The Thoracolumbar Fascia, tissue depth, and specificity
A topic commonly discussed at the Functional Anatomic Palpation Systems seminars is that of tissue layering and tissue depth. When palpating, assessing, and treating soft tissue structures it is often forgotten that the body is a 3 dimensional structure and therefore thinking of the anatomy from a cross-sectional perspective is even more important than thinking of it
in the 2 dimensional way it is often presented or drawn in textbooks.
Because of this concept of “tissue depth,” it is important for practitioners to alter their compressive forces depending on the target structure. Similar to injection therapy, or acupuncture, the use of soft tissue techniques should be applied with the concept of depth/penetration in mind. I often hear for example practitioners at our seminars discuss that they find that in many of their patients scalene muscles are hypertonic, tight, and painful. When I ask these same practitioners to demonstrate their palpation technique on me I soon know why this finding is so prevalent for them…it is because they are compressing so hard that they are actually palpating the bone tissue of the cervical spine!! …not to mention that they are often compression/crushing the carotid artery in the process. This is also common with palpation of the gastrocnemius where I see the nails of practitioners going white due to the amount of compression that they are utilizing.
It is also common for these same practitioners to ask how my thumbs and hands are not sore after a day of treating. The answer is simple…. despite popular belief, you will not achieve any better results if you compress every tissue as hard as you possibly can. The main concept behind many of the commonly utilized soft tissue techniques is to take tension into the tissue that you are treating. This means that you must utilize only enough compression as is needed to access/palpate the targeted tissue, then take tension into that specific tissue depth. For example, when treating the gastrocnemius, only a small amount of compression is needed to “sink” into the muscle fibers vs. when tibialis posterior is the target. In the case of tibialis posterior, it is necessary to compress the overlying gastroc, and soleus in order to access the necessary tissue depth (the use of the ‘Layering Technique’ is needed for proper access and can be learned at F.A.P. anatomy palpation seminars). Once the desired tissue is accessed, then, and only then is any tension taken up in that tissue so that treatment can commence. Another example would be the scalene group which is located directly under the skin, and thus only a very small amount of compression is necessary for effective treatment.
A new study was presented at the 2009 Fascia Congress that is suitable to
emphasize this concept. The study, entitled “The Innervation of Fascia Thoracolumbalis” by Jonas Tesarz, Department of Anatomy and Cell Biology, University of Heidelberg, Germany (Follow the linked text to read the studies abstract). This study demonstrates the presence of substance P containing free nerve endings (nociceptive nerves) situated in the external layers of the thoracolumbar fascia (TLF) in adult male Sprague-Dawley rats. By demonstrating dense neural innervation of the TLF, this breakthrough article creates important implications on the current concepts of lower back pain suggesting new targets for therapeutic strategies. Although human trials are pending, clinically I have target the TLF in treatment of low back pain (especially in chronic low back pain) in several of my patients. Palpation and treatment of this structure is obviously performed with very little compression due to the tissue depth, but a considerable amount of tissue tension. Although many therapists target the deeper layers right from the start (multifidis, QL’s, etc.), I advise that you assess, and if necessary treat external structures first, then work your way through the deeper layers. Also keep this in mind in the cervical spine where platysma treatment is often very helpful in reducing cervical tension.
Remember that pushing harder doesn’t make it a better treatment…. tissue specificity is the key.
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Mr Spina,
Super post as usual. But how do you “tension” a muscle considering the frictionless interface between the skin, fascia and muscle? Would you be able to flex a straight elbow by taking up the slack in the biceps with first your right thumb and then your left thumb and then your right thumb and so forth…much like pulling someone up on a rope. I would love to hear your thoughts on this.
All the best (and with no answers myself),
Greg
Hey Greg, thanks for the question
Regarding the “frictionless interface,” anatomists such as Gil Hedley would disagree with the findings of Dr’s Ross and Bereznik despite their attempt to demonstrate the relationship as such. When considering the different layers of fascia, the first being the fascia superficialis, which is also known as the “subcutaneous fat layer,” simple dissection procedure clearly demonstrates a great amount of fibrotic tissue connecting it with the underlying profunda layer (ie. the muscular encasements – endo, peri, epi). In fact, due to this relationship, even the concept of separating the layers is highly hypothetical. Anyway, it is due to the presence of these connections that we are able to create the “skin wedge” as many people like to call it. Therefore, the fact that an end-point can easily be found by sliding one layer past another demonstrates that at the end range, the fibrotic tissue must create “tension.” Further, as is noted by several authors (see my posts on the layers of fascia), in cases of chronic injury, the movement of the fascia superficialis on the profunda layer is hindered (ie. the skin seems to be ‘stuck’ to the the underlying tissue…the same happens with post surgical scarring)…treatment of this restriction, when given the proper time for the fascia to release, can improve the sliding. To me this demonstrates that there is an increased amount of abnormal ‘tension’ between the layers which can be addressed by imparting a load (“wedgie”) and allowing sufficient time to modify the fascial fibrosis.
Regarding the underlying “muscle layer”….I don’t believe that this is EVER the target of our soft tissue therapy. If we are attempting to “break down adhesion,” where does the adhesion form? What is it made of?…..connective tissue (fascia). Thus our goal is to improve the sliding occurring between muscle cells by reducing fibrosis that occurs in the fascial components surrounding them. Regarding imparting tension on this tissue….this is the exact reason why my technique only treats at the outer ranges of motion. As you note, to try to apply tension into a tissue when it is shortened for example is futile. However, by compressing a lengthened tissue, you can cause a ‘bowing’ effect under your contact….when imparted during a stretch, you are conceptually increasing the intensity of the stretch under your finger….which would create tension at that point.
…..of course as you and I have discussed previously, I, like you am coming at this from the original conclusion that I also have no answers myself. But I find addressing tissue in this manner to be far superior to the “shorten, compress, lengthen, repeat” method which is highly popular….I am talking about ART btw 🙂
I hope this ramble made sense as I am firing it off just before zzzzzzz time.
talk soon
Thanks again Dre,
That addresses my concerns. As you can tell my concerns weren’t really directed at you as at other practitioners. It was good to hear your take on the area. What you a wrote is a very good justification for your treatment and makes much more sense than some simplistic responses I hear given by “experts”.
All the best,
Greg