Fibromyalgia Facts

Fibromyalgia (FM) is a common and complex chronic pain disorder that affects an estimated 10 million Americans, mostly women. FM is a syndrome rather than a disease. Unlike a disease, which is a medical condition with a specific cause or causes and recognizable signs and symptoms, a syndrome is a collection of signs, symptoms, and medical problems that tend to occur together but are not related to a specific, identifiable cause. FM is characterized by chronic widespread pain, multiple tender points, abnormal pain processing, sleep disturbances, fatigue and often psychological distress. Fortunately, FM is not a serious life-threatening illness and can be diagnosed properly by a physician who is knowledgeable about this condition.The National Fibromyalgia Association (http://www.fmaware.org/) is a nonprofit organization that provides educational information and support for Fibromyalgia patients and their family members; it is an excellent resource for gathering more information on this elusive disorder

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The tender point locations of fibromyalgiaMense S, Simons DG. Muscle Pain. Lippincott, Williams & Wilkins; 2001.


When should I see a doctor?
As with many other medical problems, proper diagnosis is half the cure. People with FM tend to look healthy on the outside but feel miserable on the inside, and therefore it is important that a physician knowledgeable about FM be the person to make the appropriate diagnosis. Many physicians are still not well educated about the diagnosis of FM and may be too quick to give a diagnosis of FM. It is important that you first have standard laboratory tests performed – before a diagnosis of FM is given – in order to rule out some other medical problems that could be the cause of widespread pain and fatigue.Many other medical problems can mimic the symptoms of FM including anemia, Lyme Disease, rheumatoid arthritis, low thyroid, diabetes, vitamin and mineral deficiencies, and other chemical imbalances. Sometimes the key symptoms of FM - widespread pain and fatigue – can be caused by reactions or side effects to common medications such as statins for high cholesterol, some blood pressure medications, and even some anti- depressant medications. Your doctor should be able to rule out these other causes of widespread pain and fatigue with standard laboratory tests. The diagnosis of FM should only be given after a thorough physical examination and laboratory tests fail to detect another medical problem. As noted above, FM is a complex pain disorder that requires a multifaceted treatment approach including the following components:

Pain management with various medications

Gentle exercises

Sleep management

Nutritional guidance

Psychological and emotional support

Complementary therapies such as chiropractic, acupuncture and massage.

There is no single cause or single treatment for FM, and each individual with FM requires an individualized treatment approach using a combination of the above therapies. It is normal to worry about the cause of your pain and the impact it may have on your life. Talking with your healthcare provider about these worries and concerns can be helpful. Although the pain of FM can be debilitating at times, you and your healthcare provider can find many ways to relieve the symptoms and get you back to your normal activities.


When should I see a doctor?

Keep in mind that staying active with your normal activities is the best thing you can do to limit the effects of fibromyalgia on your life. You may have to modify the way that you perform certain activities of daily living, slow down your pace and intensity of physical exercise. However, you need to keep moving and exercise within the limits of your abilities. Many FM patients find that gentler forms of exercise are better tolerated, such as Tai Chi and Yoga. Avoid intense or aggressive forms of exercise, such as high impact aerobics or heavy weight lifting.Proper sleep hygiene is an extremely important component to the successful management of FM. You should avoid excessive amounts of caffeine and alcohol, as these substances can alter your normal sleep cycle. Regular exercise can be a helpful aide in promoting good sleep. It is important that you try to maintain a normal bedtime and time to awaken in the morning; keeping to a routine sleep cycle is very helpful. Some patients will require certain medications for improving their sleep, which should be discussed with an appropriate licensed healthcare provider. Emotional stress and depression tend to afflict many FM patients. Taking classes in stress management, mindfulness meditation, yoga, and relaxation therapy may be very helpful in the self-management of these emotional states. Some FM patients will have severe depression and/or anxiety that need to be treated with therapeutic doses of anti-depressant or anti-anxiety medications often in conjunction with a licensed psychologist or psychiatrist. It is important to note that this does not mean FM is a psychiatric condition; patients will simply find it easier to cope with their FM symptoms when their mental health needs are addressed. Many FM patients experience specific areas of muscle pain, in addition to the overall sense of widespread pain and fatigue. For these discrete areas of muscle pain known as myofascial trigger points, various types of massage or manual therapy can be very beneficial. As a rule, most FM will not respond well to heavy or aggressive types of deep tissue massage. Instead, FM patients should consider lighter forms of massage that do not involve deep friction or stripping of the tissues. Deep breathing and relaxation, along with massage, can aide in the relaxation of tight painful muscles.

Rehabilitation
The FM patient can benefit from the assistance of a trained rehabilitation specialist who understands that FM must be addressed with more gentle types of exercise than other patients with musculoskeletal pain. It is important for both the FM patient and their rehabilitation specialist to understand that “hurt does not mean harm”. FM patients can expect to experience a modest amount of post-exercise soreness, but this should not be excessive or debilitating. As a rule, exercises should be performed at a very low intensity and gradually increased to a level that is tolerable for the FM patient. Mild aerobics and strength training are indicated for the treatment of FM, with many patients reporting that yoga and tai chi exercises are excellent adjuncts to a standard rehabilitation program.One simple way to get started with an exercise program is begin a daily walking program. You could start by walking just 5 minutes the first day, and gradually keep adding 2-3 minutes per day until you are walking 30-40 minutes a day. When the weather is bad, you can substitute the use of a stationary bicycle indoors. Keep track of your time on the bicycle and set a goal of reaching 30-40 minutes. Some fibromyalgia patients prefer to exercise in the water, by treading water, swimming a few laps, or taking a beginner’s water aerobics class. One benefit of pool based exercise is the fact that the buoyancy of the water takes a lot of pressure off your joints.The type of exercise you choose is up to you. It's important that you start exercising and keep doing it. Exercise relieves much of the pain fibromyalgia causes. Some people even find that exercise makes all their pain go away. You will also feel better if you have some control over your own care and well-being, by doing things to help yourself get better.

Sources from Clinicalrehabspecialist.com

FAI – What is it & why we are seeing more of it?



On September 13, 2011, in Controversies, Hip, Overuse Syndromes, by Craig Liebenson
Femoral-Acetabular Impingement (FAI) is an increasingly popular diagnosis for patients with stubborn hip problems. Hip replacement surgery has been a great advance, but recently the hope for it being a panacea has been dashed. Now, surgeons are diagnosing FAI in many aging athletes & weekend warriors. What is it? How do we diagnose it. And, how can we treat it?

WHAT IS IT?
FAI is a wear & tear injury from repetitive strain.

HOW CAN WE DIAGNOSE IT?
There are no specific diagnostic tests for it, however groin pain is one signature of it’s presentation. According to the revolutionary hip surgeon from Colorado Dr Philippon “A positive impingement test was defined as groin pain with 90 degrees of hip flexion and maximal internal rotation.”.
He also states that the Faber Test can be positive – limited & painful abduction & external rotation.
X-rays may show bony reaction on the femoral head or neck, and on the acetabular rim.
MRI can reveal fraying or tears of the cartilage and labrum.

FAI has to be distinguished from Hip Dysplasia (HD), and a Labral Tear (LT).

HD is present if the hip socket -acetabulum – is too shallow for the ball – femoral head. It is a congenital condition. This can be associated with tearing of the labral and articular cartilages. There should be laxity & instability.

A LT can be visualized on an MRI and can occur with AFI or HD. Like FAI, pain with hip flexion, internal rotation and adduction are hallmarks. The MRI finding of a LT does not mean there is a clinical problem since is it is present in many asymptomatic individuals.

Since tears can be asymptomatic and dysplasia occurs with instability when we have restricted or painful motion FAI is a reasonable working diagnosis.


HOW CAN WE TREAT IT?
Surgery is not the first choice, but last resort. Conservative care should always be considered

option 1.
Activating the posterior chain in order to “check” uncontrolled or excessive hip flexion is a key.
Integrated core activity with lower quarter control is a “no brainer”.

Frontal plane stability
Visualization training for movement education of the hip
Regarding acetabulo-femoral amnesia this is inspired by Eric Franklin’s movement education work. Most people have no idea where their hip is. When they learn it’s actual location it becomes much easier to train the hip hinge and activate the posterior chain. This is an example of the neuro-matrix whereby an new neural signature is created via motor control training.

WHAT IS THE ROLE OF MUSCLE IMBALANCE?
It is unlikely that FAI caused by muscle imbalance, however muscular compensations such as gluteal inhibition are typically present. Pr Janda put our attention on the gluteus maximus (posterior chain), gluteus medius (lateral chain) & abdominal wall (anterior chain) with his revolutionary work from the 1960′s. Today, our terms have changed – posterior chain, frontal plane stability, and functional core control, but it the same faulty movement patterns which Pr Janda the Father of Rehabilitation Medicine spoke about.


HOW CAN REHAB BE PROGRESSED TO RETURN TO SPORT & SELF-CARE?
First, identify quad dominance. Check where the patient “feels” squats, lunges, balance reaches, etc.. Most patients only feel their anterior thighs. This is our trigger to commence a posterior chain facilitation program. There are “many roads to Rome”. Find what works best. I am not about methods, but principles. If you know the goal you will find the means.

A few ideas though would include – 2 & 1 LDLs; functional reaches; 2 & 1 leg box squats; reverse lunge steps; Rear foot elevated split squats; monster walks, and bridges.

Second, ensure integrated core-lower quarter control. Planks; Supine foam roll marching with med ball chest press; 2/1 Hamstring bridges & curls with the gym ball; Kolar dying bug vs the wall; and Nordic or Russian eccentric hamstring lowers.

Third, determine if lateral hip stability is present check single leg balance for pelvic unleveling. Then, look at single leg squats to see if pelvic unleveling leads to medial knee collapse occurs. Third, check side lying hip abduction to determine if there is gluteus medius insufficiency or asymetric strength. Training can include clam shells; lateral band walks; kettlebell carries, posterior-lateral balance reaches (5:00 or 7:00).

If these 3 fundamental components can be mastered, then to maximize functional stability plyometric control must be ensured. This is essential for athletes as a functional test of improved stability resulting from the initial rehab. If the stretch-shortening cycle is sluggish overload will occur at the “weakest link” – achilles, anterior knee, or hip. Start with 2 legs jump squats; scissor lunges; and 360 degree jump squats. Progress to lateral hops, diagonal X-Hops; and single leg hop and holds.

For functional training once plyometric stability is ensured begin to build power by utilizing triple extension exercises such as Waterbury’s High Pull.
The key is to train for power by finding the athlete’s 10 RM then train only as many reps as can be performed at top speed without breaking form. The 1st set might by 6-7 reps. When performed as part of circuit of perhaps 3 exercises with each successive set the reps performed will drop before speed or form decays. 5 sets are ideal and if the initial RM was chosen wisely a Russian Reverse Pyramid of training will have occurred naturally. For instance, Set 1 – 6 reps; Set 2 – 5 reps; Set 3 – 4 reps; Set 4 – 3 reps; Set 5 – 2 reps. Grand Total of reps might be 15-20 reps. To increase power start by finding the 7-8 RM, so Set 1 at top speed is likely to be only 5 reps. Individualize this to the patient’s capabilities and demands.

Sources from craigliebenson.com

The Web of Life

Just beneath your skin lies a complex network of connective tissue called fascia. It helps you move well, stand straight and play hard. Keeping it healthy might be one of the fastest — and most overlooked — ways to improve your health and fitness.

Features,
There’s a good chance you’ve never heard of fascia: the stretchy, mesh-like substance that interweaves through and around your musculature, surrounds and supports your organs, and shrink-wraps your entire internal structure like a second skin.But if you were able to peek beneath your epidermis, you’d probably be surprised to see that this messy, elastic white stuff

— made of collagen fibers, and similar to the material that makes up your ligaments and tendons — is virtually everywhere.Unlike muscles and bones, though, fascia has historically been given so

little attention by therapists, trainers and other fitness pros that it’s not even on the standard gym-wall anatomy chart.“From an anatomical perspective, fascia is often seen as ‘the gunk you cut through to get to the good stuff,’” says corrective exercise specialist Anthony Carey, MA, owner of Function First in San Diego, Calif., and a leading fascia expert.In recent years, however, some forward-thinking trainers and therapists have begun to recognize that this seemingly inconsequential webbing plays a far more important role in everyday functioning than was once believed.Building on ideas outlined by anatomy teacher and bodyworker Thomas Myers in his book Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists (Churchill Livingstone, 2009), these therapists have begun to devise ways to improve the quality and elasticity of the fascia directly through bodywork, stretches and targeted exercises.Among these novel methods are Kinesis Myofascial Integration (KMI) — an approach to Rolfing developed by Myers — and Fascial Stretch Therapy (FST), founded by the husband and wife stretch-therapy team of Chris and Ann Frederick. These methods can significantly enhance the benefits of a stretching and strength program, making you stand taller, run faster and play harder. At the same time, fascial work often provides relief from chronic back and joint pain where many more conventional, muscle-based stretching and massage methods fail.“Everybody needs to start incorporating the fascia into their conception of the musculoskeletal system,” says Myers. To his way of thinking, however, that may mean a fairly substantial shift in the way we think about how we’re made and how we move.So if you still think “the foot bone’s connected to the ankle bone,” get ready to expand your thinking.

Facing the Fascia
Anatomy textbooks will tell you that the musculoskeletal system consists of thousands of separate parts: a couple hundred bones held together by more than 600 muscles and a near-countless number of ligaments and tendons. But Myers and Carey both assert that these divisions are largely artificial, created not by nature but by an anatomist’s scalpel.“The fascia links the entire muscular system, not just muscle to bone but muscle to muscle, along with all the structures in the body, like organs, ligaments and tendons,” says Carey. “Whether you’re exercising or treating pain, it doesn’t make sense to treat it like a machine with separate parts because of this head-to-toe continuity.”Seen from this perspective, Myers contends, “You don’t have 600-some-odd muscles, as we’ve always been taught: You have a single muscle with 600-odd stopping points, all linked by the fascial web.”Far from the haphazard mesh that the first anatomists perceived, this fascial network is now described by researchers as sensitive, dynamic and extraordinarily adaptable. “There are 10 times as many more nerve endings in your fascia as there are in your muscles,” says Myers, making fascia far more susceptible to pain and sensation in general than your muscles are. “Most sports injuries are in fact failures of fascial structures, not muscle tissue.“We say ‘muscles attach to bones,’” he continues, “but muscle can’t attach to anything. It’s formless, like hamburger. It’s the fascia that goes over and around and through your muscles that organizes that tissue into linear pulling machines.” When you perform a biceps curl, for example, the fascia of the biceps muscle shortens, tugging on your tendons and drawing your hand closer to your shoulder. And when you perform a quick, athletic movement — a layup in basketball, for instance — it’s the whip-fast elastic action of the fascia in your legs that transfers the force of those contracting muscles into the floor and launches you off the hardwood.Through decades of experience as a bodyworker and an extensive study of anatomy, Myers began to notice that the fascial webbing appeared to be organized into distinct meridians, or “trains” — dense bands connecting multiple muscles and spanning multiple joints, tacked down at numerous bony “stations” along the way. If you were to think of the entire fascial network as a suit of clothing, these “anatomy trains” would be a series of elastic straps, suspenders and seams that give it structure and shape. Myers has found about a dozen of these fascial superhighways, which seem especially effective in understanding human movement and treating pain and dysfunction. Some run the length of your body, head to toe; others spiral the torso, shoot over the top of your head, and run down the middle of your back.Like guy-wires on a well-rigged boat, a balanced, harmonious tension among these myofascial meridians helps support fluid, effortless movement. Too much chronic tension or slack in key meridians can, however, lead to poor posture and pain — and not always in the places you expect. Trace the fascial lines through the muscles and across the skeleton, and it’s possible to see, for instance, how shoulder pain might be caused by dysfunction in your opposite ankle, or how “tight hamstrings” might actually be caused by tension in the soles of the feet.According to Myers’s model, it is through these myofascial lines, moreso than through individual muscles, that the body adapts to and reinforces alignment and movement. Says Carey, “Fascia adapts to every move you make — good, bad or indifferent.” Over time, a competitive rower, for example, might develop thicker fascia in her back and shoulders to support the repetitive movement of pulling oars. The fascia in the front of the rib cage of your typical desk jockey, on the other hand, may become thick and short to reinforce a habitually caved-in posture. And injuries, even minor ones, often result in fascial “patches” in the muscles that can cause restricted motion, leading to compensations in gait and movement. These might remain long after the injury itself has healed.“Injured or poorly adapted fascia can start to act like glue, binding to muscles, other fascia, even your ligaments,” says Carey. In a sense, your entire individual life history — exercise habits, injuries, common sitting and sleeping positions — is written in your fascia. Depending on these and other behavioral factors, fascial adhesions can subtly accrue over years and decades, leading to movement inhibition and sometimes chronic pain.“Certain things in our bodies become tight, certain things become weak, and before you know it, our joints and limbs begin to make subtle twists and turns, making us a human game of Jenga,” jokes Sue Falsone, vice president of physical therapy at Athletes Performance and Team Sports in Phoenix.

The Tangled Web

So, think you might have a few kinks in your fascia? In a sense, if you’re already exercising and stretching regularly, you’re ahead of the game. “Muscles and fascia are so interwoven that you can’t affect one without affecting the other,” says Falsone.Nevertheless, standard, static stretching and muscle-isolating exercises, while beneficial in some ways, often have little effect on deeply ingrained fascial tension, especially if, like most people, you spend a large portion of your day sitting down.“If we spend months, years, even decades sitting at a desk and think that a few hours in the gym per week are going to undo all that, we’re probably fooling ourselves,” says Carey. Stretching a muscle with bound-up or poorly adapted fascia is a bit like trying to stretch a knotted bungee cord: You’ll get much better results if you get the knots out first.Some of the best methods for untying these knots take a therapeutic approach, in which a practitioner works with an athlete or client on a massage-style table. Other methods have the client participate more actively, moving and stretching him- or herself in fascia-friendly patterns.“Table work helps a client find more pliability and elasticity throughout the body,” says Carey. “Exercises help the client integrate the new range into their daily lives.” (For suggested exercises, see the Anatomy Trains at Work sidebar.)Although KMI and FST are among the first treatments to fully integrate Myers’s anatomy-trains concept into their methodology, other treatments have had measurable impact on the suppleness of the fascia, including active release therapy, resistance flexibility and strength training, and even self-myofascial release with foam rollers and other implements. As Myers’s research gains wider recognition, it’s likely that massage therapists, bodyworkers and trainers in other fields — from yoga to Feldenkrais — may well begin to emphasize fascial relationships in their teachings as well. (For more on Feldenkrais, read “The Feldenkrais Fix.")Myers’s KMI approach, which builds on the Structural Integration model developed by Ida Rolf (of Rolfing fame), takes the form of about 12 structured, progressive hands-on sessions with a KMI-certified practitioner. Initially, the practitioner takes photos and makes detailed observations about the client’s carriage and posture, noting especially where his or her fascial meridians appear shortened or contracted. From that point, each session focuses on a specific area of the body, starting with more superficial muscles, working gradually inward toward the core as the sequence progresses, and, finally, incorporating fully integrated movement.Throughout the treatment, the practitioner manually works out the fibrotic knots and scarring in the fascial tissues, restoring balance among the meridians by applying direct, sometimes fairly intense, pressure directly along the affected fascial lines. Although treatment can be painful at times, the results often feel terrific. Many people report marked improvements in everyday activities like sitting and standing, and even more impressive strides in active pursuits.

Flexibility Reclaimed
Forty-seven-year-old Nancy Di Benedetti, from Calgary, Alberta, began her KMI treatments with therapist Nadine Samila with the goal of touching her toes. “After the first session I was already walking differently. And after 12 sessions not only was I able to touch my toes, but I actually started skiing again,” she says.Chris and Ann Frederick bring to bear many of Myers’s principles in their Fascial Stretch Therapy (FST) system, which takes an unusually gentle approach to athletic flexibility training. “When you stretch too quickly or intensely, as many athletes do, the muscles go into a protective mode, contracting and resisting,” says Ann. “To get around these protective mechanisms, you’ve got to romance — not attack — the nervous system for optimal results. If the client is in a relaxed, calm state, his or her muscles and connective tissue will be much more responsive to the work. So you can’t yank on a muscle or deliberately push past a person’s comfort zone.”In practice, FST can be almost dancelike, as the practitioner slowly and rhythmically moves the client’s limbs in a series of slowly expanding arcs.These gentle, oscillating movements can elicit a soothing, parasympathetic response from the client’s nervous system, much like rocking in a chair or swinging in a hammock. “I never push the joints to their limits. I just gently test the boundaries of what’s possible for them at that moment,” says Carey. “A rhythmic tempo lowers apprehension, allowing the trainer to get past resistance in the fascia and into the muscles themselves.”This calm state also primes the client for learning new movement patterns, while at the same time, the broad, multidimensional movements stretch the entire fascial fabric in ways that conventional, single-plane stretching and many other types of therapy don’t.“I once worked on an insurance executive who had knee pain from years of high school and college athletics. His doctors were at a loss because the joints themselves seemed fine,” says Chris Frederick. “Through soft-tissue work and some well-chosen stretches, I was able to create space in his hip joints and relax the tension in his hip flexors, which took the pressure off his knees. And the pain he had had for 10 years was gone.”Frederick emphasizes that treating the whole person — rather than a single symptom or a single part of the body — can often mean paying attention to issues farther up and down the various meridian lines from the site of pain or dysfunction: “Where there’s pain,” he says, “ain’t usually where the problem is.”

DIY Anatomy Trains
Although working with a qualified therapist is the best way to deal with acute problems in the fascia, smart exercise choices involving the fascia can also help address some imbalances.One very effective option is to focus on full-body movements like Olympic lifts (and their regressions) and medicine-ball throws. Working with implements like battling ropes, Indian clubs and kettlebells, rather than trying to build or work different body parts in isolation, can also be helpful. Many of these movements require a dynamic transfer of force from the ground, through the body, and out through the arms or hands, in a pattern that simulates a wave. Done correctly, these wavelike motions parallel the sequential, muscle-to-muscle transfer of force that occurs along the fascial meridians just below the skin. As a result, they help reinforce healthy, integrated relationships among the myofascial meridians.You can approach flexibility training with a similar mindset: Rather than stretching one muscle group at a time, think about stretching an entire plane of the body at once, and of long movements that extend and spiral the body head to toe.Myers recommends stretching in multiple planes, adding rotation of the feet to a toe-touching stretch, for example, in order to more fully stretch the fascia across the hamstrings, calves and lower back. The asanas in yoga and the gentle oscillations of Feldenkrais are good examples of fascia-releasing work that helps enhance flexibility. (For more specific exercise and stretching choices, see the “Anatomy Trains at Work,” sidebar.)For greater suppleness throughout the fascial network, Myers also encourages people to incorporate bouncing of some kind in their workouts: skipping rope, jogging, jumping on a trampoline. “You lose elasticity in your fascia as you age. Kids exemplify that bouncy elasticity in their fascia, and bouncing helps you hold on to what you have.”Variety, however, may be your best safeguard against tightness and adhesions in the fascia, notes Myers: “If there’s one thing I could say to people who wanted to get fit or stay fit, it would be ‘Stop repeating yourself!’”Repetitive physical action — including forms of exercise like running or cycling — can leave its mark on the fascia, unnaturally tightening certain areas and eventually leaving you more susceptible to injury. The take-home lesson? Mix things up. Hike or cycle on uneven terrain, switch strength-training exercises frequently, and seek out new ways to move, through dance, sports, martial arts or other activities.For some time now, progressive fitness professionals have been emphasizing integrated forms of exercise, from dynamic flexibility work to full-body strength training to outdoor exercise and Eastern-style movement. In a sense, the anatomy-trains model represents the anatomical basis for this approach: Just as the fascia links the muscles together in interconnected chains, so integrated exercise and movement link the muscles functionally, through dynamic, coordinated movement patterns.In all likelihood, the more we can shift our perspective to see the body that way — as a whole system working together — the healthier we’ll be.

Anatomy Trains at Work
To experience the interconnectedness of your own fascial webbing, try some of the following exercises, and consider building similar moves into your workouts. Activities that include long, sweeping patterns, full extension of the limbs, and spiraling gestures through the torso (notably yoga, tai chi and Feldenkrais) can enhance awareness and foster optimum balance of your body’s major fascial lines. Many types of dance as well as racquet and ball sports, which require jumping, leaping, throwing and reaching, also have similar benefits.

"The World's Greatest Stretch"

• Stand and step forward with your left foot into a deep lunge position.

• Lean forward and place both hands on the floor, with your left knee outside your left arm and shoulder.

• Keeping your right leg straight and your back long (aim for a perfect line between your head and right heel), gently press your left elbow against the inside of your left knee for a two-count.• Still keeping your right leg fully extended, slowly straighten your left leg as much as possible, rocking your weight back onto the heel of your front foot. Hold for a two-count.

• Rebend your left knee and lift your torso from the bent-over position, assuming a standing lunge position with your right knee floating 2 inches off the floor. Hold for a two-count, then step forward with your right foot and repeat on the opposite side.

• Perform six to eight repetitions on each side.“The World’s Greatest Stretch,” recommended by Sue Falsone, vice president of physical therapy at Athletes Performance and Team Sports in Phoenix, mobilizes both front-of-the-hip and back fascial lines in their entirety, head to toe.Side

Bend with Rolling Feet

• Stand upright with your feet parallel and about shoulder-width-and-a-half apart.• Keeping your hips and shoulders square, reach your right hand directly overhead.

• Perform a side-bend to your left, reaching your right arm over your head and as far to your left as possible.

• Once in this position, roll both feet to the right, shifting your weight onto the outside edge of your right foot, and the inside edge of your left foot. Hold for 10 seconds and repeat on the opposite side.Although the standard side bend is traditionally seen as a stretch for the lats and obliques (the muscles on the sides of your torso), rolling the feet in this position — which inevitably intensifies the stretch — makes it clear that you are in fact extending a unified fascial line that extends along the side of the body from the outside edges of your feet all the way up to your ear.

A Better Hip Mobilization

• Lie flat on your back on a firm surface. Bend both knees with feet flat on the floor.

• Lift your right leg in the air.

• Take hold of your leg with both hands — behind your knee, on the outsides of your thigh, or wherever feels comfortable.• Keeping your neck relaxed and your head on the floor, gently pull your leg toward your upper body until you feel a gentle stretch.

• Maintaining your hold on the leg, gently rotate your foot, circling your leg to the outside, then to the inside of your torso.

• Continue to experiment with easy movements of your leg in whatever range and plane of motion feels comfortable for about two minutes, then repeat on the other side.Many people stretch their hips and hamstrings in one plane of motion: generally straight forward (as in, touch your toes). Since the fascia runs through and around the entire musculature, it can be more thorough to stretch in this multiplanar way: up, down, forward, back. And, avoiding the pain threshold can be more effective because you fly beneath the radar of the protective mechanisms of the joints, which tighten and shorten muscles when you stretch forcefully.

Snuffing Out Fascial Inflammation
Long-term inflammation and irritation in the fascia — the intricate web of connective tissue that holds your body together — is fairly common, and can sometimes aggravate and make worse certain arthritic conditions.What causes fascial inflammation? “No one knows for sure. It’s partly genetic, but it’s often related to overdoing one particular type of movement,” says Nadine Samila, a practitioner of Kinesis Myofascial Integration (KMI) and Myofascial Release Therapy (MRT) from Calgary, Alberta.Inflammation and tightness in the iliotibial, or “IT,” band (the thick fascial strap that runs along the outside of your thigh), for example, is common in avid runners. “A tight IT band can pull the kneecap off its track, which irritates the knee joint and can eventually lead to arthritis,” says Chris Frederick, PT, coauthor of Stretch to Win (Human Kinetics, 2006). Similarly, habitual slumping and slouching can cause the fascia in the front of the chest to shorten and tighten, restricting freedom of movement in the arms and shoulders. Desk-sitters, for example, will often be unable to reach behind themselves comfortably from a seated position because the fascia in and around their pectoral muscles is so short and tight. As a result, the smaller, weaker muscles of the rotator cuff can get strained or injured, even during seemingly harmless movements. “I’ve had clients who have torn their rotator cuffs trying to reach something in the back seat of their car,” says Frederick.Perhaps the worst-case scenario of fascial inflammation is called compartment syndrome, which is a restriction of the fascia surrounding the muscles of the lower leg. It often occurs in seriously overtrained athletes and exercisers. Let this condition go on too long, says Frederick, “and you could even lose your leg.”But it’s plain old inactivity that causes the most fascial troubles. Healthy fascia is well hydrated and smooth, like the fine membrane that covers fresh, uncooked chicken. But the connective tissue in older and inactive people, explains Samila, “gets fuzzy and sticky, like cobwebs. It doesn’t move well. That’s partly due to age, but inactivity makes it much worse. We just don’t move enough!”The antidote? Move. As much as you can, and in as many different ways. “The more you move, and the more ways that you move,” says Samila, “the more you keep the fascia soft, hydrated, and healthy.”

Tennis Ball Trick

• Perform a standing toe-touch in bare feet, with your knees soft, and note how far down your legs you can comfortably reach without straining.

• Stand, and carefully roll the bottom of your right foot over a tennis ball, paying particular attention to spots where your feet are tender or sensitive. Hold on to something stable for balance if necessary. Continue for at least a full minute, then repeat on the left foot.

• Perform the standing toe-touch test again.Fascia Facts: After a quick foot massage, many people will feel as though their hamstrings suddenly got looser. The hamstrings are affected as the tennis ball helps loosen the Superficial Back Line as a whole, a fascial train that runs from the bottoms of your feet to your head, allowing many people to reach further on their second try.

By Andrew Heffernan, CSCS / November 2011

Soft (and Not-So-Soft)-Tissue Overview

In my opinion, quality chiropractic care begins with combining soft-tissue techniques with joint manipulation and rehabilitation exercise. Muscles move bones. If you are not addressing the dysfunction in the muscles, your adjusting is much less likely to have long-term success.
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This article, the first in a series on soft-tissue techniques, reviews some of soft-tissue methods I have been introduced to over the past 35 years.
One underlying theme when it comes to the various soft-tissue methods is that pain is a liar. The pain generator may be the local joint, or the nerves affected by disc pathology or impingement, but we need to look beyond that. "He who treats (only) the site of pain is lost" has been attributed to Lewit. Research proving that soft tissue is the source of a particular pain is difficult. Sometimes the pain generator can be identified, but the question remains, what is pulling on the pain generator?

Clinical confirmation that a particular soft-tissue restriction is significant to the patient's complaint is not so difficult. My usual protocol for difficult conditions is fairly straightforward. Find a functional test, a limited ROM, a difficult motion, that relates to the main complaint. In addition or as a substitute, find one or more tender points that are in the area of pain. Next, do your search pattern, whatever that is. You can use palpation, AK- style muscle testing, Barral's "listening," logic; whatever.

Find an area of soft tissue, either nearby or distant, that you suspect relates to the symptomatic area. You could do the "treatment test" in one of three ways:

briefly treat the soft tissue;
completely treat the soft tissue; or
hold the soft tissue in the direction you think will help.

Treatment could be Graston Technique, myofascial release, or just finding the barrier and holding the lesioned area toward the barrier or away from the barrier (indirect).
Having initiated the "treatment test," now go back to the original functional test or tender points and recheck them. Are they somewhat improved? If so, this area is significant to the patient's complaint. If not, find other areas you suspect may be involved.

The goal of this protocol is to individualize treatment to the patient, to their particular set of fascial patterns. There is good research suggesting that identifying a treatment that works during the clinical session helps make any therapy more effective.1-2

Soft-Tissue Techniques
Let's briefly review several soft-tissue techniques with which I am familiar. Keep in mind that this list is not complete; there are many brilliant therapists who have either invented or evolved different systems.

I divide soft tissue into low-force and higher-force methods. Although I tend to prefer to do most of my joint manipulation with low-force methods, I like and appreciate both low-force and higher-force soft-tissue methods. I suspect that they do different things.

Craniosacral therapy: Lower-force soft-tissue methods probably start with craniosacral therapy and variations on it. Cranial has many variations; it can be a therapy that focuses on the bones of the skull or it can be a therapy that feels for a particular rhythm, and disturbances of that rhythm. The rhythm is seen as the motion of the fluids, a cranial respiratory motion, and expansion and external rotation of the whole of the body, followed by a contraction and internal rotation of the whole body. This is thought to start in the cerebrospinal fluids and spread throughout the body.

Myofascial release: Another popular low-force fascial method is myofascial release. Popularized by John Barnes, PT, it uses a gentle, long three-dimensional release. You could it call it fascial stretching, but it is much more sophisticated than that.

Strain-counterstrain: Another low-force method is strain-counterstrain. This was developed by Lawrence Jones, DO, around 1955. The points are named after joints, but most of the points are in muscles, tendons, ligaments or fascia. It seems to be particularly effective on spots that are extremely tender to the touch. You fold and hold, or slack the tissue, until you find a position at which the point is much less tender. Then hold the positioning for 90 seconds while monitoring the point. When you are done, the tender point is usually gone. It is postulated that the original strain left the muscles spindles or GTOs in an aberrant set point, and that slacking the tissue helps reset them.

Visceral manipulation is another of my favorites, although not as well-known. Visceral was developed by a French osteopath, Jean Pierre Barral. He postulates that the fascia surrounding the visceral organs can become restricted, and developed sophisticated anatomically based techniques to release these restrictions. I find that I use this technique mostly for musculoskeletal pain, and that often, these visceral restrictions can be key soft-tissue lesions keeping the musculoskeletal system from healing. A related method is scar tissue therapy. Here, one would use slow three-dimensional myofascial release on old scar tissue. Again, the theory is that active scar tissue can have profound distant effects.3

Fascial release techniques can be divided into direct and indirect techniques. Direct techniques involve finding the barrier and doing your manual release toward the barrier, feeling the barrier recede and melt. Indirect techniques take the tissue in the direction of ease, away from the barrier. Counterstrain is always done indirect. The others mentioned above are usually done as indirect, but can also be done as direct methods. I've noticed that chiropractors tend to prefer direct techniques. This may be secondary to our training in high-velocity manipulation.
During the early years of my career, I focused on both low-force manipulation and low-force soft tissue. This changed when I was introduced to Graston Technique. Once it began to grow in the chiropractic profession, GT really changed the playing field. The concept of using instruments to perform soft tissue spread rapidly, throughout both the chiropractic and the manual therapy field. Gua sha, the Chinese medicine version of instrument-assisted soft-tissue manipulation, became more popular. The verb form, to Graston, although it has not yet made it to the dictionary, began being used by soft-tissue therapists.

I have continued to use Graston Technique, and the more generic instrument-assisted soft-tissue manipulation (IASTM), and have added other more direct, somewhat more physical methods of soft tissue. More direct, more physical methods would include FAKTR, active release technique (ART), Stecco's fascial manipulation, Rolfing and other deep-tissue methods. Any article on soft tissue should mention both Janet Travell, who popularized trigger-point therapy, and Raymond Nimmo, DC, a chiropractic pioneer who developed receptor-tonus technique.
There is good evidence that pressure changes tissues, both on the gross level and on a subcellular level. Breaking up fascial adhesions can be done with both low-force and higher-force techniques. Once you start to use deeper, higher pressures, you add an additional component. You can restart first-stage healing, re-initiating the acute self-limiting inflammation that is an important part of the healing that occurs after an injury. Pro-inflammatory techniques require further explanation to the patient, as the patient can be very sore for a day or two after treatment. These methods can be dramatic in starting the healing process for chronic soft-tissue injuries.

Active release technique (ART), developed by Michael Leahy, DC, is a popular technique within chiropractic, especially within chiropractic sports medicine. ART could be called pin and stretch, as the doctor holds the point or area, as the patient moves the limb or body. ART was one of the first soft-tissue methods I know of that incorporated active motion on the part of the patient during soft-tissue treatment.

FAKTR: Functional And Kinetic Treatment with Rehabilitation, including provocation and motion, is another deep-tissue method, developed by Tom Hyde, DC, and Greg Doerr, DC.4 It was originally presented as an advanced methodology for using Graston Technique.
What I love about FAKTR is how it blurs the lines between passive soft-tissue therapy and active care. The patient is not just having something done to them. FAKTR treatment is unique, as it is done during functional ranges and functional activities. An example would be treating the soft tissue of the shoulder and scapula during a baseball pitcher's pitching motion.
The diagnostic aspect of FAKTR involves using the kinetic chain, following the movement pattern throughout the body. Try to imagine how pulls on the fascia transfer aberrant motion patterns throughout the body. The goal, of course, is to truly resolve the injury, not just treat the pain or loss of motion.
The algorithm of FAKTR follows the outline I mentioned above. Of course, you would start with history and then do a functional screening. Treatment is diagnostic; go back and retest and retreat, and see what changes after the initial treatment. This five-step outline illustrates how FAKTR is really unique:
Take them into position of provocation; not just pain, but also imbalance, instability and/or restrictions (loss of ROM).
Find the motions of provocation (dynamic).
Add in resistance, isometric and/or concentric and/or eccentric. As you treat, you'll feel the texture of the tissues change.
Do your actual soft-tissue treatment while the patient is doing the functional motion, such as working on the various soft tissues as the pitcher goes through their pitching motion.
You can add in further proprioceptive and perturbation inputs, such as having the patient stand on unstable surfaces during treatment.
I really like this concept. It is all about creating increases in afferent input, magnifying the proprioceptive bombardment. I will admit that I tend to simplify it and do it on my treatment table most of the time. For example, when I am releasing the piriformis area, the patient is side-lying, and I will have them abduct their leg against my resistance, and then let the leg back down toward the table while I am doing my IASTM. It tends to feel more painful to the patient, but tends to release more completely.

These concepts can be applied to any age group and with almost any soft-tissue technique. You can even use the FAKTR concepts with passive modalities, such as laser or estim, making them more active and adding the increased proprioceptive input.
There is so much growth happening in the field of soft tissue, both within and outside of our own profession. I encourage you to help more patients and expand your toolbox by using more soft-tissue techniques.

By Marc Heller, DC

References
Tuttle N. Do changes within a manual therapy treatment session predict between-session changes for patients with cervical spine pain? Aust J Physiother, 2005;51(1):43-8.
Liebenson C. "The Role of Reassessment: The Clinical Audit Process." Dynamic Chiropractic, July 1, 2010.
Lewit K, Olsanska S. Clinical importance of active scars: abnormal scars as a cause of myofascial pain. Journal of Manipulative and Physiological Therapeutics, July-Aug 2004;27(6).
Thanks to Drs. Greg Doerr and Tom Hyde for the classes and conversations that informed this part of the article.