Posts Tagged ‘connective tissue’

Some gutsy learning

| May 26th, 2014 | No Comments »

vis·cer·al

adjective

  1. of, or relating to, the viscera
  2. relating to deep inward feelings rather than to the intellect

synonyms: instinctive, instinctual, gut, deep-down, deep-seated, deep-rooted, inward


 

 

I found this definition online and it perfectly encapsulates the nature of the course I went on this weekend. The course was called Visceral Manipulation I and both of the definition options above speak clearly to the nature of the work we did this weekend.

 

The course reviewed the anatomy and physiology of the internal organs – and reminded me that the lungs, heart and brain – with all their accessory bit are a part of that viscera. Our focus though was on the gut organs this time. The other definition is very appropriate to as the work requires that you use your knowledge of the structure of the body and then release it to simply feel the body. I knew going in that for myself the need to be patient and quiet my mind in favour of listening to my body would be my greatest challenge.

 

I am very aware, with a kind of chagrined pride, that I tend to over-think things at times. I often have said that I am more comfortable in my mind than in my body – but I have also said that my education and practice as a massage therapist has balance that to some degree. This weekend was, for me, another step toward embracing that balance. I do not think that I will ever be someone who first speaks to how they FEEL, I suspect I will always first go to the place of THINKING, but I do believe my life is richer for the fact that I strive to improve the balance between the two.

 

What is all this work for anyway? What will it help and might you be one of the people that experiences this work when next you are on my table. There are many indications for this work, some are emotional or life related (stress, depression, anxiety), many more physical – including digestive issues, disease process or history in the body – especially those where organs have been damaged or altered – right through to pain patterns in the body, especially those that are persistent and respond to, but do not resolve, with direct massage. Quite a few of you might just be finding yourself experiencing something a bit different in the near future. If you are interested in this work specifically feel free to ask more when you are in next time or to drop me an email or call.

 

For myself, I had an interesting time on the receiving end of all of this work and will be bringing some of treatments into my own self-care regime. I am interested to see the way this subtle and progressive work unfolds within me over the next weeks.

 

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International Fascia Research Congress, Vancouver, BC – Day 3

| March 30th, 2012 | No Comments »

Today began with a keynote speech by Carla Stecco who spoke on the nature of fascial anatomy.  One of the most amazing pieces of information I took from this was the fact that the sheaths of the limbs and trunk (aponeurosis of the deep fascia) that are traditionally classified as “disorganized” can actually be dissected into 2-3 layers of highly organized, aligned collagen fibers that are each oriented in discrete directions in each layers whose fibers are shifted 78 degrees from each other throughout the body and are capable of gliding on each other.  The other aspect, which actually came up several times over the last days is that there are penetrating collagen fibers that bind across various levels of fascia to affect sensory organs and allow force transmission across nested fascial layers.

I chose not to attend the discussion of imaging techniques and devices that followed, but from the tweets that I have seen there is a huge desire for a 4D sonograph now.  I have no idea what that is nor why it is so lusted after but I am glad that those that stayed had a good time.  I was not alone in missing some of the events of the day, I think overload was being reached by many of us and I know I enjoyed the time to be quiet with my thoughts and organize myself for the trip home.  

In the afternoon I returned to congress-land and heard some very interesting presentations, one on plantar fasciitis, one on immobilization of rats (which requires metal harnessing and ankle cuffs, those rats are apparently very much not keen on bondage), one on trigger point release using myofascial techniques and finally a study designed to demonstrate the actual force generate with different applications of Swedish massage.  This last one was an amazing demonstration of several important facts.  One, that the Fascial Research Congress model is generating clinically relevant research (the study was conceived after the presenter attended the second congress in Amsterdam.  Two, that there is a lot of very basic research to do on clinical application of manual therapy – after all, we cannot actually say with any scientific certainty the amount of force that we are generating on the tissue of our clients.  Three, that research is a rough go.  The presenter, brave soul that she was, led us through an elegantly designed trial to determine the compressive force generated by Swedish massage technique.  She covered the various challenges she faced and how she managed to overcome many of them.  She showed us some lovely, very tidy printouts of force generation waves generated by the strokes, and then she had to tell us she had no data to share.  All of her data was invalid due to faulty calibration of the testing equipment.  Oh my.  Despite this I would say she did in fact share quite a lot of data, just no outcomes.  I was relieved to hear she hasn’t given up and she may be able to salvage some of the data she had acquired through the magic of algorithms (okay, I think they are magic, some people think of what I do as magic, I think of algorithms as magic, we each have our own perspective).

After the bittersweet conclusion of the parallel panel presentations we concluded the afternoon with a panel entitled “Art & Science/ Research & Practice”.  Here was our opportunity to hear the thoughts and hopes of a few that I think reflected the hopes and dreams of many of us.  

Maureen Simmonds and Paul Standley both spoke about the importance of clearer, more standardized language and communication between clinicians and researchers to aid in the development of a greater understanding of whether what we do in the clinic is actually doing what we think and if it can create the kinds of impacts in the real world that simulated work in the lab does in petri dishes and research animals.  

Robert Schleip likened himself to Alice in Wonderland as he as a clinician who has entered the world of the scientist and continues to find both worlds “curiouser and curiouser” (I think I have applied the analogy a bit differently than he did, but I think the idea is the same).  He also pointed out the fact that he is not the only person to have shifted their position on the continum of clinician and scientist, nor is there only one direction to go on that voyage.  the rabbit hole goes both way and it is the both the people that switch burrows and those that simply reach a hand into the other hole to give or receive, or perhaps to join with a hand reaching back, that enrich and invigorate the worlds of fascial research and manual therapy.

Geoffrey Bove concluded the panel with an case study of his experience in reaching hands across the divide, and switching rabbit holes both.  Initially a clinical practitioner, he is now the researcher stretching his hand out to the clinician, in the person of Susan Chapelle, to bridge the gap and create new and fascinating (fascia-nating?!?!) discoveries regarding the outcomes of rubbing rat adhesions.  He presented with an interesting combination of practicality and emotionalism as he discussed the challenges of research and collaboration clearly demonstrating the passion that is brought to the work.

I departed prior to the final remarks to catch a ferry but I left feeling full of knowledge and enthusiasm and hopeful for the future of my profession.

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International Fascia Research Congress, Vancouver, BC – Day 2, the night

| March 29th, 2012 | No Comments »

Tonight I watched a prophet perform. Not what I expected to see at a Fascial Congress but I am not sure what other words to use. Gil Hedley was the final act in our multimedia night. After three amazing, room-stilling videos that were highly anticipated, onto the stage came a wiry, kinetically unstable bundle of poetry reading anatomist.

Perhaps I have had too much coffee, not enough sleep or entirely too much mental stimulation but Gil Hedley’s presentation on his new thinking around fascia makes me what to sign up to join whatever cult he’s leading or drink whatever kool-aid he’s pouring. He brings an inspiring combination of respect, enthusiasm, joy and intellect into the world of fascial dissection.

I am someone who loves my words and concepts and rather resent having to give up a perfectly good story for a new idea. Even though Hedley’s whole presentation was a debunking of his own, infamous “fascial fuzz” speech that has become an easy, u-tube click away, introduction to fascia for the uniformed, I loved it. I now have to discover a new story to tell myself about the development of adhesions and what I am doing in my work. Daunting. I am inspired though by the enthusiasm, dance, poetry and joy that was displayed on the stage of the grand ballroom of the Sheraton Wall Centre tonight in Vancouver, BC

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International Fascia Research Congress, Vancouver, BC, Day 2

| March 29th, 2012 | No Comments »

Today is a new day of learning and the overload is starting to set in.  Not in a bad way, but you can see the shiny eagerness beginning to fade, there is more movement during presentations and alternate seating is becoming more popular and the familiar seats begin to feel entirely too familiar to our posteriors.

A great day none the less with some wonderful clinical information and tonight a multimedia presentation of fascial videos that I, along with several others from the look of the bar and cafe here at the hotel, will be late for.  I admit that I have stepped away from a few presentations seeking some quiet retreat time to process some of the information.  After some dinner though I look forward to watching some highly visual presentations that I am betting won’t stress my lack of chemistry knowledge as several of the presentations today did.  

The flip side of the restlessness is an increase in casual interaction between attendees and lots of chatter.  As I sit and type several tables of congress attendees sit together chatting, eating and drinking.  I suspect many a new research project will be hatched over the next several days.

In terms of the learning there was a shift from the mechanical to the fluid as our keynote speakers focused on the issue of fluid dynamics in the interstitium and the wonderous fourth state of water – bound water.  The water talk, given by Gerald Pollack from the University of Seattle, was my third exposure to his theories and seems to have been a bit of a charm as several of the concepts seemed to sink right into my brain rather than flying inches or feet over my head.  Dr. Pollack’s research has focused around the behaviour of water at it’s edges, where it contacts hydrophilic (water lovings) substances and air, and there is the creation of an exclusion zone where the water enters the bound, or fourth state.  In this zone the water is denser, negatively charged, has a viscosity similar to honey and just generally is really different from what he calls bulk water.  Beyond the interesting implications for us manual therapy practitioners whose clients are all largely composed of water there are real world implications.  

 

In the real world the exclusion zone offers explanations for cloud to cloud electric activity (= lightning), why the basilisk lizard really can walk on water, why heavy objects float and offers interesting possibilities for water decontamination, perhaps even desalination, and the ability to harvest electricity from water – all using only the radiant energy of light to accomplish the task.

There is the report for today, stay tuned for the final day’s report where imaging and more anatomy and clinical discussion look to be the highlight.

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International Fascia Research Congress 3 – Vancouver, BC, Day 1

| March 28th, 2012 | No Comments »

***Beware – this post is a total fascia geekfest, if you are not prepared to deal with that, read a different post!  Also, any factual errors are my faulty memory, not faulty presentations.***

 

Today I had the absolute pleasure of beginning my time at the 3rd gathering on scientists and clinicians who have an abiding interest in fascia in all its varied and wonderous forms.  I began the day with a flight to Vancouver and a slightly late arrival – but I got before the real geek-out stuff began, so it is all good.  

After some general introductory speeches we dove right into the first keynote speaker.  A anatomist from Temple University, Mary Barbe spoke to us about her research in duplicating repetitive stress injuries (RSI’s) in rats and the tissue changes that occurred in response to various types (high, low and negligable intensities) of work.  How could this possibly relate to massage therapy you ask? Well the road hasn’t fully been built, but knowing that rest doesn’t always fix the problem and that inflammatory processes have likely come and gone prior to anyone presenting at my office (they peak between week 4 and 8 of performing the task) after months or years of a repetitive task, provides me with insight into what interventions and homecare might best benefit my clients.  simply knowing that there are significant connective tissue changes that occur within weeks of undertaking an repetitive task shouts loud and clear about the importance of the fascial work that I am a huge advocate for.

After a quick break we moved our second speaker, Michael Kjaer, whose topic was the impact of exercise on tendon tissues.  We discovered that exercise (and not a lot, 1x creates 72 hours of increased collagen production which is what builds your tendons) increases the density of tendons.  Interestingly, there seems to be little issue with maladaptive changes in the tissue to repetitive exercise as there is to repetitive work activity (there’s a thinker).  More surprisingly, it turns out men exhibit greater tendon density increase than women, and that within the female population women taking oral contraceptive exhibit even lower levels of tendon response than the general population.  Further interest in gender issues came when it was revealed that in post-menopausal women being on hormone replacement heightened tendon response.  Hmmm, that estrogen, funny stuff.  

 

After a break for lunch we broke into three groups for presentations on specific areas of fascial research.  I chose the “biomechanics” room and got to learn about different means of trying to empirically measure different types of mechanical interventions.  From pressure sensitive pads on fingers to rather medieval looking table devices this part of the afternoon was an interesting insight into the various ways we can try to research the interventions we apply with our hands and their outcomes.  I also gained an interesting insight into the world of research.  Failure, or rather, not proving your hypothesis fully or at all.  Even in those cases it was interesting to see how that research could be used to launch into better studies.

Our next keynote speaker, Albert Banes, was a doozy.  I am pretty sure I learned so interesting things, but they went by so fast I think I might be lucky to catch up with them sometime next week – after reading the paper a few times!  He seemed to be summarizing quite an extensive array of studies in the field of fascia research and had some very interesting things to say – and showed us pictures of some lab grow tendons, but it was a lot in just a little time

The final event of the afternoon, academically, was a panel of  four clinicians presenting of “scars and adhesions”.  One of the exciting bits of us BC RMT’s was having one of our own on the panel – Susan Chapelle of Squamish, BC who talked about the benefits of integretive treatment and the need for increased research that included a manual therapy aspect.  She was preceeded by a surgeon, Dr. Michael Diamond, who discussed post-surgical adhesions (things sticking together that shouldn’t after surgery) which I was surprised to find has a 65-100% incidence rate in abdominal surgeries (though they are not limited to those surgeries).  We were then treated to a new movie by Jean Claude Guimberteau, a French physician, who has now produced several in vivo movies of fascia using endoscopic techniques (his first being “Strolling Under the Skin”, presented at the first fascial congress).  We also had a naturopathic doctor, Hal Brown, present some of his case studies of the impact of the injection of aenasthetic under the skin into scars to improve function in both near and far tissues. 

The day finished with a welcome reception that was very well attended that allowed us all to review and discuss our reactions and thoughts regarding the days flood of knowledge.  I can hardly wait for day two….

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Healing Series #4 – Sprains

| February 14th, 2011 | No Comments »

I was trying to stop my toddler from running about the parking lot while coaxing my slightly lame dog into the back of the minivan. In frustration, I bent forward, wrapped my arms around the dog’s middle and lifted him into the back of the vehicle. I felt a funny twinge in your back but nothing seems to come of it – until later. Stiffness and pain began in my low back and radiated down into my butt.  I had sprained my ilio-lumbar ligament (it is right at the base of the spine and goes from the ilium to the 5th lumbar vertebrae). It was a mild injury, a moderate grade one. The grading for sprains is similar to strains, which were roughly outlined in the my muscle strains post.

As with all the other healing processes we have looked at there will be the clearing out of damage and the repairing of the tissue. In a ligament we see scar tissue fill in the ruptured area, restoring the continuity of the ligament. The differences comes from the fact that this is the first avascular, poorly innervated structure we will be looking at.

First, let’s look at what a ligament is and what it is supposed to do. Ligaments are sheets of tightly packed, closely aligned collagen cells.  Structures with little elasticity or extensibility, they are the brakes on the engine of muscular motion.

Without direct circulation, ligaments will be slower to send out the chemicals that signal the need for healing. The exchange of healing materials for waste products will be slow and inefficient. This slow fluid exchange will create and prolong irritation and inflammation. The lack of innervation will further slow healing.  The body’s ability to know when it is being re-injured is be limited. Most of the pain will come when surrounding tissues become over-taxed, irritated and inflamed.  The ankle and low back, two of the most frequently sprained regions, also have the highest rates of re-injury and chronic acute conditions (basically when the area is so regularly being injured it never truly heals and is always painful).

the ligament fibers end up looking as messy as these twigs

How long is slow? A year. It takes a year for a ligament to fully restore itself. If there is no intervention you will be lucky to get 50% functional integrity at the injury site.

For the first three months you are especially vulnerable to re-damaging the healing ligament. After three months most of the basic repair is done and the new scar is in place. We are entering that retraining period I talked about in the muscle strains blog. This is one of the most tricky times, you need to be active, you are generally pain free, but your ligament is just not capable of what it once was. Directional stress tells scar tissue fibres what direction they need to line up and be strong in. To be functional, ligaments need proper structure, something that can only be achieved through safe movement. By six months or so you might be okay in most activity but be aware that you are still at risk. The wrong move at the wrong time can spell a reversal back to the beginning.

 

How much of a difference can proper care make? Immensely, think 98% integrity vs the aforementioned 50%. What is proper care? In

with good healing the fibers flow together smoothly in line

the early stages RICE is the answer. If an activity brings on pain, stop it. Get help or modify for safety activities you need to do. Once you are moving without pain through normal activity, return to more vigorous pursuits. If the activity creates similar risks to the injury, tape the injured area. Tape creates some small physical stability, and, more importantly, it brings your brain’s attention to the area.

The other aspect of proper care is some professional assistance. Help to keep compensating structures healthy and ensure optimal circulation using massage therapy, physiotherapy, or acupuncture. The first two, along with a kinesiologist can help with rehabilitation exercises. The kinesiologist can help with bad movement patterns too, as can Alexander technique instructors or Feldenkrais practitioners. You do not have to use the whole spectrum of care, but think about what you need help with and what you have to invest in your health and match that to the practitioner best suited to assist you.

Finally – be patient. This is a long haul situation, if you try to shortcut it you will make it worse.

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Healing Series #2 – Deep Wounds

| November 1st, 2010 | 2 Comments »

You are chopping onions and your knife slips a bit and you cut your finger tip. As fingers, with there plentiful supply of blood, are prone to, it bleeds, a lot. You put some pressure on the wound, lift your arm over your head and it’s off to the band aids. When you take away your pressure the blood is still flowing but has slowed, and a quick look shows you have cut through so the length of the wound is bleeding but you haven’t really gotten into the meat of the finger. No stitches required, a tightly wrapped band-aid squishes the edges together and reduces the blood flow. Unlike that wee scratch you got on your walk last week, this cut will be there for a while, and for the next few hours the finger will throb and pulse and hurt. Within a couple weeks you will be healed, but there will be a scar. What is different inside your body for this injury compared to that scrape?

In medical-ese you have given yourself a deep wound, a wound that extends through the hard, dry (keratinized) epidermis and into, not just to, the living portion of the skin, the dermis. This is an important distinction, in the previous example the damage was able to be repaired easily in part because there was no real impingement on living tissue with extensive blood supply. Once you are into the structural part of the skin and the physical protective capacity of the skin has been broached, your body must mobilize its other protections and staunch the escape of the blood while working to restore integrity to its tissue.

There are four stages that this type of wound will pass through on its way back to normal function. These phases overlap but begin sequentially. First, the clotting phase, then the inflammatory phase (some meld these two together), then comes the migratory phase and healing finishes with the maturation phase. Different activities, chemicals and processes dominate these phases and all are necessary to restore proper function.

The cut happens and within moments, reacting to the damage of their lining cells (endothelial cells), the damaged blood vessels go into spasm to reduce their diameter (vasoconstriction), which also has the added benefit of bringing the wound edges closer together. The damaged lining cells also cease to release the chemicals they usually secrete to prevent coagulation of the blood and begin to secrete chemicals that encourage clotting (von Willebrand Factor and thromboplastin), as well as proteins (cytokines) that jump starts the immune responses of the body. Within the hour the clotting factors encourage small cell fragments in the blood (platlets) to stick to the damaged areas of the blood vessels, holding the edges together and stopping the flow of blood. Once this plug is in place a protein (fibrinogen) is converted into a non-soluble protein (fibrin) and forms a web-like framework for blood to coagulate around. Once sufficient blood coagulates around this framework the plug becomes a clot.

As clotting occurs another process, inflammation, is beginning to help clean and protect the wound and to ensure that all the other chemicals and cells needed for healing are able to reach the wound site. The first event in inflammation is the enlargement of the blood vessels around the injury (vasodilation) which both increases the volume of blood flow to and from the area and enhances movement of material through the walls of the blood vessels. The first new cells to arrive are White blood cells (specifically neutrophils and macrophages) and cells (mesenchymal cells) that transform into tissue building cells (fibroblasts). This is also the process that will cause the throbbing in your finger. More and more fluid, chemicals and cells crowd the limited space of the fingertip until you can literally feel the surge of your pulse pushing more into the constricted space. Fingertips, or any constricted space that swells will manifest this throbbing. In more spacious areas swelling of the tissue over a larger area allows these materials to disperse into a larger area and you rarely feel the pulsing. Within about 24 hours the inflammation has subsided to the point that the throbbing isn’t evident, you may not even note any swelling.

At around the 3 day mark the migratory phase becomes dominant. At this point the clot has become a scab and under that the epithelial cells are migrating across the gap (see “Healing Scrapes”). The fibroblasts migrate on the fibrin threads producing scar tissue (primarily collagen and glycoprotein, this tissue also secretes a antibiotic-like fluid) as they move. At the same time the damaged blood vessels are healing. This phase can take up to about 3 weeks.

By the 3 week mark healing moves into the maturation phase. This is when the wound undergoes its remodelling. In a house remodel this would be the painting stage, in the body this is when the new structures attain more organization, when the cells involved in healing begin to disperse or die off, and the blood vessels are fully restored. Depending on the severity of the injury this phase can be ongoing for up to 2 years. You would see this as the slow fading of the visible scar. For you body the tissue would be slightly less sturdy and perhaps have slightly altered blood flow until this process completed.

Nutritionally speaking your body will be using more Vitamin C (connective tissue production and blood vessel healing) and more Vitamin E (to decrease scarring and speed the process). In the early stage Vitamin K would be used heavily in clot production.

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My Willem Fourie Course

| June 2nd, 2010 | No Comments »

I was one of a lucky few who got to attend a three day course on treating connective tissue in breast cancer patients taught by Willem Fourie. This course provided me with more specific knowledge and alternate approaches for helping women with breast cancer.

As a Registered Massage Therapist I am required to take a certain number of continuing education hours every two years to maintain my professional standing. A practice I wholeheartedly support and enjoy. When this course was offered, even though I didn’t need all the credits, I leaped at the chance to attend.

Mr. Fourie is a physiotherapist from South Africa and a student of anatomy. He brought an enthusiasm and curiosity to the course that was wonderful. This was not a course full of recipes for treatment, this was a course about understanding. Understanding the structure of the body and what treatment for breast cancer does to that structure. He had brought many dissections that included intact connective tissue, something that is not usual in anatomy books, and ultrasound examinations of post-cancer treatment patients that were enlightening.

This excellent basis was then used to apply our skills in an intelligent, thoughtful way to create better function and ease for our patients. Though I learned few specific techniques in the class, the learning for me was in the specific knowledge about surgery – both tumour removal and reconstruction – that was presented, and the approaches and thought processes used.

Mr. Fourie has a great deal of respect for the human body, and for the human being within that body, which informs all of his approaches. I found his thinking very much in tune with what I try to bring to my work and welcomed the opportunity to work with other professionals in my industry that bring the same thoughtfulness to their work.

Mr. Fourie has participated as a presenter at both the fascial congresses that have happened and taught hundred of practitioners in the UK about his very successful approaches to breast cancer aftercare.

I thoroughly enjoyed this event and am already bringing some of the approaches into my practice – even on non-cancer patients. I look forward to bringing this enrichment of my skill set to more breast cancer patients in future.

 

Willem Fourie’s website

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