Is it all its been made out to be????
Fascia, connective tissue, ECM, collagen. Whatever name you put on it has been garnering a lot of attention recently from researchers and manual therapists alike . The peak of the interest is highlighted by a whole international conference dedicated towards the study of it! The Annual international congress on Fascia has been a melting pot for therapists and researchers to share their accumulated knowledge regarding the subject clouded in mysticism and perhaps an understudied one too. People are probably used to hearing something along the lines of “its all connected” or “ it’s the key we’ve been looking for” or we have to “release the fascia”. While I would stray away from generalizing anatomical structures with anecdotal sayings, I do really have to admit it has provided some pretty interesting reading with the new research being published. This is just a selection of the things I have read on the topic and there will probably be a part two to this study because it’s really a very vast subject.
The Fascia Manipulation method: Although a number of myofascial release techniques have been proposed, nonesofar have been as effective as the fascial manipulation method. Somebody actually dedicated their lives to the study of the fascia and its effect on the musculoskeletal system. A man by the name of Luigi Stecco who was frustrated by his lack of success with conventional methods of physical therapy. He used anatomy and eastern medicinal acupuncture maps to help himself formulate a fascial map of the body. The method provides detailed information on manipulating this system to provide pain relief and has seen some good results so far on back pain, wrist pain and other conditions! (Cosic et al. 2013 ) (Pratelli et al 2015 ) ( Branchini 2015 ) His work is currently carried on by his son and daughter, Carla and Antonio Stecco both medical doctors. I do believe this to be breakthrough treatment in the world of physical therapy and to me is a breath of fresh air compared to other waffle Im so used to hearing about fascial techniques. 1 because they’re anatomists and publish regularly and 2 because they have an actual map, something to navigate by. I feel we have to be specific here and they really are indeed.
Link to some more good stuff: http://www.fascialmanipulation.com/en/about-fascial-manipulation.aspx?lang=en
Force transmission: Conventional biomechanics theorise that the movement of joints is generated through myotendinous force. Joints in the body act as levers and the surrounding musculature cross over articulations acting as “pulleys” providing all of the energy to move joints in different planes of motion which has been demonstrated empirically and conclusively by in vitro studies. ( Tidball 1981 )( Tissue 2000 ). The highly mechanical or Newtonian approach to the body co-incided with anatomy that rigorously dissected and isolated muscles from their surrounding structures. It was understood that by dissecting a muscle at its origin and insertion we could better understand it’s precise function in the body which is to an extent true but this type of thinking led to disregarding the role fascia has in moving the body and distributing the load internally ( P. A. Huijing 1999 ) There is interesting work at the moment that even suggests a complete revision should be made into the conventional biomechanical theory. Some researchers report that our bodies don’t operate in such a manner as proposed by the current biomechanical model.( Levin 1980 ) This is a topic for another discussion but here are a few examples about how connective tissue handles and responds to load both externally and internally.
Consider for a second a uni lateral straight leg raise in which the hamstring muscle is lengthened. From a classical anatomical model you would think tension would only occur in the hamstring but researchers have found it’s not the case at all. It actually distributes tension into the foot, the back , the lateral thigh and nearly 38% at the ITB according to researchers.( Miller et al. 2013 ). The mechanisms proposed for this observation have been the relative equal distribution of load by the fascial network.
The Lumbar erector muscles have been well known amongst the fitness community to account for the force necessary to deadlift heavy weights as they act on the spinous processes of the lumbar verterbrae and contribute to back and hip extension. We know powerlifters and strong athletes are well equipped to lift loads of up to 200 kg. Well when Bradford first described the necessary forces the lumbar erectors would need to exert for lifting weights as heavy as this he had a problem, the problem was that the force calculated was so large it would practically break our spines in half. (Bradford 1945) Further studies also confirmed that the compressive loads experienced during heavy lifting( 36.2 Kn) were far over the 10 – 12 Kn limit vertebrae could handle.( Granhed 1987 ) Bradford then concluded that there was something else that had to account for our ability to lift weights as heavy as this. Another researcher called Bartelink then proposed that intra-abdominal pressure accounts for the rest of the work load by providing an extensor moment arm ( Bartelink 1958 ). Research shows it still wasn’t enough to account for the incredible loads handled by the spine (McGill and Norman, 1987). So what is it? Well it’s the fascia and Gracotevsky who we’ll talk about later on concluded that it was the thoracodorsal fascia that made the lift possible through its mechanical advantage on leveraging the spine. Anatomically The thoracodorsal fascia attaches more posterior compared to the erectors which explain its advantage ( Gracotevsky 1989 )( Willard 2012 )
Remember again that the conventional biomechanical approach theorises that force specifically arises within and along the myotendinous unit. Along the myotendinous unit are muscle fibers that contract in order to generate force and movement at the joint. ( Ebashi 1969 ) While most research has focused on the individual myofibular elements in the process of contraction, recent studies show that the connective tissue that enwraps and embeds all of the myofibers has a key role to play too.( Turina 2002) Here are a few examples:
1 Up to 40 percent of the force a muscle generates is distributed not directly through the tendon but to the connective tissue outside of the muscle instead ( Huijing 2003 ).
2. It was long believed that muscular contraction involved individual muscular fascicles to shorten uniformly.( Gordon 1966 ) But Contemporary developments on muscular contraction with advanced imaging have provided contradicting evidence and suggest that the muscle fascicles shorten non-uniformly during contraction.( Blemker 2005 )( Pappas 2002 ) Due to the new understanding of uneven muscular contraction it is now believed that the connective tissue plays a key role in harmonizing the uneven force production and calls for a new model of muscular contraction to be made. Researchers who conducted the studies view the process of muscular contraction part and parcel with the accompanied fascial changes. ( Turrina et al 2002 )
Myofascial Meridians: Franz Reuleaux first theorized the kinetic theory in engineering that later became widely adopted to describe muscular chains responsible for movement of the body (Karandikar 2001). Hans von Baeyer and Steindler building upon the work of Reuleaux theorized that muscles activate along chains or with other groups of muscles and Instead of working in isolation they worked synergistically. ( Steindler 1955 ).
Fast forward over half a century and things have changed. The story starts with Thomas Myers. From his soft tissue training with Ida P Rolf and an accompanied interest in anatomy he began theorizing that there are in fact Body wide Myofascial Lines or “Meridians” that exist within the body. Well it turns out there are and 7 of them!!!( Myers 2014 ) While earlier works on kinetic chains were more theoretical and anatomically not yet proven, Thomas Myers has provided detailed maps about these kinetic chains and some of the chains even been proven by contemporary anatomy observations.( Wilke 2015 ) He goes into much further detail in his book Anatomy Trains but the basic premise is that groups of muscles in the body are arranged and function along a myofascial continuum. One of his proposed Fascial lines is the superficial backline and it runs from the cranium down along the back of the body ending at the plantar fascia. This line can be demonstrated right now just by using your chair! Sit down with your legs slightly spread apart, now fold forward and round your back, keep both of your hands on your head pulling down with some pressure, notice the stretch you feel in your lower back. Now take your hands off your head, extend your neck and look straight ahead of you. Notice how the feeling of stretch decreases in your lower back. This is because tension is taken off the back line by extending your head and reduces the tension in your lower back. Interesting huh J
Link to some his website and his other good stuff. www.anatomytrains.com
Serg gracotevsky: Now this man, a legend by my standards is currently living in Quebec Canada and a man I have to see before I die. He is one of the only researchers to provide a detailed proposal as to the theory of human locomotion and calls it the Spinal Engine Theory. Let’s not get complicated here but Gait up to now has viewed the lower extremities as the primary engine to human locomotion while the upper extremeties including the torso as relatively passive in the proess or otherwise as ‘passenger units’(Ebnezar 2013 ) ( Browne 1987 ). There are many fundamental flaws in this theory and Gracotevsky has experimentally proven that Human Locomotion is largely derived from the motion of the Spine and the coupled functional properties of the Thoracodorsal fascia.( Gracotevsky 1989 ) This is some ground breaking stuff. Naturally you would think that it is the legs that drive motion since they’re the ones that move but not on Mr Gracotevskys watch. It took me a while to really think about this when I first heard it but it just goes to show another amazing thing about the fascial network and how essential it is.
Well folks that’s all for today, was a bit of a heavy article so need to decide what sort of style I am going to go for in these blog posts but suppose ill figure it out on the way. Thanks so much.
1. Ćosić V, Day JA, Iogna P, Stecco A.( 2014 ) Fascial Manipulation(®) method applied to pubescent postural hyperkyphosis: A pilot study. Journal of Bodywork and Movement Therapies Oct;18(4):608-15.
2. Pratelli E, Pintucci M, Cultrera P( 2015 ) “Conservative treatment of carpal tunnel syndrome: comparison between laser therapy and FascialManipulation(®)” Journal of Movement and Body Work Therapies Jan;19(1):113-8
3. Branchini M, Lopopolo F, Andreoli E et al. ( 2015 ) “Fascial Manipulation® for chronic aspecific low back pain: a single blinded randomized controlled trial” US National Library of Medicine
4. Tidball JG (1991): Force transmission across muscle cell membranes. J Biomech 24 Suppl 1: 43–52
C TISSUE ( 2000 ) Joint Anatomy and Basic Biomechanics Chapter 2, : Uploaded Harmony Medical
5. Stephen M Levin(1980) “Discontinuous Tension, Discontinuous Compression: A Model for Biomechanical Support of the Body” pdf
6. Miller A, Falvey E, Clark S et al. ( 2013 ) “The Strain Patterns of the deep fascia of the lower limb” Department of Anatomy and Physiology, University of Melbourne
7. Bradford, f. k., and spurling, r. g. (1945): the intervertebral disc. springfield, Illinois
8. Bartelink ( 1958 ) “ the role of abdominal pressure in relieving the pressure on the lumbar intervertebral discs” vol. 39 b, no. 4, November
9. McGill, S.M., Norman, R.W., 1987. Reassessment of the role of intraabdominal pressure in spinal compression. Ergonomics 30, 1565–1588
10. Granhed H, Jonson R, Hansson T: Loads on the lumbar spine during extreme weightlifting Spine 12:146, 1987
11. The Spinal Engine Theory 1989 – Serge Gracotevsky
12. F. H. Willard, Vleeming, Schuenke, L. Danneels and R. Schleip ( 2012 ) “The thoracolumbar fascia: anatomy, function and clinical considerations” Journal of Anatomy
13. Paul W. Hodgesa,*, Andrew G. Cresswellb,c, Karl Daggfeldtb,c, Alf Thorstenssonb,c ( 2001 ) “In vivo measurement of the effect of intra-abdominal pressure on the human spine “ Journal of Biomechanics 347–353
14. Weightlifting: Chapter 45 , Joesph D Fortin.
15. Ebashi s, Endo m , Ohtsuki (1969) “ Control of muscle contraction “Quarterly Reviews of Biophysics 2, 4 pp. 351-384
16. Pappas, G.P., Asakawa, D.S., Delp, S.L., Zajac, F.E., Drace, J.E., 2002. Nonuniform shortening in the biceps brachii during elbow flexion. Journal of Applied Physiology 92, 2381–2389.
17. Turrina A, Antonio M, Gonza´lez M , Carla Stecco( 2013 ) “The muscular force transmission system: Role of the intramuscular connective tissue “ Journal of Bodywork & Movement Therapies
18. Gordon, A.M., Huxley, A.F., Julian, F.J., 1966. The variation in isometric tension with sarcomere length in vertebrate muscle fibres. Journal of Physiology 184, 170–192
19. Silvia S. Blemkera , Peter M. Pinskya et al. ( 2005 ) “A 3D model of muscle reveals the causes of nonuniform strains in the biceps brachii “ Journal of Biomechanics
20. Pappas, G.P., Asakawa, D.S., Delp, S.L., Zajac, F.E., Drace, J.E., 2002. Nonuniform shortening in the biceps brachii during elbow flexion. Journal of Applied Physiology 92, 2381–2389
21. Turrina, PT a,b, *, Miguel Antonio Martı´nez-Gonza´lez, PT, PhD c , Carla Stecco,( 2013 ) “The muscular force transmission system: Role of the intramuscular connective tissue” Journal of Bodywork and Movement Therapies 17, 95e102
22. Ninad Karandikar, MD, Oscar O. Ortiz Vargas, MD “ Kinetic Chains(2001) A Review of the Concept and Its Clinical Applications Ninad Karandikar” Journal of Bodywork and Movement Therapies
23. Kinesiology of the Human Body Under Normal and Pathological Conditions ( 1955 ) Blackwell Scientific Publishings
24. Anatomy Trains 3e (2014 ) – Thomas Myers, Churchill Livingstone Publishings.
25. Jan Wilke, Frieder Krause, Lutz Vogt et al. ( 2015 ) “What is evidence-based about myofascial chains? A systematic review” Archives of Physical Medicine and Rehabilitation
26 . The Human Gait (1987 ) W. Browne, O Fischer
27. Essentials of Orthopedics for Physiotherapists 2003 – John Ebnezar Chapter 20
Caolan here. Im a curious man to say the least and as an enthusiastic enrolling physiotherapy student. I have felt the need to share my thoughts and conclusions on the topic that is pain. Its something that will effect us all. Above all its very mysterious, misunderstood and complicated one and Im here to figure out more.