Anne Hoff: You are a fascia researcher as well as a Rolfer. For those who don’t know your background, how did this come about?

Stephen Evanko: In graduate school, I had studied how tendon tissue responds to compressive forces by transitioning into fibrocartilaginous tissue. I was learning intricate details of the cell biology and biochemistry, so I was very interested in connective tissue plasticity – by default I guess. Then during my post-doc work, I had my first series of Rolfing® Structural Integration (SI) from Michael Reams, at a time when I was wondering if science was going to be my true calling. The great work I received made me realize the true power and depth of this process and approach. I went home from my first Rolfing session with plenty of literature and became even more interested.

AH: What is your current research about?

SE: My current research is focused on the myofibroblast, the cell that is responsible for most of the fibrosis in the body, and the role of the extracellular matrix in promoting and maintaining myofibroblasts. I have also done some work on inflammation, looking at the role of hyaluronic acid (HA) during interactions between the connective-tissue fibroblasts and adherent immune cells, such as lymphocytes and monocytes. It’s interesting how the ground substance can quickly transition from slippery to sticky under conditions of inflammation, and that property helps to dictate how fluid our tissues are. Combine that with the varying degrees of contractility of the fibroblasts and it makes for a very dynamic system.

AH: What developments in fascia research do you find particularly interesting and relevant to our work?

SE: I think one of the most exciting findings (from studies at the cellular level) that has direct relevance to bodyworkers is that tension-release attenuates the m y o f i b r o b l a s t s –i t hr c a u s ig programmed cell death (apoptosis), or down-regulating collagen production and the expression of alpha-smooth muscle actin, a characteristic protein that promotes the contractility of myofibroblasts. Stated more simply, the release of tension calms down the myofibroblasts, so they make fewer fibers and are less contractile. One of the likely consequences of our style of working the fascia is the release of tension between fibroblasts. Also, the primary factor that drives fibrosis in the body, TGF-beta, can be activated by cellular tension and repetitive strain. So our manipulations can potentially help in reducing the fibrotic quality of the fascia at the cellular level by this tension-release mechanism. We are literally altering the mechanics that the cells experience, at least temporarily.

AH: One of our themes in this issue of the Journal is aging. What happens to fascia as we age, and what can we do to maintain optimal fascial health – in terms of bodywork, nutrition, exercise, etc?

SE: As we age, our fascia and other connective tissues tend to become more fibrotic, stiff, and dehydrated. Hyaluronic acid seems to diminish with age. HA helps to maintain hydration in the extracellular matrix, spacing between cells and fibrous matrix components, and lubrication in the joints. Experiments we’ve done with lymphocytes suggest that supplements of HA potentially could have an anti-inflammatory effect. This is probably the main reason that HA supplements seem to help with arthritis-type pain. Coconut oil applied topically on the joints really seems to improve hydration and tissue quality also.

Another consequence of aging and stiffening tissues can be diminished range of motion, which means less muscular pumping of fluids and poor nutrient exchange and waste removal. As we know, introducing motion into places where it is lacking is important to restore those vital functions. Lack of good nutrient exchange and ischemia, or poor blood flow, particularly around the nerve endings in stiff joint capsules and ligaments, will compromise proprioception and balance as we get older. I try to always encourage my clients to find ways of moving joints through full range of motion and to explore movements they don’t normally do.

Robert Schleip, who has promoted a neurobiological explanation for tissue release and done some great research on fascial contractility, has also developed his Fascial Fitness program for maintaining proper tone and flexibility in the fascial network. I encourage anyone interested to explore that as well.

AH: You are also a key proponent of manual nerve therapy. What got you interested in that, and how did learning this affect your Rolfing work?

SE: I attended a brief introduction to nerve work given by Christoph Sommer at the 2006 IASI conference, and then quickly purchased Barral and Croibier’s book Manual Therapy for the Peripheral Nerves. I was then fortunate to have two classes with Don Hazen before he passed away. Firsthand experience of the dramatic and instantaneous pain relief and increased range of motion when tethered nerves were liberated is really what got me interested. I’ve just been playing with it ever since, working any nerve within the territory for that particular Rolfing session. Nerves are on the forefront of my awareness pretty much most of the time now.

AH: What do you understand about the nerves and fascia that we should be aware of?

SE: Nerves control tissue (muscle and connective tissue) tone and range of motion. They transmit pain signals and can drive inflammation. Without motor neural stimulation, muscles are flaccid bags of protein. We need good sensory input for proper motor output. Addressing the neurofascia directly makes so much sense to me.

Recent studies have shown that the nerve sheath contains nociceptive fibers, which means pain and inflammation can be generated by mechanical irritation or overstretch of the nerve sheath. The nerve sheaths can get tethered in the fascia through which they travel. Mechanical irritation can also trigger what’s called the ‘dorsal root reflex’, in which anti-dromic activity (impulses traveling in the opposite direction from normal) can be measured in sensory nerves and inflammatory mediator proteins are transported to the distal end of the nerve. They can cause swelling and vasodilation, among other things. This is the basis of neurogenic inflammation. I’m convinced this phenomenon is more widespread throughout the body than people realize.

Setting nerves on a straighter course and making sure they glide and stretch over their entire length, I think, is vital to the SI process. Show me a stiff joint and I will show you one or more tethered nerves that cross that joint. Hazen argued, and I agree, that successful Rolfing SI in part, either purposefully or inadvertently, frees up tethered nerves. This is where I would disagree with Dr. Rolf’s premise that we are not addressing nerves. It is really ‘myo-neuro-fascia’, and not just ‘fascia’. I consider the nerves part of my scope of practice, and see no reason that nerves should not be considered during the Ten Series.

Careful palpation reveals that there is strain along the neural pathways. (In actuality, it is often the entire neurovascular bundle that becomes strained.) The fibroblasts in the nerve sheath collectively can shorten the nerve, especially if they have a tendency toward being myofibroblasts. The fascia literally bunches up around the nerve branches and twigs, especially where nerves might overlap and entangle with each other. There is also research showing that neurons themselves can generate tractional forces, suggesting they may participate in driving their own strain. Inflammation and fibrosis can create more fascial bonding between the nerve sheath and surrounding connective tissue. This means that older clients who’ve had repeated bouts of inflammation and fibrosis – for example, someone with rheumatoid arthritis – will have lots of tethered nerves. Once sensitized, a nerve can be more easily induced to fire ectopically and/or become inflamed.

Nerves run along fascial planes between muscles, so any manipulation that differentiates along fascial planes will be freeing up the nerves that run in those seams. Nerves also run through fascial canals and bony tunnels, and bringing this to mind when we work only improves the outcome when we are deciding what direction to take the tissue. If our manipulation overstretches an already irritated nerve, we will be digging ourselves a deeper hole and perhaps setting up inflammation in our clients unknowingly.

AH: Can you say more about how nerve tethering relates to aging? One thought I’ve had is that some degree of nerve tethering is inevitable over time – from falls, strains, repetitive use, the kind of things most people will have some experience of over time – and if it’s not dealt with it will cause mobility restrictions. If this is the case, could many of the issues that we assume relate to aging be reversed with appropriate work to restore roll and glide in the nerve sheaths?

SE: Absolutely. I think good Rolfing SI and other bodywork is the closest thing to the fountain of youth that we have. It’s especially exciting when you consider that our manipulations potentially could be releasing stem cells from various niches in the body, including adipose, muscle, tendon, etc.

Another under-appreciated fallout from aging is the sagging and twisting in the fascia, particularly the superficial fascia. I think the superficial fascia and the cutaneous nerves are totally under-appreciated with respect to their roles in aberrant movement patterns, limited joint range of motion, and structural distortion. When you think about how thick the superficial fascia can be, with the adipose layer, and the significant downward pull that some cutaneous nerves are subject to, it starts to make sense that relieving the strain on a chronically overstretched or mechanically irritated nerve is going to have huge ramifications on chronic pain and structural issues. Any twisting in that sagging superficial fascia also creates torsional strain along the nerves in that layer, further sensitizing the area and locking up the underlying muscles. I’ve been playing with using spiral and lemniscate motions in releasing the nerves and it is super-effective.

I kind of see it as a resculpting process of the skin suit. One of my primary goals during my Rolfing sessions, as part of the territory for that particular hour, is to reposition the superficial fascia specifically to relieve the strain on the cutaneous nerves. I like to also make sure that nerves are not overlapping each other and creeping into each other’s territory, causing the tissue to bunch up. Multiple passes with light fingernails and finger pads works very well to differentiate tangled nerve fields in the superficial layers.

AH: What are some common nerve entrapment sites you look at in your practice?

SE: Nerves get tethered everywhere, really, regardless of age. For low back pain, I tend to look at all the nerves crossing the iliac crest and the hips, from where they perforate the lumbar fascia down into the legs. These would be the cluneal nerves, iliohypogastric nerve, twelfth thoracic nerve, lateral femoral cutaneous nerve, obturator nerve. The proximal portions of these all get overstretched where they are tethered such as along the iliac crest (i.e., the inguinal and groin straps described by Louis Schultz and Rosemary Feitis in their book The Endless Web). The sagging fascia literally pulls on these nerves. With slouching posture, we then sit on the distal portions of the posterior nerves, dragging them farther ‘southward’. I know from personal experience that acute overstretch of one or more of these cutaneous nerves can induce back spasms and inflammation, as if a disk had gone out. The iliohypogastric nerve is frequently tethered behind the greater trochanter and can be a key nerve to release for back pain. In my own experience, strain on this nerve also contributes to irritable gut issues.

There is always torsion in the fascia lata that twists most of these nerves, usually into external rotation. Even a small amount of sag and lateral rotation of the superficial fascia can pull the lateral femoral cutaneous nerve around to the back of the hip, and pinch the proximal portion of the nerve against the inguinal ligament. The entire wad of muscle, fascia, and nerves of the thigh needs to be untwisted and lifted headward to take the strain off of the cutaneous nerves. There is usually a branch of the lateral femoral cutaneous nerve that creeps around to the back of the leg. I always give attention to the fascia overlying the sacroiliac joint and glutes, and differentiating the posterior femoral cutaneous and inferior cluneal nerves at the gluteal fold.

The twelfth thoracic nerve, caught in sagging abdominal subcutaneous fat, often gets tethered over the TFL muscle. Strain along this nerve pulls T12 closer to the pelvis, exacerbating compression of the lumbars.

For tight hamstrings and the posterior line, the common peroneal and posterior femoral cutaneous nerves are crucial. They get caught in the fascia lata that sags like a stocking down around the knees. Sitting repeatedly pushes that fascia farther down the legs. This sagging and twisting of the fascia lata is part of the issue in creating spider veins and varicose veins. Swollen ankles and cellulitis seem to respond quite positively to untwisting the superficial fascia stocking of the lower leg and freeing up the saphenous, sural, and superficial peroneal nerves around the leg and ankle retinaculum.

In the mid-back, I find that the dorsal rami and the lateral branches of the ventral rami are nerves that, together with the long thoracic nerve, really participate in holding scoliotic patterns. These can be part of Sixth- or Third-Hour territory. These can be addressed at the same time one is working to differentiate the latissimus from the ribs and differentiating along the margins of the lower trapezius. The dorsal rami can be tethered where the neurovascular bundles perforate through the thoracolumbar fascia in this region.

In the shoulder girdle, the suprascapular nerve, the dorsal scapular nerve, the supraclavicular nerve, spinal accessory nerve, and axillary nerve are all tethered in older and younger people with limited shoulder mobility. For example, the suprascapular nerve makes a U-turn as it passes through the bony canal of the scapular spine, and heads back towards the spine within the infraspinatus muscle. Here it is subject to multidirectional pulls and mechanical irritation and is at least partially inflamed in most everyone. There is also torsion in the brachial plexus and neurovascular bundle as those cords pass across the axilla and down the arm, usually pulling those nerves and muscle groups into medial rotation. I like to pay careful attention to untwisting the torsion, beginning at the armpit, including the cords as they pass under the clavicle, down across the fascia at and above the elbow, and down the forearm, all the way to the retinaculum of the wrist and into the fingers.

AH: So releasing tethered nerves can do a lot to help range of motion, alignment, and fascial mobility at any age. How well do results from nerve work and Rolfing fascial manipulation hold in an older person versus a younger person? Do you see differences and what can you attribute them to?

SE: Young or old, there can be tethering of nerves wherever scar tissue forms, whether from bruises and contusions, other injuries, or surgical scars. However, younger tissues tend to have a higher capacity to heal and regenerate. Younger connective tissues and skin tend to have more HA and hydration and a more supple quality. There is more HA generated during inflammation, in both young and older people, but I suspect it leads to more fibrosis in older people because of their tendency to have more chronic inflammation and more mechanical history and traumas to leave their marks on the structure. Younger tissues probably have a bigger supply of available stem cells that might be recruited for repair processes, as well. However, I’ve seen some pretty fibrotic tissues in very young clients. It can be kind of shocking, really, how someone so young can have such tight and dried-out tissue.

In spite of having more fibrosis in general, older people do respond very well to neurofascial work. It may take more work to get the same degree of release, but not necessarily. You can see how the skin quality improves almost instantaneously when the nerves are released and the proper relationship between deeper layers and the superficial fascia is restored.

In my experience, the degree to which any nerve or fascial manipulation holds depends on the degree to which you have freed up the nerves and how well you have differentiated along the adherent fascial planes. Any residual adhesion or gluing along a fascial plane or nerve sheath, or even intramuscular fibrosis, can pull somebody back into his or her pattern. Inflammation comes and goes and can return again depending on further irritation. Remaining pain and stiffness suggests there is still some tethering or swelling fluid in the nerve sheath, putting stretch or pressure on a nerve. That indicates there is more work to be done.

Stephen Evanko was certified as a Rolfer in 1998 and completed his advanced certification in 2007; he maintains his Rolfing practice in Seattle, Washington. He is also a Staff Scientist at The Benaroya Research Institute, where he studies the role of the extracellular matrix in inflammation and myofibroblast formation. Anne Hoff is a Certified Advanced Rolfer also in Seattle.Nerves, Superficial Fascia, and Aging[:]