CONNECTIVE TISSUE MANIPULATION CONNECTIVE TISSUE MANIPULATION By Liz Holey, MCSP

INTRODUCTION Every therapist hopes to find the technique which will offer a solution to the most challenging clinical problems. When such a new modality is found, it brings with it the temptation to overuse it, as the prospect of a fix-all is a seductive thought. Connective tissue manipulation (CTM) can be a solution to the most difficult clinical problems, as it is a manual therapy which can have sig- nificant effects on the more intractable spinal pain, nerve root pain/parasthesia and compartment syndromes. However, the key to its consistent positive effects is an understanding on the part of the therapist of its complex reflex mechanisms, as clear, accu- rate clinical reasoning and decision-making is as important as a skilful application of the technique.

The CTM referred to here began as the German Bindegewebsmassage, described in detail in the German works of Diche (1), Teirich-Leube (2) and more recently, Schuh (3). The writings in English by Ebner (4) and then Holey (5-10) replaced connective tissue massage with connective tissue manipulation to more accurately reflect the complexities of the application of the technique. Since then, some practitioners of Rolfing-based tech- niques have adopted the term ‘connective tissue manipulations’ to describe their practice. There are, indeed, some similarities with Rolfing and Bowen therapy, but it is important that the therapist does not confuse the techniques.

CONNECTIVE TISSUE MANIPULATION The unique aspect of CTM is that while, in practice, it appears to be a manual therapy, in application it is in fact a reflex therapy and an understanding of this drives the decision-making of the therapist. The reflex zones which are utilised in CTM are based on Head’s Zones (11) which can be seen and palpated with a degree of inter-rater reliability (6). They appear as slightly raised areas in an acute phase, or drawn-in areas of tissue in the more chron-

ic phase of a condition. The manipulations are carried out by a specific stroke which causes gentle shear forces, targeting specif- ic interfaces within the skin and connective tissue (5). These interfaces carry circulatory plexi which are accompanied by a dense network of autonomic nerve endings. The strokes are used as a way of directly stimulating the autonomic nervous system via these endings. The Zones are used to inform the areas which require treatment and the decisions about application and pro- gression of treatment.

CTM can be used to treat pain, circulatory alterations (mostly seen in chronic conditions) and autonomic imbalances. ‘Shin splints’ is an example of the coexistence of these features. A more gener- alised autonomic imbalance can be seen in states which are accompanied by tenseness or anxiety (sympathetic hypertonus) or lethargy (parasympathetic hypertonus), and a localised autonom- ic imbalance can be seen in, amongst others, nerve root dysfunc- tion or sympathetically-maintained pain syndromes. Skilful appli- cation of zonal CTM can impact on everything which is supplied through a particular spinal segment/s such as the circulation, muscle tone, sensory nerves, and bowel or stomach function. It is thought that this is due to an influence on the whole spinal seg- ment, which can become ‘facilitated’ (12), or sensitised, which results in an over reaction to normal stimuli. The whole segment can be influenced as all impulses travelling through and from structures within the segment converge in wide dynamic range neurons, in the spinal cord. It has been found experimentally that skin can influence and be influenced by other structures through this mechanism. The reflex pathways are known as cutaneo-vis- ceral reflexes and these are well accepted within physiology (13,14). Their exact mechanisms and evidence-base make inter- esting reading, but are outside the scope of this article. They may, however, offer some explanation for some of the stronger effects of other soft-tissue therapies.

Within sports medicine, CTM can particularly help the more The unique aspect of CTM is that while, in practice, it appears to be

a manual therapy, in application it is in fact a reflex therapy. Liz Holey, physiotherapist

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