By Marc Heller, DC
Fascial manipulation (FM) is a systematic approach to soft-tissue work evolved over 30 years by Luigi Stecco, an Italian physical therapist.I'll start out with my thoughts on this treatment approach in the format of a Web review. My rating is 4.5/5 stars; very good.
Pros: It's a unique way of looking at the soft tissues. An amazing map of the body, identifying many significant fascial points that most of us in the soft-tissue world have not previously looked at. A clear-cut end point for the therapeutic soft-tissue session; when the treated points have decreased in tenderness by 50 percent and have markedly softened, you are done. A treatment strategy that, in my limited experience, seems to completely eradicate the fascial densifications. The problem points, once treated, do seem to "hold" and not recur or require multiple treatments.
Again, in my limited experience, this work seems to make a significant clinical difference, helping some of my most chronic patients I was previously unable to help. It is a commitment to an evidence-based approach and to understanding the underlying biological process, with research into fascia and several peer-reviewed papers.
Cons: It is a bit too much of a "technique" for me; the work is taught as a freestanding methodology, without integration of rehab, joint manipulation or other soft-tissue techniques. (I recognize that to bring something new into the world requires singular focus over the long haul; Stecco certainly has that quality.) Additionally, the work can be painful to the patient. I am not saying that one should not do it for that reason, I am just noting a downside.
Is this just another variation on soft-tissue / fascial work? Fascial manipulation goes beyond the usual soft-tissue approaches in a couple of ways. One is the extensive dissection studies of unembalmed cadavers that have been done by the Stecco family, well-pictured in his texts. Stecco has studied the fascia in a comprehensive and direct way. FM is not just a new way to push on muscles, but a more comprehensive systemic approach to the influence of soft tissue on pain syndromes in the body. There is a correlation between pain patterns, tender and dense points, and functional testing, with movement and resistive testing to guide your treatment.
The treatment is not necessarily applied to where the patient hurts, but involves a search pattern based on the extensive mapping that Stecco has provided. The emphasis is multifactorial. The doctor is taught to look and test at old trauma sites and see how they may contribute to current fascial problems; and to look above and below the site of pain. The doctor is also reminded to look at the antagonist muscles and fascia.
Stecco has also extensively reviewed the existing literature on fascia and connective tissue. His large body of work includes several books, including two in English, and multiple articles in peer-reviewed journals. He has many new hypotheses about what we are doing to soft tissue, and how it works. He is not just a another technique guru, but one of those rare practitioners who has both a scientific mind and is a profound clinical innovator.
I have always been attracted to and appreciated systems that recognize pain is a liar. My interest in applied kinesiology, visceral manipulation and other systems has been in search of the Holy Grail: What is underneath this pain? I think and hope that Stecco has really advanced our understanding of what causes pain and what we can do to help effectively treat chronic musculoskeletal pain.
Stecco says search the fascia in a more comprehensive way. Once you have found the significant points, completely erase them. I have always done my soft tissue quickly. I assumed that once I initiated a change, once I began to feel the soft tissues melt or change, the body could complete the process. In FM, first you find a dense and tender point or small area that correlates with the functional testing and the pain pattern. You then treat it with a combination of 80 percent compression and 20 percent oscillation until the tenderness has diminished at least 50 percent, and the density of the knot is gone. This process, which is painful to the patient, takes between two and five minutes.
This work, like most deep-tissue techniques, is both painful and pro-inflammatory. This requires explanation to the patient. It is OK if they are sore or even hurt like heck the next day. The Steccos have looked at the literature and have fascinating evidence-based theories about this component. One, there is a cycle of about 48 hours of inflammation that centers around the hyaluronic acid system, found in the ground substance. I don't fully understand the science, but what I do understand is that when the soft tissues are deeply manipulated, you have initiated an inflammatory process that contributes to healing of the tissues; a process that peaks at about 24 hours and is mostly gone within 48 hours. I have observed this phenomenon while doing Graston Technique; it is great to have further biological explanation of what is happening at the cellular level.
The mapping of the fascia and its correlations with specific pain patterns and specific functional tests is amazing. This is an amazing body of work, clearly the work of a lifetime. This is not just a tweak, but a new way to look at the musculoskeletal system.
An Example: Knee Pain
An example will help. Anterior knee pain, patellar pain, is certainly a common problem in athletes and aging people. We have many tools for this already, including rehab, ART, Graston Technique, and others. Stecco noted a specific point, in the anterior quadriceps at the junction of the rectus femoris and the vastus lateralis, that seems to correlate with this pain pattern. If the patient has difficulty with a deep lunge or squat, and this point is tender and dense, you treat it with the deep fascial manipulation. The patient will frequently have an immediate improvement in their function. Of course, there are other fascial points that one would search and potentially treat, but this one is key. I have almost never focused on this area previously for knee pain.
This is not just anecdotal, Pedrelli, Stecco, et al., wrote a peer-reviewed article on this particular issue ["Treating Patellar Tendinopathy With Fascial Manipulation." J Bodyw Mov Ther, Jan 2009;13(1):73-80]. One of the fascinating things about this article, this study, is that it represents a dumbing down, an oversimplification of the Stecco model. In the complete FM model, one would treat more than one point, and assess anterior knee pain via various functional tests. The study just treated the one usual main point, in the upper quadriceps, and got great results anyway.
A Couple of Cases
I'll extensively quote a colleague of mine, Phillip Snell, DC, another recent student of FM, to comment further on the knee and on fascial manipulation. Dr. Snell both tells his own clinical case story and looks at why this may work.
"The interplay and the inherent limitations of manual therapy vs. functional rehab exercise was apparent to me recently at a Fascial Manipulation (Stecco) seminar. I had chronic anterior knee pain with an orthopedic diagnosis of 'osteoarthritis.' I looked for unconventional solutions after ART, 'quad sets' and manipulation were not productive. About this time, Graston Technique came on the scene, and I was able to get 80 percent relief in ADLs using it on myself.
"In recent years, functional assessment brought a diagnosis of patellofemoral syndrome, and rehab working on the gluteals got another 10 percent function. My litmus test for whether I felt my knee was whole (as I approach 50 with a history of ACL surgery) was whether I could do a deep single-leg squat, a pistol. Single-leg variations of squats, deadlifts and hip thrusts still resulted in intermittent pain in the knee. (In behavioral medicine, intermittent reinforcement is one of the most effective ways to inculcate behavior.) Thus, I had a 'hard deck' of about 70 degree depth on my single-leg squat for several years. That is, until the Stecco class.
"While attending a Fascial Manipulation seminar, a couple of points in the hip adductors and TFL of my affected knee were positive on assessment. After applying FM techniques for 15 minutes, I dropped into not one, but 4-5 consecutive assisted single-leg pistols! Mind you, I had been doing gluteal rehab, working on mobility in the hip flexors and adductors, and using my kit bag of myofascial release techniques on those areas for over a year."
[Author's note: Phillip was working at the table right behind me. I turned around and was amazed to see him comfortably in this extreme single-leg squat position; I wish I had a picture.)]
"Such quick results are almost certainly neurological in nature. FM work appears to eliminate the neurological inhibitors. In this case, I think a possible cause of the limited motion was possible shearing of free nerve endings in densified fascia. This may have produced local pain and/or decentration of joints; so the brain would not allow that full movement pattern."
I will share one more case history. This is a 20-year-old female, who was in an auto accident two years prior. She had chronic, 8/10 thoracic pain, with no changes on MRI. She was referred to me as a last resort by her orthopedist. I did all of my magic, all of my thinking outside of the box, for eight weeks. I cleared her anterior cervical spine, I addressed the thoracic and rib-cage restrictions. I did anterior visceral manipulation. I found lumbosacral issues and corrected those.
She came in, just after I had taken this FM seminar, for her ninth visit, and was quite frustrated. She still was in severe pain, still flared up whenever she was active at all. I suggested we try a couple of sessions of FM. Despite my inexperience in this technique, I somehow found the right points. Two treatments and her pain levels came down to a 2-3/10, and she seemed like a different person. I thank you, Luigi Stecco, and so does this patient.
What is the take-home from this article for you, the practicing DC? One, if you can, study fascial manipulation. If not, remember to look above and below the pain site, look at the antagonist muscles and fascia, not just the site of pain. With patients in which the same fascial restrictions or tight tender knots recur, consider treating these points longer and deeper, until you completely erase the hot spots. Don't forget to warn the patient that they will be sore.
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