You can tell in the East Bay when the summer weather takes a sudden turn toward the foggy side. People who were outside moving about the day before suddenly start to notice aches and pains. If they feel stiff enough, sometimes they’ll finally get around to dealing with things they’ve let build up in their bodies for years. That’s when they start finding our door.
In its heyday, the building’s wooden floors felt the footsteps of lawyers. Those footsteps have long since moved on to taller buildings of steel and glass, leaving behind a space that’s well-worn but still serviceable. Today, the sign on the frosted glass door simply reads “The Fascial Agency”. If your hand has found the tarnished brass knob on that door, you’ve likely been pointed here by another client. It’s a neighborhood within the foggy fingers of the bay that’s a leftover from another time. Some in the business know we’re here, but mostly our agency has a low profile. There are several of us fascial operatives, or just ops for short, that you might find behind that frosted glass and wooden door. Which one you get is pretty much a matter of your choice of timing and the arbitrary nature of fate. Part of that nature and fate is the mood you happen to find our receptionist in. She’s got a low tolerance for nonsense and a keen eye and ear for deciding in a moment whether we’re booked solid or have a slot open for you. Today, she must have been in a good mood, despite the sudden chill outside, because she was filling our sessions.
The story on the left side is fiction, but fiction with its roots deeply entwined about quite serious clinical massage concepts. The story came about of its own volition rather than as a planned project.
In August of 2007, I was coauthoring a book chapter on Myofascial Release with Art Riggs. During the same period, the local library was highlighting the detective stories written by Dashiell Hammett. One day, the normal summer warmth departed for a bit and the cold and foggy air blew over the hills forming the eastern rim of the San Francisco Bay. That night, the story to the left took over my fingers and wrote itself. From a brief moment of pondering the similarity of sound of Dashiell and fascial, a synthesis emerged.
Back in the 1920's, Dashiell Hammett helped to pioneer a new style of hard-boiled detective story. While his best known character is Sam Spade, in The Maltese Falcon, Hammett's earlier stores featured a detective known only as The Continental Operative. It's from the Continental Op and a hard-boiled, tough-love way of thinking from which “The Fascial Operative” took form. While Hammett's stories were located in San Francisco, I've relocated this one east across the bay.
I’d barely cleaned up from my last client, tossing used linens in the hamper, washing up my hands in cold water, and laying out new sheets and towels, when I got the buzz that I had another client waiting. It was literally a buzz. We’d had this wireless announcement system for about six months. We each had small vibrating clips, about the size of a car door remote, which the receptionist could activate. They worked; they were also quiet. They probably could be put to other uses, but that’s a different sort of story. Anyway, I pushed the button on the clip that was the “ready” reply.
This is basically a nod to the intricate ways that changes in technology enter our lives. It also builds the character of the “out the side of your mouth” narration. Everything has multiple uses and multiple perspectives.
As my client walked in, I did a quick visual once over. She didn’t have one of those “trophy faces”, but something in how she inhabited her face and eyes would prompt many, including myself, to take a second look. She had the kind of face and appearance that wears well over time. Right now, a second look showed more than a little suppressed pain. My first guess was that she was a bit under thirty, old enough to have had a few years to abuse her posture and just old enough to be losing a bit of the elastin from her collagen and starting to pay for it. Her rolled forward shoulders and slightly forward head confirmed that this was more likely to be a case of flexion addiction than a result of over-enthusiastic soccer play.
This paragraph combines the visual assessment typical of clinical massage with the hard-boiled visual assessment of character and body typical of Hammett. We look at what what the client has from nature and where she is from environment. life-style, and the passage of embodied time. When we are young, our collagen has more elastin. As we age it has less, and we are less elastic. The costs in pain and loss of freedom of motion from bad postural habits increases. Forward shoulders and forward head syndrome are common postural dysfunctions. Erik Dalton coined the phrase flexion addiction to describe our cultural tendency to spend large amounts of time in flexed positions.
My first glance had caught her shoulders; my second glance picked up her facial expression and her tight erector spinae. I didn’t even have to look at the intake form to know that she was double-crossed. This didn’t mean that anyone had promised her something and then betrayed that trust. It also didn’t mean that they hadn’t. What it did mean was that, in both her upper and her lower torso, she had some muscles that had shortened into dysfunction and some that had weakened. Likely the fascia in those areas wasn’t too happy either. But all of this is racing ahead on the intake process.
I took up her input forms, motioning her toward one of the oak chairs against the wall. As she sat down, she bent forward at first and then fell back into the chair, more arriving in two motions than a controlled motion. “I’ve been stiff and hurting, for a while”, she said. “I’ve seen a couple of doctors, but didn’t like the surgery they were suggesting. A friend of a coworker said you might be able to help me.” I nodded. “We likely can. The particulars will depend on what shows up as I put you through our assessment paces.”
Upper and lower crossed syndromes are common patterns of postural dysfunction. Vladimer Janda, M.D., of Czechoslovakia developed the conceptual distinction of postural and phasic muscles. Postural muscles tend to shorten in dysfunctions and phasic muscles tend to weaken in dysfunction. In part, and in accord with Sherrington's principle of reciprocal inhibition, the overactive postural muscles neurologically inhibit the antagonist phasic muscles.
For fascia, Davis's Law for soft tissue (cf. Wolfe's law for bone) tells us that tissue will adapt to use. Tissue will be laid down along lines of stress and shorten toward the maximum range of use. Thus chronic patterns of holding and tension become embedded in our tissues. Pain and tissue restriction, lead to compensations in motion and loss of smooth neuromuscular control, thus a tendency to “arrive” in a chair, rather than to sit down in a smooth, controlled motion.
As I glanced down the written input, I noticed the next-of-kin space was blank. We like to collect that in case a client keels over from some serious medical condition they haven’t bothered to tell us about. Well, the space wasn’t quite blank, but had a spot where a pen had pressed down and then slid off, leaving a faint trail. Normally, the front office is pretty quick in catching such paperwork things. When she lets it by to me that generally means there’s a reason. I looked up. “Next of kin?” I asked. The client looked at me for a moment. “I had a younger brother”. She paused, and then looked down. Softly, almost starting from a choke, “Iraq; two years ago.” I felt clumsy, but simply said, “I’m sorry”. She didn’t react for a second or two, then shook her head and looked up, “Generally, I hold together, but sometimes it just sneaks up on me.” “It’s ok”, I said gently. “One of the rules here is that you don’t have to keep it all in”. “We don’t provide psychotherapy, but we can give you a space to relax your control”. She nodded.
I continued down the intake information; nothing too unusual, for the area. She worked for one of the local commercial tech firms. This pretty much insured that she’d spent long hours at a computer terminal pushing a mouse, confirming my visual impressions.
Many practitioners have stories about serious conditions that a client forgot to list on an intake form.
Part of the concept of “hard-boiled” is that of survival in a world that can deal out a tough hand. Laurance Gonzales, in Deep Survival, tells us about who survives and why. Peter Levine's Waking the Tiger and Healing Trauma and Clyde Ford's Compassionate Touch bring up us to the point of processing the traumas that we initially had to stuff and the role of touch and bodywork in helping allow that to happen.
While we don't do psychotherapy, while we don't listen to all the words and stories, we can simply be present and provide touch and comfort and a safe space to relax self-control. When the person is ready, we can help to remove the holding patterns that trauma may have left in the tissue itself. They still have to face their own dragons and do their own internal work.
“So what are you going to want to sell me?” she asked. “Back support belts?” “Exercise supplies?” “Fifteen sessions?”
“No, we really don’t work that way here at the Fascial Agency”, I replied. “We simply try to figure out where you’ve got yourself hung up — what you’ve managed to do your body to cause you pain and loss of movement —then we work with you to get that better. If it isn’t something we can work with, we’ll refer you to someone who can. Partly our work is in coaxing you to let loose of the muscles you’ve been unconsciously contracting. Partly we need to go in and get some tissues that have stuck together to let loose. That last bit isn’t likely to be anything you’ll be thrilled with as I’m doing it—it’s likely to burn some—but we’ll go slow and my guess is you’ll like the result afterwards. You can tap out or just say stop anytime you need a break.”
Sometimes it seems that everything is about branding and sales. So people come to expect the hit. The other approach is simply to have the tools and knowledge and be able to do the work well. It's a matter of deeper understanding and practice with self-reflection.
Her shoulders assessed pretty much as I expected, classical upper-crossed syndrome, shortened pecs, shortened upper traps and weakened rhomboids, middle to lower traps, and anterior neck. Her hips were similar, shortened and tight psoas and erector spinae, weakened abdominals and glutes. With the abdominals, shortened didn't mean strong; just shortened, weak, and stuck. To all appearances, she spent most of her time more folded than a piece of Origami.
Janda's upper-crossed syndrome involves shortening of the pectoralis and upper trapezius. In contrast the anterior neck muscles and mid-thoracic muscles weaken.
In Janda's lower-crossed syndrome, the iliopsoas and erector spinae shorten and the abdominals and glutes weaken.
I talked about what I was finding as we went through the various range of motion and resistance tests. She didn't say much, just nodded. I checked out the height of her iliac crests, both standing and sitting, and had her bend forward to check for any upslip. We then compared her ASIS and PSIS heights to check for anterior or posterior rotation of each innominant, running through various compensations and sources of stress.
“You've done a number on yourself over the last few years”, I said as I got a clearer picture of what she had going on. “When you weren't working at your computer, you must have been curling up like a pill bug.” She gave me a look that wasn’t going to deny anything but also wasn’t going to admit to much. I backtracked. “Ok, I won’t hassle you about it. I’m sure you’ve had your reasons.” She sighed, and relaxed a notch.
There are SOAP notes, standing for Subjective, Objective, Assessment and Plan. There is also the HOPRS examination, standing for History, Observation, Palpation, Resistance/Range-of-motion, and Special orthopedic tests.
To check if the hips are level, one looks at the crests of the ilium on each side, both standing and sitting. The comparision of the Anterior Superior Iliac Spine (ASIS) and Posterior Superior Iliac Spine (PSIS) give and indication of whether the innominant (half-pelvis) is tilted anterior or posterior.
Observation coupled with palpation helps to discern lines of stress. Staying in a chronically flexed (rolled up) position will show up in tissue shortening and possible adjesions between layers of fascia.
“The good news”, I told her, “is it hasn't gotten into you joint capsules, it's all in the surrounding tissues.”
“How do you know that,” she asked.
“A medical guy named Cyriax figured out than when joint capsules start adhering to themselves that there's a pattern to the way the movement goes away in different directions. In the shoulder, the greatest loss is lateral rotation. You go to rotate your arm out to grab a cup of java and you can’t. Then next thing you can’t raise your arm out to the side to steady yourself in the shower without playing games with shrugging your shoulder. In the hip it's the same idea, but the losses are greatest for rotation of the front of the thigh inward and for flexion. But tight as you are, you don't have those patterns, so it's not in your joint capsules and that makes it a whole lot easier to get you moving again. That doesn’t mean that it’s a piece of cake or that we can clear it all today or that you won’t swear at me while I’m working on you, but we'll get a good start and you'll be walking out of here easier than you walked in.”
Cyriax discusses capsular restriction patterns in Cyriax's Illustrated Manual of Orthopaedic Medicine. A capsular restriction at the shoulder is often referred to as a “frozen shoulder”.
The session went well, considering where she started from. She had the ability to ride with the work, letting it sink in, that you generally find with athletes and dancers who are used to putting themselves through more than anything you’re likely to do to them. I started with a lot of anterior torso work to open up all the lines she’d been keeping shortened. When you’ve worked with connective tissue for a while, you get a feel for it. It talks back to you and you adjust the angle and pressure here and there without giving it much thought. A little more oblique, a little more medial, until that particular piece of restriction gives up. It’s a lot like meeting someone and getting into a conversation that opens up as you get a sense of each other. It’s not something you can really teach someone as such, but most can learn it from someone who knows how if they’ve got the time and patience and their senses aren’t all closed down. Some just think too much, and never do pick it up and you do your best to avoid letting them do anything meaningful on you.
This bit really is about the necessity of practice with awareness and reflection about sensation and results. You can watch a demonstration, but then you have to try it, and try it, and try it. Eventually, you palpate and continually question the tissue beneath your fingers and hands without consciously thinking about. Your hands and body and techniques respond to what you sense by unconscious pattern matching. You start out as a novice consciously practicing new kinesthetic skills that feel awkward. Then one day, without even trying, you look down at your hands doing techniques that once seemed next to impossible.
Those who don't bother with reflection or don't trust the unconscious process of learning and responding to patterns stay limited in their kinesthetic abilities. As with skiing or playing a musical instrument, at some point, your conscious mind has to let go and get out of the way.
After a bit of direct work, I gave her a break, shifting to muscle energy technique (MET) on the pecs, major and minor, and then following that by some more direct tissue work. Then into some compression on points where things had really adhered, with having her actively move her arm up over her head and then back in front of her. More MET, this times using her breathing against my resistance to loosen her rib movement, then some gentle pressure in several planes.
Opening up her anterior lower torso started with some preliminary passive clearing of hip motions, the progressed into both MET and direct work on her iliopsoas. I added in active movement to the direct work, having her flex and extend her hip, sliding her foot along the table surface. It was intense work, earning her another short breather to regroup. After a minute or two, she gave me a thin-lipped half-smile and nodded. “Get going again.” Then, our work progressed on to the posterior lines, working her upper traps and spinal erectors, using a mix of MET, jostling, and deep tissue.
Initial direct work helps to warm and make the tissue supple, but direct work against a hypertonic muscles is simply unnecessary effort. By using a neurological technique such as Muscle Energy Technique, a form of post-isometric relaxation, or positional release, we can first reduce the tension of the muscle. Then, the direct work to release fascial adhesions goes much more easily.
By the time I was finishing, it was about all her nervous system and energy were going to tolerate well in a single session. I don’t like to push clients too far, since sometimes that triggers an immune response and leaves them in a mental fog and malaise for a couple of days. The research out there suggests it’s from cytokines; chemical messengers involved in allergies, cold viruses, and response to exercise. Playing on the cautious side with a new client, I wasn’t able to catch everything, just a lot. It can be a mixed feeling doing this kind of work. You feel bad about causing a nice person a fair amount of discomfort up front and good that they’re likely going to feel a lot better just down the road.
The body, immune system, and neurological systems are, by current research, far more tightly coupled than once believed. Part of that coupling appears to come from a group of messenger chemicals known as cytokines.
After the session, after she’d dressed and I came back into the room, she looked taller, more fluid and a bit dazed.
“Wow, that feels different”, she said while moving her head and shoulders around a bit. Playing with them as if she weren’t quite sure they were hers. “Thanks so much”.
“Well, you can do a lot to keep it that way, if you want,” I said, as she started to move toward the door. She stopped and turned back. “What? What do you suggest?”
“Nothing too much, kid. Just move your body more. Don’t sit still for so long, and … get a life. Spend some time away from your computer. Also, don’t plan on cutting in front of any Mack trucks today. You’re timing might be a bit off.”
She paused, and then with a half-smile looked me straight in the eye. “Yeah”, she said. “I guess it’s time to face that life thing too”. “Thanks.” With that, she was out the door to the receptionist. Sometimes, when you free up a person’s body, you also free up their life and heart. I hoped it held true this time.
I glanced at the clock. Just time to clean up and grab the sandwich I’d placed in the fridge yesterday and hadn’t gotten to. I had a hunch it wouldn’t be long after that before the clip buzzed again. It was that kind of a day.
We can work with the tissues and help the client to achieve change. Freeing the body can create new options in life which, in turn, feed back on body usage.
Ultimately, the client has to do the work. If they have been shoved out of the main flow of life by a trauma, we can assist, but the responsibility and choice to move back into the flow is theirs. Sometimes, all they need is a little bit of help and a bit of a nudge.
Then, as the practitioner, it's time for us to let go and move on to the next challenge that comes our way.