Primary Care in Fascia Series
~”Diarrhea/Nausea/Vomiting” was the Chief Complaint for 32 year-old CB, my first patient of the day in Urgent Care. He was not dehydrated by his vital signs, and I expected to diagnose gastroenteritis, the “stomach flu,” as I entered the room — but the full story was that he had awoken with vertigo two days prior, severe enough to cause these symptoms. A quick review of his history confirmed Benign Positional Paroxysmal Vertigo (BPPV). Though only his first episode, he reported 10/10 dizziness and was moving guardedly.
I noticed that he had moderate Genu Recurvatum (knee hyperextension). He had started a new job two weeks ago that required standing all day, which would have increased his anterior thigh muscle tone. (Standing requires the contraction of the anterior thigh muscles while sitting/squatting stretches them.)
Conventional options included offering a maneuver like the Epley (based on otolith theory) and/or prescribing medications for dizziness and nausea with the hope that his symptoms would resolve quickly with rest. Patients can suffer with intensified nausea and vomiting with the Epley, however, especially if symptoms are already intense; in addition, they can miss days of work while they wait for the episode to resolve on its own.
I had already been treating BPPV by releasing the SCM muscle and contiguous fascia. Based on my theory about fascial histodynamics connecting the thigh and neck, I had been waiting for an opportunity to treat BPPV by starting with the legs. A former car mechanic, CB was very intrigued by the possibility that the origin of his vertigo could be from his legs, and agreed to a trial of soft tissue manipulation.
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I had another compelling reason for my interest in starting with the legs for CB’s vertigo. A few months prior, a new patient had presented with many ailments, including chronic back, neck, and arm pain. In her initial side-view photo (Fig. 1a), I noted that she had moderate Genu Recurvatum with typical compensations that I had observed in many other patients.
To help balance the forces around her pelvis, I released her anterior thigh fascia and then had her stand. Luckily, I happened to notice a focal change in blood flow to her neck (Fig. 1b-d). The flushing was more intense on the right, which corresponded to her more symptomatic side.
This phenomenon suggested that the anterior thigh fascia was physically connecting to her neck. Indeed, according to the Functional Atlas of the Human Fascial System, the Superficial Fascia is anatomically continuous from the thigh to the neck.9
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CB reported 10/10 dizziness even while sitting. Since bending the knee stretches the quadriceps muscle, I chose to release his anterior thigh fascia while he was seated. Pre-stretching his fascia, or what I call fascial potentiation, is like pulling a ribbon taut before cutting it with scissors, maximizing the degree of fascial tension just prior to release.
When I quickly but firmly released his anterior thigh fascia, CB’s vertigo relief was immediate and dramatic. He was able to turn his head and then stand up and walk without any dizziness.
Since this breakthrough with treating CB, I routinely treat BPPV with immediate results by selectively releasing the thigh after fascial potentiation.
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If otolith theories as proposed by Schucknecht (1969) and Hall (1979) are accurate, then how is it possible that BPPV could be stopped by releasing fascia, without moving the head?
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My treatment results would be described as “anomalies” by Thomas S. Kuhn, the theoretical physicist who transformed the world with his description of paradigms and their shifts in The Structure of Scientific Revolutions.
In the 50th anniversary edition of the book, Ian Hacking introduces Kuhn’s fundamental premise:
“That is the structure of scientific revolutions: normal science with a paradigm and a dedication to solving puzzles; followed by serious anomalies, which lead to a crisis; and finally resolution of the crisis by a new paradigm.”6
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Many studies document the efficacy of Particle/Canalith Repositioning Maneuvers (PRMs and CRMs) like the Epley. Pages of illustrations analyze the theoretical location of the particles in their canals, based on observed nystagmus (rapid eye movements) and head position of the patients.4,7,8
While the initial response to these PRMs/CRMs may be rapid, however, recurrence rate of BPPV is as high as 50 percent within ten years — most of these occur within the first year after the “successful” treatment. Thus, a significant population of chronic sufferers exist with the negative impact on their quality of life.4,7,8
Over the years, more treatments have been developed in the otolith paradigm, including the home-based Half-Somersault program3 and the TRV® chair11. (Interestingly, both of these newer methods involve significant stretch of the thigh fascia, whether via kneeling or sitting.)
Despite the dominance of otolith theories, there have been ENT researchers who published results challenging this prevailing model.
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In 1999, Dr. Richard Buckingham, an ENT surgeon from the University of Illinois at Chicago, published, “Anatomical and Theoretical Observations on Otolith Repositioning for Benign Paroxysmal Positional Vertigo.”2
He used rice grains and Kodachrome photographs of temporal bone slices to simulate movement of otoliths during PRM’s and with return to standing.
“PRMs do not remove or fix otoliths in any specific site in the labyrinth. . . The good results obtained by physiotherapeutic procedures suggest that some other mechanism than repositioning of otoliths [emphasis added] is responsible for the relief of BPPV.”2
Could this “other mechanism” involve traction on nerve fibers transmitted via fascia?
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According to Dr. Alf Breig, the Swedish neurosurgeon and researcher who wrote Adverse Mechanical Tension in the Central Nervous System, the spinal cord length changes by 5-7 cm depending on postural extremes. Contrary to the prevailing belief about the mass effect (compression) of tumors and discs as the mechanism for neural dysfunction, he argued that it is actually increasing tension on the nerve tissue with movement that provokes the symptoms.
“Even a demonstrably compressive force generates short-range axial tension. . . The magnitude of the tension in the cord depends firstly on the anatomical factor of body posture which determinates the relative lengths of the spinal canal and cord. . . .
The total tension induced may well lead to neural dysfunction, and then the involved nerve-fibres in the cord or nerve-roots may be said to be over-stretched. The most significant consequence of over-stretching nerve-fibres is impairment of their conductivity [emphasis added].”1
Prior to this, in 1977, an older colleague of Dr. Buckingham, Dr. Nicholas Torok, presented his paper, “An Experimental Evidence of Etiology in Positional Vertigo” at a conference.10 A respected vestibular researcher and inventor, Dr. Torok noted that, while the otolith organs could sense change in gravitational forces, these changes in head position also occurred with neck movements.
After ruling out vascular, brain, and otolithic causes, he proposed another neural mechanism based on the stimulation of cervical nerves in dogs. He and his colleague were able to cause nystagmus, a sign of BPPV. Based on this consistently reproducible neural-based reflex, they proposed changing the name of BPPV to positioning neurocervical vertigo (PNV).10
Why didn’t these outlier results by ENT clinicians promote proliferation of research into alternatives to otolith-based theories?
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Kuhn provides an answer to this question in Chapter VIII, The Response to Crisis:
“ . . first what scientists never do when confronted by even severe and prolonged anomalies . . . they do not renounce the paradigm that has led them into crisis . . . a scientific theory is declared invalid only if an alternate candidate is available to take its place. . . “6
So while their results may have challenged the otolith theory, the original theory likely remained because no viable replacement was offered.
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Perhaps, with the growing appreciation of fascia’s ability to transmit forces over great distances, a fascia-based theory is possible as a mechanism for BPPV, whether treatment focuses on neck movements (as with PRMs/CRMs) or fascial release of the thigh.
Even when the original paradigm cannot explain the obvious anomaly, however, Kuhn explains that the transition to the new theory is not smooth:
Chapter XII, Resolution of Revolutions: “The competition between paradigms is not the sort of battle that can be resolved by proofs. . . . the proponents of competing paradigms practice their trades in different worlds. . . . the transition between paradigms cannot be made a step at a time, forced by logic and neutral experience. Like the gestalt switch, it must occur all at once (though not necessarily in an instant) or not at all.”6
Introduction, A Role for History: “. . . a new theory, however special its range of application, is seldom or never just an increment to what is already known. Its assimilation requires the reconstruction of prior theory and re-evaluation of prior fact, an intrinsically revolutionary process that is seldom completed by a single man and never overnight.”6
Where Lavoisier (1772) saw oxygen, Priestley only saw “dephlogisticated air” for the remainder of his career. Similarly, many scientists never accepted Dalton’s atomic theory (1808) — his precise measurements and calculations were not adequate proof in their eyes.
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While the conceptual breakthrough of thigh fascia impacting the neck or head could be explosive, Kuhn describes the kinds of obstacles that can slow the pace of scientific community acceptance.
I. Limitations of research techniques
The discovery of oxygen in 1778 was made possible by the research advances made in the years after two key developments occurred: the invention of the air pump and innovative use of the balance scale in chemical experiments. Before the ability to control air and measure mass changes with reactions, chemists since the late 1600’s had believed that “phlogiston” was a property of matter and released during combustion.
The temporal bone houses the semicircular canals and cochlea in a volume smaller than a blueberry. Completely encased bone, this inaccessible inner ear space is also traversed by Cranial Nerves VII and VIII, which originate from the pons and cerebellopontine angle respectively.
Dr. Breig explains that posture and whole body movements are inseparable from the spinal cord:
When the trunk is fully flexed the dura is under tension, as is also the cord, and stretching occurs. . . . by far the larger component of the tension is set up directly in the cord by virtue of its anchorage at its two extremities, namely the brain stem and the cauda equina.
From the biomechanical aspect the spinal cord therefore cannot be considered in isolation but must be treated as a continuous tract of nervous and supporting tissues . . . This is referred to in this book as the pons-cord tissue tract, or simply the pons-cord tract. . . .1
Fascia has entered the consciousness of scientific research only recently. Like the revelations to chemists that reactions were utilizing surrounding air, which drove them to study the composition of this “air,” the possibility that thigh fascia (via the deep fascia) can impact cranial and/or cervical nerves creates an “essential tension” in science to develop methods to study this connection.
II. Limitations in “seeing” fascia
In Chapter X, Revolutions as Changes of World View, Kuhn points out:
“. . . the typical natural history often omits [emphasis added] from its immensely circumstantial accounts just those details that later scientists will find sources of important illumination. Almost none of the early “histories” of electricity, for example, mention that chaff, attracted to a rubbed glass rod, bounces off again. That effect seemed mechanical, not electrical.”6
Within otolith theory, moving the head means changing the gravitational forces on the debris within the semicircular canals — only the movement of the head is relevant. In his article proposing a cervical etiology for vertigo, Dr. Torok remarked that when the head moves, the neck must move.10
If we understand fascia as an all-encasing, viscerally interwoven dynamic organ, we know that when the neck moves, fascia, however anatomically remote, moves.
III. Egocentric or teleological bias
Kuhn describes this bias in Chapter XIII, Progress Through Revolutions:
“When Darwin first published his theory of evolution by natural selection in 1859, what most bothered many professionals was neither the notion of species change nor the possible descent of man from apes. . . All the well-known pre-Darwinian evolutionary theories . . . had taken evolution to be a goal-directed process [emphasis added] . . . Each new stage of evolutionary development was a more perfect realization of a plan that had been present from the start. . . .
The Origin of Species recognized no goal set either by God or nature . . . Even such marvelously adapted organs as the eye and hand of man . . . were products of a process that moved steadily from primitive beginnings but toward no goal.”6
Could there have an evolutionary advantage with Genu Recurvatum or joint hypermobility that became more of a liability as we stopped squatting or climbing as civilizations modernized?
If we shift from perceiving evolution as oriented toward perfection — to accepting it as part of evolution’s randomness, we could liberate our minds to recognize the physics of the body and the resulting problematic mechanics.
IV. Incommensurability of standards: head movements are exclusive of the body vs. the head is inseparable from the body
Kuhn discusses this concept extensively over several chapters, including Chapter XII, The Resolution of Revolutions:
“Consider, for another example, the men who called Copernicus mad because he proclaimed that the earth moved. They were not either just wrong or quite wrong. Part of what they meant by ‘earth’ was fixed position. Their earth, at least, could not be moved. Correspondingly, Copernicus’ innovation was not simply to move the earth. Rather, it was a whole new way of regarding the problems of physics and astronomy, one that necessarily changed the meaning of both ‘earth’ and ‘motion.’ Without those changes the concept of a moving earth was mad.”6
When we say that “the body is all connected,” do we mean “discretely” connected — that the head (or any body part) is connected to the torso like in a toy Barbie doll, but functionally separate; or do we mean “inextricably” connected?
V. Value Prejudice — incomprehensibility
Dr. Alexander Fleming, a physician-scientist, is credited for discovering penicillin in 1928. Known for his “sloppy” methods, he had left a petri dish of bacteria near an open window and mold had started growing on it (how long had he left it there?!).
Not one to throw anything away (obviously), he looked at the petri dish under the microscope and was shocked to find the bacteria dying in the vicinity of the mold spores. He published his research in 1929 to skeptical reception — how could common mold spores be life-saving?
More studies and data eventually made his findings indisputable. Dr. Fleming received the Nobel Prize for Physiology/Medicine, twenty years later in 1945.
In his later essay, “Objectivity, Value Judgement, and Theory Choice,” Kuhn observed:
“However incomprehensible the new theory may be to the proponents of tradition, the exhibit of impressive concrete results will persuade at least a few of them that they must discover how such results are achieved.”5
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As a Family Medicine physician, I have one of the most unique perspectives on the dynamic and evolving nature of fascia across an entire lifespan. Having treated thousands of patients conventionally, I have experienced firsthand what Kuhn described as a “gestalt switch.”
Chapter X, Revolutions as Changes of World View: “Scientists then often speak of the ‘scales falling from the eyes’ or of the ‘lightning flash’ that ‘inundates’ a previously obscure puzzle, enabling its components to be seen in a new way that for the first time permits its solution. . . . No ordinary sense of the term “interpretation’ fits these flashes of intuition through which a new paradigm is born.”6
Once I overcame my “value judgment” of limiting fascia to the musculoskeletal realm, my brain could begin to entertain fascia-based mechanisms for many chronic medical conditions that plague Primary Care medicine.
It has been over five years since I improvised a fascial treatment on my patient with chronic chest pain; and now, as I share incredible treatment results that beg for clinical fascia research, I am reminded even more strongly of Einstein’s quote from my first article.
“Imagination is more important than knowledge. For knowledge is limited, whereas imagination embraces the entire world, stimulating progress, giving birth to evolution.” ~
References:
1 Breig, A., 1978, Adverse Mechanical Tension in the Central Nervous System: An analysis of Cause and Effect, Relief by Functional Neurosurgery, Almqvist & Wiksell International (John Wiley & Sons, Inc.), Stockholm and New York City, 264 p.
2Buckingham, R.A., 1999, Anatomical and Theoretical Observations on Otolith Repositioning for Benign Paroxysmal Positional Vertigo, Laryngoscope, 109: 717-722.
3Foster, C.A., et al, 2012, A Comparison of Two Home Exercises for Benign Positional Vertigo: Half Somersault versus Epley Maneuver, Audiol Neurotol Extra, 2: 16-23.
4Imai, T, et al, 2017, Classification, Diagnostic Criteria and Management of Benign Paroxysmal Positional Vertigo, Auris Nasus Larynx, 44: 1-6.
5 Kuhn, T.S., 1977, The Essential Tension: Selected Studies in Scientific Tradition and Change, University of Chicago Press, Chicago, 351 p.
6 Kuhn, T.S., 1962, The Structure of Scientific Revolutions, University of Chicago Press, Chicago, 208 p.
7Perez-Vazquez, P. and Franco-Gutierrez, V., 2017, Treatment of Benign Paroxysmal Positional Vertigo: A Clinical Review, Journal of Otology, 12(4): 165-173.
8Lee, S and Kim, J.S., 2010, Benign Paroxysmal Positional Vertigo, J Clin Neurol, Jun; 6(2): 51-63.
9Stecco, C., 2015, Functional Atlas of the Human Fascial System, Elsevier, United Kingdom, 384 p.
10Torok, N., Kumar A., 1977, An Experimental Evidence of Etiology in Positional Vertigo. Presented at the 6th Extraordinary Meeting of the Barany Society, London, England, September.
11West, Niels, et al, 2019, Reposition Chair Treatment Improves Subjective Outcomes in Refractory Benign Paroxysmal Positional Vertigo, J Int Adv Otol, Apr; 15(1): 146-150.
