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Fascia Perspectives: Clinical models, theories and evidence. PART 1

In early September a Fascia Research Summer School will be running at the University of Ulm. I will be presenting an overview of selected clinical models that focus attention on fascial dysfunction.
The focus will be on both the common and unique features of a number of fascia-related soft issue modalities, and will briefly evaluate the theoretical as well as practical features of different methods where there has been evidence of efficacy. Evidence informed suggestions will be offered as to which biochemical, biomechanical, hydraulic, circulatory, neurological or other (e.g. biopsychosocial?) factors might be involved in their application.
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I will deliver a  similar presentation, but with a more osteopathic bias, as a keynote speaker at the mid-September  9th International Conference on Advances in Osteopathic Research (ICAOR),  to be held in London at the British College of Osteopathic Medicine.
For more on this topic the newly released book : Fascia: The tensional network of the human body should be of interest.

In this posting –  PART 1 of a 2 part topic – I have selected a few extracts from those presentations that may be of interest, that I believe highlight the expanding awareness – via research – of the multiple roles played by fascia in healthy function…..and of what can go wrong, with a glimpse at some of the possible clinical solutions.
Fascia’s Multiple Roles in health and dysfunction:
Fascia provides structural and functional continuity between the body’s hard and soft tissues, as an ubiquitous elastic–plastic, sensory component, that invests, supports, separates, connects, divides, wraps and gives cohesion, to the rest of the body while allowing gliding, sliding motions – as well as playing  an important role in transmitting mechanical forces between structures (Huijing 2007)
Due to age, trauma or inflammation – fascia may shorten, becoming painful and restricted (Langevin 2009).  Binding may occur among layers, that should stretch and glide on each other, potentially impairing motor function (Fourie 2009).  Densification’ may occur involving distortion of myofascial relationships, altering muscle balance and proprioception (Stecco et al 2009) and chronic tissue loading, may form ‘global soft tissue holding patterns’ (Myers 2009)
Mechanical loading:
Many manual approaches claim to relieve dysfunctional fascial states, with a variety of  hypothesised explanations.
Clinical experience suggests therapeutic value of appropriately applied:
·      Shear force  e.g Connective Tissue Massage/Manipulation (CTM); Rolfing
·      Compression + Friction  e.g. Fascial Manipulation®)
·      Torsion  e.g. Myofascial Release (MFR), Neuromuscular Technique (NMT)
·      Stretch  e.g. Muscle Energy Technque (MET)
·      Bending  e.g. MFR, NMT
·      Isometric or Isotonic contraction  e.g. MET
·      Mild irritation to induce inflammatory, remodelling responses  e.g.  Graston, Gua sha, Cross fibre friction
For example – in relation to recovery and rehabilitation following trauma tissue loading converts mechanical force into a biochemical response:
Exercise & Manual methods stimulate tissue repair and remodeling in tendon, muscle, cartilage and bone
Mechanocoupling:  Physical load (e.g. shear or  compression) perturbs cells, transforming into chemical signals –  within and among cells
Cell–cell communication:Stimulus in one location leads to a distant cell registering a new signal, despite distant cell receiving no mechanical stimulus
Effector cell response: Mechanical loading stimulates protein synthesis at the cellular level, promoting tissue repair and remodelling (Chiquet et al 2007)
Neurophysiological responses:
Mechanical forces (soft tissue & manipulative) initiate neurophysiological responses – peripheral and central – evoking the clinical outcomes of manual therapy  (Bialowski et al 2008) . A review by Schleip (2003) documents myelinated and unmyelinated fibers in fascia, including sympathetic endings, while Stecco et al. (2008) found that the outer layers of the deep fascia contained “a rich vascular and nerve supply, with intrafascial nerve fibers seen throughout. ….[some were ] presumed to be stretch receptors”
Simmonds et al (2012) note that: “The number of receptors around a joint is outweighed by those in surrounding fascia so that absolute joint motion may not play a large component in the [neurophysiological] response”  
Physical responses to…. CTM
Using ultrasound imaging and electromyography, Pohl (2010) charted changes in collagen density in various layers of skin before and after connective tissue massage (skin rolling). This method was shown to have clinically useful effects in cases of chronic pelvic pain by Fitzgerald et al (2009).
In a recent study Holey et al (2011) showed that, following application of CTM there was evidence of effects on autonomic function
..and  MET
An isometric contraction – as used in MET & PNF-  lengthens the series elastic component of the sarcomere (fascial, tendinous), while the parallel elastic (actin/myosin) component shortens – so that the muscle does not change length. Repetitions of isometric contractions effectively lengthen these structures overall – particularly if active or passive stretching is added. (Lederman 1997)
Using a different form of MET, orthopaedic surgeons, Parmar et al (2011) report that isotonic ecccentric  (“Isolytic”)  MET  – i.e.  stretching during a contraction – is used to prevent adhesions, to increase knee range of motion (ROM) and decrease pain in patients following surgery for hip fracture.
Analgesic effects:  Both high and low-intensity  isometric contractions have analgesic effects in healthy  adults. Bement (2011) compared pain ratings and thresholds in men and women with fibromyalgia, before and after isometric contractions, of varying intensity and duration, performed with the elbow flexor muscles:               
1.    Maximal voluntary contractions (MVC) 25%
2.    MVC sustained until task failure
3.    25% MVC- for 2 minutes 80%
4.    MVC sustained until task failure
RESULTS:    Significant analgesic responses were noted  in some patients,  with the  greatest change noted after the long-duration, low-intensity contraction sustained until failure. Most benefit was experienced by younger women (average age 39) who had the lowest pain thresholds at outset
But why would MET have analgesic effects?
·      “A consequence of fibroblast responses to connective tissue tension may be homeostatic adjustment of interstitial fluid pressure and transcapillary fluid flow. Transmission of forces from fibroblasts to the extracellular matrix …. ……causes changes in interstitial hydrostatic pressure. Alterations in these functions may play an important role in the influence of mechanical forces on the response to injury and inflammation.” (Langevin et al 2005)
·      “This increases drainage from interstitial spaces & reduces concentrations of pro-inflammatory cytokines” (Fryer and  Fossum 2009)
Or, analgesia could result from release of  endocannabinoids during MET?
  The endocannabinoid Anandamide (AEA) is upregulated by –Myofascial Release, Muscle Energy Technique, and HVLA –involving shear and stretching load
   Treated subjects experienced analgesic/euphoric cannabimimetic effects, correlated with an increase in serum AEA levels (more than double pre-treatment levels). 
   Neither cannabimimetic effects, nor changes in AEA levels, occurred in control subjects. (McPartland 2007)
   A different trial reported little change in AEA levels, but showed significant post-treatment augmentation of another endocannabinoid, N-palmitoyl-ethanolamine (PEA) a short-chain AEA analog (Degenhardt et al 2007)
·       Bement  M et al 2011 Pain Perception After Isometric Exercise in Women With Fibromyalgia  Arch Phys Med Rehabil 92:89-95
·       Bialowsky J et al 2008 Manual Therapy 14:531-538
·       Chiquet M et al  2007 Gene regulation by mechanotransduction  in fibroblasts. Appli Phys. Nutrition and Metabolism 32 : 967-73
·       Degenhardt, B et al  2007. Jnl. American Osteopathic Association 107:387–394
·       FitzGerald, M.P. et al  2009 Randomized Multicenter Feasibility Trial of Myofascial Physical Therapy for Treatment of Urological Chronic Pelvic Pain Syndromes. Journal of Urology 182(2):570-580
·       Fourie W Robb K  2009  Physiotherapy 95:314–320
·       Fryer G Fossum C 2009  Therapeutic Mechanisms Underlying Muscle Energy Approaches. In: Physical Therapy for tension type and cervicogenic headache:. EDS: de las Peñas F  et al Jones & Bartlett, Boston.
·       Langevin H et al 2005 Dynamic fibroblast cytoskeletal response to subcutaneous tissue stretch ex vivo and in vivo. Am J Physiol Cell Physiol 288:C747–C756
·       Holey L et al 2011 An exploratory thermographic investigation of the effects of  CTM on autonomic function. J Manipulative Physiol Ther 34:457-462
·       Huijing PA 2007 J. Electromyography and Kinesiology 17(6)
·       Langevin H et al 2009 Presentation 2nd Fascia Research Congress
·       Lederman E. Fundamentals of manual therapy. London: Churchill Livingstone 1997. p34
·       McPartland, J et al 2005.. Jnl. American Osteopathic Association 105, 283–291
·       Myers T 2009 Anatomy Trains, 2nd edition Edinburgh: Churchill Livingstone
·       Parmar S  et al 2011 Effect of isolytic contraction and passive manual stretching on pain and             knee range of motion after hip surgery. Hong Kong Physiotherapy Journal 29:25-30           
·       Pohl H 2010 Changes in structure of collagen distribution in the skin caused by a manual technique JBMT. 14(1):27-34
·       Stecco L  Stecco C 2009 Fascial Manipulation: Practical Part.   Piccini Italy
·       Schleip R 2003 Journal of Bodywork & Movement Therapies 7:104-116
·       Stecco et al  2008  Journal of Bodywork & Movement Therapies 12:225-230



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