Ebook Advanced myofascial techniques (Vol.2): Part 2

CervicalIssues
11TheSuperficialCervicalFascia
12TheDeepPosteriorNeck
13TheScalenes

Thesuperficialcervicalfascia(transparentouterlayer)andthedeepcervical
fascia (violet inner layer) are continuations of superficial and deep fascial
layersthatsurroundtheentirebody.Thedeepermyofascialstructuresofthe
neckthattheselayerssurroundarealsovisibleinthisview,andincludethe
scalenes,thetransversospinalis,theplatysma,etc.
PrimalPictures,usedbypermission.


TheSuperficialCervicalFascia

11

TheImportanceoftheSuperficialLayers
Whatarethemostcommonclientissuesthatyouseeinyourpractice?Chances
are,neckpainanddiscomfortarehighonthelist.Althoughcervicalcomplaints
andconditionscanhavemanycauses,you’llalmostalwaysseebetterresultsif
youbeginyourworkwiththeseverycommonissuesbyaddressingrestrictions
in the superficial layers of the neck and shoulders. Whether caused by deep
articular fixations, posture and misalignment, habits, stress, injury, or other
reasons, neck issues respond quicker and stay away longer when the
differentiation and elasticity of the outer wrappings is addressed first. As with
other parts of the body, many seemingly deeper neck issues resolve when the
externallayershavebeenfreed.Inthischapter,I’lldescribehowtoworkwith
these superficial but important layers, which will also prepare for working the
neck’sdeeperstructures(whicharecoveredinthenextchapter).

Figures11.1/11.2(overleaf)
Thesuperficialfasciaoftheneck,ingreen,surroundsthedeepercervicalstructures,likeasleeveor
cowl.Itiscontinuouswithsimilarlayersintheface,head,shoulders,back,andchest.


Encircling the neck and shoulders like an over-large turtleneck sweater, or a
surgicalcollar(Figures11.1and11.2),theneck’souterwrappingsarecomposed
of multiplelayersof myofascia.Theseincludesuperficial layersjustunderthe
skin(suchasthefasciacolliinback,andthefasciacollisuperficialisinfront),as
well as the investing fascia that surrounds the outer neck muscles (such as the
trapezius, sternocleidomastoid, infrahyoids, and the platysma, Figure 11.3).
Together, these cowl-like superficial layers extend from their superior
attachmentsontheoccipitalridgeandconvergencewiththefasciaofthelower
face, to their merging with the outer layers of the shoulders, chest, and upper
back at their inferior margin ( 1). Like a sleeve, they encircle the deeper
myofascial,skeletal,andvisceralstructuresoftheneck’score.

The outer layers of the neck have a surprising thickness and resilience. When
theylosepliabilityorareundifferentiatedandadheredtootherstructures(dueto
injury, postural strain, or other reasons), the outer layers have the ability to
restrict movement range, disrupt balanced alignment, and bind the structures
they surround. Imagine trying to move in a wetsuit that is a size too small
(Figure 11.4)—the outer layers of the neck can tether, distort, and constrain
movement in the same way. And the thickness, elasticity, and sliding of these
layerscandirectlycorrelatetopain.Inoneultrasoundstudyoflivingsubjects,
neck pain was seen to be proportional to the thickness of the cervical fasciae,
whichinturnwasobservedtomeasurablychangeasaresultofhands-onfascial


techniques ( 2). In another ultrasound study, sliding between fascial layers in

people with neck or back pain has been seen to measurably improve after
myofascialwork(3).


Assessingsuperficialrestrictions
Try this: observe your standing client turn his or her head from side to side.
Watchwhathappenswiththesuperficiallayersoftheneck,shoulders,chest,and
back. Are there areas of the torso’s fascia that move along with the head and
neck? Or, do you see lines of tension and pull appearing in the skin and outer
layers? Often, these signs of fascial inelasticity, binding, and lack of
differentiation will be most visible at the extremes or end-range of the
movement.Lookfromboththefrontandtheback;compareleftandrightsides
for any differences. Then, look again as he or she gently looks up and down.
Your client might feel different kinds of restrictions when moving; including
pulls in the deeper musculature, or catches involving neck articulations or the
upper ribs. For now, we’re going to leave these aside and focus on the outer
layersfirst.

Figure11.3
Thesuperficiallayersoftheneck,incross-section(afteranillustrationfromIdaRolf’s1979“The
IntegrationofHumanStructures”).

Sometimes superficial fascial tension will be visible as linear “tug” patterns in
theskin(Figure11.5).Inothercases,awholesheetoffasciawillmoveorcreep
along with the rotating or nodding head. Linear “tug” patterns are more


commonly seen in the thinner layers of the anterior neck and chest, while the
“creep” of whole fascial sheets is seen more often when looking at the thicker
posteriorlayersoftheback.

If it is difficult to see restrictions in the superficial layers, you can use your
hands instead to feel for tugs and pulls in the outer layers while your client
rotates his or her head. Whether watching or feeling, note any areas that don’t
display a smooth, even lengthening of the dermis and superficial fasciae when
theheadmoves.
When testing for fascial tension with active movement, don’t confuse
movements of deeper structures for movement in the superficial fascia. For
example, you’ll sometimes see the ribcage turning along with the head, or a
shoulder roll forward, etc. Some of this movement is normal; if you see
exaggeratedorasymmetricalmovementoftheribcageorshoulder,thismightbe
because of deeper or larger restrictions. Make a note to check for and address
thesepatternslater,butrememberthatsincethesedeepermovementsmightalso
becausedbyrestrictionsintheouterlayers,releasingthesuperficiallayersisthe
logicalfirststep.


ReleasingSuperficialRestrictions
Onceyou’veseenorfeltwhereyourclient’souterlayersaretuggingorcreeping
along with head and neck movement, you can go to work. A word about
sequencingyoursuperficialworkontheuppertorso:mostclientswillfeelmore
balanced if you begin by working the posterior restrictions of the upper back,
andendbyaddressingtheanteriorrestrictions.Thisistheorderwe’reusingin
thischapter.Whythisback-to-frontprogression?Sincemostofustendtohave
our heads forward of the coronal midline to some degree, and are narrower
across the front of our chest than across our upper back, the anterior fascial
layersofthechestandshoulderscanbethoughtofasshorterthantheposterior
layers of the shoulders and back. Ending with the anterior restrictions
counterbalances the earlier work on the posterior side of the body, and usually
leavestheclientwithagreatersenseofanteriorwidth,length,andfreedom,and
so helps with overall postural balance and ease. A possible exception to this

ordering: if your client has a very flat upper thoracic curve, you may want to
reversethesequence,andendwithworkonthebacktoencouragemorespinal
flexion.

Figure11.4


Thesuperficiallayersoftheneckcanrestrictmotionoftheneck,jaw,shouldersandchest,muchlike
atoo-tightwetsuitmight.

Over-The-EdgeTechnique
Askyourclienttoliefacedownonyourtable,armsatthesides,withhisorher
headandneckjustoverthetopedgeofthetable.Theedgeofthetableshould
fallaninchortwobelowthetopofthesternum.Yourclientmayneedtoadjust
upwardsordownwardsabitsothattheedgeiscomfortable.Youwon’twantto
leaveyourclientlikethistoolong,butyou’llusuallyhaveatleasttwoorthree
minutestoworkbeforehisorherheadstartstofeeltoofull.
Once your client is comfortable, ask for active side-to-side head and neck
rotation,asyouobserveagainorfeeltheoutertissuelayers.Thisallowsyouto
recheckyourfindings,andcomparethispatterntowhatyousawinanupright
stance.Lookattheflexion/extension(up-and-down)movementstoo,againusing
caretoavoidexcessiveneckcompressionwithextension.Becausetheeffectsof
gravity are different in this position, you may see or feel additional
undifferentiatedareasthatweren’tobviousinstanding.Often,thisproneposition
willmakethesuperficialrestrictionsevenmoreobvious.
The tool we’ll use to differentiate these less-pliable layers is the flat of our
forearm; specifically, the first few inches of the ulna just distal to the elbow
(Figure 11.6). Use this tool to gently anchor the inferior margins of the areas
where you saw or felt superficial restrictions. Don’t use oil or cream; we’ll be
usingfrictionmorethanpressuretocontactthelayerwewanttorelease.Also,

we won’t be sliding much—different from a passive “stroke,” our client will
actively provide the movement needed for layer differentiation and increasing
elasticity.


Figure11.5
Assessingsuperficialrestrictions:fascialstrainvisibleas“tugging”oftheouterlayerswithhead
rotation.

Figure11.6
TheOver-the-EdgeTechniqueforaddressingthesuperficiallayersoftheupperbackandshoulders.
Althoughrelativelysafe,head-downpositionsareusuallycontraindicatedforclientswith
uncontrolledhighbloodpressure,glaucoma,ahistoryorriskofstrokes,vertigo,oracutesinus
issues.

Once you have the outer layers gently but firmly anchored with your forearm,
askyourclienttoslowlyturnhisorherheadawayfromthesideyou’reworking.
Feelforthedirectionofyourpressurethatgentlylengthensthesuperficiallayers
beingpulledonbytheheadmovement.Imaginethatyou’rehelpingyourclient


lengthenandfreeherselfinsidethewetsuit-likeouterlayersofsuperficialfascia.
Alternatively,youcanaskyourclienttoliftandlowerthehead(extendandflex
theneckandspine)asyoulengthenthelayersofthebackinferiorly.You’llfind
thistechniquemosteffectiveontheeccentricphaseofthemotion,thatis,while
yourclientisloweringhisorherhead.
Remember, your client may become uncomfortable if you leave them in this
position for more than a few minutes. Although relatively safe, head-down
positions are probably contraindicated for clients with uncontrolled high blood
pressure,glaucoma,historyorriskofstrokes,vertigo,oracutesinusissues.

SeevideooftheOver-the-EdgeTechniqueatwww.a-t.tv/wb08

Figure11.7
Anopenpalmorthetipsofcurledfingersmaybeusedtoanchorthepectoralisfasciainthe
Cervical/PectoralisFasciaTechnique.

Keypoints:Over-the-EdgeTechnique
Indicationsinclude:
•Neck,shoulder,orbackpain.
•Movementrestrictionsorstiffness.
•Fasciallayercreeportugobservedwithneckrotation.



Purpose
•Increasefasciallayerdifferentiation,elasticity,andgliding.
•Preparetheneckandshouldersfordeeperwork.


Instructions
1.Positionproneclientwithheadandneckcomfortablyofftheendofthe
table;theedgeofthetableshouldbejustbelowthecollarbone.
2.Usethebroad,flatsectionofyourulna,justdistaltotheelbow,toanchor
layerscaudally.Askforactiveclientmovement.


Movements
•Activerotation,nodding,and/orsidebendingoftheneck.

Precautions
•Avoiduncomfortablehyperextensionoftheneck–cueclienttokeepneck
longwhileliftingthehead.
•Contraindicatedforclientswithuncontrolledhighbloodpressure;
glaucoma;historyorriskofstroke;vertigo;acuteorunstableneckinjuries
(includinghotwhiplash);oracutesinusissues.
•Monitorclient’scomfort,andlimittimeinthispositiontotwotothree
minutesmaximum.

Cervical/PectoralisFasciaTechnique
After differentiating the superficial layers of the back and posterior shoulders,
broaden and continue this release by addressing any surface restrictions in the
upperchestandanteriorshoulders.
To release these anterior restrictions, use either palms or fingertips to gently
anchor the superficial fascia of the shoulders, chest, and anterior neck (Figure
11.7). Then, use your client’s active movements to release the restrictions you
saw or felt earlier. The palm is especially useful where you saw fascial layers
creepwithheadmovement.Whenusingyourpalm,don’tbetemptedyettorub,
slide,ormassagethedeeperlayersofpectoralismuscle.Instead,usethebroad
surfaceofthepalmtocatchandgentlyanchortheouterlayersofthechest,while
yourclientmoveshisorherhead.

Figure11.8


Activecontractionoftheplatysma,asingrimacing,canaidinincreasingelasticityand
differentiationofthesuperficialfasciaoftheanteriorneckandthorax.

Incontrasttothebroadtoolofthepalm,usingthefingertipswillallowyouto

workveryspecificareas,andsoareusefulwhereyousawlocaltugsintheouter
layers. The fingers are slightly curved rather than straight, and can sensitively
“hook in” to the outer layer you saw or felt moving with the head. Push with
your fingertips, as if straightening out your curled fingers, to encourage
superficialreleaseawayfromthedirectionofmovement.
Whetheryou’reusingpalmorfingertips,don’tslidealongthesurface,anddon’t
digdowntothepectoralmuscles,ribs,orintercostals—youwanttofeelatugin
the outer strata, the layers of dermis and superficial fascia that lie between the
actualsurfaceoftheskin,andthemusclesorbonesbeneath.
Movement:asintheOver-the-EdgeTechnique,askyourclienttoslowlyturnthe
head away from the side you’re anchoring. Find a direction for your pressure
that gently releases the superficial layers being pulled by the head movement.
Imaginethatyou’rehelpingyourclientlengthenandfreehimorherselfinside
thewetsuit-likeouterlayersofsuperficialfascia.
A further option is to have your client tighten the platysma muscle, which lies
within the superficial fasciae that you’re working. Try it yourself as you’re
readingthis—turnyourhead,andthengrimaceorsnarluntilyoufeelatugfrom
your lower lip into the pectoral fascia of your chest. By using your hand to
anchorthelowerendofthistuginthechest,youcansnarlandrelaxrepeatedly
inordertoreleaseanyinelasticityintheanteriorcervicalandpectoralisfasciae
(Figure 11.8). Asking your client to tighten and relax the platysma in this way
whileyouanchoritsinferiorattachmentscanhelphimorherfocustheworkinto
themostrestrictedareas.

Keypoints:Cervical/PectoralisFasciaTechnique
Indicationsinclude:
•Neck,jaw,face,orshoulderpain.
•Movementrestrictionsoftheneck,jaw,face,chest,orshoulders.
•TMJpainormisalignment.
•Torticollisorposturalissues.

•Fasciallayercreeportugobservedwithneckrotation,armmovement,or
breathing.



Purpose
•Increasefasciallayerdifferentiation,elasticity,andgliding.
•Preparetheneck,shoulders,face,orchestfordeeperwork.


Instructions
1.Useabroadpalmtoanchorthesuperficialfasciaoftheshoulders,chest,
andanteriorneck.
2.Useslightlycurvedfingertipstohookandworkmorespecificareas.
3.Askforslowactivemovement.Cueclienttoslowdownfurtherorstop
andwaitforrelease,wheneveryoufeelfascialrestrictions.


Movements
•Slow,activeneckrotation.
•Activecontractionoftheplatysmaasingrimacing,frowning,orsneering,
feelingforconnectionofthesemovementstoareasoffascialinelasticity.


Finishing
Onceyou’veworkedwiththeouterlayersoftheneckandtorsofromboththe
backandfront,lookagainasyourclientturnshisorherheadfromsidetoside.
Ifyou’vebeenbothpatientandthorough,you’llseefewerpullsandtugsinthe
outerlayers,andmorethanlikely,smootherandgreaterrangeofmotion.Clients
often report that their movement feels easier, freer, or that their head is lighter

andmoreupright.
Nowthatyou’veaddressedtheouterlayers,thenextstepcouldbedeeperwork
with the neck, ribcage, or spine, either in the same session, or during the next
appointment. The deeper work will now be easier, more effective, and longer
lasting.Or,insteadofworkingdeeperrightaway,youmightwanttocontinuethe
themeofsuperficialreleasefirstbyadaptingthetechniqueswe’vejustdonehere
to other regions ofthebody, suchasthelumbars,limbs,orhips.Youcan find
techniquesfortheseareasinotherchaptersofthesevolumes.Inthemeantime,
keepinvestigatingwhathappenswhenyoutaketimetoreleasetheouterlayers
ofthebody.


References
[ 1] Breul, R. (2012) The deeper fasciae of the neck and ventral torso. In: Robert Schleip et al. (eds).
Fascia:TheTensionalNetworkoftheHumanBody.Elsevier.p.46.
[ 2] Stecco, A., Meneghini, A., Stern, R., Stecco, C., and Imamura, M. (2013) Ultrasonography in
myofascial neck pain: Randomized clinical trial for diagnosis and follow-up. Surgical and Radiologic
Anatomy.Aug23.
[3]Tozzi,P.,Bongiorno,D.,andVitturini,C.(2011)Fascialreleaseeffectsonpatientswithnon-specific
cervicalorlumbarpain.JournalofBodyworkandMovementTherapies.15(4):405–416.


Picturecredits
Figures11.1and11.2courtesyPrimalPictures,usedbypermission.
Figure11.3courtesyestateofJohnLodge,usedbypermission.
Figure11.4Thinkstock.
Figures11.5–11.8courtesyAdvanced-Trainings.com.


StudyGuide

TheSuperficialCervicalFascia
1 Where does the text say that linear skin “tug” patterns are most
commonlyseenwhenturningthehead?
aposteriorneck
bposteriorupperback
canteriorneckandchest
danteriorlowerjaw
2Whatreasonisgivenforendingthesuperficialworkontheanteriorbody,
vs.ontheback?
a Finishing this way leaves the client with a sense of strength, which is
stabilizingformostpeople.
bFinishingthiswayleavestheclientwithasenseofwidth,whichisbalancing
formostpeople.
cFinishingthiswayishowIdaRolfdidit.
dNoreasonisgivenforfinishingwithsuperficialworkonthechest.
3 The chapter recommends not keeping the client face down in the Overthe-EdgeTechniqueforlongerthan:
a20to60seconds
btwotothreeminutes
cthreetosixminutes
dtwotothreesessions
4 What is the practitioner’s ulna feeling for in the Over-the-Edge
Technique?
afasciallengtheningoftheupperback
bfascialdifferentiationoftheanteriorneck
cfascialdifferentiationonthefrontofthebody
dfascialdifferentiationofthelowerjaw
5 What client movement is mentioned for the Cervical/Pectoralis Fascia
Technique?