Fascinating Fascia: An Update on Fascia Research

Transcription

1 Fascinating Fascia: An Update on Fascia Research Marla D. Golden, D.O., FACEP Jacksonville, Florida Regional Assistant Dean Department of Clinical Education GA-PCOM

2 Objectives Discuss current research efforts directed at understanding the many roles of the fascia Describe recent findings about innervation of the fascia Discuss the contiguity of the fascial elements from the skin in Describe research on contractile properties of the fascia Discuss various studies validating the effects of manual therapies in the treatment of pain, inflammation and disease

3 4 th International Fascia Research Congress Started in 2007, subsequent meetings 2009, 2012 and 2015 Journal of Bodywork and Movement Therapies Basic Science: Biomechanics, Anatomy, Pathology, Innervation Applied: Manual therapy and it s implications, response to various exercise Ongoing discussion regarding nomenclature

4 No doubt nerves exist in the fascia When you deal with the fascia, you deal and do business with the branch offices of the brain

5 Innervation of the Fascia Neuroscience, 2011: Sensory Innervation of the thoracolumbar fascia To assess the role of the thoracolumbar fascia (TLF) in low back pain Quantitative evaluation of calcitonin gene-related peptide (CGRP) and substance P (SP)-containing free nerve endings in the rat TLF TLF densely innervated with differences in the distribution of different types between the 3 layers

6 Innervation of the Fascia Neuroscience, 2011: (cont.) Three layers: outer, middle and inner Outer: transversely oriented collagen fibers adjacent to subcutaneous tissue Middle: massive collagen fiber bundles oblique to long axis Inner: loose connective tissue covering paraspinal muscles Outer and middle layers particularly dense with sensory fibers. SP-positive free nerve endings (nociceptive) exclusively here Implications for surgical incisions Tesarz J, Hoheisel U, Wiedenhofer B, Mense S

7 Innervation of the Fascia Neuroscience, 2015: Innervation changes induced by inflammation of the rat thoracolumbar fascia Histologic study inducing inflammation in the TFL Overall density of sensory fibers same but population density changed: higher in the inner layer and lower in outer layer Significant increase in density of SP-positive nerve fibers Suggests pain from alteration and pathology in the fascia Hoheisel U, Rosner J, Mense S

8 Innervation of the Fascia Submitted for publication: Fascia and pain: findings after chemical and electrical stimulation. Schilder A et. al. Chemical stimulation TFL produces pain at higher intensity and in greater distribution patterns than muscle High frequency stimulation (HFS) of the fascia causes increased pain perception HFS of the muscle didn t change pain perception but induced decreased pain perception in the fascia

9 Anatomy of the Fascia Jean Claude Giamberteau Plastic Surgeon and Reconstructive Surgeon Video: Strolling Under the Skin Architecture of Human Living Fascia: The extracellular matrix and cells revealed through endoscopy Endoscopic video of the connective tissue elements of a living human from the skin in Brilliantly illustrates the contiguity of the fascial or connective tissue elements

10 Fascia Biomechanics Robert Schleip Ulm University, Germany Myofibroblasts and smooth muscle fibers in fascia Creates a crimp allows for contractility of fascia Thoracolumbar fascia responsible for locomotion with oppositional arm and leg movement Fibroblasts migrate through fascia to repair and maintain structure Process takes 72 hours Fascial Fitness workouts

11 Cellular level: Fibroblasts Myofibroblasts Can become neurons Responsible for tissue maintenance and repair of connective tissue Most energetic process of the body Mediates the inflammatory and antiinflammatory response via cytokine release Analagous to astrocytes in the CNS

12 Neural Dynamics of Fascial Plasticity Fascia densely innervated with mechanoreceptors responsive to manual pressure Golgi Type Ib-respond to stretch and muscle contraction Pacinian Type II: myotendinous junctions, deep capsular ligaments, spinal ligaments Ruffini Type II: ligaments, outer capsular layers, dura-respond to rapid stretch and sustained pressure

13 Neural Dynamics of Fascial Plasticity Type III and type IV = Interstitial Receptors Most abundant A delta and C fiber nerve endings Found almost everywhere, even bone Transmit 80 % of information from periphery to CNS Activation causes ANS to change local pressures in arterioles and capillaries Triggers increase in vagal tone

14 Neural Dynamics of Fascial Plasticity Type III and IV receptors (cont.) Activation influences plasma extravasation, changes fluid dynamics and changes the viscosity of the Extracellular Matrix (ECM) Increase in vagal tone leads to muscle relaxation Postulates this as mechanism for effectiveness of manual therapy/myofascial release

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17 Fascial Response to Myofascial Release Paul Standley, PhD University of Arizona College of Medicine, Phoenix, AZ Formerly at Midwestern University s Arizona College of Osteopathic Medicine Prolific research into myofascial release and manual therapies Awarded Irvin Korr Award and Northup Award by the AOA for his contributions to the Osteopathic Community

18 Validating Manual Medicine All body workers or manual therapists do some type of myofascial release (MFR) Objective: to determine best technique for, preservation of tissue, decreasing inflammation and clinical improvement Multiple studies using in-vitro modeled MFR looking at different variables

19 Response to Manual Therapies J Manipulative Physiolog Ther. 2007: Importance of strain direction in regulating human fibroblast proliferation and cytokine secretion: a useful in vitro model for soft tissue injury and manual medicine treatments. Eagan TS, Meltzer KR, Standley PR Equibiaxial vs. Heterobiaxial strain EQUI showed decreased fibroblast proliferation, inflammatory IL-6 and chemokine secretion

20 Response to Manual Therapies J Appl Physiology: Mechanical strain applied to human fibroblasts differentially regulates skeletal myoblast differentiation Musculoskeletal injury risk higher in repetitive motion strain Myofascial release used to apply long duration stretch to muscle fascia to repair injury Mechanical strain on fibroblasts in muscle fascia causes secretion of IL-6, known to start myofibroblast differentiation and muscle repair Suggests MFR after repetitive strain can improve muscle repair Hicks MR, Cao TV, Campbell DH, Standley PR

21 Response to Manual Therapies Duration and magnitude of myofascial release in 3-D bioengineered tendons: effects on wound healing. Bioengineered tendons (BETS) were stretched to 1 %, 3 %, 6 %, 9 % and 12 % beyond resting length Duration tested at 0, 1, 2, 3, 4, 5 minutes using 6 % stretch Lower magnitude ( 3 %) statistically significant decrease in wound size Longer duration causes rapid decrease in wound size Zein-Hammoud M, Standley PR

22 Conclusions Myofascial release (MFR) and manual therapies effect distinct changes in ANS, CNS and at the local cellular level May be able to tailor regimens based on needs/underlying injury MFR enhances cell proliferation and fibroblast collagen expression in wound area The fascia IS innervated Has contractility and is responsible for structure and function

23 Bibliography Sensory innervation of the thoracolumbar fascia. Tesarz J, Hoheisel U, Wiedenhofer B, Mense S. Neuroscience, 2011 Oct 27; 194: Innervation changes induced by inflammation of the rat thoracolumbar fascia. Hoheisel U, Rosner J, Mense S. Neuroscience, 2015 Aug.6; 300: Thoracolumbar fascia: anatomy, function and clinical considerations. Willard, FH, Vleeming A, Schuenke MD, Danneels L, Schleip R. J Anat2012 Dec; 221(6): Architecture of Human Living Fascia: The extracellular Matrix and Cells Revealed Through Endoscopy. Giamberteau JC, Armstrong C. Handspring Publishing, Edinburgh, 2015.

24 Bibliography Fascia is Able to Contract in a Smooth Muscle-Like Manner and Thereby Influences Musculoskeletal Mechanics. Schleip R et. al. Fifth World Congress of Biomechanics. Fascial Plasticity-A new neurobiological explanation, Part 1, Journal of Bodywork and Movement Therapies, January, Fascial Plasticity_ A new neurobiological explanation, Part 2. Jounal of Bodywork and Movement Therapies, April, Importance of strain direction in regulating human fibroblast proliferation and cytokine secretion: a useful in vitro model for soft tissue injury and manual medicine treatments. Eagan TS, Meltzer KR, Standley PR. J Manipulative PhysiologTher

25 Bibliography Mechanical strain applied to human fibroblasts differentially regulates skeletal myoblast differentiation. Hicks MR, Cao TV, Campbell DH, Standley PR. J Appl Physiol 2012 Aug: 113 (3): Duration and magnitude of myofascial release in 3-D bioengineered tnedons: effects on wound healing. Cao TV, Hichks MR, Zein-Hammoud M, Standley PR. J AM Osteopath Assoc Feb; 115 (2): Fascia Research IV: Basic Science and Implications for Conventional and Complementary Health Care. Weiring, Schleip, Chaitow, Klingler, Findley, (eds.). Kiener, Munich, 2015.