FASCIAL UNWINDING by Paolo Tozzi

Fascial unwinding (FU) is a relatively common osteopathic technique, specifically addressing fascial dysfunctions, with the aim of releasing tension, reducing symptoms, and restoring function. Despite the fact that some kinds of precursors of this approach have been around since the early years of osteopathy, the origins of FU are still uncertain, with its protocol of application being only recently defined. It has been indicated for a variety of conditions mainly affecting myofascial tissue, ranging from inflammatory processes to chronic disorders. In fact, its gentle application as well as its safe and indirect nature has made it suitable for acute presentations, while it can also be successfully applied for long-term symptoms.

This article is an abridged version of the Chapter “FASCIAL  UNWINDING TECHNIQUE” from the book “Fascia in the Osteopathic Field” (Liem, Tozzi, Chila Eds), Handspring Publishing, 2017. Reprinted with permission from Handspring Publishing. (c) 2017 Handspring Publishing

Origins

The osteopathic origins of unwinding methods are still unclear, although they have been described for decades by several osteopathic therapists (Ward, 2003a). Since the early 1920s, William Neidner, a student  of Sutherland,  who defined  his  approach as fascial twist, applied specific direct manipulative techniques to the myofascial tissue in the osteopathic field. Neidner was engaged at that time in researching effective treatment for muscular dystrophy in children. By observing and palpating the entire fascial organization of the body, he noticed that people in good health tend to show a clockwise fascial torsional pattern from head to feet (Centers et al., 2003). He then proposed that myofascial tissue dysfunctions could be globally released by various types of techniques relying on the use of the limbs as long levers for the untwisting manoeuvre (DeStefano, 2011). This approach employed mainly torsional  forces  to the extremities, aimed at restoring a balanced fascial tension by finding and maintaining a myofascial barrier until it yields. This would also promote symmetry of the transitional areas of the spine as well as reinstate compensatory postural patterns.  Mitchell in his first published work (1958), suggested applying such direct methods of treatment to the myofascial tissue before addressing any articular dysfunctions. Lately, this procedure has been indicated at the conclusion of a treatment program, after more local strain  patterns  have  been released  (Centers  et  al., 2003), since it induces a profound relaxation in the patient.

The idea of ‘twisted’  fascial  patterns  existing  in healthy conditions as a result of postural adaptationwas then re-evoked and readapted in the 1970s by Gordon Zink. He hypothesized alternating myofascial patterns occurring in healthy individuals at the level of the body diaphragms, showing preferential rotations and inclinations at around the corresponding transitional areas of the spine (Zink & Lawson,1979). Zink defined it as common patterns that show, from the top down, a preferential left–right–left–right rotation. Ideally, diaphragms should be aligned and move in a rhythmic, coordinated fashion during breathing. However, they commonly rotate and side-bend around their structural pivots to compensate for various physiological forces (e.g. uneven foetal positions during pregnancy, motor cerebral dominance, etc.) or non-physiological stressors (e.g. leg length discrepancy, etc.) (Pope, 2003). According to Zink’s model, the health status of an individual is equal to his/her ability to compensate to any given stressor, in such a way that the total homeostatic potential would remain basically the same. In other words, the greater the individual’s capacity for adaptation, the better his or her state of health will be. This is why central myofascial patterns, alternating in a functional manner, are so important and useful in maintaining the autoregulation of the organism. When this function is overwhelmed  or disrupted, the myofascial structures lose their alternating pattern, showing signs of rotation and side-bending consecutively in the same direction. This results in loss of adaptive abilities in the area involved, increasing energy expenditure, altering function, and affecting posture by overloading the correspondent spinal transitional areas (Defeo & Hicks, 1993). These patterns can be manually assessed and treated (Zink & Lawson, 1979), either  positionally  or by means of patient cooperation through voluntary muscle contraction (Chaitow, 2005).

A more dynamic concept based on the unwinding of the intrinsic fascial tensions was probably introduced by Viola Frymann:

‘The principle of this profound technique is to place the patient in the position that they were in at the moment of injury, and permit fascia to go through whatever motions are necessary to eliminate all the forces imposed by the impact.’(Frymann, 1998a)

Nowadays, FU is formally described as: ‘a manual technique involving constant feedback to the osteopathic therapist who is passively moving a portion of the patient’s body in response to the sensation of movement’ (ECOP, 2011). In this sense, FU has been considered as a form of indirect myofascial release: ‘the dysfunctional tissues are guided along the path of least resistance until free movement is achieved’.

In spite of the different definitions, FU remains a dynamic, indirect technique usually applied to the myofascial–articular complex, aimed at releasing fascial restrictions and restoring tissue mobility and function.

Indications

Thanks to its safe and gentle application, as well as its broad versatility, FU has been used for decades by osteopaths,  craniosacral  therapists,  and myofascial workers.  However, its  origin and main application remains within the osteopathic field. It has been usually described  in relation  to the release  of physical features  associated  with  fascial  restrictions,  and it has also been indicated for unwinding the so-called craniosacral mechanism (Frymann, 1998b). In this sense, the main aims are to correct somatic dysfunction, to release pain, musculoskeletal  tension,  and fascial restriction (Ward, 2003b), especially following injury (Frymann, 1998b) or surgery. A somatoemotional component has also been included, suggesting that FU might release trauma-induced energy stored in the myofascial system (Upledger, 1987).

FU is generally indicated for any myofascial condition, including those related to surgery or sports injury, such as tennis elbow, plantar fasciitis, shin splints, muscular and tendinous injury rehabilitation (Weintraub,2003), or any repetitively strained or overused joint and related myofascial structures.

Furthermore, it has been advanced as an integrative approach for a variety of visceral techniques, aimed at releasing tension in and around serous membranes, visceral ligaments, and capsules (Stone, 2007a). In a very subtle and gentle form, it has been proposed for pregnant patients too, in the prepartum or intrapartum period, to promote an optimal foetal position in a more accommodating and tensionally balanced environment (Stone, 2007b).

Finally,  FU may be also suitable for approaching scar tissues. A scar is considered to be active if at least one of its layers does not move freely and resistance to passive movement in at least one direction can be palpated (Lewit & Olsanska, 2004). FU may be used within hours or days from surgery, as it requires no significant range of motion through the scar or incision sites (Stone, 2007c). It aims to restore mobility by releasing tissue adherences and fibrotic material, so as to improve sliding motion between the involved tissue layers and enhance fluid circulation, cell nutrition, and tissue regeneration.

FU can be performed  on any single articulation or group of articulations, or even the whole body. For the latter, the simultaneous cooperation of two therapists may be required if the patient is an adult, but in the case of infants or children a single therapist is usually sufficient. Most of the time FU is addressed to the neck, arms, or legs, as these are mobile regions where strain and trauma easily manifest. However, not everyone is responsive to FU. Patients who are unable to relax may not be responsive. Therefore, alternative strategies should be used. In some cases, unwinding may happen spontaneously while the therapist is applying other techniques. For instance, neck unwinding may occur spontaneously during the performance of myofascial release  technique (Weintraub 2003) or suboccipital decompression. Finally, some patients may be particularly predisposed to respond to this method, that they can even be instructed on how to gently self-unwind. In fact, following a guided meditation session, patients may learn how to connect with their own myofascial system, feeling for any tension within, and for the ways such tension wants to release. This experience, under the operator’s guidance, may allow a spontaneous and effective body unwinding, bringing tissues back to their natural tensional state, often resulting in emotional – as well as physical – release.

FU has been demonstrated to be a beneficial integrative technique:

• to reduce pain and improve sliding fascial mobility in patients with non-specific neck pain (Tozzi et al.,2011)
• to reduce pain and improve visceral  mobility in people with low back pain (Tozzi et al., 2012)
• in the treatment of adult scoliosis (Blum, 2002), spondylolisthesis (Kuchera, 2003), and tension-type headaches (Anderson & Seniscal, 2006).

No injuries have been reported in the literature as being attributed to indirect or fascial techniques (Vick et al., 1996) apart from an isolated, documented case (Kerr, 1997) following the Rolfing method. However, it has been speculated that adverse reactions are not fully or adequately reported in the osteopathic scientific literature (Vick et al., 1996). In addition, it must be noted that a myalgic flare may occur within the first  12 hours  after treatment,  usually  lasting  not more than 24–48 hours (DiGiovanna, 2005), similar to muscle pain after a vigorous workout.

With regards applying most of the indirect techniques to a local site, the absolute  contraindications  are: recent closed head injury; acute vascular accident; bleeding or aneurysm; and acute visceral infections (WHO, 2010). Relative contraindications are malignancy, open wound, severe  osteoporosis,  infection, bone fracture, joint dislocation, and gross instability (Nicholas & Nicholas, 2008).

 

Protocol

The unwinding process can be applied to the whole body or to any part of the body, especially the limbs and neck. The neck or extremities can be treated regionally or used as levers to manipulate the trunk.

‘Unwinding methods refer to operator-induced spontaneous bending and twisting maneuvers affecting both upper and lower limbs’ (Ward, 2003a).

FU application can be described by the following phases:

1. Evaluation: that implies a thorough assessment of the myofascial system to identify any sign of fascial restriction. In this process it is fundamental to consider the entireness of fascial tissue, extending mostly in a spiral pattern from the extremities  to the axial part of the body. Due to its ubiquitous nature and structure, any disruption of fascial function at any level may potentially produce an effect elsewhere in the organism.  Abnormal areas of tension  within this system, following a recent or longstanding injury, surgery, or any sort of repetitive strain, creates adaptive compensatory patterns, following the path of least  resistance.  This can lead to altered structural alignment, impaired movement patterns, joint restrictions, pain, poor energy levels, and decreased vitality (Hruby, 1992). Therefore, a body-wide postural evaluation should be accurately performed, together  with   hands-on   assessment   of  the tone and texture of the myofascial tissue, joint range of motion, muscle  testing,  and subjective complaints of pain and/or loss of function. The ultimate goal for the operator is to identify the dysfunctional  body region  to be  worked on, including the dysfunctional vectors in the fascia. These are preferential patterns of tissue motion, perceived by the therapist as movements toward ‘ease’, usually mirroring directions of past injury or trauma.
2. Induction: at this stage, in particular, a state of relaxation from the patient is required. The operator approaches the involved area with a gentle touch, reinforcing the procedure by visualizing the anatomy of the region being worked. He or she initially induces motion, usually by lifting and holding the area in a relaxed position, so as to reduce the influence of gravity and overcome reactive proprioceptive postural tone. Alternatively, a distraction or compression force on related joints can be added to prompt the process. For example, in leg unwinding, with the patient supine, the operator lifts and supports the leg under the ankle, while a mild compression toward the hip joint can be added to promote the unwinding motion. The scope is to hold tissues in a balanced and relaxed state, remaining sensitive to fascial clues that suggest any direction of spontaneous expression of inherent tensional patterns.
3. Unwinding: the operator supports the patient while focusing on the area of major fascial tension, allowing any spontaneous movement to manifest. This is probably the most  difficult phase of the procedure, because of its dynamic nature that requires high sensitivity, kinesthetic  appreciation, and fine palpation skills from the therapist. The latter should sense movements arising from the inherent motion of dysfunctional tissues that should not be directed or forced but just acknowledged and followed. Such patterns of motion are mostly unpredictable: shearing, torsional or rotational components may arise, usually following a spiral path, sometimes very subtle, sometimes extremely vigorous, either rhythmic or random, but always at their own individual pace. The unwinding process should never be allowed to occur as a ‘fulcrumless’ circular motion, since that would be unlikely to produce any therapeutic effect. Instead, a precise fulcrum should be identified, around  which  tissues may express their dysfunctional pattern. Such a fulcrum should be the point of major fascial restriction being addressed. During the entire procedure, the patient gives constant feedback to the operator, whiles the latter supports and amplifies the range and intensity of movement, guided by inherent fascial tensions, until a spontaneous release is perceived. During this process, it may happen that the therapist feels uncomfortable with keeping the same hold of a given structure in unwinding mode or, even worse, that the manoeuvre becomes unsafe by making the patient unstable on the couch. In both cases, the operator should stop the technique to choose a more effective hold, and by instructing  the patient  to assume a safer position.
4. Still point: this is only occasionally present. It involves a cessation of the unwinding process, resulting in a still point where no motion occurs and tissues are ‘silent’. The patient’s cooperation may be requested at this stage, such as forced respiration, to promote tissue changes and release.
5. Release: a collapse of myofascial tension may be felt together with warmth and a ‘melting’ sense in the tissues that are being worked on. A release may take seconds to be obtained when working on recent and mild restrictions, whereas longstanding or severe injuries may require more than one session. In some cases, an emotional release may occur, or be induced,  during the unwinding method.
6. Reassessment: tissue should be re-examined after release has been achieved, and a sense of balanced tension within and around the myofascial tissue should be verified. Any combined therapeutic exercise and traditional manual modalities may then be found to be more effective in achieving enhanced function.

If total body unwinding needs to be performed on an adult patient, normally the cooperation of two therapists is required. In this case, with the patient lying supine, one therapist lifts and holds both legs at the ankles; while a colleague lifts and holds the head, with the patient’s arms raised up in between the osteopath’s elbows and trunk, and the patient’s hands resting on the osteopath’s flanks (Fig. 1). Both therapists focus on the areas of major fascial restriction in the respective halves of the body. A simultaneous unwinding may then take place, usually requiring a change of hand-hold and constant monitoring of patient position. If the adult patient is constitutionally smaller than the operator, or if the patient is a child, a single therapist can easily perform total body unwinding. In the case of an infant patient, full body unwinding can be started through an occipitosacral hold with the baby in a supine position (Fig. 40.2). Again, the effective movement will be felt as a spontaneous expression of tension from dysfunctional tissues, until the release is felt.

Finally, if scar tissue needs to be worked, the procedure remains basically the same, although FU is applied in a combined manner in this case (i.e., by simultaneously performing a direct and an indirect manoeuvre).  One operator’s hand takes a contact on the dysfunctional scar, with a focus on the points of major restriction, fibrosis, and tension. He or she then chooses the most appropriate lever to unwind the scar tissue – that is usually a limb or the head and neck, depending where the scar is located. Whatever structure has been selected as leverage, it is held and maintained in a relaxed position with the other hand. The combined fascial unwinding can now be performed: with one hand the therapist applies a direct fascial technique on the scar, by engaging and holding the tissue barrier; then the locally gathered tension is unwound in indirect fashion by means of the lever being supported by the other hand. Once the barrier yields, the operator looks for any further tissue restriction. Once this is found, the lever will be used again to unwind the given tension. The procedure goes on until a complete release of the scar is achieved. A still point may occur, requiring some form of patient cooperation to allow change to occur.

 

This article is an abridged version of the Chapter “FASCIAL  UNWINDING TECHNIQUE” from the book “Fascia in the Osteopathic Field” (Liem, Tozzi, Chila Eds), Handspring Publishing, 2017. Reprinted with permission from Handspring Publishing. (c) 2017 Handspring Publishing

 

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