Professional Documents
Culture Documents
Fascial and Membrane Technique PDF
Fascial and Membrane Technique PDF
ISBN-13: 978-0-443-10219-6
ISBN-10: 0-443-10219-8
Note
Neither the Publisher nor the Author assume any responsibility for any loss or injury
and/or damage to persons or property arising out of or related to any use of the
material contained in this book. It is the responsibility of the treating practitioner,
relying on independent expertise and knowledge of the patient, to determine the best
treatment and method of application for the patient.
The Publisher
The
Publisher’s
policy is to use
paper manufactured
from sustainable forests
Printed in China
ERRNVPHGLFRVRUJ
I have known Peter Schwind for a long time; we curiosity. He is able to refine individual techniques
first met seventeen years ago. Since that first meet- with personal involvement and perseverance. In
ing, we have been constantly engaged in a prolific his practice, he works with a high level of commit-
exchange of ideas. Again and again we have asked ment and he is an inspiring teacher. Everyone who
ourselves how we can structure our work as effec- meets him encounters the earnestness and passion
tively as possible so as to achieve the best outcomes which he applies to his profession.
for our patients. We have been guided by the fun- For all these reasons it was a pleasure for me to
damental concept that every aspect of the organism write this short foreword to one of his books.
is important and we must not neglect a single one In practice, our primary duty is to be there for
of its elements. This overarching philosophy of our patients and to help them. However, it is also
osteopathy served as a connection between us from important to teach and to write books such as this
that first moment and, over time, we discovered one. In so doing, we are able to make the little that
that we have much in common in our view of the we know accessible to a larger audience; we foster
human body. the sort of critical dialogue that is essential for the
Starting from my own work, particularly with continued development of our field.
regard to the diagnostic approaches of general Peter Schwind is one of the therapists providing
listening, local listening, and manual thermodiag- the drive behind this development. I am certain
nosis, which I consider so very important, Peter that he will continue to make a contribution to the
Schwind has developed his personal research progress of manual therapy in the future as well.
and way of treating patients. He has found new I thank him for having written this book.
emphases within these areas and, in so doing, has
elaborated on my own ideas. Jean-Pierre Barral, DO
It is his habit to work hard; he has a broad Grenoble, February 2006
range of interests and approaches all things with
xi
Foreword
It is a pleasure to introduce the unique synthesis of planes of myofascia, Dr. Schwind presents a com-
Dr. Peter Schwind to the English-speaking reader. plete picture that first unites and then transcends
The book in your hand represents a significant con- the source material to create an approach that is
tribution to the growing realm of what we could uniquely original.
term “spatial medicine”—the study of what can be The material within can perhaps be best under-
accomplished through the modification of shape. stood through knowing that Dr. Schwind was, prior
Within the discipline of spatial medicine, some to his long career in manipulative therapy, an excel-
have concentrated on modifying articular mobility lent musician. His sensitivity to the instrument and
via thrust or other techniques, while others have to the music itself has informed his many forays
focused on training or resetting muscle tone through into the specifics of manual therapy. Over the years
manipulation, positional release, or exercise. More of our occasional acquaintance, I have observed
recently, the plasticity of the fascial interface Dr. Schwind explore the details—osteopathic tech-
between the muscles and the skeleton has received niques, dental work, visceral manipulation—with
more therapeutic attention—namely the treatment characteristic zeal and precision, but always with
of myofasciae, tendons, ligaments, and the many an eye to the “feel” of the whole piece, the entire
fascial membranes. gestalt of the client. With this book, he rises from
All these specific fascial structures, however, musician to conductor, and I am as eager as anyone
begin as a unitary three-dimensional “spider web” to have this seminal book available to me and to
in the early embryo. Although the complex origami my students in the English language.
of development creates the illusion of separate In manipulative therapy, nothing is subtracted
structures, all these strings, sacs, and sheets are still but strain, and nothing is added but information.
part of a unitary matrix which continues to com- Thus, effective treatment rests on two elements: the
municate bodywide throughout life. Thus they ability to “listen” to the tension patterns, and the
need to be considered as a whole, not piecemeal. quality of the information the therapist can impart.
By combining the work of Jean-Pierre Barral in While the quality of “listening” is difficult to
the visceral membranes of the ventral cavity, the impart in a book, Dr. Schwind does an excellent job
insights of osteopathy concerning the spine and the of inviting the practitioner to participate “within”
dorsal cavity membranes around the nervous sys- our clients, rather than “on” them, or doing ther-
tem, and the work of Dr. Ida Rolf on the parietal apy “to” them.
xii FOREWORD
Pay attention, please, to the early chapters. The body and to improve his or her skill at plucking
proper application of the manifold techniques the right strings in the right order.
offered in the body of the book rests on his approach
to the “music” of the membranes. Absorbed from
this point of view, this book will contribute signi- Thomas Myers
ficantly to the ability of any therapist both to Walpole, Maine, USA
understand the inner harmonies of the human October 2005
xiii
Acknowledgements
I would like to thank Jean-Pierre Barral DO for the In the United States my many thanks go to
many years we have worked together in our prac- Jim Asher, Emett Hutchins, Peter Levine PhD,
tical research on the nature of fascia and mem- Jon Lodge, Jeff Maitland PhD, Peter Melchior
branes. As a teacher, as a colleague and as a friend (deceased), Stacey Mills (deceased), Tom Myers,
he has created an atmosphere of creative investi- Michael Salveson, Louis Schultz PhD, Bill Smythe,
gation for me and a group of colleagues in Jan Sultan, and Tom Wing.
Munich, by sharing his vast clinical experience, In Brazil to Monica Caspari and Pedro Prado.
showing an open mind, and stimulating the cre- In Europe to Elmar Abram, Jean Arlot DO,
ativity of his colleagues. Harvey Burns, Alain Croibier DO, Dr. Bruno
I would also like to express my gratitude to sev- d’Udine, Dr. Hans Flury, Dr. Laura Gentilini DO,
eral individuals, who have inspired me in my Dr. Michel Ginoulhac, Hubert Godard, Anne
work on the concept of fascial and membrane Koller-Wilmking, Didier Prat DO, Robert Schleip,
technique. They all have contributed, sometimes Dr. Sebastian Schmidinger, Christoph Sommer,
by practical exploration of techniques, often by and Pierpaola Volpones.
conceptual dialogue, and occasionally by produc-
tive disagreement.
1
Chapter 1
Introduction
It has been a century since A.T. Still, one of the objective reality and therefore the viability of other
pioneers of the manual treatment of the human models with other classification schemes and points
body, first noted the significance of the fascial of view is ignored.
system. Initially, his view of the comprehensive In the meantime, the science of anatomy has
significance of this type of tissue was not seriously shown us that connective tissue for each of the sys-
considered; however, an increasing number of tems mentioned above has clearly describable func-
approaches were being developed in which the tions. It is known that it is just as present in the
individual aspects of this tissue were revealed in epimysial and divisional layers of the musculo-
greater detail. During the 1930s, the science of skeletal system as in the fascial envelope layers
anatomy focused on the fascial layers of the neck of the organs and in the perineurial sheets of
region for the purpose of discovering the transmis- the nervous system. Histology is able to show the
sion paths for certain pathogens. Later, as research presence of connective tissue ranging from large
began on the function of connective tissue within areas of subdermal tissue to the periosteum and the
the immune system, the role of connective tissue smallest units of the cell. Thus, we now have
overall attracted much more interest. However, the enough information to understand the functions
layers of connective tissue and their special forma- of each of the various layers of connective tissue
tions, the fasciae, were given far less attention than within one bodily system. We can see how the
the classical areas of the musculoskeletal system, fascial system surrounds individual muscles,
organ systems, and nerve sys-tems. The role played divides them, and connects them to the periosteum
by connective tissue for and between these three by way of the tendons. We can see how membranes
individual systems was little known. extend from the interior of the cranium by way of
In spite of the excellent topographical work that the dura mater and perineuria into the finest
has been accomplished up to now, even today arborizations of the nervi nervosum. And it is there-
many anatomy textbooks contain only a marginal fore possible for us to construct an overall blueprint
discussion of connective tissue for the purpose of of the body as an interlaced system of connective
clearly representing the details of the body. In these tissue chambers.
textbooks, most of the fasciae and numerous mem- This sort of analysis and classification therefore
branes remain unnoted, considered unimportant provides insight into the functions that the connec-
filler material. Although this limited description tive tissue performs for the anatomically defined
has some use in certain branches of medicine, it subsystems. We also know which general func-
also contributes to a narrowing of perspective, in tions the connective tissue performs for metabo-
which our models of the human body are taken as lism and the immune system. However, it is still
ERRNVPHGLFRVRUJ
2 FASCIAL AND MEMBRANE TECHNIQUE
unclear how connections between the individual If treatment is restricted to the subsystem alone,
subsystems arise and how the connective tissue as i.e. if the detailed technique is used without a
an organ of form provides the building blocks for more “global” intermixing, then the therapist
these connections in the overall mosaic of the body must rely on the greatest precision. The effective-
(Varela and Frenk 1987: 73–89). ness of this sort of procedure lives and dies by the
The techniques described in this book apply to diagnostic precision of the assessment of the sub-
the outer and subdivisional layers, whether within systems and the “minimalistic selection” of treat-
the musculoskeletal system, the organ system, or the ment steps.
nervous system, or, if we choose the traditional I am of the opinion that this very efficient con-
osteopathic classifications, within the parietal, vis- cept of mobilization of precisely describable units
ceral, or craniosacral region. The goal of treatment shows its limitations as soon as we turn our atten-
is to produce physiologically expedient mobility tion to the bridging, interconnecting function of fas-
between the individual components of a region. ciae and membranes mentioned above. Fasciae and
If we achieve greater mobility in one region, membranes are the medium of interaction between
effects will also be felt in the other regions. In the the individual systems of the organism; not only
practice of fascial and membrane treatment, the do they function within the individual systems, but
three-dimensional interconnection of fasciae and they also serve as “mediators” between the various
membranes means that the effects of a manual systems of the organism.
intervention simply cannot be limited to one indi- The techniques described here address this
vidual subsystem of the body. Mobilization tech- mediating function. Although these techniques do
niques, as soon as they are applied to the connective apply to the various individual layers of those
tissue system, are always a process that changes aggregates that we called parietal, craniosacral,
the shape of the whole organism as well. However, and visceral, they should also be applied, as far as
most examination procedures, in particular the possible, to the broader, more global interrelation-
mobility tests taught in manual schools, relate ships of form.
only to the subsystems; therefore there is an infor- First of all, fascial and membrane treatment
mation gap about the way a single subsystem con- should be understood only as a technique. I have
stitutes shape regarding the interconnection of the tried to depict the practical applications in such a
systems to one another in practice as well. way that they may be used in various manual
ERRNVPHGLFRVRUJ
INTRODUCTION 3
disciplines. However, behind the technique as the cavity in such a way that, at the same time, we
well as its numerous variations in application, are influencing the organization of the exterior
there is one unified concept. I have made an effort form. Thus, for example, it is possible to influence
in some cases to describe the technique with such an adhesion of the pleura with subtle pressure
meticulous precision that this concept shines while, at the same time, the intercostal membranes
through. It is a concept that, on the one hand, is and the deep fasciae are incorporated into the
based on the basic osteopathic theme of mobiliza- treatment as well.
tion that is as precise and as gentle as possible and, A second answer may be found in the treatment
on the other hand, ties in with the form-stabilizing of the segmental organization of the leg. We treat
approach of Ida Rolf’s Structural Integration. the details of the muscular fasciae, the intermuscu-
This conceptual emphasis may best be clarified lar septa, and the interosseus membranes in such a
as follows: way that a positive effect occurs on the fine tunic
How, practically, should we proceed so that we structures of the nerves and thus an improved
can treat details in a precise manner and, at the neural function is supported.
same, have an effect on the larger form with its The nerve is the river; the fasciae, membranes,
global interrelationships? One answer to this and perineurial envelopes form the riverbed. In
question may be found in the treatment of mobil- order to ensure a better equilibrium of flow in the
ity restrictions in the ribcage: we treat the small river, we treat the riverbed.
components that may be found in the interior of
ERRNVPHGLFRVRUJ
5
Chapter 2
Fundamentals
Terminology
CHAPTER CONTENTS
The term fascia is used in anatomical literature for
Terminology 5 the envelopes and separating layers of musculature
Material properties of connective tissue 6 that are composed of connective tissue. In a nar-
rower sense, fasciae consist primarily of collagen
The significance of the tensegrity model 7 connective tissue, the fibers of which intersect in a
Plasticity: the malleability of connective latticed pattern (at 45 degrees). The tough collagen
tissue 9 fibers are also combined with true elastic fibers
to varying degrees (Waldeyer and Mayet 1993: 29;
Benninghof 1994: 169).
Fascial tissue has the ability to return to its orig-
inal form after deformation, and this is largely due
to the combination of elastic and collagen fibers
within it. The collagen fibers have a tendency to
return to their original configuration that is rein-
forced by their cooperation with the elastic fibers.
The proportion of collagen and elastic fibers within
any area of fascia depends upon the functional
demands placed upon the tissue in that area. If
there are strong tensile stresses on the tissue, then
the collagen portion will predominate and there
will be fewer elastic fibers. If the shape of a segment
of the body changes repetitively, then the equilib-
rium shifts toward the elastic fibers, which in this
case will partially replace the collagen fibers. The
fascial system is thus able to adapt to changing
functional requirements of the body over an entire
lifetime. This adaptive capacity is not reduced
until old age, when the proportion of elastic fibers
within the interstitial matrix decreases, and the
tough collagen fibers predominate more and more.
ERRNVPHGLFRVRUJ
6 FASCIAL AND MEMBRANE TECHNIQUE
In a functional approach to the musculoskeletal connections between bones, and their associ-
system, it is not possible to discuss the fasciae sep- ated sliding layers—all perform the same function
arately from the muscle fibers to which they belong. despite their structural differences: functions such
There is no muscle tone without a corresponding as the regulation of the maintenance of shape and
tensing of the fasciae and no tensing of the fasciae the possibility of motion between single compo-
without muscle tone. Anatomy refers to this insep- nents. Most types of connective tissue perform these
arable interconnectedness as “myofascial unity.” functions in a similar manner and therefore are
Yet there are also layers of fasciae with an aston- comparable to the fasciae in the narrower sense of
ishing independent dynamic that can hardly be the word. Moreover, there is a continuity, a global
caused by muscular activity. These layers connect interconnectedness, between the various forms of
to the periosteum of the bone by ligaments with connective tissue. Individual bands, such as the
no intervening musculature. One example is the retinaculae of the ankle joint, are simply local con-
lower section of the lumbar fascia. It forms a thickly centrations of fibers of fascia, in this case as part
interwoven unit with the sacroiliac ligaments of the crural fascia of the lower leg. In a certain
on the posterior side of the sacrum and, via the sense, therefore, bands may also be understood as a
sacroiliac ligaments, connects with the periosteum specialized form of the fascial and membrane
of the sacrum. system.
The investing, differentiating, and supporting
functions of normal muscular fascia will vary as
we move toward the origins of muscles. The ten- Material properties of connective tissue
sile forces increase as we approach the origins, and
this gives rise to an aponeurotic compacting of the All connective tissues typically provide the organ-
tissue. However, even these compact fascial struc- ism with both a flexibility and a connective stability
tures, like the “normal fascia” of muscles, have a because they are composed of certain intercellular
sliding layer, the epimysium, beneath them. materials as well as cells. The totality of these
The term fascia is often used in anatomy also for intercellular materials is referred to in anatomy as
layers such as the endothoracic fascia—a very fine the extracellular matrix. This matrix is composed of
layer consisting largely of loose connective tissue. The collagen and elastic fibers as well as ground sub-
endothoracic fascia displays the typical fibrous stance. The material properties of the various
structure of fascia only in its uppermost region, at forms of connective tissue depend greatly on the
the level of the pleural cupula. The endothoracic proportion of the fiber and ground substance within
fascia has a completely different function to that of this matrix. Collagen and elastic fibers have entirely
the muscular fascia in that it enables the parietal different material properties.
pleura to slide in relation to the inner thoracic wall. Collagen fibers can usually be stretched only up
The term membrane is used in anatomical litera- to 5 percent of their length.
ture for various types of connective tissue. Examples Elastic fibers do not display any ordered struc-
include the dense, two-dimensional fibrous mem- ture, and are visible in electron microscopes as an
branes that connect individual bones, e.g. the amorphous mass. They consist of elastin, in which
interosseus membranes of the extremities, as well microfibrils are embedded. Their elasticity arises
as annular elements such as the atlanto-occipital from the structure of the elastin itself. It is com-
membrane. posed of interconnected protoelastin molecules so
In osteopathic literature, the term fascia is used arranged that they can be lengthened and yet
almost synonymously with connective tissue (see return to their original length. Elastic fibers can be
Friedlin 2003). reversibly stretched up to 150 percent of their
Although such usage cannot be entirely justi- length. Within this range of extension, they return
fied from a histological point of view, its almost to their initial length; however, if they are extended
universal acceptance has a certain validity. The beyond this, i.e. beyond 150 percent of their initial
various forms of connective tissue—the tunic lay- length, then a long-term deformation of the elastic
ers of organs, the ligamentous and membranous fibers occurs. This means that connective tissue
ERRNVPHGLFRVRUJ
FUNDAMENTALS 7
which contains a high amount of elastin is particu- bones. The tendon is not affixed directly to the
larly susceptible to processes of deformation. To a bone, but rather is glued to the periosteum by a
certain extent this explains the plasticity of con- fine layer of connective tissue.
nective tissues. Hence an irreversible overexten-
sion of certain fibers will have a long-distance effect
Consequences for treatment
on other areas of the organism, since changes in
tension are transmitted throughout the intercon- The wide range of material properties found in the
nected system of the entire fascial network. diverse forms of connective tissue has definite
The material properties of elastin are responsible implications for treatment. Because all connec-
for the transmission of tensional forces, along with tive tissues develop in an environment of variable
collagen fibers, which have a more limited flexibil- stresses, it may be that the same fascia with the
ity. If tension is applied to collagen fibers, they are same topographical location has completely dif-
pulled from their crimped rest position into a lin- ferent properties in two individuals. Different
ear extension. If this force is reduced, then elastic patterns of stress will create quite distinct and
forces come into effect; the initial tension of the individual distributions of the collagen, elastin,
collagen combines with the elasticity of the elastin and fluid components. For this reason, it is not
to pull the fibers back into their crimped rest posi- possible to establish any absolute rules for the
tion. In loose connective tissue the amorphous inter- treatment of individual fascial and membrane lay-
cellular gel, ground substance, plays a role in this ers, although certainly there is a basic technical
process by allowing the sliding of adjacent sur- orientation that is valid. So, for example, layers
faces. Ground substance has a high water-binding containing elastin require a subtle treatment,
capacity and, besides its so-called fixed cells, also whereas layers containing a large amount of colla-
harbors free cells that are able to wander through- gen can tolerate quite intensive pressure. As a rule,
out the tissue. This is particularly important in the however, even in the case of the stiffest fasciae
sliding movements of the organs during the motion with a very high proportion of collagen, there will
of breath. be a sliding layer separating it from the muscle
Muscular fasciae contain very little of the loose fibers, which contain a considerably larger amount
types of connective tissue, but much more of the of fluid. We must also take this sliding layer into
formed components of the intercellular matrix: the account when treating relatively inflexible layers
slightly flexible collagen fibers and the more flexi- of fasciae. In practice, a proven procedure is to apply
ble elastic fibers. The fibers arrange themselves pressure obliquely to the surface of the skin in
according to how tensile forces act on the stiff con- order to press gently through the tender layers
nective tissue. If the tensile forces come from sev- and affect the deeper sliding layer.
eral different directions, then a woven arrangement
of fibers is typical, as is found in the fasciae of mus-
cle tissue for instance. If instead only linear forces The significance of the tensegrity model
are applied to the tissue, then the fibers will align
themselves in a parallel fashion, as can be seen, The term tensegrity refers to a construction principle
through the microscope, in the slightly crimped that may be traced back to R. Buckminster Fuller.
alignment of the fibers that form tendons. When He developed it following the work of Kenneth
longer-term heavy stresses are applied to the tis- Snelson.
sue, then the stiff collagen increasingly supplants The term is a portmanteau of the two words
the elastin. The denser tissue layers then become “tension” and “integrity” (Myers 2001: 41–50).
more able to resist strain, but in the process become The idea underlying this structural principle is
less adaptive as some of the elastic quality of the that certain kinds of stable, adaptable forms can be
elastin is lost. achieved chiefly through the transmission of elas-
Small elastic bridges may also be found in tis- tic tension. This structural principle was first used
sues that are chiefly inelastic. This can be found, in architecture, with elastic elements defining the
for example, in the interface between tendons and links between the solid components. However in
ERRNVPHGLFRVRUJ
8 FASCIAL AND MEMBRANE TECHNIQUE
ERRNVPHGLFRVRUJ
FUNDAMENTALS 9
without its being directly touched. Because of the direction. This causes a parallel alignment and a
continuous nature of the fibrous network of con- compacting of the fibers. This process allows the
nective tissue, corrections may be made in one place attachment of tendons to bones that will later
that affect different areas entirely. develop in the embryo. In the later stages of devel-
This also provides a new perspective for look- opment, a similar process occurs in the formation of
ing at the function of joints. If we observe that the the myofasciae. During the growth and develop-
transmission of pressure through joints is always ment of the muscle fibers, the muscular fascia (or
cushioned by elastic or liquid elements, then obvi- myofascia) receives mechanical stresses that align
ously we need only direct some of our attention to its fibers in certain directions. The typical lattice
the bones in diagnosis and treatment. fibers of the muscular fascia usually tend to align in
With the aid of the tensegrity model, it is easier a transverse direction relative to the line of pull
to understand that components located far from of the muscle. This occurs because forces are exerted
the individual joint may have an influence on it. in a variety of spatial directions. This weave-like
Because all fibers are interconnected, the force act- arrangement allows cooperation with the sliding
ing on a joint may be transmitted to parts of the layer, or epimysium, and the fascia and muscle
body that have no muscular connection to the joint fibers as the muscle changes its form. Here, the rela-
at all. tively large proportion of fibrous connective tissue
Consequences for the technical and practical in the muscle fascia acts as a spatial boundary allow-
side become apparent as well: if it is actually true ing it to be stretched only up to a very limited extent.
that all components are connected to one another If a change in volume acts on a fascial layer over
and that even strongly connected components are a large surface, as we may observe in the thorax
embedded within an overall elastic context, then it during breathing, more elastic fiber and fluid ele-
must be possible to treat these consolidated con- ments of the ground substance are integrated into
nections using a low or relatively low amount of the fascia. This process is evident if we look at the
force. For example, if one of the metatarsal bones morphological structure of the endothoracic fascia.
is massively limited in its movement relative to Immediately after birth, as the child is taking its
the adjoining bones, the correction of this problem first breaths, a stretching impulse is exerted on a
would normally require a very quick impulse with large area, indeed on all the intermediate layers of
a low degree of movement and a high-velocity, the thorax wall. In this process, the endothoracic
low-amplitude impulse. If instead we use the prop- fascia functions as an elastic sliding element between
erties of the tissue, the larger context of fasciae and the thoracic wall and the parietal pleura, which
bands, we need only a relatively low expenditure closely adjoins the visceral pleura and thence the
of force. Such a procedure combines the treatment lung. Two-dimensional expansive forces are exerted
of significant details with the effect on a larger during breathing and this induces the endotho-
interconnection of form and may be expected to racic fascia to develop into a relatively thin, elastic
produce a more lasting result. layer. Peculiarly, it has a different material consis-
tency in only one small section. This section is
located in the uppermost region of the pleural
Plasticity: the malleability of cupula where the endothoracic fascia covers over
connective tissue the bulges of the cupula. In this area, the endotho-
racic fascia has a higher proportion of fibrous lay-
Fasciae and membranes respond to the forces acting ers and therefore has properties reminiscent of a
through them. Therefore, they are not simply the muscular fascia. These features do not arise by
passive filler tissue that is sometimes described in chance. In the uppermost section of the endotho-
anatomy. The dynamic growth properties of the racic fascia, in the region referred to in the litera-
fascial tissue of the mature human being hark back ture as Gibson’s fascia, tensile forces are constantly
to the early stages of embryonic development. As at work. There is a direct connection between
cartilage forms within the embryo, forces act on the Gibson’s fascia and the cervical spine by way of a
collagen fibers adjoining the cartilage in a specific band-like divergence of tissue from the scalene
ERRNVPHGLFRVRUJ
10 FASCIAL AND MEMBRANE TECHNIQUE
fascia. As the scalene muscles contract and raise The example of whiplash
the upper ribs, an essential part of the breathing The rapid reshaping of a stable tension pattern can
process, rhythmic tensile forces act upon the be seen in a fairly extreme form in the case of
upper part of the endothoracic fascia. The fascia whiplash injury (see Chapter 8). In this injury the
reacts to this unified, directionally dependent ten- fibrous portions of both the fasciae and the mem-
sile effect by aligning its fibers and partially replac- branes of various components of the organism are
ing the elastic portion of the fibers with inelastic rapidly overextended within a fraction of a sec-
collagen fibers. ond. The collagen fibers, which have limited flexi-
This example shows how the functional exer- bility, absorb a large portion of the energy. If bone
tion of forces can have a lasting structural effect on fractures occur, however, much of the energy is
the morphology of an individual fascial layer and absorbed in the process of the break. Curiously, in
can induce different kinds of tissue structure within the case of these severe bone injuries fewer overex-
the same fascia depending on its function. The tensions of the myofascial layers tend to occur,
fibrous, less elastic layer in the uppermost part of whereas the same process without fractures leads
the Gibson’s fascia is consistent with the tensile to more permanent and severe effects on fasciae
mechanics that act in the superior direction at every and membranes. In such cases, the fibers contain-
intake of breath and with the small changes in vol- ing elastin are overextended by a multiple of their
ume that occur there. The thin, elastic layers of the initial length in some places and are only partially
fascia in the middle and lower thoracic region, able to return to the original tension pattern. Sub-
however, are richer in fluids, and are more consis- sequently, severe long-term effects may be expressed
tent with the manifestly large changes in respira- symptomatically, for example, with headaches,
tory volume that occur there; this thoracic expansion neck discomfort, and vertigo. Interestingly, per-
has a two-dimensional effect on the fascia in addi- manent changes to the form of the organism can
tion to the tensile forces that have a relatively result from traumas with a relatively small forces
small effect there. acting on the body. It is not so much the magni-
These adaptations occur over a long period of tude of the forces but their direction that is respon-
time. The exterior form of the body is in a process sible for the changes in the tissue. In other words,
of constant change through the processes of new even a relatively small force can cause significant
tissue formation, fiber realignment, and changes in deformities if it acts from a particular direction on
the hydration of the connective tissues. fascia that contains elastin, particularly if that fas-
cia normally stabilizes various elements of the body.
This process is easier to understand if we apply
Consequences for treatment
the tensegrity model. The structure of the body is
In treating the fasciae and membranes, we try to remarkably stable when we consider the intercon-
influence this process of adaptation and encour- nected nature of its solid and elastic elements. If
age it in a particular direction. We influence the tis- even one structurally vital element has its elastic
sue so that its inherent self-regulatory tendency is consistency irreversibly changed, a very sustained
reinforced in a direction that is more appropriate process of adaptation spreads throughout all the
to its function. In a way, therapy ought to acceler- parts and therefore alters all spatial relationships.
ate the ongoing, long-term processes of functional We often find that the organism then strives to
adaptation. Experience suggests that our thera- find a new equilibrium.
peutic interventions can lead to immediate changes It should be stated again: the overextension of
in the pattern of tissue tensions. Tension patterns fibrous connective tissue may be found not only in
are simply the spatial interlacing of various fascial high-speed traumas but also in cases with a rela-
tensions; they persist despite superimposed mus- tively low-speed impact. One possible explanation
cle activity and postural changes. Thus, besides for this may be found in the different material
long-term processes of adaptation, there appears properties of the fasciae and membranes. For each
to be a direct change of tension in the fascial net- fascial and membrane layer, there is a threshold
work that is more or less irreversible. value of the return forces acting through the elastin.
ERRNVPHGLFRVRUJ
FUNDAMENTALS 11
This threshold value is high in layers that contain Recently, research has attempted to view this
a large proportion of collagen and is correspond- activity of the nervous system during therapeutic
ingly low in layers with a large proportion of treatment in a new light. Robert Schleip has sum-
elastin. If the mechanical force is greater than that marized the research approaches and thus arrives
threshold value and impacts the corresponding at a new interpretation of the plasticity of the fas-
layer, then a drastic deformation will occur and ciae (Schleip 2003: 20–8).
the tissue will be unable to return to its neutral ini- Schleip correctly refers to the presence of
tial position. mechanoreceptors in the fascial system and to the
I think that the form-altering effects that man- possible significance of the interstitial receptors
ual therapies can have on connective tissues paral- and Ruffini’s endings to myofascial treatment. He
lels to a certain degree the effect of forces involved emphasizes the connection between fasciae and the
in whiplash. In this sense, the therapeutic effect autonomic nervous system in general. In this
can be seen as a “whiplash” divided into small sense, fasciae are “outposts” of the autonomic nerv-
and carefully applied steps, each with a positive ous system.
presymptom. It acts locally through lengthening In this scientific research, there are numerous ref-
the tissue. However, this lengthening will modify erences to this kind of a link between the autonomic
tension patterns only if the extension threshold nervous system and the fascial and membrane sys-
value of the elastic layers is exceeded. tem. In therapeutic practice, the long-lasting effect
In practice, this means that, while applying a of treatment of fasciae on the autonomic nervous
technique, the therapist must constantly monitor system is known.
the changes in tension at the contact points in order If the initial findings of the research into the
to modulate the intensity of the contact according inherent contractility of fasciae are borne out, this
to the organism’s response. would lead to an entirely new view of the term
This entire process is a complex one, and research plasticity. In this manner, we could arrive at a
so far has yielded only some of its features. All broader view of the biomechanical significance of
manual therapies are applied to the skin, but we fascia and membrane techniques. A.T. Stills’ spec-
don’t really know how this contact affects the skin ulative statement describing the fasciae as “branch
and its connection to the subdermal connective tis- offices of the brain” would thus be confirmed.1
sue and the tiny, honeycomb structures of the sub-
cutaneous fatty layer and their bridges to the deep 1
Cited in Schleip; see there as well the compilation of
fascia. We can be certain, however, that the organ- research literature.
ism reacts to the contact. While the patient is lying,
apparently passively, on the treatment couch, the
patient’s nervous system is highly active.
ERRNVPHGLFRVRUJ
13
Chapter 3
Principles of treatment
in practice
ERRNVPHGLFRVRUJ
14 FASCIAL AND MEMBRANE TECHNIQUE
question for anyone engaged in day-to-day prac- for the therapist to be neither in an overactive state
tice to explore the manner in which this “hands- nor in a too-passive one. In this state, both poles of
free” treatment differs from treatment in which the therapist’s autonomous nervous system, the
the hands of the therapist are used. The use of ergotropic and trophotropic sides, are equally acti-
medical devices that administer mechanical, elec- vated. As soon as the therapist emphasizes one side,
trical, or electromagnetic impulses may, for exam- this emphasis will be transferred to the patient
ple, locally or globally alter the muscle tone or through the quality of the contact. In this manner,
provide stimuli to the nervous system in a clearly the internal state of the therapist is intertwined with
defined manner. However, such devices are unable, the overall state of the patient, making an objective
or able only to a very limited extent, to register the diagnosis no longer possible.
response of the organism at the same time as they
administer the impulses, to process the response Presence of the therapist
as feedback, and to use this feedback to durably
modify the impulses being administered. The In order for the spectrum of observation to be as
stimuli of these devices are therefore fundamen- broad as possible, the therapist must be completely
tally different from the stimuli originating from present mentally. During the application of diag-
the human hand. The difference lies in the fact that nostic or therapeutic techniques good coordination
the human hand is able to vary its stimuli using is essential.
feedback from the brain in an almost infinite vari- Efficient therapeutic contact is characterized
ety of ways, and therefore is able to register the by the fact that it is sensitive enough to detect
responses of the organism being treated while it the most minuscule differences in surface charac-
administers the impulses. To put it differently, the teristics while at the same time registering the
hand may be used simultaneously to transmit and condition of components that are distant from the
receive information; the hand provides a stimulus immediate point of contact and that may be
and, at the same time, registers the effect of this detected only through the interconnection of the
stimulus on the organism of the patient. In order three-dimensional fascial network.1 Differentiated
to allow this process to take place, a series of pre- attentiveness lends a sensual quality to the con-
conditions for the therapeutic setting must be taken tact. At the same time, however, it is important to
into account. maintain an “objective” or neutral quality to the
In order to make use of both aspects of touch, contact. Only in this manner is a specific and
transmission and receipt, i.e. administration of the precise impulse effect possible.
impulse and observation of the response, the ther- To a certain extent, therapeutic contact has par-
apist must depend on being able to switch freely adoxical qualities. On the one hand, it adapts very
between an active and a passive use of the hands. gently to the form of the body and thus automati-
We will see that, for certain techniques, it is possi- cally attains an expressive character, for example,
ble and even necessary for part of the hand to be in the sense of support, friendliness, or a positive
actively engaged while another part of the same prevailing mood. On the other hand, therapeutic
hand behaves passively. This sort of differentiated contact should also be distanced without produc-
use of therapeutic contact can succeed only if the ing callousness or giving the impression of emo-
therapist is able to guarantee a “neutral” setting. tional detachment.
This “neutral” setting, the therapeutic sett- This paradox can also be seen in the basic
ing, is characterized by some basic rules of communicative role of the therapist. The therapist
communication. should simultaneously express closeness through
the physical contact with the patient but yet remain
Internal equilibrium of the therapist at a friendly distance as a person. This can be best
as a basis for observation described by the following image: the hands of the
therapist are very close to the organism while the
In order to be able to observe the patient with as
few outside influences as possible, it is necessary 1
This ability is widely referred to as “end-feel.”
ERRNVPHGLFRVRUJ
PRINCIPLES OF TREATMENT IN PRACTICE 15
therapist’s self is distant from the personality of and not only during the diagnostic process. In this
the patient. Only in this manner is it possible to manner, it is possible for the directive impulses
produce a therapeutic setting that, to some extent, originating from the therapist’s hand to be modi-
corresponds to Sigmund Freud’s working princi- fied in such a way that they utilize forces already at
ples. In the context of this setting, the therapist will work in the organism of the patient and therefore
hardly be influenced by the patient’s own moods are more effective and gentler at the same time.
and feelings. Only within such a setting is the thera-
pist able to efficiently control the course and efficacy
of the therapy. The use of the hand-contact
technique
Therapeutically efficient contact The first and generally applicable distinction for the
practical use of the hand is the distinction between
It is extraordinarily difficult to document scientifi- weight and active pressure. As soon as the thera-
cally what occurs during the manual treatment of pist’s hand is placed on the surface of the patient’s
the human organism. Part of the difficulty lies in body, the weight of the therapist’s hand, forearm
the fact that human contact always manifests itself or upper arm, and shoulder is transferred onto the
in the organism on completely different levels at body of the patient. The therapist can intensify this
the same time. And whenever we observe one level weight, for example, by leaning forward over the
in isolation, there is the danger that we will take axis of the hip and adding the weight of the torso. In
into account only a partial aspect of the investiga- this case, the coordination of the therapist plays a
tion or even “measure” a pseudoresult. In addition, large role in the quality of the contact. Finally, the
contact always has an individual quality. The qual- contact becomes more effective as soon as the thera-
ity of contact may be similar in different people pist uses active, directive pressure in addition to the
but ultimately is always individual, like the hand- applied, passive weight.
writing of two different people. However, it is still In the treatment of fascial and membrane layers,
possible to formulate a kind of basic technical ori- it is essential that we train our own perception so
entation that may be valid for the most varied types that we can clearly differentiate between the various
of contact. forms of contact. When the patient is lying on his
I have already referred to the fact that every or her back and the therapist’s hand is placed on
human contact unites in itself two aspects. One the surface of the patient’s body, the weight of the
aspect may be characterized as passive and non- therapist’s hand and forearm is transferred onto the
directive—this means to observe, to diagnose—and body of the patient no matter how carefully the ther-
the second may be characterized as active, direc- apist is making the contact. The therapist’s hand
tive, and providing a stimulus—this means to being placed supportively under the patient’s back
actually treat. Many forms of treatment attempt to however is a completely different process. In this
separate these two aspects from one another to the case, the weight of the therapist’s hand and forearm
greatest extent possible. They use the non-directive, is transferred onto the treatment couch and the
passive side of contact for diagnosis and the active, patient’s weight is transferred to the therapist’s hand
directive side for precisely defined manipulations. and forearm. Both forms of contact have a different
I think that this kind of separation is not entirely quality, reach different levels, and are perceived by
realistic and, moreover, carries with it increased the patient as two fundamentally different ways of
risks in treatment. Every form of human contact in being touched.
the therapeutic realm should unite directive and The most efficient treatment techniques for the
non-directive qualities. In other words, one of the fascial and membrane system use both forms of
aspects can move more into the forefront while the touch at once. The therapist can thus use one hand
other aspect retreats into the background and vice dorsally to support the patient lying on his or her
versa. This means that the passive/non-directive back, i.e. to accept the weight, while using the other
aspect is present throughout the entire treatment hand ventrally to work with weight and/or active
ERRNVPHGLFRVRUJ
16 FASCIAL AND MEMBRANE TECHNIQUE
pressure. The therapist is therefore literally taking to the tension of the tissues; the denser the fibers,
the organism in his or her hands. This allows the the slower the contact must be.
therapist to give consideration to the entire three- The next step toward technical differentiation of
dimensional network from the outset instead of contact is the differentiation between the use of the
receiving just a selective, linear, or superficial palm and the individual fingers or the thumb.
impression. A large number of possible combinations are avail-
Another important distinction is the difference able in practice. Despite a widespread misunder-
between stationary, local contact and sliding con- standing, the palm is much more sensitive than the
tact. In sliding contact, the speed must be adapted fingertips in differentiating fine distinctions. For this
ERRNVPHGLFRVRUJ
PRINCIPLES OF TREATMENT IN PRACTICE 17
reason, the combined use of the palm and the fin- stretching impulses in different directions independ-
gers is particularly efficient when the palm is used ently from one another.
in a supportive and observational capacity while the The most important technical condition for being
fingers provide an active stretching impulse. able to treat the fascial and membrane system effi-
Another differentiation of contact is made pos- ciently in its spatial structure is the independence
sible by the fact that each of the fingers can be used of one hand from the other, the independence of
to apply a different amount of force and can apply the palm from the fingers and thumb, and finally
ERRNVPHGLFRVRUJ
18 FASCIAL AND MEMBRANE TECHNIQUE
the independence of the individual fingers and lowered somewhat so that the fingertips contact
thumb from one another. the surface of the body diagonally. When the ther-
apist relaxes the musculature of the pectoral girdle
and upper arm, more weight is applied to the fin-
Direct application of the fingertips
gertips. At the moment when this increase in weight
in the region of the deep fascia
acts on the deep fascia, the therapist applies an
The therapist initially places only sufficient weight active stretching impulse by extending the finger-
on the fingertips to allow him or her to reach tips a little more.
through the skin and the subcutaneous fatty layer This technique lends itself to the treatment of
to the deep fascia. The base of the fingers is then the deep fascia of the torso.
ERRNVPHGLFRVRUJ
PRINCIPLES OF TREATMENT IN PRACTICE 19
ERRNVPHGLFRVRUJ
20 FASCIAL AND MEMBRANE TECHNIQUE
Indirect application of the medial edges of This technique is appropriate for the treatment
both index fingers of the dorsal intercostal membrane and the myofas-
cial layers of the subcostal musculature.
The therapist places both hands on the treatment
table in such a way that the outer edge of the hand
and the little finger transfer weight onto the table. Direct application of the second phalanges
With the lateral edges of both index fingers, the over small areas
therapist accepts the weight of the body part to be
treated. The contact is gradually adapted to the The flat contact of the second phalanges of the index
surface form and finally to the interior form. Then, and middle fingers is suitable for the treatment of
while “listening,” the therapist follows the domi- tough layers of tissue. The therapist applies pres-
nant direction of pull. sure in order to directly influence the muscular
This contact technique is appropriate for the treat- fascia by stretching.
ment of the dorsal intercostal membranes.
Application of the first phalanges
Indirect application of the backs of bent for direct stretching over large surfaces
fingers of both hands
In order to use this technique, the therapist forms a
It is possible for the therapist to vary the preceding fist only far enough that no blunt pressure contact
technique by placing the back of both hands and the results, but rather an elastic effect is maintained, or
elbows flat on the treatment table and bending the the fist is held open. The therapist takes care that
fingers in such a way that the patient comes to rest his or her wrist does not bend as soon as weight or
precisely on the foremost finger joints. In this case as pressure is applied. The transfer of force should
well, the contact of the individual finger joints is ini- occur more or less in a straight line from the fore-
tially adapted to the surface and then to the inner arm to the first finger joints. Only when the thera-
form that can be felt below the surface until clear pist has gently used the contact to access the deep
directions of pull emerge. The therapist follows these fascia through the surface layers does the therapist
directions of pull by “listening” while supporting begin to slide perpendicular to the fiber direction
the larger form with the balls of the hands. with a strong contact.
ERRNVPHGLFRVRUJ
PRINCIPLES OF TREATMENT IN PRACTICE 21
ERRNVPHGLFRVRUJ
22 FASCIAL AND MEMBRANE TECHNIQUE
Two-dimensional application of both palms stretch of a few millimeters in which both of the
therapist’s hands should be moved slightly toward
The two-dimensional application of the entire sur- one another without forcing the neck as a whole into
face of the hand and fingers is primarily suitable for a stronger flexion or extension (see Upledger and
the treatment of the superficial layers of the neck and Vredevoogd 1983: 54–5).
the transitional layers between the upper thoracic
cavity and the lower cervical region. The contact
Selective contact in the treatment
should be made in such a way that the longitudinal
of small membrane units
vessels are not compressed. In order to do so, the
contact should be kept two-dimensional and should The application of contact to small tissue units
not translate into exterior sliding on the surface of requires a precise approach, almost at a single
the skin. The sliding that is used is actually only a point. This procedure is primarily suitable for the
ERRNVPHGLFRVRUJ
PRINCIPLES OF TREATMENT IN PRACTICE 23
treatment of transitional areas in the organism, that produce more intensive contact with the mem-
which naturally have a narrow structure, e.g. for the brane system. In the treatment of the entire path of
treatment of the transition between the posterior the dura between the cranium and sacral bone, the
section of the neck and the base of the skull. The therapist maintains slightly elastic and, at the same
deciding factor is that the fingertips remain in con- time, strong contact with the base of the skull and
tact with the lowermost edge of the occiput of the the frontal bone. The tensile behavior of the dura
cranium, the palms very gently support the back of mater of the spinal cord and the structures con-
the head at the same time, and the foremost pha- nected to it may be diagnosed and influenced
langes actually point vertically to the ceiling. They using this treatment.3
should not exert any active pressure but rather sim- Although the mode of functioning of this tech-
ply support the weight of the head and thus act on nique emphasizes the interior membrane system in
the suboccipital layers. If applied correctly, this type the area of the head and spine, it has a drastic effect
of contact acts initially on the muscular connections on the surface structures as well. It is only too easy
between the axis, atlas, and occiput and, if the ther- for us to forget that, even when we are treating
apist waits patiently, also on the membrane layers deep membrane structures, our hands first come
located in the region of the foramen magnum.2 into contact with the skin and the layers close to the
skin of the organism. The technique described
Global contact with membrane layers in the above affects not only the falx cerebri and the ten-
interior of the cranium and/or vertebral canal torium cerebelli but also the galea aponeurotica,
which is rich in sensory and motor nerves.
In traditional craniosacral osteopathy, which works
with Sutherland’s flexion–extension model, very
subtle pressure of only a few grams is used. Tech- Combined contact with the body stocking and
niques may be used to supplement this procedure structure of the thoracic cavity
Given the three-dimensional interconnection of the
2
fascial and membrane system, the manual influence
Upledger has made reference to the fact that this technique
also affects the foramen jugulare and thus the cranial nerves
3
that pass through this foramen. see Upledger and Vredevoogd The tests that must first be performed before this treatment
(1983: 58). are described in detail in Barral and Croibier (1999: 184–90).
ERRNVPHGLFRVRUJ
24 FASCIAL AND MEMBRANE TECHNIQUE
on one individual fascial layer always has side- Indirect application of both hands
effects in producing broader spatial consequences as for the treatment of the interosseous
well. Techniques that are not only selective, linear, or membrane of the lower leg
two-dimensional, but rather are applied in a three-
In order to reach the interosseous membrane in the
dimensional, spatial manner from the outset, have a
lower leg, the therapist places both palms dorsally
particularly long-lasting effect. One example is the
below the upper and lower thirds of the calf. The
simultaneous treatment of the body stocking and
lower leg should be resting in both of the thera-
deep membrane layers in the region of the thoracic
pist’s palms in such a way that the therapist is able
cavity. The therapist produces a contact with one
to support its entire weight while the fingers still
palm on the front side of the thoracic cavity by liter-
have room to move. The therapist now also dorsally
ally modeling the cur-vature of this section of the
contacts the medial edge of the fibula with the fin-
body. At the same time, the therapist’s fingertips are
gertips of one hand and the medial edge of the
anchored in the body stocking. Because the thera-
tibia with the fingertips of the other hand. While
pist’s palm is now slightly compressing the ribs, the
both palms continue to support the weight of the
therapist can then influence the sliding behavior of
lower leg, the fingertips attempt to reach as close
the membrane layers located between and beneath
as possible to the periosteum of both longitudinal
the ribs. While doing so, the therapist maintains
bones. The indirect efficacy is now possible because
strong contact with the deep fascia and applies an
the therapist is following the tension of the mem-
active stretching impulse in places where com-
brane by “listening” through the fingertip contact
pacted fibers are noticeable. While doing so, the
and is keeping both hands sufficiently relaxed that
therapist’s other hand is supporting the same rib
the contact points move toward one another in the
region from the posterior side. Here as well, the
direction of tension of the membranes until relax-
form of the therapist’s hand is adapted to the indi-
ation occurs.
vidual form and grips into the thoracolumbar fascia.
If this technique is applied correctly, it is possible to
treat simultaneously the body stocking and deep
Indirect application of the fingertips to the
membrane structures that occur on the anterior and
periosteum of the bone
posterior surfaces of the thoracic cavity. In this man-
ner, the tension patterns underlying the exterior and After a fracture has healed, a compression of the
interior form are treated at the same time. bone tissue and the surrounding periosteum occurs
ERRNVPHGLFRVRUJ
PRINCIPLES OF TREATMENT IN PRACTICE 25
at the break point. The treatment of this type of tis- inherent tendency of bones to bend in on themselves
sue compression requires a special application of after a fracture. At the same time, the therapist inten-
the fingertips and the thumb. This technique, which sifies the contact between the two contact points
can be used for all bones of the extremities as well as if to displace the periosteum slightly from its
as on the sternum and collarbone, is indirect. The connection to the bone.
therapist surrounds the bone on both sides of the
break point with the tips of the fingers and thumbs
Direct application of the ulna to the large
of both hands. In so doing, the therapist is definitely
ligaments of the pelvis
in contact with the periosteum but avoids holding
the bone stiffly in place. By “listening” and follow- The application of the ulna makes it possible to
ing, the therapist exaggerates only very slightly the produce an extremely strong contact with tough
ERRNVPHGLFRVRUJ
26 FASCIAL AND MEMBRANE TECHNIQUE
structures. It is primarily suitable for the treatment so is for the therapist to gradually apply more upper
of larger myofascial units and for the treatment of body weight to the ulna by way of the pectoral gir-
the larger ligaments of the lower pelvic region. It is dle and upper arm without additionally tensing
important to ensure that the ulna does not have the pectoral girdle or the upper arm. With some
strong contact with the patient’s tissue until it has coordinated deftness, the ulna may be applied
arrived at the layer in question. For example, in very intensively in this manner in that the therapist
order to affect the sacrotuberous ligament, it must increasingly relaxes the musculature of the pectoral
first make its way through the muscle layers located girdle and upper arm and almost exclusively uses
on top of this ligament. The best method for doing body weight.
ERRNVPHGLFRVRUJ
PRINCIPLES OF TREATMENT IN PRACTICE 27
Support of the interior form in the region the therapist’s palm is supporting the base of the
of the thoracic cavity: the “natural table” skull and the therapist’s fingers are attempting to
gain contact with the atlanto-occipital connection.
The following type of contact can be varied in a
This form of contact and its variations are pri-
number of ways. However, one consideration has
marily suitable for the treatment of tension patterns
fundamental significance: very deep components
in a psychoemotional context.
of the myofascial system and the membranes may
A comparable technique can be applied in the
be contacted only if patients are allowed to main-
region of the pelvis and lumbar spine. One of
tain a certain basic equilibrium in their exterior
the therapist’s hands is supporting the interior
musculature that is typical or habitual for them.
curvature of the sacral bone and the other hand is
This basic equilibrium arises when their preferred
supporting the curve of the lumbar spine.
postures have become obvious in their bodily form
or structure. The therapist’s task is to position his or
her hands such that the patient can lie on them and Basic rules of fascial and
maintain their preferred position of the back and membrane technique
thoracic cavity. In a certain way, the therapist’s sup-
porting hands reinforce the typical pattern of ten- In the section about the material properties of
sion with the autonomic musculature of the connective tissue (Chapter 2), we saw that connec-
patient’s back and thoracic cavity. Thus the thera- tive tissue has a distinctive capacity for functional
pist’s hands, forearms, and possibly upper arms adaptation. It reacts to long-term strain from com-
form a “table” beneath the patient that allows the pressive and tensile forces. In this process, collagen
patient to rest in the position that appears “natural” fibers are organized into a functionally suitable
to his or her. The deciding factor is that as many arrangement while the balance of fluid content
contact points as possible be available to the thera- between the various fascial components will vary.
pist for the construction of the “natural table.” For However, the organism does not have a control
example, this occurs when the occiput of the patient system that can regulate this process precisely. In
is supported on the one side with the therapist’s the longer term the body reacts to repetitive, mono-
lower arm, thus leaving the hand free to reach tonous motion by overcompensating. The com-
downward in the transitional region between the pression and realignment of fibers, which at the
thoracic and lumbar spine while, on the other side, outset is expedient, then develops dysfunctional
ERRNVPHGLFRVRUJ
28 FASCIAL AND MEMBRANE TECHNIQUE
properties; finally it will restrict mobility and of the band are brought closer together until a
encourage a defective exchange of fluids in the motion impulse is sensed at the origination
united cell structure. This process can occur in and insertion surface of the bone. In the case of
very different ways in individual cases. The aim of large bands, e.g. in the region of the pelvis, an
the techniques described in this book is to inter- alternative strategy may be used: the therapist
vene in the overcompensation process and assist initiates a slow-acting impulse by contacting
in regulating it. the middle section of the band while observing
In practice, the use of fascial and membrane tech- the reaction of the bone structures held by the
nique requires an approach that is precisely differ- band by “listening.” It is important to avoid
entiated on an individual basis. In spite of the vast overstraining the band fibers.
range of individual specialized forms within the
● Interosseous membranes and deep septae
fascial and membrane system, it is still possible to
respond best to subtle contact: therapy is
formulate some basic rules that have proven them-
performed indirectly here as well. It follows the
selves in practice:
dominant fiber paths, allows the bones to slide
● Overly tense myofascial layers of the muscu- more strongly into their fixations, provides a
loskeletal system require a direct lengthening; gentle impulse to reinforce the fixation, and at
this lengthening is performed as parallel as the moment of strongest fixation then follows
possible to the muscle fiber and transverse to the releasing countermotion by “listening.”
the primary fiber direction of the fascia. ● Envelopes and ligamentous structures of
● Slack myofascial layers of the musculoskeletal organs must be treated carefully. These layers
system are treated carefully and in a slowly of tissue require a sensitive contact that takes
sliding manner; the contact is broad and into account the so-called turgor effect, the
superficial, and linear contact and point inner pressure dynamics of the organ, and its
loading are to be avoided. fluid dynamics. In the course of one treatment
session, the applications must be limited to
● Band structures that create connections two or a maximum of three organ complexes in
between bones respond well to so-called order to allow the organ system sufficient
indirect techniques: the origin and connection range for self-regulation.
ERRNVPHGLFRVRUJ
PRINCIPLES OF TREATMENT IN PRACTICE 29
ERRNVPHGLFRVRUJ
31
Chapter 4
Form-oriented treatment
techniques
ERRNVPHGLFRVRUJ
32 FASCIAL AND MEMBRANE TECHNIQUE
4.1 BREATHING
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 33
ERRNVPHGLFRVRUJ
34 FASCIAL AND MEMBRANE TECHNIQUE
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 35
zones of visceral cavities. The transitional areas it will be helpful to analyze how the segments of
between the abdomen and lower chest cavity and the torso are connected to one another spatially.
between the upper chest cavity and the neck area
are particularly significant in this regard. If devia- Spatial relationships between the
tions from the norm occur in the fascial network in segments of the torso
these regions or if changes arise in the direction of
pull of individual membranes, a “displacement” The human torso is “divided” into chambers with
of entire sections of the body relative to one another various levels of hydrostatic pressure (see Fig. 4.5).
may occur. These differences in pressure play a particularly
If a limitation of movement occurs in the region important role with regard to erectness at the tran-
of an organ located inferior to the diaphragm, the sition between the abdominal cavity and the tho-
diaphragm is also affected by this limitation of rax; higher pressure conditions in the abdominal
movement. This process may be clearly observed cavity compared with the chest cavity press the
in the case of reduced organ mobility of the stom- organs in the upper abdominal region against the
ach or the liver. The excursion of the half of the diaphragm and thus form a foundation for the rib-
diaphragm on the side of the affected organ is cage, which is in constant motion. Without the
reduced. The activity of the musculature between excess pressure in the abdominal cavity, the liver
the ribs and the associated fascial layers and mem- and stomach would sink when a person is upright.
branes responds to this change as well. As a result, This support function of the abdominal organ col-
a visible exterior alteration of form, as well as ulti- umn would thus be lost and erect posture of the
mately a tangible interior alteration of form, of the torso would no longer be possible. In contrast to the
adjacent thoracic wall arises. liver, the pyloric part of the stomach is very mobile
A similar process occurs in the region of the and is constantly able to change its position in the
upper transition at the connection between the abdominal area as soon as its weight changes
chest cavity and neck region as soon as form-stabi- because of the contents of the stomach or it is
lizing layers of connective tissue display an asym- affected by displacement forces caused by turgor
metrical tensile behavior. Because there is a direct in another adjacent organ. Along with the pressure
connection between the uppermost section of the from the descending colon, the stomach can push
endothoracic fascia and the transverse processes the left half of the diaphragm so far upward that
of the lower cervical vertebrae, increased tensile the diaphragm is almost horizontal and both of the
forces acting on the cervical spine from the upper diaphragm cupulas are arching almost symmetri-
chest cavity may limit movement of the affected cally, which is a deviation from the norm. In addi-
joints. In advanced stages, this situation favors a tion, there is a very dynamic motion relationship
tendency toward arthrotic changes. between the diaphragm, spleen, stomach, colon,
adrenal gland, and kidney on the left side of the
body between the ninth and eleventh ribs. The
The endothoracic fascia is largely developed as spleen rests as if on a scale on the left phrenicocolic
a very thin layer. Only in the uppermost section, ligament, i.e. on the ligament that functions as the
in the regions in which it envelops both pleural suspension for the left portion of the transverse
cupulas, is it distinctively dense and ropy. This mesocolon on the ribs. I have referred to the tran-
natural thickening of tissue is a signal that the sition between the abdomen and thorax as an
connecting ligament, which is joined with the “upended trampoline.“ This “trampoline” is sub-
scalene fascia and leads to the cervical spine, stantially more mobile on the left side of the body
actually transmits tensile forces and functions than on the right because the spleen provides a very
as a suspension for the pleural cupulas. dynamic “intermediate element.” Even a small
change in the position of the upper body causes
the spatial displacement of this organ. In the same
Before we discuss the individual layers of con- manner, the effects of pressure originating from a
nective tissue necessary for the breathing process, full stomach can change the spatial position of the
ERRNVPHGLFRVRUJ
36 FASCIAL AND MEMBRANE TECHNIQUE
spleen as well. So we can see that the spatial rela- This process of anticipatory movement activity
tionship between the abdominal and chest cavities plays out within the breathing process as well. In
is anything but static. The right diaphragm zone is other words, a large number of muscle activities
the more stable element in this relationship, whereas precede, accompany, or obstruct the activity of the
the left half is more mobile and less stable, partic- diaphragm and the rib-lifting musculature. Anti-
ularly because of the displaceable nature of the cipatory muscle activity guarantees or limits the
spleen and the “nested system” of the spleen, stom- scope of movement within which the changes in
ach, colon, adrenal glands, and kidneys. The volume necessary for breathing can occur. From
diaphragm adapts to the pressure conditions of the this viewpoint, the myofascial units connecting
upper abdominal cavity. This adaptation in turn the leg to the pelvic area to the back are of greater
causes a shear effect on the organs of the thorax. significance. These are the layers that are responsi-
An example of this is the displacement of the ble for the position of the hip axis in relation to the
stomach in the cranial direction, which causes torso as a whole. All myofascial units that are
pressure on the pericardium and is often misinter- attached to the ischial ramus are significant for the
preted by the patient as cardiac symptoms. tendency of the pelvis to tilt.
The outer parietal spatial structure of the pelvic, The tilting of the pelvis has a considerable influ-
abdominal, and chest segments has in turn its own ence on the breathing space of the abdomen and
dynamic. There are certainly patterns of posture thorax. As soon as the pelvis tilts in the posterior
that arise again and again in various daily activities. direction on the hip axis, the back flattens in the
These patterns are the dominant tensile pattern of lumbar region and lordosis appears to be reduced.
the musculature and the fascial-membrane identity. In this case, the radiographic image shows a spine
This sort of tensile identity is determined substan- running steeply downward with a small lordotic
tially by the autonomic musculature, but also by the curvature, but a drastic curve between the last lum-
extent to which general muscle coordination allows bar vertebra and the first, uppermost segment of
the change from extension to flexion in the torso. the sacrum. For the retroperitoneal kidney, the sup-
People who always hold themselves in an over- porting pressure of the posterior layer of the peri-
erect position or who frequently sit or stand with a toneum is reduced and the effects of gravity create
slouch are not only expressing the spatial relations the tendency of the kidneys to sink downward, i.e.
of anatomical units. Rather, very specific preferred into ptosis. This sinking motion may extend to all
patterns of activity function as the “director” of the retro- and subperitoneal elements and will also
spatial units of the pelvis, abdomen, and chest. have an effect on the front of the spine. Because
The manner in which the chest cavity rests on the there is no prevertebral musculature above the ori-
abdominal cavity and on the pelvis is influenced by gin of the psoas that could counteract the down-
preferred patterns of perception as well as the tac- ward pull, the innermost deep layer of the chest
tile and visual orientation of the person in space. cavity, the large anterior longitudinal band, finally
With regard to human locomotion, we know that responds by shortening, and a general equilibrium
there is a movement pattern that is present even of tension occurs between the pre- and postverte-
before the beginning of the intended movement bral layers of the organism. From a surface observa-
process. Hubert Godard referred to this process as tion, the deep erectors of the back appear to be the
anticipatory movement activity.1 cause of the tension, but in reality the increase in
tone of the erector group is merely a compensatory
response to insufficient erection of the column of
1
H. Godard, Improvement of Sensory Dynamics [Verbesserung organs in the interior region of the torso.
der sensorischen Dynamik] in: P. Schwind, All in Line: An The room that is available for breathing motion
Introduction to the Rolfing Method [Alles im Lot. Eine Einfuhrung is influenced by the dynamic described above
in die Rolfing-Methode], Droemer Knaur, Munich 2003, p. 173: between prevertebral erection and postvertebral
“However, we are not aware of this anticipatory activity. And
for this reason, we remain ignorantly trapped in our habits
tension. The tilting of the pelvis around the hip axis
because these anticipatory activities are present in our in the posterior or anterior direction necessarily
movement without our being aware of them in the least.” limits the scope of movement of the diaphragm for
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 37
Iliopsoas muscle
Ischiocrural Rectus
muscles femoris muscle
Gastrocnemius
muscle
inhalation. In addition, the room available for of the breathing pattern with a more global treat-
breathing motion is dependent upon the upper spa- ment of segmental alignment. In this case, it is
tial limits, specifically the spatial limit placed on the important that
ribcage by the pectoral girdle. Because breathing ● the hip joints have sufficient mobility
motion is dependent upon the general segmented ● the ligaments of the pelvic region display
erection of the body in this fashion, it is necessary to sufficient elasticity
treat the breathing pattern in the context of the ● the shoulder girdle does not compress the
overall structure. Here, we place particular empha- chest cavity too severely
sis on the tension patterns that occur at the points at ● the organs are able to respond adaptively to
which the extremities are connected to the torso: the change in volume in the breathing space.
● in the lower region, the connection between the
myofascial units of the musculature of the Anatomy of the significant fasciae and
extremities to the ligaments of the pelvic region membranes of the breathing space
● in the upper region, the shoulder girdle as a
bridge between the tension patterns of the In order for the breathing process to run smoothly,
arms and ribcage. certain conditions of the interior and exterior
structure of the torso must be guaranteed:
If the patient makes an effort to maintain an
upright posture, mobilization of the layers that are ● The lungs can move or fill only as far as is
directly involved in breathing will attain few lasting allowed by the thoracic wall, which is closely
results. In this case, we must combine the treatment adjacent because of the adhesion effect.
ERRNVPHGLFRVRUJ
38 FASCIAL AND MEMBRANE TECHNIQUE
● The thoracic wall itself can move only as far as at individual points the subcostal muscles, each of
it is allowed space to do so by the generally which has a different path. They are located at the
segmental organization of the erect torso. transition between the exterior ribcage structure
● During inhalation, the ribs rise only as far and the interior layer system of the interior chest
as they are allowed by the intercostal wall and exterior pulmonary wall. There are three
membranes. layers here that are connected to one another by an
adhesion effect:
Thus, there are exterior limits in the myofascial
and membrane structure of the ribcage. In addition, ● the endothoracic fascia
however, there are also interior limits that arise ● the parietal pleura
from the fact that individual organs obstruct the ● the visceral pleura of the lungs.
motion of the diaphragm. A limitation of breathing
motion can arise literally from any fascial or mem- Regardless of whether they are located on the
brane layer or other forms of connective tissue. We outer wall of the ribcage or in the interior cavity, each
can study these limitations using the layered struc- of these layers can limit normal breathing motion
ture of the ribcage. If we wish to reach inward at and thus alter the volume patterns of the lungs.
approximately the level of the fifth rib on the right The intercostal membranes are particularly sig-
side of the thorax, we will pass through all fascial nificant. Their elasticity is essential to the movement
and membrane layers that are involved in the active of the ribs during inhalation. However, this elas-
inhalation motion and the passive exhalation motion ticity may extend only to a certain point because the
of the center section of the chest. toughness of these membranes is required for the
The deep fascia is located below the skin and the return motion of the ribs in so-called passive
superficial fatty layer. As the pectoral fascia, it is a breathing. This process of active inhalation and
continuation of the abdominal fascia. Below the the normally very passive process of exhalation is
superficial fascia is the myofascial bridge between supported dorsally by the activity of the autonomic
the external oblique and the serratus anterior. musculature of the back, the erector group. In this
Below this layer, we find the intercostal region with muscle layer, too, we find a fascial envelope that
the intercostal musculature and both intercostal influences the flexion and extension capacity of the
membranes, which have different directions in the muscles and therefore breathing movement as well.
orientation of their fibers. Farther inward, we find This is the thoracolumbar fascia, which forms an
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 39
osteofibrous canal along with the vertebral arch, the retroperitoneal space is relatively stable. The
dorsal processes, and costal processes. This fascia shear force of the diaphragm has an influence in this
influences all bending sections of the spine because region as well; during normal breathing, it moves
it is directly connected to the dorsal processes of the the kidneys approximately 2 cm. This motion and
thoracic and lumbar spine as well as to the sacrum. the muscle activity of the psoas muscle are the
In the region of the neck, it continues as the so-called dynamic components of the retroperitoneal space.
nuchal fascia. Peculiarly, it runs below the trapezius Because they take place without large changes in
muscle and the rhomboid group in this region. It volume, there is greater stability in this region than
influences the bending behavior of the spine in this in the intraperitoneal space.
section as well because it is directly connected to the The diaphragm forms the foundation of the
nuchal ligament, which in turn is connected to all of chest cavity, which is supported by organs. It is sur-
the dorsal processes of the cervical spine. rounded by an elastic membrane on both sides. In
In addition to the exterior frame structure of the addition, a fluid sliding layer, known as the serosa,
breathing space, the spatial relationship between the is located in the regions in which the strongest mus-
visceral cavities of the torso plays an important role. cle activity occurs, i.e. on the sides. This serous sur-
The chest cavity rests above the diaphragm and thus rounding layer, which guarantees sliding ability, is
on the organ column of the abdominal and pelvic not present at the connection point to the liver (area
cavities. The part located inside the peritoneum is nuda) or in the region of the central tendon.
dynamic. Owing to constant changes in volume, Conditions are similar for the organs in the peri-
peristaltic movements, and relatively large changes toneal space. In addition to their own surrounding
in the spatial position of the upper abdominal zone, layer of connective tissue, these organs also have a
there is a highly movable foundation. In contrast, serous layer that allows sliding during breathing
ERRNVPHGLFRVRUJ
40 FASCIAL AND MEMBRANE TECHNIQUE
movement. Between the organs, there are actual muscle. It is obvious that the exterior and interior
niches in which the peritoneal fluid can collect and layers are equally important for the development of
there are gaps inside which the serosa is distrib- breathing motion. Therefore, it is worth either using
uted in certain directions. techniques that affect such deep layers and thereby
influence the exterior form as well or using tech-
niques that treat the exterior form in such a way that
Mobilization techniques for the organs of the it mobilizes the inner layers as well.
upper abdomen, the stomach, the liver, and Such a process will prove its value at the upper
also for the duodenum and the sections of the pole of the breathing mechanism, in the region of
colon located farther below, have a particularly the scalene group. In this section of the body, mul-
lasting effect if the therapist also takes into tiple layers of connective tissue overlap. Here, we
account the direction of flow of the serous find extensive fascial layers covering the upper
back and shoulder area, layers whose tension pat-
fluid. The mobilization of the organ then
terns mirror a person’s dominant emotional habits.
simultaneously brings about an improved
However, we also find small myofascial elements
distribution of the sliding fluid.
such as the subclavius muscle and the minor sca-
lene muscle, which is sometimes missing.
The diaphragm changes its shape and position It is not possible to assign a definite emotional
constantly depending upon the position of the meaning to these elements. In any event, they play
body. When sitting, it is somewhat lower than when an important role in securing the breathing mecha-
supine, and when standing it sinks somewhat nism in the upper chest cavity. It is only possible for
farther. However, the position of the diaphragm them to fulfill this role just above and below the
changes even when a person bends to the side, clavicle—an area which is so important for the ven-
stands overly upright, or sits with a slouch. There- tilation of the upper lung—if their surrounding fas-
fore, while it is supported from inside by the organ cial layer is elastic enough to allow the lungs to
column, it is constantly under the influence of the expand here. These layers, which are very signifi-
exterior musculoskeletal system. In this sense, all cant for breathing motion, have another important
exterior and interior form-shaping forces are united duty to perform: they safely channel the nerves and
in the region of the diaphragm. It is precisely for this blood vessels between the chest cavity and neck,
reason that it seems reasonable to me that the lay- provided they are subjected to normal tension.
ers adjacent to the diaphragm, i.e. the coatings and
ligaments of the organs and the myofascial and
membrane frames that surround the diaphragm on Examination of breathing motion
the outside, should be treated simultaneously.
I mentioned at the outset that literally all fascial The most important layers for the breathing process
and membrane layers of the organism have signif- run in the interior of both large visceral cavities and
icance for the breathing process. To a certain extent, therefore it is possible to access them only to a
the fasciae located at the transition between the limited extent through direct touch palpation. The
torso and the extremities play a role too. clearest observation of the status of the fasciae may
This is particularly true for the connection be made by observing the movement behavior of
between the chest cavity, the pectoral girdle, and the individual components relative to one another, for
upper extremity. In this region, it is the fascial layers example, the sliding behavior of the organs relative
especially that lose their mobility in the course of a to one another, as Jean-Pierre Barral has described
lifetime, consisting as they do of a denser material with his concept of organ mobility (see Chapter 6),
with a higher proportion of collagen fibers relative or by comparing the sliding behavior of bones,
to the elastin elements. Externally and laterally, this organs, and muscles. We can then clearly determine
is the fascial boundary between the latissimus dorsi the fascial and membrane function using the devia-
muscle and serratus anterior. In the deep, retroster- tion from the norm of the spatial relationships of
nal layer, this is especially the transverse thoracis the individual elements to one another.
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 41
For practical examination of breathing motion, in firm contact with the floor. Initially the therapist
the regions in which the various components senses the global shearing motion on both sides.
overlap spatially are significant. This includes the In normal cases it can be felt that:
sections in which the visceral cavities meet: the tran-
● The ribs on both sides rise almost identically.
sition between the abdominal and chest cavities and
● The ribs perform a rotational motion in the
the transition between the chest cavity and the neck
direction of the connection to the vertebral body.
region. It is also helpful to include the lower pelvic
● The intercostal space widens while the spatial
region and the cranium in the examination with
curves of the liver and stomach, running
simple tests in order to also take into account the
opposite one another downward and medially,
segments of the body that participate in the move-
become perceptible.
ment of the diaphragm only in the form of indirect
transmission of pressure over large distances. At the beginning, precise sensing is required to be
able to detect the differences in direction of various
components within the general change in volume.
Evaluation of the transition between the
If a smaller increase in volume is evident on one
abdominal cavity and thorax
side it reveals a limitation in the movement between
Patient Seated. the elements of the body under the palpating hand.
In a second observational step, we now concen-
Therapist Seated behind the patient.
trate on the spatial, three-dimensional manifesta-
Contact With both hands: the thumb, index, and tion of this limitation of movement:
middle fingers touch the lower ribs, the ring finger
● Does the exterior structure appear to be the
and little finger are in contact with the tissue
limitation or is it the deeper layers that are
below the costal arch. Make broad contact with the
unable to expand?
palm, including the ball of the thumb.
● Does a characteristic shear motion occur in
Action While maintaining a relaxed contact on the direction of the navel due to the tilting
both sides, the therapist’s hands mold closely to behavior of the stomach and/or liver in the
the shape of the torso without exerting excessive direction of the navel?
pressure. It is important for the therapist to sit ● Or is the space for intercostal movement
upright without being tense and to have both feet limited?
ERRNVPHGLFRVRUJ
42 FASCIAL AND MEMBRANE TECHNIQUE
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 43
Lung
Visceral pleura
Anterior serratus
muscle
Costal part of
the parietal
9th rib pleura
Diaphragmatic part
of the parietal pleura
External intercostal
muscle Parietal peritoneum
Visceral peritoneum
Internal intercostal
muscle Diaphragm
Costo-diaphragmatic
recess
10th rib
Liver
Figure 4.10 Layers of the thoracic wall in the region of the overlapping of the visceral pleura, diaphragm, and liver.
ERRNVPHGLFRVRUJ
44 FASCIAL AND MEMBRANE TECHNIQUE
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 45
Figure 4.13 Evaluation of the transition between the Figure 4.14 Evaluation of the deep layers from the
upper chest cavity and the neck area in the sagittal plane. anterior side.
Additional test: evaluation of the deep layers Therapist Seated to the side at the level of the
from the anterior side patient’s hips.
Patient Seated. Contact One hand supports the sacrum from the
Therapist Standing behind the patient. posterior side while the second hand rests supe-
rior to the joint of the pubic bone.
Contact With the thumbs on the posterior side
over the first rib, with the index fingers on the
anterior side on the medial sections of the pleura
In women, we must keep in mind that the
cupulas, with the remaining fingers of both hands
uterus has a different position when the
under the clavicles.
bladder or descending colon is full. In men, a
Action While the thumbs serve as fixed points reduction in breathing movement in this region
from the posterior side, the fingers compare the provides information regarding the pressure
mobility of both pleural cupulas and the connec-
conditions acting on the prostate in the lower
tion between the two clavicles and the first rib
pelvis. The purpose of this test is to ascertain
(subclavius muscle).
the mobility of the intraperitoneal elements in
Evaluation of breathing movement in the relation to that of the extraperitoneal elements.
lower pelvic region
Patient Supine, legs outstretched, arms resting Action The therapist supports the sacrum with
on either side of the torso. one hand and, with the other hand, comes into
ERRNVPHGLFRVRUJ
46 FASCIAL AND MEMBRANE TECHNIQUE
contact with the tissue layers above the pubic bone. Therapist Seated near the head.
In a normal case, the base of the sacrum will move
dorsally during inhalation and lumbar lordosis Contact With both palms in the region of the
will be reduced, while the elements inside and parietal bone.
outside the peritoneum slide opposite one another.
We can now ascertain whether the limitation of Action Breathing motion can only become dis-
movement is primarily manifest in the back or the cernible in the cranium if an elastic effect is allowed
anterior chamber of the pelvis and then select our by the forces acting on the cranium. If the falx of the
treatment strategy depending on what we find. cerebrum overall is subjected to strong tensile force
between the base of the skull and the frontal bone,
Evaluation of breathing movement in the this sort of elastic effect cannot occur. It is essential
retroperitoneal area for this test to exercise slightly elastic pressure on
both sides from the lateral direction in order to
Patient Lying on one side. ascertain whether the cranium springs back. Subse-
Therapist Seated to the side at the level of the hips. quently, with gentle contact, the therapist’s atten-
tion is then directed toward whether the breathing
Contact With the thumb below the twelfth rib. motion can be felt in the cranium.
Action The therapist’s thumb reaches parallel
to the twelfth rib in the direction of the lower
boundary of the kidneys until the therapist is able Treatment of the fascial network of the
to feel the shear effect of breathing motion. If the respiratory area
kidney is too low or clearly limited in its move-
Treatment of the deep fascia and intercostal
ment, the shear is not easy to detect during inhala-
membranes
tion. In any event, a comparison should be made
between the two sides. Patient Supine, both legs flexed.
Evaluation of the transmission of breathing Therapist Standing at the level of the patient’s
motion into the cranium hips.
Patient Supine, legs outstretched, arms resting Contact From behind with a flat hand in the
on either side of the torso. region of the middle thoracolumbar fascia, from
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 47
the front with a flat hand directly at the transition curvature of the back. The therapist’s other hand
between the abdominal and chest cavities with the maintains a flat contact with the lower ribs and, at
fingertips between the region of the middle ribs. the same time, its fingertips reach through the sub-
cutaneous fat to the deep fascia in order to exert a
Action The therapist gently supports the curva- stretching impulse in a slightly cranial and medial
ture of the back with a flat hand from behind. The direction. If restrictions of movement can be found
therapist’s palm stays in contact with the superfi- in the deeper intercostal region when examining
cial and deep layers of the back in that the weight the chest area, the pressure being exerted by the
of the therapist’s hand is placed on the table and fingertips should be directed somewhat more
the palm is adapted as precisely as possible to the steeply inward. The steeper the direct pressure is
ERRNVPHGLFRVRUJ
48 FASCIAL AND MEMBRANE TECHNIQUE
exerted, the more interior its effect reaches. In this Treatment of the upper section of the fascia of
manner, it is possible to reach the intercostal and the rectus abdominis
subcostal regions.
Patient Supine, both legs flexed.
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 49
abdominis. With the more lateral hand, the thera- time, the other hand pushes the serratus anterior
pist gives a slight push in the cranial and medial in the direction of the oblique abdominal muscle.
direction toward the sternum. With the hand that In the region of the serratus muscle, contact is par-
was applied medially, the therapist applies a slight, allel to the course of the muscle fibers. Thus, the
direct, stretching effect in the cranial direction. two muscles are moved toward each other in such
Both hands move slightly in the anterior direction, a way that they are pushing against each other
while the hand applied farther outward moves somewhat at their point of overlap. While apply-
diagonally toward the hand applied in the middle ing somewhat more pressure along the arc of the
region. With some skill, it is possible to use this ribs of the chest cavity, both of the therapist’s
compression to reach the posterior section of the hands are moved toward one another and cause a
sheath of the rectus as well. direct stretching of the fascial layers of both mus-
cles mentioned above.
ERRNVPHGLFRVRUJ
50 FASCIAL AND MEMBRANE TECHNIQUE
Contact With one hand from the posterior direc- Therapist Standing at the head of the treatment
tion between the first and second ribs, with the table.
other hand parallel to the clavicle in the direction
of the sternoclavicular joint. Contact Supporting the head from the posterior
direction with one hand and with the other hand
Action The therapist supports the scapula from coming from the lateral direction toward the fascia
below and reaches with the fingers precisely of the posterior scalene muscle.
between the first and second ribs. With the other
hand, the therapist reaches toward the sternoclav- Action Here, it is important for both of the
icular joint parallel to the clavicle, maintaining patient’s legs to be flexed because this creates a
light contact with the clavicle itself so that it can be push in the cranial direction and the neck is length-
easily compressed into the joint connection. The ened from its connection to the ribcage. The thera-
therapist now gradually intensifies contact with pist lifts the occiput slightly and, at the same time,
this hand so that it is exerting a shearing force on brings the entire neck region into a slight rotation
the joint. The therapist then intensifies the pres- and sideways bend. At the same moment, the ther-
sure from the posterior and anterior directions as apist’s other hand reaches in the direction of the
if to move the contact surfaces of both hands toward posterior scalene muscle. The target is the deep sec-
one another. The contact from the posterior direc- tion of the lateral portions of the lamina of the neck.
tion acts as a wedge between the first and second The rotation and sideways tilt of the neck is neces-
ribs. With the hand applied on the anterior side, sary in order to keep all of the superficial muscular
the therapist now intensifies the pressure until a elements completely relaxed. Only in this way can
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 51
contact be produced in the direction of the scalene move the head a little farther in its sideways curve
fascia. As soon as the therapist is able to detect and rotation while an intense pull in the mediocra-
breathing motion of the scalene group at this point, nial direction is exerted on the contact point of the
the therapist intensifies the contact in the direction posterior scalene muscle. The pull should be paral-
of the transverse processes of the cervical spine. At lel to the direction of the muscle fibers of the scalene
this moment, the contact point should not slide. muscle and avail itself of only a minimal sliding
Rather, it is necessary to hold the contact like an motion. By changing the position of the head, it is
elastic hook. In a second step, it is now necessary to possible to reach different layers.
ERRNVPHGLFRVRUJ
52 FASCIAL AND MEMBRANE TECHNIQUE
Treatment of pleural adhesions in the we select the fixed point directly from the
upper chest cavity
front. In this case, the subtle pressure of our
hand falls precisely at the point of the
After the treatment of the upper part of the limitation of movement. While we are now
scalene musculature, it is important to examine holding the limitation of movement from the
the onset region at the upper ribs more precisely, front side, we rotate the upper chest cavity
in particular to examine the parietal pleura for around the vertical axis of the upper lungs.
any adhesions that may be present. The This rotation should only be conducted in
treatment of a pleural adhesion is an essential minimal steps. If we apply this technique
supplement to the treatment of the scalene. carefully, we will be able to influence the
sliding behavior of the major intermediate
layers of the upper chest cavity relative to one
Patient Supine, both legs flexed. another and, in so doing, reduce the extent of
the pleural adhesion.
Therapist Standing at the level of the patient’s
lower ribs.
Contact Supporting the back from the posterior Treatment of the sternum and the transversus
side with one hand, while at the same time subtly thoracic muscle
contacting the anterior side with the palm of the
Patient Prone.
other hand.
Action The therapist takes the ribcage in both Therapist Seated at the head.
hands from a posterior and lateral direction. It is Contact With the fingers of both hands directly
important for this technique that the therapist’s sup- on the sternum.
porting hand coming from the posterior and lateral
direction reflects not the exterior shape of the struc- Action In order to guarantee the efficacy of this
ture of the chest wall, but rather the inner structure. technique, it is necessary for the patient to transfer
For this purpose, it is necessary to compress the the entire weight of the thorax onto the treatment
entire rib structure somewhat at the lateral–poste- table while relaxing as much as possible. The thera-
rior transition, specifically at the precise height at pist’s fingertips now feel through the generally very
which the pleural adhesion may be found from the thin subcutaneous layer in the region of the sternum
anterior direction. Thus, we follow the effect of the in the direction of the periosteum of the sternum.
intake of air into the lungs and, in this manner, The therapist asks the patient to allow the weight
somewhat alter the sliding behavior of the interior of the upper body to sink somewhat more against
layers of the chest cavity. At the same time, our hand the contact of the therapist’s fingers. In so doing, the
applied on the anterior side moves along precisely sternum moves in the anterior direction. With the
in the direction of a pull effect occurring inward. We fingers of both hands, the therapist now intensifies
follow the movement until it comes to a stop. At that the contact, paying attention to whether parts of the
moment, we break off contact. bones in individual areas appear to be denser or less
elastic. It is precisely at these points that the thera-
pist intensifies the pressure, as if to reach inward
through the sternum into the retrosternal cavity.
In this technique, we use contact from the
If the therapist’s hands are removed from one
posterior direction as a fixed point and follow another, the therapist follows this movement and is
from the anterior direction while “listening.” therefore able to influence intraosseus tensions of
In so doing, we try to maintain contact as the sternum. In a subsequent step, the therapist’s
precisely as possible with the pleural fixation. entire attention is focused on whether the hands are
This technique can be varied very effectively if being pulled inward at individual sections of the
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 53
ERRNVPHGLFRVRUJ
54 FASCIAL AND MEMBRANE TECHNIQUE
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 55
ERRNVPHGLFRVRUJ
56 FASCIAL AND MEMBRANE TECHNIQUE
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 57
Action The patient’s arm should be positioned so hand and forearm and now changes the angle at
as not to pull on the joint capsule. The therapist now which the patient’s upper arm is supported relative
eases the patient’s upper arm into the shoulder to the ribcage. In so doing, it is possible to reach var-
joint. The pressure should be sufficient only to allow ious deep layers of the fascial system, the fascial
the deep joint structures to relax somewhat. At the network, in its three-dimensional structure. The
same time, with the other hand, the therapist makes precondition for a lasting effect is that the therapist
flat contact at the transition between the upper chest maintain firm contact at the transition between the
cavity and the arm. The therapist keeps this contact chest cavity and the arm and that the patient allow
elastic but still very firm using the weight of the the upper arm to be passively moved.
ERRNVPHGLFRVRUJ
58 FASCIAL AND MEMBRANE TECHNIQUE
Treatment techniques for the diaphragm Therapist Standing somewhat below the bound-
and adjacent membranes ary of the diaphragm.
Contact With the palm of one hand and the back
Because we cannot directly touch the diaphragm,
of the other hand in the region of the upper
we must use an indirect process to treat it. For this
diaphragm cupula.
reason, the treatment of the diaphragm is also the
treatment of the frame surrounding the dia- Action The therapist creates contact with the tho-
phragm and the treatment of membrane coverings racic wall so that the palm and fingers are adapted
and bands running between the diaphragm and to the arch of the ribcage. With the palm and back
other organs. The exterior frame of movement of of the other hand, the therapist applies gradually
the diaphragm is limited by the bone, muscle, and increasing pressure in the direction of the sternum
membrane structure of the ribcage. Its interior as if to turn one half of the thorax in toward the
frame of movement is limited by the relative mov- sternum or in toward the connection with the ster-
ability of the organs located below the diaphragm, num. With some care, the therapist will be able to
in particular the liver and stomach. Here, it is follow how a countermotion occurs on the interior
important to keep in mind that the liver is firmly wall of the ribcage as if cylinders inserted into one
connected to the diaphragm in the region of the another were beginning to turn in opposite direc-
so-called area nuda. tions. The therapist now maintains the pressure in
the direction of the sternum until the countermo-
tions discernible from the deep layers come to a
Treatment of the upper diaphragm boundary stop. At this moment, the therapist allows the pres-
sure contact to become weaker and follows the
Before using this technique, it is necessary to use rebounding movement of the structure of the
the test process described to ascertain which ribcage in the lateral direction. In principle, this is a
cupula of the diaphragm is the more restricted in very slow application of the recoil principle.
its movement. The technique should be used on However, it is indispensable for the desired effect
this side first. that we avoid a recoil effect that snaps back and
follow the ribcage in all of its changes of direction
Patient Supine, both legs extended. into a larger expansion in the lateral direction.
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 59
Treatment of the lower diaphragm boundary the elastic pressure until a strong movement is evi-
dent during inhalation. At this moment, we first
Patient Supine.
reduce contact on the front side and then also on the
Therapist Sitting at the level of the patient’s hips. back side. Here as well, we are avoiding the recoil
effect so that, during the release, we can follow the
Contact One hand supports the lowermost region various directions of movement step by step that
of the ribcage from the posterior direction while manifest on the thoracic wall.
the other hand produces a flat contact at the same
level between the lateral section and the front of
the ribcage. The hand providing support from the
Action The therapist raises the lower thoracic posterior direction acts as a slightly elastic
region slightly such that the lordotic arch of the fixed point while the hand applied in front can
lumbar spine continues minimally in the lower change the direction of pressure several times
region of the thoracic spine. At the same time, the during this process. Caution is necessary in the
therapist’s other hand exerts compression from case of poorly healed rib fractures or scoliosis,
the lateral direction. The therapist applies pres- in particular of ribs that are curved inward in
sure diagonally through the lower chest cavity in the anterior region on the side to be treated.
the direction of the twelfth thoracic vertebra, more This technique may be applied on both sides of
specifically in the direction of the front of the ante- the thorax. On the right side, this technique is
rior side of this vertebra.
also suitable for treating restrictions of
Here, we are exploiting the fact that the abdomi-
movement in the region of the coronary
nal organs are somewhat higher in relation to the
ligament and/or the right triangular ligament.
diaphragm when the body is lying down and the
diaphragm itself also appears to have been dis-
placed somewhat in the cranial direction. In other Simultaneous treatment of the diaphragm
words, we use the framework of the lower thorax to cupulas
intensify the tendency followed by the diaphragm
Patient Supine, legs extended.
in the lower chest cavity when lying down. This
process may last for several breaths. We intensify Therapist Standing at the level of the hip joint.
ERRNVPHGLFRVRUJ
60 FASCIAL AND MEMBRANE TECHNIQUE
Lower
boundary Lower
of the lung boundary
Lower of the lung
boundary Lower
of the pleura boundary
of the pleura
Figure 4.34 Spatial relationship between the lung, pleura, Figure 4.35 Spatial relationship between the lung, pleura,
and diaphragm from the anterior direction. and diaphragm from the posterior direction.
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 61
coming from the other side, to press the other half so doing, the therapist pushes the costal arch
of the thorax against this resistance until it dimin- somewhat over the edge of the therapist’s right
ishes somewhat. In this technique, it is important hand, which thus moves farther inward and care-
that the therapist avoid resistances by varying the fully makes contact with the liver. Because the ther-
direction of pressure. As soon as a strong counter- apist is compressing the exterior structure of the
pressure becomes noticeable, the contact from both chest cavity in the sagittal direction, the liver can
hands is slowly released. This release should be clearly follow its suspension on the coronary liga-
fluid and gradual, with the therapist initially avoid- ment and the right triangular ligament. It is as
ing contact with the side where the stronger pres- though the therapist, by compressing the chest cav-
sure had build up. ity, pushes the tensional forces originating from the
chest cavity into the background for a few moments,
thus allowing the therapist’s tactile observation of
Carefully executed, this technique can the relationship between the liver and the
influence the exterior structure of the ribcage diaphragm to be more precise. The patient’s posi-
as well as the interior connections between tion on the left side supports the natural movement
organs in relation to the diaphragm. In order to of the liver during inhalation in the direction of the
reach both areas, it is necessary for the navel. If this movement cannot be felt in spite of the
therapist not to slide on the contact areas, but chest cavity being compressed, this is a clear indica-
tion of a restriction. It is best to treat this restriction
rather to maintain consistent contact with the
by continuing to compress the chest cavity from the
subcutaneous tissues and deep fascia. It is
side and, with the hand below the costal arch, lifting
sometimes helpful to actually anchor the
the liver precisely in the direction of the discernible
fingertips in the superficial and deep fascia restriction and subsequently releasing it again
while the palms concentrate on the interior slowly. Under certain circumstances, the fixation of
layers of the body with their perception and the liver may be detected precisely in the region of
combine an indirect influence on the organ the right triangular ligament. In this case, it is possi-
region with active influence on the surface of ble for the therapist to increase the efficiency of this
the chest cavity. technique by moving the hands toward one another
precisely in the direction of the course of the fibers of
the triangular ligament.
Treatment of the relationship between the
liver and the right cupula of the diaphragm
Treatment variation for the relationship between
Patient Lying on the left side with knees slightly the liver and diaphragm
flexed. Patient Lying on the right side with the knees
slightly flexed.
Therapist Standing at the level of the pelvis.
Therapist Standing at the level of the patient’s hips.
Contact With the relaxed edge of the hand below
the right costal arch and with the other hand flat in Contact The therapist encloses the patient’s right
the lateral region of the middle and lower ribs. side, with the patient transferring his or her weight
precisely at the level of the liver into the therapist’s
Action The therapist initially gently touches the
hand. With the ball of the thumb of the other hand,
region below the patient’s right costal arch with the
the therapist makes contact with the left costal arch
edge of the right hand. The quality of this touch
while making contact with the stomach with the
should be completely free of any penetrating vec-
palm of the hand.
tor. Then the palm of the therapist’s other hand cre-
ates an elastic contact with the ribcage in the lateral Action The therapist’s right hand supports the
region of the middle and lower ribs. In the next side on which the patient is lying. The therapist
treatment step, the therapist compresses this rib makes sure not to apply strong pressure to less elas-
section, precisely toward the patient’s navel. In tic ribs so as to allow the exterior layers of the
ERRNVPHGLFRVRUJ
62 FASCIAL AND MEMBRANE TECHNIQUE
ribcage to relax. In so doing, the quality of the thera- Treatment of the stomach in its relationship
pist’s touch should be such that the density of the to the left cupula of the diaphragm
tissue structure of the liver can be felt. With the other
Patient Resting on the right side with knees
hand, the therapist now compresses the ribcage so
slightly flexed.
that the connection of the stomach with its ligamen-
tous suspension relaxes somewhat. During this, the Therapist Standing at the level of the patient’s
therapist feels with the palm of the hand how the costal arch.
pyloric end of the stomach moves somewhat in the
direction of the right side of the body. As soon as this Contact With the flat left hand laterally on the
movement becomes discernible, the therapist gently costal arch and with the relaxed edge of the right
lifts the liver against the stomach and, by “listen- hand approximately in the region of the sphincter
ing,” follows the stomach as well as the liver until of Oddi.
the movement comes to a stop.
Action As with the treatment of the liver, the
therapist also compresses the lower costal region
This technique is particularly suitable for from the lateral direction toward the patient’s
restrictions between the liver and the diaphragm navel. With the other hand, the therapist attempts
that have been present for a long time. For to contact the pyloric section of the stomach; the
example, for restrictions caused by hepatitis that contact here is flat, avoiding the use of the finger-
have influenced the mobility of the organ as a tips. In a second treatment step, the therapist
whole I am of the opinion that prolonged raises the pyloric section of the stomach as if in
restrictions of an organ can deform the inner a small semicircle toward the lesser curvature of
the stomach by moving both hands toward one
shape of the chest cavity in a very lasting
another. In so doing, the therapist avoids the
manner. It is possible that the deformations occur
weight of the pyloric section affecting the upper
due to spasm-like changes of tone in the region
section of the stomach and its ligamentous con-
of the intercostal or subcostal musculature. The nection to the diaphragm. At this moment,
advantage of the technique described above lies the therapist somewhat reduces the compression
in the fact that it not only works for detail on the ribcage and, by “listening,” follows the
fixations, but also treats the global interrelations upper section of the stomach to the end of its
of space in the lower chest cavity. movement.
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 63
Treatment of the relationship between the pressure on any prominent or inelastic ribs. Both
liver, stomach, diaphragm, and pleura hands form precisely the arch of the individual
ribs without exerting more pressure on one indi-
Patient Prone.
vidual rib than on the others. The fingertips of
Therapist Standing to the side at the level of the both hands point in the direction of the xiphoid
hips. process. With both palms, the therapist now first
compares the breathing motion on both sides. If a
Contact Precisely at the lower boundary of the
difference is discernible, the therapist uses the
ribs of the anterior chest cavity.
palm of the hand to try to sense the extent of the
Action The therapist surrounds the lower thoracic movement restriction. For this purpose, it is neces-
cavity with both hands, avoiding placing strong sary to slightly modify the contact on both costal
ERRNVPHGLFRVRUJ
64 FASCIAL AND MEMBRANE TECHNIQUE
arches so as to ascertain whether the restriction of Treating the breathing pattern using
movement is located in the intercostal region, in globally applied spinal techniques
the region of the organ connections toward the
diaphragm, in the region of the connection between I have already referred several times to the fact that
the diaphragm and the pleura located above it, or the sections of the body where the individual vis-
between the diaphragm and the pericardium. The ceral cavities meet are of primary importance for
therapist then compares the mobility of the vari- the unrestricted motion of breathing. In the preced-
ous elements in relation to one another and tries to ing chapters, techniques were described with
determine the spatial location of the most obvious which these regions can be treated from the front
restriction of movement. On the side of the most and lateral sides of the body. These techniques are
obvious restriction of movement, the therapist intended to achieve an improved erect organiza-
then gently compresses the ribcage toward the tion of the column of organs in the interior of the
restriction of movement until a counterpressure is organism. However, they should also allow a more
discernible. At this moment, the therapist reduces effortless alignment of the body along the line of
the pressure on the ribcage so that the countermo- gravity, so that less work must be done by the mus-
tion can occur. cles to accomplish daily activities. In this sense, the
techniques described above influence both the
movement of the individual elements of the organ-
While the therapist increases the pressure on ism relative to one another and the structural con-
the chest cavity on the side of the restriction, stellations that result from this improved mobility
the therapist also keeps the ribcage at the same time. In the most favorable cases, they
are simultaneously mobilizing and form-stabiliz-
compressed on the other side with somewhat
ing techniques. As soon as we have achieved a
less exertion of pressure. This is necessary in
more favorable alignment of the organ column, a
order to prevent the fixation from escaping to response occurs in the region of the autonomic
the other side in the interior of the thorax. This musculature of the back and ribcage.
technique also shows that it is possible to treat The techniques described in this chapter con-
restrictions in the interior of a visceral cavity centrate on the fascial sheathing layers of the
along with the adjacent myofascial exterior back musculature. They do not concentrate on the
structure. individual anatomical structures, however, but
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 65
attempt to influence the larger fascial network region below the ninth thoracic vertebra. The
globally. For this purpose, it is technically neces- palm of the other hand very flexibly supports the
sary for us to evaluate the curves of the spine in its occiput and the curve of the neck while the finger-
larger myofascial context. The following tech- tips engage the tissue layer on both sides of the
niques can be described using a visual analogy uppermost cervical vertebra.
similar to the one used in Chapter 1, which was a
Action In the region of the thoracic spine, the
description of the technique used for the course of
therapist’s hand adapts to the curve of the back. In
the nerves in the leg: we imagine the full, mobile
so doing, the therapist takes care to emphasize the
interconnectedness of the vertebrae as a river, and
existing curvature of the thoracic spine. In the case
all of the myofascial and ligamentous units sur-
of a severe kyphosis, the therapist follows the
rounding this spine as the riverbed. The goal then
kyphosis in a somewhat more exaggerated curve.
is to influence the riverbed in such a way that a
In the case of a pronounced flat back, the therapist
better flow pattern is achieved for the river.
follows into an even more exaggerated flat back.
It is crucial for the therapist’s hands to be used
Subsequently, the therapist applies the same treat-
in such a way that they touch the tissue structure at
ment strategy to the neck. In the case of a short,
all of the contact points to the left and right of the
compressed neck with a strong lordotic curve, the
spine. The goal is not to hold the spine in a fixed
therapist exaggerates this curve somewhat. In
position because then correction with “listening”
the case of a tendency toward hyperextension, the
would not be possible. Rather, the goal is to relax
therapist’s hands follow the hyperextension. Thus,
the tissue bed of the spine by touching the major
the therapist reinforces the dominant curve pattern
myofascial units in such a way that the tension
at both curvatures of the spine, in the region of the
pattern of the dominant minor myofascial and lig-
thoracic and cervical spine. It is now crucial for
ament units emerge more clearly.
both curves to be amplified simultaneously. My
assumption is that, in this way, we are able to
Treatment of the curvature of the cervical induce a passive sliding of the dura within the
and thoracic spine spinal canal and perhaps even achieve a passive
sliding of the perineurial sheaths.
Patient Supine with legs extended.
Therapist Sitting at the head.
Treatment of the transition between the
Contact With the palm of one hand on both
thoracic spine and cervical spine and between
sides of the spine at the level of the ninth thoracic
the cervical spine and cranium
vertebra, while the fingers of this hand, also on
both sides of the spine, touch the tissue in the Patient Supine, both legs flexed.
ERRNVPHGLFRVRUJ
66 FASCIAL AND MEMBRANE TECHNIQUE
Therapist Sitting at the head. first and second ribs using firm fingertip contact.
This contact is made on both sides at the costover-
Contact With the fingertips of one hand on both tebral connections. The therapist maintains this
sides of the spine between the first and second contact in a very flexible manner and prevents any
ribs. The palm of the other hand supports the sliding in the cranial direction. The patient rests on
occiput and the fingers support the atlanto-occipi- the therapist’s fingertips as if bending backwards
tal junction. over the points of a garden fence. On the fascial
level, this induces a stretching of the deep cervical
Action The therapist slightly raises the occiput fascia and, on the muscular level, an activation of
until the dominant curvature of the cervical spine the longus coli muscle. If this technique is correctly
is more evident. In this technique as well, the applied, the therapist can now detect how a shear
dominant overall form of the neck is supported effect at the transition point between the upper chest
and very slightly exaggerated. cavity and the anterior region of the neck is devel-
With the other hand, the therapist now pre- oping. The patient is given the impression that the
cisely contacts the intermediate space between the neck is growing from the inside of the ribcage.
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 67
Falx
of the cerebellum
Posterior
atlanto-
occipital
membrane
Nuchal ligament
Epidural cavity
Dura mater
of the spine
ERRNVPHGLFRVRUJ
68 FASCIAL AND MEMBRANE TECHNIQUE
the middle of the lumbar spine to slowly return to find a kink on the radiograph between the lumbar
the posterior position, i.e. the exaggerated lordotic spine, which is running straight without a curve,
curve is reduced farther. The therapist remains in and the sacrum, which is located between the two
contact with the layers of tissue running next to the alae of the ilium. The following technique intensi-
lumbar spine in such a way that a pull or, even bet- fies the kink between the sacrum and the fifth
ter, a shear effect is exerted in the cranial direction. lumbar vertebra in order to then reduce it gradu-
ally such that the hypertonically pronounced ten-
sion pattern of this very small area is distributed
This technique for treating hyperlordosis of the over larger sections of the lumbar spine.
lumbar spine may be divided into two steps. Patient Supine, both legs extended.
In one step, the therapist intensifies the curve
Therapist Standing at the level of the thigh.
of the lumbar spine and the anterior tilt of the
pelvis on the hip axis. In a second step, the Contact With flat contact on the sacrum with one
therapist guides the patient’s back and pelvis hand, contact with single spots in the region
out of the exaggerated lordosis and out of the between the fourth and fifth lumbar vertebra and
exaggerated pelvic tilt back into their usual the upper boundary of the pelvis using the tips of
the fingers and thumb of the other hand.
position and then beyond it. It is crucial that, at
the moment in which the spine reduces its Action This time, the therapist provides only a
usual lordotic bend, a strong stretching of the gentle impulse in the direction of the stronger
lower portion of the lumbar fascia is achieved anterior tilting of the sacrum, while the other hand
reaches in the anterior direction on both sides
in the distal direction. Using the fingertips, it
through the muscle layers near the spine in the
should be stretched in such a way that only a
direction of the iliolumbar ligaments. In a second
minimal sliding motion of a few millimeters
treatment step, the therapist then minimally alters
occurs between the therapist’s hand and the the tilt of the pelvis on the hip axis several times
surface of the fascia. At the same time, the using the hand supporting the sacrum, while
hand applied to the lumbar spine produces a maintaining the contact with the other hand in the
subtle stretching of the thoracolumbar fascia in direction of the iliolumbar ligaments, i.e. in the
the opposite, i.e. cranial, direction. direction of the connection between the fourth
lumbar vertebra and both alae of the ilium. If this
technique is performed correctly, the fifth lumbar
Treatment of flat back of the lumbar spine
vertebra now comes to be suspended between the
In the case of flat back in the lumbar region, hardly two hands of the therapist. The therapist tries to
any curve is visible at all. However, we usually exploit this state of suspension by allowing a sort
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 69
ERRNVPHGLFRVRUJ
70 FASCIAL AND MEMBRANE TECHNIQUE
Greater
gluteal muscle
make their effect in the region of the lumbosacral slightly farther into the out-flare. Experience
transition more precise. shows that the tuberosity on the lower edge of the
pelvis moves somewhat toward the contralateral
Patient Lying on one side.
tuberosity. Both of the therapist’s hands follow the
Therapist Standing at the level of the hips. movement of the ala of the ilium, while the contact
between the biceps femoris and the semitendi-
Contact With the fingertips of one hand just nosus muscle continues unabated. As soon as the
below the ischial tuberosity, precisely between the movement into the out-flare has reached its end-
origins of the biceps femoris muscle and the semi- point, the therapist considerably intensifies the
tendinosus muscle, and with the outside edge of contact between the two muscles below the ischial
the other hand gently contacting the superior edge tuberosity until a new direction of motion is
of the ala of the ilium in the direction of the ilio- sensed: the therapist accompanies the upper edge
lumbar ligament. of the pelvis in the direction of an in-flare and, at
the same time, moves the tuberosity in a very slight
Action The therapist first reaches between the
spreading motion. In the in-flare, the ilium moves
biceps femoris and the semimembranosus muscle
in the frontal plane and the iliac crest wanders in
slightly below its origin and attempts to arrive
the medial direction and the ischial tuberosity in
between the fascial sheaths of both muscular units.
the lateral direction.
It is not easy to differentiate both of these muscular
units in this area since it contains multiple tendon
origins. However, it is necessary to reach precisely Combined treatment of posterior pelvic tilt
in the intermediate space between both fascial and out-flare of the ilium on both sides
sheaths because experience shows that contact
Patient Prone, ankles extending over the lower
which provides direction is sufficient to produce a
edge of the treatment table.
response from the tissue. With the other hand, the
therapist moves the upper portion of the ilium Therapist Standing at the level of the thigh.
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 71
Contact With the erect foremost fingertips of both burning pain. This extremely intense action should
hands beneath the fourth segment of the sacrum. be made up to slightly below the upper edge of the
sacrum while, as mentioned above, preventing the
Action The therapist ensures that the patient’s
base of the sacrum from tilting forward. While
legs are parallel to one another and are not rotated
pushing in a cranial direction, the therapist modi-
outward. The therapist then makes contact at the
fies the very slow speed of movement so that it is
level of the fourth segment of the sacrum bilaterally
possible, through “listening,” to detect how both
from the center line of the sacrum. In so doing, it is
ilia are released somewhat from the constant ten-
essential for the touch to press persistently through
sion of the interosseus sacroiliac ligaments and are
the subcutaneous fatty layer in order to reach the
wandering from their fixed out-flare position in the
interosseus sacroiliac ligaments located on both
direction of an in-flare.
sides at this point. This band structure is located
under the dense fiber network of the lumbar fascia
adhering to the sacrum. The contact should be
as if trying to release the lumbar fascia from its When the therapist applies the contact with a
connection with the ligament’s structure beneath it. very flat angle, i.e. almost parallel to the arch of
In a second treatment step, the therapist then begins the sacrum, a pulling effect occurs on the
to exert pressure in the cranial direction with the fin- posterior side of the tailbone in the inferior
gertips of both hands while avoiding pushing the direction, which continues to the superficial
sacrum anteriorly. The therapist matches the arch of posterior sacrococcygeal ligament. If the
the bone precisely, but remains in extremely intense
therapist follows this pull effect deeper with
contact with the lower fascial layers surrounding
“listening,” it is possible to influence the
the sacrum from the posterior direction and embed-
tension patterns in their connection to the dura
ding it in the overall formation of the back. The qual-
ity of the contact should be gradually intensified mater. In the case of a very lasting effect on the
as if the periosteum, i.e. the layer located below the ligament’s connections between the sacrum
interosseus sacroiliac ligament, were being pushed and both ilia, the technique described above is
onto the bone in the cranial direction. Experience also suitable for correction of strongly
shows us that the patient will experience a mild, pronounced knock knee.
ERRNVPHGLFRVRUJ
72 FASCIAL AND MEMBRANE TECHNIQUE
Treatment of flat back in the thoracic spine the habitual flat back of the thoracic spine is not
altered. The contact must be kept flat with the palm
Patient Supine, legs extended.
of the hand; in other words, the patient’s spine is
Therapist Sitting at the head. resting in the hand of the therapist, who produces
additional contact with the layers of tissue near the
Contact With one hand on both sides of the
spine using the fingertips. The therapist uses the
spine at the level of the sixth thoracic vertebra,
other hand to hold the occiput in such a way that
while the other palm supports the occiput and the
the spatial relationship between the head, neck,
fingers produce contact at the transition between
and chest cavity approximates the spatial relation-
the atlas and occipital bone.
ship displayed by the patient when standing. The
Action It is a precondition for the efficacy of this therapist then allows the patient’s head to sink
technique that the therapist be able to place one minimally in the posterior direction, i.e. toward the
supporting hand under the back in such a way that treatment table, but avoids any pull on the cervical
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 73
Posterior sacroiliac
ligaments
Interosseous
sacroiliac ligaments
Posterior sacroiliac
ligaments
Sacrospinal
ligament
spine. Under no circumstances should strong trac- manifestations. Before and after the application of
tion forces be acting on the neck. At the same time, this technique, it is worth examining the affected
the therapist’s other palm supports the spine in the section of the spine with joint tests to verify the effi-
thoracic region somewhat more, such that the flat cacy of this technique (Barral et al. 1993).
back in this region becomes more pronounced. In
addition, the therapist places the fingertips strongly
into the tissue to the left and right of the thoracic Treatment of exaggerated kyphosis of the
spine. As soon as the therapist is able to feel the tho- thoracic spine
racic spine trying to move even a little bit out of the
Patient Lying on one side with flexed knees.
flat back in the direction of a natural kyphotic bend,
the therapist follows and intensifies this movement. Therapist Standing at the level of the hips.
In so doing, it is important that the therapist
respond to and emphasize the three-dimensional Contact Depending on the tone of the tissue,
structure of this movement of the vertebral bodies, with the flat front phalanges of both hands, gently
i.e. rotations and side tilts, even in their smallest used edges of the hand, or the palms.
ERRNVPHGLFRVRUJ
74 FASCIAL AND MEMBRANE TECHNIQUE
Action In order to guarantee the efficacy of this Coordinated treatment of strongly pronounced
technique, we must rely on the patient’s active par- kyphosis of the thoracic spine
ticipation. While the therapist makes contact in the
lateral portion of the ribcage approximately at the Patient Sitting on a bench with thighs parallel to
level of the sixth rib, the patient allows the arm on one another.
this side to hang over the edge of the treatment
Therapist Standing to the side next to the patient.
table. The therapist examines the density of the
various fascial layers in this region. It is possible Contact Supporting the sternum with one palm
that the therapist will find a large density of fibers from the anterior direction, at the same time mak-
on the surface, possibly at the lateral boundary of ing contact with the other hand on both sides of
the fascia of the latissimus dorsi muscle and its the thoracic spine, approximately at the level of
connection to the upper arm, or possibly not until the sixth thoracic vertebra
the fascial connective layer between the serratus
anterior and the oblique abdominal muscle, or in Action The therapist asks the patient to maintain
the intercostal region. The therapist uses both good contact between the feet and the floor. While
hands and intensifies the contact simultaneously supporting the chest cavity from the anterior and
posterior and anterior of the lateral midline of the posterior sides, the therapist applies a very gentle
torso. It is important to ensure that the shear effect impulse in the cranial direction, as if to lift the
in the cranial direction acts on the surface only to ribcage away from the abdominal and pelvic cavi-
the extent that the layers located below can follow ties. At the same time, the therapist asks the patient
the stretching effect. The goal is not a mechanically to completely relax the abdominal wall so that the
local effect on the side of the ribcage, but rather pelvis is tilting slightly forward. Subsequently, the
more of a solution for the three-dimensional con- patient should intensify contact with the floor
nection between the shoulder and chest cavity. For somewhat so that the pelvis sinks back into its start-
this reason, it is necessary for the patient’s arm to ing position and slightly into the posterior position.
be allowed to hang from the treatment table with This sequence of movements should be repeated
more and more weight during manual treatment several times. The therapist registers the shear effect
as if the patient were reaching for an object on the in the region of the chest cavity caused by the
floor. motion of the pelvis, and influences the tissue
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 75
ERRNVPHGLFRVRUJ
76 FASCIAL AND MEMBRANE TECHNIQUE
Here, it is crucial for the therapist to be able to is important to keep in mind that the intensity of
penetrate between the trapezius muscle and the touch is modified relative to the tension that is
sternocleidomastoid muscle to the middle scalene present.
muscle. As soon as the middle scalene muscle is
contacted, the therapist intensifies the quality of
the touch and begins to slide the hand in the direc-
This technique may be varied in relation to the
tion of the muscle origin to the side of the cervical
shape of the neck. If the neck appears
spine. Thus, the therapist’s hand is moving diago-
nally, i.e. in the mediocranial direction. By slightly contracted in all of its levels, i.e. in the
changing the position of the head by increasing or superficial fascia, deep fascia, and myofascial
decreasing the neck’s rotation and/or curve to the layers, it is advisable to create contact with the
side, layers at different depths may be accessed. scalene muscle selectively rather than with the
This technique should be applied to both sides; it flat hand. This works especially well in male
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 77
ERRNVPHGLFRVRUJ
78 FASCIAL AND MEMBRANE TECHNIQUE
It is not simple to make general statements on and mobility relative to the organs. In so doing, we
the etiology of scoliosis solely on the basis of indi- should focus our attention on the elastic capacity of
vidual cases. However, our diagnostic observations, the intercostal membranes and the subcostal
along with the practical results of the treatment myofascial layers as well.
techniques we used, at least provide a starting point During embryonic development, all of the organs
when reconsidering the traditional diagnosis and undergo a characteristic shift in position, a type of
treatment of scoliosis. “voyage through space,” until they arrive at their
We must observe that the form of the spine diag- destination within the interior of the visceral cavi-
nosed as scoliosis obviously arises from fundamen- ties. In practice, we can see that there is at least one
tally different causes. In many cases, a genetic common type of scoliosis that can be attributed to
disposition is obviously present. In other cases, an incomplete spatial curve of the stomach. In this
however, these genetic factors do not have a role case, the back appears to be sunken in the upper
and in other cases it was an unusual position of the left lumbar region and the vertebrae above it dis-
fetus during development which apparently play the typical scoliotic curvature such that the
caused a change in the membrane structure in the entire upper body appears to have been displaced
interior of the visceral cavities, especially in the area to the right in relation to the pelvis.
of the chest cavity and within the craniosacral sys- At first glance, there appears to be an imbalance
tem. Finally, we encounter the cases that are rele- in tone of the erector muscles, and the latissimus
vant to the treatment technique we describe, dorsi muscle is indeed usually very weakly devel-
namely the cases that display a drastic displace- oped on the left side. The muscular support of the
ment of the axes of mobility of the organs located quadratus lumborum muscle that spans the upper
below the diaphragm. crest of the pelvis and the lower edge of the twelfth
In most of such cases that we have investigated, rib appears hardly present at all.
the stomach plays an important role. In the section If we direct our attention to the examination of
that examined the significance of the breathing the prevertebral region, we also find a drastically
pattern (section 4.1), we have seen that the dynam- altered spatial position of the stomach in relation to
ics of the breathing process will fashion and stabi- the midline of the body. Apparently, in these cases,
lize the chest cavity. All pronounced changes in the stomach did not completely follow the spatial
the mobility of an organ on one side of the curve intended for it during embryonic develop-
diaphragm will influence the chest cavity. As we ment. For this reason, it is located more medially
can see, this sort of altered spatial excursion of the compared with its normal position and therefore
diaphragm and lung occurs on the same side. can provide only minimal support for the left
Here, altered rotational forces are acting from the cupula of the diaphragm. Its relationship to the
anterior direction on entire groups of thoracic ver- spleen is altered in the cranial direction and its rela-
tebrae; as soon as one cupula of the diaphragm has tionship to the left kidney in the inferior direction.
the tendency to be in permanent descent, the joints Therefore, on the right side of the thorax, a stable
within the back must compensate for this descent support is present from the liver, which is “denser”
with a corresponding lateral bend. To a lesser than the stomach. The left cupula of the diaphragm
extent, similar influences are conceivable if an drops and, as I assume, the formation of the typical
infection within the chest cavity has caused one- scoliotic curvature occurs in the sections of the
sided adhesions on the connective layers of the spine located over it.
thoracic wall. A displacement of the axis in the Unfortunately, in this sort of situation, I was able
lung area occurs that follows the reshaped tho- to achieve very few results with treatment tech-
racic wall. In this manner, the shape of both halves niques applied to the back. There is even the dan-
of the chest can change drastically. ger that manual influence on the myofascial layers
However, in relation to this, the subdiaphrag- of the scoliotically curved back could cause a
matic organs appear to be of greater significance destabilization of individual joint sections. In con-
in influencing the curvatures of the spine. So it trast, a subdiaphragmatic, i.e. visceral, procedure
is important to examine both cupulas of the is consistently able to provide satisfactory results,
diaphragm carefully for their spatial relationships in particular when we select the treatment strategy
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 79
ERRNVPHGLFRVRUJ
80 FASCIAL AND MEMBRANE TECHNIQUE
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 81
ERRNVPHGLFRVRUJ
82 FASCIAL AND MEMBRANE TECHNIQUE
Tendon of the
long head of
the brachial
biceps muscle
Glenoid lip
Humerus
between the pectoral girdle and the ribcage, running muscle. As a muscle, the supraspinatus has a less
between the third, fourth, and fifth ribs to the cora- sturdy structure than the infraspinatus, in contrast
coid process of the scapula (route of the pectoralis to their fasciae. Spanning the capsule of the shoul-
minor) and from the first rib to the clavicle (route of der joint, the supraspinatus muscle has an impor-
the subclavius muscle), as well as the fascial bridge tant function. For this reason, its fascia also plays an
that runs between the shoulder and upper arm from essential role in our treatment technique.
the coracoid process and to the crest of the lesser In practice, it is important to keep in mind that
tubercule (route of the coracobrachialis muscle). only the teres minor muscle lies inside the fascia
If we now turn our attention to behind the pec- infraspinata. The teres major muscle is outside it,
toral girdle, we also find a particularly strongly in a common fascial sheath with the latissimus
pronounced fascia that forms the counterpoint to dorsi muscle.
the clavipectoral fascia: the fascia infraspinata. It is If we now include the costal side of the scapula
attached to the spine and at the lateral margin of in our consideration, we encounter the fascial
the scapula and surrounds the infraspinatus sheath of the subscapularis muscle. Its fascial
muscle with its various fibrous directions along sheath also has a sturdy structure and, in addition,
with the teres minor muscle. The fascia infra- is loosely displaceable. By means of this layer, it is
spinata not only serves as a muscular sheath, but possible for the scapula to make sliding move-
also functions as an attachment for the muscle ments on the torso.
fibers in places, in particular in the region of the In the literature, the cooperation of the scapulo-
vertebral border of the scapula. humeral fasciae as a flat configuration of connective
Furthermore, similar conditions are also present tissue is described. This disk of connective tissue is
in the supraspinatus muscle above the infraspinatus important because it surrounds the entire muscular
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 83
Greater pectoral
muscle
Smaller pectoral
muscle
Anterior serratus
muscle
Subdeltoid Scapula
bursa
Subscapular muscle
Joint cavity of
the articulation
of the shoulder Infraspinous muscle
Subdeltoid fascia
Deltoid muscle
cuff of the pectoral girdle and the upper end of the function. Because of their particular significance, I
humerus. It is particularly important because of its would like to emphasize the serratus anterior mus-
contact with the elements of the circulatory and cle, the levator scapulae, and their fasciae. However,
nervous system at the transition between the shoul- sheet-like layers such as the trapezius and latis-
der and upper arm. In a horizontal cross-section, simus dorsi muscles can play a role in a dysfunction
this disk of connective tissue displays a slightly of the shoulder joint as well. It is a characteristic of
arched triangular shape. If we localize the course of the fascial network that it cannot be forced into one
the nerves and blood vessels within this triangular general pattern; there are always special individual
shape, it is easy to see what a limiting effect the forms. However, one fundamental rule is repeatedly
forces of contraction have on the passage of nerves shown to be true: the portions of the fascial network
and blood vessels and therefore on the blood sup- that are connected to small muscular units or mus-
ply and nerve function. cles that have only a limited range of flexion and
In addition to the layers mentioned above, there extension are more significant for the stability of
are numerous other elements of the fascial network bodily form than those aspects of the fascial net-
that influence the shoulder joint and its movement work that surround muscles with a very large area.
ERRNVPHGLFRVRUJ
84 FASCIAL AND MEMBRANE TECHNIQUE
The techniques described above follow this fun- anterior is frequently responsible for the thorax
damental rule. For this reason, they are primarily sinking down in the posterior direction along the
focused on the fasciae of the pectoralis minor, lateral line. In such a case, the connection between
infraspinatus, supraspinatus, and subclavius mus- the external oblique and the serratus anterior will
cles so that a maximally stable treatment result feel rigid. The interdigitating border between the
may be guaranteed with a minimum of treatment. two muscles is sensitive to pressure and can be
moved only a small distance relative to the ribs
located below it, and the associated fasciae appear
Examination of the shoulder region fibrous.
In a second step of the examination, compare
In order to evaluate a dysfunction of the shoulder the normal position of both shoulders from the
joint in the context of the overall structure, it is front and from behind to see how they connect
helpful to first observe the patient’s usual sequence into the ribcage and the arms. Ask the patient to
of movement. This observation gives us an insight raise both arms and observe this motion from the
into the everyday posture into which a dysfunc- side. Continue the examination by passively guid-
tion of this joint is integrated. ing the motion of one arm at a time in order to
First, watch the patient from one side, both sit- identify local limitations associated with the coor-
ting and standing. dinative level of movement.
Pay attention to the spatial relationship between In order to include patterns of ligamentous ten-
the hip axis and the shoulder. If the shoulder sion in our observations, we should also examine
appears to be slouched forward relative to the hip the sternoclavicular joint. Because patients virtu-
axis, i.e. if it droops strongly forward over the ally never feel symptomatic pain in the region of
ribcage, this is a sign of a lack of movement coordi- this joint and, in my experience, want the therapist
nation in the region of the serratus anterior muscle. to treat the painful shoulder directly, it is easy for
In this case, it is valuable to examine the patient us to overlook the significance of the sternoclavic-
while the patient is lying on one side and pay par- ular joint.2
ticular attention to the connection area between
the external oblique muscle and the serratus ante- 2
The test for the sternoclavicular joint is described in detail
rior (see Fig. 4.60). A lack of activity by the serratus in Barral et al. (1993: 70).
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 85
Besides the ligamentous components, the sub- and its fascia, a precise examination is recom-
clavius muscle, with its strongly pronounced fas- mended for any dysfunction in the pectoral region.
cia, is also responsible for the fixation of the
sternoclavicular joint. This muscle connects the Shoulder test in the dorsal position
clavicle to the first rib. It plays a decisive role in
venous return from the neck region to the extent Patient Supine, both legs extended, arms resting
that the subclavius vein runs between the anterior beside the torso.
scalene muscle and the subclavius muscle. As so Therapist Sitting at the head.
often occurs in places of transition, a restriction of
movement means not only a reduction in motor Contact With the palms over the shoulder joints.
function, but also a change in fluid exchange, in Action The therapist pushes the shoulder elasti-
this case the venous return. cally in the inferior direction. If it is not possible to
A similar pattern may be found in the case of push the shoulder elastically against the ribcage,
nerve supply. The course of the brachial plexus at this is a sign that strong contracting forces are preva-
the level of the clavicle is structured as a sliding pas- lent between the first rib and the clavicle. In order
sage surrounded by fatty and connective tissue. to ascertain whether the subclavius muscle and its
Like the venous passage, it can tolerate only a fascia are responsible for these forces, Barral’s sup-
limited level of stabilizing pressure. If the surround- plementary test is recommended.
ing fatty and connective tissue of the nerve is sub-
jected to too much pressure, it will no longer be able
Shoulder test lying on one side according
to adapt to the abduction movement of the upper
to Barral
arm. Thus, the tension and pressure conditions are
altered in the sheath layers of individual nerve Patient Lying on one side, legs slightly flexed,
fibers. This process affects not only the transitional arms in front of the torso.
passage between the shoulder and upper arm, but
Therapist Standing behind the patient at the
potentially other important bottlenecks of the nerve
level of the ribcage.
located farther below: in the elbow joint and carpal
tunnel as well as Guyon’s canal. Because of the com- Contact With one hand in the lateral region of
prehensive significance of the subclavius muscle the deltoid muscle, with the thumb, index finger,
ERRNVPHGLFRVRUJ
86 FASCIAL AND MEMBRANE TECHNIQUE
and middle finger of the other hand surrounding muscular activity, and a typical restriction of
the clavicle. movement occurs when the upper arm is raised or
moved backwards.
Action The therapist reaches below the upper However, we sometimes encounter a periarthri-
arm of the patient and surrounds the clavicle from tis of the joint without a mechanical trauma hav-
below with the thumb and from above with the ing occurred. In these cases, it is valuable to examine
index and middle fingers. It is best if the contact is the transition between the abdominal cavity and
somewhat medial of the subclavian artery, as if to ribcage precisely. Barral pointed out that a signifi-
surround the clavicle. Naturally, it is not possible cant interdependency exists between the restric-
to surround the bone entirely, so our thumb is tion of the costal and vertebral joints on the one
touching the two fingers only in our imagination. hand and the restrictions of movement of the liver
The contact is strong and yet slightly elastic. With on the other hand. He assumes that tensions in the
the other hand, the therapist then surrounds the region of the sheath layer of the liver are trans-
shoulder from behind and examines whether it mitted throughout the fascial system and usually
can be pushed upward and forward. Normally, to the right shoulder (Barral and Mercier 2002:
the subclavius muscle would yield for such a 100–1).
movement; however, long-term tension around We can only guess how this transmission of ten-
the subclavius muscle and its fascia will resist this sion occurs. It is possible that there is a transmission
movement. of fascial tension, because an interdependence
Before we decide on a treatment technique for appears to exist between the restrictions of indi-
the shoulder, it is necessary to take another look at vidual costal vertebral joints and the liver, and in
the larger fascial context. If the restriction of move- this manner, producing an irritation of the cervical
ment in the joint arose from a mechanical shock to and brachial plexus (Barral and Mercier 2002:
the shoulder, the local technique has a good 101–2).
chance of success. In this case, an overstretching of Interestingly, a comparable relationship can be
individual fiber groups occurs in the ligaments observed in the region of the left shoulder; here
near the joint. The ligaments are no longer able though, it is to dysfunctions of the stomach that
to clearly perform their orienting function for periarthritis can be attributed (Barral 2002: 74).
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 87
Treatment techniques
Treatment of the fascia of the pectoralis minor
in relation to the fascial investment of the
latissimus dorsi muscle
Patient Seated, hip axis slightly higher than the
knees.
Action First, the therapist raises the patient’s Figure 4.64 Treatment of the fascia of the pectoralis minor
shoulder somewhat and moves the thumb in the in relation to the fascial investment of the latissimus dorsi
rear region of the axilla around the common fas- muscle.
cial investment of the latissimus dorsi muscle and
the teres major muscle in order to create a firm
contact point there. Using the palm, the therapist this movement with both hands and intensifies
guides the shoulder slightly forward and then this movement somewhat until it comes to a stop.
makes contact in an analogous fashion with the At the same moment, the therapist intensifies the
fascia of the pectoralis minor and teres minor mus- contact with the fascia of the pectoralis minor and
cles. To a certain degree, the shoulder is now riding teres minor muscles and exerts an active stretch-
on the therapist’s two thumbs. In a second step, ing impulse so as to continue following the shoul-
the thumbs follow the shoulder with “listening.” If der with “listening.” The shoulder will now move
the shoulder moves forward, the therapist follows backwards somewhat. The therapist follows this
movement until the contact in the rear region of
the axilla intensifies. The therapist exerts gentle
3
Barral (2002: 14): “One hand rotates the arm in an
pressure on the fascia of the latissimus dorsi and
abduction–adduction pattern and the other hand sets a teres major muscle. This entire sequence of move-
visceral inhibition point. Let us assume that you suspect the ments can be repeated three to four times. If the
possible involvement of the liver in a case of periarthritis on shoulder slips backwards at the beginning of “lis-
the right side. After you have abducted the right arm and tening,” we first follow this movement and then
rotated it outward, lift the liver slightly […]. If this allows you
to attain an increase in mobility of at least 20 percent, you can
exert a stretching impulse at the endpoint in the
assume that the cause of the shoulder problem lies either in rear axilla so as to follow it forward and perform a
the liver or the right kidney that is connected to the liver.” more gentle correction there as well.
ERRNVPHGLFRVRUJ
88 FASCIAL AND MEMBRANE TECHNIQUE
The patient should keep the shoulder region as Acromial process Deltoid muscle
relaxed as possible during this entire technique
and the therapist should select the quality of
the touch so as to guide the movement of the
shoulder without inducing an increased muscle Spine
tone. As soon as the patient moves the shoulder of the scapula
Treatment of the fascia infraspinata Figure 4.65 Course of the fascia infraspinata in relation to
Patient Supine, both knees flexed. the adjacent muscles.
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 89
ERRNVPHGLFRVRUJ
90 FASCIAL AND MEMBRANE TECHNIQUE
grasps the clavicle in an approximately medial resistances with minimal avoidance maneuvers,
direction from the course of the subclavian artery, as i.e. the circular motions of the shoulder are varied.
if to surround the clavicle. While maintaining this In this process, the clavicle comes to attention on
contact, the therapist pushes the shoulder in a circu- the sternum like a tiny flagpole; it makes a small
lar motion upward, forward, and then downward circular motion in the connection to the sternum
and finally describes a complete circle back to the while we make a larger circle with the shoulder.
initial position. While doing so, the therapist is look- This gives us the ability to affect the ligamentary
ing for any resistance that may be noticeable. tensions of the sternoclavicular joint and the mus-
The efficacy of this technique succeeds or fails cular tension patterns and the fascial tension of the
with the sensitivity of our touch: while the clavicle subclavius muscle and all of the muscles that par-
remains firmly surrounded, it is important to avoid ticipate in shoulder motions at the same time.
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 91
Treatment of the fascia supraspinata arm to follow gravity and glide slightly out of the
glenoid fossa.
Patient Prone.
Therapist Sitting at the level of the pectoral girdle.
Because the fascia supraspinata is closely
Contact With the fingertips of one hand reaching connected to the coracoacromial ligament, we
through the superficial layers of the trapezius
should make a constant effort during treatment
muscle.
to ensure that as regulatory an effect as possible
Action Similar to the preceding treatment of the occurs on this ligament as well. In a joint that
sheath layer of the subclavius muscle, the clavipec- offers as much range of motion as the shoulder
toral fascia, the therapist abducts the patient’s arm joint, we should avoid pulling the fascia apart
and lifts it. If a resistance to movement occurs, it is mechanically. The goal is to provide a sustained
important to avoid the restriction by using mini-
impulse on the critical bundle of fasciae and, at
mal movements. At the same time, we use the fin-
the same time, to observe the effects on the
gers of the other hand to reach through the
ligaments near the joint.
superficial layers until we feel the tension of the
supraspinatus muscle. It is now crucial that we
direct our attention to the prominence of individ- Treatment of the fascia infraspinata and the
ual groups of fasciae. As soon as we observe a fascia supraspinata
high-density group of fibers, we gradually inten-
Patient Lying supine, both knees flexed so that
sify our contact at this point. At the same time, we
the soles of both feet are in complete contact with
slide the upper arm into the joint so that the joint
the treatment table.
capsule can relax somewhat. As soon as this relax-
ation occurs, we modify the angle between the Therapist Sitting below the pectoral girdle.
upper arm and the thorax minimally in various
Contact With both palms and the fingertips of
directions until a change in tone occurs at the criti-
both hands.
cal point of the supraspinatus muscle. At that
moment, we reduce the shear force between the Action The therapist first abducts the patient’s
upper arm and the shoulder joint by allowing the arm and guides it into elevation. In this starting
ERRNVPHGLFRVRUJ
92 FASCIAL AND MEMBRANE TECHNIQUE
position, the therapist’s forearm supports the in the interior of the joint while, at the same time,
patient’s upper arm. The second support surface is we exert a direct and very drastic influence on
provided by the palm on the upper third of the both of the decisive fasciae.
scapula. This double support is necessary in order
to have both hands free for direct contact with
the fascial layers of the infraspinatus and supra- The efficiency of this method lies in the fact
spinatus muscles. While the supporting contact that the subtle, indirect access of the joint
in maintained, the therapist’s fingertips reach capsule is combined with a very direct
strongly into the fascia infraspinata and the finger- treatment of both fasciae (infraspinata and
tips of the other hand reach through the layer of supraspinata). The patient’s arm should be
the trapezius muscle at the point where the cora- elevated only as far as is possible without
coacromial ligament is embedded in the fascia
causing pain. In the case of a drastic restriction
supraspinata. In this manner, the scapula and
of movement, it is advisable to abduct the arm
clavicle are resting in their fascial bed in such a
only to a small extent and guide it very slightly
way that they will be able to tilt relative to one
another in three-dimensional space. While we, fig- upward during treatment in minimal passive
uratively speaking, make both bones hover in movement steps. It is a considerable technical
their fascial suspension, we now give a gentle challenge for the therapist to conduct two
push on the joint capsule with both support sur- fundamentally different modes of treatment
faces, i.e. we move our forearm, which is support- with the same hand and arm.
ing the patient’s upper arm, and our palm, which
is holding the scapula, very slightly toward one
another. As soon as a counterpressure occurs, we Additional remarks
follow it and guide the arm minimally out of the
joint. With some skill, we can evoke an indirect At the beginning of this chapter, I mentioned that
relaxation of the fibers that connect directly to the the shoulder joint is described in the literature as
joint capsule. During this process, we intensify the the most mobile of all the joints. In local treatment,
contact between our fingertips and the fasciae this mobility requires a considerable amount of
infraspinata and supraspinata. In other words, we precision. Imprecise influence on the fascial sheath
are working indirectly and with detailed “listening” of the joint may encourage momentary changes in
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 93
tension, but may also destabilize the joint under the back and the transitions between visceral cavi-
certain circumstances. For this reason, the preci- ties before a precise treatment of the shoulder joint.
sion of the manual influence on fasciae in the
immediate vicinity of the joint has essential signif-
icance if the treatment is to have a lasting result. 4.4 UPPER EXTREMITY: UPPER ARM,
However, in addition to the need for precise, FOREARM, AND HAND
detailed work of correction, there is also a global
context of bodily form within which the joint is Aspects of form
arranged. The manner in which the thorax as a
whole rests on the organ column of the abdominal The fasciae of the arms are subjected to different
cavity, the spatial relationship of the hip axis and functional demands from the fasciae of the pectoral
pectoral girdle, and also the preferred movement girdle. The influence of gravity on the pectoral gir-
patterns of the arms and hands, are all reflected in dle is cushioned by a dynamic visceral cavity and
the fascial network. The quality of the the client’s the curvatures of the back. Such a dynamic is lack-
movements allows the therapist to read how the ing within the arm: there is no buffer within this
individual segments of the torso are connected. extremity like the visceral cavity, while the respi-
Under certain circumstances, the problem zone of ratory motion acts only as a minimal rotational force
the shoulders is merely a response to structural on the tissue without causing a significant change in
weaknesses in a deeper zone of transition. This is the position of the arm. Let us regard these circum-
primarily true in the case of the transition between stances in relation to our central working hypothe-
the abdominal cavity and chest cavity. sis, which is that fasciae and membranes change
I have already mentioned Barral’s hypothesis their appearance according to their functional con-
regarding the relationship between the shoulder text. As soon as repetitive sequences of movement
joint and restrictions of movement in the organs occur, the fibers realign themselves correspond-
located below the diaphragm, and this is certainly ingly and regulate the distribution of components
very significant. Moreover, there are many other with high and low fluid contents. The dominant
critical zones within the fascial system whose ten- functions of the arms are flexion and extension and
sion patterns have an influence that reaches into the the interplay between those two functions. This is
shoulders. Because the pectoral girdle is located clearly reflected in the layers of the fasciae of the
between the relatively immobile ribcage and the upper arm and forearm. Here, there are none of the
neck region, which is mobile, it must be able to flat sliding layers as can be found in the pectoral
adapt to the dynamic rotational forces acting from girdle. Instead, there are deep membranes that
the cranial direction as well as the shear forces act- form individual osteofibrous canals for flexors and
ing from the base below it. In my opinion, it is for extensors, respectively.
this reason that the treatment of restrictions of In most day-to-day activities, the flexion move-
movement at the transition between the abdominal ment of the forearm and the extension movement of
and chest cavities is sometimes not entirely suffi- the hand are dominant. So, in people who perform a
cient to guarantee a stable result. It is wise also to manual activity, we usually find a lack of equilib-
examine and treat the transitions between the indi- rium in the joints of the arm between the prevailing
vidual curvatures of the back. We must direct our tone of the flexors and the tone of the extensors. The
attention to how the curve of the sacrum meets the resting tension of the flexors is elevated in compari-
lumbar region, how the upper lumbar spine is con- son with the resting tension of the extensors. The
nected to the thoracic region, and how the upper- fasciae of the flexor musculature are subjected to dif-
most section of the back transitions into the neck. ferent forces than those of the extensor musculature.
Correspondingly, we encounter a small selection of Because these fasciae have a direct connection to the
techniques for the treatment of the pectoral girdle intermuscular septa and interosseus membranes,
before we begin the detail corrections on the shoul- this lack of equilibrium between flexors and exten-
der joint itself. In practice it has proved useful first sors also has an effect within the membrane struc-
to treat the transitions between the curvatures of ture of the osteofibrous canals. In my opinion, the
ERRNVPHGLFRVRUJ
94 FASCIAL AND MEMBRANE TECHNIQUE
Biceps muscle
Figure 4.72 Cross-section at the level of
of the arm Musculocutaneous nerve the middle of the upper arm.
Skin Median nerve
Lateral Medial
intermuscular intermuscular
septum of the arm septum of the arm
limits that we encounter in the treatment of muscu- groups internally within the limbs, that is, as inter-
lar function of the arms may be traced back to this muscular septa. Thus, delicate dividing layers
fact. At some point, the lack of equilibrium between extend from the antebrachial fascia to the perios-
the tone of the flexor and extensor musculature is teum of the humerus. These dividing layers, the
present not only in the fascial layer of the arm, but medial septum and lateral septum, divide the
also in the deep membranes. In advanced stages, the upper arm into two self-contained chambers in
deep membranes have a higher fiber density and which the flexion musculature runs on the ventral
fewer elastic components than the superficial layers, side and the extensor musculature runs on the
which can no longer be solved with muscle-build- dorsal side.
ing and equalizing activity. Faced with this situa- The medial intermuscular septum runs between
tion, we must rely on a detailed treatment strategy the attachment of the coracobrachialis muscle
that allows the musculature to gain a new range of and the medial epicondyle. The less strongly pro-
action by treating the deep membrane layers. nounced lateral intermuscular septum extends
between the attachment of the deltoid muscle and
Anatomy of the fasciae and membranes the lateral epicondyle.
Both intermuscular septa serve as muscular
The fascial sheath of the upper arm, the brachial fas- attachments, the medial septum as an origin for
cia, surrounds the entire upper arm. Its layers are the fibers of the brachialis and the medial head of
more strongly pronounced on the lateral and dorsal the triceps brachii, the lateral septum for the fibers
sides of the arm. Strangely, this fascial layer is pres- of the triceps brachii, the brachialis, the brachiora-
ent on the strong flexor of the upper arm, the biceps dialis, and the extensor carpi radialis longus.
brachii muscle, only as a delicate, thin layer. The For manual treatment techniques, it is important
fibers of the brachial fascia primarily run perpendi- to keep in mind that the brachial fascia surrounds
cular to the fiber path of the musculature it encloses. the surface of the arm, but is also responsible for
The fascia transitions seamlessly into the adjacent the deep structure. According to observations in
fasciae: distally into the antebrachial fascia and practice, it is not possible to treat one layer without
proximally into the axillary fascia and the fasciae of producing an effect on the other.
the pectoral girdle. I have already mentioned that the brachial fascia
It is a characteristic of the fasciae of the extrem- of the upper arm transitions seamlessly into the
ities that they serve as both a superficial sheath as antebrachial fascia of the forearm. Using the exam-
well as a partition separating antagonistic muscle ple of this fascia, it is possible to clearly see how
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 95
Radius Ulna
Antebrachial
fascia
Posterior interosseous
Interosseous path
membrane
unilateral pressure and tension forces change the The transition between the forearm and hand as
texture of the connective tissue. It is not for nothing a critical zone plays an important role, in particu-
that the forearm and the transition to the hand are lar for nerve supply. The transition between the
particularly susceptible to a phenomenon that has upper arm and forearm is similar. There as well, in
recently gained increased attention as repetitive the case of repetitive muscle activity, we encounter
stress syndrome or repetitive strain syndrome. tough layers that can place the nerve passages
The kinds of strain to which the forearms and under pressure. The bicipital aponeurosis plays an
hands are subjected are so variable that we must essential role here as a bridge that may reduce
always take into account the idiosyncratic form of space because, as a fibrous extension of the bicipi-
their connective tissues. With high levels of strain, tal fasciae, which are weakly pronounced in and of
the proximal layers of the antebrachial fascia can themselves, it fixes sustained bending tendencies
become very dense, almost aponeurotic. The den- at the elbow joint.
sity of the fibers is particularly palpable at the tran- The fascia of the forearm is closely connected to
sition to the wrist, specifically in the area in which the periosteum of the edge of the ulna and to the dis-
the fasciae are aligned in a circular shape parallel to tal third of the radius and, with its dividing layers,
one another and condense as the flexor retinaculum. reaches into the deep layers of the forearm. In treat-
It is important for treatment practice to bear in mind ment practice, the close connection to the bones of
that this band does not maintain its tension pattern the forearm allows us indirect access to the interior
independently from the global fascial tension of the membrane connections of both bones. In my opin-
forearm. The chances of treatment are very favor- ion, the attachment of the fascia of the forearm to the
able when the dense fibers of the flexor retinaculum posterior edge of the ulna allows us a highly effi-
ligament (also called the transverse carpal ligament) cient access to the entire tension complex of the
are embedded in an environment of antebrachial elbow joint. Similarly to the upper arm, we find the
fascia that is generally tense. manifestation of functionally bundled chambers in
ERRNVPHGLFRVRUJ
96 FASCIAL AND MEMBRANE TECHNIQUE
the forearm as well: fascial dividing walls separate to the palmar fascia of the palm located above them;
and contain antagonistic groups of muscles. in the direction of the deepest flexor layer, they are
The deepest dividing layer between flexors and also perpendicular to a thinly pronounced fascial
extensors of the forearm is the antebrachial layer.
interosseus membrane. Like the interosseus mem-
brane of the lower leg, it plays the deciding role in
securing the bones against lateral displacement. In Treatment techniques
my opinion, the treatment of this membrane plays a
prominent role among the techniques for the upper Treatment of the deep fascial layer according
extremity (see below, under Treatment techniques). to Ida Rolf
If we continue to follow the course of the forearm To a large extent, Ida Rolf’s technique for the treat-
fascia in the distal direction, we encounter a distinct ment of the deep fascia in the region of the upper
difference between the flexor and extensor side of extremity acts parallel to the path of the muscle
the hand: the fasciae of the back of the hand, the fibers and transverse to the fiber direction of the
extensor side, have a relatively delicate structure fascia. It is characteristic for this treatment that the
and play a subordinate role in treatment. In contrast, therapist uses the patient’s active joint movement
the fasciae of the flexor side are complex and very to assist the technique and is thus able to facilitate
fibrous in some levels. Directly under the surface of a deep effect for a technique that is applied to the
the hand, we find the flat palmar aponeurosis, surface.
which is a direct extension of the fascia of the fore-
arm and, on the muscular level, represents an exten- Patient Supine, both legs flexed, arms next to the
sion of the palmaris longus. It connects the fascia of torso.
the forearm to the four fingers. Shortly before its
Therapist Standing at the level of the patient’s
intersection with the finger joints, it is reinforced
pectoral girdle.
with transverse bundles of fibers, the transverse fas-
ciculi. Contact With the surface of the first phalanges of
In the deeper layers of the hand, the fasciae form the fingers of a gently closed fist at the level of the
individual chambers for the tendons. Here, these deltoid muscle and, with the other hand, direct
fascial dividing walls are more or less perpendicular with the antebrachial fascia.
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 97
Action We act on the fascia at both contact points septum and the periosteum of the upper arm, with
in such a way that we cross the fibers with strong the fingertips of the other hand on the connection
pressure. In so doing we slide over the exterior between the lateral septum and the periosteum of
surrounding layer extremely slowly and ensure the upper arm.
that the pressure is exerted not directly onto the
Action With the fingertips of both hands, we
deep layers, but rather diagonally onto the bone.
carefully feel our way to the point where the
While we maintain this slowly gliding contact, we
medial brachial intermuscular septum transitions
ask the patient to move the elbow joint approxi-
into the periosteum of the upper arm. At the same
mately 2 cm outward and inward several times.
time, we use the fingertips of our other hand to
create contact with the transitional point of the lat-
eral septum on the bone. In so doing, we should
The amount of pressure used should be in
carefully avoid the fatty and connective tissue bed
relation to the fascial tone of the layers being
of the nerves and blood vessels, produce a very
treated. We should not exert any pressure from energetic contact, and act directly on the connec-
our shoulder joint, but rather successively tion between the septa and the periosteum.
relocate our weight into both of our hands. The
patient’s elbow movement allows us to achieve
an effect on the intermuscular septa.
Direct influence on the dividing layers between
the flexors and extensors of the upper arm
Treatment of the intermuscular septa of the takes place as if we were trying to loosen the
upper arm tissue of the triceps muscle from the bone. This
active stretching should be combined with
Patient Supine, both legs flexed, arms resting
“listening” because the septa respond to overly
next to the torso.
direct influence with resistance. Attentiveness
Therapist Sitting to the side at the level of the is also required for the radial nerve. Pushing
upper abdominal cavity. the radial nerve and its adjacent blood vessels
Contact With the fingertips of one hand at the con- against the humerus from behind would have
nection between the medial brachial intermuscular an adverse effect on the treatment.
ERRNVPHGLFRVRUJ
98 FASCIAL AND MEMBRANE TECHNIQUE
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 99
Tendon of the
brachial
Articular
biceps muscle
circumference
Oblique cord
of the
elbow joint
Interosseous
membrane of
the foream
Ulna Radius
Treatment of the interosseous membrane direction of the interosseus membrane (using either
of the forearm our fingertips or, in the case of strongly pronounced
musculature, the second phalanges of the index and
Patient Lying supine, legs flexed, arms resting
middle fingers). It is essential to the efficacy of this
next to the torso.
technique that we pay precise attention to the direc-
Therapist Standing at the level of the patient’s tion of the pressure we apply. The membrane has a
pectoral girdle. hiatus in its upper portion for the radial tuberosity
and the bicipital tendon that is attached there. Both
Contact With the surface of the second phalanx
bones of the forearm are stabilized against lateral
of the index and middle fingers of one hand, while
displacement next to this hiatus by the strong fiber
the other hand supports the forearm from behind.
tension of the oblique cord of the elbow joint. We
Action Like the treatment technique described must now ensure that the direction of the fibers is
above, it is important here as well to surround the different in this oblique cord and the substantially
forearm from below and press it against the upper flatter main portion of the membrane (see Fig. 4.77).
arm in order to ensure that the joint capsule relaxes Only in the last fifth of the membrane, i.e. slightly
during the application of pressure. With the other above the wrist, is the orientation of the fibers once
hand, we apply gradually increasing pressure in the again parallel to that of the oblique cord.
ERRNVPHGLFRVRUJ
100 FASCIAL AND MEMBRANE TECHNIQUE
Increased tension in the region of the oblique Contact With the flexed fingers of both hands on
cord can be recognized by the fact that it is no the medial and lateral boundary of the palmar
longer possible to compress elastically the ulna aponeurosis.
and radius at this point. It is important to stabilize
Action The patient positions the forearm verti-
the tissue layers that are located directly distal to
cally while the upper arm rests on the treatment
the elbow joint while we work our way layer by
table in the shoulder region. The therapist now
layer through the extensors with the pressure of
surrounds the layers distally from the flexor liga-
our fingers in the direction of the oblique cord so
ment slightly laterally and medially from the pal-
that we can very slowly exert an impulse there
mar aponeurosis, applies pressure to the tissue,
between the two bones. The pressure should work
and follows the effect of this pressure with “listen-
diagonally between the ulna and radius, i.e. paral-
ing.” The patient’s hand initially remains flexed.
lel to the fiber orientation of the cord.
The therapist now gradually begins to change the
In the farther path of the forearm, we maintain
position of the wrist in space and, while doing so,
the diagonal pressure as if we were trying to rotate
combines the subtly stretching of the fascia with
the ulna toward the radius. With some practice,
passive pronation and supination. Owing to the
it is possible to apply “listening” to the membrane
change in the tension conditions, “listening” now
even during this extremely intense application
provides information about the deep fascial cham-
of pressure. Thus, we are able to connect our
bers of the hand. It is important to give a sustained
direct influence to the membrane’s self-regulating
impulse only where the most distinct compression
ability.
of tissue is found.
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 101
TREATMENT OF CARPAL TUNNEL the boundary surfaces. The nerve is able to correct
SYNDROME the pressure conditions over the long term by
forming additional fascicles and epineurial con-
Conceptual background nective tissue. However, it is precisely this protec-
tive process that can damage the nerve in the
There are two fundamental preconditions for the passages where there is not enough room for con-
undisturbed function of a nerve: the nerve requires nective tissue to absorb additional pressure. The
a positive basic tension and a certain degree of carpal tunnel is one such passage. The carpal bones
mobility relative to adjacent layers, known as and flexor retinaculum surrounding the tunnel
boundary layers. Only then is it possible for the form a bottleneck in which even a small deposit of
chemical life processes of the nerve to function opti- protective fascicles or Renaut’s bodies can over-
mally. The basis of this process is primarily arterial load the nerve. Van den Berg (1999: 226) reports
oxygen supply and, in addition, its supply of that the increase in volume by Renaut’s bodies can
transmitters and enzymes.4 reach up to 30 percent of the volume of a nerve.11
To a large extent, the functionality of a nerve is However, the change to the connective tissue in
dependent upon its oxygen supply. This supply and around the nerve is not the only source of the
process in turn is dependent upon a particular changes in pressure conditions. As a rule, there is
pressure gradient between arterial pressure and either already an edemic blockage due to inflam-
the pressure acting on the nerve from the sur- mation or a cross-sectional increase in nearby
rounding tissue. To a certain degree, the nerve is tendons over a long period in time before the
capable of adjusting to conditions of unfavorable increased formation of connective tissue begins.
pressure. It has a control organ, known as the Moreover, as we will see, there is an entire
nervi nervorum. The nervi nervorum are small range of influencing factors that are not located
branches of the nerve that provide information to directly at the carpal tunnel.
the central nervous system about the interior con-
dition of the nerve and the pressure conditions on
Methodical considerations
4
A detailed discussion of this subject matter may be found in For decades, carpal tunnel syndrome has been dis-
van den Berg (1999: 223–31). cussed in the orthopedic literature as the most
ERRNVPHGLFRVRUJ
102 FASCIAL AND MEMBRANE TECHNIQUE
widespread form of lesion of peripheral nerves. The wrist. On the radial side, the flexor retinaculum is
anatomical units in and around the carpal tunnel connected to the tubercles of the scaphoid bone
itself are at the center of the traditional orthopedic and trapezium bone and on the ulnar side to the
viewpoint. Therefore, it is primarily the transverse tubercles of the pisiform bone and hamulus of the
carpal ligament (also called the flexor retinaculum) hamate bone. Under normal conditions, the carpal
and the sheaths of the tendons of the flexor muscu- tunnel guarantees that the sheath-covered tendons
lature running through the carpal tunnel that have of eight flexor muscles and the median nerve can
been described for almost a century as the pivotal pass through the narrow passage. Here, the flexor
anatomical units for this problem. In orthopedic retinaculum functions as the “guiding band” for
examination, the etiology is concentrated on the the tendons passing through the carpal tunnel
local pressure and tension events in the carpal (Rauber and Kopsch 1987: 411).
tunnel itself. Tension patterns located farther away From the structure of the carpal tunnel, it can be
from the wrist are therefore brought into considera- seen that the nerve function of the median nerve
tion only to the extent that they are necessary for can be disturbed by spatial changes in the tunnel.
differential diagnostic clarification. Such a case occurs if constant pressure is exerted
The treatment concept introduced here is based from outside on the narrow passage between the
on the methodical assumption that disrupted ten- forearm and hand or if the tissue layers passing
sion patterns in the connective tissue system origi- through the tunnel, i.e. the eight flexor tendons
nate in an overarching context. In this sense, it makes with their surrounding sheaths, or the median
sense to classify local tension and pressure events in nerve require more space than the diameter of the
and around the carpal tunnel in the context of the tunnel. In such a situation with constantly increas-
overarching pattern. This results in a technique that ing pressure in the carpal tunnel, the median
does treat large-surface layers of connective tissue, nerve will be the victim of the stricture because
the muscular fascia, septa, and interosseus mem- nerve tissue is less tolerant of pressure than the
branes, but also details such as the sheath and divid- sheath layer of the tendons.
ing layers of the affected nerve cords. It is significant for evaluating the pathology and
Therefore, it is not only the tissues running also for treatment techniques that the median nerve
through the tunnel that are at the center of the dis- is a “mixed” nerve, i.e. it contains motor, sensory,
cussion, but also the tissue layers in the region of and vegetative fibers. The sensory fibers have the
the shoulder, the upper arm, the forearm, and also largest portion in terms of space (Wilhelm 1987).
the forehand on the other side of the tunnel. The nerve is composed of many fascicles in a
Correspondingly, the nerve that is decisive for the plexus-like connection. On the exterior, it is sur-
pathology, the median nerve, is considered in its rounded by a connective tissue epineurium that
entire path, from the cranial branch at the brachial contains a considerable amount of fat. The fascicles
plexus into its very various paths after passing themselves are also surrounded by a thin perin-
through the tunnel. Accordingly, the practical treat- eurium, producing a septum-like division of the
ment suggestions target not only the local events fascicles. Within the fascicles, the individual nerve
at the carpal tunnel itself, but also the larger “tissue fibers are embedded in an elastic, finely fibrous
landscape” within which the unfavorable pressure endoneurium containing capillaries (Kleinau,
conditions of the carpal tunnel develop. unpublished: 17).
In order to be able to understand the topic of the
Anatomical conditions carpal tunnel from a structural viewpoint, it is
important to bear in mind that there are also ele-
The carpal tunnel consists of a 2- to 3-cm long pas- ments outside the tunnel that may be susceptible
sage between the bones of the wrist and the flexor to dysfunction on the nervous or muscular level:
retinaculum. Viewed in cross-section, the bones of the tendon of the long palmar muscle has particu-
the wrist appear concavely arranged. The flexor lar significance because it ends in the aponeurosis
retinaculum consists of tough fibers that are con- of the palm and thus comes into connection with
nected to the radial and ulnar eminences of the the flexor retinaculum. The flexor carpi ulnaris
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 103
Examination
ERRNVPHGLFRVRUJ
104 FASCIAL AND MEMBRANE TECHNIQUE
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 105
ERRNVPHGLFRVRUJ
106 FASCIAL AND MEMBRANE TECHNIQUE
the shoulder. The patient’s thumb is abducted, the therapist reaches somewhat higher, the ulnar nerve
contact between the hand and the treatment table will be found in the direction of the triceps slightly
is initially slightly elastic, the wrist should not be above the medial brachial intermuscular septum;
guided too far into hyperextension, especially not the ulnar nerve may be treated in an analogous
if there is restricted movement at a carpal bone. manner. Treatment of the ulnar nerve is particularly
The therapist’s left hand exerts a shear-like pres- advisable if, in addition to the carpal tunnel, a
sure against the elbow joint. At the same time, the compression of the ulnar nerve has also occurred
therapist’s other hand reaches into the interior of in Guyon’s canal, i.e. outside of the carpal tunnel.
the elbow joint passage in order to reach the medial In both cases, in the treatment of the median
nerve precisely next to the path of the blood ves- nerve and of the ulnar nerve, it is essential to
sels, i.e. next to the aponeurosis of the biceps. If the access the corresponding nerve as precisely as
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 107
possible. The effect on the nerve’s sheath can be Contact Both hands surround the carpals to be
increased by pressure against the elbow joint and treated.
by changing the angle at which the patient’s fore-
arm is flexed. In this manner, we achieve a direct Action The therapist’s thumb presses against the
stretching of the fascia of the pronator quadratus. head of the ulna and the end of the radius as if to
slide both longitudinal bones away from the
Step 5: Treatment of the flexor retinaculum carpals. At the same time, both of the therapist’s
index and middle fingers strongly compress the
Patient Supine, both legs extended.
patient’s carpal tunnel and exercise a drastic
Therapist Standing to the side at the level of the stretching force on the layers of the palm. In this
patient’s hips. manner, we have the opportunity to affect different
ERRNVPHGLFRVRUJ
108 FASCIAL AND MEMBRANE TECHNIQUE
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 109
In any event, neurological examination to can affect the pelvis and thus involve the back as
accompany treatment is advisable in order to guar- well. However, this process can occur in reverse as
antee objective information regarding progress of well: a structural weakness in the back forces one
treatment. leg or both legs into a compensatory movement
pattern and thus causes a long-term change to the
fascial network.
4.5 LOWER EXTREMITY: THIGH, Thus, there is an interdependency between the
LOWER LEG, AND FOOT local hypotonic or hypertonic tension patterns of a
problem zone and a larger context of form. For the
Aspects of form lower extremity, this context is primarily relevant
in standing and walking.
Upon closer observation of the fascial and mem- From an anatomical perspective, the close con-
brane system, chronic structural problems of an nection between the myofascial complex of the
organism should not only be classified as local upper leg and pelvis is responsible for this fact.
restrictions of movement and changes to tissue; On the posterior side of the thigh, there is a direct
rather, they should also be classified into the connection between the fascia of the leg and the lig-
overarching structural patterns of muscular coor- aments of the pelvis: at the ramus of the ischium, the
dination and comprehensive tone patterns of the fasciae of the biceps femoris muscle and the adduc-
connective tissue. For this reason, in the case of tors unite with the strong cords of the sacrotuberous
chronic problems, it is not sufficient to treat the ligament. The layers coming from the distal side act
local complex of symptoms. For some acute prob- on the lower edge of the pelvis with a massive lon-
lems, the precise treatment of a few individual ele- gitudinal pull. In this manner, the tension pattern of
ments is sometimes sufficient. However, in the the posterior side of the thigh becomes the deter-
case of chronic problems that have existed over a mining factor in the tilting of the pelvis around the
period of time, the circumstances are different. hip axis.
However once the compensations for local dys- Once additional increased tension initiates from
functions have exceeded a critical threshold, they the adductor group, the ischial bones are no longer
develop their own problem dynamic, which con- able to move apart from one another during sit-
tinues to exist even if the original problem has ting, and the pelvis retains a posterior tilt during
been successfully treated. We try to be as precise as the most various sequences of movement. The
possible with detailed corrections within the prob- “posterior tilt” becomes the determining posture
lem zone but combine this with a global correction pattern.6
of the cohesive form of the body’s structure. As a result, the curvature of the lumbar spine is
This cohesion may be studied by way of exam- reduced. Seen from the side, a flat back results
ple on the lower extremity with pelvic and back while, on the level of the vertebral bodies, a direct
structures. An onset of arthrosis in the hip joint curve occurs between the last lumbar vertebra and
will influence the movement pattern in the lower the upper edge of the sacrum instead of the curva-
leg and, over the long term, change the fascial, ture. As soon as a lasting structural image of the
membrane and band structures of the ankle joint. structure of the body has resulted from this, the
Damage to the knee joint will not only impact the organ column of the pelvic and abdominal cavities
joint’s function, but will cause a change in coordi- will respond as well:
nation over entire sections of the body. If they exist
● In men, the posterior tilt of the pelvis and the
long enough, changes of this type will produce
reduction of the distance between the ischial
new tone patterns of the musculature and finally
rami increases the pressure on the prostate
influence the fasciae as well.
because more of the weight of the
One characteristic of the connective tissue sys-
tem is that, as a three-dimensional network, it
allows for compensatory changes in all spatial
directions. So, the altered tone pattern of one leg 6
See the detailed description in Flury and Harder (1988).
ERRNVPHGLFRVRUJ
110 FASCIAL AND MEMBRANE TECHNIQUE
Greater psoas
muscle Piriform muscle
Ischiococcygeal
Superior ramus muscle
of the pubis
Obturator Sacrotuberal
fascia ligament
Pubic
symphysis
Ischical
tuberosity
Internal obturator
muscle
Ramus of the
Inferior ramus of ischium
the pubis
Long head of the
Adductor biceps muscle
muscle of the thigh
Rectum
Uterus
Bladder
Vagina
Figure 4.89 Competition for space between the uterus, rectum, and bladder: (a) with an empty bladder and empty rectum;
(b) with a full bladder and empty rectum; and (c) with a full bladder and full rectum.
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 111
on the front of the spine occurs that must be caught the tibia and influences knee joint function there
by the autonomic musculature with increased tone. because individual fibers are connected to the
This causes forced tensions and compressions in the capsule.
intervertebral region to occur simultaneously. As has been mentioned above, the fascia lata
Because of these circumstances and interdepen- has a considerable tissue density in its lateral por-
dencies, it can be seen that, for example, the roots tion, known as the iliotibial tract, and thus has the
of an acute, recurring ischialgia may well be found appearance of a flat aponeurosis. To a certain
in the tension patterns of the lower extremities. For degree we find this tissue density in the dorsal
this reason, the treatment techniques described in region as well, although without the aponeurotic
this chapter are not only extremity techniques, but structure. In contrast, in the ventral and medial
belong to the armory of pelvic and back tech- region of the upper leg, the fascia lata is very thin.
niques as well. On the medial side, it manifests as part of the fas-
cial covering of the adductor group. It is therefore
Anatomy of the fascia of the thigh part of a fascial group that acts as a displacement
layer during muscular activity.
In anatomical literature, reference is repeatedly Although the fibers of the fascia lata have a
made to the fact that only a portion of the mobility ring-shaped orientation, they cover only part of
that is typical for the upper extremity is available the thigh. Predominately, they connect to the
to the lower extremity. Compared with the dynamic intermuscular septa and are thus anchored in the
arm, which is dominated by the grasping function, deep layers of the leg. However, there is also a
the leg has a clearly pronounced static component. smaller portion of the fibers with a low level of
This fact is revealed in the determining fascia of tensile strength that encircles the entire thigh.
the thigh, the fascia lata. In some sections, it shows These fibers are located directly below the subcu-
a mesh-like density of tissue that is not found in taneous layer.
the region of the upper extremity even in the pres- The core layer of the fascia lata is so tough that
ence of the greatest pressure. The greatest density it can inhibit the mobility of the muscle fibers. The
of the intersecting fibers of the fascia lata is found in change in the muscles’ shape in flexion and exten-
the lateral section of the upper leg. This is because sion is only possible because another loose sliding
the fascia has a unique function to perform here: its layer is located between the actual fascial layer
increased basic tension catches the immense pres- and the musculature. We find a comparable slid-
sure acting on the thigh during standing and walk- ing layer in the front and rear region of the thigh
ing. By its existence, the fascia lata prevents the between the subcutis and the fascia. In this man-
femur from flexing outward. Functionally, it works ner, the solid, difficult-to-stretch elements of the
like an interosseus membrane that has been dis- fascia lata are embedded on the surface and in the
placed toward the outside. The density of collagen deep layers of the thigh in sliding layers with a
fibers in the fascia lata is so strongly pronounced greater elasticity. I think that this results in a kind
on the side of the leg that, at first glance, one tends of “combinational elasticity” for these fascial lay-
to doubt the efficacy of manually influencing such ers, which at first glance appear to be impossible
tough layers. However, upon closer examination, to stretch.
we recognize that the deep layer of the fascia lata It is important for treatment techniques that we
has a high degree of elasticity and movability that keep in mind that the fascia lata does not function
allows manual influence to appear quite plausible. only as a superficial layer. In the deep layers, it is
The fascia lata surrounds the entire thigh. In its linked to the intermuscular septa of the thigh.
upper part, where it is connected to the inguinal Moreover, there are a few other peculiarities in
ligament and iliac crest, it is a component of the the region of the fascia lata that are worthy of atten-
gluteal fascia and thus part of the connective tis- tion for treatment practice: the muscles embedded
sue bridge between the lower extremity and the in the fascia lata have their own directional fascial
pelvis. With its distal branches, it connects to the sheaths, inside of which the muscles can slide some-
superficial fascia of the knee and the periosteum of what with the aid of an epimysium. In isolated
ERRNVPHGLFRVRUJ
112 FASCIAL AND MEMBRANE TECHNIQUE
cases, this epimysium is a cylindrical fascial tube, Action With an elastically closed fist, we gently
such as in the case of the sartorius muscle. This is a push through the skin and fatty layers just under
special form that is typical of diagonal muscle the gluteal fold in order to produce a flat hand con-
paths. Also, the fascia of the sternocleidomastoid tact on the seat halter of the fascia lata. We main-
muscle has a similar position in the region of the tain a flat contact at this point without sliding. The
fasciae of the neck. We find a comparable invagina- holding surface that results is significant because
tion in the case of the gracilis muscle. Finally, there the seat halter has a unique, three-dimensional
is one other peculiarity of the fasciae of the lower branching, specifically outward in the direction of
extremity that has significance for the circulatory the skin, laterally toward the iliotibial tract, and
system. Von Lanz and Wachsmuth (1972: 48) have medially until the tuberosity of the ischium. Thus,
shown that the large vascular routes of the leg are it connects the subcutaneous layer, the aponeuro-
located not inside the musculature, but rather sis, and the periosteum. With the palm of the other
between the “stiff-walled fascial tubes.” hand, we press on the posterior edge of the longi-
The musculature requires the resistance of the tudinal path of the iliotibial tract, first anteriorly in
stiff fascial tubes in order to produce their charac- a diagonal direction. The pressure that we exert
teristic effect as muscular pumps on the accompa- goes barely past the outer edge of the femur. We
nying veins of the arteries. follow the tract along its entire length with strong
contact up to the layer of the head of the fibula. It
is important to adapt the contact to the density of
Treatment techniques the fibers and the sliding layer located below them
in order to prevent a squeezing effect on the bones.
Treatment of the fascia lata (lateral layer)
Patient Lying on one side with knees flexed,
small pillow between the knees. Treatment of the fascia lata (posterior layer)
and the fasciae of the biceps femoris,
Therapist Standing next to the patient’s hips. semimembranosus, and semitendinosus muscles
Contact With a slightly closed fist at the medial Patient Supine, one leg flexed, one knee pulled
end of the subgluteal, horizontal part of the fascia up and held with both hands.
lata (see Figure 4.94), with the other hand right on
the posterior edge of the longitudinal path of the Therapist Standing at the level of the diaphragm,
iliotibial tract. facing distally.
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 113
Contact Using the shoulder to provide counter- This technique can be applied analogously to
pressure on the patient’s pulled-up knee, strong, the semitendinosus and semimembranosus, while
sliding contact in the posterior layers of the fascia. we work between the semimembranosus and
adductor magnus muscles.
Action We ask the patient to hold the knee with
both hands so that the thigh rotates minimally
inward. It is important for the other leg to maintain The efficacy of this technique depends on the
a good functional contact with the treatment table careful graduation of the very strong pressure
so that the orientation of the hip axis remains hori- as well as the coordination of this pressure with
zontal, even if massive pressure is exerted on the the pull that the patient is exerting on the upper
posterior side of the thigh. The therapist’s shoulder
leg. The pull should be just strong enough that
now leans against the patient’s pulled-up knee so
the ischial bones expand somewhat, but the hip
as to apply some of the therapist’s weight against
this knee. At the same time, the majority of the joint should not be compressed too strongly.
weight of the therapist’s upper body is transferred
into the palms, and the therapist exerts a slow Treatment of the deep layer of the iliotibial
stretching force on the posterior layer of the fascia tract in connection with the subgluteal,
lata. This stretching motion extends over the entire horizontal part of the fascia lata
posterior side of the thigh, beginning just below the
hollow of the knee and ending at the point where Patient Supine, one leg pulled up with both hands.
the gluteal fascia overlaps the biceps femoris. Therapist Standing distally of the hip axis, fac-
In a second treatment step, we produce contact ing in the cranial direction.
specifically between the posterior boundary of the
Contact One palm on the upper third of the ilio-
iliotibial tract and the biceps femoris by reaching
tibial tract with the second phalanx of the index
with our second hand between the biceps femoris
and middle fingers of the other hand on the
and semitendinosus muscles. We exert strong,
medial portion of the subgluteal, horizontal part
slowly gliding pressure, which this time acts
of the fascia lata.
deeply into the grooves between the muscles. This
contact is less two-dimensional than in the first Action The therapist’s hands move in opposite
step. In the case of a high degree of muscle tone, it directions. In order to protect the therapist’s own
is advisable to use the edge of the hand. neck, it is essential to keep the shoulders loose and
ERRNVPHGLFRVRUJ
114 FASCIAL AND MEMBRANE TECHNIQUE
for the movement impulse to originate from the respond to the shifting pull and pressure forces
elbows. The palm on the tract slides freely, with the and readjust itself in its fascial bed.
pressure moving first through the tough superfi-
cial fascial layers into the sliding intermediate Treatment of the fascia lata (medial layer) and
layer, and then acting almost parallel to the exterior the investing fascia of the adductors
of the femur. In no way should we attempt to pull
Patient Lying on one side, the lower leg almost
on the exterior layers. The contact by both pha-
extended, the upper leg to be treated slightly flexed.
langes on the subgluteal, horizontal part of the fas-
cia lata wanders slowly. It works in slow motion, as Therapist Standing behind the patient at the
if we were constantly waiting for the bone to level of the thigh.
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 115
Action The patient’s ankle is allowed to rest on Treatment of the anterior layer of the fascia
the therapist’s flexed thigh while the therapist lata in combination with the posterior layer
surrounds the patient’s knee on the medial side with
Patient Supine, one leg flexed, the other leg
one hand. With the fingertips of the other hand, the
extended.
therapist now absorbs the weight of the thigh and
carefully reaches through the fascia lata, which is Therapist Sitting at the level of the patient’s
very thin here, in order to arrive behind the sartorius hips, facing distally.
muscle at the boundary of the fascial sheath of the
Contact With one palm on the front of the thigh
adductor magnus and the semimembranosus mus-
and with the fingertips of the other hand lateral of
cles. No contact is established here with the blood
the group fascia of the adductors.
vessels or the saphenous nerve at the level of the
intermuscular septum. The therapist first waits for Action First, we produce a flat contact with the
the tissue response and then, using the weight of the fascia on the front of the leg, which is relatively
thigh, gradually reaches between the fascial tubes. thin there. As the same time, our fingertips reach
At this point we maintain contact and now we mod- into the tissue behind the leg, lateral to the adduc-
ify it with our other hand by slight abduction and tor fascia and toward the femur. While we now
adduction of the angle of our contact. Subsequently, cross the fascial fibers with flat contact in the distal
we follow the course of the muscles in a slowly direction on the front of the leg, the far more
ERRNVPHGLFRVRUJ
116 FASCIAL AND MEMBRANE TECHNIQUE
Internal obturator
muscle
Fascial sheath of the
sartorius muscle
Medial vastus
muscle
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 117
between the superficial and deep crural fascia in the triceps surae of the calf is also formed by the
that one anterior and one posterior intermuscular deep lamina of the crural fascia, forming an addi-
septum runs inward from the superficial layer. tional chamber between the superficial and deep
Similarly to the forearm, longitudinal displace- plantar flexors.
ment of the bones is prevented in the lower leg by A few peculiarities of the crural fascia are of
a strong interosseus membrane. Along with the importance for the techniques described below.
tibia and fibula, this membrane separates the From a purely mechanical viewpoint, its superfi-
extensor musculature located in the front section of cial layer is closely connected to the periosteum of
the lower leg from the flexor musculature located the tibia. A connection to the fibula by way of the
in the rear section of the lower leg. In addition to front intermuscular septum is present as well.
this osteofibrous separation, a fibrous chamber for From a neurological viewpoint, since Staubesand’s
ERRNVPHGLFRVRUJ
118 FASCIAL AND MEMBRANE TECHNIQUE
Peroneal compartment
Fibula
Posterior
intermuscular
septum
Superficial
flexor compartment
Deep flexor
compartment
Superficial crural
Deep lamina of the crural fascia fascia
research, the fascia has prompted far-reaching con- This dissimilarity in the morphology of the fas-
sideration (Staubesand and Li 1996; Schleip 2003): cia requires an extremely precise differentiation in
Staubesand found contractile fibers in the crural the quality of touch when treating the lower leg.
fascia. Using altered tensile stress, the fascia could There is one other characteristic of the crural
therefore modify the tough spatial delimiters in the fascia that requires a particular treatment tech-
lower leg down into the interconnection of mem- nique. At its lower end, where it comprises only a
branes and periostea. relatively thin layer, it transitions seamlessly into
This sort of modification would have a substan- the retinacula; it forms regular guiding canals into
tial influence on the muscle tone because the fascia which the tendon sheaths are embedded, in the
serves as the origin of the muscle in the proximal front it forms them for the extensor tendons along
direction. with two retinacula and in the rear it forms them
For treatment techniques, it is helpful to pay for the flexor tendons.
attention to the different formations of the fascia. Each of the retinacula continues on the rear of
Depending on the level of load, the fascia on the the foot and the sole of the foot into the fascial lay-
superficial and deep levels will develop in a more ers of the foot. Thus, the retinacula provide a con-
or less fibrous fashion. It can sometimes be so stiff nection to the plantar aponeurosis in the distal
that it can hardly be distinguished from the adja- direction and to the crural fascia in the proximal
cent musculature. In individual deep sections, it direction. For the treatment of these structures,
can also function as a simple displacement layer. it is important to bear in mind that the retinacula
Von Lanz and Wachsmuth (1972: 303) have do not represent a separate band structure;
referred to the fact that the deep crural fascia dou- rather, they are a functionally determined local
bles over the tuberosity of calcaneus while farther thickening of fascia. Correspondingly, any effect
in the cranial direction it becomes quite delicate on their tough fibrous structure is always also an
and, in the proximal direction, it frequently effect of the overall fascial complex of the leg and
becomes a simple “displacement device.” foot.
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 119
ERRNVPHGLFRVRUJ
120 FASCIAL AND MEMBRANE TECHNIQUE
inferior extensor retinacula of the lower legs and, at then the toes. During this entire sequence of move-
the same time, supports both longitudinal arches ments, the therapist maintains strong contact with
from below with the thumbs. The therapist asks the the retinacula and fixes the hinge joint axis. While
patient to adduct first the toes and then the foot. the patient repeats the sequence of movements sev-
Subsequently, first the foot should be stretched and eral times, the therapist stretches the fibers.
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 121
Third step
Patient Same position as above.
Figure 4.102 Fiber orientation of the retinacula at the
transition between the lower leg and foot. Therapist Standing, one knee flexed on the treat-
ment table.
ERRNVPHGLFRVRUJ
122 FASCIAL AND MEMBRANE TECHNIQUE
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 123
lifts the lower leg by grasping the crural fascia in on the medial side of the tibia instead of on the
the distal direction from the medial portion of the head of the fibula and to follow the leg farther into
gastrocnemius muscle and the fingertips (medial the genu varum.
side) and the thumb (lateral side) of the other hand In both cases, genu valgum and genu varum, the
surround the head of the fibula. indirect guidance into joint fixation should be com-
bined with the direct impulse applied to the fascia.
Action The foot of the patient’s slightly raised The effect presumably arises because we are simul-
leg is in contact with the therapist’s shoulder. The taneously exerting influence on the ligaments near
therapist surrounds the head of the fibula while the joint and the insertion of the crural fascia in the
using the other hand to produce a flat contact on proximal position of the tibia and fibula.
the rear side of the lower leg. The therapist uses
the shoulder contact to move the patient’s ankle
passively while using the contact with both hands Treatment of the interosseous membrane
to move the knee and hip joints in the movement of the lower leg
direction of the hinge joint axis. While doing so,
Patient Supine, both legs extended.
the therapist follows the deviations from the hinge
joint axis passively, with “listening” and without Therapist Sitting at the feet.
reducing contact with the fascia.
Contact Initially, with two fingertips of one hand
In the case of genu valgum, the leg will move
from behind on the farthest distal point of the lat-
farther into the knock-knee configuration. The
eral malleolus, with the fingertips of the other
therapist follows the movement until it has almost
hand also from behind, slightly above the distal
come to a stop and, at this moment, applies a
fifth of the tibia.
sustained impulse into the fascial tissue and/or
the connecting ligaments at the head of the fibula in Action The therapist’s fingertips gently push the
order to then follow the leg in its countermovement. lateral malleolus from the distal and posterior
In the case of genu varum, the leg usually moves directions precisely parallel to the fiber orientation
somewhat more strongly into the bow-legged of the anterior tibiofibular ligament so that the lat-
shape. In this case, it is better to maintain contact eral malleolus slightly approaches the lower
ERRNVPHGLFRVRUJ
124 FASCIAL AND MEMBRANE TECHNIQUE
Anterior ligament
of the head of
the fibula
Tibial tuberosity
Head of the fibula
Crural interosseous
membrane
Anterior
tibiofibular
ligament
Lateral Medial
malleolus malleolus
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 125
ERRNVPHGLFRVRUJ
126 FASCIAL AND MEMBRANE TECHNIQUE
Action Both of the therapist’s hands are placed on force and break off the process. However, if we can
the treatment table with the outer edge and the fin- feel a difference, we first follow the more elastic side
gers are slightly flexed. The hand applied below in as far as we can and wait for the reverse impulse to
the region of the talus is somewhat flatter under the exert a subtle shear pulse on the side that was origi-
patient’s lower leg than the second hand so that the nally more strongly “blocked” until the lateral and
patient’s knee is slightly raised. The therapist now medial edges of the knee offer the same amount of
gradually modifies the quality of the touch—it resistance. This is the moment of equilibrium in
becomes gradually more elastic until the tone of the which we remove our touch.
superficial muscles relaxes more and more and a
contact is produced with the deep crural fascia. At
this moment, the therapist applies a slight impulse
TREATMENT OF THE HIP JOINT IN THE
upward, in the direction of the ceiling, as if to gently
CASE OF ONSET OF ARTHROSIS
reach upward with the fingertips through the deep
In recent years, considerable advances have been
crural fascia. In so doing, the therapist follows any
made in the implantation of artificial hip joints.
tensile forces that may occur that guide both hands
The implants themselves as well as the surgical
together or apart while remaining constantly in
procedures have improved substantially so that
strong yet elastic contact. It is as if the therapist were
today a positive long-term prognosis can be given
touching a stretched trampoline from below, tracing
in most cases.
the tension patterns that manifest there, and noting
The manual techniques described below are
the tensional forces working on this trampoline in
directed at two goals:
order to set them against one another and gradually
neutralize them. Successful neutralization can be ● On the one hand, the attempt should be made
recognized by the patient’s lower leg finally resting to optimize the transmission of pressure forces
on the therapist’s fingertips in a completely motion- onto the hip joint, to facilitate a better
less fashion. At this moment, it is worthwhile to gen- distribution of joint fluid and thus slow the
tly push both contact points in the cranial direction course of progressive changes to cartilage. In
until the resistance of the knee joint is felt. If the the most favorable case, it should be possible
resistance has the same quality in the medial and lat- to postpone the time at which an implant is
eral directions, it is advisable to remove the shear required.
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 127
● On the other hand, the treatment of the way that tendencies toward “normal” pressure
involved connective tissue structures should and tension conditions are already manifest in the
achieve a type of rehabilitation before the myofascial units that intersect the joint capsule or
surgical intervention. have their course in its vicinity before the implan-
tation of the artificial hip joint. In order to achieve
In the course of progressive arthrosis of the hip an effective treatment result, it is necessary to
joint, considerable compensatory changes occur combine globally applied techniques that act on
not only in the pelvic region, but also in the distal the fascial complex above and below the joint cap-
direction from the hip joint, primarily in the sule with techniques that influence structures
ankles. In the superior direction from the hip joint, inside the capsule.
primarily in the region of the pectoral girdle, com-
pensatory changes to muscle tone and fascial ten-
sion may be frequently observed as well. In my
Anatomy of the fasciae and membranes in
practice, I have observed again and again that
manual treatment as preparation for an implant,
the region of the hip joint
i.e. rehabilitation before the surgical intervention, Because the hip joint is located directly at the tran-
is more important than postoperative care. This sition between the lower extremity and the interior
may be due to the fact that compensatory changes of the pelvis, very different myofascial units of the
already emerge in the myofascial system at the body components mentioned above—pelvis, legs,
beginning of arthrosis. These compensations man- feet—can have an influence on the function of this
ifest themselves progressively in the muscular joint. The joint must be able to withstand compres-
units of the pelvis, primarily in the rotators, which sional forces originating from the torso as well as
connect the sacrum to the femur on the greater strong tensional forces from the lower extremity.
trochanter. After a longer period of time, these In the superficial layer, we encounter the ante-
changes not only act on the musculature, but also rior portion of the fascia lata. It is significant as the
extend to the fibers of the ligaments: overarching layer for the hip joint because it is
● the sacrotuberous ligament connected to the iliac crest, inguinal ligament,
● the sacrospinous ligament pubic bone, and ischial bone and continues in the
● the obturator membrane. distal direction to the superficial fascia of the knee
(Lanz and Wachsmut 1972: 100).
If these changes are not treated before the surgi- In addition, the fascial sheath layers of the adduc-
cal intervention, the implant will be included in tor group, which are referred to in their distal region
the compensatory tension pattern that corre- as the pectineal fascia, are significant as the middle
sponds to the inflamed joint that was restricted in layer. I would speculate that these fascial sheath lay-
its movement. In the case of a strongly pro- ers, along with the predominant tone pattern of
nounced compensation pattern, the ability of the their associated musculature, play a role in the distal
organism to adapt is overextended. In this case, portion of the hip joint. It is possible that the tensile
we are confronted by a situation in which, in spite forces that act on the medial and distal portion of the
of a “new,” functional hip, the dysfunction of the joint are responsible for the narrowing of the seam
surrounding tissue continues to hinder coordi- of the joint that is visible in radiographic images. It is
nated overall function. possible that tensile forces acting in the posterior
It is not simple to differentiate to what extent direction, i.e. the entire myofascial complex of the
the changes mentioned above actually correspond rotators, play a role. In the case of these layers that
to a compensatory pattern and to what extent they run posteriorly between the sacrum and the great
already had an effect before the onset of the arthro- trochanter, individual muscles have a particularly
sis, perhaps as a mechanical component of changes important role because they are able to intensify the
to cartilage. This differentiation, however, does compressive forces within the joint. All muscles that
not play any role in our practical treatment strat- rotate the leg outward and that run parallel to strong
egy. In any event, we must treat the hip in such a ligaments should be emphasized. For example, the
ERRNVPHGLFRVRUJ
128 FASCIAL AND MEMBRANE TECHNIQUE
superior gemellus muscle, which runs from the capsule, there is a cushion of connective tissue and
spine of the ischium to the trochanteric fossa, should fat as well as the ligament of the head of the femur.
be mentioned because its fibers have an orientation The mobility and cushioning function of these ele-
that runs parallel to that of the sacrospinous liga- ments play a considerable role in intracapsular
ment, which has a high tensile strength. The three- distribution of fluid.
dimensional, not just two-dimensional, impact on
the hip joint becomes clear when we observe that
Treatment techniques
the fibers of the obturator internus muscle have an
orientation parallel to that of the sacrospinous liga- Treatment of the myofascial tension patterns
ment. The obturator internus has a strongly pro- that transmit onto the ischial ramus
nounced fascial sheath and, in its tendinous portion,
is connected to the tendons of the superior and infe- Patient Supine, one knee flexed.
rior gemelli muscles where they insert into the Therapist Sitting next to the treatment table at
trochanteric fossa. the level of the patient’s knee.
In this myofascial context, the iliopsoas fascia
also plays an important role. Along with the perios- Contact With the flat underside of the fingertips
teum of the iliac fossa, it forms an osteofibrous tube of one hand between the origin of the adductor
that offers space for the iliac muscle. Von Lanz and magnus and semitendinosus muscle as near as
Wachsmut (1972: 98) have pointed out that the possible to the ischial tuberosity; at the same time,
posterior side of this tube has grown into the cap- the other hand supports the entire thigh from the
sule of the hip joint. posterior direction.
Moreover, the interrelation of connective tissue Action The supporting hand raises the thigh
elements of the pelvic cavity with the iliopsoas slightly so that a passive flexion of the hip and knee
fascia is significant as well: the path of the renal joint occurs. At the same time, the fingertips of the
fascia is in the direct vicinity of the psoas muscle. other hand gradually move between the adductor
Its posterior layer is connected to the psoas fascia magnus and semitendinosus toward the ischial
and the medial crus of the diaphragm (Breul 2002). tuberosity. The passive movement of the thigh
For the diagnostic evaluation of the hip joint, it is causes the contact to wander gradually inward and,
important to bear in mind that disease processes can once it arrives under the subgluteal, horizontal part
spread by way of the renal fascia from the perirenal
space in the inferior direction by way of the lacuna
of muscles to the lesser trochanter. In the latter case,
pain occurs in the region of the hip joint, the cause of
Iliac bone Connective tissue
which can be found in the perirenal space. cushion in the
Finally, it should also be mentioned that the acetabular fossa
chamber of the pelvic and abdominal cavities
Iliofemoral
located above the hip joint transmits pressure in ligament
the direction of the hip joint. We can only specu-
late as to the extent to which this transmission of
Ligament
pressure has unfavorable effects on the hip joint of the head
due to restrictions in organ movement. In practice, of the femur
techniques that take into account the peritoneal
space and the retroperitoneal concentration of con-
nective tissue of the organs have proven useful.
In addition to the numerous layers that inter-
sect with the hip joint outside of its capsule, the Transverse
interior of the joint capsule has significance for acetabular ligament
the treatment concept described above as well.
Between the head of the femur and the hip joint Figure 4.110 Frontal section of the right hip joint.
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 129
of the fascia lata, it should work determinedly and Treatment of the myofascial complex of the
unyieldingly in the deep layer. As soon as the con- rotator group
tact arrives in the deep layer between the two mus-
Patient Supine, one leg flexed.
cles, we can increase the efficacy by using our
supporting hand to guide the entire leg passively in Therapist Sitting next to the treatment table at the
slight inward and outward rotations. In so doing, it level of the patient’s knee.
is important for our contact to be applied parallel to
the muscle fibers and transverse to the primary Contact With the fingertips through the exterior
direction of the fascial fibers. gluteal muscles in the direction of the rotator
ERRNVPHGLFRVRUJ
130 FASCIAL AND MEMBRANE TECHNIQUE
group, while the other hand maintains contact the foot in a flat manner, the patient’s attention is
with the sole of the foot. directed toward the tactile perception of the
“artificial ground” formed by our hand (this des-
Action The therapist uses the patient’s weight ignation was originated by Moshe Feldenkrais,
initially to reach through the superficial gluteal although he used a wood board held in both of the
musculature. The contact of the therapist’s fingers therapist’s hands to produce the artificial floor).
is placed precisely between the obturator internus The patient is now asked to exert slight pressure
and the piriformis. The pressure is thus transmit- with the soles of the feet; the therapist’s hand pro-
ted approximately to the layers of the gemellus vides counterpressure so the patient’s knee is raised
superior. While the other hand supports the sole of somewhat. During this process, the therapist
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 131
Iliofemoral Acetabulum
Ligament of the Obturator
ligament
head of the femur membrane
Orbicular
zone
Figure 4.115 Reinforcing ligaments of the joint capsule of Figure 4.116 Right hip joint after the opening of the joint
the hip. capsule.
follows the contact on the level of the gemellus Treatment of the connective tissue cushion in
superior in “listening,” so that the entire leg the acetabular fossa and the ligament of the
rotates minimally, either outward or inward. This head of the femur
movement is followed until it stops, then the ther-
Patient Supine, both legs extended.
apist attempts to slightly reinforce the counter-
movement that occurs. At the same time, the Therapist Sitting at the foot of the treatment table.
contact with the fascia of the superior gemellus Contact The sole of the patient’s foot presses gen-
muscle is intensified as if the therapist’s fingertips tly against the therapist’s sternum, the weight of
were trying to reach through the patient’s pelvis in the leg is resting on both of the therapist’s hands;
the direction of the ceiling. the therapist is using one palm to support the thigh
from the posterior direction and the other hand to
The technique described above requires the support the lower leg from the posterior direction.
independent use of both of the therapist’s hands, Action While the therapist’s sternum gently
and attention to the contact of the sole of the foot touches the sole of the foot, the therapist supports
from the patient. If there is sufficient the lower leg and thigh from the posterior direction
coordination between the therapist and the and follows rotations that occur between the two
patient, it is possible for us to produce an indirect sections of the legs, which may take on a slight
connection to the ligaments that surround the
knock-kneed or bow-legged shape. It is important
to follow the dominant pattern and, at the same
hip joint from the outside. In order to do so, it is
time, maintain contact with the sole of the foot. As
important that we actually follow the rotation of
soon as the dominant pattern is manifest, the thera-
the leg within only the most minimal spatial pist gently pushes along the central line of the leg
changes without inducing too much muscle toward the hip joint. This push should be per-
activity. In the most favorable case, this allows us formed at the same time with the sternum against
to achieve a three-dimensional division of the the sole of the foot and the supporting hands on the
reinforcing ligaments of the joint capsule. thigh and lower leg. At the moment at which the
ERRNVPHGLFRVRUJ
132 FASCIAL AND MEMBRANE TECHNIQUE
ERRNVPHGLFRVRUJ
FORM-ORIENTED TREATMENT TECHNIQUES 133
There is also one other starting point for treat- its boundary surfaces. In the region of the hip
ment that deals with the nerves bordering the hip joint, the technique mentioned above can be
region. Barral and Croibier have developed tech- applied to the femoral and obturator nerves.
niques for the treatment of the peripheral nerves
that go beyond the original visceral concept. These
techniques appear to act directly on the connective A very efficient technique for the treatment of
tissue sheath layers of the nerves and therefore the obturator membrane may be found in Prat
influence the forces acting between the nerve and (1993: 7–33).
ERRNVPHGLFRVRUJ
135
Chapter 5
ERRNVPHGLFRVRUJ
136 FASCIAL AND MEMBRANE TECHNIQUE
Action The weight of the therapist’s forearms is sides, this process may take approximately two to
transferred onto the treatment table in such a way three minutes.
that the flexion musculature of the forearms is as
relaxed as possible and the back of the patient’s
head is resting on it as if on two soft pillows. The Treatment of costal vertebral joints in the
therapist now positions the fingertips of both hands mid-region of the thoracic spine
on both sides of the blocked joint slightly below Patient Sitting on a stool.
the transverse processes of both vertebrae. If the
therapist’s forearms are offset from one another on Therapist Standing at the patient’s side with one
the treatment table, one hand will be able to reach foot on the seat of the stool in order to support the
somewhat farther downward than the other. It is elbow of the hand applying the treatment on the
crucial that the patient be relaxed, with the critical thigh.
zone resting on the therapist’s fingertips. The ther-
Contact Precisely below the affected rib and
apist supports the region of the thoracic spine in
slightly lateral of the costotransverse articulation.
such a way that the habitual curvature of this sec-
tion of the spine and back that is typical for every Action The patient relaxes both hands and places
patient shows up. At the same time, the therapist them on the pectoral girdle without interlocking
uses “listening” to follow every movement, no them. The therapist holds both of the patient’s
matter how small, that is sensed in the movement- elbows so as to be able to guide the patient’s upper
restricted joint. The therapist intensifies this move- body in passive rotation and lateral flexion. The
ment tendency in the direction in which it can be therapist now examines how the tissue and the
felt most strongly and, in so doing, moves the joint blocked joint in the area of fixation behave when
more into its restriction. In the brief moment of the ribcage is rotated slightly to the left and right.
this “wedging,” the tactile sense of the therapist’s For this treatment, it is important to prevent rota-
fingertips concentrates on the pull of the soft tis- tion to the side where the blockage is reflected.
sue. The therapist gradually intensifies the contact Instead, the therapist rotates the patient’s upper
in a very precise manner with these tissue units, body in the other direction while using the thumb
which may be quite small, until a countermotion to maintain the pressure in the tissue below the rib.
can be felt that guides the joint out of its blockage. It is important that the patient’s upper body not be
In the case of a genuine fixation of the joint on both overextended in this process. It is crucial that the
ERRNVPHGLFRVRUJ
SPECIAL JOINT TECHNIQUES 137
ERRNVPHGLFRVRUJ
138 FASCIAL AND MEMBRANE TECHNIQUE
Contact With one hand on both sides next to the upper lumbar area in relation to the passively
the sternum, in the region in which the fifth, sixth, induced movement.
and seventh ribs are connected to the sternum; at If performed precisely, this technique has the
the same time, with the other hand and extended advantage that it includes prevertebral and posterior
forearm supporting the thighs from the anterior layers in the treatment at the same time. If the fixa-
direction. tion of the upper lumbar vertebrae is more strongly
pronounced on the left side, a variation of this tech-
Action The therapist first places both hands in
nique is advisable: with one hand, the therapist
the initial position described above and then
grasps not the arch of the ribs and sternum, but
selects the contact in the region of the lower ster-
rather the left section of the duodenum in the direc-
num as the fixed point and uses the fingertips and
tion of Treitz’s ligaments and uses a stretching
heel of the hand to press in the direction of the
impulse to guide it to its connection point on the
xiphoid process. This pressure should act inward,
upper lumbar spine and back again.
that is to say, influence the tension of both cupulas
of the diaphragm and their ligamentous connection
to the stomach and liver. The arm and hand that Decompression technique for the transition
the therapist is using to support the thighs now between the lower lumbar spine and sacrum
perform a slight rotational motion to the left and
right, which is then repeated several times in min- In the literature, there are numerous descriptions
imal steps. This causes a spatial displacement of of techniques for treatment of the transition
the insertion of the psoas on the lesser trochanter. between the lumbar spine and sacrum. The tech-
By this repeated subtle movement, which covers nique described here is similar to techniques that
only a few millimeters, an induction of the flexion are already known.1
and extension of the psoas muscle occurs. Finally, Patient Supine, both legs extended.
the therapist rotates the patient’s pelvis, which is
moved as one unit, and legs against the fixed tho- Therapist Standing at the level of the thigh.
racolumbar transition.
If the therapist now applies the diagnostic prin-
ciple of general “listening,” the therapist will be 1
For example, cf. the detailed descriptions in Upledger and
able to sense the behavior of the joint fixation in Vredevoogd (1983: 141–2).
ERRNVPHGLFRVRUJ
SPECIAL JOINT TECHNIQUES 139
Contact With the palm of one hand supporting major muscle layers is only the precondition for the
the sacrum, with the fingertips just reaching the actual treatment of the small muscular units and
base of the sacrum, while the other hand creates a ligament and tendon units of this section of the
contact with the tissue layers near the joint on both body. In this context, it is of interest to observe that
sides of the lumbar spine at the level of the fourth the iliolumbar ligament is first constructed as a
and fifth lumbar vertebrae. muscular structure and does not turn into a purely
ligamentous structure until an advanced age,
Action The therapist supports the sacrum with approximately around the thirtieth year of life. If
one hand, trying to adapt the shape of the palm there is a compression between the fifth lumbar
to the individual shape of the posterior surface of vertebra and the first sacral vertebra due to a gen-
the sacrum as best as possible. With the other hand, eral, very strongly pronounced muscle tone, the
the therapist creates contact on both sides of the therapist can, without reservation, use the finger-
fourth and fifth lumbar vertebrae with the tissue tips to apply a massive pull on the part of the
layers of the lower back. This action is a specifica- lumbar fascia that runs between the sacrum and
tion of the technique that we have already learned subdermis instead of the subtle traction on the
in the treatment of curvature of the lumbar spine in sacrum in the inferior direction. In this regard, the
its transition to the sacrum (see section 4.1, technique is similar to Ida Rolf’s “pelvic lift.” 2
Treatment of lumbar lordosis at the transition to
the pelvic cavity). First, the last lumbar vertebra
and sacrum are compressed and, in so doing, we Treatment of motion restrictions of the
precisely trace any small rotation and lateral flex- lower cervical spine
ions movements that may occur between the bony
Patient Supine, both legs bent.
units on our hands. Only when the tissue layers
involved no longer provide resistance to us is the Therapist Sitting to the side at the head of the
sacrum moved in the inferior direction out of its treatment table.
compression against the last lumbar vertebra.
Superficially regarded, this process first appears
to be a simple relaxation technique. In reality, how-
ever, the relaxation of the musculature and the 2
The term “pelvic lift” also occurs in Sutherland (1990: 281–2).
ERRNVPHGLFRVRUJ
140 FASCIAL AND MEMBRANE TECHNIQUE
Contact The therapist supports the back of one contact around the uppermost thoracic vertebra
forearm and the back of the hand on the treatment remains very firm.
table and places the four fingertips and tip of the If the restriction of movement in the vertebral
thumb vertically around the spinous process of segments described above is the result of a spasm-
the first thoracic vertebra, supporting the occiput like, lasting flexion of the scalene group, the con-
with the other hand. tact should be made between the upper ribs to
which the scalene musculature is attached instead
Action With the position of the fingers and thumb
of around the first thoracic vertebra.
around the upper thoracic vertebra described
above, the therapist forms five support points
more or less in the shape of a circle in the region of
Treatment of the atlanto-occipital
the lower section of the nuchal ligament, which
connection
begins at that point to connect to the fascia of the
trapezius muscle. With the other hand, the thera- There is such a variety of tissue layers in the short
pist raises the patient’s head somewhat and section between the axis, the atlas, and the base of
pushes it gently in the inferior direction, as if to the skull that it is not easy to decide where the
push the entire cervical spine slightly into the force is originating that is ultimately causing a
ribcage. The contact around the first thoracic ver- restriction of movement at the atlanto-occipital
tebra is maintained throughout this process, as if joints and, under some circumstances, fixating it
the therapist were trying to send all imaginable on a lasting basis. At the transitional zone between
energy from the fingertips, through the patient’s the cervical spine and the head, quite literally all
tissue, and in the direction of the ceiling. The ther- of the layers may be involved, beginning with the
apist now begins to minimally move the head and surface of the galea aponeurotica, which contains
neck alternately to the left and right in rotation motor and sensory nerves, through the suboccipi-
and lateral flexion. Here, the therapist is gradually tal musculature, into the interior of the vertebral
reducing the push in the inferior direction. In canal and cranium through the dura. In addition,
other words, the therapist is no longer pushing the tension patterns from sections of the body located
cervical spine and neck into the upper chest cavity, in the inferior direction can easily transfer onto the
but rather is accompanying the neck in the oppo- atlanto-occipital connection.
site, cranial direction. In so doing, the therapist Restraint is advisable in the case of unilateral joint
allows every lateral movement of the neck, regard- fixations because they rarely have a local origin;
less of how minimal, while the supporting contact rather, they arise from the various compressional
at the base of the skull remains very light and the and tensional conditions in both halves of the body
ERRNVPHGLFRVRUJ
SPECIAL JOINT TECHNIQUES 141
below the neck. However, it is also true for bilateral, nuchal line. This small muscle, which appears to
genuine joint fixations on the occipital condyle that have a fascial connection to the dura, is of central
the dominant tensile forces can originate at a greater significance to treatment practice because it can
distance from the joint, for example, at the joint cause a massive compression of the atlanto-cranial
between the coccyx and sacrum. If the coccyx is joints due to its almost vertical course.
chronically displaced in the anterior direction and is However, in the case of chronic joint fixation, it is
limited in its mobility relative to the sacrum, then certainly not only the tone pattern of one individual
the dura comes under a large amount of tensional muscle or muscle group that plays a deciding role.
forces over its entire course into the foramen mag- Rather, it is the cooperation of the various tissues
num. It is possible that the tensional conditions are that changes the mobility of a joint on a lasting
also changing in the large anterior longitudinal liga- basis. Therefore, the following technique combines
ment, which is directly connected to the atlanto- direct tissue contact with a type of positioning
occipital membrane. In any event, it can be seen known from Jones 1981.
over and over in practice that a mobilization of the
Patient Supine, both legs bent.
coccyx leads to a direct and very long-lasting relief
of the transition between the atlas and the base of Therapist Sitting at the head.
the skull. Then we must make only a minimal sub-
Contact With the fingertips of both hands on the
sequent correction at the atlanto-occipital transition.
atlanto-occipital transition, if possible.
If we apply our treatment directly to the region
of the joints at the head of the atlas, the relatively Action It is fundamental for this technique that
small muscles that run in the posterior direction the therapist first exaggerate the joint position that is
are important. typical of the fixation. The therapist supports the
Here, it should be taken into account that the patient’s occiput very gently, then reaches directly
obliquus capitis inferior, the rectus capitis major, below the base of the skull toward the atlanto-occip-
and the rectus capitis posterior minor all run diag- ital membrane after having moved the joint laterally
onally to the middle line of the neck at different and rotated it corresponding to its fixation. Now, the
angles of incline. The angle of incline is most pro- therapist’s sternum pushes directly against the top
nounced in the rectus capitis posterior minor, of the skull in such a way that the joint position is
which runs almost vertically between the posterior reinforced. In so doing, the therapist pushes the
atlantic tubercule and the internal third of the foremost part of the fingertips of the index and
ERRNVPHGLFRVRUJ
142 FASCIAL AND MEMBRANE TECHNIQUE
Superior oblique
muscle of the
head
Splenius muscle
of the head
Posterior
occipital membrane
Inferior oblique
muscle of the head
middle fingers toward the more strongly fixated Treatment of the membrane connections
side in the direction of the joint connection and between the axis, atlas, and occipital bone
maintains a “melting contact” with the tissue there.
Patient Supine, both legs extended.
The therapist pays the greatest attention to every
small change in tone at this point. As soon as the Therapist Sitting to the side at the level of the
therapist’s fingertips are able to sense an increase in neck.
radiated heat or a reduction in tone of the small
Contact Supporting the tissue covering the pos-
muscular units, then the therapist slowly rotates the
terior arch and transverse process of the atlas from
head and neck back into their normal position.
the posterior direction with the thumb and index
finger; the other hand supports the occiput and its
fingertips maintain contact just below the base of
Compared with direct joint manipulation, the
the skull.
technique described above has the advantage
that it has a very gentle and protective effect on Action The primary weight of the head is trans-
the tissue layers. Moreover, it is advantageous ferred onto the supporting hand on the base of the
skull; only part of the weight of the neck is resting
that the combination of positioning the joint and
on the contact point at the posterior arch of the atlas.
applying a direct effect on the tissue layers
The therapist gradually lifts the atlas slightly in the
allows us to reach the myofascial units,
anterior direction, specifically in such a way that the
membranes, tendons, and ligaments at the same vertebra moves minimally along the articular fascia.
time. If we omit the push against the roof of the While doing so, we are guided by imagining that we
skull and vary the hand position accordingly, are moving the anterior arch of the axis onto the
this technique can also be applied effectively in anterior part of the pons of the occiput so that a
the region of the middle cervical vertebral joints. relaxation occurs in the anterior portion of the
ERRNVPHGLFRVRUJ
SPECIAL JOINT TECHNIQUES 143
Anterior
atlanto-occipital Cruciform ligament of the atlas:
membrane Longitudinal fasciculi
Apical dental Transverse ligament
ligament of the atlas
Tooth of Longitudinal fasciculi
the axis
Dura mater
of the spine
Occipital
Tectorial
squama
membrane
3rd cervical Posterior atlanto-
vertebra occipital membrane
atlanto-occipital membrane. Once the therapist is For this purpose, it is necessary to twist the occiput
able to sense the relaxation, the therapist first fol- and axis minimally opposite one another while “lis-
lows only the atlas with “listening”—the occiput tening,” finally to guide them together and wait for
remains a fixed point—then the therapist follows the shear effect that occurs in the small intermediate
the occiput in any small movements that may occur. area between the occiput, atlas, and axis.
As soon as these movements abate, the therapist
changes the contact to the second cervical vertebra
Treatment of the iliosacral joints using the
while continuing to support the patient’s occiput.
ligament and membrane connections of the
The therapist now attempts to affect the tectorial
pelvic cavity
membrane and the short piece of the spinal dura
mater that runs between the occiput and the axis. Patient Prone.
ERRNVPHGLFRVRUJ
144 FASCIAL AND MEMBRANE TECHNIQUE
Therapist Standing at the level of the hips. Mobilization of the inferior section of the
iliosacral joint
Contact With one hand on the sacrum and the
other hand transverse to it from the anterior direc- Patient Supine, both legs extended.
tion slightly below the navel.
Therapist Standing at the level of the thighs.
Action The therapist tests the mobility between
Contact One hand supports the region of the
the organs and the sacrum by exerting vertical pres-
upper lumbar spine from the posterior direction
sure in the anterior direction precisely on the sec-
and the other hand supports the sacrum, with the
ond segment of the sacrum. The therapist observes
palm touching the lower part of the sacrum in
whether this pressure arrives at the anterior hand
order to guarantee that the fingertips can be moved
placed on the abdomen. If this is not the case, it is a
laterally.
sign that strong tensions exist between the sacrum
and the organs located anterior to it. In this case, the Action The supporting hand in the region of the
therapist uses the anterior hand to lift the entire lumbar spine reinforces the lordotic curvature.
abdominal cavity in the posterior direction toward This causes a general reduction in tension in the
the sacrum. During this movement, the contact with major extensors of the back. We ensure that the
the posterior hand on the sacrum is maintained. The patient is not “holding” the position, but rather
therapist subsequently allows the abdominal cavity that the weight of the patient’s entire body is being
to sink back a few millimeters in the anterior direc- transferred into our hands. By reinforcing the lor-
tion and follows the movement with “listening.” If dotic curvature, the pelvis is tilted slightly in the
the therapist’s hand rotates in one direction, the anterior direction. We follow this movement with
therapist follows this movement to its end in order the hand supporting the sacrum. We now observe
to exert posterior pressure in the direction of the how the sacrum behaves with regard to the reduc-
sacrum. The contact with the other hand on the tion in tone of the musculature in the region of
sacrum is maintained unabated during this process; the lower lumbar spine. The pulling effect of the
its quality should be slightly elastic. In this manner, ligaments will become far more tangible. Under
the ligamentous connection between the cervix certain circumstances, the sacrum may tilt in a diag-
and sacrum becomes more mobile. This in turn onal direction, rotate slightly, or move in a clockwise
improves the mobility of the neck of the uterus. The or counterclockwise direction. We first register the
forces that may be fixating the sacrum from the direction in which the sacrum is being pulled or
anterior direction find an improved equilibrium. pushed and use our hand to feel both lateral edges
ERRNVPHGLFRVRUJ
SPECIAL JOINT TECHNIQUES 145
Broad ligament
of the uterus
Round
ligament
of the uterus
Vesicouterine
ligament
of the sacrum very precisely. We concentrate However, sometimes it is also the region of the ori-
entirely on detecting whether we can feel one indi- gin of the anterior piriform muscle. Under certain
vidual segment of the bone as conspicuously rigid. circumstances, we can feel a type of rigidity on the
This is frequently the point at which a ligament posterior section of the lower joint connection itself,
with a high concentration of fibers exercises pull. which I presume comes from the lasting tension of
ERRNVPHGLFRVRUJ
146 FASCIAL AND MEMBRANE TECHNIQUE
the sacroiliac ligament, which is interwoven with of a drastic protrusion being visible on the MRI
the lumbar fascia. Some skill is required to keep the image but no dysfunction being associated with it
lumbar region in a lordosis to support the lower and the patient being free of discomfort.
part of the sacrum with the palm and use one or With this fact in mind, it is worthwhile to
two fingertips to produce contact on the connec- attempt to treat disk problems manually, even if it is
tion of the ligament or the tendinous insertion of a not entirely certain that the dysfunction is actually
muscle on the periosteum as if we wanted to make originating from the intervertebral disk. Manual
this connection “melt.” If this technique is per- treatment should be applied only if we can rule out
formed precisely, the sacrum “swims” into a nor- the danger of neurological damage—and even then
mal relationship to the two ilia. under neurological supervision.
In order to check the result of treatment, it is The techniques below are particularly suited for
advisable to have the patient stand up and walk application in the region of the lumbar and cervi-
a few steps. Then the patient should lie supine cal spine. It is fundamentally necessary for the
again, the therapist lifts the patient’s spine into an patient to be positioned such that compensatory
increased lordosis, allows the sacrum to tilt slightly muscle spasms are reduced to the greatest extent
in the anterior direction, and determines whether possible and the acute symptoms are alleviated for
the unfavorable pull effect of myofascial units and the moment. The therapist should avoid any
ligaments has been reduced. Ideally, the sacrum abrupt manual intervention and only conduct
will now exhibit an intensified tilt without escap- shear, rotational, and tilt movements slowly and in
ing more to the side or making rotational motions. small degrees in order to avoid additional irrita-
tion of the affected nerve.
ERRNVPHGLFRVRUJ
SPECIAL JOINT TECHNIQUES 147
space under the weight of its gelatinous filling as intraperitoneal organs diagonally in the anterocra-
soon as the pressure from the two adjacent verte- nial direction toward the diaphragm. This causes a
brae has been reduced. slight release of pressure between the intra- and
retroperitoneal space, while the positioning of the
Patient Lying on one side, legs bent. patient reinforces the stricture in the critical inter-
vertebral space. The therapist now attempts to use
Therapist Standing at the level of the hips facing
“listening” to precisely detect the behavior of the
the patient’s back.
vertebrae located above and below the herniation.
Contact With one flat palm in the region of the I assume that, in so doing, we are able to influence
lower lumbar spine at the transition to the sacrum; the fiber pulls of the intervertebral disk ring in the
the other hand surrounds both ankles from the moment of an indirect release of pressure.
anterior side. In addition to “listening,” we also need the per-
manent feedback from the patient regarding the
Action The therapist uses the palm to precisely pressure or release of pressure on the critically
sense the motion behavior of the vertebrae in the affected nerve in order to regulate this technique.
critical zone. With the other hand, the therapist The angle of pelvic tilt and extent of induced pelvic
surrounds both of the patient’s ankles and gently rotation are crucial.
pulls the patient’s bent legs in the posterior direction If the application of this technique causes the
in order to change the kinked transition between pain situation to spontaneously improve, it is help-
the lower lumbar spine and the sacrum into a “soft” ful to allow the patient to rest for a while longer in
curvature. the treatment position.
In the second treatment step, the therapist’s This technique is also suitable for treating mul-
thigh is positioned for support below the patient’s tiple protrusions in the region of the lower lumbar
lower leg in such a way that the tilt of the right spine.
side of the pelvis around the hip axis in the ante-
rior direction is somewhat more pronounced and
Treatment of lumbar intervertebral disk
the right side of the pelvis rotates slightly in the
protrusions in the retromedial region
direction of the center line of the body. With the
according to Barral
other hand, the therapist maintains flat contact in
the lateral region of the lower ribs and pushes the Patient Prone.
ERRNVPHGLFRVRUJ
148 FASCIAL AND MEMBRANE TECHNIQUE
Therapist Standing, one knee bent on the treat- Action The therapist positions the patient prone
ment table. carefully enough to avoid additional nerve irritation.
The therapist then places one hand in the region of
Contact The thigh of the therapist’s bent leg sup-
the affected segment of the back. The contact
ports the patient’s legs slightly in the cranial direc-
should be loose enough to allow the most subtle
tion above the knees and, at the same time, the
“listening.” The goal of the position is to create a
therapist reaches around both legs in this region.
“soft” lordosis instead of the kink characterized by
compression between the fifth lumbar vertebra
and first sacral segment or between the fourth and
fifth lumbar vertebrae.
ERRNVPHGLFRVRUJ
SPECIAL JOINT TECHNIQUES 149
segment. Rotation by rotation, the therapist relieves much. If there is a tendency toward a pronounced
the intervertebral disk under pressure or, more pre- lordosis, the therapist should support this form as
cisely, the various components of the organism at well without exaggerating it. In both cases, it is cru-
the level of the intervertebral disk. Following with cial that the therapist avoid placing a mechanical
“listening,” the therapist provides a minimal push pull on the cervical spine in the cranial direction.
in the anterior direction and, in so doing, allows the Any pulling effect on the exterior myofascial layers
contents of the intervertebral disk to sink farther in of the neck should be omitted as well because such
the anterior direction under the influence of gravity an effect could lead to a counterreaction of small
and the protrusion of the membrane being com- muscular units in the deep layers and thus cause an
pressed in the retromedial direction to subside. The unfavorable compression of the affected segment.
therapist subsequently allows the patient to slide The therapist holds the other hand between the
out of the treatment position slowly and carefully. upper ribs on both sides of the spine in such a way
that the fingertips are placed precisely between the
second and third ribs and the costovertebral joints
Treatment of lateral intervertebral disk to the left and right of the spine come to rest on the
protrusions in the region of the neck therapist’s fingertips. The therapist now performs
various small rotational and lateral movements
Patient Supine, both legs bent.
until a neck position has been achieved that is
Therapist Sitting at the head. pleasant and relaxing for the patient. If radiating
pain is present in the arm, it will be reduced at the
Contact One hand supports the neck and the
moment at which correct positioning is achieved.
base of the skull from the posterior direction while
While the therapist maintains this position, the con-
the fingertips of the other hand produce a contact
tact with one hand on the tissue that covers the cos-
at the level of the costovertebral joints between the
tovertebral joints from the posterior direction is
second and third ribs.
intensified. The therapist’s other hand now follows
Action The therapist supports the neck and head with “listening” and the therapist attempts to main-
lifted at the same angle as the general curvature tain the most precise possible contact with the tis-
that is present in the patient’s cervical spine. If the sue below and above the affected intervertebral
tendency toward hyperextension is present, the disk. As soon as a change in tone manifests in this
therapist supports it without reinforcing it too region, the therapist reduces the intensity of the
ERRNVPHGLFRVRUJ
150 FASCIAL AND MEMBRANE TECHNIQUE
contact on the neck and, at the same time, directs treatment result in cases of pronounced lateral pro-
tactile perception toward the minimal movement trusion. In such cases, it is advisable to apply this
that manifests in both vertebrae above and below technique while the patient is lying on one side. It
the affected intervertebral disk and accompanies is important that the patient lies on the side that is
both bones in this movement, which reduces the not affected and that the patient’s head is sup-
compression on the intervertebral disk. ported by a pillow.
Treatment variation for strongly pronounced lateral Patient Lying on the side contralateral to the
intervertebral disk protrusions in the neck region herniation.
The technique described above, with the patient
lying supine, does not always yield the desired Therapist Sitting at the head.
ERRNVPHGLFRVRUJ
SPECIAL JOINT TECHNIQUES 151
Contact The therapist supports the patient’s head Action It is important to ensure that the thera-
from the side; the index and middle fingers of the pist completely supports the patient’s head when
other hand are located slightly cranially to the the patient assumes the position. This prevents
clavicle. any unpleasant pull effect in the critical region of
the neck. The therapist holds the complete weight
Action The therapist now uses the two fingers to
of the head in one hand and should under no cir-
make a direct contact to the brachial plexus on the
cumstances use the weight of the head to pull the
side of the protrusion. The therapist exerts a slight
neck in the cranial direction or, conversely, bend
pull on the perineurial sheath as if to gently pluck
the head in the dorsal direction. Rather, the thera-
the string of a guitar. While doing so, the therapist
pist takes the head in the hand in such a way that
raises the patient’s head slightly in lateral flexion
the curvature of the cervical spine and the myofas-
and rotation. Then the lateral flexion and rotation
cial layers in the interior of the neck are in such a
of the neck is gradually scaled back to its starting
position as to relieve the critical segment. Feedback
position so that a pull occurs on the perineurial
from the patient regarding the radiating pain is
sheath of the brachial plexus. The interaction of the
essential to this treatment as well. The therapist
positioning of the neck and pull effect on the nerve
attempts to select the position of the neck and head
itself decompresses the intervertebral foramen.
in such a way that the acute pain is reduced some-
what or, in the most favorable case, disappears
entirely. The position in which this occurs is the
Treatment of retromedial intervertebral
position that must be maintained. The therapist
disk protrusions in the region of the
can find this position by applying supportive force
cervical spine
on both sides in the region of the subclavius mus-
Patient Prone, with the head and neck extending cle while the therapist’s other hand moves the cer-
past the head of the treatment table. vical spine above the head in the most minimal
lateral flexion and rotation movements. This move-
Therapist Sitting at the head.
ment should be gradually repeated to the left and
Contact With one hand supporting the frontal right while the head and neck are guided mini-
bone and with the other hand inferior to both clav- mally in the anterior direction. In my experience,
icles in the region of the subclavius muscle. the impression arises after a certain amount of time
ERRNVPHGLFRVRUJ
152 FASCIAL AND MEMBRANE TECHNIQUE
ERRNVPHGLFRVRUJ
SPECIAL JOINT TECHNIQUES 153
dura as a whole beginning from the occiput. This on the second segment of the sacrum while the
pull should come into effect at the moment at which therapist contacts the foramen magnum in a man-
the cranium appears to become more filled with ner similar to the one described above.
cerebrospinal fluid.
Patient Supine, both legs extended.
5.3 THE SACROCOCCYGEAL JOINT
Therapist Sitting at the head.
Contact With one hand providing support on both A.T. Still, the founder of osteopathy, attached great
sides at the level of the ninth thoracic vertebra and significance to the coccyx and described the correc-
with the palm of the other hand on the occiput and tion of movement restrictions at the sacrococcygeal
its fingertips slightly below the base of the skull. joint. Ida Rolf, founder of the Rolfing Method, also
assigned a prominent role to the coccyx in the
Action The therapist supports the back at the level
course of the sixth of ten treatments in her basic
of the ninth thoracic vertebra, i.e. at the point where
treatment series. Recently, the coccyx has received
the vertebral canal is particularly narrow. The thera-
renewed attention, primarily from Barral’s practi-
pist’s fingertips are guided below the occiput as
cal research on visceral manipulation. This is cer-
near as possible in the direction of the foramen mag-
tainly no coincidence because the effects of a
num and the therapist attempts to transmit a pull
motion-restricted sacrococcygeal joint can be seen
effect onto the interior of the vertebral canal. In other
in a particularly drastic fashion in the visceral
words, the point is not to pull on the exterior on the
region. Dysfunctions of the vesical sphincter,
neck or spine as a whole, but rather for the pull force
movement restrictions in or even sinking (ptosis)
to be transmitted by way of the attachment of the
of the kidneys, movement restrictions at the liga-
dura to the foramen magnum all the way into the
mentous environment of the cervix and prostate—
interior of the vertebral canal, i.e. to the dura mater
all of these phenomena can be better understood
and the spinal cord. Using this pull effect, the thera-
on the basis of the stabilizing role of the coccyx.
pist now creates a subtle contact with the segment
inside which the protrusion is present. It is impor-
tant to subtly modify the direction and extent of the The significance of the coccyx as the
pull in such a way that the compressive forces acting stabilizing element of the lower
on the intervertebral disk change. pelvic cavity
Applying this technique with two people
increases its chances of success. The treatment In light of modern imaging techniques, the sacro-
assistant contacts the dura by way of its attachment coccygeal joint appears at first glance to be an
ERRNVPHGLFRVRUJ
154 FASCIAL AND MEMBRANE TECHNIQUE
inessential appendage of the sacrum. Upon closer fascial sheaths of the semitendinosus and semi-
examination, however, although it is given little membranosus muscles have a direct connection to
consideration in manual medicine, this joint proves the ligaments and tendons that transition into the
itself to be one of the key points of the spine. coccyx at the lowest edge of the sacrum.
On the radiographic image taken from the sagit-
tal direction, the coccyx is recognizable as a process
of the sacrum that can display a quite varied indi- Anatomy of the coccyx and
vidual angle of incline relative to the sacrum. If this adjacent structures
angle of incline manifests itself in the form of a
kink that is clearly visible in the radiographic image, The coccyx has numerous variations in its bony
this may be a sign of a restriction of movement structure. The number of bone segments can vary
between the sacrum and coccyx. This sign is not greatly (up to six units): in some cases, it is very
entirely absolute because the radiographic image long, but it can also be short and broad. These dif-
provides only a momentary picture of the position ferences originate during embryonic develop-
of the bone. Manual tests are required to determine ment. As a rule, until the beginning of the second
whether a reduction in normal mobility, which month, an embryo has a regular caudal process
should be at least 15 degrees, is actually present. which the neural tube fills with the chorda, intes-
For example, if the coccyx is fixated in the ante- tine, and mesoderm. During the second month of
rior direction, i.e. the range of motion between the embryonic development, a reabsorption of this
coccyx and sacrum is considerably less than 15 process gradually occurs.
degrees, then the distance between the origin and The coccyx is connected in the cranial direction
insertion of this muscle group is reduced as well to the fifth segment of the sacrum by the sacrococ-
and a reduction in muscle tone occurs. This process cygeal synchondrosis. Both joint processes of the
alters the pressure conditions in the pelvic cav- coccyx that point upward are connected by way of
ity and thus influences the normal mobility of the the articular sacrococcygeal ligament at this low-
organs. est segment of the sacrum here as well.
The coccyx also plays a significant role with On the inferior side and in the deep layer of the
regard to the lower extremity because the large pelvic floor, the coccyx is the insertion for the three
ERRNVPHGLFRVRUJ
SPECIAL JOINT TECHNIQUES 155
Anterior sacroiliac ligament Iliolumbar ligament Anterior sacroiliac ligament Iliolumbar ligament
Sacrotuberal Sacrotuberal
ligament ligament
Sacrospinal Sacrospinal
ligament ligament
Superior pubic ligament Inguinal ligament Superior pubic ligament Inguinal ligament
Figure 5.24 Pelvic bones and ligamentous apparatus of Figure 5.25 Pelvic bones and ligamentous apparatus of
the male from the anterior direction. the female from the anterior direction.
ERRNVPHGLFRVRUJ
156 FASCIAL AND MEMBRANE TECHNIQUE
ERRNVPHGLFRVRUJ
SPECIAL JOINT TECHNIQUES 157
Piriform muscle
Coccygeal
muscle and
sacrospinal
ligament
Sacrotuberal
ligament
Internal obturator
muscle
ERRNVPHGLFRVRUJ
158 FASCIAL AND MEMBRANE TECHNIQUE
(a)
(b) (c)
Figure 5.30 Examination of lateral fixation during lateral flexion of the torso to the right. (a) Lateral bend to the right
shown on a skeleton, corresponding to phase 1. (b) Phase 1. (c) Phase 2.
ERRNVPHGLFRVRUJ
SPECIAL JOINT TECHNIQUES 159
(a)
(b) (c)
Figure 5.31 Examination of lateral fixation during lateral flexion of the torso to the left. (a) Lateral bend to the left shown
on a skeleton, corresponding to phase 1. (b) Phase 1. (c) Phase 2.
ERRNVPHGLFRVRUJ
160 FASCIAL AND MEMBRANE TECHNIQUE
ERRNVPHGLFRVRUJ
SPECIAL JOINT TECHNIQUES 161
(a) (b)
Figure 5.32 Treatment of anterior fixation. (a) Making contact. (b) Transmitting pressure.
If the injury to the joint was a very long time the relationship between the sacrum and the adja-
ago, then it is not only the fibers directly attached cent iliac bone and the lower lumbar vertebrae
to the joint that are involved in the fixation. Over becomes tangible, particularly in the ligamentous
the course of time, the altered tensional pattern has bedding. While the therapist holds the lumbar
also manifested in the sacroiliac ligament and the spine area in a slight hyperlordosis, the therapist
large-area fascial layers located above it such as follows all movement of the sacrum that may occur,
the lumbar fascia. and finally applies a slight impulse in the region of
In order to encourage a balanced tension between the lower thoracolumbar fascia in the direction of
the deep ligament and tendon structures and the the diaphragm and, at the same time, applies a gen-
exterior sheath layers, it is advisable to use the fol- tly pull to the lumbar fascia in the distal direction.
lowing technique to act on the lumbar fascia and
the tissue bed of the lumbar spine and the fascial
layers adjacent to the lumbar area. The precise mechanism of effect of this
technique is described in the section regarding
Treatment of fascial layers adjacent to the movement restrictions in the region of the
lumbar area lower lumbar spine (see section 4.1, Treatment
Patient Supine, both legs extended, arms resting of lumbar lordosis at the transition to the
next to the torso. pelvic cavity and Treatment of flat back of the
lumbar spine). Because the correction of the
Therapist Standing to the side at the level of the
coccyx influences the tensional relationships in
thighs.
the spinal dura mater, it is advisable to
Contact One hand holds the sacrum from the
subsequently examine the transition between
posterior direction while the other hand produces
the axis and foramen magnum. In practice, we
a contact with the lower third of the thoracolum-
frequently find compressions within the short
bar fascia.
section of the atlanto-occipital joint that
Action It is important for this technique that the
disappear after the mobilization of the coccyx.
patient allows the weight of the pelvis and lower
However, the mobilization of the “lower pole”
back to sink completely into the therapist’s hands.
between the coccyx and sacrum can also cause
The therapist supports the sacrum with one hand in
such a way that the weight of the pelvis is evenly an irritation at the transition of the upper pole
distributed. With the other hand, the therapist lifts between the atlas and base of the skull. For this
the lower back region in a slight bend so that the reason, the connection between the upper
muscle groups that run parallel to the spine relax cervical spine and head should be treated
slightly. Now, after the reduction in muscle tone, subsequently, if necessary.
ERRNVPHGLFRVRUJ
162 FASCIAL AND MEMBRANE TECHNIQUE
5.4 JOINTS OF THE FOOT calcaneonavicular ligament and the long plantar
ligament and the medial intermuscular septum
As a rule, the transition between the foot and lower are reduced during the application of the treat-
leg can be treated with techniques that have already ment technique. The relaxation of individual mus-
been discussed in the section on the lower extrem- cular insertions is secondary. The larger myofascial
ity (see section 4.5). However, there is a series of units of the foot are less important than the liga-
motion restrictions between the bones of the foot ments, particularly because the talus, which is so
itself for which a special technique must be used significant for the entire static situation of the foot
that is applied directly to the joint surfaces. If and leg, does not serve as the origin or insertion of
movement restrictions have occurred in the bones any muscle. In a manner of speaking, it is the key-
of the foot, the self-regulation of the organism is stone of the arch of the foot, whose relationships to
subjected to certain limits by the structure of the the adjacent bones are dependent on the tensile
arch of the foot. This is also the reason why the direct force of the tendons and ligaments.
manipulation of these joints sometimes requires a All of the mobilization techniques described here
considerable application of force and does not follow the same treatment strategy:
always meet with success.
If, for example, the navicular bone shows a limi- ● The therapist gently exaggerates the relative
tation of motion in relation to the talus, if the cuboid spatial position of both foot bones to be
bone shows a restriction of motion in relation to the mobilized, as is typical of the present fixation.
calcaneus, or if a disruption of the spatial relation- ● At the same time, the therapist uses active
ship occurs between the distal end of the tibia and pressure to distort the two bones relative to one
the talus, the joint surfaces can quite literally lock another in such a way that they are somewhat
into one another. The tendon and ligament struc- released from the tension of the longitudinal
ture of the arch of the foot, if it has a pronounced arch of the foot caused by ligaments, tendons,
tension pattern, causes a long-lasting manifestation and intermuscular septa and so that the
of this limitation of movement. surfaces of the joint can be moved.
The following techniques take these facts into
account. These are techniques that cause the major If the techniques are applied successfully, the
units of the foot to be distorted relative to one therapist’s hands will feel a gradual scraping
another such that the tensile forces of the plantar sound, although it cannot be heard by the human
ERRNVPHGLFRVRUJ
SPECIAL JOINT TECHNIQUES 163
Talocrural
articulation
Posterior
Plantar calcaneo- talofibular ligament
Plantar Long plantar navicular
aponeurosis ligament ligament Calcaneo-
fibular ligament
Figure 5.34 Construction of the longitudinal arch of the
foot from the medial direction. Interosseous
talocalcaneal ligament
ERRNVPHGLFRVRUJ
164 FASCIAL AND MEMBRANE TECHNIQUE
minimal changes in tension occur at points at which to move closer to one another. If the navicular bone
the tendons and ligaments are interconnected to is displaced in the cranial direction, the cuneonav-
the periosteum. icular joint is affected as well. An increased tensile
force of the long plantar ligament running between
the cuneiform bones and an increase in tone of
Treatment of the joint between the navicular
the posterior tibial muscle may be involved in the
bone and talus
joint fixation between the navicular bone and the
Patient Supine, one leg bent; the leg to be treated talus. In any event, it is advantageous in this situ-
is extended. ation to move the cuneiform bones and the talus
toward one another so that the navicular bone slips
Therapist Sitting at the foot next to the treatment
farther in the cranial direction in its fixation and
table.
the long plantar ligament relaxes. It is not until
Contact With the fingers and thumbs of one hand this moment that the therapist begins to twist the
on the navicular bone and the other hand on the navicular bone and talus toward each other, releases
talus. the cuneiform bones in the direction of the toes,
and allows the navicular bone to follow the pull
Action At this joint as well, the therapist uses both
direction of the plantar calcaneonavicular ligament
hands to follow with “listening” in order to sense
and glide out of the fixation.
the dominant direction in which the two bones want
Figure 5.36 Treatment of the joint between the talus and Figure 5.37 Treatment of the joint between the navicular
calcaneus. bone and talus.
ERRNVPHGLFRVRUJ
SPECIAL JOINT TECHNIQUES 165
Treatment of the joints between the cuboid zigzag path. Because the cuboid bone, with its mul-
bone and calcaneus tiple joints with adjacent bones, has contact with
various directional surfaces of the joint surface, it is
Patient Supine, one leg bent; the leg to be treated
very important to follow this zigzag path gradually
is extended.
until the endpoint of the joint fixation.
Therapist Sitting to the side at the foot. In this technique as well, the therapist uses a
twisting of the arch of the foot in order to relax lig-
Contact One palm supports the calcaneus from
aments and aponeuroses in such a way that the
the medial direction and surrounds its exterior with
restricted joint surfaces come into motion.
the fingertips, while the other hand grasps the
cuboid bone with the thumb and index finger.
Treatment of intraosseous tension of the
Action While “listening,” the therapist moves the calcaneus
calcaneus and the cuboid bone toward one another
This technique is particularly suitable for treat-
in such a way that, as in the previous techniques, the
ment of healed fractures of the calcaneus.
joint fixation becomes more pronounced. It should
be borne in mind that, owing to the very individu- Patient Supine, both legs extended, with the feet
ally pronounced shape of the foot, the directions in extending past the edge of the treatment table.
which we move the two bones together may vary Therapist Sitting at the foot.
greatly. As a rule, the bones also do not move in a
Contact With a relaxed palm on the calcaneus
linear fashion in their fixation, but rather on a tiny
from the posterior direction, while the other hand
supports the back of the hand.
Action The therapist takes the calcaneus with one
palm in such a way that the hand precisely reflects
the surface contour of the bone. While doing so,
the therapist supports the back of the hand pro-
viding treatment with the palm of the other hand
such that the patient’s heel rests in both of the
therapist’s hands. The therapist first follows the
calcaneus with “listening” into the position that
the calcaneus wants to take in relation to the other
adjacent bones and then allows this movement to
come to its end. Sometimes the calcaneus will glide
more strongly in the medial, lateral, anterior, or pos-
terior direction. As a rule, this will not be a move-
ment in a straight line, but rather more of an
elliptical curve in which the calcaneus moves into
the preferred position. Once it has arrived at the
endpoint of this movement, the therapist reduces
the intensity of the contact somewhat and now uses
“listening” to first feel the periosteum of the calca-
neus. The therapist now concentrates on whether
individual points on the periosteum appear to be
more compacted than others. At the same time, the
therapist alters the quality of touch at these points
as if to reach into the interior of the bone. This
requires the therapist’s palm to minimally compress
Figure 5.38 Treatment of the joints between the cuboid the entire calcaneus, as if to squeeze out a sponge
bone and calcaneus. only a little. As soon as the counterforce coming
ERRNVPHGLFRVRUJ
166 FASCIAL AND MEMBRANE TECHNIQUE
ERRNVPHGLFRVRUJ
167
Chapter 6
ERRNVPHGLFRVRUJ
168 FASCIAL AND MEMBRANE TECHNIQUE
(primarily severe diseases of the lungs), as well as a traditional viewpoint, Barral also described an
their effects on the spine, in greater detail and later active movement originating from the inner dynam-
on, after the demise of the patient, comparing the ics from the organs themselves. He called this subtle
results of the examination with the autopsy find- form of movement, which can be discerned only
ings. In so doing, he came across a groundbreaking with the greatest sensitivity, “motility” (Barral and
observation: if it was possible to detect tuberculous Mercier 2002: 8).
caverns on one side of the lung, considerable Motility consists of two phases:
changes were found in autopsy in the region of the
● a movement phase, which Barral refers to as
cervical spine. Barral placed these changes in rela-
“expir,” moves the organ closer to the central
tion to the restrictions of movement that he had
axis of the body
been able to ascertain as a tactile finding while the
● the countermovement, “inspir,” moves the
patient was alive.
organ away from the central axis.
As early as the beginning of the 1970s, Barral
used this observation as a starting point for extensive One characteristic of this movement, the motility
practical research, which resulted in an extremely of the organs, is that a synchronous rhythm mani-
differentiated treatment concept. Beginning from fests in all of the organs. Peculiarly, there is no direct
the first edition of Visceral Manipulation, which came correlation between mobility, which is caused by
out in 1983, he has constantly been elaborating, breathing, and the subtle movement of motility with
testing, and refining this concept in practical and regard to the directions of motion. In some organs,
technical terms. there are overlapping movements, and in others
mobility and motility are completely different.
Mobility and motility of organs Barral explains the phenomenon of motility as
follows: he attributes this form of movement to the
The treatment goal of “mobilization” did not axis rotations that individual organs make during
included only the musculoskeletal elements of the embryonic development. With the aid of this embry-
organism; it was also extended to the relational ological model, Barral interprets the motility of the
movement of organs. In a certain sense, this allowed organs as a lasting trace of movement from embry-
the organs to be assigned as if they formed “joints” onic development. Thus, motility would be a subtle
by way of their sheaths of connective tissue and lig- pendulum movement between the actual position
amentous connections, and these “joints” displayed of the organ and the spatial curve that led to this
regular and irregular movement behavior compara- position during embryonic development. In a man-
ble to a joint of the musculoskeletal system. ner of speaking, motility is a sort of “movement
In the section covering treatment of the breath- memory” of the organs.
ing pattern (see section 4.1, Tests to evaluate Barral also developed a manual, axis-oriented
breathing movement), we were able to see that the diagnostic pattern for this form of organ movement,
“joint movement” of the organs is passive motion i.e. motility, which allows us to evaluate regular
caused by movement of the diaphragm. Axes of movements and deviations in a manual diagnostic
movement that are characteristic for an organ and manner.
spatial curves that are related to the visceral cavity Beyond manual diagnostics, however, it has been
and neighboring organs can be described. The exis- difficult up to now to objectify motility. It would
tence of these axes of movement and spatial curves be very difficult to develop an empirical method
may be plausibly reconstructed by considering the of measurement that would be able to register the
organ cavities and ligaments of the organs, as well motility of the organs. However, there are suffi-
as the existing sliding layer, a “special form of fluid cient signs in practice that show us that motility is
connective tissue.” Ultimately, regular motion and a phenomenon of movement whose treatment
deviations of motion can be examined with repro- allows us to attain remarkable results. In my opin-
ducible manual tests. ion, these results are remarkable primarily because
In addition to organ motion caused by breath- they do not only influence motility itself, but rather
ing, i.e. mobility, which is easily acceptable from their effects manifest in the area of phenomena of
ERRNVPHGLFRVRUJ
VISCERAL TECHNIQUES IN THE MYOFASCIAL CONTEXT 169
joint function and segmental alignment of sections can be influenced in such a way that influence is
of the body, which is far easier to grasp. exerted at the same time on the intercostal mem-
Therefore, the assumption is obvious that the branes and thus an improvement of function in the
more refined motility, in addition to the substan- costovertebral joints is achieved. The goal of these
tially more massive mobility, has an influence on techniques is to simultaneously regulate the equi-
the interior dynamics of the visceral cavities and is librium of movement of parts of the organism as
a factor of form adaptation, which is present in all well as the stability of the whole.1
processes of life.
I assume that mobility and motility of organs are Treatment of the mobility of the liver
initially reflected in the membranous inner con- according to Barral
struction of visceral cavities. I also assume that the
dynamics of the organs are an influencing factor Patient Sitting on a bench.
on the exterior parietal structure of the torso and Therapist Standing behind the patient.
ultimately have an effect into the fascia (see Rolf
1993: 140). Contact With the gently applied outer edges of
both hands (without the fingertips) slightly below
the lower boundary of the liver.
Consequences for treatment
Action The therapist guides both hands below the
For the practice of fascial and membrane tech- right costal arch while the patient slouches slightly
niques, this assumption has the consequence that, in order to relax the abdominal musculature. If the
in treatment techniques that are aimed at stabiliza- liver tends to be fixated in the pattern of inhalation,
tion of form, we must take into account the mobil- i.e. sinks more prominently in the direction of the
ity and motility of organs. In treatment practice, navel, in this body position its right section will be
therefore, we must examine the organs in a detailed clearly tangible on the therapist’s hands. Because
manner and only then can we classify our findings the liver and diaphragm are lower when sitting than
in a larger form and movement context. when lying down, this tendency appears to be rein-
To repeat our central hypothesis, the connective forced in the inferior direction. The therapist is now
tissue sheaths of the organs also form a network of able to lift the liver against the diaphragm in the
bridges between musculoskeletal, nervous, and vis- anterior direction in the manner described by Barral
ceral components. For this reason, treatment of a and thus sometimes achieves a redistribution of the
fixation that has been diagnosed as visceral is not serosal layer between Glisson’s capsule and the
only treatment of the fixation itself, but also at the adjacent organs. However, the therapist can also
same time a treatment of all fascial layers formed maintain elastic contact with the organ without
and maintained by repetitive movement patterns changing its position, guide the patient into more of
that are connected to the organ or even only spa- a slouched posture and then guide the patient back
tially assigned to it. into a straighter posture. This allows the therapist to
The following techniques must be understood achieve a displacement of the entire peritoneal
in this context. Based on Barral’s concept of organ space relative to the adjacent diaphragm. The thera-
mobilization, I have attempted to develop a treat- pist can now ensure that this displacement mani-
ment strategy by means of which individual ele- fests at the lowest sections of the boundary surface
ments of the visceral system are mobilized in the between the peritoneum and diaphragm. Thus, the
context of form of the walls and intermediate lay- therapist can gently rotate the upper body relative
ers of the parietal structure of the visceral system. to the abdominal cavity while the therapist’s hands
In my opinion, we can derive treatment steps from constantly maintain the contact below the liver and
this that, for example, increase the motility of the affect the ligamentous suspension of the organ.
lungs in that they simultaneously improve the inner Here, it is important that the quality of the touch be
form of the chest cavity and the exterior capacity for
movement associated with it. Or the movement 1
A summary of the anatomy relevant for visceral treatment
capacity, the mobility of the liver and diaphragm, can be found in Barral and Mercier (2002).
ERRNVPHGLFRVRUJ
170 FASCIAL AND MEMBRANE TECHNIQUE
ERRNVPHGLFRVRUJ
VISCERAL TECHNIQUES IN THE MYOFASCIAL CONTEXT 171
Anterior
Liver
Stomach
Posterior
Figure 6.3 Motility of the liver in the frontal plane Figure 6.4 Motility of the liver in the horizontal plane
according to Barral. according to Barral.
ERRNVPHGLFRVRUJ
172 FASCIAL AND MEMBRANE TECHNIQUE
process, the motility of an organ can temporarily ever so slightly in the anterior direction. The ther-
come to a standstill.2 apist now uses the push of the peritoneal space in
the anterior and superior directions and supports
the expir movement of the liver simultaneously
Treatment of expir fixation of the liver with the expir movement of the stomach. In this
Patient Lying on the left side, knees slightly bent. case as well, influence should be exerted on the
motility of the stomach only if it is free. As soon as
Therapist Standing at the level of the hips. a countermovement begins to make itself felt, the
Contact This time, the patient lies with the side therapist supports it in a very subtle fashion, as if
of the stomach on the therapist’s left hand. The to follow the movement of a pendulum. If no “rest
therapist’s other hand touches the area of the point” is established, it is advisable to guide both
lower right chest cavity. organs through the movement cycle several times.
ERRNVPHGLFRVRUJ
VISCERAL TECHNIQUES IN THE MYOFASCIAL CONTEXT 173
The therapist first observes the motility of the direction of the dominant motility and support
lungs. If a dominant direction of movement is evi- this movement additionally by an extremely care-
dent, then the therapist intensifies it. This means that ful compression of the costal–muscular–membrane
the expir movement is intensified if it is dominant. structure of the exterior chest cavity. Then we reduce
However, if the inspir movement is more strongly this compression so that the development of the
tangible, it is supported correspondingly. Because motility in the limited direction is facilitated.
the lungs themselves can only follow the movements The objective of our global treatment is to reduce
of their walls, we must rely on tracing the dominant or even eliminate detail fixations while we include
motility in the intermediate layers of the chest cavity. the inner form in which these fixations have left
In other words, we push the parietal pleura in the their mark.
ERRNVPHGLFRVRUJ
174 FASCIAL AND MEMBRANE TECHNIQUE
ERRNVPHGLFRVRUJ
VISCERAL TECHNIQUES IN THE MYOFASCIAL CONTEXT 175
contact somewhat below the normal position Contact With the palm of one hand providing
instead. In the case of a normally mobile kidney, the support in the lower region of the sternum and the
therapist will feel a slight but clearly tangible push adjacent ribs; the other hand below the navel in the
against the hand. This push will not occur in the region of the small intestine.
case of a fixation of the kidney, nor will it occur in
Action The therapist uses one hand to support the
the case of a sinking of the kidneys. The therapist’s
lower chest cavity while the other hand accepts
other hand now supports the patient’s leg on the
the lower peritoneal cavity as if the organs were
side of the kidney to be treated on the other leg so
sinking more and more into this hand. Using the
that the ankles are resting on one another. The inner
hand placed on the lower chest cavity, the thera-
rotation occurring on the leg causes a slight exten-
pist tries to make contact with the lowest portion
sion of the psoas muscle that is sufficient to increase
of the retrosternal transversus thoracis and its fas-
somewhat the scope of movement available to the
cia as well as the uppermost part of the transver-
adjacent kidney. Now, every time the patient
sus abdominis and its fascia. The fibers of the
exhales, the therapist applies a minimal push later-
uppermost part of the transversus abdominis and
ally of the psoas in the cranial direction and slightly
the lowest part of the transversus thoracis have
in the medial direction, i.e. diagonally relative to
the same orientation in this section.
the center line of the organism. In so doing, the ther-
The therapist now moves the fingers and heel of
apist avoids any direct mechanical push against the
the supporting hand more closely together so that
kidney. Rather, the therapist’s goal is a gentle move-
the flexion movement of the two muscles is sup-
ment impulse in the retroperitoneal section that is
ported, and, at the same time, pushes the fingers
available to the kidney as its range of movement.
and heel of that hand in the cranial direction in
order to achieve an effect transverse to the direc-
Stabilization of the peritoneal cavity tion of the fascial fibers. Thus, the therapist lifts the
relative to the retroperitoneal and chest cavity slightly. At the same time, the thera-
subperitoneal cavity pist uses the other hand to follow any rotational
movements that occur if they manifest in a two-
Patient Prone.
dimensional fashion in the peritoneum or in a
Therapist Sitting at the level of the abdominal counter-clockwise direction. If these movements
cavity. occur, the therapist intensifies them and then waits
ERRNVPHGLFRVRUJ
176 FASCIAL AND MEMBRANE TECHNIQUE
Retrorectal space
Parietal peritoneum
Preperitoneal Mesorectum
space
Chorda urachi
Rectal fascia (tunica
Vesicoumbilical adventitia of the rectum)
fibrous septum
Vesical fascia Rectovesical
excavation
Retropubic
space Coccyx
Suspensory ligament Caudal retinaculum
of the penis
Rectoprostatic space
Pubovesical
ligament
Capsule of the prostate
Figure 6.11 Medial section of the pelvis of the male to show the connective tissue cavities.
Mesorectum
Suspensory ligament
of the ovaries
Rectum
Visceral
Rectal fascia
peritoneum
Figure 6.12 Medial section of the pelvis of the female to show the connective tissue cavities.
until a countermovement occurs and then follows placed on the lower chest cavity to push the peri-
this movement to a resting point. While the con- toneum and the organs it contains in a sliding man-
tact is maintained unabated in the region of the ner relative to the retroperitoneal cavity. While
lower chest cavity, the therapist now uses the hand doing so, the therapist uses “listening” as well.
ERRNVPHGLFRVRUJ
VISCERAL TECHNIQUES IN THE MYOFASCIAL CONTEXT 177
Because this technique can affect the connection fiber orientation, and fluid balance, organ move-
and possible adhesions between the posterior ments can be understood as the motor of inner
layer of the peritoneum and fascia of the kidney, form. If, for example, the connective tissue sheath
any mechanical jerking or stretching should be of an organ is reacting to a chronic inflammation,
avoided. Rather, the contact should act layer by changes occur in the venous return flow from the
layer through the peritoneum into the retroperi- organ as well as to the gas or fluid status of a hollow
toneal cavity such that a somewhat “inductive” organ. Moreover, along with the axis of movement
stretching occurs in the connective tissue bedding of the organ, the orientation of the organ column
of the organs at points where the density of the tis- in the entire space of the torso changes as well.
sue has increased. This change to the inner form also forces the exte-
rior myofascial system into different tension pat-
terns. Thus, it becomes comprehensible why a
This technique may be varied in order to treat restriction of movement of a kidney on one side
the relationship between the subperitoneal and leads to one side of the torso being slouched from
peritoneal cavities in that the therapist selects a inside and compensatory changes occur in the
contact point farther below directly transverse region of the neck.
of the pubic bone rather than in the lower In general, we can say that changes in the
abdominal cavity and, in so doing, touches the retroperitoneal cavity have a direct effect on the
prevertebral area. Thus, influence may be felt on
ligamentous connection between the bladder
one section of the curvature of the spine which as
and pubic bone. In the case of a bladder
a result can be transmitted to all other spinal cur-
fixation, the therapist now keeps this contact
vatures. So it is possible that, as a result of a fixa-
point and, with the other hand, switches from tion of the left kidney caused by impact from a
the lower chest cavity to the lower abdominal traffic accident, for example, the form of the cur-
cavity. With this hand, the therapist moves the vature of the spine could change at the transition
entire complex of the small intestine toward between the lumbar and thoracic spine. Without
the bladder in such a way that the pressure pain necessarily occurring in this area itself, com-
from the bladder is transmitted onto the pubic pensatory reactions occur farther in the cranial
bone. In the male, care must be taken that the direction, in the region of the cervical spine, which
hand on the pubic bone does not exert any then cause chronic discomfort on the left side as
acute contact on the spermatic ducts; in the well and cannot be cured in the long term by local
woman, caution is advisable in the region of
treatment of the neck.
It is not easy to produce a simple schema to
the ovaries, which cannot be felt. In a second
explain the effect of organ fixations on the curva-
step, the therapist moves the lower peritoneal
tures of the spine and the general segmented pos-
cavity with its organs in the anterocranial ture of the organism. However, we can name
direction while the other hand supports the fundamental tendencies that we encounter again
ligamentous connection between the bladder and again in practice. Thus, we can establish that
and pubic bone just above the pubic bone. there is a close connection in the lower pelvic
region between the sacrum and the organs of the
pelvis. Organ fixations in this region change the
Summarizing aspects tilt angle of this section of the body in the sense of
a greater tilt in the anterior or posterior direction.
At the beginning of this chapter, I made reference They can also influence the tendency of both alae
to the fact that Barral has described axes of mobil- of the ilium to move more strongly into the inflare
ity and motility for all organs. In the light of the or outflare position.
central hypothesis that it is the fascial and mem- As we have already seen in the chapter on
brane system that reacts to increased pressure and breathing (Chapter 4), the organs located directly
tension conditions with changes in fiber density, below the diaphragm influence the excursion
ERRNVPHGLFRVRUJ
178 FASCIAL AND MEMBRANE TECHNIQUE
space of the diaphragm. As a result, we primarily entirely with changes in direction of shear and
encounter changes in the transitional passages pull forces alone. We should assume that the entire
between the chest cavity and shoulders. Changes nerve supply of various elements of the body
to organs in the chest cavity itself, to the fascial– plays a role as well. A typical example is the role
ligamentous bridge between the upper cupulas of that the phrenic nerve must play simultaneously
the pleura and the neck, lead to lasting changes in in the region of the shoulder and the triangular lig-
the region of the cervical spine. aments of the liver.3
It is certainly not possible to explain the rela-
tionships behind these form and movement events
3
I refer here to the section performed by Professor Arnaud
and Jean-Pierre Barral in 1972 (Hôpital de la Tronche,
Grenoble).
ERRNVPHGLFRVRUJ
179
Chapter 7
1
See the critical and extraordinarily perceptive description
by A. Abehsera (2000 and 2002).
ERRNVPHGLFRVRUJ
180 FASCIAL AND MEMBRANE TECHNIQUE
from his course published by Anne L. Wales that My hypothesis is that, in various respects, the
deserves to be taken seriously even by the skeptics independent dynamic of the craniosacral system is
(Sutherland 1990: 281–2). able to develop as a micromovement only as far
Interestingly, there are no references in these class as the membranes in the region of the adjacent
notes to the idea that the craniosacral system should sections of the body allow it to do so. The tension
be treated in isolation from the other systems of the of the intracranial membranes is extensively
organism. In a surprisingly direct manner, it clearly dependent on the pressure of bodily fluids that
refers to the restrictions of the musculoskeletal and arrive in the interior of the cranium by way of the
visceral systems. For both fields, the documenta- neck and flow back out by way of the neck into the
tion shows a series of manipulations that are illus- chest cavity. In order to be able to maintain an
trated with photographs and make clear that intracranial equilibrium of the membranes, unres-
Sutherland advocated a very broad basic approach tricted inward and outward flows are necessary. I
in his treatment practice. think that, to a certain degree, the complexity of
It is also this aspect that justifies my opinion that the craniosacral system can be circumvented if, in
the craniosacral system should first be examined the course of our treatment, we first concentrate
independently of the model of the craniosacral on freeing the inward and outward paths of
pulse. The techniques for treatment of the mandibu- restrictions. Thus, the craniosacral system has
lar joint described below represent an effort in this the ability to regulate itself to a large extent. Only
direction. In a certain way, these techniques take after this step is it possible that a detailed cranio-
into account the traditional concept of flexion and sacral correction in the original sense may be
extension of the craniosacral system; however, there necessary.
are fundamental differences in the practical proce- Moreover, there is yet another aspect that sug-
dures in comparison with the classical craniosacral gests an “extracranial” treatment strategy for the
approach. cranium: the cranium is in a myofascial, ligamen-
I assume that the components of the craniosacral tous, and membranous connection to the mandible.
system are connected to the universal fascial and In many patients, it is precisely in this one connec-
membrane connections in the same manner as all tion where the center of tension of the entire
types of tissue. It is certain that the relative isolation organism may be found. Presumably, this connec-
in a partially closed system causes a certain inde- tion plays a central role in the craniosacral system
pendent dynamic. In practice, we encounter con- in areas other than dysfunction of the mandibular
stellations again and again in which the problem joint as well.
has manifested primarily within the craniosacral The connection between the cranium and the
context and which also appear to be treatable only mandible is subjected to a constant dynamic dur-
within that context. However, there are numerous ing speaking and swallowing as well as to consid-
other connections: craniosacral tension patterns erable fluctuations in pressure during chewing.
and restrictions of movement often have an effect The pressure acts on layers that are connected to a
on the myofascial system of the large visceral cav- highly sensitive control system by way of mastica-
ities, the interior of the ribcage, the abdominal cav- tory surfaces. It is thus possible for us to sense even
ity, and the pelvic cavity. Because the fasciae and minimal discrepancies of fractions of a millimeter
membranes function like locks in the access pas- on masticatory surfaces.
sages of the fluid systems, they influence the In this chapter, a number of techniques are intro-
intracranial pressure and therefore the intracranial duced that are particularly suitable for treating
membrane system as well. Even muscle tone plays dysfunction of the mandibular joint. If they are
a role at the transitions of the cranium and between applied to transitions from the chest cavity to the
the lumbar spine and sacrum. Finally, there is also neck and the neck to the head, they are also suit-
one other direct connection to the spinal dura able, independently of mandibular joint dysfunc-
mater from the vertebral canal into the fascial lay- tion, for the treatment of cranial tension patterns
ers of the musculature by way of the direct con- in the intracranial region of both membranes and
nection to the perineurial sheaths. sutures.
ERRNVPHGLFRVRUJ
TREATMENT OF THE MANDIBULAR JOINT AND THE CRANIOSACRAL SYSTEM 181
Anatomy of the fasciae It extends from the hyoid bone in the inferior direc-
tion down to the interior surface of the clavicles
The mandibular joint is at particular risk of being and sternum. In contrast to the exterior layer, it is
influenced by an increase in the tone of the muscu- in close connection with the visceral components
lature as well as by tension forces from other of the neck that have a longitudinal path: the tra-
regions of the body transmitted by the connections chea, the esophagus, and also the thyroid gland
of the fascial system. At the same time, it is con- and larynx. It is also connected to the next deepest
stantly subjected to varying pressures due to its fascial layer, the prevertebral fascia, specifically at
role in the act of swallowing. In a certain sense, the the level of the thyroid gland. At both lateral
mandibular joint can be described as the buffer edges, it adheres to the fascial sheath of the sterno-
zone for opposing force vectors. Immense pres- cleidomastoid muscle.
sures can act on the mandibular joint if the tone The deepest layer of the fascia of the neck, the
pattern of the muscles that run between the upper prevertebral lamina of the cervical fasciae, plays
and lower jaw is elevated. In such a situation, the the most significant role for the techniques. I
mandible is constantly being pushed against the describe for treating the transitions between the
maxilla while, at the same time, tension forces are chest cavity, neck, and cranium: it is connected at
acting in the opposite direction, i.e. in the inferior the same time to elements of the deep structure
direction toward the neck and chest cavity. The fine and superficial structure and is part of the fascial
structure of the mandibular joint itself is able only sheath of the prevertebral muscles of the neck, i.e.
up to a certain point to cushion the combination of the longus coli, the rectus capitis anterior, and the
pull and shear forces that occur in this process. longus capitis. To the side of the neck, it comes into
The fasciae of the neck region play an important a connection with the longitudinal vessels and, in
role in the transmission of these active forces. the anterior direction, it is loosely connected to the
Anatomy differentiates between three fascial lay- sliding layer of the retropharyngeal connective tis-
ers in the region of the neck: sue. It also has connections to the levator scapulae
and, in its posterior region, to the superficial fascia
● a superficial layer, the superficial lamina of the
(Waldeyer 1993: 152).
cervical fasciae
For the transition between the upper chest cavity
● a middle layer, the pretracheal lamina of the
and the lower neck cavity it is significant because
cervical fasciae
it is connected to the endothoracic fascia, which in
● a deep layer, the prevertebral lamina of the
turn is connected to the peritoneum in the nearest
cervical fasciae.
transitional area in the inferior direction. The tho-
It is a peculiarity of the superficial fascia lamina racic fascia there forms the bridge between the inner
of the neck that it is located not only under the skin, sheath layer of both large visceral cavities and the
but also under the platysma. Below the platysma, prevertebral layers of the neck. In the cranial direc-
this layer forms a direct connection from the tion, there is finally one other connection of the
mandible and clavicles to the sternum. The connec- deep fascia of the neck with the pharyngobasilar
tion to the sternum in the inferior direction plays a fascia and thus to the nasopharyngeal space.2
particularly important role because the superficial In the context of the cervical fasciae, the nuchal
lamina ends at this point and does not extend any ligament is also significant because it also has an
farther over the surface of the sternum. At individ- important bridging function between the superfi-
ual points, this superficial layer has a connection cial and deep layers: on the one hand, coming
to the deeper, middle-layer fascia of the neck and from the deep layers of the occiput, it is connected
connects to the hyoid bone and its greater horn. In to all posterior processes of the cervical spine, but
the posterior region, it is connected to the highly it also has a large-surface insertion in the fascia of
elastic layers of the nuchal ligament and it sur-
rounds the trapezius muscles.
The middle fascia of the neck, which runs far- 2
See the description of the nasopharyngeal space in Liem
ther inward, is less laminar than the exterior layer. (2000: 415–23).
ERRNVPHGLFRVRUJ
182 FASCIAL AND MEMBRANE TECHNIQUE
Branches of the
brachial plexus
Nuchal fascia
the trapezius muscle in the upper region of the long-postulated connections between tooth status
chest cavity. and surface morphology of the mandibular joint.4
The superficial fascia of the neck ends on the As reasonable and necessary as corrections to
clavicles and, in the inferior direction, it is con- bite surfaces may be, their positive effect appears
nected to the fascial layers of the thoracic muscu- to primarily lie in a better distribution of pressure
lature. In the cranial direction, it meets the lower on the teeth, but not in the region of the mandibu-
boundary of the fascia of the masticatory muscula- lar joint.
ture on the mandible. An important fascial layer The diagnostic situation is complicated by the
for our treatment techniques in this area is the fact that the imaging techniques cannot fulfill the
temporal fascia, which extends as a large plate of expectations that were initially placed on them.
connective tissue between the superior temporal The articular disk, which plays such an important
line and the zygomatic arch. The fascial sheaths of role in normal joint function, is shown on MRI
the smaller masticatory muscles are of secondary images as a structure rich in collagen fibers, a low-
significance. Finally, the pterygotemporomandibu- signal zone (Müller 1990: 138).
lar aponeurosis plays an important role in the As Müller has convincingly described, it is
techniques described below for correction of the sometimes possible to confuse the disk with other
lateral deviation of the mandible when opening low-signal structures because imaging methods
the mouth.3 do not allow a clear distinction between ligamen-
tous and tendon elements and hard tissue struc-
tures on the one hand and the disk on the other
Notes on diagnostics hand. Unfortunately, the diagnostic value of endos-
In view of the complex structure of the mandibu- copy appears to be very limited in the region of this
lar joint and its many connections in the region of joint as well (Müller 1990: 141).
the head and neck, it stands to reason that we The examination of the active and passive move-
should ensure our diagnosis by examining its rela- ment sequence at the mandibular joint is initially
tionship to the masticatory surfaces. Unfortunately, sufficient for a manual diagnosis. If there is suspi-
in recent years, it has not been possible to confirm cion of morphological changes, the diagnostic
4
Müller (1990: 129–30) assumes that there is no simple or
3 strict correlation between the biomechanical facts of the
See the description in Liem (2000: 270) (in reference to
Perlemuter and Waligora). masticatory system and joint morphology.
ERRNVPHGLFRVRUJ
TREATMENT OF THE MANDIBULAR JOINT AND THE CRANIOSACRAL SYSTEM 183
ERRNVPHGLFRVRUJ
184 FASCIAL AND MEMBRANE TECHNIQUE
in the posterior–inferior part of the muscle run advisable before beginning specialized treatment of
almost horizontally, in the center part they run the mandibular joint. This sort of preliminary treat-
diagonally, and in the frontal portion almost verti- ment can be applied to various sections of the body.
cally. The temporal muscle has a very peculiar ori-
gin that is subdivided in three dimensions. With First step Treatment of the thoracocervical
its deep layers, it originates from the temporal line transition
inferior of the temporal plane, i.e. a “normal” ori-
gin on the periosteum of the bone. At the same The goal of this technique is to reduce tension pat-
time, however, its superficial layer originates on terns in the region of the clavicle, the subclavius
the exterior sheath layer, the temporal fascia and its muscle, and the first rib.
connection with the galea aponeurotica. In addi- Patient In the dorsal position, legs bent, arms
tion, the muscle has other attachments in its course lying next to the torso.
in the anterior direction: on the temporal face of
the sphenoid bone and on the posterior side of the Therapist Sitting at the head.
zygomatic bone. Finally, there is still the variant of
Contact With the fingertips of one hand on the
an additional tissue fixation when the fascial sheath
lower edge of the clavicle; with the surface of the
of the temporal muscle is conjoined with the fas-
second phalanx of the other hand in the lateral
cial sheath of the masseter muscle.
region of the neck next to the lateral boundary of
Thanks to its three-dimensional origin, the tem-
the trapezius muscle.
poralis muscle is able to perform two functions:
Action Before the application of this technique,
● hold the mandible against the maxilla and it is necessary to examine the sternoclavicular joint
move the mandible toward the maxilla in motion on both sides. On the side where we find
● allow grinding motion during mastication. a restriction of movement in the upper chest cav-
In order to understand this movement in its spa- ity, the therapist’s hand surrounds the lower edge
tial process, it is helpful to examine the normal of the clavicle in the direction of the subclavius
movement pattern in its process over time. muscle and is elastic against the tissue while push-
ing the clavicle against the sternum (the patient’s
left side in the picture). At the same time, the neck
Treatment of the mandibular joint is flexed passively to the side and rotated so that
the superficial layers (platysma and sternocleido-
It is typical of normal joint function for the mandible mastoid muscles) relax. It should now be possible
to be able to perform each of these four movement to effortlessly make contact in the direction of the
steps without pain or side noise. A six-step tech- middle scalene muscle (the patient’s right side in
nique will be described below that is suitable for the picture). In the figure, it is visible how the ther-
general improvement of joint function and, in par- apist uses the surface of the second phalanx to pro-
ticular, for correction of the lack of protrusion. duce an intensive contact with the middle layer of
This technique is not appropriate for the treatment the neck by reaching inward at the anterior edge of
of severe, degenerative changes or inflammatory the trapezius muscle. It is crucial that the therapist’s
processes. The mandibular joint is very susceptible left and right hands be moving slightly diagonally
to tension from all segments of the body. For this relative to one another. The patient’s breathing
reason, it is necessary to prepare for the technique motion will give us information about the activity
described below by treating the significant restric- of the scalene muscles. This technique should be
tions of movement in the organism as a whole. performed as a comparison between sides, for
Peculiarly, this sort of restriction of movement may which purpose we use the hands on opposite sides.
be present in quite diverse sections of the myofascial With some skill, this technique allows us to
system and the ligaments and sheaths of the organs. treat the structures of the fascial network that run
Therefore, an examination of the entire organism longitudinally and diagonally through the neck.
using general listening (see Chapter 8) is always The technique described above can be applied in
ERRNVPHGLFRVRUJ
TREATMENT OF THE MANDIBULAR JOINT AND THE CRANIOSACRAL SYSTEM 185
a modified fashion for treating the layer that As soon as we have localized the point described
branches off from the scalene fascia and ends on above, we can now act simultaneously on the exte-
the upper portion of the pleural cupula (applica- rior sheath structure and the interior membrane
tion after whiplash in an automobile accident with structure: we produce an intensive contact with
a seatbelt). the galea aponeurotica and compress the skull
seam, which is already quite “interlocked” at this
Second step Simultaneous influence on the point, while we maintain intensive contact with
exterior and interior structure of the cranium the exterior sheath layer as if to loosen the galea
in the region of the sagittal suture aponeurotica from the layer located below it. We
wait briefly until a strong counterpressure becomes
Patient In the dorsal position, legs bent, arms
discernible. As a rule, this occurs within a few sec-
lying next to the torso.
onds. We observe and follow the reactions in the
Therapist Sitting at the head. lateral portion of the cranium until our thumbs are
pressed upward and apart.
Contact With both thumbs in the galea aponeu-
It is important to take into account the asymme-
rotica on both sides of the sagittal suture.
tries in the head, both when compressing and also
Action Before applying this technique, we first when slowly releasing and also to follow the open-
examine the general mobility of the cranium. We ing slowly outward so as to be able to affect the
test whether the seam of the bone can be elastically interior and exterior layers at the same time.
compressed by feeling along the entire suture If, in spite of strong tension in the cranium, no
beginning at the anterior edge. While doing so, we counterpressure occurs, we slightly raise the head
should bear in mind that there are considerable and modify the direction of pressure toward the
variations in the course of the seams of the skull. foramen magnum, while continuing to hold the
In the posterior region, the peaks of the seam are suture compressed. In so doing, we align the pres-
broader and allow a greater “spring effect.” In this sure as if to push into the vertebral canal through
test, the point of the strongest restriction of move- the interior of the head using the foramen mag-
ment is localized and the exterior fascial and interior num, until increased pressure acts from the inside
membrane fixation located behind it is evaluated on on the sagittal suture and we can feel our two con-
this basis. tact points being literally pushed apart.
ERRNVPHGLFRVRUJ
186 FASCIAL AND MEMBRANE TECHNIQUE
Third step Treatment of the fascial layer of Action At first, we feel along the entire origin of
the temporalis muscle the temporalis muscle until we find layers that are
particularly closely connected to the bones located
Patient In the dorsal position, legs bent, arms
below them or to the galea aponeurotica running
lying next to the torso.
above them. It is at these points—they may be
Therapist Sitting at the head. located at a different place on either side—that we
Contact With the surface of the fingers of both make gentle contact.
hands bilaterally in the posterior region of the We ask the patient to slowly open the mouth and
temporalis muscle. then close it; this allows us to ascertain whether
ERRNVPHGLFRVRUJ
TREATMENT OF THE MANDIBULAR JOINT AND THE CRANIOSACRAL SYSTEM 187
parts of the muscle are permanently contracted and tissue sheaths of the temporalis muscle meet the
whether the fascia has thickened. It is frequently periosteum of the mandible. If the tensile forces
possible to discover a layer on one side that feels are permanently present, the insertion point of the
considerably denser than the comparable layer on temporal muscle on the mandible will feel dis-
the other side. tinctly hardened. In this case, it is always worth-
We exert a subtle pull in the cranial direction while to produce a “melting” touch contact at the
(parallel to the treatment table). Although we connection point between the muscular fascia and
are maintaining intensive contact with the tempo- periosteum until the fingers producing the contact
ralis fascia, we should not pull on the bone; rather, receive the impression that the bone has received
we should act on the layers surrounding it in sufficient freedom of movement within the tissue.
such a way that the bone can find its appropri-
ate mobility. The goal of this technique is to
Fifth step Treatment of the spatial
improve the opening function of both mandibular
relationship between the maxilla, the
joints.
base of the skull, and the neck
Patient In the dorsal position, legs bent, arms
Fourth step Treatment of the insertion of
lying next to the torso.
the temporalis muscle on the mandible
Therapist Sitting at the head.
Patient In the dorsal position, legs extended,
arms lying next to the torso. Contact With one palm in the region of the occiput
on the nuchal ligament; with the index and middle
Therapist Standing to the side at the level of the
fingers of the other hand intraorally in the center
patient’s pectoral girdle.
section of the palate.
Contact One hand is supporting the occiput; the
Action The goal of this treatment is to guarantee
tip of the index finger of the other hand contacts
that both halves of the maxilla provide adequate
the insertion of the temporalis muscle intraorally.
orientation as the stable pole of the mandibular
Action If a permanent contraction of one side of joint while the internal membrane lining and exte-
the mandibular joint has occurred, the tensile forces rior fascial layer of the base of the skull display
will manifest at the point at which the connective equivalent tension patterns.
ERRNVPHGLFRVRUJ
188 FASCIAL AND MEMBRANE TECHNIQUE
The precondition for such a global and, at the slightly elastic contact with the center section of
same time, detailed strategy is that the therapist the palate. As soon as one half of the palate moves,
use one hand to produce intensive contact with the contact finger follows it. If a twisting of the two
the origin of the nuchal ligament on the occiput halves occurs axially, we can “exaggerate” it with-
without compressing the intracranial cavity in the out risk until the “wings” of the maxilla find a har-
process. The ligament originates as a large surface monic movement.
from the occiput and is attached to each of the pos-
terior processes of the cervical spine before it ends
Sixth step Correction of reduced or absent
in the fascia of the trapezius muscle. It is essential
protrusion on one side
that we not limit the dynamics of the base of the
skull. In other words, all tension modifications This treatment step has proven itself in practice in
that become evident at the occiput during our cases in which the push is reduced on one side. In
treatment will be followed but not inhibited. As such cases, drastic deviation occurs from the cen-
soon as the supporting hand has found sufficient ter line when the mouth is spontaneously opened.
contact with the occiput, we adapt the index and
Patient In the dorsal position, legs extended,
middle fingers of the other hand intraorally to the
arms lying next to the torso.
form of the center of the palate and create a spa-
tially tangible connection between the two hands. Therapist Standing to the side at the level of the
While the occiput remains stable, it is important to patient’s pectoral girdle.
sense the dynamics of both halves of the maxilla: it
Contact With the thumb and middle finger on
is as if we were placing our hands below two
the frontal bone; the little finger of the other hand
wings of an airplane and pushing against them in
intraorally parallel to the course of the lateral
order to gradually stretch inflexible membrane
pterygoid muscle.
layers (the wings) until the impression arises of an
even spatial distribution of forces. Action In order to reduce the tissue tension that
During this process, we should bear in mind is responsible for the lateral deviation, we must
that “normal” mobility of the bones in tissue is not attempt to position the little finger used for treat-
forced: the index and middle fingers of the intra- ment as high as possible next to the lateral ptery-
oral hand come into intensive and, at the same time, goid muscle. While the therapist’s little finger glides
ERRNVPHGLFRVRUJ
TREATMENT OF THE MANDIBULAR JOINT AND THE CRANIOSACRAL SYSTEM 189
gradually higher and higher, we ask the patient technique according to Summers, in which a
again to open the mouth a few millimeters and then regional lift of the base of the maxillary sinus is
to close it (without the teeth touching each other). performed with circumscribed small fractures of
The little finger used for treatment finally attains the lamellated bone of the base of the maxillary
the highest possible position. At this moment, we sinus with the aid of condensation instruments
ask the patient to energetically close the bite while (round bit 1–5 mm in diameter). Here, even if the
the finger providing the treatment exerts a stretch- procedure is conducted correctly and carefully, irri-
ing force on the deep tissue structures around the tations of the craniosacral system can occur.
joint like a wedge. Depending on the therapist, irritating sensations
This treatment directly affects the pterygotem- may occur in 1 to 3 percent of cases.5
poromandibular aponeurosis. It is helpful to envi- The low percentage of complications should in
sion the spatial relationship between the lingual no way be taken for granted. I would like to make
and alveolar nerves between the medial pterygoid reference to reports during the meeting of the
and lateral pterygoid muscles so as not to press the Bavarian Society of Implantology (Bayerischer
nerve against the jawbone. Subsequently, we should Landesverband Implantologie) on April 19–20,
repeat treatment step 5 again and examine the cer- 2002, in Würzburg. In contributions to the discus-
vicocranial transition. sion, it became clear that some implantologists
assume a significantly higher percentage of
complications.
Schmidinger assumes that the number of
TREATMENT AFTER IMPLANTATION OF
problematic implants is very low if the implantol-
IMPLANTS IN THE REGION OF THE
ogist has the appropriate surgical experience, but
MAXILLA
5
In the last 20 years, oral implantology has become I have obtained these numbers from Sebastian Schmidinger,
considerably more widespread. If the procedures who has performed this technique on over 600 patients. I
would like to thank him for his willingness to discuss
are conducted in an appropriate and careful man-
critically the few complications in his own practice. Over
ner, long-term negative reactions in the craniosacral the years, he has given me the opportunity to use manual
system are extremely rare. However, one excep- diagnostics to examine complicated cases and test treatment
tion is the so-called minimally invasive sinus lift options.
ERRNVPHGLFRVRUJ
190 FASCIAL AND MEMBRANE TECHNIQUE
irritations that may occur in the cranial region in order to allow pressure differentials and thus
should be taken seriously in any event. Moreover, guarantee swallowing and breathing processes
he assumes that implantology, even though it is a independently of one another. This function of the
minimally invasive procedure, sometimes can maxilla is essential to life and is already present at
cause lasting changes in the area of membrane ten- birth. The teeth and their alveolar processes do not
sion and osseous suture connections in the region appear until later.
of the cranium. In the posterior region of the palate, this bone is
only a few tenths of a millimeter thick.
In the figure, it is visible that the maxilla is a
Anatomy of the palatine bone divided bone that consists of four primary bones.
The visible seam of the palate remains even in
The primary function of the maxilla is to form a old age. From the preparation shown, we can see
partition between the maxillary and nasal sinuses that the alveolar processes are disposed in such a
ERRNVPHGLFRVRUJ
TREATMENT OF THE MANDIBULAR JOINT AND THE CRANIOSACRAL SYSTEM 191
way that they are at a particular angle to the actual when biting on a molar tooth. The alveolar process
roof of the palate on the palatine surface. This can disintegrate under the influence of inflamma-
angle causes a stiffening in the region of the alveo- tory and atrophic processes.
lar processes and thus a functionally correct adap- However, the disintegration of the alveolar
tation of the bone to the conditions of the bite processes leaves the center of the maxilla untouched.
function. From the fine structures in which the The inner edge of the palate is completely pre-
tooth is embedded, we can see how force effects served; in other words, there is no palatine change.
influence the direction of the trabeculae and bone The disintegration is merely limited to regions in
structures. which teeth have been lost. This process is particu-
The alveola consists of relatively little material, larly visible in the picture in the region of the left
but can endure enormous pressure thanks to its canine and the fourth tooth. We can see here that,
fundamental structural principle: experimentally, even in the advanced stages of tooth loss, the
forces up to 2000 newtons have been measured uppermost structural principle of the maxilla is
ERRNVPHGLFRVRUJ
192 FASCIAL AND MEMBRANE TECHNIQUE
maintained, namely to form a partition between membrane, is guided in the cranial direction using
two cavities. a round bit.
The bones that separate the two cavities from Lifting Schneider’s membrane is technically
one another are a razor-thin structure. necessary in order to create a space between the
Under the influence of diabetes, the trabeculae membrane and the osseous base of the maxillary
are rarefied; very little cancellous bone still remains. sinus so that the implant can be inserted.
The individual laminar layers are thickened. When opening the maxillary sinus, the implan-
tologist is forced to work with a round bit, tapping
in the cranial direction. This can lead to changes in
Technique of the surgical intervention the region of the sutures of the maxilla and adja-
cent bones. However, it is also conceivable that
In a sinus lift, the implantologist opens the maxillary transmissions of vibrations could cause a dysfunc-
sinus from the ventral or lateral side. In so doing, tion of the membranous equilibrium of the cran-
the mucous membrane, known as Schneider’s iosacral system located at a distance from the
ERRNVPHGLFRVRUJ
TREATMENT OF THE MANDIBULAR JOINT AND THE CRANIOSACRAL SYSTEM 193
ERRNVPHGLFRVRUJ
194 FASCIAL AND MEMBRANE TECHNIQUE
restrictions of movement that manifest in the neu- Therapist Standing to the side at the head.
rocranium and only then continue with the treat-
Contact When treating the right half of the max-
ment of the viscerocranium.7
illa, the therapist supports the maxilla on this side
If a restriction of motion is found in the maxilla
from outside, while at the same time placing the
or especially on one side of the maxilla, initially
little finger of the other hand into the nasal cavity
treating the spatial relationships between the max-
using a water-soluble lubricant gel.
illa, base of the skull, and neck as I described in the
preceding section (Fascial technique for the treat- Action The weight of the patient’s head is
ment of the mandibular joint) is advisable. allowed to rest on the therapist’s right hand. The
Sometimes it is possible to diagnose an almost contact point is approximately in the region of the
absolute restriction of motion of the maxilla on the roots of the left premolars of the maxilla.
side where the implant was placed in the maxilla. The little finger of the left hand, the treatment
In such a case, the affected half appears to be com- finger, is in a vinyl glove that is coated with lubri-
pletely rigid as soon as we exert pressure on it cant gel. This finger is very gently inserted into the
while the other side gives way under pressure in a nasal cavity parallel to the nasal septum. Here, it is
very elastic fashion. As a rule, this is caused by a important that it be guided not in the superior
global fixation of the membranes on one side of direction toward the eye, but rather parallel to the
the cranium with a simultaneous “pressure inter- arch of the palate. The therapist thus uses the little
lock” in one half of the maxilla. finger to make contact with the bone and mem-
brane structure of the mandibular cavity by way
of the nasal cavity while supporting the lateral
Treatment of unilateral restriction of motion
osseous boundary of the same region from the
of the maxilla
outside. The therapist uses the weight of the cra-
Patient Prone, with the head rotated to the side nium so as to guide the entire fine bone structure
such that the part of the maxilla to be treated is of the maxilla more intensely into its twisted dis-
resting on the treatment table. tortion. At the endpoint of this movement, the
therapist applies a slow pull—albeit with lasting
7
See the description of treatment of the sutures of the skull effect—in the interior of the nasal cavity until the
in Liem (1998: 510–35). movement of the maxilla begins to emerge.
ERRNVPHGLFRVRUJ
TREATMENT OF THE MANDIBULAR JOINT AND THE CRANIOSACRAL SYSTEM 195
ERRNVPHGLFRVRUJ
197
Chapter 8
Mechanics of whiplash
CHAPTER CONTENTS
In whiplash, acceleration forces act in an abrupt
Mechanics of whiplash 197
manner on the human body and may have impact
Examination of whiplash 198 on the entire connective tissue system. Here, the
extent of the forces at work is not necessarily an
Treatment of whiplash 203
indicator of the damage caused. We know from
practice that there are high-speed traumas with
multiple fractures that leave the basic structure of
the fascial and membrane system relatively undam-
aged, while it is sometimes the effect of relatively
small forces, if they are acting from a certain unfa-
vorable angle, that can create lasting problems from
which the organism is no longer able to free itself.
It is a complication for diagnostics that most of
the changes that occur to connective tissue due to
whiplash cannot be seen using imaging procedures.
As a result, it is all too easy to push into the psy-
chological field symptoms that are unbearable for
patients. I do not believe that the psychological
side of certain types of trauma should be disre-
garded—even in traffic accidents where no injuries
occur, there is the potential for psychoemotional
complications. As a rule, however, accidents of this
sort are a primarily mechanical event that extends
into the interior, interconnected structure of the
entire organism. The physical changes can be com-
plicated by the psychological reaction, but they
still require treatment on a physical level if they
can be clearly diagnosed.
As mentioned at the outset, forces in whiplash
act on the body in a very abrupt fashion. This can
ERRNVPHGLFRVRUJ
198 FASCIAL AND MEMBRANE TECHNIQUE
be caused by acceleration, but also by deceleration the organism, which can influence not only move-
or stopping. In order to understand the effect of ment functions, but also a number of other bodily
this process, it is helpful to consider again the functions such as the metabolic and endocrine pro-
properties of membranes and fasciae. cesses, for example.
We have described it as a characteristic of this
type of tissue (Chapter 2, The malleability of con- Examination of whiplash
nective tissue) that it has a certain degree of elastic-
ity and plasticity. These characteristics are typical of In every case, an orthopedic examination should
all forms of connective tissue. In whiplash, be made first in order to rule out any fractures that
demands are placed on both characteristics of the would prohibit manual treatment for the time being.
connective tissue: the sudden effect of acceleration Sometimes a neurological examination is advisable
forces causes the layers that have primarily elastic as well. In the case of the most severe traumas,
components to be stretched in a particularly lasting possible ligamentous ruptures between the upper
manner, while the very tough layers are able to cervical vertebrae and the base of the skull should
resist this stretching to a large extent. Because colla- be considered as well. As soon as the traditional
gen fibers have a maximum extensibility of 5 to 10 medical examinations have been concluded, a
percent, they guarantee that the basic shape of the general manual examination may be performed.
organism is maintained even under the influence of When doing so, it is important to bear in mind that,
strong forces (e.g. in the case of high-speed trauma). in cases of whiplash, we are confronted not only
Nevertheless, the effects of a minor, lasting defor- with current results of the accident, but also with
mation of these tough fibrous layers should not be problems that existed beforehand. The state of the
underestimated. However, the more lasting defor- organism before the accident is usually reinforced
mation occurs in the layers that contain a high per- and made worse by the mechanical influences.
centage of elastin. This is true not only for layers of Whiplash has a particularly lasting effect at the
connective tissue in the literal sense, but also for points where restrictions of movement or degener-
individual ligaments such as the ligamentum ative changes were already present. In a way, this
flavum and nuchal ligament. also explains why a relatively small force can cause
In order for the connective tissue to be able to lasting problems in one case whereas, in a differ-
perform its function, the shape-maintaining colla- ent case, the same degree of force leaves no effect
gen fibers must cooperate with the elastic elements. on the organism. The significance of the state of the
Changes in form may be reversed using the elastic organism before the accident, known as the “pre-
fibers. The elastin returns to its own “resting length” lesional state,” as Barral and Croibier have called it,
and, in so doing, guides the less elastic elements cannot be emphasized enough (Barral and Croibier
back to their original position before the stretching 1999: 184–90).
process. However, during an accident, the elastin is Fundamentally, deformations of the fascial and
stretched beyond its limit of elasticity. This means membrane system are possible in all regions of this
that the spatially changed, low-elasticity fibers are three-dimensional network. Details can be changed,
also unable to reach their original position. A last- or a global deformation process can be set into
ing displacement and deformation of the inner form motion, which is initially quite diffused and is
structure of the organism ensues. difficult diagnostically to categorize to individual
In the literature, the deformability of elastic lay- layers or joints. Unfortunately, the conversion pro-
ers is described as irreversible as long as the origi- cesses associated with global deformation have a
nal length of a tissue unit has been increased over negative and progressive dynamic that can extend
one and a half times (150 percent). In whiplashes, over long periods of time, months and sometimes
this increase in length can be exceeded many times years. I have already mentioned that the state of
over. In high-speed traumas, individual layers are the patient is crucial for the positive treatment
overstretched even up to ten times their original capacity of our treatment principles. In general, we
extension. This can result in a lasting alteration should direct our attention to peculiarities of this
process of the entire inner fundamental blueprint of preceding situation. In particular, arthrotic changes
ERRNVPHGLFRVRUJ
TREATMENT OF THE FASCIAL AND MEMBRANE SYSTEM AFTER WHIPLASH 199
ERRNVPHGLFRVRUJ
200 FASCIAL AND MEMBRANE TECHNIQUE
General listening in the standing position General listening in the sitting position
(according to Barral) (according to Barral)
Patient Standing with the legs slightly apart. Patient Sitting.
Therapist Standing behind the patient. Therapist Standing behind the patient.
ERRNVPHGLFRVRUJ
TREATMENT OF THE FASCIAL AND MEMBRANE SYSTEM AFTER WHIPLASH 201
ERRNVPHGLFRVRUJ
202 FASCIAL AND MEMBRANE TECHNIQUE
Alternative test to Barral’s general listening the pelvis. The therapist first feels whether a resist-
ance to the shear force manifests inside the leg, for
Patient In the dorsal position, legs extended with
example at the level of the knee or at the transition
the ankles reaching just over the edge of the treat-
to the pelvis. This is a sign of an injury or restriction
ment table.
on the side in question. It is possible to avoid the
Therapist Sitting at the foot. resistance and continue with the test if the therapist
slightly reduces the shear force and then succes-
Contact With both hands from the posterior direc-
sively intensifies it again as if to slowly turn up the
tion in the lower third of the calves.
dimmer on a light switch. Thus, the therapist is
Action Both of the therapist’s feet are in good con- gradually able to transmit the shear force into the
tact with the floor and the therapist’s posture is nei- interior of the pelvic and abdominal cavities and the
ther slouched nor overly erect. The object is for the area can be localized in which resistance is occur-
therapist’s posture to be contributed by the organ ring. In this area as well, we first reduce the shear
column and the autonomic musculature while the force somewhat as soon as we encounter resistance
exterior musculature of the ribcage and pectoral gir- and then gently intensify it again and transmit it
dle are relaxed. The weight of the therapist’s fore- through the diaphragm into the interior of the chest
arms is rested on the treatment table and the cavity. As a rule, as soon as we are pushing against
therapist’s hands hold both calves. The primary the diaphragm, we must wait for a moment because
weight of the legs is resting on the therapist’s palms the force we are applying is initially transmitted by
while the therapist’s fingers are relaxed and slightly way of the arch of the diaphragm into the preverte-
bent. The therapist now closes his or her eyes in bral space of the central tendon.
order to aid visualization. The therapist imagines In the most favorable case, we will be able to
that the two calves are scales resting in his or her continue the shear test into the region of the neck
hands. The therapist then adjusts the touch of these and cranium. This test is primarily suitable for
scales so that it has precisely the same quality on localizing severe restrictions in the region of the
both sides. This means that the therapist’s hand has ligamentous connections of the organs by sensing
been adapted on each side to the existing shape of resistance to the subtle push. This technique pro-
the right or left calf. Now the therapist gradually vides little information on restrictions of movement
exerts a subtle but very steady shear force along the located very close to the middle central axis of the
inner longitudinal axis of the legs in the direction of body such as restriction in the joint of the tailbone or
ERRNVPHGLFRVRUJ
TREATMENT OF THE FASCIAL AND MEMBRANE SYSTEM AFTER WHIPLASH 203
sacrum or the large longitudinal components such process that is very difficult to understand ration-
as the esophagus and trachea. ally. I can only refer to its performance and signifi-
cance in practice (Prat 1999).
Variation of general listening in the
dorsal position
This test can deliver misleading results if
Patient In the dorsal position, legs extended.
unilateral tension patterns are present in the
Therapist Sitting at the head. suboccipital region of at the base of the skull.
Contact With the bent front phalanges of the In such a case, it is necessary to differentiate
index, middle, and ring fingers of both hands in precisely between the local restrictions of the
the tissue just below the base of the skull. atlanto-occipital connection and the forces
acting from a greater distance.
Action The therapist first moves the fingertips
slightly in the vertical direction in order to intensify
the contact with the suboccipital tissue. Then the Treatment of whiplash
therapist uses all involved fingertips to pull gently
longitudinally through the whole body. In so doing, In cases of whiplash, it is advisable to wait a few
the therapist precisely observes whether this pull is days or even a few weeks before the first manual
met with stronger resistance on the left side or right treatment. The reason for waiting lies in the fact
side. On this side, the therapist now precisely dif- that a drastic development of symptoms frequently
ferentiates which finger is able to feel the resistance does not occur until days or weeks after an acci-
most clearly. We speculate that the localization of dent. Especially if the patient has a tendency toward
the resistance with the ring finger, which is applied psychological reactions, it is advisable to wait for
in the medial plane, is a sign of fixations in the the first high point of the pain symptoms. If the
region of the dura; resistance in the region of the therapist treats the patient immediately after the
middle finger is a sign of fixations in the region of accident during a relatively pain-free period of time
the organ system; and resistance in the region of the and the symptoms do not develop in their full scope
index finger is a sign of fixations in the region of the until after this treatment, the patient will be under
parietal system. This test procedure is naturally a the impression that these problems were made
ERRNVPHGLFRVRUJ
204 FASCIAL AND MEMBRANE TECHNIQUE
worse by the therapy. This will necessarily lead to treatment normalizes the dynamics between
the development of inner resistance and can con- ergotropic and trophotropic activation. In other
siderably complicate the course of treatment. It is words, the treatment should first give only mini-
also significant that the accident represents a dras- mal stimuli so that, after every agitation of the sys-
tic physical development and the possibility that tem, the corresponding relaxation is allowed to
the patient may initially experience any physical emerge. The first touches are crucial.
treatment on the subconscious level as a continua- In practice, we see again and again that, if the
tion of this physical effect cannot entirely be ruled lower extremity is carefully treated, a calming of the
out. For this reason as well, treatment techniques state of agitation occurs. If changes have occurred in
should be selected with the greatest care and it is this region, it is advisable to begin treatment there,
essential to treat only the problems that can be for example, with a careful correction of restrictions
clearly diagnosed. Too little is better than too much! of movement in the region of the ankle or metatar-
In selecting the treatment technique, we should sus. The method that I showed in the section on
remain strictly within the framework of the injuries special joint techniques (see Chapter 6, Special
and restrictions of movement found in general lis- techniques for treating the joints of the foot) is suit-
tening and attempt to reconstruct which portion able for this purpose.
was already present before the accident and which The usually comprehensive fixation of the dura
injuries and restrictions of movement can actually mater and its tensile effects should be treated in
be attributed to the accident. It is helpful to use the connection with the large anterior longitudinal
most gentle techniques possible, avoiding strong ligament of the spine. Techniques applied to the
pull effects and abrupt applications of force. sacrum should be used first, and then the treatment
The patient is frequently still in a state of shock should be continued in the region of the cranium.
even weeks after the accident. This means that the The essential subsequent step is the treatment
autonomic nervous system is subliminally in a of the elements inside the visceral cavities, i.e. the
constant state of ergotropic agitation. In addition treatment of changes to ligamentous and mesen-
to the purely physical causes, this is the reason for teric layers of organs.
the sleeplessness that we sometimes observe. The mobility of any of the organs may have been
For this reason, the therapist must select the qual- affected by the force of the accident. For the first
ity of the touch in such a way that the manner of treatment steps in the visceral region, it is crucial
ERRNVPHGLFRVRUJ
TREATMENT OF THE FASCIAL AND MEMBRANE SYSTEM AFTER WHIPLASH 205
to evaluate the transitions between the visceral for the time being. Direct joint manipulation could
cavities. Because of the transition between cavities have drastic negative consequences from which it
having different hydrostatic pressure, these transi- takes the patient a long time to recover.
tions are particularly at risk because the existing In cases of whiplash, there is frequently a strong
pressure differential may have been increased many emotionalization of which the patient is usually not
times over by the force of the impact. By gliding on aware. This emotionalization should be respected
their serosal layer and through the overstretching for the purpose of a positive course of treatment.
of ligamentous connections, entire organ groups On the physical level, it is expressed in tonal chains
can be spatially displaced. This displacement causes of the musculature and an individual bodily pos-
the segments of the body to appear displaced rela- ture. We should avoid applying so-called myofas-
tive to one another on the exterior as well. In such cial release stretching to the large fascial layers of
a situation, corrective attempts applied to the pari- the system. Rather, the patient should at first have
etal system have little effect. the opportunity to assume the body positions that
We should give particular attention to the organs correspond to the interior expression. Only after
located directly below the diaphragm and the retro- the dominant inner fixations have been released
peritoneal organs or sections of organs, particu- will we move the large exterior sheath layers in the
larly the kidneys. If the victim in an accident was direction of the normal pattern.
wearing a seat belt, the transition between the To give an example, if the organism appears to
chest cavity and the lower cervical region should be slouched, this may be attributable to a restric-
be precisely examined, particularly in the anterior tion of movement in the kidneys. In such a case, an
region. The deep laminae of the neck are frequently alignment by treating the myofascial layers at the
affected, as well as the ligamentous suspension of surface would only cause additional discrepancies
the pleural cupula that connects the central cervi- between the interior structure and the exteriorly
cal spine to the uppermost section of the endotho- visible static of the body. In comparison, a treatment
racic fascia and thus to the pleural cupula itself. strategy that first makes contact with the entire sys-
In whiplash, massive impactions can occur at tem by way of the lower extremity and then releases
the sutures of the bones of the skull. However, we a few restrictions in the interior of the visceral and
should bear in mind that the classic, very subtle craniosacral system and only then addresses the
craniosacral application in treatment of whiplash autonomic musculature of the back and ribcage is
has its limits. As much as we should allow our associated with far fewer risks.
actions in this region to be guided by caution, it is
a reality that severe changes may have been caused
Treatment of altered tensile effects of the
in the craniosacral region by the accident, requir-
dura mater by mobilizing the second segment
ing a very decisive intervention, otherwise our work
of the sacrum
in the craniosacral system would produce only a
deep relaxation. The relatively drastic techniques of
Barral and Croibier, which are primarily directed If the dura mater is under abnormal tension, the
at the inner elasticity of the bones of the skull, and
sacrum as a whole appears limited in its
associated techniques for treating the membranous
movement. The second segment, to which the
connections between the maxilla and skull have
dura is attached, also appears to be harder than
particularly proven themselves in practice (Barral
and Croibier 1999: 184–90, 266–7). the rest of the bone.
Although these changes that typically occur in
whiplash particularly manifest in the area of the Patient In the dorsal position, both legs extended.
neck, extreme restraint is advisable in this section
Therapist Standing to the side at the level of the
of the body. This is the region where the patient
thighs.
feels the symptoms particularly intensely. If there
are restrictions of motion between cervical verte- Contact Supporting the sacrum from the poste-
brae, it is advisable to avoid direct manipulation rior direction with a flat palm while the other hand
ERRNVPHGLFRVRUJ
206 FASCIAL AND MEMBRANE TECHNIQUE
supports the lower lumbar spine, also from the At the contact point on the sacrum, the therapist
posterior direction. The hand position is subse- now exerts a pull in the direction of the tailbone
quently switched so as to produce direct contact without altering the existing tilt of the pelvis or the
on the sacrum with the fingertips of both hands. bend of the lumbar region. In other words, the ther-
apist pulls the sacrum in such a way that the pull
Action The therapist first takes the sacrum in one acts inward in the vertebral canal and the state of
hand so as to adapt it to the posterior arch of the the dura mater can be evaluated. In the case of
bone. At the same time, the other hand is supporting changes to the tension pattern, the counterpull will
the lower lumbar spine from the posterior direction, manifest at the second segment of the sacrum. The
but avoids exerting pressure on the spine itself. therapist now positions the tips of the fingers and
ERRNVPHGLFRVRUJ
TREATMENT OF THE FASCIAL AND MEMBRANE SYSTEM AFTER WHIPLASH 207
thumbs around the second segment of the sacrum Contact With the palms of both hands in and
so that several contact points are produced on the above the region of the twelfth rib from the poste-
bone. The therapist ensures that the sacrum as a rior side, parallel to the course of the ribs.
whole is resting on these contact points without
Action The therapist registers the breathing move-
changing its position. The therapist now modifies
ment and compares the right and left sides. On the
the touch reaching through the subcutaneous
side where less spatial excursion of the diaphragm
layer and lumbar fascia as though to compress the
can be felt, the therapist successively compresses
periosteum more strongly against the bone, avoid-
the posterior chest cavity. During this, it is important
ing any sliding of the surface of the sacrum, and
that the patient continue to breathe so that several
intensifies the contact as if to push through the
breathing cycles occur during compression. The
sheath of the periosteum into the bone. While
therapist now begins to use the palm to compress
maintaining this very peculiar type of contact, the
the lower chest cavity on the other side. The thera-
therapist feels whether a “melting reaction” is
pist maintains the compression of both halves of
present at the connection points between the tissue
the thorax and pushes the side that feels freer some-
and the bone. As a rule, this is a minimal move-
what more strongly toward the central line while
ment that the therapist should follow in all direc-
following the direction of the costal arch. This will
tions until the rigidity at the second segment of the
cause the inner pressure to increase even more on
sacrum begins to be released. Subsequently, reas-
the side of the restriction. The therapist now uses
suming the original position of the hands on the
this increase in pressure to release the costal arch
sacrum and lumbar region is recommended so as
and guide it into a greater expansion in the lateral
to examine the result of the treatment.
and posterior directions. The therapist’s hands are
now returned to their initial position in order to
Treatment of the shock pattern in the compare the spatial excursion of both halves of the
region of the diaphragm diaphragm yet again. If the desired effect is not
felt, I recommend waiting a few minutes and then
Patient In the dorsal position, legs extended.
performing the technique again with a slightly dif-
Therapist Standing to the side at the level of the ferent direction of pressure.
thighs.
ERRNVPHGLFRVRUJ
208 FASCIAL AND MEMBRANE TECHNIQUE
ERRNVPHGLFRVRUJ
TREATMENT OF THE FASCIAL AND MEMBRANE SYSTEM AFTER WHIPLASH 209
ERRNVPHGLFRVRUJ
210 FASCIAL AND MEMBRANE TECHNIQUE
ERRNVPHGLFRVRUJ
211
Chapter 9
ERRNVPHGLFRVRUJ
212 FASCIAL AND MEMBRANE TECHNIQUE
It is characteristic of the process of change that the distal end of the gastrocnemius muscle, the
occurs during pregnancy that precisely localized second hand supports the lower leg from the ante-
detailed fixations as well as large-area layers of the rior direction in the region of the tibialis anterior.
parietal system are influenced. In the case of first
Action The therapist supports one knee on the
pregnancies, it is entirely possible that the increased
lower end of the treatment table and the therapist’s
effects of force inside the abdominal and pelvic cav-
thigh supports the toes and transverse arch of the
ities may release fixations. Pregnancy is, after all, a
foot. The patient’s knee is slightly bent. Using
natural process and this process has a great positive
the surface of the middle phalanges of one hand,
potential for the correction of the inner structure of
the therapist first applies pressure to the superficial
the myofascial system. It is precisely for this reason
layer of the crural fascia in order to then apply pres-
that it is necessary to proceed in a very targeted
sure at a very oblique angle almost parallel to the
manner with corrective treatment impulses after
skin to the superficial and middle layers of the gas-
birth. The woman’s organism has completed a far-
trocnemius and soleus muscles. The other hand
reaching conversion process and many tissue layers
supports the lower leg from the anterior direction
are in a rather hypotonic state. Therefore, the thera-
with firm contact on the anterior portion of the fas-
pist’s job is merely to treat a few restrictions of
ciae. While the contact is maintained in the anterior
motion as carefully as possible and otherwise influ-
region without any sliding, the therapist exerts a
ence the overall form of the organism with globally
stretching push in the posterior section, sliding at
applied techniques in such a way that the natural
the contact point very slowly and only a few cen-
regeneration process can occur without a problem.
timeters. The therapist then asks the patient to push
the knee gently into the treatment table and stretch
the heel somewhat. It is crucial that the sliding
Treatment of shortened myofascial layers in
on the posterior side of the thigh be conducted very
the region of the lower leg
slowly and the intensity of the contact be main-
Patient Prone, both legs extended, arms resting to tained during the entire sequence of movements.
the side of the torso. This technique should then be applied analo-
gously to the other leg. We have to pay close atten-
Therapist Standing at the feet.
tion to the differences between sides and modify
Contact With the middle phalanges of one hand the angle of application and intensity of pressure
at the transition between the Achilles tendon and correspondingly.
ERRNVPHGLFRVRUJ
TREATMENT AFTER PREGNANCY AND BIRTH 213
Treatment of the myofascial tension patterns the adductor magnus and semitendinosus mus-
of the thigh cles as well as on the other leg. It may be necessary
to modify this technique in relation to existing ten-
Patient Prone, both legs extended, arms resting
sion conditions.
to the side of the torso.
Therapist Standing at the level of the knees.
The technique described for the lower leg and
Contact One hand supports the thigh from the
thigh can be applied in a modified form to any
anterior direction while the other hand reaches
between the biceps femoris and semitendinosus longitudinal muscles of the posterior side of
muscle from the posterior direction above the knee. the leg. For the efficacy of this technique, it is
necessary to create an intensive contact with
Action The therapist supports the thigh with one
the fasciae and to ensure that the pressure
hand in such a way as to produce a flat contact with
actually reaches the fascial layer between the
the anterior layer of the fascia lata parallel to the
muscle bellies. Any tugging, gliding motion on
outside shape. The therapist holds the entire leg so
that approximately horizontal hinge axes manifest the skin must be avoided. In addition to this
at the ankle, knee, and hip joint. With the other technique, which is applied to a large area, the
hand, the therapist reaches parallel to the orienta- techniques described in the chapter on the
tion of the muscle fibers between the muscle bellies lower extremity can be used as well (see
of the long head of the biceps femoris and the semi- section 4.5, Lower extremity).
tendinosus muscle. The therapist uses his or her
body weight to allow the touch to first sink through
Treatment of the fascia of the transversus
the superficial layer and then make contact between
abdominis and the spatial relationship between
the fascial sheaths of the two muscle bellies. The
intraperitoneal and retroperitoneal components
therapist selects the direction of pressure in such a
way that the tissue is not crushed against the bone Patient Sitting upright on a stool with the knee
located below it. With intensive contact, the thera- joints at a lower level than the hip joints.
pist gradually moves in the proximal direction
Therapist Kneeling in front of the patient.
toward the ischial tuberosity.
This technique is then applied in an analogous Contact With the palms completely relaxed on both
manner for the fascial boundary layers between sides of the abdominal wall just below the navel.
ERRNVPHGLFRVRUJ
214 FASCIAL AND MEMBRANE TECHNIQUE
ERRNVPHGLFRVRUJ
TREATMENT AFTER PREGNANCY AND BIRTH 215
ERRNVPHGLFRVRUJ
217
Concluding remarks
For psychologists who have had little education in tissue and can be read there. Thus, a shape devel-
anatomy, there is sometimes the danger of over- ops that is more than a collection of discrete
looking the fact that the physical side of a person anatomical parts. In the treatment of the fasciae and
has its own dynamics. Therefore, overinterpreta- membranes, the therapist communicates with this
tions of physical expression may occur in psy- shape. Anatomical knowledge is helpful, but it
chotherapy. On the other hand, a therapist following serves more as topographical orientation than as
a manual approach has the far greater risk of the actual therapeutic technique.
blindly believing in the laws of matter. However, a A great virtuoso of the violin once said, “The best
bent back is not only a pronounced kyphosis of the technique is the kind that you don’t even notice.”
thoracic spine; it is also an expression of a bent I think that what he meant was that efficient
person. technique is applied inconspicuously and is never
The spatial form of the fascial and membrane an end in itself. It is in this spirit that Fascial and
network can be read like the story of a person given Membrane Technique addresses the organism as a
shape. Recurring motion sequences, the preferred structure of form. It is applied to the physical struc-
orientation and perception, as well as the prevailing ture in order to reach the psychological unity of the
basic emotional pattern, leave their marks on the person.
ERRNVPHGLFRVRUJ
219
Bibliography
Abehsera A. (2000) Craniosacrale Osteopathie: Ein wichtiger Breul R. (2002) Die Blätter der Fascia renalis. Osteopathische
Baustein der Osteopathie. Osteopathische Medizin, 1. Medizin, 2.
Abehsera A. (2002) Craniosacrale Osteopathie unter der Croibier A. (2005) Diagnostic Ostéopathic Général. Elsevier: Paris.
Lupe—Teil II. Osteopathische Medizin, 4. Friedlin M. (2003) Annäherungen an den Faszienbegriff—
Barral J-P. (1993) Manipulations Uro-Genitales. Éditions de Eine semantische Untersuchung. Osteopathische Medizin, 1.
Verlaque: Aix-en-Provence. Flury H and Harder W. (1988) The tilt of the pelvis. Notes on
Barral J-P. (1996) Manual Thermal Diagnosis. Eastland Press: Structural Integration, Zurich, 1.
Seattle, WA. Godard H. (2003) Verbesserung der sensorischen Dynamik.
Barral J-P. (2002) Lehrbuch der viszeralen Osteopathie. Vol. 2. In Schwind P (ed.) Alles im Lot. Eine Einführung in die
Urban & Fischer: Jena. Rolfingmethode. Droemer-Knaur: Munich.
Barral J-P and Croibier A. (1999) Trauma. An Osteopathic Heine H. (1997) Lehrbuch der biologischen Medizin.
Approach. Eastland Press: Seattle, WA. Grundregulation und extrazellulare Matrix. Grundlagen und
Barral J-P and Croibier A. (2005) Manipulation peripherer Systematik. 2nd edn. Thieme: Stuttgart.
Nerven. Osteopathische Diagnostile und Therapie. Elsevier: Horwitz G. (1981) Pneumatic and tensile structures. The
München. work of Frei Otto. Bulletin of Structural Integration, 7 (2).
Barral J-P and Mercier P. (1988) Visceral Manipulation. Ingber D. (1998) Architekturen des Lebens. Spektrum der
Eastland Press: Seattle, WA. Wissenschaft, 3.
Barral J-P and Mercier P. (2002) Lehrbuch der viszeralen Jones LH. (1981) Strain and Counterstrain. American
Osteopathie. Vol. 1. Urban & Fischer: Jena. A second Academy of Osteopathy: Newark, NJ.
edition in translation of Barral and Mercier (1988), above. Kleinau A. (n.d.) Lang- und mittelfristige Ergebnisse nach
Barral J-P, Mathieu P and Mercier P. (1993) Die Operationen wegen eines Karpaltunnelsyndroms.
Untersuchung der Wirbelsäule. In Handbuch für die Unpublished manuscript and research report.
Osteopathie. The International Academy of Osteopathy: Köpf-Maier PS. (2000) Wolf Heideggers Atlas der Anatomie des
Gent. Menschen, 5th edn. 2 vols. Karger: Basel.
Benninghoff A. (1994) Anatomie. Vol. 1, 15th edn. Urban & von Lanz T and Wachsmuth W. (1972) Praktische Anatomie.
Schwarzenberg, Munich. Ein Lehr- und Hilfsbuch der anatomischen Grundlagen
Benninghoff A. (1934) Über die Anordnung und die ärztlichen Handelns. 1 vol. Part 4. Springer: Heidelberg.
Bedeutung der Bindgewebssysteme im Gefüge der Lanz U. (1967) Anatomical variations of the median nerve in
Muskulatur. Verhandlungen der Anatomischen Gesellschaft, 42. the carpal tunnel. Journal of Hand Surgery, 147.
van den Berg F. (ed.) (1999) Angewandte Physiologie. Vol. 1: Liem T. (1998) Kraniosakrale Osteopathie. Ein praktisches
Das Bindegewebe des Bewegungsapparates verstehen Lehrbuch. Thieme: Stuttgart.
und beeinflussen. Thieme: Stuttgart. Liem T. (2000) Praxis der kraniosakralen Osteopathie. Thieme:
Bienfait M. (1982) Les Fascias. Societé d’édition Medicale “Le Stuttgart.
Pousse”: Bordeaux. Megele E. (1991) Diagnostische Tests beim
Boebel R. (1957) Über die Beziehungen des M. iliopsoas Karpaltunnelsyndrom. Der Nervenarzt, 62.
mittels seiner Faszie zu den Gefäßen der Fossa Meert GF. (2003) Das Becken aus osteopathischer Sicht.
iliopectinea. Zeitschrift für Anatomische Funktionelle Zusammenhänge nach dem Tensegrity-Modell.
Entwicklungsgeschichte, 120. Urban & Fischer: Munich.
ERRNVPHGLFRVRUJ
220 BIBLIOGRAPHY
Maitland J. (2001) Spinal Manipulation Made Simple. A Manual of Schleip R. (2003) Faszien und Nervensystem. Osteopathische
Soft Tissue Techniques. North Atlantic Books: Berkeley, CA. Medizin, vol. 1.
Myers T. (2001) Anatomy Trains. Myofascial Meridians for Schleip R, Klinger W and Lehmann-Horn F. (2005) Active
Manual and Movement Therapists. Churchill Livingston: fascial contractility: Fascia is able to actively contract and
Edinburgh. relax in a smooth muscle like manner and thereby
Morton DJ. (1952) Human Locomotion and Bodyform. A Study influence biomechanical behavior. Acta Physiologica, 186
of Gravity and Man. The Williams & Williams Company: (Suppl. 1).
Baltimore, MD. Schulz L and Feitis R. (1996) The Endless Web. Fascial
Müller H. (1990) Morphologische Grundlagen der Anatomy and Physical Reality. North Atlantic Books:
Kiefergelenksfunktion und deren Störungen und Berkeley, CA.
Konsequenzen für Diagnostik und Therapie. Professorial Schwind P. (2003) Alles im Lot. Eine Einführung in die
dissertation, Ludwig-Maximillians-Universität, Munich. Rolfingmethode. Droemer-Knaur: Munich.
Mumenthaler M. (1962) Über Lähmungen peripherer Schwind P. (2001) Die manuelle Behandlung des
Nerven im Extremitätenbereich. Deutsche Medizinische Karpaltunnelsyndroms—Faszien- und Membrantechnik.
Wochenschrift, 38. Osteopathische Medizin, 3.
Mumenthaler M. (1964) Die Therapie des Schwind P. (2002) Faszientechnik für Behandlung des
Carpaltunnelsyndroms. Deutsche Medizinische Kiefergelenks. Osteopathische Medizin, 1.
Wochenschrift, 51. Sobotta J. (2001) Atlas der Anatomie des Menschen, 21st edn.
Mumenthaler M and Schlack H. (eds.) (1982) Läsionen 2 vols. Ed. R Putz and R Pabst. Urban & Fischer: Munich.
peripherer Nerven. 4th edn. Thieme: Stuttgart. Staubesand J and Li Y. (1996) Zum Feinbau der Fascia cruris
Oschman JL. (2000) Energy Medicine. The Scientific Basis. unter Berücksichtigung epi- und intrafaszialer Nerven.
Churchill Livingstone: London. Manuelle Medizin, Springer: Berlin, 34 (5).
Pernkopf E. (1987) Atlas der topographischen und angewandten Sutherland WG. (1990) Teachings in the Science of Osteopathy.
Anatomie des Menschen, 2nd edn. Ed. H Fermer. Urban u. Ed. A Wales. Rudra Press: Portland, OR.
Schwarzenberg: Munich. Tittel K. (1978) Beschreibende und funktionelle Anatomie des
Paoletti S. (2001) Faszien. Anatomie—Strukturen—Techniken— Menschen. 8th edn. Gustav Fischer: Stuttgart.
Spezielle Osteopathie. Urban & Fischer: Munich. Upledger JE and Vredevoogd JD. (1983) Craniosacral Therapy.
Prat D. (1993) Le cadre osteo-musculaire de la sphere uro- Eastland Press: Seattle, WA.
genitale. In Prat D et al. Nouvelles Techniques urogenitales. Varela FJ and Frank S. (1987) The organ of form: toward a
Éditions de Verlaque: Aix-en-Provence. theory of biological shape. Journal of Social and Biological
Prat D. (1999) Manual diagnostics. Lecture at the Structures, 10.
interdisciplinary symposium by the Munich Group, Villa Waldeyer A and Mayet A. (1993) Anatomie des Menschen, 16th
Degiani, Friuli. edn. 2 vols. De Gruyter: Berlin.
Rauber A and Kopsch F. (1987) Anatomie des Menschen. Wilhelm K. (1987) Kompressionssyndrome des Nervus
Lehrbuch und Atlas. Ed. H Leonhardt, B Tillmann, ulnaris und Nervus medianus im Handbereich,
G Töndury and K Zilles. Thieme: Stuttgart. Orthopäde, 16.
Rolf IP. (1993) Rolfing im Überblick. Junfermann: Paderborn. Zumhasch R and Hinz C. (1999) Das Karpaltunnelsyndrom.
Rolf IP. (1997) Rolfing—Strukturelle Integration. Wandel und Anatomie, Ätiologie, Diagnostik und präoperative und
Gleichgewicht der Körperstruktur. Ed. and rev. P Schwind. postoperative Behandlungsmöglichkeiten. Part I: Ergotherapie &
2nd edn. Irisiana: Munich. Rehabilitation, 5.
ERRNVPHGLFRVRUJ
221
Index
ERRNVPHGLFRVRUJ
222 INDEX
ERRNVPHGLFRVRUJ
INDEX 223
ERRNVPHGLFRVRUJ
224 INDEX
ERRNVPHGLFRVRUJ
INDEX 225
masseter muscle 183, 184 chronically hyperextended 75, 76 ligamentous connection restrictions
masticatory muscles 182 fascia 39 202
maxilla 191–192 layers 181–182 ligamentous structures 28
anatomy 193 mandibular joint 181 ligamentous suspensions 208
implants 189–190 intervertebral disk protrusions mobility 33, 40, 42, 168–177
membranous connections with 149–151 after whiplash 204–205
skull 205 retromedial 151–152 limitation 35, 42, 54, 63–64, 93,
motion restriction 194–195 myofascial layers 151 132
spatial relationship with base of shear test 202 mobilization 42
skull and neck 187–188, 195 spatial relationship with maxilla motility 168–169
maxillary sinus 192, 193 and skull base 187–188, pelvic 132
mechanoreceptors 11 195 serosal layer distribution 208
median nerve 102 thoracic cavity transition 35, 41, treatment after whiplash 204–205
anatomical variations 108 44–45 osteopathy 3
direct influence below carpal whiplash treatment 205 craniosacral 23
tunnel 107–108 see also atlanto-occipital junction; overcompensation process,
passage in elbow joint 105–107 atlanto-occipital membrane; intervention 28
radices 105, 106 atlas; axis; cervical spine;
tissue bed treatment 104–105 occiput
membranes 2 nerves P
definition 6 function 101
functions 2, 3 organ movement relationship to palatine bone anatomy 190–192
treatment 2 form 178 palm
metatarsus nervi nervorum 101 direct application 19
calcaneus intraosseus tension nervous system independence 17–18
treatment 166 activity during manual therapy 11 listening 48
movement restriction correction see also autonomic nervous system two-dimensional application 22, 22
204 neurocranium 194 use 16–17
mobility 33 nuchal fascia 39 palmar aponeurosis 96, 100
mobilization techniques 2 nuchal ligament 67, 67, 181–182 palmar muscle, long 102
motility 33 connection to occiput 75, 188 parietal system
movement patterns 36 whiplash treatment 208 fixations 203
Müller H 182–183 pregnancy 212
muscle fibers 6 pectineal fascia 127
myofascial bridge, thoracic cavity 38 O pectoral fascia 81–83
myofascial skeleton 8 pectoral girdle
myofascial units, subcostal 20 oblique abdominal muscle 80 adaptation to forces 93
myofascial unity 6 external 84 examination 84–87
myofascia/myofascial layers obliquus capitis muscles 141 form 80–81
contraindications to treatment in obturator internus muscle 128 periarthritis 87
whiplash 205 obturator nerve 133 thoracic cavity connection
embryonic development 9 occiput 66, 144 treatment 56–57
overly tense 28 membrane connections 142–144 treatment techniques 87–93
pregnancy 212–213, 215 nuchal ligament connection 75 pectoralis major 81
shortened in lower leg 212 support 27 pectoralis minor 81
slack 28 whiplash treatment 208 fascia treatment 87–88, 89
see also atlanto-occipital junction pelvic cavity
oral implants 189–190, 192–193 ligament connections 144, 145
N organs membrane connections 144, 145
abdominal 39 myofascial structure after giving
nasal cavity 194–195 during inhalation 33 birth 214
nasal–pharyngeal space 181 mobilization techniques 40 pregnancy 211
natural table 27 connective tissue sheaths 208 shear force test 202
navicular bone 162 diaphragm influence 177 pelvic organs, movement restriction
talus joint 164–165 embryonic development 78 132
neck/neck region envelope 28 pelvic region, lower, breathing
chronically contracted myofascial fixation 53, 177, 203 movement evaluation
layers 75–77 fluid dynamics 28 45–46, 46
ERRNVPHGLFRVRUJ
226 INDEX
ERRNVPHGLFRVRUJ
INDEX 227
ERRNVPHGLFRVRUJ
228 INDEX
ERRNVPHGLFRVRUJ