Part 3: NEURAL ENVIRONMENT

Next Friday, 3/22, please join us for the long-awaited Part 3 of the “Seeing the Sphenoid” Series.  As with all Enrichment Seminars, this one is free and open to anyone.  Plus there will be juice and crackers.    (Click on the poster to show details.)

My goal with this whole Sphenoid series is to offer a view of this most important bone that bolsters any number of clinical paradigms.  You don’t need to be a craniosacral aficionado or some intricate osteopath to derive immense benefit from this kind of inquiry.  If you work with human beings, and if you ever ponder their peculiar anatomy… well, this is the most peculiar of all bones, the most convergent fascial structure, the center of the whole neuroendocrine system, and the node from which much of our embryology initiates.  The more you know the sphenoid, the more beautiful it becomes.  And if I can communicate some of that, the clinical applications are quite secondary.

But since you asked, there are numerous clinical applications to relating to the Sphenoid.  I think most folks would agree that structural distortion in and around the sphenoid can plausibly have big physiologic consequences — although there is disagreement over the degree of distortion required for ill effect, and the depth of contact required for effective treatment.  Suffice it to say that if you want to treat cranial or facial pain, visual or occulomotor disturbance, sinus health, jaw movement, balance and spatial reasoning, and endocrine health, then you might benefit from having a better mental map of this bone.

So that’s been the plan:  a better map.  Let the clinicians figure out their own cause and effect.  But let’s all actually be able to see the damn thing, be able to feel it between our fingers, and understand its relationship to surrounding structures.  Part 1 was about seeing the 14 different fascial planes that comprise the sphenoid.  Part 2 was a view of the sphenoid as the deepest part of the face.  Next Friday, in Part 3, we’ll be looking at the various neuro structures — nerves, ganglia, and CNS, that surround this fascinating bone.  See you there — and bring your friends!

     This weekend in NfR Spine & Ribcage II, we’re all about the deep stuff:  the spinal dura, nerve roots, and all those converging fascial planes near the body’s midline.  This afternoon I handed out colored pencils, and had students draw along with me 3 different cross-sections of the body.

NERVES, BONES, AND BUBBLES (c) Hamm 2013

     In this schematic, everything blue is a neural axis, everything black is bone, and everything green is a “bubble”, or fascial compartment.  As we went along, we were careful to name the structure typically associated with each compartment, but we emphasized the fascial compartment and its fluid content.  Despite the fact that we did this right after lunch (when brains are notoriously sluggish), I think that folks began seeing some clarity that otherwise would have eluded them.  And the task of drawing every little compartment (simplified of course), demonstrated not merely that “it’s all connected” but how it’s all connected.  

More than anything, however, I just wanted to throw the anatomy lesson in a slow-cooker, so that facts could be synthesized and not merely learned.  Because deep palpation is challenging, and it’s essential to have patience, humility, and — above all — comfort with uncertainty.

If you desire complete clarity, you might as well never touch a patient.  It’s one thing to palpate nerves when they’re near the surface of the body:  When embedded in the subcutaneous fascia (such as the lateral femoral cutaneous nerve) or covered by relatively squishy things (such as the sciatic nerve beneath gluteus maximus), nerves are pretty easy to feel.  You just need to know what a nerve feels like (firm, springy, slippery), and where it’s located.  After that, the nerves emerge under your hand with surprising clarity.

But many neural structures are buried deeper in the body, and the assumption is that they can’t be felt or precisely manipulated.  In my opinion this is not true.  Depth is only a temporary obstacle, and always yields to patient inquiry.  Today on the white board, I tried putting it like this:

1) There is never anything you’re touching but skin.

2) There is no structure in the body you cannot contact.

Point #1 is obvious enough.  Bodyworkers use a shorthand to say “I contacted the Psoas muscle” or “I placed my thumbs on the Iliac crest.”  But no, you didn’t.  You touched skin, and the skin transmitted force into subcutaneous fascia, which stretched and compressed until it engaged with deep fascia, which deformed and transmitted force to its contents, and back up through that chain a mechanical resistance was transmitted to the skin, and thence to your palpating fingers. When these intervening layers are relatively thin or moveable, you can ignore them and (kind of) be OK.  But the deeper you go, you will need more fidelity to what’s actually pushing back.

     Point #2 is tougher to argue, but in my experience, it’s absolutely true.  I’ve talked before about palpatory vision, so I’ll keep this quick:  As long as you know the shape and behavior of the intervening structures, you can feel the target structure with utter clarity.  Put another way: deep structures only feel murky because your mental picture doesn’t match what’s actually beneath your fingers.

In this honing process, none of us are perfect.  We’re all learning new subtleties — those of us still in the game — and we will be until we retire.  Even the unmatched anatomist, when faced with a unique individual on the table, must keep her knowledge flexible to the particularities of this tissue, this person, this moment.

And so in the learning of palpation, it turns out to be a half-truth that you can “get it” at all, as one might solve a math problem.  You never will.  Instead, you must be willing to arrive, over and over again, with the palpatory task at hand.  Here are some guideposts that help me arrive on a daily basis:

• The body is a water balloon.  Every structure in the body was initially organized by two elements: fluid pressure and membranous tension.  Include them in your mental picture, and the details resolve better.

• Depth is not pressure.  The layer you contact is not dependent on how hard you push, but on how you engage the intervening structures.

• When first learning, separate depth from shear.  Sink to the desired layer, then engage it.

• Everything that can be felt, can be felt with greater ease.  Every time you’ve reached a target structure, adjust your body mechanics and hand shape, and breathe.

• What you feel is changed by you feeling it.  Don’t expect a static landscape; it’s not what it was two seconds ago.

I love it when I get ambitious students.  Folks who lean in to the demo, eyes fixed on the prize of a new skill, gobbling up ideas.  But when it comes to palpation, take it from me:  you need to slow your roll.  Stop pushing, start sinking, and when possible, get lost.

This week, some thoughts on a recent favorite of mine: the Costal Neurofascia.  The contemporary ribcage, twisted as it is from messenger bags and gall bladder removals, seems to assert itself as a frequent problem area.  If you look at a single segment of the thoracic nervous system, it’ll look something like this:

Thoracic nerves — with a few exceptions — most follow this pattern:  Starting inside the vertebra at the spinal cord,  they send out dorsal and ventral roots, which join into one while exiting the intervertebral foramen.  Immediately upon exiting the foramen the nerve root splits in three very different directions.

The dorsal ramus exits dorsally (duh), right between the ribs, and sends two major branches (medial and lateral) toward the surface.    This dorsal ramus innervates everything dorsal to the transverse processes, including the facet joints, spinal ligaments, paraspinal muscles, lumbodorsal fascia, and skin.  As it emerges toward the surface, the dorsal ramus usually follows a gentle downslope (postero-inferiorly) at a similar angle as the adjacent spinous process.  The medial branch eventually makes it to the areolar fascia just underneath the skin, but to do so it has to perforate several thick fascial sheets and traverse big changes in surrounding fluid pressure.  Fascial pathology in the back often leads to chronic inflammatory pain — and sometimes motor and sensory changes — in these dorsal rami.

The thickest nerve branch — the ventral ramus — exits laterally from the spine and follows a tunnel just beneath its corresponding rib.  The rib’s periosteum hangs downward to make a long fascial “hammock” for the nerve as it rounds the curvature of the ribcage, and this sheet is then thickly invested with intercostal muscles.  When it reaches the lateral ribs, it sends a branch perforating to the surface that emerges right between the tapered ends of serratus anterior, and innervates the skin on the side of the torso.  Then it continues anteriorly, innervating the abdominal muscles and sending a last branch to the surface at the sternal notch or rectus sheath.  Just like the dorsal ramus, these lateral and anterior branches are common culprits for pain, inflammation, and movement dysfunction.

Oft-forgotten are the rami communicantes (white and grey) — a pair of thin filaments extending anteriorly along the vertebral body and connecting to a sympathetic ganglion.  These filaments provide a two-way communication between the somatic and sympathetic nervous systems, allowing both to respond synergistically on a local level.  (For example a muscle may contract around an injured organ.)  Both ganglion and rami communicantes are embedded in a nested cylinder of prevertebral fascia, and from there the ganglion sends branches into various visceral compartments.  The prevertebral fascia must, like a well-fitting sock, be able to twist and torque along with the spine, or local forces can alter (or injure) the function of the sympathetic chain.

Deep to the ribs, the visceral chamber has two major neurofascial players — the vagus and phrenic nerves — each of which descends from above  and enters the ribcage at the thoracic inlet.  The vagus spreads out like angelhair pasta around the heart, major blood vessels, trachea and esophagus.  The phrenic nerve traverses and innervates the pericardium/diaphragm unit.  While these nerves don’t emerge segmentally like the others, their fascial envelope certainly exchanges force with the rest of the nervous system.  The visceral cylinder’s role in producing movement dysfunction and chronic pain/inflammation should not be ignored.

Try to build this map in your mind just as an embryo would — first the compartments, then the organs/muscles/bones.  Doing so will lead to a much easier time palpating and working on these nerve structures, and inform your model of how the whole neurofascial organ moves together.

Heads up bodywork nerds — this Friday we’re doing another (free) seminar, this one called “Feeling into the Body: Learning palpatory vision from the feet and ribcage.”  We’ll be exploring how skilled bodyworkers are able to pull off a seemingly “voodoo” move:  contact some distal or exterior part of the body, and then get detailed spatial information about a structure that’s far away or deeply buried under opaque tissues.

As a teacher who hangs out with researchers, teachers, students, and consumers of bodywork, I often encounter two erroneous attitudes on this subject:  One, that such a skill does not actually exist, and two, that it cannot be taught.

To the second notion, I’ll simply say that “You either got it or you don’t” is a hallmark saying of burnt-out teachers and ego-stricken artisans, and has no place in a classroom.  People vary in their learning ability, but rarely is there no point in trying.  More often, “it” has not been sufficiently explicated, and so we treat “it” as needlessly mysterious.

To the first point, I readily admit that I can’t yet use words to convince an ardent skeptic.  I’ve not seen an RCT or a meta-analysis on the subject of “feeling in”.  Most scientific attempts to investigate palpatory skill use a research methodology called “intrarater/interrater reliability”, and the variables measured (such as in trigger point evaluation or vertebral mobility assessment) are too sparse to give us much insight into the richer (but squishier) world of palpatory vision.

However, I think I can make a decent appeal to reason.  Palpatory vision does not require some extra sense, nor is it limited to a small segment of the population.  All it requires is a mental map of how things connect to each other, and some time spent interacting with the anatomy.

Imagine driving a car — one familiar to you — and suddenly blowing a flat tire.  Vibrations of rubble and asphalt shake the frame, fill the air inside the car, jar the steering wheel, the window pane, the driver’s seat.  Do you need to go out and look at which tire is flat?  Or can you simply feel into the car and notice which wheel is bumping?

Imagine swinging a baseball bat with your eyes on an incoming ball.  POW, the ball is struck, and you are off running.  But feel your hands in that moment: could you tell whether the ball was hit nearer the handle or the tip?  Could you sense whether it was a glancing blow or dead-on?

Your mental map of the car allows you to extend your sensory field into its parts.

This sensation-by-proxy is a fascinating skill, seemingly universal to all humans, and we’re only beginning to articulate the mechanisms behind it.  But the same ability we have to feel into familiar objects,  discern information about their inner workings, and sense through them their contact with surroundings… that can be taught in bodywork.  By holding the feet, for example, we can learn to sense tensional asymmetry along the spine, or feel peritoneal adhesions resist the movement of breath.  By placing a receptive hand on the sternum, the entire thorax comes alive with spatial detail.

Is this skill dependable enough that it should be used in the absence of conversation or direct palpation?  Not in my experience.  Should it be used to contradict imaging or physician’s advice?  Obviously not.  But it’s a powerful tool in the art of anyone who uses their hands to treat human bodies, and it’s high time we had a straightforward vocabulary for teaching it.

(Pre-Reading for Friday: KEG’s article in Massage Today Leon Chaitow’s excellent text, Palpation & Assessment Skills.)

The human hand is a wondrous machine and the maker of wondrous machines.  With its image we can depict the most intimate kindness and the basest violence.  Through it we accomplish almost every task, we signal our intentions, we connect to the world.  But with each gain in ingenuity, the hand manufactures challenges to its own health.  That’s what this Wednesday’s free seminar is about — trying to get an integrative clinical grip on today’s upper extremity.

Pain and injury is partly a mind-body challenge.  The hand’s very usefulness often masks it from our awareness until it’s too late:  Often we are so intent on doing, assembling, tinkering, and investigating the tactile world, that we become de-sensitized to the early complaints of an awkward usage.  Then when the complaints get loud enough to surmount our neglect, the healing process requires more than simple cessation of injurious acts.

When’s the last time you were simply aware of your hands, without a specific task or focus?  Can you feel into them without orienting to some object or surface on the outside?  Can you survey, without attempting to alter, the emotions that accompany each hand sensation?  What shape do the hands take in your mind’s spatial map?

Dorsal dissection of the hand (Gray's Anatomy)

The somatic challenge — healing the mind-body divide — is, however, only one of many lenses to view hand health.  Without a sense of specific anatomy/physiology, the local details get missed, and the hand remains a poetic abstraction.  Without a nod toward innervation and brain plasticity, the hand gets treated too roughly — a mutinous mechanism, robbed of its neurologic nuance.

For clinicians working with repetitive stress injury (RSI), the hand seldom yields to only one model.  Try to grasp (ha!) the hand’s inner workings, its sources of injury and healing, and you are bound to feel incomplete.  The best you can do is to cultivate some parallel modes of investigation and encounter a range of different patients.  Over time you gain a bigger toolset, more comfort in switching between approaches, and also a sense of where conceptual models cease to be useful.

Wednesday’s seminar (open to anyone) is a 90-minute snapshot of my current understanding.  We’ll look at the hand in terms of its embryology and evolution, and thus get a sense of how its functions have been grafted on to old structures.  We’ll watch it navigate the daily tasks of a modern person, and look at some examples of imbalance and awkward positioning.  We’ll build a decent map of the neurovasculature, the bones and ligaments, the muscles and tendons.  And through it all, we’ll notice how the brain and the spinal cord re-map connections based on injury and experience.

(Interested folks should skim this related article:  Work-Related Musculoskeletal Disorders of the Hand and Wrist: Epidemiology, Pathophysiology, and Sensorimotor Changes (Barr et al, 2004))

For the last 4 years, as I’ve built up and refined several condition-specific workshops around Neurofascia, I kept finding the need for a more basic inquiry — what’s it like to palpate nerve tissue directly, and how can we better feel the nervous system moving within us? If we can explore palpation and movement with a vivid awareness of the nervous system, we have the chance to create far more intuitive and effective neurofascial treatments on our own.

We don’t have to palpate the Teres Minor with an “idea” of the Axillary nerve — we can just feel it embedded there in its fascial envelope, assess its mobility and health, and devise treatments based on a dynamic conversation with the nerve’s environment. Likewise, we don’t need to stretch our Hamstrings with an “idea” of how the Sciatic nerve might be stretched — we can just stretch the nerve, feel it gently connect into the spinal dura, and feel the gradual unwinding of muscles & fasciae around its perimeter.

This direct experience of neuroanatomy — underpinning more complex treatment approaches — is the theme for next Sunday’s double header: “Touching a Nerve” and “Neurofascial Movement”.  Each class can be taken separately, or bundled as a discount. Click on the picks for more info, and see you there!

A few things are noteworthy about next Friday’s Seminar.  First is the brand-new subject material, which takes a layered tour of the fascial architecture of the ribcage, and then delineates a few common fascial strain patterns and some basic treatment strategies.  I promise it will be entertaining.

Second, the seminar is in a new location — up in the Forum at Seattle Healing Arts (63rd & 9th in Ravenna).    Lastly, please keep in mind that Enrichment Seminars are community events — free and open to anyone — so please invite anyone who you’d think would be interested.  See you there!

Phrenic Neurofascia

Two seemingly opposite things are true about depth in bodywork:  First, there is nothing you’re ever touching but skin.  All else is literally untouchable (unless you decide to become a surgeon).  Once you’ve accepted that limitation, however, another truth emerges:  There is no structure in the body that you cannot contact with therapeutic intent.  Every bone, every foramen, every ligament, every joint capsule, every fold between organs — all are accessible with the right combination of angle and approach.

The problem is that when learning bodywork, you try too hard, and you confuse depth with pressure.  But they are different qualities, and in some places — such as the ribcage or the cranium — too much pressure will make surface tissues opaque and prevent your contact with anything deeper.  But if you cultivate a practice of “just enough” pressure, and then pair it with reasonably accurate anatomy, you can profoundly affect deep structures in the body.

So it is with the phrenic nerves — innervators of the diaphragm — as they spill over the anterior scalene and begin their journey down each side of the heart.  Once inside the ribcage, they descend the crevice between pleura and pericardium, and must contend daily with the pressures and tensions conferred by the movements of the mediastinum.  The pericardium, especially, is often quite joined to the phrenic nerves.  Which makes sense, since the pericardium then connects seamlessly into the diaphragm’s central tendon.   Near the bottom of the heart, each phrenic nerve sends a branch anteriorly, toward either side the xiphoid process.  Then, upon joining the diaphragm, each nerve branches in multiple directions to innervate the whole dome of the diaphragm.  These branching points are of particular interest since adverse neural tension can converge there.

When in doubt, stare at cross-sections!

OK, let me ask the obvious question here:  Is it really possible to put your hand on the outside of someone’s ribcage and make a specific therapeutic contact with the phrenic nerve?  In my experience — and in the experience of many students — yes, absolutely.  After some practice, most practitioners wouldn’t even call it difficult.   Furthermore you can learn to feel quite a lot of detail inside the ribcage, and make keen palpatory assessments as to what’s sliding, what’s under tension, and what’s limiting the motion of the whole breathing apparatus.

It helps to begin with simple abstractions, and then zoom in when you get curious.  To begin with, it may be useful to visualize the heart and diaphragm as one structure, with a heart-balloon above and then a muscular skirt below.  This shape is the ‘phrenic neurofascia’ — a single fabric with the phrenic nerves along its major axes.

Try this:  Place a few fingertips from each hand on your sternum. Acquaint yourself with the landscape — the divots between rib attachments, the horizontal ridges and fascial lines, the broad manubrium above, the xiphoid extending below. This is your depth: the sternal surface. Feel the slippery bone when you make tiny circles, and feel the firm grab of fascia when you carry the skin in one direction. Now make a depth adjustment. Instead of sliding on the sternum, take the sternum with you. You’ll be tempted to push hard — but stick with medium pressure. Just slide upward until the fascia engages. And then pay close attention: the sternum has joined your motion. If you gently go farther, you’ll notice a slight pull into your rectus abdominis. If you add a sideways component to your hook, you’ll feel the ribs compress slightly on that side. If you breath deeply, you’ll gain a sense of the sternum as the center of the rib cage, and you might feel how the ribs connect to the spine.

Pericardium (Sagittal View)

Now adjust your depth again, and imagine the underside of the sternum. Realize that the sternum is firmly attached to a tight fascial balloon — the pericardium — that surrounds the heart and stretches toward the spine. The sternum is no longer an object of your curiosity; it has become your tool for contacting the next layer. Try to keep your pressure the same, and explore the curved expanse of the pericardium. You can hook into its front surface, a mere half-centimeter from your fingertips, or your intention can reach into the top, the sides, the back. Can you feel the valley between the heart and lungs? Can you hook into the broad attachment to the diaphragmatic dome? Take another deep breath, and feel the pericardium become taut as the diaphragm descends.

I call the phrenic nerves the “neurofascial axis” of pericardium-diaphragm.  The nerves are part of the pericardium’s fabric (indeed, they innervate the pericardium), and you can create space, mobility and tensile balance in the phrenic nerves by doing the same with the whole landscape.  Once you become used to engaging the interior in this way, you’ll often be able to find local adhesions, contractures, and bands of tension, whose resolution coincide with profound changes in breathing.

When in doubt, look at pictures, and then try again. As your mental picture improves, the shape of the pericardium will emerge naturally in your palpatory vision. You will realize that the apparent hardness of the sternum is no obstacle at all if you know how it’s connected. The question of pressure is easy: what level of pressure feels comfortable for your patient? What level of pressure allows you to feel the most detail in your object of inquiry?

Last week in Vancouver there transpired an amazing event:  The Third International Fascia Research Congress.   I’ll soon talk more about the Congress, some of its key findings, and what it means for nerve- and fascia-oriented bodyworkers.  But for starters, here’s a little poster submitted by me and Wil, summarizing some of our cross-sectional study of spatial relationships between nerves and fascial planes:

(Bonus points to the readers who can spot the typo.  Yes, I left it in.  For science.)