Thesuperficialcervicalfascia(transparentouterlayer)andthedeepcervical fascia (violet inner layer) are continuations of superficial and deep fascial layersthatsurroundtheentirebody.Thedeepermyofascialstructuresofthe neckthattheselayerssurroundarealsovisibleinthisview,andincludethe scalenes,thetransversospinalis,theplatysma,etc. PrimalPictures,usedbypermission.
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).
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.
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.
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.
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.
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.
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.
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. Tozzi,P.,Bongiorno,D.,andVitturini,C.(2011)Fascialreleaseeffectsonpatientswithnon-specific cervicalorlumbarpain.JournalofBodyworkandMovementTherapies.15(4):405–416.
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?