treatment_related_research

The Explosion of Fascia Research

by Dr. Leon Chaitow, D.O.


When I was studying osteopathy in the late 1950s (BCNO - now BCOM) fascia entered into the lessons and lectures as a somewhat mysterious part of the economy of the body. It featured large in the historical aspects of osteopathy's evolution, with early pioneers referring to its all-pervading nature - it was everywhere, and there were theories and assertions as to its relevance, but there was very little that was rooted in science. (Still 1902)


So, the question remained - what did fascia do?

Clues were to be found in American osteopathic writing. For example, decades ahead of his time Cathie (1974) described fascia's potential for contractility as well as its rich neural supply - features that would not be validated by research until very recently. (Schleip 2006, Stecco 2008).


Osteopaths - and others - in the USA (Little 1969, Taylor 1958, Rolf 1962) made it clear that that fascia was not just a background material, with little function apart from its obvious supporting role, but rather a widespread, tenacious, connective tissue involved deeply in almost all of the fundamental processes of the body's structure, function and metabolism.


In therapeutic terms it became clear there can be little logic in trying to consider muscles and joints as separate structures from fascia, because they are so intimately related. Remove connective tissue from the scene and any muscle left would be a jelly-like structure without form or functional ability, and joints would quite simply fall apart. (Cantu et al 1992)


We now know that there exists a state of structural and functional continuity between all of the body's hard and soft tissues, with fascia being the ubiquitous elastic-plastic, gluey, component that invests, supports and separates, connects and divides, wraps and gives cohesion, to the rest of the body - the fascial, connective tissue network. (Ingber 2008, Myers 2009)


Any tendency to think of a local dysfunction, as existing in isolation needs to be discouraged as we try to visualize a complex, interrelated, symbiotically functioning assortment of tissues, comprising skin, muscles, ligaments, tendons and bone, as well as the neural structures, blood and lymph channels, and vessels that bisect and invest these tissues - all given shape, form and functional ability by the fascia. (Schleip 2006, Ingber 2008, Solomonow 2009)


Fascial function and dysfunction revealed

Fascia, when healthy, forms a gliding interface with underlying muscle [allowing] free excursion of the muscle under the relatively immobile skin. A plane of potential movement exists in the form of the areolar tissue layer, apparently lined with a lubricant, hyaluronic acid. (McCombe et al 2001)

This process of 'sliding fascia' can now be visualised, using real-time ultrasound and elastography - as was demonstrated recently by Langevin (2010b). Dramatic video images demonstrated the free movement of lumbodorsal fascia in pain free individuals, contrasted with that of individuals with low back pain.


Similar images were displayed of myofascial trigger points, during the same panel presentation, that I co-chaired (Shah 2010). Both elastography and ultrasound images show trigger points to be denser than surrounding, normal, tissue.


When fascia is excessively mechanically stressed, inflamed or immobile, collagen and matrix deposition becomes disorganized, resulting in fibrosis and adhesions, and fascial 'thickening' (Langevin et al 2009), also described as 'densification' (Stecco et al 2009). This process involves distortion of myofascial relationships, altering muscle balance and proprioception. Consequent binding among layers, that should stretch, glide and/or shift on each other, potentially impairs motor function (Fourie 2009), and leads to chronic tissue loading, which contributes to 'global soft tissue holding patterns' (Myers 2009).


Cramer et al (2010) in rat studies showed that "hypomobility results in time-dependent adhesion development within the zygapophyseal joints". Such adhesion development may have relevance to spinal manipulation, which could theoretically break up Z joint intra-articular adhesions"


Some therapeutic implications

A review by Schleip (2003) has documented both myelinated and unmyelinated fibers in fascia, including sympathetic endings. Stecco et al. (2008) found that the outer layers of the deep fascia contained a rich vascular and nerve supply, with intrafascial nerve fibres seen throughout. Some of these were presumed to be stretch receptors.


Bialowski (2008) has hypothesised that mechanical force (soft tissue & manipulative) initiates neurophysiological responses - peripheral and central - possibly evoking and explaining the clinical outcomes of manual therapy. These hypotheses have been expanded on by Simmonds et al (2011) who suggest that HVLA manipulative therapies (i.e. rapid) stimulate fascial tissues (as in the Z-joint example described earlier), while myofascial therapies (such as myofascial release and muscle energy technique) deliberately stimulate fascial tissues


Langevin's in vivo and in vitro studies have shown that loose connective tissue responds to light tissue stretch, which "may be key to the therapeutic mechanism of treatments using mechanical stimulation of connective tissue" (Langevin & Sherman 2006, Langevin 2010a)


Myers (2010) suggests that stretching can be applied not only to 'length' problems, but also to 'stuck layer' problems, using shear stress to allow the restoration of increased relative movement between the adjacent planes of fascia (Schwind 2004)


In Germany, Pohl (2010) has demonstrated, using real-time ultrasound imaging, changes in collagen density in various layers of skin before and after connective tissue massage (CTM) involving skin rolling


Mechanotransduction and strain transmission

What has now been established is the remarkable degree to which muscular effort depends on the multiple links that muscles have with connective tissue structures.


These connections mean that - for example - a hamstring stretch will produce 240% of the resulting strain in the Iliotibial tract - and 145% in the ipsilateral lumbar fascia - compared with the hamstrings.


The process of strain transmission that occurs during stretching, involves many other tissues beyond the muscle that is being targeted, largely due to fascial connections, making the use of the word 'isolated' - together with 'stretching' - difficult to justify. (Franklyn-Miller et al 2009)


A fascial hydraulic effect?

Klingler & Schleip (2004), at the University of Ulm, measured wet & dry "freshly harvested" human fascia and found that during an isometric stretch, water is extruded, refilling afterwards. As water extrudes temporary relaxation occurs in the longitudinal arrangement of the affected collagen fibres. If only moderate strain is involved there are no micro-injuries, and water soaks back into the tissue until it swells, becoming stiffer again. It therefore seems that some tissue responses to manual therapy may relate to this sponge-like squeezing and refilling in the semi-liquid ground-substance, with its water binding glycosaminoglycans and proteoglycans.


Fascia related therapeutic approaches

The range of methods and modalities that focus attention on fascial dysfunction are proliferating. A few of those where a degree of supporting validation exists are summarised below :


  • Heat in the therapeutic range, relaxes many fascial contractures associated with myofascial dysfunction. External heat has been shown to be beneficial in low back pain (Klingler 2011)

  • Graston Technique (GT) is an instrument-assisted soft tissue assessment and mobilization method delivering load deformation via stainless steel instruments. Mechanical deformation influences the extracellular matrix (ECM,) modulating the synthesis of proteoglycans and collagen by fibroblasts, increasing collagen formation (Hammer 2007)

  • Neurologically active scars can restrict back flexion, which the patient feels as low back pain. This can be relieved by treatment of scars on the abdomen and/or below the symphysis (Kobesova, 2007)

  • Fryer & Fossum have suggested that apart from the influence of mechanoreceptors on pain (via both ascending and descending pathways), Muscle Energy Techniques induce in-vivo mechanical stretching of fibro-blasts that both alters interstitial osmotic pressure as well as increasing blood flow, so reducing concentrations of pro-inflammatory cytokines, reducing sensitization of peripheral nociceptors.

  • Standley & Meltzer (2008) have demonstrated - on a cellular level - the beneficial effects, on fibroblasts, of both myofascial release and positional release (Strain/counterstrain) methods. "...strain direction, frequency and duration, impact important fibroblast physiological functions known to mediate pain, inflammation and ROM...."

  • Borgini et al (2010) have demonstrated the influence of direct compressive force on dense fascial restrictions, using the Italian modality developed at the University of Padua, Fascial Manipulation

  • The benefits of Connective Tissue Massage have been demonstrated in a number of clinical trials - notably in relation to chronic pelvic pain (Fitzgerald 2009)

  • The methods used in structural integration (Rolfing) are directed mainly at fascia and connective tissue, which are treated with fingers, open hands, clenched fists, and elbows, with pressure directed to release adhesions between what should be freely sliding structures. (Findley & Schleip 2007)

  • Fernandez-de-las-Penas and Pilat (2010) have described the successful use of neuromuscular technique (NMT) in treatment of myofascial pain

References

  • Bialosky J et al 2009 The mechanisms of manual therapy in the treatment of musculoskeletal pain Manual Therapy 14:531-538

  • Borgini E et al 2010 How much time is needed to modify fascial fibrosis? Jnl Bodywork & Movement Therapies 14(4):318-325

  • Cantu R Grodin A 1992 Myofascial Manipulation Gaithersburg Maryland; Aspen Publications

  • Cathie A 1974 Selected writings. Academy of Applied Osteopathy Yearbook 1974, Colorado Springs

  • Cramer G et al 2010 Zygapophyseal joint adhesions after induced hypomobility. Journal of Manipulative and Physiological Therapeutics 33:508-518

  • Fernandez-de-las-Penas C Pilat A 2010 IN: Chaitow L Lovegrove R (Eds.) Practical Physical Medicine Approaches to Chronic Pelvic Pain (CPP) & Dysfunction Elsevier IN PRESS

  • Findley T Schleip R 2007 Fascia Research. Basic Science and Implication for Conventional and Complementary Health Care vols. 2-3, Elsevier, Germany

  • FitzGerald, M.P. et al 2009 Randomized Multicenter Feasibility Trial of Myofascial Physical Therapy for the Treatment of Urological Chronic Pelvic Pain Syndromes. Journal of Urology 182(2):570-580

  • Fourie W 2009 IN: Fascial Research II: Basic Science and Implications for Conventional and Complementary Health Care Munich: Elsevier GmbH

  • Fryer G Fossum C 2009 Therapeutic Mechanisms Underlying Muscle Energy Approaches. In: Physical Therapy for tension type and cervicogenic headache: physical examination, muscle and joint management Fernandez de las Penas C Arendt-Nielsen L Gerwin R (eds): Jones & Bartlett, Boston

  • Hammer W 2007 Functional Soft-Tissue Examination & Treatment by Manual Methods 3rd ed. Sudbury, MA, Jones & Bartlett pp 33-161

  • Ingber D 2008Tensegrity and mechanotransduction, Jnl Bodywork and Movement Therapies 12(3):198-200, 2008.

  • Klingler W Schleip R Zorn A 2004 European Fascia Research Project Report. 5th World Congress Low Back and Pelvic Pain, Melbourne, November 2004

  • Klingler W 2011 IN: Chaitow L Lovegrove R (Eds.) Practical Physical Medicine Approaches to Chronic Pelvic Pain (CPP) & Dysfunction Elsevier IN PRESS

  • Kobesova A et al M 2007 Twenty-year-old pathogenic "active" postsurgical scar: a case study of a patient with persistent right lower quadrant pain. Journal of Manipulative and Physiological Therapeutics 30(3):234-238

  • Langevin H, Sherman K 2006 Pathophysiological model for chronic low back pain integrating connective tissue and nervous system mechanisms. Medical Hypotheses 68(1):74-80

  • Langevin H 2009 Fibroblast Cytoskeletal Remodeling Contributes to Viscoelastic Response of Areolar Connective Tissue Under Uniaxial Tension, as reported in Fascial Research II, Elsevier GmbH Munich

  • Langevin H et al 2010a Tissue stretch induces nuclear remodelling in connective tissue fibroblasts. Histochem. Cell Biol. 133(4):405-15

  • Langevin H 2010b Presentation: Ultrasound Imaging of Connective Tissue Pathology Associated with Chronic Low Back Pain. 7th Interdisciplinary Congress on Low Back & Pelvic Pain (Los Angeles, November 11 2010)

  • Little L 1969 Towards more effective manipulative management of chronic myofascial strain and stress syndromes. Jnl American Osteopathic Association 68:675-685

  • McCombe D et al 2001Jnl. Histochemical structureof the deep fascia and its structural response to surgery. Hand Surgery 26B:2: 89-97

  • Meltzer K et al 2009 In vitro modelling of repetitive motion injury and Myofascial Release. Jnl Bodywork & Movement Therapies 14:162-171

  • Myers T 2009 Anatomy Trains, 2nd edition Edinburgh: Churchill Livingstone

  • Myers T Fascial Stretching. IN: Schleip, Findley, Huijing & Chaitow. Fascia in Manual Therapy. Elsevier, Edinburgh IN PRESS

  • Pohl H 2010 Changes in structure of collagen distribution in the skin caused by a manual technique J. Bodywork Movement Th. 14(1):27-34

  • Rolf I 1962 Structural Dynamics. British Academy of Applied Osteopathy Yearbook 1962. BAAO London

  • Schleip R, Naylor I, Ursu D, et al 2006 Passive muscle stiffness may be influenced by active contractility of intramuscular connective tissue, Med Hypotheses 66(1):71

  • Schleip R 2003 Journal of Bodywork & Movement Therapies 7:104-116

  • Schwind P 2006 Fascia and Membrane Technique, Edinburgh: Churchill Livingstone

  • Shah J 2010 Ultrasound techniques reveal objective abnormalities of myofascial trigger points and surrounding connective tissue. 7th Interdisciplinary Congress on Low Back & Pelvic Pain (Los Angeles, November 11 2010)

  • Simmonds N et al 2011 A theoretical framework for the role of fascia in manual therapy. Jnl. Bodywork & Movement Therapies IN PRESS

  • Solomonow M 2009 Ligaments: A source of musculoskeletal disorders, Journal Bodywork and Movement Therapies 13(2):136-154

  • Standley PR, Meltzer KR 2008 In vitro modeling of repetitive motion strain and manual medicine treatments: potential roles for pro- and anti-inflammatory cytokines. Journal of Bodywork & Movement Therapies 12:201-203.

  • Stecco A et al 2009 Anatomical study of myofascial continuity, anterior upper limb. J Bodyw Mov Ther. 13: 53-62

  • Stecco C et al 2008 The expansions of the pectoral girdle muscles onto the brachial fascia: morphological aspects and spatial disposition. Cells Tissues Organs. 188: 320-9.

  • Still AT. 1902 Philosophy and mechanical principles of osteopathy. Kansas City, MO: Hudson-Kimberly Pub. Co.

  • Taylor R 1958 Bioenergetics of man. Academy of Applied Osteopathy Yearbook 1958. Carmel California

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