When I met this female dancer she was complaining of IBS (irritable bowel syndrome). As usual I asked her not to tell me anything else so that I could read her body without thinking in terms of what other people had told her.
When doing a general evaluation, her body led me to the lower left side, more posterior than anterior. So I asked her to lie down on the treatment table. I started to listen at the legs and although looking at her right leg it was obviously restricted at the knee, It was slightly in flexion, it was the left leg that was attracting my hand. I did a very gentle mobility test for the hips. They were as stiff as a board. Despite being a dancer he rotation was very limited. I asked her is she had problems with her legs and she told me she had a problem with her right leg. But I followed the listening up the left leg and by a process of prioritisation I was led to an area above the superior to the pubic bone. The listening pulled me deep into the body; very posterior. It was so posterior I was let to ask the dancer to lie face down and checked the tailbone. The tailbone was tender when she sat for a longer time. As I palpated it I felt it was under quite a lot of tension and as she told me she had had quite of lot of bumping on her bottom while dancing it also seemed pragmatic to engage it. There was also an attraction to the Sacrum at around S4. This happens to be the level where the Pudendal nerve.
At this point I would like to start the atmospheric music. The villain just walked in….or danced in! In this case he’s a strong suspect for being a villain. Actually in the working healthy body he’s a superhero. The pudendal nerve as a superhero does so many great things for us. It is very connect to the autonomic function of the of the body. Known as the “Peepee, pooh pooh, sex nerve” by anatomy teachers. You just never forget that expression. It runs deep inside the pelvis and runs a gauntlet of confided spaces. It even has its on canal (thank you Mr Alcock for naming the canal). It gives tension to the urogenital diaphragm.
So there’s a kind of Nexus of problems here. The tiny Ligament from the ischial spine to the sacrum forms two holes (foramen) though which neves and arteries for bottom and legs pass. The superior hole is the piriformis (it’s infamous for imitating a spinal disc prolapse). It presses on the pudendal nerve nerve, ischial nerve and inferior gluteal nerve from above.
The function of the pelvic nerve:
So let’s just look at the symptoms of an entrapment of the pudendal nerve. It’s like a way story:
Back to my dancers tail. My hand was also attracted to the tailbone of the dancer. The tailbone has a muscle called the Coccygeus - going from the tailbone and sacrum to the ischial spine. So after doing an external release of the tailbone and pelvic floor I rechecked the tailbone and it was fine. However when I checked from the front there was still a strong attraction from above the pubic bone deep inside the body. So I released this.
Now here’s something interesting. The coccygeus is enmeshed in the Sacrospinous ligament which is in turn enmeshed in the Sacrotuberal ligament. When one is damaged it can affect them all. Theses ligaments are essential for spinal health as a whole. The pelvis which locks up here cannot roll easily and allow the rotations of the spine which we all need for our health.
My lovely dancer led me to research all this. Also she told me she’s suffered very very regular bouts of bladder infections (pudendal nerve - is my suspect). It was a first treatment. I am sure it will not be fully treated in one treatment, but she already said she notices a difference.
If you have "piriformis syndrome" or above symptoms you can now suspect the pudendal nerve.
Bad Marketing Post from an “Anatomy Nerd”.
Frozen Ovary. - It means it isn’t moving.�The client a young female (obviously) was having back pain, knee pain on both knees but the right knee was worse. Also she had regular dysmenorrhea (or painful periods). Like many mothers she’d had a C-section. Extensive full body evaluation led me to consider the C section scar needing to be treated as a priority. Both legs we restricted at the hips too.
I explained that the fascia is the most prolific tissue in the body and that as such holds, supports, and connects all other tissues. It is like a web. You can feel tension throughout the whole system when there is an unhealed injury anywhere in the body it can be sensed as a tension in many other strands of fascia. Of course there are quite specific zones where fascia has crossroads one of them being the peritoneum and the neck. She asked about the foam roller. I said that is surely beneficial to stretch local fascia but internal fascia which is hasn’t been treated is a potential poison thorn inside the body. Only treating the superficial fascia means you run the risk of getting out of pain when the pain is trying to warn the body of internal problems and dysfunctions. I make the analogy that you wouldn’t turn of the smoke alarm when there’s a fire, and in the same way stretching muscles to relieve pain when the issue is internal is short-sighted.
Being terrible at marketing; as I saw hope growing in her eyes I knew I had to lower her expectations. Actually this is the responsible thing to do, although the ego loves to feel like a god who can heal, the fallout when it doesn’t happen is so demoralising for the client, it’s unethical to take that role. Unlike “quick fix” treatments fascia therapy is a “slow fix” approach. It treats internal lesions (problems) which are sapping vitality from the constitution and it treats them. So instead of feeling suddenly out of pain it is quite likely that there is no perceivable change after a treatment. Vitality is what heals us. Vitality heals not just one problem but all problems. The viscera are often where we find lesions which hold the muscles in place (see cuto-visceral reflex and myo-visceral reflex.) So she asked me about CranioSacral therapy. I told her that the osteopathic method adopted CranioSacral therapy but it was also taught separately. While the skin of the brain and surrounding all nerves (meninges, Dura mata, perineurium) was made up of Fascia, and so physical approach was similar in CranioSacral therapy to all forms of fascia. Stand alone CranioSacral therapy is fantastic, but have you seen the psychology experiment with the gorilla appearing among the group of students, it’s called the “selective attention test”. You are tasked with paying attention to a group of people passing a basket ball to each other. While you are doing this a gorilla will appear and ninety percent of people cannot see it. In a similar way when you only pay attention to one type of tissue you will ignore the obvious in many cases. As Abraham Maslow often quoted “if the only tool you have in your toolbox is a hammer, every problem looks like a nail.” This phenomena is true for me and other health professionals by the way. We are limited by our reality tunnel vision.
Finally I explained that fascia being made up of collagen and elastin is very strong and so my touch would be gentle in most cases. She may even feel I’m doing nothing. She wouldn’t be the first person who’d thought that. I promised that I was doing something and that the changes though slow are lasting. I stopped doing the quick fix approach because I want to have long lasting improvements in the whole life of my clients. This also means taking bigger breaks in between my treatments because sessions work much much deeper in many cases.
As I evaluated the tissues of the C-section and the tension around the scar was not allowing me to enter into the abdomen very deeply. So I released superficial tension and then the quality of the tension changed. The superficial tension started to pull to the right and then deeper into the body. It was hard to say what kind of tissue it was because it was very deep posteriorly. It must have been the ovary. When I palpated this area I felt an extended pulling towards the back. Anatomically there is a connection via the suspensory ligament between the fascia of the back and the ovary. This ligament is really stretched a lot during pregnancy. So I engaged the ovary and the back at the same time and they started to communicate with each other like long lost friends. The client had a feeling of releasing in the back.
The suspensory ligament is very interesting because it contains the artery and veins supplying the ovary. It leaves the ovary and travels up behind the caecum and travels up the psoas muscle and joins the aorta all the way up to the level of the kidneys. This connection to the psoas would make it a suspect for back pain when this ligament is under tension.
What the connection between the ovary and the knee? There can be in some people a strong relationship between the ovary and the obturator nerve. The obturator nerve sits behind the ovary and on some young ladies during puberty it gets caught and they suffer from “unexplainable” knee pain (please see my website for a case study where 12 years of knee pain in a 18 year old girl were cleared by treatment this adhesion. It runs through the obdurate foramen and down the inside of the thigh.
The root of the obturator nerve is conjoined with the femoral nerve and the lumbosacral trunk. It’s called the lumbosacral plexus. So if the obturator nerve is affected we shouldn’t be surprised to see it spilling out onto the femoral nerve which does knee extensor muscles on the leg and the pelvic nerves. Also the femoral nerve is also nicely connected to the Psoas. It also provide feeling to the inner side of the thigh as does the obturator nerve.
So I said goodbye to my young female client suggesting that at least for a few days she avoid massage and drink more water. She wanted to see me in a week but I told her that the changes when done from the inside take at least 10 days to manifest.
Richard Wickes is available for one on one personal consultations in Hong Kong.
Big Shoutout for my amigo Roberto Bonanzinga, who brought the anatomy back to life; and for my pal Ron Mariotti who helped me keep the fire going. Also Joanne Enslin de Wett, who inspired me again.
#anatomy,#fascia, #manualtherapyhongkong #fasciatherapy#badmarketing #c-section
Photos: Netter Anatomy app, Wikipedia, Grays Anatomy (I guess), and Testut
6 Most Useful Tips to Improve Your Palpation Skills
As a body worker its my job to feel. I have to feel sometimes ridiculously small variations of change in someone. Honestly the difference between a excellent bodyworker and a good one is nuance.
Here are my tips for improving:
You want to enter into a meditative state. The meditative state is a state of flow. In other words you might consider it to be like floating in a swimming pool. You are aware of the water, you are aware of the waves and currents and yet you are not making waves so to speak. When you make the waves it means you are projecting your impressions on the client.
3. Develop your gut feel. So there has been scientific research into this and so while it still needs research we don’t need to wait for science to catch up. Let’s just educate your feeling to yes and no. Things which feel heavy, dead, unresponsive are a no. That’s a general rule but also consider that there’s a lot more you have the potential to feel, and so this process can be confusing (ref. Prof. D.Bem - Feeling the Future: Experimental Evidence for Anomalous Retroactive Influences on Cognition and Affect at Cornell University). Now, just stick with it. The first time you meet something you may not recognise it’s true nature. Even when you encounter something many times if you are good you will be open to seeing it in a new way.
Paraphrasing Donald Rumsfeld and expanding on it slightly: there are things we know we know; there are things we know we don’t know; there are also things we don’t know we know and things we don’t know we don’t know. In other words you are not infallible but your know more than you know.
4. Meditate. Bodyworkers are typically down to earth people. We get our hands dirty on peoples problems. It might seem to some that meditation is the antithesis of what we do. It isn’t. Meditation is the practice of experiencing who you are beyond your habitual self. Now I spend time looking for where I heard this definition and I couldn’t find it, so my thanks goes to the wise man who said it. A further definition of meditation clarifies this:
“The basic definition of meditation is having a steady mind. In meditation when your thoughts go up, you don’t go up, and you don’t go down when your thoughts go down. Whether your thoughts are good or bad, exciting or boring, blissful or miserable, you let them be. You don’t accept some and reject others. You have a sense of greater space that encompasses any thought that may arise.
In other words, in meditation you can experience a sense of existence, or being, that includes your thoughts but is not conditioned by your thoughts or limited by your thinking process. You experience your thoughts, you label them ‘thinking‘, and you come back to your breath, going out, expanding, and dissolving into space. It is very simple, but it is quite profound. You experience your world directly and you do not have to limit that experience. You can be completely open with nothing to defend and nothing to fear.” (retrieved from the internet: http://www.elephantjournal.com/2010/01/chogyam-trungpa-rinpoche-meditation-101/)
5. Beware of big and/or overwhelming feelings. Kind of see point 4. You see when you really identify yourself with a feeling you think it’s you. At some point you are going to feel a strong feeling. It might be that you feel like you are physically being moved by the patient. Now, this is an intriguing feeling and so you might want to know what it is. While I agree it is interesting for me it’s polluting your perception because it is so big. Your job is to feel what is going on inside the body of your client. You need to remind yourself of that and recenter. What I do is I say to myself that I have become to entwined in my listening and so I need to relax up until my feeling is under my fingers. I am not saying that you are wrong but identifying too strongly with what you feel is a double edged sword. It can certainly be very symbiotic empathic and cuddly to feel so connected to the client but you don’t want to be caught up in this when it’s pathological or unhealthy feelings.
6. Anatomy, anatomy and anatomy. Learn the map.
The measurement of a good therapist is in nuance. Great discoveries have often been small observations and so while being mindful be aware that you are on the cusp of new knowledge. Don’t let anyone tell you your feelings are wrong, you feel what you feel and they feel what they feel. Most people feel a bone in a similar way but don’t copy, allow yourself to grow into your own feelings. This is personal development.
ADHD - Trauma - Hypervigilance common after trauma
Irritable Bowel - Trauma - Fight/Flight reflex (FF) lowers digestion power
Heart Disease - Trauma - Via Vagus etc
Asthma - Trauma - via Vagus etc
Gastritis - Trauma - via Vagus
Vertigo - Trauma -
Psychosomatic Pain- Trauma -
Self-Harm - Trauma - self harm to feel self to combat disociation
Addictions - Trauma - self-medication (Food, Sugar, Sex, substance abuse in general)
Anxiety - trauma - Amygdala etc become over functioning
Depression - trauma - Freeze part of fight flight system over functioning
Amnesia - Trauma - Hippocampus under-function part of general brain harm
Insomnia - Trauma - FF reflex overactive, amygdala
Brain Fog - Trauma -
Lack of Life Direction - Trauma - Posterior Cingulate functional suppression
Low Energy - Trauma - see above...
Quite simply if we have unresolved emotional traumas this literally pops out somewhere else. There are strong correlations between Trauma and the above problems so much so some people consider unresolved Trauma to be the health threat today.
Personally, in my manual therapy practice I've noticed symptoms improve considerably when trauma is addressed. As any clinician I don't jump to a diagnosis. However sensitivity to the powerful influence of trauma in various area led me to research it.
Emotional Trauma influences the organs via the Vagus nerve because of the fight/flight/freeze response.
So I thought I would share an article about the effects of emotional trauma on the brain.
The major areas influenced are the Amygdala which goes into overfuctntion and the Hippocampus which goes down in function. The amygdale is for fear so anxiety can become chronic. The hippocampus is for memory and emotional regulation. The memory is the most severely affected by emotional trauma.
I found research also saying that it affect the Wernicke and Brocks corner of the brain too. These are the areas for speech and understanding of language. Ever speechless with shock? That's why. Also people cannot explain why they feel anxiety.
ref: The Body Keeps the Score (Bessel), Betrayal Bonding (Cames)
The Polyvagal Theory (Porges - Paper, book), Stress Breaks Hearts (webMD), Waking the Tiger (Levine).