of the central nervous sys-
the finest expression of the neural aspect of the fascial
tem are performed. PSCs are considered indispensable to
system, following all the twists, turns, and contours of the
Terra Rosa E-mag No. 21 3
Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436

short-term plasticity in the neuromuscular junction12. It is happily inside them.

here where the Schwann cells interact with fascial mecha-
noreceptors, rather like they do at the myodural bridge.
PSCs are vital to the healthy formation of both Golgi and
Pacini receptors, and where PSCs are absent, these mech-
anoreceptors cannot regenerate after injury. They have an
interdependent relationship13.
Just as we are beginning to map the fascial pathways of
force transmission in the muscles and bones (the muscu-
lobonular system?) so too I believe we are discovering the
pathways that more intimately link our mind, body, and
emotions via the pathway just described.
But corollary is not causation, nor is association attesta-
tion. It is my fervent wish that some researcher(s) some-
where will begin to put some of these pieces together. It
has been my direct experience that glia scientists are igno-
rant of fascia science, and why should it be otherwise?
Our own silos are so deep and rich that it is easy to stay
However, I believe the deeper one digs into the mecha-
nisms between the mind and the body, one is left with the
realization that this unitary relationship is so. That it is
ineluctably interconnected. And while it is useful, even
necessary, to separate and isolate things for study, that
we are irrefutable one. And that the fascia seems to be
the interface of that oneness.
References:
1) Von Lanz T. Uber die Ruchensmarkshaute. I. (1929) Die kon-
struktive Form der harten Haut des menschlichen Ruckenmarkes
und ihrer Bander. (The structural form of the hard skin of the
human spinal cord and its bands). Arch Entwickl Mech Org
118:252–307
2) Khan j l, Sick h and Kortike J G (1992) Les espaces interver-
tébraux postérieurs de la jointure craniorachidienne. Acta Anat
(Basel). 144 (1) 65-70

4 Terra Rosa E-mag No. 21

3) Scali F, Pontell M E, Enix D E and Marshall E (2013) Histological
Analysis of the rectus capitis major’s myodural bridge. The Spine
Journal. May; 13 (5) 558-563
4) Nam MH, Baek M, 2014, Discovery of a novel fibrous tissue in
the spinal pia mater by polarized light microscopy. Connect Tis-
sue Res. 2014 Apr;55(2): pp. 147–155
5) Bulbena A, Gago J, Sperry l, and Berge D (2006) The relation-
ship between frequency and intensity of of fears and a collagen
condition. Depress Anxiety, July;23 (7) 412-417.
intrathecal morphine. J Neurosci. August; 24 (33) 7353–7365
12) Colomar, A, Robitaile, R., Glia Modua Costandi, Mo, (2012),
Snapshots explore Einstein’s unusual brain, Nature News
(online) Nov. 16, 2012
13) Kopp D M, Trachtenberg J T and Thompson W J. (1997) Glial
growth factor rescues Schwann cells of mechanoreceptors from
denervation-induced apoptosis. J Neurosci. September; 17 (17)
6697–6706

6) Lesondak, D. (2017) Fascia and the Brain, Fascia: What it is and

David Lesondak, BCSI, ATSI,
Why it Matters, Handspring Publishing, pp. 87-104
FST, FFT, VMT, is the author of
7) Nedergaard, M, (1994) Direct signaling from astrocytes to the international bestseller,
neurons in cultures of mammalian brain cells. Science, Mar
Fascia What it is and Why it
25;263(5154):1768-71
Matters (Handspring 2017). He
8) Eroglu C and Barnes, B A (2010) Regulation of synaptic activity is a member of the Allied
by glia. Nature. November; 468, 223–231 Health professional staff in the
9) Hassanpoor H, Fallah A and Raza M (2012) New role for as- Department of Family and
troglia in learning: Formation of muscle memory. Medical Hy- Community Medicine at the
pothesis. December; 79 (6) 770–773 University of Pittsburgh Medi-
10) Fields R D (2009) New culprits in chronic pain, Scientific cal Center. A Fascia Specialist in
American. November; 50–57. UPMC’s Center for Integrative
Medicine, David lectures and teaches hands-on course
11) Johnston I N, Milligan E D, Wieseler-Frank J et al. (2004) A
role for proinflammatory cytokines and fractalkine in analgesia, worldwide. For more information
tolerance and subsequent pain facilitation induced by chronic www.fasciamatters.health

Available from www.terrarosa.com.au Terra Rosa E-mag No. 21 5

Fascial Net Plastination Project
– January, 2018
Francesca Philip
There aren’t many reasons to visit Guben, Germany. With
a population of only 1800, the town boasts little in the
way of tourist attractions. In winter, the temperature
rarely reaches positive digits, the streets are slick with ice,
and the dark settles in hours earlier than it should. The
grey sky is rather dull and gloomy. But that’s where I
spent one week in January, my coat pulled up to the tips
of my frozen Australian ears.
Guben was one of the most exciting experiences of my
life.
On my first morning in town, I escaped the cold by step-
ping into a crowded entry foyer. The atmosphere was
6 Terra Rosa E-mag No. 21
festive and bright. Old friends hugged and laughed, pink-
cheeked, while new acquaintances echoed introductions.
Every person had a different accent, a different title. I
found some of my old friends, people I’d worked with on
past projects—my buddy from Singapore, colleagues
from San Francisco. Still, the air was thick with suspense.
See, while Guben has few claims to fame, this building,
the Gunther von Hagan’s Plastinarium, is one of them. All
around us, thousands of plastinated models stood ar-
ranged—hearts, muscles, lungs, bones, all perfectly pre-
served in poses and museum cases. A few rooms over
from the lobby was a laboratory, waiting for the gathered
guests to don lab coats and level scalpels.
Now is probably a good time to mention that all of us had
flown into Guben for a human dissection workshop. Spe-
cifically, the Human Fascial Net Dissection and Plastination
Project. We were anatomy nerds, and we were about to
do more with fascia than anyone had ever done before.
This project was a long time in the making. It took years of
appealing to the Plastinarium before Dr. Robert Schleip
(Germany), a renowned fascial anatomy teacher, was fi-
nally authorized to lead our dissection team at the Guben
laboratory. He and his co-leaders, John Sharkey (Ireland)
and Dr. Carla Stecco (Italy), had a clear purpose: they
wanted to study three-dimensional fascial anatomy on
human bodies in an educational setting. In other words,
they wanted our team to be the first in the world to plasti-
nate fascia. If successful, the pieces produced would be
presented at the Fascia Research Congress in Berlin in
November 2018.
Coming at the workshop from a massage therapist’s point
of view, I was excited that our project would give me an
insight into the mechanisms of the body. For all my work
in anatomy and movement education, I’ve always been
frustrated at the limitations posed by textbook learning.
Even working on bodies from the outside fails to give me
a window into the real processes I’m trying to employ to
heal and help my clients. Only interactive dissection cours-
es have allowed me to appreciate crucial insight into how
the body is really held together.
Of course, not every massage therapist loves the idea of
working with cadavers. Some lack the financial resources
for it; others lack the stomach. And both restrictions are
understandable! But neither should be a barrier to a thera-
pist’s education. That’s why plastination of fascia was a
thrilling idea—finally, we would be able to take one of the
least understood parts of the body out of the lab. With
any luck, we would make fascia more than a buzzword.
We would make it accessible.
Our first day in the Plastinarium lab showed just what a
diverse crew of participants we were. Our ranks included
Photos © Fascial Plastination project.
movement specialists, doctors, coroners, physical thera-
pists, pilates and yoga teachers. John and Robert made it
clear that such a combination was exactly what they’d
hoped for. We were each to bring our passion and unique
skillsets to the dissection table.
After a few introductory lectures, we began to brainstorm
sub-projects. We broached and debated the benefits of
dissecting full iliotibial bands, complete posterior diagonal
lines, and superficial fascia of major joints. Often, the ex-
pert plastinarium staff would weigh in on which proposals
might work and which would leave us with nothing but
chemically-dissolved collagen. Together, we began to
make progress.
By Thursday, the fourth day of the workshop, the steady
thrum of work filled the lab. My group’s original attempt
to render the fascia of the knee had failed. Rendering fas-
cia, a process developed by Gil Hedley, requires you to
dissolve the adipose globules from the structural network
of fibers. After deciding we did not have sufficient time to
produce a rendered piece, I moved from table to table,
lending a hand where I was needed. There were so many
projects that it was dizzying. While Robert had to leave
mid-way through the day, Carla Stecco entered our midst
with fresh passion and focus. With her to help guide us,
no one’s hands were ever idle.
After hours of careful differentiation, I stepped back from
work to take a breath. One of my colleagues did the same.
We gazed at the room, awed by how enthralled everyone
was in their tasks. “It looks like a dissection quilting bee,”
she noted.
I blinked—it really did.
The next morning, my friend Jo Phee and I walked into
the Plastinarium with the bittersweet awareness that this
was our last day. Most of our projects lay completed,
waiting only for the next stage of chemical treatment to
Terra Rosa E-mag No. 21 7
make them permanent. Our final group discussion was
analytical and reflective.
Deep questions arose: if fascia is the new frontier of anat-
omy, would this project contribute to a common good?
Would the information gleaned be of any benefit or inter-
est to humanity? The understanding of the importance of
fascia is so new [if you don’t want what follows, please
add a period after ‘new’], with studies, research and appli-
cations coming from all corners of the globe. Would this
small mission be a first step in doing together what we
could not do alone?
I’d heard it said that if the body is considered the physical
home of the heart and soul, then that would make fascia
the locus of the emotions. Watching my colleagues grow
from strangers to close friends after only one week of
diving into fascial layers, I could only wonder if the spirit
of the fascia somehow strengthened the connections we
made. This group’s profound amount of collective wis-
dom truly inspired me.
That evening, I stood at the train station and waited for
my train back to Berlin. Around me, Guben was much the
same as it was on my arrival—dreary, grey and icy. My
coat was still tucked up to the tips of my Australian ears.
But there was a new fondness in my heart for the little
town. It had given me opportunities I had never thought I
8 Terra Rosa E-mag No. 21
would receive. In its streets, I’d walked with people I nev-
er thought I would ever work with. And in the Plastinari-
um lab, I had contributed to a project that I hoped would
nudge the anatomical world just a little further.
On that platform, I called my husband, back at home in
California. “Enjoy yourself,” he said. “You never know
when you’ll be able to go back to Germany.”
“Oh, I do,” I said.
“You do?” he asked, surprised. “When?”
I grinned. “November, for the Fascia Research Congress.”
Francesca Philip has been in the high-tech industry, and is
now a massage therapist, rehabilitation specialist, group
fitness instructor, personal trainer, and Pilates instructor.
Currently, she is considered a movement specialist. Her
practical experience has allowed her to help seniors, stu-
dents and athletes achieve their wellness and fitness goals.
Fran is an Australian who now lives in Silicon Valley with her
husband, daughter and lifetime collection of “great chats”.
There is a Third Deep Layer of
the Iliotibial Band
A new research from orthopeaedic surgeons from Austria
shows the existence of a deep layer of the ITB.

Fascia Latae and Iliotibial Band (ITB)

The thigh is enveloped in a layer of fibrous tissue known as

the fascia latae, which thickens in the lateral thigh and is
described as the iliotibial band (ITB). The ITB is well recog-
nized as having two layers, one superficial to the tensor
fasciae latae (TFL) muscle, and the other deep to the TFL.
But it is not generally known that the ITB actually has a
third layer that lies deep to its other two layers. Therefore,
the ITB actually has three layers: superficial, intermediate, The deep layer of the ITB. From Putzer, D., Haselbacher, M., Hörmann,
and deep layer. R. et al. Arch Orthop Trauma Surg (2017). https://doi.org/10.1007/s00402
-017-2820-x (Creative Common License)
The ITB

The ITB attaches on the iliac crest and extends distally to

the anterolateral side of the proximal tibia onto an attach- from Austria recently published a study. Their interest in
ment site known as Gerdy’s tubercle. The three layers of the detailed anatomic knowledge derives from their inter-
the ITB fuse in the region of the greater trochanter and
est in minimally invasive total hip arthroplasty surgery.
form the proximal ITB. The superficial layer arises from the
ilium superficial to the TFL, while the intermediate layer The study used ITBs from 20 human cadavers, where both
arises from the ilium slightly distal to the proximal attach- hips were included resulting in 40 measurements with ref-
ment of the TFL and lies deep to the muscle. The superficial erence to the anterior superior iliac spine (ASIS) and the
and intermediate layers of the ITB merge at the distal end tibia. The deep layer of the ITB was exposed up to the hip
of the TFL and serve as the tendon for the TFL. joint capsule, and width and length measurements were
taken. Sections of the deep layer of the iliotibial band were
The ITB is connected intimately with the TFL anteriorly and removed from the hips and the thickness of the sections
the gluteus maximus (GM) posteriorly in the region distal
was determined microscopically after staining.
to the greater trochanter. The ITB is not fixed at the great-
er trochanter, but uses it as a diversion point. The Deep Layer of the ITB

The distal tendon of the gluteus maximus and a major por- The deep layer is a constant structure arising from the su-
tion of ITB intermingle near the gluteal tuberosity on the pra-acetabular fossa between the hip capsule and the ten-
proximal posteromedial femur. don of the reflected head of the rectus femoris. This deep
layer merges into the ITB just distal to where the superficial
However, even though many studies on the ITB have been and intermediate layers of the ITB fuse.
done and much is known, little information in the anatomy
literature is available regarding the (third) deep layer of the The mean maximum thickness of the deep layer was 584
ITB. μm, in other words, a millionth of a meter. Its width was
found to be approximately 3 cm (3.3 ± 0.6 cm). And its
The Austrian Study mean length was found to be approximately 10 cm (10.4 ±
In an effort to better understand the structure of the ITB, 1.3 cm); however, unlike the superficial/intermediate as-
especially its deep layer, a group of orthopaedic surgeons pect of the ITB whose length (50.1 ± 3.8 cm) was found to

Terra Rosa E-mag No. 21 9

 band as an aponeurosis (which according to these authors
is a different connective tissue structure than proper fas-
cia). Such a distinction may indeed be possible when focus-
ing on the previously known superficial portions of the ili-
otibial band only. But not with this newly described third
layer! What I found particularly intriguing in this study is,
that this third layer of the iliotibial band is mostly (in 83% of
the cases ) not connected with the tensor muscle, and of
course also not connected with any gluteal muscle. One
should then ask the question: Are there any other muscular
forces to whose tension this fascial layer will be adapting
its morphology? I would suspect that this could be the ex-
pansional tension of the vastus lateralis, which by contrac-
tion will increase its diameter and thereby stretch the over-
lying fibers of the iliotibial band. While this will also effect
the other two layers of the iliotibial band, the described
independence of this third layer from the usual proximal
muscular extensions puts an additional emphasis on the
importance of the vastus lateralis for the functioning of the
iliotibial band.

For me this is one more reason not to trust standard anat-

omy books anymore, and in this example to expand my
frame of perspective from the usually considered proximal
muscles when treating runners knee or similar iliotibial
band pathologies, and to include additional muscular forc-
es, such as from the vastus lateralis. One more good thing:
be related to the length of the thigh and body, the length
If you run into somebody wanting to fiercely debate for a
of the deep layer of the ITB was instead found to be de-
clear distinction between fascia and aponeuroses, this new
pendent on the length of the TFL.
paper will serve you well in making them ponder about
their clear and righteous distinctions and to possibly in-
crease their acceptance of a more continuation-oriented
Conclusion
fascial net perspective in understanding musculoskeletal
This research study has given more definitive evidence of dynamics. “
not only the existence of the third “deep” layer of the ITB,
but also information regarding its morphology, and by ex-
tension, its function. This deep layer of the ITB acts both as
a second enveloping structure on the deep side of the TFL,
as well as a fascial structure that sits over and stabilizes the
anterior aspect of the hip joint.

What does it mean?

Dr Robert Schleip commented:

“This is another wonderful example that in musculoskele-

tal anatomy almost everything is quite different than we
originally learned from our classical anatomy books; at
least if we stop the century old nonsense of considering
fascia as a mere packing organ and ‚cutting it away‘ in ana-
tomical dissections. For example many standard texts de-
scribe the fascia lata as ‚proper fascia‘ and the iliotibial

10 Terra Rosa E-mag No. 21

Consensus Statement: dependent on the mechanical properties of myofascial tissue linkag-
es. Initial in vivo evidence points towards a significant role of myofas-
Fascial tissue research in sports medicine cial force transmission for the locomotor system. It has also been
shown the existence of (1) remote exercise effects and (2) non-local
Fascial tissues deserve more detailed attention in the symptom manifestations in musculoskeletal disorders.

field of sports medicine. Injury of fascial tissues: cellular and mechanical responses to dam-
age
This consensus statement, published in British Journal of Sport Medi-
cine, was authored by 12 international scientists, including Paul Hodg- Excessive or prolonged loading or direct trauma to fascial tissues
es, Andry Vleeming, Thomas Findley, Robert Schleip and others, This initiates micro and macro changes necessary for tissue repair. These
statement is an outcome of the Second International CONNECT Con- effects may also contribute to pathological changes that modify tis-
ference held at the University of Ulm, Germany in 2017. sue function and mechanics, leading to compromised function of the
healthy tissue. Exercise, physical modalities and pharmacological
Injuries to a variety of fascial tissues cause a significant loss of perfor-
interventions have all been shown to reduce the inflammatory pro-
mance in sports and have a potential role in the development and
cesses associated with fascial tissue injury and fibrosis.
perpetuation of musculoskeletal disorders, including lower back pain.
A major goal of clinicians is to return athletes and patients to activity, Mechanobiology of fascial tissues: effects of exercise and disuse
training and competition after injury. Thus, a better understanding of
Human tendons respond to the application of chronic overloading by
their adaptation dynamics to mechanical loading as well as to bio-
increasing their stiffness and to chronic unloading by decreasing their
chemical conditions promises valuable improvements in terms of
stiffness. The mechanisms underpinning these adaptations include
injury prevention, athletic performance and sports-related rehabilita-
changes in tendon size and changes in Young’s modulus.
tion.
Interventions for fascial tissue pathologies in sports medicine
The consensus statement reflects the state of knowledge regarding
the role of fascial tissues in the discipline of sports medicine and call Foam rolling seems to improve short-term flexibility and recovery
for more research. from muscle soreness and decrease latent trigger point sensitivity.
Nevertheless, the physiological mechanisms remain unclear. Prelimi-
Molecular adaptation of fascial tissues
nary evidence suggests increases in arterial perfusion, enhanced
Molecular crosstalk between extracellular matrix (ECM) molecules fascial layer sliding and modified corticospinal excitability following
and cellular components is an important determinant of fascial tissue treatment. Manual therapies, such as massage, osteopathy or
physiology and pathophysiology. Small functional and structural Rolfing, are frequently used to improve fascial tissue regeneration or
alterations in the ECM result in complex cellular adaptation processes athletic performance, but their efficacy remains to be validated.
and, vice versa, changes in cell function and structure leading to ECM
Finally the authors added that advancing this field will require a coor-
adaptation. Therefore, fascial tissue homeostasis is the result of a
dinated effort of researchers and clinicians combining mechanobiolo-
complex interplay and dynamic crosstalk between cellular compo-
gy, exercise physiology and improved assessment technologies.
nents and the ECM. ECM is affected by ageing, sex hormones and
inflammation. Reference: Zügel, M., Maganaris, C.N., Wilke, J., Jurkat-Rott, K., Kling-
ler, W., Wearing, S.C., Findley, T., Barbe, M.F., Steinacker, J.M., Vleem-
Myofascial force transmission
ing, A. and Bloch, W., 2018. Fascial tissue research in sports medicine:
Experiments showed that intermuscular and extramuscular fascial from molecules to tissue adaptation, injury and diagnostics. Br J
tissues provide a pathway for force transmission, which in part, is Sports Med, http://dx.doi.org/10.1136/bjsports-2018-099308

Components of the fascial system. The fascial system includes large aponeuroses like the first layer of the thoracolumbar fas cia (A), but also a myriad of enveloping containers around and with-
in skeletal muscles (B) and most other organs of the body. The internal structure of fascial tissues is dominated by collagen fibres which are embedded in a semiliquid ground substance. From Zügel et
al. 2018 (CC BY-NC 4.0)

Terra Rosa E-mag No. 21 11

 “Oh Baby – now that’s a scar!”
Scar Release & C-sections

By Marjorie Brook, LMT

According to the World Health Organization1, caesarean (c
-section), rates continue to rise around the world. The
rate in Australia is 33% and in the United States of America
it is 32.2%, which works out to 1-in-3 women2. But no mat-
ter how well-trained the surgeon may be, there will be
scar tissue formation after a C- Section. Scar tissue needs
to form to help the wound heal, but there is a tiny prob-
lem: adhesions. Adhesions occur internally when the
body undergoes severe trauma such as a surgery, inflam-
mation or infection. Unfortunately, most doctors either
fail to disclose or show concern in regard to adhesion for-
mation and a protocol to minimize it and the issues that
can arise from them has never be established.
The most common incision for a C- Section is made hori-
zontally (often called a bikini cut), which is just above the
pubic bone. The incision is cut through the lower abdo-
men at the top of the pubic hair just over the hairline. The
muscles of the stomach are not be cut but they are pulled
apart so that the doctor can gain access to the uterus. In
an emergency caesarean the incision will most likely be a
vertical incision (from the navel to the pubic area) which
will allow a faster deliver. The surgeon also pulls the blad-
der down to protect it during surgery.
Scarring from the incision builds up underneath the inci-
sion as well as in the uterus. As the c-section scar starts to
heal and the uterus reduces back adhesions form.
While it contains the same materials as normal tissue, the
quality of the scar tissue is inferior to that of the tissue it
replaces. It is very important to understand that the scar
that you can see is actually only the tip of the iceberg. All
surgeries involve multiple layers of sutures and go much
deeper than just the visible scar on the surface.
Another significant factor to be considered is the effect of
adhesion formation on the internal organs. The organs
are supposed to slip and slide around each other. Organs
need this movement in order to function properly. When
adhesions are present, the sliding surfaces stick to each
other and drag across one another causing tensional pulls.
The resulting restrictions can cause limited range of mo-
tion and pain in other areas of the body.
It can take up to two years after a surgery or trauma to
fully heal. Pain and issues may not even surface until well
after the Mom has “recovered” from the surgery. Years
can pass and by then, the symptoms may not be associat-
ed with the scar.
Common complaints after a c-section can include sensitivi-
ty of the scar itself and nerves being caught up in the scar
tissue causing itching, hyper or hypo sensitivity. This will
make pants irritating or leaving the Mom unable to feel
anything from the scar to the pubic bone. Leaning over to

Scar tissue after a C Section is not preventable. Scar tissue

is fibrous tissue that replaces normal tissue after an injury.

12 Terra Rosa E-mag No. 21

Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436
pick up baby can be painful. The tensional pull from the
scar may cause postural changes, that along with a de-
crease in the support of the back from the abdominal
muscles could result in back pain. The scarring can cause
the adjacent muscles to develop trigger points that refer
pain to areas like the clitoris or urethra.
There can be issues with lower digestion such as irritable
bowel syndrome or constipation and bloating. Adhesions
around the uterus, bladder and fallopian tubes can lead to
painful intercourse, frequent urination and fertility chal-
lenges.
Let’s not forget the emotional issues that can arise as a
direct result of the scar. There is the self-consciousness
about the appearance of the scar. Some women will not
touch the scar and surrounding area. A simple pull or
pressure on the scar can cause a continual minor or a sud-
den major PTSD reaction. Lack of sleep and mental stress
from chronic pain that doctors do not acknowledge and
family members do not understand can be detrimental.
Scar tissue can have an adverse effect on every one of the
bodies systems. They are interconnected and encased by
the fascia and the smallest of restrictions can cause prob-
lems. The good news is that there is much that can be
done to minimize and correct the issues.
C-section scarring can be improved or corrected altogeth-
er by releasing the tissue and proper therapeutic rehab
(every expecting mother needs to be trained in pelvic
floor exercises for both pre & post pregnancy). As the
scar tissue is release layer by layer, and fibres encouraged
to lay down in the proper alignment, the softer it be-
comes and function can be restored to the tissue sur-
round the area. This reduces tensional pulls and reduces
the adhesions. The tissue needs to be released in all direc-
tions, proper circulation (lymph included), range of mo-
tion restored and body mechanics re-established.
The body needs time to heal, so for the best results light
therapy such as myofasical release and lymphatic mas-
sage can start right after the surgery. Gentle range of
motion stretching and proper body mechanics (how to
feed, pick up and carry the baby etc) should be done in
accordance with the mother’s ability and healing. After
twelve weeks the tissue can be released via the STRAIT
(Scar Tissue Release And Integrated Therapies) Method a
Terra Rosa E-mag No. 21 13
three-dimensional, fascial-release system that works to
minimize scar-tissue development and the subsequent
physiological restrictions. As tissue is forever remodelling
there in no time limit to working on scars. A difference
can be made and balance restored no matter how old the
scar is.

References:
1
World Health Organization http://www.who.int/
2
Centers for Disease Control and Prevention
www.cdc.gov
3
William’s Obstetrics Twenty-Second Ed. Cunningham, F.
Gary, et al, Ch. 25.

Several caesarean sections

“I was fortunate enough to have a massage with Marjorie in
Sydney, Australia on her recent visit. I was astonished by
the immediate results and by Marjorie’s open, giving atti-
tude. Post massage benefits included greater energy, im-
proved posture, a huge sense of release and opening to my
abdomen which had felt frozen after surgery. It was such a
relief. Emotionally I felt noticeably stronger after the treat-
ment.” Deborah S, Australia.
“I found Marjorie after doing a search for a solution to my c-
section scar and pain. She is a miracle worker. After just one
session my scars have flattened significantly and the color
has improved. She has helped with my back pain and sleep-
ing problems. She is also very personable, caring and easy to
talk to. I highly recommend her to anyone that has scars,
surgery, or any kind of pain.” Jennifer G, USA.
Is: supra-umbilical incision
Im: median incision
IM: Maylard incision
IP: Pfannenstiel incision
From: Wikipedia
“As a physiotherapist and practitioner in KMI structural
Integration l have followed the course with Marjorie Brook
about Scar Tissue releases (STRAIT METHOD). In my daily
practice it is evident having knowledge about scar tissues
and skills how to treat them. Understanding the influences
of scars on posture and movement is important not to for-
get to mention the influences scars may have on the psyche.
The course given by Marjorie Brook is helpful to that. Bring-
ing you knowledge, giving you tools to treat, all in her en-
thusiastic way of presentation. “ Harry Hoogenbosch,
KMI Amsterdam, NL.

14 Terra Rosa E-mag No. 21

 SCAR TISSUE RELEASE

Marjorie Brook
World-renowned Scar Tissue Therapist,
the STRAIT method

A Powerful tool
To enhance your Therapy

Find out how to assess fascial restrictions and Discover how to breakdown scar tissues
& adhesions from Superficial to Deep Fascia

• Scar Tissue Release Fundamental: 27-28 April 2019

• Integrated Therapeutic Stretching for the Upper body: 3-4 May 2019
• Scar Tissue Release for the Thoracic Region: 5-6 May 2019

“ Marjorie presented comprehensive evidence-based instruction. This was the first

time I have heard someone combine the physical and emotional impact of scar that
we as therapists see every day - which can be very long lasting and life changing for
many.
Marjorie offered a very clear understanding of the scar tissue, adhesions and chang-
es to connected tissues. When it came to practice at the workshop, you knew ex-
actly what you were working on, in your head, and then your hands had the oppor-
tunity to start feeling the variance and extent of these changes.
We had a range of people with very significant scars who generously allowed evero-
ne to practice new hands on skills. The 2 days allowed for feedback regarding the
emotional impact of the hands on scar release work. Burns, old ( and traumatic)
Caesarian scars, traumatic avulsion scars and skin cancer scars were assessed and
treated over the 2 days. A great learning experience and a great opportunity for
having your own mature scar treated in a comprehensive way. ”
Denis Stewart, Occupational Therapist

I place Marjorie high among the best Stretching Practitioners in the world. She is a cutting-edge teacher, students across the nation rate her as exception-
al.” — Aaron Mattes, MS, RKT, LMT, Pioneer of Active Isolated Stretching
Terra Rosa E-mag No. 21 15

Visit www.terrarosa.com.au for more information

 Can We Precisely Define
Deep Tissue Massage?
With comments by Art Riggs

A recent article published in Journal of Bodywork and Movement Therapies by authors from Is-
rael attempted to objectively define deep-tissue massage to provide an evidence-based therapy.
However, massage therapist and instructor, Art Riggs, commented that gallant as their effort is,
the task of defining deep tissue massage is not only impossible, but is unproductive.

Deep-tissue massage (DTM), is a term commonly used as
a form of “deep” therapeutic massage, but the term was
also used loosely implying many different modalities. It is
unclear what elements define DTM and makes it unique.
Researchers from Department of Physical Therapy in Ben-
Gurion University of the Negev, in Israel attempted to
clarify this by conducting an evidence-based research on
DTM to establish its efficacy and safety. The research pa-
per was published in the April 2018 issue of Journal of
Bodywork and Movement Therapies.
The definition of Deep Tissue Massage
Not surprisingly, the researchers cannot find a commonly
accepted definition of deep tissue massage in the litera-
ture.
Steve Capellini and Michel van Welden in their book
“Massage for Dummies” jokingly gave a non-massage
definition of Deep Tissue as Kleenex stuck deep between
the cushions on your couch.
In massage therapy, some referred DTM as “myofascial
release” (MFR), “trigger point therapy” and
“neuromuscular therapy” while others consider it as the
application of Swedish massage strokes using strong pres-
sure.
Carole Osborne-Sheets in her book Deep Tissue Sculpting
states: “ …. as a generic category, myofascial work in-
cludes sculpting, structural imbalance, self-massage … it
also includes Rolfing, Chua k'a, Lomi-Lomi, Hellerwork,
postural integration, MFR, trigger point therapy …”.
The authors of the paper suggested the term DTM is com-
monly used to describe the intention or aim of the thera-
pist to target a deep tissue by applying a greater pressure
or force. To avoid confusion, they suggested differentiat-
ing the terms “deep massage” and “deep tissue mas-
sage”.
Deep massage can be used to describe the intention of
the therapist to treat deep tissue by using any form of
massage.
Meanwhile, deep-tissue massage should be used to de-
scribe a specific and independent method of massage
therapy, utilizing the specific set of principles and tech-
niques as defined by Art Riggs in his book Deep Tissue Mas-
sage: “The understanding of the layers of the body, and
the ability to work with tissue in these layers to relax,
lengthen, and release holding patterns in the most effec-
tive and energy efficient way possible within the client's
parameters of comfort”.
The authors particularly endorsed Art Riggs’ definition
which has the following principles:
• Slow strokes.
• Diagonal applications (except for treating MTrPs).
• Maintaining depth of treatment according to targeted
tissue.
• Understanding of the differences between deep and
forceful applications.
• Using body weight to generate the force transmitted
through the hands, knuckles or elbows.
• When working on a muscle belly parallel and cross-
fiber strokes should be included.
• Include stretching or activation of muscle.
• Special attention to origin and insertion of muscles.

16 Terra Rosa E-mag No. 21

• The application should be within the client's parame-
ters of comfort (minimally painful or no pain at all).
As for the root techniques, the authors again quoted Art
Riggs (2007) “… deep tissue techniques … are based up-
on broad principles of massage, and must be taught in
that context”. For instance, pressure application can be
perpendicular, oblique or transverse to muscle fibers, de-
pending on the desired outcome, and still be considered
DTM. On the other hand, these principles can be identical
to other forms of massage which are not DTM. They
stressed that techniques are not method-specific.
Evidence-based DTM
The authors from Israel tried to find clinical studies on
DTM. However, they were confounded by the heteroge-
neity of techniques and protocols used in published stud-
ies. The authors listed some studies on Myofascial Trigger
Point treatment, which may be part of DTM, but not nec-
essarily following the principles as stated above.
The authors first evaluated the effect of DTM on heart-
rate and blood pressure. Two studies listed in the review
seem to be interesting and relevant, Cambron et al.
(2006) defined DTM as the intention to access deep lay-
ers. In their case series, it was demonstrated that some
forms of massage can cause a decrease in blood pressure
while others cause an increase. What the authors defined
as DTM did not influence blood pressure. In contrast, trig-
ger point therapy caused a minor increase in blood pres-
sure.
Ce et al. (2013) evaluated the efficacy of five modalities in
recovery after a heavy-duty cycling exercise by using deep
and superficial massage as two of the modalities. Their
definition was based on the intention of the therapist.
Preliminary measurements showed that therapists apply
650 N/m2 for deep massage and 190 for superficial. The
authors found that neither a deep nor superficial massage
influenced recovery rate. They also found that stretching
and deep and superficial massage do not influence blood
lactate levels after heavy-intensity cycle exercise.
The authors found few studies that showed favourable
outcomes from deep tissue massage in pain populations
(such as chronic low back pain).
In particular, a study by Frey Law et al. (2008) used de-
layed onset muscle soreness as a model to evaluate the
efficacy of DTM for “deep muscle pain”. In this study, the
authors demonstrated that both DTM and a superficial
massage were able to reduce hyperalgesia (elevated pain
pressure threshold), but only DTM reduced stretch pain
(with only 11 mm difference between the groups). In this
study, the term DTM was used to describe the intention
to treat deep tissue with the application of “deep knead-
ing”. Few studies also show various forms of DTM can
help patients with decreased range of motion.
Nevertheless, there are several rare serious adverse
events were found related to deep tissue massage, mostly
as a result of the forceful application of massage therapy.
The authors ended the paper by stating “future research
on massage therapy should be based on a common defini-
tion, classification system and the use of common com-
parators as controls.”
Terra Rosa E-mag No. 21 17
Comments by Art Riggs
Author, therapist, and instructor Art Riggs was amused to
find his writings referenced in a scientific article, stating,
"I've forever been confused about what deep tissue mas-
sage actually is, both in my therapeutic work and in teach-
ing." Art further commented:
Two different clients with different issues would probably
have very different definitions of the work.
The authors of the article do a fine job of attempting to
define an unquantifiable skill. Gallant as their effort is, I
feel the task of defining deep tissue massage is not only
impossible, but is unproductive. The line along the contin-
uum between “regular” and deep tissue massage is not
sharp and can’t be clarified by a list of techniques. I re-
member great debate 35 years ago about whether to call
one’s self a massage therapist or a bodyworker, not only
for one’s ego, but as a reason to charge more for doing
bodywork.
An accurate description of the practice should not only
cover the varied eclectic techniques and philosophies that
they list, but also some of the things that exclude work
from being classified as deep tissue massage. I do like the
authors’ distinction between deep massage; (the all-to-
common practice of performing any form of massage
while simply pressing harder) and offering a different
form of therapeutic bodywork called deep tissue massage
based upon advanced training and emphasis upon varied
18 Terra Rosa E-mag No. 21
goals and strategies.
In reality, the term deep tissue is actually misleading;
many of the techniques that they list actually may be per-
formed in other modalities and often treat superficial tis-
sue.
• Superficial fascia release—Ask any Rolfer® or myo-
fascial specialist working with superficial fascia, and they
may strongly deny that they are performing deep tissue
massage, although fascial work is usually involved in deep
tissue protocol.
• Working on superficial muscles such as pectoralis
major; any of the muscles of the rotator cuff; specific mus-
cles of the arm and leg including the IT band; and of
course, dozens of other superficial muscles that need skil-
ful work to align, lengthen, and patiently release adhe-
sions rather than just squeezing.
• Conversely a great amount of the skill of deep tis-
sue massage does, indeed, entail the skill of working
through superficial tissue to access deep restrictions. Ex-
amples would be isolating pectoralis minor deep to pecto-
ralis major, focusing work on the deep rotators under glu-
teus maximus, and flexing the knee to shorten and soften
gastrocnemius for easy access to soleus.
• Accessing deep tissue does not necessarily imply
that the work has to apply a lot of pressure under the “no
pain/no gain” fallacy. Work to deeper layers can be quite
subtle and is different from hard pressure.
The length of this response prevents giving details of spe-
cific techniques, so I will confine myself to discussing the
broader issue of “evidence-based research” which by defi-
nition is constrained by its attempt to control multiple
complex factors of techniques, strategies, variations in
patient symptoms, and therapeutic benefits into strict
parameters to study results. The whole in deep tissue
massage is much more than the sum of the parts.
One could easily add (or subtract) many of the authors’
specific techniques and strokes such as trigger point,
cross fibre friction, stretching, etc. that would fall not only
under the umbrella of deep tissue massage, but other
modalities. Like the clubs in a golf bag, the actual tech-
niques often have less to do with the specific club one
chooses and a lot more to do with the terrain, the actual
symptoms being treated, their causes, the indefinable skill
of touch, intuition and creativity that the therapist uses to
satisfy the needs of the human being behind the symp-
toms. Attempting to strictly control these factors under
the guise of evidence-based research seems futile and
misleading.
It seems crucial to distinguish between a limited academic
list of techniques and the actual practice of giving a deep
tissue massage SESSION in real life, based upon a blend-
ing of the therapist’s skill, the wildly varied public percep-
tion of proper deep tissue therapy, and the individual
needs of the client.
Practical applications
Let’s leave this topic of definition and semantics of deep
tissue massage and discuss some practical applications for
a bodywork practice. The tools and philosophy of a deep
tissue practice are so varied that each practitioner must
be thoughtful about blending their individual expertise
(having an eclectic tool box, but not being a “jack of all
trades/master of none”) and philosophies to satisfy cli-
ents’ varied definitions of a deep tissue massage.
I hear three basic complaints from the public about Mas-
sage:
• By the numbers /one size fits all routines or protocols
for everyone that don’t address the needs of clients,
sometimes called McDonald’s massage.
• Excellent general massage that feels good at the time
but does not address the specific complaints or re-
quest for issues of the client, who often complain, “I
felt good for an hour, and then went back to normal.”
• Deep tissue therapists, mimicking a medical model,
focusing solely on complaints, without a plan for inte-
grating a whole body. This often results in a client
walking out disorganized as the therapist plays hop-
scotch in isolated areas in what Tom Myers and others
call “chasing pain.“ One financial drawback to this type
of practice is that you only see clients when something
is wrong rather than having the rewards of a large
base of grateful regular clients and a consistently full
practice.
I know countless very gratified and successful therapists
who combine very pleasing full body massage while using
specific skills of deep tissue massage on specific areas.
Many clients long for a session that offers the benefits of
relaxation while being a therapeutic part of a health
maintenance program. These therapists consistently re-
port a rewarding full practice of regular clients who love
their work and refer to others.
Terra Rosa E-mag No. 21 19
Michael
Phelps’
Forward Head
Posture
and
Swimmer’s
Shoulder
A recent social media post showed photos of Michael study of high school competitive swimmers showed that
Phelps with rounded shoulders and forward head pos- 72% used pain medication to manage their shoulder pain
ture. Comments were made that there is no such thing as during practice. Nevertheless, there is still a belief among
perfect posture. That all posture is normal, and surely bio- many in the swimming world that shoulder pain is normal
mechanics do not matter. The proof is Phelps who has and should be tolerated to complete practice.
won 28 Olympics medals despite his poor posture. How-
Swimmer’s shoulder is a condition which includes several
ever, such simplistic thinking is problematic.
pathologies including rotator cuff tendinitis, shoulder in-
Phelps’ posture is common in competitive swimmers: stability, and shoulder impingement. Swimmer’s shoulder
head forward, rounded shoulders, flat lumbar spine, hips is a result of several factors such as postural malalign-
forward, and slight posterior pelvic tilt. Swimmers devel- ments, altered scapular kinematics, and muscular imbal-
op strong and hypertrophied musculature of the chest, ances surrounding the shoulder and scapula.
upper back, arms, and shoulders, but not necessarily in
Stephanie Lynch and colleagues in an article2 commented
balance and not necessarily in all other parts of the body.
that forward head posture can cause muscular imbalances
Muscle imbalance can caused swimmer’s shoulder, which
and may change the position of the scapula and decrease
is prevalent in competitive swimmers.
the ability of the scapula to rotate upwardly, a common
Note that swimmer’s shoulder is also often written as characteristic found in patients with shoulder impinge-
swimmers’ shoulder. ment. Upward rotation of the scapula is necessary to in-
crease the space between the head of the humerus and
A 2017 review published in British Journal of Sports Medi-
the acromion process above. Shoulder impingement syn-
cine1 stated that a large number of shoulder revolutions in
drome usually involves the distal tendon of
swimmers could easily overload soft tissue structures
the supraspinatus, the subacromial bursa (also known as
around the shoulder which lead to pain during daily activi-
the subdeltoid bursa), and the long head of the biceps
ties, swimming, and at rest.
brachii.
Competitive swimmers practice 6-7 days a week with an
Rounded shoulder posture is associated with a protracted
average swim being up to 14,000 meters each day, which
position of the scapula, caused by a muscular imbalance
requires up to 16,000 shoulder revolutions per week1.
between a shortened pectoralis minor and a lengthened
There is a price to pay for this. One study found that 47%
rhomboids and middle trapezius muscles. This condition
of collegiate swimmers experienced shoulder pain persist-
increases anterior scapular tilt (also known as upward tilt
ing for three weeks or more, causing eventual alteration
in which case the inferior angle of the scapula lifts up
or cessation of their normal swimming routines. Another
away from the thoracic rib cage wall) and scapular inter-

20 Terra Rosa E-mag No. 21

nal rotation (also known as lateral tilt in which case the
medial border of the scapula moves away from the tho-
racic rib cage wall), which are associated with shoulder
impingement. These altered scapular mechanics create
shorter pectoralis minor length and decreased serratus
anterior and lower trapezius activity.
3
In addition, another study found that swimmers had sig-
nificantly greater decreased subacromial space distance
during the training season compared with non-overhead
athletes. Decreased subacromial space will likely predis-
pose the person to have shoulder impingement syn-
drome.
Lynch’s 2010 study2 examined a program to correct the
forward head posture of 28 elite swimmers. The program
consisted of an 8-week stretching and strengthening pro-
gram aimed at correcting the posture. The strengthening
exercises targeted the periscapular muscles (muscles
around the scapula) with an emphasis on scapula stabili-
zation. The stretching intervention was aimed at increas-
ing the flexibility of the pectoralis musculature and cervi-
cal neck extensors. The results showed that the exercise
intervention successfully decreased forward head as well
as the rounded shoulder postures in elite swimmers.
Shoulder function, although not statistically different fol-
lowing the intervention, demonstrated a trend toward a
decreased level of perceived shoulder pain and dysfunc-
tion.
The 2017 review1 looked at musculoskeletal dysfunctions
associated with swimmer’s shoulder and found that:
• Swimmers combine endurance, strength, flexibility,
and control repetitively.
• High levels of training easily overload soft tissue struc-
tures around the shoulder and lead to pain and
• Swimmer’s shoulder pathophysiological factors include
reduced endurance, incoordination or weakness of the
shoulder muscles, a lack of scapular stability, poor pos-
ture, and lack of core stability.
The authors summarized differences in musculoskeletal
function in swimmers with and without shoulder pain in
the table below.
Specifically, the review identified that:
• Reduced shoulder and core trunk endurance are pre-
sent with swimmers who reported shoulder pain, but it
is unclear if poor endurance is a cause or effect.
• Swimmers with shoulder pain showed an increase in
glenohumeral motion in the form of laxity and instabil-
ity. It is unclear whether laxity predisposes swimmers
to pain or if it occurs in symptomatic swimmers be-
cause of cumulative microtrauma.
• Swimming may alter scapular position, but it is unclear
if these changes are related to the development of
shoulder pain.
• Forward shoulder posture due to an anteriorly tilted
scapula may play a role in the development of shoulder
pain in swimmers.
Terra Rosa E-mag No. 21 21
• Alterations in shoulder rotational and flexion ROM are
seen in swimmers with shoulder pain but cannot be
concluded that these deficits are a risk factor for devel-
oping shoulder pain.
Comments by Joe Muscolino
All in all, yes, many elite athletes can have poor posture;
another example is that Usain Bolt has scoliosis. And cer-
tainly there is no such thing as a perfect posture. But this
does not mean that postural distortion patterns from re-
peated use, overuse, misuse, and abuse are healthy ei-
ther. Elite athletes suffer a high degree of injuries.
Further, certain distortional posture patterns may be un-
healthy for regular life or for certain activities, but per-
haps not for the sport that excessively demands that pat-
tern and therefore causes it. For example, the rounded
trunk and shoulder posture (Vladimir Janda’s upper
crossed syndrome) that may be caused by excessive cy-
cling is likely not a functional deficit for cycling itself be-
cause that is the posture required for that sport (although
because of the excessive stress and demand on certain
tissues, it might cause pain in time). So, harking back to
the initial comments of this blog post article that men-
tioned someone stating that bad posture cannot matter
because Michael Phelps was able to win all those medals
with his bad posture, it is worth pointing out that perhaps
if Michael Phelps were to try a sport that required more
trunk extension and shoulder retraction and lateral rota-
tion, he might not fare as well as someone who did not
have his posture.
But an old saying said: “There is no such thing as a bad
posture, as long as you don’t get stuck in it.”
The problem is that remaining in a certain posture for ex-
tended period of the time does tend to get us stuck in
22 Terra Rosa E-mag No. 21
that posture because of neural facilitation, from the brain,
that causes increased muscle tone (tightness) in certain
muscles. And because of fascial adhesions. Both of these
factors would likely lead to decrease potential for move-
ment in the opposite direction because of the lack of soft
tissue flexibility.
The Role of Manual and Movement Therapy
Manual and movement therapists can help these athletes
improve their structural balance. Therapists may not “fix”
the postural distortion pattern, but therapists might be
able to provide balanced muscle tone across joints,
whether it is across the shoulder joint complex in swim-
mers, or other joints for other athletes.
From an overview of all the available evidence-based re-
search, as well as a common-sense approach of critical
thinking applied to fundamental principles of soft tissue
and bony biomechanics, creating more balanced muscula-
ture and therefore a more balanced musculoskeletal pos-
ture just might help reduce the incidence of pain and inju-
ry in athletes. It certainly should decrease dysfunction!
References
1
Struyf, Filip, Angela Tate, Kevin Kuppens, Stef Feijen, and Lori
A. Michener. "Musculoskeletal dysfunctions associated with
swimmers’ shoulder." Br J Sports Med (2017): bjsports-2016.
2
Lynch, Stephanie S., Charles A. Thigpen, Jason P. Mihalik, Wil-
liam E. Prentice, and Darin Padua. "The effects of an exercise
intervention on forward head and rounded shoulder postures in
elite swimmers." British journal of sports medicine44, no. 5
(2010): 376-381.
3
Hibberd, Elizabeth E., Kevin G. Laudner, Kristen L. Kucera, Da-
vid J. Berkoff, Bing Yu, and Joseph B. Myers. "Effect of swim
training on the physical characteristics of competitive adoles-
cent swimmers." The American journal of sports medicine 44, no.
11 (2016): 2813-2819.
Differences in musculoskeletal function in swimmers with and without shoulder pain (From Struyf et al.
2017)

Shoulder muscle performance

Muscle activity during freestyle swimming Less activity of Upper Trapezius, Rhomboid, Anterior Deltoid,
Middle Deltoid (hand entry);
less activity of Serratus Anterior; higher activity of Rhomboid
(pulling phase); less activity Subscapularis (mid-recovery)
less activity of Anterior Deltoid and Middle Deltoid; higher activ-
ity of Infraspinatus (hand exit);
Muscle activity during breaststroke swimming Less activity of Teres Minor; higher activity of Subscapularis
(pulling phase); less activity of Middle Deltoid, Upper Trapezius,
Subscapularis; higher activity of Infraspinatus (mid-recovery)
Muscle strength Tendency of reduced Internal Rotation strength

Muscle endurance at the shoulder Less abduction and external rotation endurance

Core endurance Less core endurance

Shoulder range of motion Higher (≥100°) or lower (<93°) External Rotation ROM;
Reduced shoulder flexion and Internal Rotation ROM
Laxity and instability Greater Glenohumeral laxity and instability

Shoulder posture Greater posterior humeral head position; shorter pectoralis mi-
nor
Scapular dyskinesis Tendency to greater incidence of scapular dyskinesis; decreased
scapular upward rotation after swim practice

Terra Rosa E-mag No. 21 23

Thoracic Hyperkyphosis –
The Critical Component of Upper
Crossed Syndrome
Joe Muscolino

Upper Crossed Syndrome and Thoracic Hyperkyphosis

The postural distortion pattern known as upper crossed
syndrome has many components to it. It involves:
• thoracic hyperkyphosis
• hypolordosis of the cervical spine
• hyperextension of the head upon the atlas at the at-
lanto-occipital joint
• forward head carriage
• protraction of the shoulder girdles
• medial (internal) rotation of the arms at the gleno-
humeral joints.
Each and every one of these components is important in
and of itself, and can cause pain and dysfunction. But for
many clients, one of these components, thoracic hy-
perkyphosis, is the primary critical component, and if not
sufficiently addressed, will lead to failure to improve the
rest of the pattern.
Thoracic Hyperkyphosis
I would propose that the critical, the essential, compo-
nent of upper crossed syndrome is thoracic hyperkypho-
sis. At least for middle-aged and senior clients, this is the
primary postural distortion that usually drives all the rest
of the postural distortions of this larger distortion pat-
tern. And if not treated, will lead to failure to achieve any
lasting improvement for our clients who present with this
condition. Following are the steps by which thoracic hy-
perkyphosis causes the rest of the postural distortion pat-
tern to occur. Upper and Lower Crossed Syndromes. Permission Joseph E. Muscolino. Art-
work: Giovanni Rimasti.
Hypolordosis of the Cervical Spine
The cervical spine sits on the top of the thoracic spine.
The superior surface of T1 acts like the pedestal upon a curve of extension, a hypolordotic neck is in greater flex-
which the cervical spine rests. If the angle of T1’s superior ion.
body changes due to thoracic hyperkyphosis, the curve of This posture results in increased loading of the cervical
the cervical spine must change. When the thoracic spine is discs (the more anterior of the spinal joint complex). In-
hyperkyphotic, the superior surface of T1 becomes much creased loading increased compression and the likelihood
more vertical than with a healthy thoracic posture. As a of disc pathology. Posteriorly, cervical flexion opens up
result, C7 of the cervical spine must begin being projected the facet joints, which places them in a less stable pos-
much more anteriorly, and the rest of the cervical spine ture, decreasing the ability of the cervical spine to absorb
follows the kyphotic posture of the thoracic spine, there- weight bearing shock forces that occur with each step we
fore being less lordotic, hypolordotic. Because lordosis is

24 Terra Rosa E-mag No. 21


Anterior (Forward) head carriage, Permission Joseph E. Muscolino. Artwork:
Giovanni Rimasti.
take. Further, a hypolordotic, flexed cervical spine leads
to adaptive shortening of the flexor musculature of the
neck: scalenes, longus muscles, and the sternocleidomas-
toid.
Hyperextension of the Head at the Atlanto-Occipital Joint
So now we have thoracic hyperkyphosis leading to hypo-
lordosis of the lower and middle cervical spine. When the
lower and middle cervical spine is hypolordotic, the head
would not be level – the eyes would be oriented down-
ward toward the floor, which would make it difficult if not
impossible to see where we are going. Further, the inner
ears would not be level making it more difficult to judge
Sternocleidomastoid – Permission Joseph E. Muscolino. The Muscular System Manu-
al – The Skeletal Muscles of the Human Body, 4th ed. (Elsevier, 2017).
proprioception (our ability to sense our position in space
and our movement through space). To compensate for
this hypolordosis of the lower and middle cervical spine,
the posture of the head at the AOJ must become hyperex-
tended, in effect, hyperlordotic. This results in jamming of
the facet joints, increasing the weight-bearing load upon
them. By Wolff’s law (calcium is laid down in response to
physical stress), the osteoarthritic process would likely be
accelerated. This also allows for adaptive shortening of
the upper cervicocranial extensor musculature in the sub-
occipital region (e.g., rectus capitis posterior major), lead-
ing to hypertonicity and myofascial trigger points. Fur-
ther, the increased pull of these muscles upon the scalp
increases the chance of the client developing tension
headaches. The increased extension of the head at the
atlanto-occipital joint also leads to a constant stretching
pull upon the suprahyoids, which can lead to increased
tension stresses upon the temporomandibular joints
(TMJs), which can lead to TMJ syndromes.
The Sternocleidomastoid
When we look at the adaptive shortening of cervical spi-
nal musculature as part of upper crossed syndrome, the
sternocleidomastoid (SCM) is particularly relevant. The
SCM crosses the lower and middle cervical spinal joints
anteriorly so it flexes the lower and middle cervical spine.
But it crosses the upper cervical spinal joints, especially
the atlanto-occipital joint, posteriorly, so it extends the
head at the AOJ. For this reason, the SCM is adaptively
shortened and tightened with both the hypolordosis of
the (lower and middle) cervical spine and with the hyper-
extension of the head at the AOJ.
The Chicken and the Egg
By the age-old wisdom of the chicken and the egg, once a
postural distortion results in adaptive shortening of mus-
culature, in other words, locked-short musculature. This
increased muscle tightness then plays back on the skeletal
postural distortion, in effect, locking it in place. The skele-
tal postural distortion causes the tight musculature, which
causes the skeletal postural distortion – the chicken and
the egg.
Forward Head Carriage
Now that thoracic hyperkyphosis leads to the lower cervi-
cal spine being hypolordotic, the head is projected anteri-
orly to the body so that instead of its center of weight
being balanced over the trunk, it is imbalanced over thin
air. This should result in the head and neck falling into
flexion (until the chin essentially hits the chest) due to the
force of gravity, unless some force opposes this move-
ment. That force will likely be isometric contraction of the
cervicocranial extensor musculature in the back of the
neck (e.g., upper trapezius, splenius capitis, semispinalis
capitis, etc.,). This leads to use, overuse, misuse, and
abuse (a la Leon Chaitow’s famous verbiage) of these
muscles, leading to tightness, and likely myofascial trigger
points, pain, and dysfunction.
Protraction of the Shoulder Girdles
Returning now to the upper extremity, when the spine
Terra Rosa E-mag No. 21 25

Thoracic Joint Mobilization into Extension. Permission Joseph E. Muscolino.
rounds forward into thoracic hyperkyphosis
(hyperflexion), the natural pull of gravity on the shoulder
girdles (scapulas and clavicles) is to make them fall for-
ward, in other words, protract. Protracted shoulder gir-
dles result in shortening (locked short) of the protractor
pectoralis musculature and lengthening (locked long) of
the retractor musculature (rhomboids and trapezius, es-
pecially the middle trapezius). Beyond causing the crea-
tion of myofascial trigger points, a tight pectoralis minor
can also cause pectoralis minor syndrome version of tho-
racic outlet syndrome, resulting in neurovascular com-
pression of the brachial plexus of nerves and/or subclavi-
an/axillary artery and vein.
Medial Rotation of the Arms
When the thoracic hyperkyphosis leads to to the shoulder
girdles falling forward into protraction, they also fall in-
ward, leading to increased medial (internal) rotation of
the arms at the glenohumeral joints. Beyond shortening
the pectoralis major (and latissimus dorsi and teres major)
musculature, and stretching the infraspinatus and teres
minor, leading to locked short and locked long muscula-
ture with all of its effects as previously explained in this
article, all overly shortened and overly lengthened mus-
cles become weaker by something known as the length-
tension relationship curve. Also, with a medially rotated
posture of the head of the humerus, the lesser tubercle
would now be lined up with the acromion process during
abduction of the arm, leading to the increased likelihood
of impingement syndrome of the distal tendon of the su-
praspinatus and subacromial bursa when the arm is raised
into abduction. There, upper crossed syndrome can even
lead to shoulder tendinitis!
Putting it all Together
Putting all this together, upper crossed syndrome can
result in many “fires” that need to be put out all around
the body with competent manual therapy, as well as com-
petent movement therapy (strengthening and stabilizing,
26 Terra Rosa E-mag No. 21
etc.,)…
HOWEVER, the critical component that usually drives all of
this postural distortion pattern is the thoracic hy-
perkyphosis / hyperflexion. At least this is almost always
the case with middle-aged and older clients.
Solution?
So what is the solution? What is the critical component?
Whatever manual and movement therapy is necessary to
lessen the thoracic hyperkyphosis. Most every manual and
movement technique can have great value here, especial-
ly those oriented at stretching the anterior tissues and
strengthening the posterior tissues, but I would like to
propose one specific technique, that if left out, at least in
most of our middle-aged and older clients, will result in a
futile attempt to ameliorate this condition. That is joint
mobilization of the thoracic spine into extension. We
must introduce extension motion into the facet joints of
the thoracic spine and it must be specifically targeted to
reach the joints that are hypermobile. This usually requires
very specific application of force, in other words, joint
mobilization. General stretching of the spine into exten-
sion with a client who has rigid thoracic joints stuck in
flexion will usually result in the person initiating the move-
ment from the joints of the spine that can move into ex-
tension. This will often be the lumbar spine (or perhaps
some thoracic spinal joints that are mobile and compen-
sating for the hypomobile rigid joint levels). Thus we have
the typical hypomobile tissues being allowed to persist
due to the compensatory hypermobile tissues. Treatment
must specifically target the hypomobile joints, hence joint
mobilization technique. Joint mobilization can be done
Grade IV (slow oscillations) or Grade V (fast thrust). The
application depends on your licensure and technical ex-
pertise. Please always stay within your legal and ethical
scope of practice.
The point of this article is to make the case that for most
of our clients who present with the postural distortion
pattern known as upper crossed syndrome, it is im-
portant, perhaps absolutely necessary, to include thoracic
spinal joint mobilization technique into extension as part
of the treatment plan to address the thoracic hyperkypho-
sis.
 Clinical Orthopedic
Massage Therapy
with Dr. Joe Muscolino

The Neck Joint Mobilization

Clinical Orthopedic Manual Therapy (COMT) for the Neck
covers the major clinical orthopedic assessment and treat-
ment techniques for the neck.
31 May-1 June 2019
This workshop covers motion palpation and joint mobilisa-
tion of the entire spine (cervical, thoracic, and lumbar) as
well as the sacroiliac joint and rib cage. The essence of a
joint mobilization is to stretch the arthrofascial intrinsic
tissues of the joint (ligaments, joint capsules, short deep
muscles) . A Valuable hands-on workshop
2-3 June 2019, Sydney.

ATMS, AMT, Approved CPE/CEU

Points
Don’t miss this unique experience to
train with Dr. Joe Muscolino.
"Joe Muscolino is a master of his profession! His broad
knowledge on the human body and extensive experience
made the workshops interesting and engaging. I would
highly recommend his workshops to anyRosabody-worker.
E-mag No. 21 27 I,
Terra Rosa e-magazine, No. 11 (December 2012) Terra
myself, can't wait for the next one!" Zuzana G, North Syd-
ney.
A Client-Centered Model
of Manual Care
By Walt Fritz, PT

The application of manual therapy and myofascial release
differs between providers, sometimes quite dramatically.
Most approaches seem to rely on the expertise of the
therapist to determine what is “wrong” and apply the
treatment that their training and education has shown to
be the correct path. Clients typically allow and even ex-
pect this model, having come under the assumption that
the therapist is the “expert” and knows what is best.
Even though this scenario often pans out the way it was
intended, I see a few flaws with this model.
My biggest concern is the massive amount of variation in
the way therapists (and health professionals in general),
have been trained and what they view as the problem, or
cause. Invariably the therapist claims the problem to be

28 Terra Rosa E-mag No. 21

the target of their training, whether trigger points, fascial
restrictions, knots, etc., with little regard for the lack of
outward validity of these targets. The lack of outside va-
lidity calls into question reliance on claims made.
My second issue is the amount of impressionability owned
by most clients. They want to believe us and our claims,
hoping that we have the answers to their issues, so much
so that they can quite easily be led astray. I am not making
accusations that therapists are purposely misleading; I am
simply stating that all might be better served if we backed
off on our claims. I try to ask myself, “Would my claims be
accepted by the larger scope of the medical profession?”
If not, I try to soften my claims. For instance, my evalua-
tion findings often concluded that fascial restrictions in
the area in question were to blame for the client’s pain.
But understanding that fascial restrictions are (1) not ac-
cepted as actually occurring in the manner taught to me,
and (2) there is fully acceptable proof that we can singu-
larly and selectively impact such fascial restrictions to the
exclusion of other tissues, I no longer speak in such terms.
What might I say? While I accept the concepts and under-
standings of pain science, I also understand that many of
those concepts stray far from what a client expects to
hear. As such I will negotiate a conversation and language
that is not misleading or pathologizing but still gives them
a simpler answer. I give them answers of what might be
possibly contributing, such as, “you may have tightness
within the soft tissue creating a situation of pain, or your
nervous system may not have allowed a return to your
previous state after whatever injury happened.” I may
allude to what they believe, even if I do not agree, but I
quickly turn the conversation around to what they are
feeling, vs. what I am thinking. Read through the infor-
mation below to see if you can understand my approach. I
wrote it in a format I will be sharing with clients in my
physical therapy/manual therapy practice, so feel free to
adapt it for your purposes.
Walt Fritz, PT’s Foundations Approach to Evalua-
tion and Treatment
I follow a rather novel way of performing an evaluation
and applying the treatment, one that requires much more
input from you, my client. I need your input in determin-
ing such things as whether or not my input (stretching,
pressures, etc.) feel like they would be helpful, hurtful or
neither. I cannot know what you are feeling unless I ask/
you tell me and I rely very strongly on this feedback in
making treatment decisions. The need for feedback will
most probably exceed what health professionals have
asked you in the past, allowing you (or making you) con-
tribute much more to the process. If you are expecting to
have me make all of the decisions, then our therapeutic
relationship may not work out.
• Before I begin, I will fully explain the purpose of the
session or technique and of my hand placement, followed
by obtaining permission.
Terra Rosa E-mag No. 21 29
• I begin in the area of complaint. Many therapists may
try to convince you on the belief that your pain stems
from issues (or causes) elsewhere in the body. While this
could theoretically be true, I will begin where you feel
your symptoms.
• I will lightly place my hand/hands on the area, but I ini-
tially do nothing. This slow introduction allows you to de-
termine if my touch feels safe to you.
• If my touch feels safe, I will begin by adding graded
pressures and stretch, trying to seek out areas of tight-
ness.
• If I find tightness (or similar), I will lightly add a bit more
pressure or stretch (what I term, “snagging the area”) to
the area, to bring about awareness.
• If you’ve not already given feedback, I will ask, “Am I
reproducing a sensation that is familiar to you?”
• If you note nothing, I may linger a bit unless sensation is
too negative. This lingering allows you time to process,
but if nothing about the pressure, stretch, etc. is familiar,
then I will move on.
• If I did replicate a familiar feeling, I would use the 0-10
pressure/pain scale to determine the intensity of the sen-
sation, followed by 0-10, “At what number would you
stop me?” You determine the pressures that you feel
would be helpful, without me influencing your decision.
• A will adjust pressures according to your feedback.
• I may then ask, “Does this stretch feel like it might be
helpful or useful?”
• If you respond to the previous question with, “yes,”
then I will remain in the area and treat.
30 Terra Rosa E-mag No. 21
• If you respond to the previous question with, “no,” I
will ask, “Is there anything about this stretch that feels
like it might be harmful?” If you believe it might, I will im-
mediately stop.
• If all feels right to you and you feel that my stretch,
pressures, or intervention feels like it might be helpful, my
therapy involves me holding a slow, static stretch for long
periods of time with the goal of reducing your pain or
helping you to improve your functional abilities. It is a very
dynamic back and forth process between the two of us. I
will require you to stay aware and present throughout the
session, and I may repeat my questioning on numerous
occasions throughout the session(s). Please remember, I
cannot know what you feel unless I ask, and I will always
ask. I will stop on occasion to allow you rest and to move
a bit to see what you are feeling. The goal of my treat-
ment is to allow you to move more freely, with less pain
or difficulty. I will typically follow-up with functional activi-
ties and home stretching or activities, as appropriate.
Walt Fritz, PT will be his client-centered, science-informed
version of myofascial release in Sydney, NSW during August
of 2019, with
MFR for Neck, Voice, and Swallowing Disorders on 7-8 Aug
2019
MFR for the Upper Body: 10-11 August 2019, and
MFR for the Lower Body: 13-14 August 2019.
Full details and registration at: www.terrarosa.com.au
You may contact Walt at walt@myofascialpainrelief.com.
 Foundations in Myofascial Release
with Walt Fritz
Neck, Voice, and Swallowing Disorders: 7-8 Aug 2019
The Upper Body: 10-11 Aug 2019, Sydney
The Lower Body : 13-14 Aug 2019, Sydney

This foundational course presents an in-depth introduction to a

client-centered, science-informed version of myofascial release.
Walt Fritz PT is a physiotherapist with a private practice in Rochester, NY
USA and head of the Foundations in Myofascial Release Seminar™ Series..
Walt has taught his version of MFR with a sense of humour and humility
throughout the USA, Canada, the U.K., Jamaica, and now Australia.

“Wow what an amazing course . Walt was an amazing instructor, knowledgeable,

approachable and very helpful to help us achieve our learning goals. Walt made
sure that we got the MFR technique and understood how to apply it to practical
situations. I have been able to apply my new skills learnt and have had positive out-
comes for my clients. “ Lisa, Newcastle, AU.
Visit www.terrarosa.com.au for registration & detailed information
Terra Rosa E-mag No. 21 31
Frozen Shoulder:
The role of muscle guarding
Frozen shoulder, also called adhesive capsulitis, is a com-
mon shoulder condition characterised by the pain and
stiffness in the shoulder. It causes a restricted range of
motion (ROM) at the shoulder.
Frozen shoulder’s pain is reported to be worse at night,
and is aggravated by sleeping on the affected shoulder
often leading to the patient waking up several times a
night. This condition tends to afflict individuals who are
aged 40 and over and is more predominant in diabetics
and people who have suffered a stroke, thyroid disease,
recent surgery or Parkinson’s disease.
Although spontaneous recovery can be expected in some
cases, the average length of symptoms is 30 months. As
the name suggests, it was thought to be caused by shoul-
der capsule chronic inflammation and fibrotic adhesion of
connective tissues surrounding the glenohumeral joint.
However, the pathoanatomy of this condition is not yet
fully understood.
Researchers from Australia conducted a preliminary cross-
sectional observation study to investigate if muscle guard-
ing caused movement restriction in patients with idio-
pathic frozen shoulder. The study was published in the
October 2018 issue of Musculoskeletal Science and Prac-
tice.
32 Terra Rosa E-mag No. 21
Five patients with painful, global restriction of passive
shoulder movement volunteered for this study. The pa-
tients were scheduled for capsular release surgery for
frozen shoulder. Passive shoulder abduction and external
rotation range of motion (ROM) were measured before
and after the administration of general anaesthesia.
The observation showed that passive abduction ROM in-
creased following anaesthesia in all participants, with in-
creases ranging from approximately 55°–110° of pre-
anaesthetic ROM. Three of these participants also demon-
strated substantial increases in passive external rotation
ROM following anaesthesia ranging from approximately
15°–40° of pre-anaesthetic ROM.
See the video here https://twitter.com/LuiseHollmann/
status/1017339041803481088
This case series of five patients with frozen shoulder
demonstrates that active muscle guarding, and not capsu-
lar contracture, may be a major contributing factor to
movement restriction in some patients who exhibit the
classical clinical features of idiopathic frozen shoulder.
These findings highlight the need to reconsider our under-
standing of the pathoanatomy of frozen shoulder.
 (Sharkey. 2017) or changes in fascial densification (Pavan,
Response from Clinical Anato- et al. 2014). While this brief response does not provide the
mist John Sharkey to article on opportunity to discuss this important topic in comprehen-
sive detail it does provide the opportunity to highlight the
frozen shoulder following need to investigate every option in terms of therapeutic
interventions and not assume we have had the only word
anaesthaesia or the last word on frozen shoulders.

This is a most interesting observational cross-sectional References

study providing results that, while based on a small cohort Latremoliere A., Woolf C. J. (2009). Central sensitization: a
of patients, calls into question the current assumptions generator of pain hypersensitivity by central neural plas-
concerning this painful and life impacting “syndrome”. ticity. J. Pain. 10, 895–926. 10.1016/
The results identified in this observational study call for a j.jpain.2009.06.012 [PMC free article] [PubMed] [Cross
larger investigation. As a Clinical Anatomist I have had a Ref]
special interest in the topic of Frozen Shoulder, or adhe-
sive capsulitis, for over three decades. Pavan, PG., Stecco, A., Stern, R., Stecco, C. 2014. Painful
connections: densification versus fibrosis of fascia. Curr
Adhesive capsulitis infers that the joint capsule of the Pain Headache Rep. 18(8):441.doi:10.1007/s11916-014-0441-
shoulder has adhesions and inflammation thereby limiting 4
the motion available at the shoulder or glenohumeral
joint. While this condition is common, its underlying origin Sharkey, J. 2017. The Concise Book of Dry Needling: A
is not well understood. This condition is more common in Practitioner's Guide to Myofascial Trigger Point Applica-
females than in males. The non-dominant shoulder is tions. North Atlantic Press
more affected than the dominant shoulder.
The arm generally and the glenohumeral joint specifically John Sharkey MSc.
is a highly mobile and complex anatomical structure Clinical Anatomist (BACA)
providing the widest ranges of motion of any joint in the Anatomical Society (Full Member)
body. When I am teaching anatomy via cadaveric dissec- Exercise Physiologist (BASES)
tion I instruct students not to open the shoulder of cadav- BioTensegrity Interest Group (Founding member)
ers until I am present at the table. In over thirty years of Dry Needle Trigger Point Specialist
teaching anatomy and having performed many hundreds Senior Lecturer and Programme Leader MSc NMT Univer-
of dissections I have rarely found a truly adhered capsule sity of Chester
on cadavers who were identified as having adhesive cap-
sulitis when they were alive. This has led me to the conclu- johnsharkeyevents.com
sion that many people are “diagnosed” with a specific
pathology that they simply do not have. Director
What this recent observational study demonstrates is that National Training Centre
even when a true adhered capsule is present the joint can 16a St Josephs Parade
demonstrate near normal range of motion under anesthe- Dorset Street
sia. What does this mean for practicing therapists in the Dublin D07 F6CR
clinical setting? This finding suggests that it is not the ad-
hesion alone that restricts range of motion. Motion is pos- Tel: 00353 18827777
sibly restricted by a protective neuromuscular “splinting” Fax: 0035318308757
resulting in hypersensitivity (i.e. central sensitization) in email: john.sharkey@ntc.ie
the contractile and neural tissues resulting in pain on at-
tempted movement. According to Latremoliere and
Woolf , “Central sensitization represents an enhancement
in the function of neurons and circuits in nociceptive path-
ways caused by increases in membrane excitability and
synaptic efficacy as well as to reduced inhibition and is a
manifestation of the remarkable plasticity of the soma-
tosensory nervous system in response to activity, inflam-
mation, and neural injury.”
A treatment plan must take into account the possibility
that the true source of pain and limited range of motion is
due to a protective or guarding increase in contractile
tone. This observational paper also highlights the need to
rule out other possible sources of pain and changes in
range of motion, such as myofascial trigger points

Terra Rosa E-mag No. 21 33

Fascial Manipulation®
– Stecco® method:
The practitioner’s perspective
Despite the plethora of information that we have access
to these days, don’t we still turn to our peers for inspira-
tion and guidance? The immense popularity of Twitter is
just one example of how we seek information from oth-
ers. Clinician’s don’t always have the time to peruse
through all of the available literature regarding any given
subject but having access to other colleagues’ insights
and experience can guide us in new, thought-provoking
34 Terra Rosa E-mag No. 21
Julie Ann Day
directions.
As an Australian-trained physiotherapist who moved to
Italy many years ago, since 1998 I have had the chance to
study with the founder of the Fascial Manipulation® -
Stecco® method, Luigi Stecco, who is also a physiothera-
pist.
The Fascial Manipulation® - Stecco® method is a manual
therapy based on biomechanical
models that introduce new para-
digms for incorporating the fascial
system into the interpretation of
musculoskeletal and internal dys-
functions. In turn, as these models
are based on anatomical studies
and dissections that have investi-
gated the complexity of the fascial
system they offer an approach that
has a solid anatomical rationale. A
significant number of professionals
have recognised and embraced
these models in their clinical work
and, in 2017, approximately 2,500
therapists from over 50 countries
attended courses addressing this
method.
While teaching this method in nu-
merous countries, I have witnessed
this growth of interest in the Stecco
models, particularly over the last 10
years. During this time, I have en-
countered a wide range of thera-
pists who have impressed me with
Fig. 1. List of Contributors
 Fig. 2. Fourteen functional segments composed of parts of muscles, one or more related joints and their fascial surround. Latin terms are used to describe these
segments (Illustration reproduced with kind permission from Handspring publishing).
their background knowledge, clinical experience and, yes,
curiosity. In effect, the opportunity to share the impact
that the Fascial Manipulation® - Stecco® method has had
on modifying the clinical practice of a selection of these
practitioners was the chief catalyst for compiling a new
book called ‘Fascial Manipulation® – Stecco® method:
The practitioner’s perspective’ (2018). Professionals from
different countries, including USA, Canada, Finland, Japan,
Israel, Poland and Italy, and different disciplines, such as
physiotherapy, osteopathy, chiropractic and massage
therapy, have contributed to this book.
While there are several texts books by Luigi Stecco that
explain in detail the theoretical bases and practical appli-
cations of the Fascial Manipulation® - Stecco® method
(Stecco 2004, 2009, 2016, 2017), as well as a number of
articles regarding clinical research into this method, this
new book places emphasis on the value of clinical exper-
tise and clinical judgement skills in such an emerging field.
What struck me most while editing and compiling this
book was that this representative group of 16 profession-
als had no particular need to adopt a completely new par-
adigm. They were all successful in their careers when they
first encountered Stecco’s proposals. While completing
and publishing quality clinical research is vitally important,
it does not always provide clinicians with practical guide-
lines that readily assist them in their work. Case reports
are often more immediate examples that clinicians can
relate to. Quite rightly professionals who have contribut-
ed to this book have approached these new models from
an analytical position yet, effectively, it was the clinical
results they witnessed by applying the Stecco models that
convinced them to explore the method further, integrat-
ing it into their work to varying degrees. These colleagues,
and many others like them, have inspired me to keep
teaching this method, sharing what knowledge of fascial
anatomy I have gained over the years and continuing to
explore possible clinical applications.
Clinical experience is one of the three cornerstones of the
Evidence Based Medicine (EBM) triangle, the other two
being the best available literature and patient prefer-
ences. Clinicians in all health fields are actively encouraged
to cultivate evidence-based practice (EBP) approaches,
and professionals have an ethical obligation to inform
themselves about current evidence, to update their skills
and knowledge and to apply the best available treatment
modalities. However, for a number of reasons, profession-
als are frequently coerced into thinking that published
Terra Rosa E-mag No. 21 35

Fig. 3. Practitioner using her elbow to apply deep friction to the lumbar region
(Photograph reproduced with kind permission from Handspring publishing).
research alone validates any given approach and that the
other two cornerstones of EBP impact on their treatment
choices to a much lesser degree. Yet we still look to our
peers, particularly those who have more experience than
us. What they are interested in, the trends they are ex-
ploring and their opinions can have great value for all of
us.
In this new book, each professional has been asked to
present a case study, or a short case series, in which they
have applied the Fascial Manipulation® method and to
discuss how their understanding of the musculoskeletal
system and the role of the fasciae in interactions between
the musculoskeletal and internal systems has been modi-
fied since encountering this approach.
The book is particularly useful for practitioners who are
interested in approaching fascial work and would like to
know more about the areas where it can be applied have
already started to explore the models presented by Luigi
Stecco by attending some of the courses and simply want
to know more by hearing about the experiences of others
who are currently applying this method.
So, what’s new in ‘Fascial Manipulation® – Stecco®
method: The practitioner’s perspective’?
The introduction presents some historical background to
the development of the Fascial Manipulation® - Stecco®
method. Some of you may not be aware that Luigi Stecco
36 Terra Rosa E-mag No. 21
compared many human anatomy textbooks with the di-
versity of vertebrate and invertebrate anatomy from the
animal world, along with texts concerning acupuncture
and myofascial trigger points, before developing models
that focus on the role of fascial tissue in 1) musculoskele-
tal and 2) internal dysfunctions.
Through his anatomical studies, Stecco realised that fascia
is structured in a way that is suited to coordinating and
perceiving the movements of the human body. According
to the various anatomical layers of fascia, he divides the
fascial system into 14 functional segments (Fig. 2). Each
segment is governed by myofascial units that make up
myofascial sequences, diagonals and spirals for musculo-
skeletal dysfunctions; tensile structures and catenaries for
internal organ and apparatus dysfunctions and quadrants
for superficial fascia dysfunctions. Stecco has identified
and mapped key areas in these fascial structures where
lack of sliding between fascial layers can apparently alter
proprioception, muscle recruitment and internal func-
tions, leading to symptoms of non-specific pain or myofas-
cial pain. Therapists use his models to identify alterations
in these key areas and then apply either deep friction or
more superficial techniques to restore inter-fascial gliding
(Fig. 3).
The fascial system is a very complex, three-dimensional
and multi-layered network. Simplified models are essential
because they provide a sort of GPS we can follow to un-
derstand how tensional compensations spread through-
out the body, where to act to resolve these tensions and,
perhaps most of all, how to backtrack and re-think about
our hypotheses whenever our manual therapy does not
give the desired outcome.
In the Introduction to this new book, you will find an out-
line of the two Stecco models and the assessment pro-
cess used in the Fascial Manipulation® - Stecco® method,
and readers can refer to these outlines to follow the clini-
cal reasoning used in the case reports presented in each
chapter. Those who are interested in exploring these
models further can consult the more detailed texts by
Stecco.
Chapters have been divided into three main sections:
Musculoskeletal dysfunctions: in this section you will find
case reports dealing with the application of the Fascial
Manipulation® - Stecco® method in cases of low back
pain, TMJ dysfunction, chronic ankle instability, severe
sciatic-type pain in an elderly patient and runner’s knee
pain, as well as several cases dealing with extended pain
patterns.
Internal dysfunctions: here you can read about the treat-
ment of chronic neck pain, thoracic outlet syndrome,
chronic polyuria, Bell’s palsy sequels, post-partum urinary
incontinence, the resolution of partial nipple necrosis and
bilateral calcaneal pain. Some of these cases sound like
they could have a musculoskeletal origin but symptoms
were addressed by following Stecco’s model for internal
dysfunctions.
Other perspectives: this section presents a case series
report on postural changes after treatment, some new
Julie Ann Day is an Australian
proposals for Fascial Manipulation® - Stecco® method
trained physiotherapist with
practitioners to consider and observations from a physio-
over 35 years of clinical experi-
therapist who applies this method in neurological paediat-
ence. In 1998 she began studying
ric cases.
Fascial Manipulation® with Luigi
The concept of this book is to give voice to clinicians who Stecco, the Italian physiothera-
in some ways have been pioneers in exploring a new para- pist who developed this method,
digm for musculoskeletal and internal dysfunctions. Not and she has translated four texts
all clinicians are in a position to carry out scientific studies, by Luigi Stecco from Italian to
so their opinions and experiences often remain unheard. I English. An authorized teacher of
hope you will find their reports as interesting as I do. Fascial Manipulation® since 2002,
Julie has taught Level I and Level II courses of Fascial Manip-
ulation® in Italy, Canada, USA, UK, Poland, Finland, Den-
mark, and Australia, as well as presenting numerous work-
shops and presentations on this subject at International
References:
conferences. She is one of the founding members of the
Day J A (Editor) Fascial Manipulation® – Stecco® method: AMF (Associazione Manipolazione Fasciale) and has been an
The practitioner’s perspective (2018) Edinburgh: Hand- active part of its Executive Council.
spring publishing.
Stecco L. (2004) Fascial Manipulation for Musculoskeletal
Pain. Padova: Piccin.
Stecco L. (2016) Atlas of Physiology of the Muscular Fas-
cia. Padova: Piccin.
Stecco L, Stecco A. (2016) Fascial Manipulation for Inter-
nal Dysfunctions-Practical Part. Padova: Piccin.
Stecco L, Stecco C. (2009) Fascial Manipulation: Practical
Part. Padova: Piccin.
Stecco L, Stecco C. (2014) Fascial Manipulation for Internal
Dysfunctions. Padova: Piccin.

Terra Rosa E-mag No. 21 37

The Value of Confidence

Til Luchau

When it comes to having the size of practice you want, er really tested my opinions and advice about how to
what really, truly makes a difference? After more than 30 build a great practice.
years training and coaching thousands of bodyworkers,
So, when a large professional organization asked me to
from entry-level to expert, I’d formed some opinions
teach an online course on the “psychology of a full prac-
about how to build a full and satisfying practice; and I had
tice” a few years ago, I didn’t want to just list my own
a ready repertory of advice to give. But though I had a
opinions and ideas, no matter how good I thought they
long list of practitioners who had built fulfilling practices
were. I wanted to know, in concrete, data-driven terms:
using this advice, I also knew good therapists who just
what beliefs or attitudes do successful practitioners have,
couldn’t seem to get enough clients, even after years of
and what tangible actions do they take, that set them
trying. Was the difference something the practitioners
apart from those that don’t have the practices they want?
did? Or, their attitudes and beliefs? Or something else, like
their gender, location, or personality? Other than collect- Working together with fellow business coaches, other
ing a lot of success stories (which some would say did educators, and a good data analyst, we designed a large-
little more than strengthen my confirmation bias), I’d nev- scale survey to look for correlations between practice

38 Terra Rosa E-mag No. 21

satisfaction (including both size and quality) and a variety
of attitudes, characteristics, and actions. Though (with
144 questions) the resulting survey took some time for
participants to complete, it proved popular, with over
2,000 practitioners completing it (including massage ther-
apists, bodyworkers, structural integration practitioners,
and a very long list of related hands-on specialties). We
targeted both practitioners in private practice, and those
working for someone else. Professionals from sixteen
countries participated and in very similar proportions to
the profession as a whole1: survey respondents were 83
percent female/17 percent male, an average age of 49,
and in practice for an average of 11 years.

Confidence

Analyzing the data revealed a treasure trove of surprises,

both in terms of what did, and what didn’t relate with
practice-size satisfaction. Though I’ll share more of these
highlights in future articles, one of the most significant
factors was self-assessed confidence in one’s own skills.
No matter what their practice size, practitioners were
much more confident in their “soft” skills, such as touch
Chart 1: Our survey of over 2,000 professional bodyworkers revealed stronger collective confi-
and listening, than in their “hard” skills, such as anatomy dence in “soft” (relational) skills than “hard” (cognitive) skills. It also showed a large gap in self-
assessed confidence in all areas between those who described their practice sizes as “much too
or assessment. This generally lower level of technical con- small” compared with those who said they were “just right.” Vertical scale shows percentage of
fidence suggests there are opportunities for schools, edu- practitioners in each group who strongly agreed with statements expressing confidence in each
respective skill area. Chart courtesy Advanced-Trainings.com.
cators, continuing education providers, and regulatory
agencies to help boost practitioners’ cognitive skills and
confidence. But even more interesting was that in all 6
skill areas assessed (which included a range of cognitive
and relational skills), lower self-confidence was strongly
correlated with saying that one’s practice size was “much
too small” (Chart 1).

Not surprisingly, too much self-criticism was also a signifi-

cant detriment to practice satisfaction. Two thirds of
those with too-small practices strongly agreed with the
statement “I am often critical of myself and my abilities,”
while less than half of those with just-right practices
agreed (Chart 2).

Of course, not all confidence is good, and not all self-

criticism is bad. Over-confidence has its downsides too:
egotism, arrogance, grandiosity, insensitivity, and a lack
of caution or humility could be thought of as pitfalls of an
excess of confidence, or self-confidence out of proportion
to other’s perceptions. And without self-criticism, there
would be no drive to improve. But when confidence is too
low, or self-criticism too high, the survey’s results suggest
that our practices suffer.
Chart 2: Self-criticism also correlated with too-small practices. Percentage of respondents who
While our survey measured the practitioners’ confidence agree or strongly agree with the statement “I am often critical of myself or my abilities,” by
practice-size satisfaction. Chart courtesy Advanced-Trainings.com.
in themselves, there is interesting evidence that practi-
Terra Rosa E-mag No. 21 39
 Enhancing Confidence

Twelve great ideas for increasing confidence in your skills from

our panel of expert advisors, survey-takers’ comments, and
from the many stories shared in our discussion forum:

1. Rack up lots of experience. If need be, give sessions

away for feedback. Keep working.

2. Stick with it. Our data showed that confidence and prac-
tice satisfaction both went up significantly with time.

3. Invest in quality training, or additional credentials you

value. Without enough of those to believe in your own possibili-
ties, you’re wasting the time and money you’ve already put in.
Chart 3: In an influential study of practitioners’ confidence in their methods, clinicians (n=60) gave
patients placebos for dental pain relief. One group of clinicians knew they were giving a placebo;
the other group of clinicians believed they were giving active pain medication (but were unknow-
4. Search for a mentor who believes in you.
ingly also giving placebos). Pain was significantly less in patients whose practitioners thought they
were giving actual pain medication (bottom line), suggesting that practitioner expectation and 5. Find a coach, accountability buddy, or goals-group to
confidence can have a meaningful impact on patients’ subjective results, such as pain. After stay on track.
Gracely et al, 1985.

6. Get even better at providing the results your clients

want. Supervision or a good training will help.
tioners’ confidence in the efficacy of their methods can
influence their client’s perceived results as well (Chart 3), 7. Collect, share and celebrate your successes, both small
suggesting that it’s important to believe in your modali- and large, with friends, family, peers, social media, your web-
site. (Get a website.)
ties and techniques, as well as your own skills2.
8. Trade with peers; ask for feedback.
I should point out that though it's quite reasonable to
expect that increasing confidence would likely result in 9. Ask for specific feedback from your clients.
more clients and more satisfaction overall, our survey 10. Just do it, even if you’re afraid. Action counts.
showed only correlation, not cause. In other words, it’s
11. Get help with self-compassion. We all need it.
also possible that some of the confidence/practice size
correlations were due to a lower number of clients caus- 12. Lighten up. Enjoy what you do.
ing practitioners to doubt their skills. However, even
when this might be the case, increasing one’s skill and
confidence clearly brings direct benefits when a practice is
smaller than desired, including self-fulfillment, a sense of Til Luchau is the author of Advanced Myofascial Techniques
purpose, client satisfaction, and higher efficacy; all worthy (Handspring Publishing, 2016), a Certified Advanced Rolfer,
aims, no matter how satisfied or unsatisfied we are with practice coach, and a member of the Advanced-
the size and nature of our practices. Trainings.com faculty, which offers online learning and in-
person seminars throughout the world. He invites questions
or comments via info@advanced-trainings.com and
An abridged version of this article was first published in Advanced-Trainings.com’s Facebook page.
Massage & Bodywork magazine. Thanks to expert advisors
Anne Williams, Cherie Sohnen-Moe, Drew Freedman, Eric
Notes
Brown, and Irene Diamond; and to in-kind contributors in-
cluding Advanced-Trainings.com, ABMP, and the World 1. ABMP. (n.d.). Massage Profession Metrics. In mas-
Massage Conference. sagetherapy.com. Retrieved Aug. 2018, from http://
www.massagetherapy.com/media/ met-
rics_massage_therapists.php.
Assess Your Confidence
2. RH Gracely, R Dubner, WR Deeter, PJ Wolskee (1985)
Want to know how confidence compares? Clinicians' expectations influence placebo analgesia. The
Take a quick self-assessment of key confidence indicators, Lancet, 1985.
or the entire full-practice survey, at http://www.a-t.tv/
abmp-full-practice-survey

40 Terra Rosa E-mag No. 21

Altered patterns of pelvic bone motion
determined in subjects with posterior
pelvic pain

A summary of the study by Barbara Hungerford, Wendy Gilleard,

Diane Lee. Published in Clinical Biomechanics (2004)

In our daily practice, we all encounter patients presenting with

low back pain, and there is no doubt that on-going low back pain
results in a significant financial and economic burden to the
health care system and society in general. In many instances low
back pain is still poorly understood and not well managed, this is
partly due to the medical professions obsession with costly im-
aging such as MRI scans and with an over-emphasis on only look-
ing at the structure of the lumbar spine when addressing low
back pain.

The spine instead should be considered as a fully integrated

structure rather than only examining or treating the sensitive
region and what better place to start than at the base, in other
words at the pelvis. The pelvis should be considered as a funda-
mental corner stone of the body encasing and surrounding vital
organs but also constituting an important part of the spine and
skeletal structure of the body.
Outside of the mainstream medical profession, there is a recog-
nition of the importance of the pelvis and sacroiliac joints, but at
the same time, there is also a lot of unnecessary confusion about
how best to assess and treat the pelvis.
Without a clear understanding of the anatomy as well as the
biomechanics of the sacroiliac joints that contribute to pelvic
stability, treatment of this area has in the past utilized methods
that are unsubstantiated and are not supported by the research.
There is now quite a substantial body of work that has in recent
years helped to clarify many of the mysteries surrounding the
sacroiliac joint.
A study by Barbara Hungerford, Wendy Gilleard, Diane Lee, pub-
lished in Clinical Biomechanics (2004) aimed to determine al-
tered patterns of pelvic bone motion in subjects with posterior
pelvic pain using skin markers.
Lumbar spine and pelvis
A primary function of the lumbar spine and pelvis is to transfer
the loads generated by body weight and gravity during standing,
walking and sitting. During weight bearing activities, control of
intra-pelvic motion is required for the transference of loads be-
tween the spine and the lower limbs. According to Panjabi
(1992) stability is achieved when the passive, active and control
systems work together to produce an approximation of the joint
surfaces.
The ability to effectively transfer load through the pelvis is dy-
namic and therefore depends on:
• Optimal function of the bones, joints, and ligaments,
• Optimal function of the muscles and fascia, and
• Appropriate neural function.
For every joint, there is a position called the self-braced (close-
packed) position in which there is a maximum congruence of the
articular surfaces and maximum tension on major ligaments. In
this position, the joint is under significant compression, and the
ability to resist shear forces is enhanced by tensioning of the
passive structures and increased friction between the articular
surfaces. The self-braced position of the SIJ is nutation of the
sacrum or posterior rotation of the innominate.
The study
The study by Hungerford et al. determined whether the pattern
of pelvic bone motion, determined by skin markers, differs be-
tween control subjects and subjects with posterior pelvic pain.
Design. A cross-sectional study of three-dimensional angular and
translational motion of the innominate relative to the sacrum in
two subject groups.
Methods. Fourteen males with posterior pelvic pain and healthy
age and height matched against fourteen controls were studied.
Fifteen lightweights highly reflective 15 mm diameter balls were
used to define the bony landmarks of each innominate, femoral
segments, and the sacrum. A 6-camera motion analysis system
was used to determine 3D angular and translational motion of
pelvic skin markers during standing hip flexion.

Terra Rosa E-mag No. 21 41


Each subject in the posterior pelvic pain group reported unilat-
eral pain over the posterior pelvic/SI region for greater than two
months and no pain above the lumbosacral junction. The pain
was consistently and predictably aggravated by activities that
vertically loaded the pelvis (walking, standing or sitting).
Positive results on the side of posterior pelvic pain in clinical
tests for impaired lumbopelvic stabilisation.
These tests included:
Active straight leg raise test: A positive test was indicated when
the pelvis failed to remain in neutral alignment, and the subject
reported difficulty or inability to elevate a straight leg in supine.
Standing hip flexion test: During a left standing hip flexion test,
the subject stands on their right leg and flexes the left hip to-
wards 90⁰. The left innominate should posteriorly rotate relative
to the sacrum. A positive test was indicated when the superior
motion of the posterior superior iliac spine (PSIS) was palpated
relative to the sacrum.
Neutral zone analysis test (joint play): this test was used to evalu-
ate motion in the neutral zone of the SIJ. All symptomatic sub-
jects demonstrated asymmetric stiffness of the SIJ when the
innominate was glided relative to the sacrum (analysis of the
neutral zone).
42 Terra Rosa E-mag No. 21
Results
During the hip flexion component of the standing hip flexion
movement, there was no significant difference in the patterning
of translational motion between groups on the side of hip flex-
ion. Posterior rotation of the innominate occurred with hip flex-
ion in control subjects and pelvic pain subjects as previously
reported in the literature.
However, on the side of single leg support: a significant difference
in the pattern of translational motion of the innominate be-
tween controls and symptomatic subjects was determined.
In the control group, posterior rotation of the weight bearing
innominate occurred on the side of single leg support.
However, in the posterior pelvic pain group, anterior rotation
occurred on the symptomatic side.
In summary, on the supporting leg, the innominate rotated poste-
riorly in controls and anteriorly in symptomatic subjects.
Conclusion
Posterior rotation of the innominate, as measured using skin
markers during weight bearing in controls may reflect activation
of optimal lumbo-pelvic stabilisation strategies for load transfer.
Anterior rotation occurred in symptomatic subjects, suggesting
a failure to stabilise intra-pelvic motion for load transfer. Coun-
ternutation of the sacrum, or anterior rotation of the innomi-
nate, is thought to be a relatively less stable position for the SIJ.
The findings from this study support the self-braced position of
the SIJ as one that relies on nutation of the sacrum or posterior
rotation of the innominate.
Relevance
This study found that posterior rotation of the innominate oc-
curred during weight bearing in controls. This movement pat-
tern is thought to optimise stability of the pelvic girdle during
increased loading. Conversely, anterior rotation occurred in
symptomatic subjects during weight bearing. This is a non-
optimal pattern and may indicate abnormal articular or neuro-
myofascial function during increased vertical loading through
the pelvis.
 Maximise Oxygenation

Demystifying the SIJ & Pelvis

with Taso Lambridis
Sydney, 17-18 November 2018

Why another SIJ and pelvic course?
Over the past 15 years there has been a continued in-
terest and research into this often complex region how-
ever there are still many unanswered questions regard-
ing the fundamental function and role of the SIJ. There
is an ongoing debate on what if any role the SIJ plays in
the cause of low back pain as well as continued contro-
versy about how best to treat SIJ or pelvic problems.
Taso has been running his SIJ series of courses since
2010 and presents a comprehensive 2 day course
aimed at enhancing your understanding of this key re-
gion of the body.
Over the 2days participants will have the opportunity to
explore the biomechanics and fundamentals of pelvic
stability responsible for optimal function of the SIJ and
pelvic region.
The course is designed around the small group learn-
ing experience so that you can benefit from the individu-
al attention.
The course material is underpinned by current
knowledge of the anatomy and biomechanics and pro-
vides an evidence approach to treating SIJ dysfunction
that will challenge previously acquired misconceptions
about the cause of SIJ dysfunction and ultimately lumbo
-pelvic pain.

Taso Lambridis is a highly skilled Physiotherapist from South Africa with over 20 years experience treating
musculoskeletal and sporting injuries. He has gained extensive experience having worked internationally and
his clinical area of expertise is treating complex lumbar spine and pelvic injuries.
Taso has a post-graduate MSc Sports Medicine degree from the UK and has worked in elite physiotherapy
and sports clinics in London where he treated professional rugby players, English Premiership football play-
ers, elite triathlete and runners as well as dancers from London’s leading West End theatre shows, dance
academies and schools for the performing arts.

Terra Rosa For more information & Registration

Terra Rosa E-mag No. 21 43

Visit www.terrarosa.com.au
The Efficacy of
Vibrating Rollers
Foam rollers has become a popular a self-myofascial re-
lease gizmo among health and fitness professionals. Stud-
ies have shown that foam rollers can enhance joint range
of motion (ROM). Recently vibrating foam rollers were
introduced allowing a combination of vibration therapy
and foam rolling. A few studies have confirmed its effica-
cy.
On Range of Motion and Pressure Pain Threshold
A study headed by Dr. Scott Cheatham from California
State University compared the effectiveness of a vibrating
roller and a conventional roller intervention on knee flex-
ion range of motion (ROM) and pressure pain thresholds
(PPT) of the quadriceps.
The study, published in Journal of Sport Rehabilitation,
recruited 45 recreationally active adults, whom were ran-
domly allocated to one of three groups: vibrating roller,
non-vibrating roller, and control.
The results showed that vibrating roller had the greatest
increase in PPT (180 kPa), followed by the non-vibrating
roller (112kPa), and control (61 kPa). A high value indicates
the participant can withstand higher amount of pressure
pain. For knee ROM, the vibrating roller demonstrated the
greatest increase in ROM (7 degrees), followed by the
non-vibrating roller (5 degrees), and control (2 degrees).
The authors suggested that a vibrating roller may increase
an individual’s tolerance to pain greater than a non-
vibrating roller.
Part of Warm-up Routine
Another study from Taiwan published in Journal of Sports
Science investigated that the immediate effects of foam
rolling, vibration rolling, and static stretching as a part of a
warm-up regimen in young adults.
Compared with the pre-intervention, vibration rolling in-
duced the range of motion of knee flexion and extension
significantly increased by 2.5% and 6%, respectively, and
isokinetic peak torque and dynamic balance for muscle
strength and dynamic balance increased by 33%-35% and
1.5%, respectively. In the three conditions, most outcomes
44 Terra Rosa E-mag No. 21
between vibration rolling and regular rolling were compa-
rable; however, the participants had a significantly higher
knee joint reposition error after non-vibration rolling, indi-
cating that foam rolling could have a knee joint proprio-
ception hampering effect.
Compared with static stretching, vibration rolling signifi-
cantly increased the quadriceps muscle strength by 2-fold
and dynamic balance by 1.8-fold.
The authors suggested that these findings could inform
athletic professionals to consider vibration rolling for de-
signing more efficient and effective pre-performance rou-
tine.
Cross-education Effect
A study from Spain explored further the effects of the
application of a foam roller on the ankle dorsiflexion mo-
bility. It also examined the effect of vibrating foam roller
applied to the ankle plantar flexors muscles.
Thirty-eight undergraduate students participated in the
study (19 males and 19 females). The participants were
allocated to each of the three treatments (3 sets of 20 s)
in random order: 1) foam roller, 2) vibrating foam roller,
and 3) no foam roller or vibration (Control). All treatments
were applied to the dominant leg, separated by at least
48 hours and were conducted at the same time of day.
Ankle dorsiflexion ROM and plantar flexor were measured
in both legs before and immediately after the treatment.
The results showed that foam rolling caused an increase
in ankle dorsiflexion ROM in the treated and contralateral
untreated limb. Ankle mobility was increased 6-7% with
the application of either Roller or vibrating roller. Howev-
er, maximum voluntary IC was not affected by foam roller.
The addition of the vibration stimulus with foam rolling
did not further increase ROM compared to foam rolling
alone.
The authors concluded that foam rolling with and without
vibration increase ankle mobility and produced a cross-
education effect.
 Not just Foam Rollers
BLACKROLL® delivers unsurpassed German Engineering giving you premium tools for
myofascial release

Blackroll Booster
A combination of Foam Rolling and Vibration
The Blackroll Booster is a vibrating core engineered to fit in any 30cm
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The Vibra Motion technology of the Booster transforms your Blackroll to

deliver a unique vibration therapy.

“"I have to confess that I firstly underestimated the efficacy of myofascial self treatments with BLACKROLL® prod-
ucts. Today I suppose that a rather big part of the documented successes can be accredited to the concept of self-
efficacy. The patient is not passively lying down waiting for his or her treatment but is put into an active role. In many
cases this is very important in terms of a sustainable success." Dr. ROBERT SCHLEIP

Available at www.terrarosa.com.au
Terra Rosa E-mag No. 21 45
Research
Highlights
Stretching Reduces Tumour Growth in a Mouse Breast
Cancer Model
There is growing interest in developing non-
pharmacological treatments that could boost natural de-
fences against cancer and contribute to cancer preven-
tion. Recent studies from Osher Center for Integrative
Medicine at Harvard Medical School have shown that gen-
tle daily stretching for 10 minutes can reduce local connec-
tive tissue inflammation and fibrosis.
As mechanical factors within the stroma can influence the
tumour microenvironment, the researchers investigated
whether stretching would reduce the growth of tumours
implanted within locally stretched tissues. They tested
this hypothesis on mice.
Female FVB mice (N = 66) were injected with mammary
tumour cells. Mice were randomized to stretch vs. no
stretch, and treated for 10 minutes once a day, for four
weeks. The animals are held by the tail and gently lifted,
allowing their front paws to grasp a bar, as a stretching
treatment.
Tumour volume at end-point was 52% smaller in the
stretch group, compared to the no-stretch group in the
absence of any other treatment. Cytotoxic immune re-
sponses were activated, and levels of Specialized Pro-
Resolving Mediators were elevated in the stretch group.
The results suggest a link between immune exhaustion,
inflammation resolution and tumour growth. However,
the researchers still don’t understand the mechanism how
stretching reduces tumour growth.
The authors suggested that stretching is a gentle inter-
vention that could become an important component of
cancer treatment. They also caution that this preclinical
research on mice does not suggests that cancer patients
should stretch instead of receiving cancer treatment.
Injured an arm? Train the other arm to gain strength
The concept of contralateral effects can be very important
when rehabbing after an injury. If a limb in injured, the
immobilization necessary to allow time for it to heal, can
result in muscle atrophy in that limb, resulting in de-
creased size and strength.
46 Terra Rosa E-mag No. 21
It is known that stretching one side of the body can influ-
ence the flexibility of the contralateral, unstretched side
of the body. This effect is also observed in strength train-
ing in which unilateral training of a limb enhances perfor-
mance of the contralateral untrained limb.
A study published in the April 2018 issue of the Journal of
Applied Physiology, investigated if exercising muscles of a
healthy, uninjured limb can prevent atrophy of the mus-
cles of the contralateral immobilized limb.
The nondominant forearm of 16 participants was immobi-
lized with a cast. Participants were then randomly as-
signed to a resistance-training group in which the un-
casted limb was trained (eccentric wrist flexion contrac-
tion, 3 times/week), or a control group that had no re-
sistance training. The period of the study was one month.
In the control group, the wrist flexor musculature of the
immobilized casted limb was, on average, more than 20
percent weaker; and those muscles had also shrunk in
size, dropping approximately three percent of their mass.
In comparison, the resistance-training group showed
strength preservation of the wrist flexor musculature of
the immobilized limb that was not trained (as well as in-
creased wrist flexor strength of the non-immobilized limb
that was directly trained). Strength preservation was non-
specific to contraction type (strength preservation was
found for all three types of muscle contractions: concen-
tric, eccentric, and isometric). But strength preservation
was specific to the wrist flexor musculature that was
trained in the other limb. In other words, strength loss
was found in the other muscle groups of the immobilized
limb in the resistance-training group.
These findings suggest that eccentric training of the non-
immobilized limb can preserve size of the immobilized
contralateral homologous musculature (musculature that
had the same functional joint action).
 Research Highlights
The Effect of Massage Therapy on Blood Pressure in
Prehypertensive Women
Prehypertension, also known as high normal blood pres-
sure, is a condition when a person’s blood pressure is ele-
vated above ideal normal, but not to the level considered
hypertension. Lowering the risk of prehypertension devel-
oping into hypertension is therefore essential.
A study from University of Isfahan in Iran investigated the
long-term effect of massage therapy on blood pressure in
prehypertensive women.
A single-blind clinical trial study was conducted on 50 pre-
hypertensive women during a 6-month period. Partici-
pants were randomly selected to receive treatment or
control. The treatment group (25 patients) received mas-
sage for 10-15 min, three times a week for 10 sessions. The
control group was relaxed in the same environment but
with no massage.
The results indicated that the mean systolic and diastolic
blood pressures in the massage group were significantly
lower in comparison with the control group. The results
also showed that the lowered blood pressure was still
observed 72 hours after the treatment, and there was still
a significant difference between the test and control
groups. The control group did not show changes in blood
pressure. However, at the two-week point after the study,
there was no significant difference in the blood pressure
between the two groups.
The study suggests that blood pressure lowering effects
of massage is temporary and lasts between 3-14 days after
the massage therapy treatment.
Does text neck exist?
Text neck is referred to as neck pain caused by the head
posture during reading and texting on a smart phone.
While it is of a concern, some called that there is no such
thing as a text neck. A recent study from Brazil recruited
150 students between 18 and 21 years old from a public
high school in Rio de Janeiro to investigate whether there
is an association between text neck and neck pain. The
results showed that the majority of the participants (77%)
reported more than 4h of mobile phone use per day. The
physiotherapists’ judged 40% of the participants’ posture
as text neck, while 85% self-reported text neck. Based on
the data, the authors found that text neck was not associ-
ated with either neck pain or the frequency of neck pain.
The authors concluded that their results conflict with the
idea that the mechanical stress caused by poor posture
due to mobile phone use is a threat to cervical spine integ-
rity and challenge the belief that inappropriate neck pos-
ture during mobile phone texting is the leading cause of
the growing prevalence of neck pain.
The Chartered Society of Physiotherapy supported it with
a statement that the use of phones is likely to be
'incidental' to the development of neck pain, the use of
phone is the same as reading a book, which we have done
for centuries. Dr Joe Muscolino commented that indeed
there is nothing new in “texting neck” posture. The for-
ward flexed posture can be found while one is reading a
news paper or book. The difference, is the tremendous
increase in time spent in this texting posture. Digital devic-
es are not the enemy, it is the tremendous amount of
time that we spend in the forward flexed craniocervical
poor posture using them that is the enemy.
Pain is often the result of long-standing repetitive over-
use. Just as it is unlikely that a young adult who smokes
cigarettes would experience lung cancer or any of the
other deleterious effects of smoking when still young, it is
also unlikely that a young adult would experience any of
the deleterious effects of postural distortion patterns. So,
can we say that there is no link between texting neck pos-
ture and neck pain in young adults? Yes. But can we say
that texting neck posture is therefore healthy? NO! Me-
chanics do matter, that forces into tissues do matter, then
there will have to be some price to pay, somewhere down
the road, for the increased chronic repetitive asymmet-
rical forces into our soft and hard tissues. Even if the price
is not direct pain, it will be in tissue adaption dysfunction.
Massage is the Best Post-exercise Recovery Techniques
Training in athletes frequently involve repeated eccentric
contractions and tissue vibrations that can lead to muscle
damage (i.e., the disruption of structural proteins in mus-
cle fibres and/or connective tissues), subsequent tissue
inflammation, delayed onset muscle soreness (DOMS),
and increased perceived fatigue. These conditions can
lead to a temporary reduction in muscular force and an
increased risk of injury. Thus it is important for sports phy-
sician to optimize the recovery period in order to manage
muscle damage and alleviate DOMS, inflammation, and
fatigue.
Researchers from France attempted to provide an evi-
dence-based approach for choosing post-exercise recov-
ery techniques. They also looked at studies that measured
changes in the blood concentrations of muscle damage
indicators [i.e., creatine kinase (CK)] and inflammatory
biomarkers [C-reactive protein (CRP) and interleukin-6 (IL-
6)] that are observed after exercise and are associated
with the occurrence of DOMS.
The study published in Frontiers in Physiology conducted
a meta-analysis by searching through 3 scientific data-
bases and found 99 studies that were related to the topic.
The literature showed that active recovery, massage,
compression garments, immersion, contrast water thera-
py, and cryotherapy induced a small to large decrease in
the magnitude of DOMS, while there was no change for
the other methods (e.g. stretching). Massage was found
to be the most powerful technique for recovering from
DOMS and fatigue.
In terms of muscle damage and inflammatory markers,
the review observed an overall moderate decrease in cre-
atine kinase and overall small decreases in interleukin-6
Terra Rosa E-mag No. 21 47
 Research Highlights
and C-reactive protein. The most powerful techniques for outcome was relative muscle activation amplitude be-
reducing inflammation were massage and cold exposure. tween research and control subjects.
The authors concluded that Massage appears to be the The results of the experiment showed muscle activation
most effective method for reducing DOMS and perceived along the superficial back line was observed during distal
fatigue. Water immersion and the use of compression gar- movement (plantar flexion or neck extension). LBP pa-
ments also have a significant positive impact but with a tients showed significant lower muscle activation in the
less pronounced effect. Perceived fatigue can be effective- erector spine of lower back region compared with the con-
ly managed using compression techniques, such as com- trol group during active plantar flexion and active neck
pression garments, massage, or water immersion. Further- extension. Healthy controls were able to recruit more
more, the most powerful techniques that provide recovery proximal muscle along the myofascial chain with greater
from inflammation are massage and cold exposure, such as power. Lower muscle activation in other regions
water immersion and cryotherapy. (gastrocnemius, hamstrings, erector spine level T6) was
observed in the research group but the difference is not
The authors added that in this meta-analysis, only one re-
statistically significant.
covery session was examined. Further research needs to
confirm if similar outcomes can be obtained when the The authors concluded that LBP may causes or result in a
same recovery technique is used on a regular basis after lower muscle activation of the muscles along the superfi-
exercise. cial back line. The implication of this study is that therapists
should treat the patient in more holistically along the myo-
fascial line and not to only focus on muscles at certain re-
Massage Therapy Improves Training of Elite Para- gions.
Athletes
Researchers from South Carolina examined the effect of
Massage Promotes Muscle Regrowth Even on Opposite
massage therapy on the performance goals on the bike, as
well as the quality of life off the bike, in elite paracycling
Leg
athletes (para-athletes). The study published in the journal A recent study published in The Journal of Physiology hy-
BMJ Open Sport and Exercise Medicine, involved one pothesized that the mechanical activity associated with
team, with nine paracycling participants, during their train- massage induces an anabolic (growth) effect in skeletal
ing from January 2015 until the Rio Olympics in 2016. One- muscle undergoing regrowth after a period of atrophy.
hour massage sessions were scheduled one time per week The experiment used rats, where they were randomly as-
for 4 weeks, and then every other week for the duration of signed into four groups: weight bearing (control group
the time the athlete was on the team and/or in the study. with no muscle atrophy), hind limb suspended for 14 days,
The results showed that massage therapy afforded signifi-
hind limb suspended for 14 days followed by recovery for 7
cant improvement for sleep, muscle tone (tightness), and days, and suspended limb followed by recovery for 7 days
recovery from workout while in training for paracyclists. of weight bearing and movement supplemented with mas-
The authors concluded that this real-world study provides sage as a 30-minute cyclic compressive loading applied to
new information to support massage therapy as a valuable the right gastrocnemius every other day for 4 rounds of
treatment approach for physical improvement during treatment.
training and recovery after training in elite paracyclists. The outcomes show that the average muscle fibre of gas-
trocnemius after immobilization was decreased by 38%.
Muscle fibre cross-sectional area was enhanced by 18%
Decreased muscle activation along the back myofascial
with massage performed during the 7-day recovery period,
line in subjects with low back pain compared to 7-day recovery period without massage. This
The myofascial chain or myofascial continuity concept sug- is due to improvement in the making of protein in cells.
gests that muscles activate along kinematic chains with The surprising outcome is that the contralateral, non-
common fascial coverings. Researchers from Haifa, Israel massaged limb in the massage treatment group exhibited
examined muscle activations along the superficial back line a comparable 17% higher muscle fibre size.
in LBP patients compared to healthy controls. The study
was published in Journal of Back and Musculoskeletal Re- The authors hypothesised that massage acts through the
habilitation activation of the sympathetic nervous system to cause the
anabolic cross-over effect through direct neural mecha-
The study recruited 20 males with chronic LBP and 17 nisms as well as endocrine-like processes. Alternatively,
healthy controls. All subjects underwent five test condi- massage can cause the release of factors from muscle
tions: Conditions 1-3 involved passive movement, active (such as myokines) that can influence muscles or other
movement and active movement against maximum iso- organs at distant sites.
metric resistance of the right gastrocnemius muscle. Con-
ditions 4 and 5 involved neck extension without and with The authors conclude that massage in the form of cyclic
isometric resistance from the prone position. The main compressive loading induces an anabolic response in mus-
cles regrowing after a period of inactivity. Muscle loss can
48 Terra Rosa E-mag No. 21
 Research Highlights
be rapid during periods of immobilization, such as during
bed rest, and it is extremely difficult to grow back, espe-
cially in older people.
Do longus capitis and colli stabilise the cervical spine?
The longus colli and longus capitis are two small muscles
spanning multiple cervical motion segments and located
deep in the anterior neck, lying against the cervical spine’s
anterior bodies and transverse processes. These muscles
are often termed the ‘deep cervical flexors’, and are pro-
posed to play a role in stabilizing the cervical spine. Dys-
function of these muscles has been shown in whiplash and
chronic neck pain utilizing the cranio-cervical flexion test
(CCFT).
Researchers from University of Otago in New Zealand pub-
lished a study in Musculoskeletal Science and Practice
which describes the fascicular morphology of the longus
capitis and colli, and estimates their peak force generating
capabilities across the individual cervical motion segments.
The study used a cadaveric dissection to reveal the archi-
tecture and morphology of longus capitis and colli; mag-
netic resonance imaging (MRI) of these muscles in healthy
volunteers to measure in vivo muscle volumes, and finally
biomechanical mathematical calculationof the peak.
The authors highlight the complex anatomy and small
force capacity of longus capitis and colli, and have implica-
tions for the efficacy of their function. In particular, they
found a small peak compression forces indicate that these
muscles have a limited capacity to contribute to cervical
stability via traditional mechanisms. This implies that the
mechanism(s) by which cervicocranial flexion exercises
produce clinical benefits is worth exploring further.
Massage therapist and Educator Til Luchau commented
that, though conventional approaches often conflate sta-
bility with strength, there may be metrics other than
strength that can improve our therapeutic outcomes. For
instance, what if the neck structures involved contribute
more than just brute force? The deep muscles of the anteri-
or cervical spine, like the psoas on the anterior lumbar
spine, are extremely sensitive; could it be that they act as
length-variable sensors, contributing to stability and adapt-
ability via their rich mechanoreceptor capabilities, maybe
even more than they contribute as prime movers?
And, what if stabilization itself is also a function of refined
perception and variable adaptability, as much (or more)
than it is a function of raw contractile power (which is
what the study measures)?
The authors’ inviting conclusion leaves a door open: Re-
fined proprioception and more options for subtle adapta-
bility are two such areas that many of us are actively ex-
ploring in our practices every day.
Lumbodorsal fascia as a potential source of low back pain
In the past few years, the lumbodorsal (thoracolumbar)
fascia has been proposed as one of possible sources of
“idiopathic low back pain” (pain that is stated as having no
known cause). Authors Jan Wilke, Robert Schleip, Werner
Klinger, and Carla Stecco wrote a review in Biomed Re-
search International investigating the possible role of the
lumbodorsal fascia in patients with low back pain, with
special focus on combining findings from histological stud-
ies and experimental research.
The authors proposed three possible mechanisms for fas-
cia-mediated low back pain sensations:
microinjuries irritating nociceptive nerve endings in the
lumbodorsal fascia may directly induce back pain
tissue restructuring, for example following immobility,
chronic overloading, or microinjury, may compromise pro-
prioceptive signalling, which by itself could decrease the
pain threshold by means of an activity-dependent sensiti-
zation of wide dynamic range neurons
nociceptive input from other tissues innervated by the
same spinal segmental levels could elicit an increased sen-
sitivity in the lumbodorsal fascia (Figure 2).
And, of course, various combinations of these three pro-
cesses are possible.
All too often, the medical world ignores the contribution
of extra-articular myofascial tissues to low back and other
pain and dysfunction syndromes. Consequently, if no osse-
ous structural damage is found on radiographic examina-
tion (x-ray) and no annular disc damage is seen on MRI
examination, the patient’s / client’s pain is often described
as idiopathic, in other words pain from an unknown origin
(the word root “idio” comes from the same origin as the
word “idiot”). Dr Robert Schleip added its implication for
manual therapists:
“For manual therapists this article supports the long-held
assumption that at least some cases of low back pain may
originate from the lumbar fascia. The reduced shearing
mobility of the lumbar fascia seems to play a central role in
these cases. Since this will tend to reduce proprioceptive
signalling from the lumbar fascia, it should be beneficial to
include manual techniques in the treatment of low back
pain patients which involve horizontal tissue traction
(parallel to the skin) rather than only vertical compression.
Another conclusion for many low back pain cases will be
that a myofascial treatment focus on superficial tissue lay-
ers may often be more efficient that a focus on deeper
tissues. Working with the patient in a prayer position
(child’s position in yoga) or similar, in case that is easily
possible, can be good way to direct the manual defor-
mation mainly towards the then pre-stretched lumbar fas-
ciae on the surface, while having the deeper muscle fibres
in a relatively relaxed state. No wonder that this position is
frequently included in most fascia oriented yoga styles, but
also in the Rolfing method of myofascial integration. “
Terra Rosa E-mag No. 21 49