To Massage or to “Fix?”
In eight years of practice as a massage therapist in Madison, WI I’ve run a gamut of therapeutic massage from myofascial release, TuiNa, neuromuscular therapy to classic Swedish deep tissue techniques. At least to get a sense of what can foster lasting change and what doesn’t. What surfaced organically in the treatment room was myofascial release in the vein of Structural Integration (SI) techniques. But what didn’t come as effortlessly was a comprehension of why this style was so effective for some clients and not as much for others. As follows, an explanation of one important rule in the Holistic Paradigm lends discovery to the reason why. Uncovering further, our fascial system’s viscoelasticity (AKA plasticity) is the likely means by which this fascial characteristic holds its weight.
The Principles and Paradigms of Manual Therapy
The rabbit hole of manual therapy is virtually unending, but as the brilliant Jeffrey Maitland tediously examines in his book Embodied Being: The Philosophical Roots of Manual Therapy, some styles are principled while others, claiming to uphold a set of principles, are merely giving lip service. He gives examples of purported principles which divert from the very meaning of principle and are unwitting to the parameters that define the word in the first place. One defining characteristic of a principle is that it is not bound by circumstance. A principle is bound inherently without exceptions to its rule (Maitland, 2016).
Maitland also breaks down three important distinctions in manual intervention that may not occur to the common provider. The Three Paradigms of Intervention, are as follows: The Relaxation Paradigm, The Corrective Paradigm and The Holistic Paradigm.
Let’s tease these out a bit. Firstly, those who are familiar with my practice know that I am not a relaxation massage therapist. However, I’ve come to understand that the reason why my previous style of fascial bodywork worked well for some populations and not others was that I was crudely emulating The Holistic Paradigm but yet to be realized, from the effectual and limited standpoint of the Corrective. For example: “my knee hurts and I need you to fix it” by finding a more harmonious organization of the tibiofemoral joint complex.
Maitland explains these paradigms in hierarchical order, Relaxation cannot achieve the objectives of the Corrective or Holistic unless incidentally. Yet the Corrective and Holistic Paradigms may quite effectively meet the needs of the Relaxation Paradigm, as their results are relaxing as a given. It follows that neither the Relaxation nor Corrective Paradigms can touch the bounties awarded by the Holistic -again- unless by accident (Maitland, 2016). These accidents are often a phenomenon of practitioner’s intuition, informed by talent, skillset, education and most importantly: experience. After all, authentic healers can really only heal themselves.
So jumping back into principles- it is assumed that each of these paradigms have as many principles as they have strategies. However, I agree with Maitland when he contends that Corrective approaches contain no bona fide principles of manual therapy. (Maitland, 2016)
Due to ubiquitously variable circumstances in each unique human posture, any combination of vast structural patterns can and will appear. This is most certainly true in the totality of the individual and therefore most exemplified in affixed joint capsules or regional complexes in the body due to their roles as “hubs,” concentrating defects from the system-wide pattern. It follows that Corrective approaches, because of their blindness to the totality of strain in the whole, either employ the highest rate of exceptions in their application or use the old “work every last thing around it you can think of to fix it” trick. These divert from truly principled therapies because there are exceptions to their rule.
The entire foundation of my career was established under this desire to be holistic but deficient of a structured and holistic foundation. This “fix-it” approach had a negative impact on my client success plateaus throughout my years in practice.
Of course there’s more than one way to peel an orange. My intention is not to bash any of these paradigms as they are all tools for any given enhancement of being. But after learning under the Holistic Paradigm in the method of Structural Integration, I discovered that this style very strictly adheres to its principles. In most SI schools, one of these principles is that of Adaptability.
The Adaptability and Plasticity of our Fascial System
Adaptability describes changes in our posture through time. The principle states that as we live life, our fascial system molds our body in its shape to better anticipate and conform to our life’s daily habits (Maitland, 2016). If you sit at a computer and squint at a screen all day, your head and neck will slope forward, rightly shaping you into a computer desk body. I don’t know what this would look like, but if you play ski ball five hours a day you’re gonna get a ski ball body, and so on.
One tidbit of science behind the Adaptability Principle is the concept of fascial plasticity. On the cellular level, we have little friends called fibroblasts. These cells are like the worker bees laying down components of the fascial matrix honeycomb: collagen. Our fascial environment gives biochemical and biomechanical tensional, compressive and sheer force information that tells these fibroblasts where to patch up a weak or frequented link in the extracellular space with more collagen (Humphrey, 2014).
We call this cellular signaling cascade Mechanotransduction and one theory as to why this occurs is through piezoelectricity or compressional electric charge dictated by these vectors of information (Williams, 1995). Due to the three-dimensional continuity of this fibrous network, the fibroblasts have no choice but to do this according to the demands of the entire system. So wherever we need the reinforcement in our fascia, our bodies will make it.
These cells actively remodel our inner home to a more balanced mechanical configuration: a process so aptly coined tensional homeostasis. So how is our fascial adaptability best cultivated into the manual therapy picture?
Viscoelasticity Basics
In order to answer this question, we need to understand fascial viscoelasticity. It is a term that, when broken down, implies a quality of both the viscosity (gooeyness) and elasticity (bounciness, snappiness- or in our context: stretchiness) of our fascial groundwork. This is a characteristic of Silly Putty or its homemade version known affectionately as oobleck that you might have mixed up in preschool with cornstarch and water. Oobleck is sometimes made in bulk, put in large plastic totes and run over like hot coals. If you prance over it fast enough, your feet will imprint upon its surface as it carries you across. But as soon as you stop moving, your feet begin to sink and squelch like in quicksand.
At rest and set over time, oobleck functions as a viscous liquid, demonstrating plasticity. Upon sudden impact, oobleck retains that impact as a solid. Yet when slowly stretched, oobleck melts with the direction of pull. This is viscoelasticity in action (Myers, 2017).
When we stretch our muscles the myotatic reflex (aka the stretch reflex) engages to fire a muscle in response to the stretch. This is basically a safety feature preventing our muscles from being pulled or strained. Because this is a neuromuscular function, it is largely set apart from fascial phenomena like viscoelasticity (Myers, 2021).
As Tom Myers so elegantly describes in Anatomy Trains: Myofascial Meridians for Manual Therapists & Movement Professionals:
" A full understanding of this concept is fundamental to the successful application of sequential fascial manipulation. Practicing therapists, in our experience, make frequent statements that betray an underlying belief that fascia is either elastic or voluntarily contractile even though they 'know' it is not. The plasticity of fascia is its essential nature - its gift to the body and the key to unraveling its long-term patterns." (Myers, 2021)In a good myofascial release session, if we grip hold of the fascial sheaths around a muscle and manually stretch them (active or passive doesn’t matter since the aforementioned stretch reflex is not the focus here) the viscoelasticity of those sheaths do not allow them to bounce back in the same way nor within the same timeframe that a muscle’s stretch reflex does. Instead, they hold their new release for weeks to months after we’ve directly manipulated them (Myers, 2021).
The analogy we’ve been taught in Anatomy Trains (ATSI) is that of ripping a plastic bag. When you do so, the speed at which you pull the plastic apart determines whether or not it tears. If you do it slowly and gently enough so as not to tear, it will instead stretch and retain the length of this stretch (Myers, 2021).
Properly using our Viscoelastic Gifts
Of course, depending on any number of other postural contributions, the fascial lengthening we achieve in a session may not stay if postural disharmony in the rest of the body won’t physically permit it to. However, if these fascially short tissues are indeed directly responsible for this disharmony, then melting their fixation is paramount for purposes of sustained uprightness elsewhere in our body’s complicated tensional milieu. We do not know, as practitioners nor as clients, where these disharmonies might reveal themselves within a treatment regimen.
This is where a keen eye on the blindspots of the Corrective Paradigm must come back into focus. Under the corrective lens, a practitioner can certainly fix or “spot weld” regional pieces together again, yet what about those villainous muscly highwaymen lying in wait on the road to inner balance? And what about this incredible gift of viscoelasticity? We can certainly hunt down the culprits intuitively or accidentally walk right into them under the first two treatment paradigms, but with only limited comprehension of a few relevant short/long structural relationships, such a practitioner is only the blind leading the blind. This provider is also likely blind to the Glory of Lord Viscoelasticity. Our aches and pains may temporarily be relieved or simply shoved Lord-knows elsewhere but this will just exchange one pattern of compensation for a new one.
We get much more from a holistic manual intervention like Structural Integration, in that our goals are to systematically and repeatedly spin us out of our postural short parts, section by section. We examine not only shortness from what’s clear and obvious in the foreground, but also track their changes throughout the whole.
Structural Integration
Beginning with the superficial armoring of our larger multi-joint musculature, this unfolding process usually begins with correction in some places, overcorrection in others and/or continued fixation in certain stubborn rascals. We still use corrective measures to better appease local inhabitants of strain or symptom, though with the holistic picture in mind and foresight of what’s yet to come.
Once easing these superficial chains of musculature, the compensations held in our deeper musculature are next in line. From the Structural Integrator’s holistic viewpoint, these are the strongest holding patterns in our body and are often popular wellness circle muscles such as the psoas, the quadratus lumborum, the pelvic floor or the diaphragm. Over time, the bigger “show muscles” and their fascial linings have compensated for these of the deeper.
After gently coaxing the deep layers towards balance, the art of the work takes a more abstract configuration by focusing on harmony between the two layers: superficial and deep. This is also where we set the body up to retain and reverberate the changes after we’ve completed.
So not only have we been continually removing strain where it shows, but our viscoelasticity has long since released those shortened tissues which were previously disallowed their fullest expression. Usually these are compressed by other territories which we would happen upon later in the sequence of sessions. Those tissues, still abiding the weeks-to-months rule of viscoelasticity, are then given spatial permission to even more fully expand their plastic bags. This happens not only during the sequence but in the months following.
During and after the process, fibroblasts are receiving renewed informational pull perhaps in ways they never have before, resulting in new tensional pathways. From new mechanical demands implied upon our fibroblasts to pattern and adapt to, new viscoelastic releases occur purely by spatial de-approximation. Not only do they change in the interim, but they change indefinitely so long as our body is reconfiguring to this clean slate. Since our bodies are shaped by time and activity, then being shaped from a posturally-reset body makes it much easier for us to adapt to improved function in the long term and in the direction our organism has been reaching for all along.
This doesn’t mean that we will stay perfect forever, but it does argue a case for at least investigating a more holistic intervention before throwing indefinite sums of capital into endless massage or Myofascial Release (MFR).
What Massage Can’t Touch: Kinesthetic Literacy
Furthermore, with the aware and straightforward analysis of our bodies that a Structural Integration series can inform, our brain gets a massage. Therein lies the opportunity for one last push over the cliff, solidifying within another system entirely: the proprioception of our somatic nervous system. We can impact the structure purely by the viscoelastic changes, while opening the door for more conscious patterning to thrive. We don’t leave our desk jobs or stop deadlifting our barbells, but we do these activities as a more informed human with improved kinesthetic literacy afforded by the journey. This is different than a corrective practitioner telling us to stand with our feet closer together or our chins tucked back, because from within the old confines of our learned rigidity these cues simply don’t stick.
Over the course of a lifetime, the fascial system can become accustomed to a dysfunctional integration of its parts- like arguing toddlers fighting over a favorite Lego. The plasticity of our structure adapts to our habits as best as it can, but the structure as a whole is inevitably losing the battle with gravity. The benefits of viscoelasticity can’t usually be reaped except in cases of very scrupulous stretching, self massage and mobility exercises. Such a feat is likely doomed to failure if beginning from a dysfunctional baseline and uneducated guesses.
There’s no telling which of our compensations may recruit themselves to try to stand straighter within this dysfunction. Go ahead and try to stand perfectly within the harness of the many thousands of PSI that the fascial system can withhold (Van den Berg, 2022) and you’re ripe for a frustrating time or at the very least, a brand new postural defect on top of everything else.
Psychosomatic Cognitive Dissonance
For instance, we hold the belief that pulling our shoulders down and back will make us taller, but often our way of accomplishing this is by simultaneously engaging our upper paraspinal muscles. Since this muscle group’s job is to extend the spine, then contracting them will very effectively shorten us in the thoracic spine. This confusion is so prevalent throughout wellness society but largely goes unnoticed. It almost behaves as an ineffectual worldview manifested physically, begging to be validated despite its poison.
Education is the antidote here, as this somatic worldview will assert itself unless our conscious and informed examination can ease these discrepancies bitterly working at the expense of one another. We may need to learn some harsh lessons of where compromises must be made within us from any given direction.
Sometimes things are just plain wrong, but how can we learn if nobody validates the core intention behind these wrongs and explores the warrant as to why and how the original intention was meant to benefit us? In educating under a holistic lens, we seek to reconcile these conflicts through a means of reinforcements where they’re necessary and landing a compromise where this sabotage harms us. It’s not pleasant, but it’s necessary.
A Massage Therapist’s Call for Therapeutic Advocacy in a Changing World
Whether we target an injury’s symptom, relax a tense muscle or try to find the source, the gift of viscoelasticity is as good as trash without a comprehensive holistic lens. Weeks to months is a good timeframe for relief. It’s better than what you’d get from Swedish or even sports massage, but the blindspots within these other paradigms often detract from our healing due to their inherent (though well-meaning) ignorance.
Relaxation and Corrective styles leave room for us as clients to freely come and go at our symptomatic whim. This freedom is based on a flawed presumption that the overwhelming and convoluted noise afflicting the experience of chronic pain wouldn’t also completely distort one’s understanding of their needs. After all, we know our own bodies better than anyone else since we’re the ones living in there, but gut instincts can be just as wrong as snake oil when our survival brain is perpetually sputtering against learning how our comfort zones keep us imprisoned and hurting.
We can’t walk into the treatment room to “be healed” by somebody else and leave our utmost up to chance. Therapy is a two-way street. A practitioner is simply a guide. However if this guide hasn’t the courage nor consideration to lead someone in their flight from the cycle of wounded complacency, then most of what they can offer are piecemeal successes.
Acting within the Holistic Paradigm via Structural Integration, adaptability, viscoelasticity and somatic literacy are baked into the program; they are anticipated and implemented during the process. In a time inundated by somatic detachment, we must not allow our gifts to be buried by our merging with technology while our bodies remain a constant. These inherent biological gifts unify us and while we are also defaulted by them, they do not limit us without our consent.
-Anders Totten, ATSI, LMT
Works Cited:
1. Maitland J. Embodied Being: The Philosophical Roots of Manual Therapy. North Atlantic Books, 2016: 27-38
2. Maitland J. Embodied Being: The Philosophical Roots of Manual Therapy. North Atlantic Books, 2016: 16-17
3. Maitland J. Embodied Being: The Philosophical Roots of Manual Therapy. North Atlantic Books, 2016: 34-35
4. Maitland J. Embodied Being: The Philosophical Roots of Manual Therapy. North Atlantic Books, 2016: 38-40, 42
5. Humphrey JD, Dufresne ER, Schwartz MA. Mechanotransduction and extracellular matrix homeostasis. Nat Rev Mol Cell Biol. 2014 Dec;15(12):802-12. doi: 10.1038/nrm3896. Epub 2014 Oct 22. PMID: 25355505; PMCID: PMC4513363.
6. Williams P. Gray’s Anatomy. 38th Ed. Edinburgh: Churchill Livingstone, 1995: 412-415
7. Myers T. Tom Myers on How Fascia is like Non-Newtonian Fluid. Anatomy Trains Youtube channel, 2017. https://youtu.be/-HK-Ra-YEqM?si=md5BlTgpOMckLxqL
8. Myers T. Anatomy Trains: Myofascial Meridians for Manual Therapists & Movement Professionals. 4th Ed. Elsevier, 2021: 271-272
9. Myers T. Anatomy Trains: Myofascial Meridians for Manual Therapists & Movement Professionals. 4th Ed. Elsevier, 2021: 272
10. Myers T. Anatomy Trains: Myofascial Meridians for Manual Therapists & Movement Professionals. 4th Ed. Elsevier, 2021: 272
11. Myers T. Anatomy Trains: Myofascial Meridians for Manual Therapists & Movement Professionals. 4th Ed. Elsevier, 2021: 271
12. Van den Berg F. The Tensional Network of the Human Body: The Physiology of Fascia: An Introduction. Elsevier, 2022: 259