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Suppose a manual therapist found cause to contact the Lumbar Plexus in the abdomen.  Maybe it’s sensitized or entrapped.  Maybe the therapist suspects distal irritation to stem from a proximal cause.  How on earth could they engage the plexus with reasonable confidence,  given its depth and palpatory obscurity?

The short answer: Grab what the plexus grabs.

The same tissues that supposedly obscure it are your greatest tools.  The loose connective tissue within its layer.  The interfacing fascial planes.  The perforated and innervated tissues.

The body’s mechanical resting state is sometimes called a “Pre-Stress” or (or pre-load, or tensegrity) in which all tissues are suspended together in a balance of fluid pressure and membranous tension.  Any act of therapeutic contact depends on modifying this pre-stress, at least temporarily, to make an assessment or elicit a physiologic change.  Nerves also exist in pre-stress, pressurized from within and gently tensioned along their length.

So the method for meaningful contact is to ‘hook’ tissues mechanically linked to the Plexus — like the anterior thoracolumbar fascia and the muscular abdominal wall — and deform them in a way that is likely to change the basal pressure/tension on the associated nerves.

Likewise the innervated tissues can be a tool for engagement. The Lumbar Plexus ventral rami must perforate through the Psoas muscle and then course laterally and inferiorly within the pelvic bowl, behind the kidney capsule and peritoneal balloon. The dorsal rami peel off posteriorly just lateral to the intervertebral foramen, sending branches around the facet capsules, into the paraspinal muscles, and into the skin of the low back and buttocks.

Imagine what was cut away to be able to see this view — and you’ll have a good idea of what you want to engage manually.

All of these interfacing, perforated, and innervated tissues form a connected fabric — a neurofascia — whose skillful co-engagement might allow for a meaningful contact with the lumbar plexus nerves.

Caveats to keep in mind:

Depth ≠ Pressure!    You will notice I am not “deep tissueing” any muscles here. Gentle and slow deformation is enough to get dramatic change in the defensive behavior (pain, guarding, inflammation) of the nervous system.

Palpation ≠ Objective finding!   It is Practitioner-Subjective. You will also notice that despite the richness of my experience, I am not compelling my patient to accept my observations as fact.  I am not making key diagnoses or assessments based solely on palpation either.   What I am doing: Stating what I am feeling. Using palpation to ask more subtle questions of the body. Refining the location and depth of my work.   Scanning for sensitized or abnormal tissues.

Tactics ≠ Strategy!    As usual it feels incomplete to share videos of manual therapy “moves”, without also constructing the clinical reasoning process that makes them coherent.  I shall ask your patience with the infrequency of my posts.  And I’ll welcome you, internet friends, to be incensed or inspired according to your inclination.

Jan
05
Posted by Mike at 12:00 pm

Lots of captivatingly juicy Neurofascia classes are now on the books for 2016.    (Bodyworkers, Manual Therapists, and Healthcare folks welcome.)

JAN 23 — Neurofascial Approach to Headaches
https://nfa-headaches.eventbrite.com

JAN 30 — Neurofascial Approach to Jaw Pain
https://nfa-jawpain.eventbrite.com
** (Note: the above two combine for an IntraOral Cert)**

FEB 10 — Fascial Assessment and Practice
https://fascial-assessment.eventbrite.com

FEB 20 — Touching a Nerve: Fundamentals of Palpation & Tx
https://touching-nerve.eventbrite.com

MAR 26 — Neurofascial Approach to Entrapment (Sciatica & Related)
https://nfa-lowerextremity.eventbrite.com

(We know: the homepage is still stubbornly unjuicy when it comes to actually displaying these. We are fixing this.)

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Stay tuned for some secret-sauce developments in the coming weeks. For more upcoming courses — Check this Facebook page (https://www.facebook.com/NeurofascialApproach)  or go here: http://www.neurofascia.com/courses/

Nov
06
Posted by Mike at 4:48 pm

Unwinding is a term used in many different manual therapeutic methods, broadly centered around these intentions:

— Take a person’s tissue interface, limb, or axial segment into a position of relative safety and ease: a ‘Local Neutral’.
— Try to find the exact point of greatest ease — where tensional and compressive forces seem to balance out — and if it seems to move, follow it.
— Notice changes to breath, reflexive guarding, range of motion, and autonomic tone.  Notice as well if no change is taking place.
— Cyclically involve the conscious mind of your patient to perceive and investigate the changes.

— Use what you feel to identify structures and structural behaviors elsewhere in the body that seem linked to the present one.

How do you involve the conscious mind of your patient?   It depends on the mind, and on your therapeutic relationship.  But some common ways are: Attention to Breath, Premotor Ideation (Thinking about moving), Movement within a safe range, Verbal description of what is felt.  If too much pain is being felt, these don’t tend to work, so focus first on pain reduction.

There is a separate discussion to have about the mechanisms underlying this interactive phenomenon.  Is it all (or mostly) happening in the practitioner’s head?  Is it a neuromuscular feedback loop between two attuned nervous systems?  Is it a layered peeling free of physical adhesions?  Most importantly: Is it a useful activity?  And in what clinical situations

Sensorimotor cascades, from Minasny, 2009 (http://ijtmb.org/index.php/ijtmb/article/view/43/75)

I must confess to you, anecdotally, that Unwinding is an amazing behavior of the body to witness.  And sometimes it seems to be the pivotal moment where a surface-skating treatment session turns into a deeply effective one.  Here I am working on a physical body and a human person, and this body-person is responding to my touch in ways that feel predictable, gradual, explicable.

Suddenly, when the executive will of both me and my patient have given a little ground, this dance emerges between us which seems far too intricate for simple reflex action, but too subtle and serpentine to be directed by conscious will.  And each of us insists the other is leading!

If this is beginning to sound to you like the occult meanderings of a Ouija board, you’re on to an important clue.  Both events seem to involve the process of Ideomotion: muscle actions that are influenced by conscious thought, but are subtle enough to evade a sense of “owning” the motion.  (“I swear I’m not moving it, you are!”)

‘Tissue Response’ in this case, can be an intricate thing. (From Minasny 2009 http://ijtmb.org/index.php/ijtmb/article/view/43/75)

Is Unwinding not much more than a placeboic parlor trick?  Or are am I describing a clinical method that, when intelligently applied, brings about meaningful change?

I really don’t know.  So much of it is difficult to describe, let alone measure.  But as long as it seems unharmful, intuitively useful, and I can do it without installing dysfunctional belief systems in my patient… Unwinding will continue to show up in my approach.