New muscle activation techniques proven to reduce musculoskeletal pain used in the massage industry.
Tom Myers went to exhaustive lengths to establish the links or lines of the fascial system and how they are so important in functional mobility of the musculoskeletal system. By stripping cadavers of all but their unique fascial systems he has hypothesized that there are 7 major lines or “anatomy trains” as he has coined them. Joseph DellaGrotte also pondered the tensegrity of the connective tissue and how the Central Nervous System has an impact on it.
The smooth and fluid movement of the body is founded upon these lines working both dependently and interdependently with each other; both as single units but as a shared fascial web which propels us forward, backward, twisting turning in all planes. It has become evident that when the fascial tensegrity of the body becomes imbalanced then the musculoskeletal, nervous and endocrine systems, and in fact our general homoeostasis is compromised. Joints altered in normal arthrokinematics leading to denegation at their articulating surfaces, tendinosis through added strain to the attachment points, ligamentous micro-stress leading to predisposition to sprains and tears. The body misalignment (though minute) still alters the neutral position of the vertebral column and the normal afferent and efferent signaling of the nerve roots upon entrance of sensory and exit of motor information. This creates altered signals to the muscle, joints, skin and the viscera on a global scale.
At the 1st International Fascia Research Congress, 2007, held at the Harvard Medical School in Boston, fascia was discussed at length in the forms of abstracts, expanded abstracts, plenary’s and original papers.
“Fascia and its involvement in force transmission from one tissue to another, having major implications in explaining how the body functions, and how manual methods” (Stecco et al., 2008) can be used to influence distant tissues. “Mechanical forces, including those associated with manual treatment, influence cells and molecules via mechano-transduction, producing changes in intracellular biochemistry and gene expression” (Ingber, 2008; Wipff and Hinz, 2008) were some of the many profound realizations discovered.
Josef DellaGrotte put forth a paper on postural involvement using core integration to lengthen myofascia. “Summary. Postural organization is controlled by the central nervous system in conjunction with the skeletal, muscular, and fascial systems”. This paper explores the effects on static and dynamic postural misalignment and treatment via neuromotor re-education intervention. DellaGrotte hypothesizes six core-integration pathways or vectors of force which use the principles of functional movement used by pioneers such as Ida Rolf, Moshe Feldenkrais and Tom Myers.
The six pathways are based on common planes of movement (up-down, Sagittal, rotational and lateral movement), these pathways are defined by the following criteria:
- It contains a vector of force, direction, and myofascial tensegrity.
- It passes through the centre of gravity and represents the most efficient expenditure of energy.
- It has specific anatomical features, and can be ‘tracked’ through specific joint angles, actions of levers, muscle chains, and fascial tensile spread.
- It requires lengthening by virtue of mechanical levering and the physiology of myofascial actions.
- Muscles in the sequential contracting-lengthening phase stimulate tensile fascial spread.
DellaGrotte had designed a map of how the CNS can track and facilitate every movement through the 6 primary core pathways, secondary pathways and their sectional body components. These can also align with Myers 7 myofascial trains and as they both allude, it is the identification of the path, assessing movement and posture, tracking how movement is transmitted and determining through client response whether CNS takes on and adopts the data or whether there is a break in the system which will lead to soft tissue problems we as therapists observe.
Therefore it is most probable that not only do these lines have a specific roles within the body but when they are in correct function will minimize stresses and damage; conversely when they are out of “sync” secondary pain syndromes will occur which are associated with overuse and strains on bones, joints, muscles, tendons, nerves and fascia. The body has a set of somatic markers housed within the bony stations, which offer feedback continuously along the trains via the fascial attachments, it also uses the neuromotor myofascial pathways to continuously monitor the body’s posture and functional movement tensegrity. If the therapist has an understanding or at the very least acknowledgement the presence of these markers it is more easy to understand how primary area of pain can arise in any area where there has been a break in the neuromotor transmission or a de-railment of a Myofascial train line. Treatment of imbalances of the paths as noted by Myers and DellaGrotte include myofascial release techniques to lengthen the fascia. Using many well known treatment strategies from Rolf and Feldenkrais, the stress vectors within the pathways are normalized. This is where the astute therapist can be most profound in their treatment and I will give assessment options further in this article.
There are however many other remedial massage techniques to affect these lines to improve balance in the vector of force, direction, and myofascial tensegrity. Muscles must fire in the sequential contracting-lengthening phase stimulating tensile fascial spread and this is assessed by muscle firing sequences (Chaitow). When the muscle firing sequence is incorrect I have observed that the phasic (doing) muscles will lengthen and the postural (stabilising) muscles shorten and this creates the imbalance within the anatomy trains. Gracovetsky provided a paper at the 1st Fascial Congress on “Lumbodorsal fascia” and its role in the function of the spine. He states that it is perhaps the most important structure insuring the integrity of the spine, the viscoelastic property of its collagen has a direct impact on the way the muscles are used and forces are channeled from the ground to the upper extremities. The viscoelastic property of collagen means that it is not possible to continuously load collagen material. “To circumvent the problem of collagen stretching, a cyclic mechanism of alternatively loading and unloading collagen and muscle must then be implemented. Such an oscillation permits tissues to sequentially rest, recover and maintain core stability” (Gracovetsky). The most important outcome should be the relief of pain, reversal of dysfunction and the restoration of control of normal patterned movement, this intern should improve normal lordosis which implies restoration of balance of the innominants and sacrum along with balance of functional leg length.
If the lateral line or basic lateral path is interfered with, it can and often does create stress and pain in the neck, lateral rib region along with lumbar discomfort. This is due to the myofascial connective tissues having no real stretch, joints becoming compressed as postural muscle loses its normal resting length. Another example of a disruption of this line or path and can be noted with patients presenting of lateral leg and/or medial knee conditions and symptoms created from the medial distraction and/or lateral compression of the knee. DellaGrotte describes the basic lateral path as responsible for the earliest evolutionary developmental movement as in the dorsal movement of the fish our earliest Darwinian ancestors, with an imbalance of lateral movement so to will the patient complain of stiffness of the torso in general and more specifically, joint-jamming of vertebra and ribs, myofascial tissues and compression of the discs.
Compression of the Lumbar facets with disruption in the Lateral line is commonly a predisposing factor to both Sciatic and Pseudo sciatic pain, many authors will note that there is a reduction in neural proprioception and therefore susceptibility of instability with possible falls. Myers also suggests that this line begins in the middle of the medial and lateral arches of the foot so it is understandable that the plantar fascia can become compromised creating plantar-fasciitis. This hypothesis can be further cited by Hammer, W. when he discusses at length in his paper that the related kinetic chain must be addressed when dealing with the plantar fascia and there is often restricted dorsiflexion and fascial restrictions all along the kinetic line. Hammer produced a paper on “The effects of mechanical load on degenerated soft tissue” (2008) which was as a direct response to the Boston Fascial Congress of 2007.
As therapists’ using this theory we should activate muscles most commonly involved in the stability during lateral movement, it is most commonly observed at the pelvic level with hip drop or a positive Trendelenberg test. Applying concentric muscle activation of the Gluteus Medius on the unstable, positive side and possibly activation of the synergistic Adductor group on the contralateral leg should offer a re-establishment of pre-dysfunctional muscle tension of the myofascia.
Two more of Myers Anatomy Trains include the functional back line and superficial back line; when these are combined they mimic the back path as hypothocised by DellaGrottes biomechanical and CNS model. These pathways provide strength and support of the Sagittal plane, the muscles and connective tissue are the body’s main pillars of support and movement. When working together efficiently they provide strength of the core and all related structures along the back, but when there is a breakdown of the neuromotor myofascial pathway’s and the subsequent imbalance of the muscle firing sequence as suggested by both DellaGrotte and Myers then pain, injury and dysfunction will eventually occur. The deeper small muscles of the vertebral column i.e. the multifidii and rotatores take on much of the load and therefore pain will often present close to the spine in the sacrum, lower back, thoracic region and neck. When the pelvic innominants misalign then the potential for either Upper and or Lower Cross Syndromes can arise producing cervicogenic headaches, cervical, suboccipital and generalised back pain including shoulder pain and potential rotator cuff imbalances. Shortening of the hamstrings and calves is also noted in the Lower Cross syndrome, (Chaitow L.,2003). The evidence of anterior or posterior ilial rotations, sacral torsions and subsequent leg length changes are a common phenomenon with the functional back line or back path when unilateral cross syndrome is present.
By applying the same techniques of re-establishment of individual muscles within these lines to re-establish the neuromotor sequencing then the application of low load muscle activation to individual muscles is absolutely necessary. Either the activation of the Gluteus Maximus or the Latissimus Dorsi is needed to diffuse the Cross Syndrome pelvis, similarly by improving the quality of the Hamstring contraction this will take the load from the stabilising muscles within the spine including the Erector Spinae. The therapist needs to use a keen eye to assess anterior or posterior innominants and the subsequent leg length discrepancies.
Research continually points to the link between poor core activation and the incidence of low back pain with lumbar instability, and the positive effects in reducing pain when restoring the postural equilibrium. The presence of functional front lines or paths both deep and superficial promote both core dynamic support and uplifting functions to the body. The muscle combinations of the core include the diaphragm, Psoas, Pelvic floor or Transverse Abdominus, and their anterior stabilising cohorts the internal and external Obliques along with the Rectus Abdominus, the inclusion of the functional front lines also adds small intrinsic muscles of the spine i.e. the multifidii, and will include some of the fibres within the Adductor groups. This is confirmed by the statement from DellaGrotte “Balancing this pathway also strengthens the thoraco-lumbar fascia and engages the spine through the multifidii as stabilizers and rotators. In addition, the mapping of the deep support system works well with the psoas [and adductor] complex, allowing the psoas to perform its major function as a dynamic mobiliser” . The remedial massage therapist, Musculoskeletal Therapist or Exercise Physiologist should have the skills to activate these core muscles and look for any imbalance between strength and length which would signify pelvic torsion potentials.
More recent empirical evidence comes from Finch K developer of Arthroneural Myofacilitation discusses a symptomatic picture which includes dysfunction of the mid thoracic region with associated neck pain, shoulder pain, thoracic and rib discomfort, Sacro Iliac Joint pain, groin pain and upper limb neural irritability. Myers and Finch agree that lateral leg and/or knee pain may be associated with imbalance within these anatomical lines.
DellaGrotte includes a turning path which can be included with the deep front line of Myers due to the 3 dimensional role it takes on. “This turning path is the ‘missing link’ in the leg>pelvis>spine pathway, and the key to effective CNS pre-programmed natural strengthening and supported upright posture”.
In my clinical practice I have observed that when these fascial trains are compromised then overtly excessive loads on the deep back muscles occurs and this creates premature firing of the internal and external obliques as the antagonistic groups. Back muscles become tighter, shorter and weaker, and this dysfunctional state may result in a posteriorization of the ilium and a short leg situation; it will inevitably involve dysfunction of the diaphragm function through reduction in accessing the thoracic turning path which then affects breathing and metabolic function. The therapist may decide to treat with conventional methods or may decide to awaken the agonist/antagonist groups of the Adductors on one side that the contralateral obliques of the trunk. An imbalance between these two opposing muscles of trunk stability will make detrimental influences in a) how the ilium sits with the fixed sacrum and b) how much medial torsion is present in the femur produced by shortening of the Adductors. Therefore Low load Recruitment of the Adductors and obliques in a side lying position will help re-set the firing order (as hypopathysed by Finch) should return the muscle tone and myofascial length to pre-dysfunction length. This will often result in reduced pain not only in the local area but other complaints both distal and proximal to the treatment area.
When a client presents with standing rotations of the Thoracic trunk or Pelvis it is prudent to also assess the diagonal spiralic path or spiral line which is involved with turning, twisting and elevating; these actions recruit the opposite or stabilizing leg as most commonly this is the thrust leg. This spiral line maintains secondary balance with the majority of other planes and assists to determine knee tracking in gait. If this pathway is disconnected or interrupted in force transmission through the spine then low back may be stressed (Hodges and Richardson, 1996) and gait negatively affected (Gracovetsky, 1988: Tandon et al., 2008), the symptoms of suboccipital tenderness, burning between the scapulae, coccyx pain and shin splints (Finch 2007) have been noted. If we continue to use the principle initiated by Gracovetsky then low load muscle activation should be performed on those muscles effecting the rotations e.g. Rhomboid Major and Rhomboid Minor, to correct the imbalances noted along the core pathways. By activation of muscles within the hip complex or shoulder complex we can minimize the undue torque through each vector, allow for return of tensegrity between the specific joint angles, which in turn will improve the actions of levers, muscle chains, and fascial tensile spread. The myofascial lines are equalized by virtue of mechanical levering and the physiology of myofascial actions.
The process is rapid and the most likely hypothesis from the author is via specific cell surface receptors called “integrins”. They bridge between the internal “cytoskeleton” of the cell and the external Extracellular Matrix. “They act as mechanoreceptors and are amongst the first to sense mechanical signals, the signal speed is transmitted rapidly through these load-bearing elements, in fact, much faster than chemical signals and the stress application to the surface integrin receptors results in almost immediate changes in molecular structure deep in the cytoplasm and nucleus, as well as activation of signaling events at distant sites almost as rapidly as those that occur at the cell surface.” (Ingber D). More on this type of transmission is important to understand but has no place in this article due to size restrictions.
What order we treat our clients is often subjective but if we follow some strong principles regarding return of hip height then the lateral path would be the first point of treatment. The femur needs to be in best position to maintain correct gait, leg length and if not achieved, the secondary neural/musculoskeletal conditions that arise from this will continue to hinder the healing process. The basic lateral path needs to function with the hip rotator cuff in balance and therefore low load recruitment of these muscles should be a first priority to the treatment plan. The need to return the pelvic balance and lumbar lordosis is also an early priority so that the hip rotators may need to be activated at a stronger level to achieve this task. Both movements are often used in Pilates though for the best results it is a requirement that the muscle must be fully unloaded. Generally movements performed at the rotator cuffs of the shoulder and hip joints appear to balance the pull of a de-railed train as Myers describes it. Finch K., uses seven “muscle activation techniques” and hypotheses that the gate theory is the cause of the rapid return to normal fascial balance though this is probably unlikely given that the ECM works at a much more efficient speed. These seven movements are mapped closely to both Pilates movements of core control and follow Grimaldi’s concepts of necessity for femoral and humeral position. The order of activation via low load recruitment from the Remedial or Medical massage therapist should be hip height balance via the Gluteus Medius, then re-establish pelvic rotations and leg length anomalies via efficient contractile muscle in the Gluteus Maximus, Latissimus Dorsi and/or Adductor Longus and Magnus. Trunk rotations should then be controlled via the Rhomboid and Rotator Cuff imbalances followed by the angonist and antagonistic imbalances of the fascia of the front and back superficial lines. Addressing tight Hamstrings and Pectoralis muscles and their union of tension can be unloaded by either myofascial release techniques or low load activation techniques with the latter being easier on both the client comfort and the therapist’s hands.
Hopefully the balancing of the Myofascia of the body can be achieved more readily and long lasting by applying these different technique choices so to produce far more efficient outcomes for our clients.