The structural and functional importance of the fascial system has largely been overlooked by the therapeutic community in the past. If you are a committed manual or movement therapist wanting to better understand how the body works and achieve the best outcomes for your clients, you can no longer be ignorant about the fascial system. Increasingly, scientific and clinical evidence is emerging which provides valuable insights to aid our understanding and the opportunity for improved therapeutic care.
The exciting thing about the Fascia Congress is that it actually does provide a forum for productive cross pollination between those involved in hard scientific research and clinical practice around the subject of fascia – connective tissue in all its forms and functions.
A broad church of interest was evident in the congress plenary presentations – for example: ‘Changes in fasciae related to repetitive motion disorders’ (Mary Barbe); ‘Adaptations of tendinous connective tissue to exercise’ (Michael Kjaer); ‘Mechanical loading and fascial changes’ (Al Banes); ‘Fluid dynamics’ (Rolf Reed); ‘Interfascial fluid: The secret life of water’ (Gerald Pollack); ‘Fascial anatomy overview’ (Carla Stecco); ‘Ultrasound and micro analytical techniques’ (Jay Shah).
In addition there were multimedia presentations including Dr Gumberteau’s latest film on the micro aspects of fascia; parallel sessions; multidisciplinary panels and dedicated poster sessions around numerous subjects – cytology and histology; mechanotransduction and biomechanics; gross anatomy; surgery and scars; pathology; pain and innervation; therapy; imagery and hypothesis; research methods and planning.
I was also lucky to do a fascial dissection workshop under the tutelage of the renowned ‘fascial anatomist’ Dr Carla Stecco. Having long considered that the body’s structure and function are interrelated, I found this workshop very illuminating. Muscles are ‘tension pockets’ within the entire fascial envelope.
Our fascia serves multiple functional roles. Besides its many mechanical roles, fascia is also plays an important part in supporting our metabolic and immunological systems.
The mechanical functions of fascia are myriad. Fascial layers allow ‘sliding’ between different tissues such as muscles, tendons and retinaculae. In particular, fascia forms an uninterrupted 3D web of tissue forming a tensegrity like structure providing for multidirectional force transmission and balancing particularly tension and compression forces during posturo-movements of the body. The elastic/kinetic energy storage properties of fascia allow for energy efficient movement.
Fascia is highly innervated and probably our most sensitive organ for proprioception, particularly the deep layers. Exteroceptive receptors appear to reside more within the superficial fascia.
The ‘deep fascia’ – a general term, has a high collagen content with regular fibre directions and not many elastic fibres. It can be basically subdivided into aponeurotic sheets and epimyseal tissue. It is amazingly tough in places serving to compartmentalise tissues; provide a degree of ‘soft tissue’ postural support; and furnishing significant intrinsic and extrinsic joint stability. It provides a deep connective tissue matrix which both encloses and attaches muscles and neurovascular tissues.
The superficial fascia contains a lot of elastic fibres and even some muscle cells allowing easy adaptation to stretching of the skin in movement. The superficial vessels including the lymphatics and free nerve endings are predominantly within this layer.
Fascia in the form of loose connective tissue liberally doused with hyaluronic acid (responsible for the water level in fascia) not only allows autonomy between various tissues but also enables the unique and important ‘sliding systems’ between the various fascial layers including those that surround muscle and neurovascular structures. This layer is particularly sensitive to changes mechanical stresses. Any inflammation predictably leads to ‘glueing’ and fibrosis in this tissue layer and loss of ‘slide’, uneven force transmission and inevitably the development of various symptoms.
Fascia will adapt according to the needs of the body. – wound healing; inflammation; aging; and similar to Wolfe’s Law (where bone remodels according to its exposure to tensile and compression forces) the early indications are that fascia behaves in the same manner.
Because fascia forms a continuous 3D web throughout the body, if one part of the system is compromised, adaptations can occur through the whole system.
I have a particular interest in the adaptive changes that occur in the myofascial envelope and associated joints in response to altered, more stereotypical and repetitive loading conditions.
In this light, Mary Barbe’s plenary presentation was fascinating – “Changes in fascia related to repetitive motion disorders”. Chronic increased muscle tension has been shown to increase collagen proliferation around tendons and related fascia (Fedorczyk et al 2010). In Barbe’s rat model studies, she was able to demonstrate that performing highly repetitive low force motions (reaching through a hole to pull a lever for a food reward) in odd postures for 2 hours a day, 3 days a week over a six week time frame set up a cumulative micro trauma disorder – leading to an inflammatory reaction, consequent fibrosis and an ensuing functional behavioural decline. Significantly, every tissue in the whole of the upper limb showed increased inflammation though this was more prominent in the forearm. (Interestingly, changes were also found in the support upper limb and even the hind limb on the reaching side! – though much less so) Increased inflammatory cytokines and macrophages were present not only in tendon but also in fascia, muscle, bone and nerves! This correlated with nociceptive neurochemical increases in the spinal cord.
Insufficient time for recovery between actions was a significant factor – typically actions were performed twice a minute at 40% maximum power. Symptom severity increased with higher repetitions and levels of force. Repetition rather than the level of force appeared to be the more significant. Declines in motor coordination were apparent and more marked in the high repetition low force group. Increasing age with exposure to cumulative high repetition low force exposure also increased the effect.
Also significant was that they found that fibrosis does not go away with rest alone – you need to treat it! Manual therapy has been shown to decrease inflammation. Barbe’s studies showed that administering ibuprofen helped limit collagen proliferation particularly if instituted early at the time of pain onset. This however did not change function – grip strength or mechanical allodynia, suggesting the possibility of central sensitisation with neural plasticity.
Barbe’s work indicates that peripheral inflammation and cortical plasticity jointly contribute to chronic repetitive motion disorders (Coq et al 2009).
Her important message is not to ’miss the moment’ for intervention – rest has little effect. Early intervention in administering ibuprofen was better in limiting fibrosis, movement decline and changed cortical behaviour. This work also has big implications for early intervention and prevention.