As a Rolfing® Structural Integration (SI) instructor I am keenly aware of the limitations of our training process. By any measure Rolfing and other SI trainings are too brief, unable to expose students to even the relevant knowledge that has been accumulated in the thirty-four years since Ida P. Rolf wrote Rolfing: The Integration of Human Structures. In addition, one often hears about the pressures of competition and market forces constraining the ability of the SI practitioner to deliver the breadth and depth of the true SI experience. And, it is often said, with a note of resignation, that the real education of a Rolfer happens on the job, through experience and personal study, and is augmented by workshops and, eventually, advanced training.
Thus, it is rare and fortuitous when an instructor discovers two books by an author that he knows will be transformative in creating a higher baseline of skills for new and even experienced SI practitioners. Such are these two volumes, Facial Manipulation for Musculoskeletal Pain and its awkwardly titled companion Fascial Manipulation Practical Part (both published by Piccin in 2004 and 2009, respectively). The first is authored by relentlessly studious Italian physiotherapist Luigi Stecco, and the second is coauthored by Stecco and his daughter Carla Stecco, an orthopedist. These two volumes are major contributions to the field of structural integration and should be included in every practitioner?s core library.

Upon first encountering these books, anyone familiar with SI will naturally wonder why a work that is so akin to SI has only a slight reference to Ida Rolf and her scientific contributions in understanding the importance of fascia. It is well-known that Stecco knew of and was influenced by Rolf?s work, but he pays her scant homage. He describes her contribution as ?posture modification,? and lists Rolfing SI as an influence among other modalities such as trigger point therapy, shiatsu, acupuncture, etc, In spite of this failure to properly attribute Rolf?s contribution, these books deserve to be incorporated into the curriculum at the Rolf Institute® and every other SI training program as they offer an updated and detailed refinement to our understanding of the role that fascia plays in the body and how to treat its dysfunction.

For experienced practitioners who have an interest in the phenomenology of the body and a desire to know the body as it is, devoid of conceptual abstraction, these are must-read volumes. For those who welcome rigor and complexity, the volumes present an opportunity to dig deeper and increase the precision of their knowledge. While these volumes require time to digest and consider, they reward anyone who commits the necessary time to study and learn from them.

Each volume presents detailed descriptions, useful charts that illustrate complex concepts, and excellent photos of fresh cadaver dissections that expose important elements of fascial architecture and correlates them with structural, energetic (acupuncture), and trigger-point patterns. The first volume is primarily concerned with describing the form and function of myofascia, while the second is a manual for how to evaluate and work with the myofascial patterns that produce pain.

A New Nomenclature

To be clear, the Steccos? goal in these two volumes is not SI but the reduction of musculoskeletal pain. However, their perspective on mechanisms that produce musculoskeletal pain are so similar to the perspective of SI that it stimulates questions about the similarities and differences between the two approaches. Throughout my reading, I found myself wondering if treating the body with their ?facial manipulation? (FM) method would also yield an integrated structure. Similarly, I remain curious as to whether the SI approach reliably delivers the pain relief of FM. The Steccos? pain-relief approach fits squarely into what Rolfing colleague Jeff Maitland described as corrective, or ?second paradigm,? but their correlation of pain with three-dimensional patterns of myofascial dysfunction echoes the holistic ?third paradigm? argument that integration is necessary to relieve pain.

My personal belief is that all effective methods have a significant degree of overlap with other methodologies. The Steccos? work supports this idea with innovative descriptions of fascial anatomy and physiology and intriguing perspectives on pattern and function. Taken together these works come closer than any I have seen to describing the body and method that SI practitioners work with every day.

At the heart of the Steccos? presentation lies a detailed description of myofascial and musculoskeletal architecture. These are not mechanical, textbook origin-insertionaction descriptions! Rather, they offer a new perspective that precisely describes the twisted-body patterns every SI practitioner is keenly aware of. For example, the tissues of the leg do not descend in straight lines from the knee to the foot. Nor do individual muscles fire along their whole length. Instead, coordinated portions of muscles are activated along with portions of other muscles, at the same time that corresponding portions of antagonist muscles lengthen. To describe this in detail, the Steccos had to create a new way of talking about the body?s musculosketetal structure and the way it functions. Because anatomical names and descriptions have a tendency to conflict, Stecco presents a new anatomical nomenclature that describes both segmental and whole-body myofascial patterns. Simply put, function is described in terms of the directions that segments move. Further, he proposes using Latin terms to describe the direction of limb movement. Don?t worry, you won?t need to learn Latin to use the Stecco system, but you will need to learn a few easy abbreviations like ?ante? (forward) and ?retro? (backward). The Latin, he contends, makes for easier crosscultural understanding. No longer will we be confused by knee flexion and hip flexion describing motions in opposite directions. All sagittal-plane motions are either ?antemotion? or ?retro-motion.?

Myofascial Units, Centers of Perception and Coordination

Following the introduction?s excellent description of fascia (it should be required reading for every new student, and is an enlightening review for the old pro), the first chapter of Fascial Manipulation for Musculoskeletal Pain describes the interrelationship of muscle, nerve, fascia, and bone, called a ?myofascial unit? (MF). This is the kernel of Stecco?s approach: ?A myofascial unit is composed of a group of motor units that move a body segment in a specific direction, together with the fascia that connects these forces or vectors. The myofascial unit is…the structural basis of the locomotor system.1

A MF creates movement of a musculoskeletal segment in a particular plane. Within each MF are ?centers of coordination? (CC) that organize motor vectors, and ?centers of perception? (CP), which perceive a joint?s movement. In fact, Stecco asserts that six unidirectional myofascial units coordinate every joint movement. CCs and CPs are found in the fascia of each MF unit and ?act as peripheral references for the nervous system: the first [CC] interacts with the muscle spindles and the second [CP] provides information to the various joint receptors about the directional significance of each movement.?2 These distinctions form the basis for separating symptoms from their causes. Centers of perception (CP) are where sensation is felt, while centers of coordination (CC) ?direct muscular forces.?

According to Stecco, the whole body is comprised of eighty-four myofascial units, each with a name that describes its anatomical, or segmental, location and the motion it makes. For example, the MF unit he calls retro-cubitus (re-cu), straightens or extends the elbow, is described as being composed of monoarticular (lateral and medial heads of the triceps and anconeuous) and biarticular fibers (long head of the triceps). The CC for the re-cu is at the level of the deltoid insertion, between the long head and the lateral head of triceps. This CC corresponds to acupuncture point TE1 and to the 1º trigger point of triceps.

The Big Picture

The second volume, Fascial Manipulation Practical Part, focuses on multi-segment patterns of dysfunction and how to treat them. This volume reiterates some of what is in the first book and then presents how and where to treat larger body patterns. Our colleague Robert Schleip wrote the forward for this edition, which does a splendid job of encapsulating the Steccos? contributions to the field. In fact, it was this introduction that first got me interested in the books themselves. Just the pictures of fresh cadaver dissections ? which show fascia somewhat close to how it exists in the human body ? make these volumes worth adding to you library. Still, pictures, as good as these are, should not be mistaken for the tissue we touch every day. As Schleip warns, ?these pictures, as beautiful as they are, show a drier body than the one you are living in and the one you are touching [in] your clients. Please keep the fluid dynamics of the living body in mind and in your touch when you turn from this book to the properties of fascia in a real living person. Fascia in living bodies is much more slippery and moist than you may tend to imagine.?

The Method

After describing each of the body?s eightyfour myofascial units, in Chapter 7 the Steccos present an elaborate method for assessing the body. MFs corresponding to each plane of motion are motion tested to see which ones elicit pain symptoms. They are then considered together as part of agonist/antagonist pattern of dysfunction. Once the therapist has determined which MF sequences are involved in the pain pattern, he then searches for tissue ?densification? near the CCs. Once found, these densification zones are treated using manual-therapy techniques that resemble deep cross-fiber friction. One technique is used to treat CCs that produce pain in a single segment, and a slightly different technique is employed when trying to tease apart ?centres of fusion? or places where planes of fascia are interwoven.

At a one-day workshop on the FM method, I was very impressed by the assessment process, and equally unimpressed by the treatment process ? a rather mindless application of rubbing vigorously with the knuckles. The technique is justified by theoretical assertions that fascia requires tissue to be contacted at a certain angle with a certain amount of force in order for it to change. I was astounded that some of the latest research suggests the old gel to sol approach might be right after all! The techniques being used did not seem to require the therapist to connect with the client or feel the effect propagate through the client?s fascial network, and I was rather astounded that the demonstrator showed no interest in anything more than the MF that was being manipulated, and whether it was reducing pain. Admittedly, it was a short demonstration, but my body reading of the subject from afar was inclusive of far more information than the tests were revealing.

There is much more to find in the pages of these books: I can?t say enough about them. If you are a serious student of the body and a serious practitioner of manual therapy, you must read and digest these books. You will not agree with everything they contain, but I promise you will learn things you never knew. These material in these books, if adopted, can revolutionize the way the larger world understands human structure and function ? they are that innovative! Naturally, I have, in this brief review, skipped over much for it is hard to encapsulate a life?s work in a few pages. My hope is that what I have communicated to you will scare and inspire you to not rest, as the Steccos have not rested, in your pursuit of understanding the body as it is.

Here I will leave you again with the words of Robert Schleip:

If you are a beginner with the field of physiotherapy . . . be prepared that it is not a book to skim over lightly while watching TV. It is a gold mine of condensed information. If you mistakenly skip over a sentence, it may easily occur that you will miss this information later, when trying to understand the logic of the following pages, as there is not much redundancy in this book. Yet I give you my word that even most experts in this field will look at and read this book with immense excitement and a state of joyful discovery. While other books have been written on fascia from several different angles, this one clearly sets a new standard.

Endnotes

1. Stecco, Luigi, Fascial Manipulation for Musculoskeletal Pain. Padova, Italy: Piccin, 2004, pg. 23.

2. Ibid.

Special offer: The publisher of these titles has generously offered a discount to Rolfers. Please contact Paolo Roselli, Director of Piccin North America, at [email protected] to place an order</i>A Commentary on Stecco?s Fascial Manipulation Work