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FASCIA AS A SENSORY ORGAN: Clinical Applications

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2 Terra Rosa E-mag No. 20
FASCIA
AS A SENSORY ORGAN:
Clinical Applications
by Robert Schleip
Terra Rosa E-mag No. 20 3
It is now recognized that fascial network is one of
our richest sensory organs, the fascial element of
the muscle is innervated by approximately 6 times
as many sensory nerves than its red muscular coun-
terpart. Fascia contains four types of sensory nerve
endings, which are responsive to mechanical stimu-
lation: Golgi organs, Ruffini receptors, Pacini cor-
puscles, and Interstitial receptors. These sensory
nerve endings can be called fascial mechanorecep-
tors, meaning that they respond to mechanical ten-
sion and/or pressure. These mechanoreceptors
have been found in intramuscular, as well as extra-
muscular, and fascial tissues. Therapists working
with fascial tissue now understand that these mech-
anoreceptors respond to various kinds of touch
(Table 1). This article provides examples of how
specific techniques can be utilized in order to opti-
mize an intended stimulation of specific mechanore-
ceptors in fascial tissues.
Stimulation of muscle spindles
The ‘petrissage’ from Swedish massage – a form of
deep, rhythmical kneading that can be best ap-
plied for this purpose. In order to use the myotatic
reflex arc in a muscular relaxation direction, the
therapist uses both hands to grab hold of two larger
muscular tissue portions and moves them towards
each other in a compression manner. Using a more
rhythmical style, the therapist attempts to quickly
decrease the length of the muscle spindles in the
zone between the two hands. A different version of
this basic technique is sometimes used in sports
massage for the purpose of increasing muscle tone
before an athletic performance. In this case the two
hands move away from each other in a rhythmic
fashion, thereby inducing a stretching effect rather
than compression in order to ignite the well-
known myotatic reflex in a way that stretches mus-
cle spindles and thereby exerts a stimulatory effect
on the active muscular tonus regulation. In contrast,
in the style described here, the two hands attempt
to create a rapid tonus decrease within the spindle
fibres, which is expected to induce a tonus-
decreasing effect on alpha motor tonus activity.
Stimulation of Golgi receptors
In myofascial mobilization it is typical that slower
tissue deformations are created, with a focus on re-
laxation rather than on tonus augmentation. The
Golgi receptors are a good target for such an ap-
proach, since stimulation of these neural receptors
tends to induce muscular relaxation in those muscle
fibres that are mechanically linked with the area
of stimulation. However, when applying stretch in
tissue areas that are serially arranged with soft and
compliant muscle fibres, all stretch can be
‘swallowed’ by the softer myofibres (rather than the
more rigid collagen fibres) and the Golgi receptors
within the collagenous fibres may not sufficiently
lengthened.
One way to prevent this seems to be a cross-fibre
mobilization across the muscle belly area (rather
than the muscular attachments) in order to mini-
mise the spreading effect towards the compliant
muscle fibres. A common technique, often taught as
part of the Bowen method, involves cross-friction
across the muscle bellies, which might induce at
least a temporary regional muscular relaxation via
stimulation of related Golgi receptors. If one wants
to work within the more tendinous areas, another
approach is advocated. Here the client is asked to
activate the related myofibres against external re-
sistance, while the therapist applies a moderate to
strong stimulation (usually 1050 N/cm2) to the
tendinous collagenous tissues that are tensed by the
respective muscular contraction. One way of achiev-
ing this seems to be by using the post-isometric re-
laxation technique, as frequently used in the pro-
prioceptive neuromuscular facilitation or (PNF)
concept. Here the client is usually instructed to con-
tract a joint musculature against the handheld resis-
tance of the therapist for a period of between 60
and 90 seconds and a ‘tissue release’ is often ob-
served during the subsequent relaxation. Some-
times there is also a brief antagonistic contraction
included immediately before the final relaxation.
A more advanced and proprioceptively stimulating
approach was taught as ‘pandiculations’ by Thomas
Hanna (1998). Here the therapist also provides an
4 Terra Rosa E-mag No. 20
external resistance to the actively moving body part
of the client, however, client and therapist cooper-
ate in such a way that the client is instructed to
move against the resisting hand of the therapist in a
super-slow continuous fashion. Subsequently the
respective limb is pulled back towards the body,
again against a moderated resistance of the thera-
pist; and this movement is also performed in a
smooth and super-slow fashion. Client and therapist
direct most of their mindful attention toward
achieving a non-erratic movement quality (i.e., with-
out any perceived ‘stop and go’ interruptions). As
soon as such an erratic moment is detected, the cli-
ent is instructed to return to the position immedi-
ately before it happened, and then try to repeat the
movement at an even slower speed and, hopefully,
with less bumpy movement orchestration. This ac-
tive resistance phase with the client participating
in both concentric as well as eccentric activation is
usually practiced for between 60 and 90 seconds
and as in the PNF technique is followed by a
brief moment of isometric contraction of the an-
tagonistic muscles. In addition, the therapist pro-
vides a strong myofascial stimulation (but not be-
yond the comfort zone of the pressurepain toler-
ance of the client) to the fascial tissue area within
Table 1. Overview of the different sensory receptors in myofascial tissue, the responses triggered by their stimulation, and
the manual techniques that can evoke those responses. From Schleip (2017), Reproduced with permission.
Terra Rosa E-mag No. 20 5
the tendinous portions of the related musculature.
For example, when sitting, a client may be in-
structed to slowly raise her right shoulder against
the external resistance of the therapist. Then she is
asked to gradually lower her muscular activation in
order to allow the downward pushing force of the
therapist to gradually lower the shoulder to the
starting position. Each of these two movements
should occur in a smooth, uninterrupted, continu-
ous manner, lasting at least five seconds each.
Whenever a tiny ‘jerk’ is detected by either the cli-
ent or therapist, the movement is repeated with in-
creased mindfulness from the position shortly be-
fore it occurred. During all of this the therapist
works with a deep stretching myofascial release
approach on the aponeurotic insertions of the upper
trapezius on the superior nuchal line of the cra-
nium. After approximately 60 to 90 seconds the
myofascial hands-on work is finished and the client
is asked to perform a downward active shoulder
movement for one or two seconds only, with her
elbow pressing isometrically against the resisting
hand of the therapist. Finally, the client is asked to
relax and to subjectively compare the perceived
height and sensation of the treated shoulder with
the other shoulder.
Stimulation of Pacini corpuscles
The following example is for the stimulation of spi-
nal joint receptors in the cervico-thoracic region.
The client is asked to lie comfortably on her right
side with the therapist sitting behind the client’s
back. The therapist starts with a prominent spinal
process, for example, from C6, C7, or T1, and lifts
this process a few millimetres away from the table
toward the ceiling. It is then wiggled two to four
times in a random manner before it is lowered again
to the starting position. This is repeated in slightly
different lifting directions, varying between slightly
more cranial and more caudal lateral directions. The
lifting amplitude is calibrated so that the maximal
delay occurs between the movement of the manipu-
lated vertebrae and its two adjacent neighbours.
The intention of the therapist is to show the central
nervous system of the client that the spine in this
region is not a rigid column but rather a series of
mobile elements that are arranged like a string of
pearls. If successful, this may support a related ref-
ormation of the respective cortical mapping of what
is called ‘body schema’ representation in the brain.
One or two minutes are spent in this way on each
vertebra before the neighbouring vertebra is ap-
proached in a similar manner. The natural breath-
ing movements of the client are carefully observed.
Sometimes during a slow lifting movement of a tho-
racic spinous process a normal inhalation move-
ment is slightly increased in time and amplitude
(maybe 10% more than usual). If this happens, the
therapist may play with the concept of ‘taking a
ride’ on this extended inhalation and lifting the ver-
tebra a tiny bit more (and for a second longer) at
the apex of the inhalation movement. If successful
this may result in a release-like response around
the costo-vertebral joints of the respective verte-
brae on the side on which the lifting movement
causes a temporary decompression.
Note that it may take 10 minutes to apply this tech-
nique to the spinous processes of, for example, C6 to
T5. In most cases the technique does not need to be
repeated for the opposite side-lying position at
least not in those cases for which the main intention
is to produce a more refined representation of this
spinal area in the client’s body schema in terms of a
mobile rather than rigid body portion.
Stimulation of Ruffini corpuscles
Here a slow but firm touch is provided that exerts a
lateral tangential shearing motion to the skin, as
well as to fascial membranes below the subcutane-
ous loose connective tissue. Once the pressure
achieves a slow gliding of the therapist’s hand in
relation to the skin of the client, the speed of this
gliding motion is calibrated toward the slowest pos-
sible continuous speed. For a beginner this may be a
speed around 5 cm per second, while for a more ex-
perienced therapist much slower gliding motions of
around 1 cm per second or less are possible. If pos-
sible the client can be instructed to assist this tech-
nique by conducting a slow active movement par-
ticipation that provides an expansional stretch to
6 Terra Rosa E-mag No. 20
the working area (Fig. 1).
During the gliding motion, the therapist feels for the
optimal vectorial direction of his/her hands
whether slightly more vertical/horizontal, more
distal/proximal, or more medial/lateral, etc. at
which the local tissue relaxation response spreads
out most readily toward a larger, more spacious tis-
sue response. The analogy of a school of fish can be
employed to foster the related empathic palpatory
sensitivity of the therapist (Fig. 2).
Stimulation of free nerve endings
The recent discovery of the tactile C-afferents in the
dermis of the hairy skin of humans (and other mam-
mals) has led to an increase in research on ‘affective
touch’. Based on this, therapeutic methods – usually
involving gentle and slow stroking are explored,
and these provide the cortical insula with a sensa-
tion of nurturing touch, also called ‘social touch’,
which can induce a general sense of well-being and
relaxation in the client. The depth of responses can
involve profound shifts in immunological, psychoso-
cial, and neurophysiological parameters (McGlone
et al., 2014). For related instruction on this intrigu-
ing aspect of therapeutic touch the reader is re-
ferred to the new literature on this subject, for ex-
ample, Lloyd et al. (2015) and McGlone et al. (2014).
Another method for stimulation of C-fibres or A-
delta fibres (both terminating in free nerve endings)
targets the high density of their related nerve end-
ings in the periosteum (i.e., the fascial envelope
around bones). This approach is inspired by the
ancient Chua K’a method, as taught by Oscar Ichazo
(Hertling & Kessler, 2006). Here strong pressure is
applied to bony surfaces until a slight sympathetic
activation is observed in the client. This response
may involve a slight dilation of the pupil, an in-
creased and elongated inhalation, an increased cir-
culation in the face, and/or a turning of head and
eyes toward the respective body part. It should be
an expression of the so-called ‘orienting response’
in behavioural biology, during which an animal re-
sponds to a new challenging stimulus by straighten-
ing its neck upwards toward the perceived place of
Figure 1. Example of the use of AMPs (active movement participa-
tion) with the client during a Ruffini-oriented release technique.
While deeply melting with one hand into the tissue and specific
joints of the upper thorax, the therapist guides the client to sup-
port his myofascial work with subtle and random slow-motion
participations. Here the client performs a lateral bending move-
ment of the thorax combined with a cranially directed extension
(following the elbow) in order to increase an opening of the tho-
racic vertebral joints. Photo (c) Schleip.
Figure 2. Myofascial tissue illustrated as a school of fish. A thera-
pist working with myofascial tissue may feel several of the motor
units responding to the touch. If the therapist then responds sup-
portively to their new behaviour, the working hand will feel other
fish joining this release, and so on. Photo (c) Schleip.
Terra Rosa E-mag No. 20 7
stimulation in a general state of alertness. Care
should be taken that an avoidance-and-withdrawal
response is avoided, which expresses itself in very
different behaviour involving a flexion movement of
the trunk and limbs, a turning away from the per-
ceived stimulus location, a shortening of the neck,
and either a halt in breathing or an augmented
breathing speed. The client may be instructed to
participate with an active movement that intensifies
the perceived pressure with an assertive gesture,
such as arm abduction and pushing the elbow into
the working stimulus of the therapist. The use of
tools such as in instrument-assisted manual
therapies could help with more precision.
Once a slight sympathetic orienting response is
achieved, a moment of rest without any touch is
added, during which the therapist waits for at
least three to five of the client’s breathing cycles
until a parasympathetic shift (or general relaxation)
is observed. Subsequently a spot on the periosteum
in very close proximity to the first spot is treated in
a similar manner. If there is a hyperalgesic zone,
the treatment starts first in the nearest area with a
normal pressure sensitivity. Once a relaxation re-
sponse is achieved there, gradually periosteum
zones nearer to the hyperalgesic spot are treated.
The goal is a gradual desensitization process lead-
ing to increased resilience to pain. Most likely this
process will involve an activation of cortical de-
scending modulatory pathways (Bingel & Tracey,
2008).
Summary
Stimulation of spindle receptors can be facili-
tated by quick compressional impulses to the
muscle bellies.
Golgi receptors can be stimulated by techniques
that require temporary resistance by the client.
Ruffini techniques attempt to apply slow shear
sensations while finding the respective optimal
vectorial direction.
Pacini corpuscles require constantly changing
novel sensations.
Free nerve endings can be stimulated by work
on the periosteum.
This article is an extract Chapter from the book
“Fascia in the Osteopathic Field” (Liem, Tozzi, Chila
Eds), Handspring Publishing, 2017. Reprinted with
permission from Handspring Publishing.
References
Bingel, U., Tracey, I. 2008. Imaging CNS modulation
of pain in humans. Physiology. 23:371-380.
Hanna, T., 1998. Somatics: Reawakening the Mind’s
Control of Movement, Flexibility, and Health. Da
Capo Press, Cambridge MA, USA.
Hertling, D, Kessler, R. M 2006. Management of
Common Musculoskeletal Disorders. Lippincott Wil-
liams & Wilkins, Philadelphia, p. 170.
Lloyd, D. M., McGlone, F. P., Yosipovitch, G.2015.
Somatosensory pleasure circuit: from skin to brain
and back. Experimental Dermatology.24(5):321
324.
McGlone, F., Wessberg, J., Olausson, H. 2014. Dis-
criminative and affective touch: sensing and feeling.
Neuron. 82(4):737755.
Picture CC0. Public Domain
Excerpt from: Terra Rosa E-mag No. 20
https://issuu.com/terrarosa
... The consequence is that the loose connective tissue will act like glue instead of oil, making adjacent structures stick to each other -all the way up to densification. Furthermore, the fibroblast will turn into a myofibroblast and have a contractile force in the fascia -when affected by the sympathetic nervous system [14,15]. Back to my children and adolescents that are feeling stiff. ...
... Another interesting observation regarding the loose connective tissue is that it contains a lot of interoceptors [14,15]. Interoceptors are part of our sensory system that gives us the opportunity to feel our selves. ...
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