MANUAL THERAPY

intractable pain syndromes of a non-mechanical origin such as chronic nerve root pain or compartment syndromes.

The technique certainly sounds intriguing, and clarification can be gained through an understanding of how it is applied in practice. The strokes are generally applied with the thumb or the middle finger, to ensure accuracy when attempting to target a specific interface in the tissues. The interface is chosen in relation to intended outcome and condition of the tissues, as induced by the autonomic nervous system (ANS). The layers are targeted, moving from superficial layers in an acute phase, or when the skin has increased tension and/or tissue fluid. Deeper layers cannot be accessed satisfactorily until the epidermis and dermis lose ten- sion, tenderness and excess fluid. Each layer of tissue has its own stroke - the skin technique, the subcutaneous technique, the flat technique and the fascial technique. The most potent effects occur when the fascial layer is reached, which is accessible between muscle bellies (intermuscular septa) or where it attach- es muscle to bone. A powerful autonomic response is created which means that only a limited number of strokes can be safely applied at any one time. Symptoms of overdosing can range from headaches to fainting, which demonstrates the potency of the technique and the importance of a sound understanding of the physiological principles which underpin the use of CTM.

The strokes are applied around the sacrum initially in a prescribed order and pattern. It is believed that this ensures parasympathet- ic stimulation first which ‘desensitises’ the ANS in some way, prior to treatment in dermatomes which are richly innervated by the sympathetic nervous system (eg. close to the thoracic chain) (16). This is so that once the sympathetic stimulation occurs, the effects will be gentler and adverse side effects less likely to occur. As mentioned above, the pattern of application relates to areas of fascial access, or the position of specific Head’s zones. The pro- gression of treatment is directed by clinical decisions which relate to the pathology and desired outcomes.

SUMMARY In summary, CTM is a manual therapy which applies gentle trac- tion forces which are targeted very specifically at the different interfaces within the skin and connective tissues. It is a powerful reflex therapy which utilises Head’s zones to asses the condition of the autonomic nervous system, to inform decisions about appli- cation and progression of treatment and to indicate improvement following therapy. It is not a cure-all, but it is effective where other therapies have failed, due to its uniquely combined mechan- ical effects in the tissue with those reflex effects on the auto- nomic nervous system. There is some research evidence, but CTM remains under-researched (16-23).

LAURA - A CASE HISTORY

The progression of treatment is best described through a case his- tory of a ‘typical’ patient.

Laura is 32 and is complaining of low back pain. She is a regular exerciser (3 times weekly, for 90 minutes) at the gym, progress- ing gradually under the guidance of an instructor. She does no other sport. She is a care manager, her work being a combination of driving, office work, meetings and visiting clients in their home. It is physically varied and there are no apparent ergonom- ic causative factors. Her assessment is non-specific in that no par- ticular mechanical element appears to influence the symptoms. The pain appears unrelated to biomechanical abnormalities, mus- cle imbalance or training effects.

The pain is felt to the left of

the sacrum (7/10, after remaining in one position such as sitting for 15 minutes) and down the lateral aspect of the left thigh, with some parasthesia - a ‘tingly’ feeling when the skin is touched, with some dullness of sensation. It appeared to come on after a short stay in hospital, three years ago, for a kidney stone and infection.

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There were no contraindications to CTM, so treatment began with the patient in side lying. As always, with CTM, treatment began in the areas around the sacrum known as the ‘basic section’. ‘Flat’ technique was performed with the thumbs lifting the connective tissue away from the bone at the apex of the sacrum, in the space between the base of the sacrum and the L5 transverse process and

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Due to the non-specific nature of this problem, a CTM component was added to the assessment and Laura was found to have some obvious tissue changes within Head’s zones - A connective tissue (CT) zone visual examination revealed positive bladder and pelvic zones. On palpation, the zones were identified as chronic, as the skin covering the zones was superficially oedematous - it had open pores and the superficial layers exhibited a ripple effect when tapped. Slightly deeper palpation, on the fascial layer, found resistance to an upwards glide of the skin on the fascia and ridges were felt where the fascia connected to the lateral edge of the sacrum. On deep palpation against the border of the bone, pain was reproduced down the lateral aspect of the thigh.