Friday, January 11, 2013

Sander Myofascial Release

Sander Myofascial ReleaseBy Cassandra Wang


It began with my client who particularly had a difficult shoulder problem in early 2009. I commented jokingly to my client, who refurbishes old wooden windows, that I needed a sander. As the joke settled, the seed of possibility sprouted. He looked at me in disbelief as a smile dawned across my face. Could a sander provider the heat and friction needed for fascia work? I purchased a small variable-speed craft sander, and rubberized drawer liner (this replaced the sand paper.) At at my client’s next appointment, we were ready.



The therapy involves the use of a quarter sheet sander, drawer liner, cotton handkerchiefs, and silk handkerchiefs. I use Luigi Stecco’s myofascial maps as a guide. For stretching the fascia lines, use the drawer liner (silicon gel pad can also be used) as there is a more traction effect. For gel to sol state therapy, use the cotton as more heat is generated. 30 seconds at a time or until there is increased redness to the skin. For adding qi to the fascia, use the silk as there will be static electricity transfer (in ancient Chinese medicine, it was tradition to massage through silk.) The session fully reduced the thickened tissue to a normal state resulting in the restoration of pain free range of motion. 

Since that time, I have continued to apply the therapy in cases of extreme tissue thickening such as a chronic (8 yr. history) Kyphosis-Lordosis, and a knotted rhomboid (36 yr. history). Also plantar fasciitis responds to it very well. I don’t know why this works from a scientific viewpoint but clients find the therapy comfortable. Suggestions for a name for this therapy are welcome.



Cassandra Wang has been practising holistic health for 17 years. She practiced at her clinic Body-Psynse in San Diego, CA. Cassandra is a graduate of Pacific College of Oriental Medicine. Her postgraduate education includes all major western and resonant modalities. She has been a massage instructor and a presenter at various conferences and seminars. A native of Greensboro, N.C. She has served 13 years as an Electronics technician and Command Fitness Coordinator in the US Navy. While serving, she obtained a BS in Sociology and was awarded Sailor of the Year. Honourably discharged in 1993, Cassandra continues to serve the cause of better health. Her clientele ranges from infants to seniors and those seeking general health improvement to the terminally ill. Cassandra can be contacted at http://www.bodypsynse.com/

Disclaimer: The information presented on this site is offered as-is. The author and publisher of this article disclaims any responsibility and liability for loss or damage that may result from using the information from this article.

What’s New in Fascial Anatomy

What’s New in Fascial Anatomy By Julie Ann Day


At the 2012 Fascia Research Congress in Vancouver, physiatrist, Dr. Antonio Stecco, and physiotherapist, Julie Ann Day are teaming up to present a full day, post conference workshop entitled “Fascial Manipulation and its Biomechanical Model”. Furthermore, Dr. Carla Stecco, orthopaedic surgeon and anatomy researcher, is an invited keynote speaker as well as being part of the scientific committee. She will also be holding an innovative pre-conference fascial dissection workshop. See www.fasciacongress.org for more details. 

The more we know about fascial anatomy, the more our clinical work can be effective. The Stecco family and their collaborators continue to produce studies about fascia, emphasizing the importance of researching this tissue in depth. Here is some updated information from Julie Ann Day about their more recent findings.

First, it is important to distinguish between the superficial fascia (SF) and the deep fascia (DF) layers, mostly because they are distinctly different in terms of structure and function. According to the Stecco studies, the superficial fascia is a membranous layer rich in elastic fibres lying beneath the cutis and within two layers of what is called the “retinacula cutis”. The retinacula cutis layers consist in fibrous septa that extend vertically from the skin to the SF, and somewhat obliquely from the SF layer to the DF; adipose lobules lie between these fibrous septa. In general, the hypodermis layer is involved in the gliding of skin on underlying structures, thermoregulation, metabolic exchange, and the passage of nerves, blood, and lymphatic vessels. Clinically, it is probable that light touch techniques (e.g. lymphatic drainage, superficial massage and others) produce effects within this layer.

The deep fascia lies below the hypodermis, forming a sleeve-like layer, particularly in the limbs, which surrounds muscle groups. This layer is continuous with intermuscular septa, the epimysium (and consequently perimysium and endomysium) and, in some areas, with periosteum. The DF as compared to the SF has a robust, multilayer collagen structure and relatively fewer elastic fibres. It is thought to have a mechanical function of force transmission and, due to the large numbers of embedded mechanoreceptors, a possible proprioceptive role. Clinically, it appears probable that sustained or deep friction techniques are capable of altering tissue consistencies in this layer.

Interestingly, recent studies[1], [2] have shown that the deep fascia layer in the trunk is quite different, both morphologically and functionally, from that of the limbs. Generally, apart from the thoracolumbar region, the deep fascia of the large superficial muscles (e.g. pectoralis major, latissimus dorsi and trapezius) is thinner (approx. 300 microns) because these muscles actually develop within the superficial lamina of the deep fascia, and are not separable from the same. This fascia adheres to these muscles via numerous intramuscular fibrous septa. Many muscular fibres are inserted into both sides of these septa and into the fascia itself, which provides additional insertions for these fibres. In fact, these muscles originate in the embryo as part of the limbs muscles but they then extend towards the midline of the trunk. Migration of limb muscles into the trunk forms an additional myofascial layer with respect to underlying muscular planes. This ensures functional continuity between limbs and trunk, including myofascial connections between the upper and lower limbs, and the two upper limbs. This firm relationship between trunk fascia and muscles allows for fine orientation of the vectorial forces created by the activation of the muscles: different portions of these muscles are activated according to the degree of movement. This modulates the transmission of tension more effectively.

On the contrary, the DF in the limbs is a relatively autonomous structure with respect to the underlying muscular plane. It is a much thicker (0.5 -1.8 mm), with multi-layers of parallel collagen fibre bundles, each layer oriented in a different direction. The difference in direction between one layer and the next has been repeatedly measured to be around 78 degrees. That means that the DF layer can respond to outside stretch quite nicely, with each collagen bundle layer being capable of sliding a little on one another.

In the lower limbs, the DF has significantly fewer elastic fibres as compared to DF in the upper limbs. It is easily separable from the underlying muscles due to the presence of the epimysium, which permits to the muscles to slide independently from the overlying DF. A thin layer of loose connective tissue between DF and epimysium further facilitates sliding. The DF in limbs can perceive contractions of the muscle it surrounds due to myofascial expansions that the muscles extend to the fascia and muscle fibres that insert directly onto its inner surface. We can say that limb fascia is less adaptable than trunk fascia but, being ideal for the transmission of force, it is suited to the function required of our limbs. 





Dissection by Dr. Carla Stecco showing superficial and deep fascia of anterior brachial fascia region. Lacertus fibrosus is highlighted to demonstrate its role as a myofascial expansion between upper arm and lower arm.





The body is a complex system made up of interacting sub-systems

We require interpretative models that simplify the complexity. Stecco’s biomechanical model [3] is an interpretation of one of the body’s sub-systems, namely the fascial system and its focus is on the role of the DF within the musculoskeletal system. It essentially shifts our focus from muscles with origins and tendinous insertions moving bones, to motor units activating groups of muscle fibres united by fascia that bring about movement. It suggests that deep muscular fascia could act as a coordinating compo­nent for motor units grouped together into functional units (called Myofascial Units: MFU). Stecco has identified key areas of the deep fascia, called Centres of Coordination, where the tensional forces of each MFU coincide. If the DF in these areas is not sliding, then the MFU will be dysfunctional. The premise is that if manual work can restore gliding to the DF in these key areas then it can influence poor muscle recruitment, myofascial force transmission, faulty movement and pain avoidance patterns.

For example, in RSI (repetitive stress injuries) it is often important to look beyond the local area of strain, questioning our clients carefully about past injuries in order to identify areas that may have never resolved completely in terms of fascial gliding. While deep fascia derivatives (endo, peri, and epimysium) unite the muscle fibres of single MFUs, the myotendinous expansions mentioned above, together with biarticular muscles, form anatomical bridges between adjacent body segments to form myofascial sequences (see photo of lacertus fibrosus as an example). Therefore, myofascial sequences on each plane essentially unite single MFUs together. Knowledge of myofascial sequences can help us to trace back to the origin of a given dysfunction.


The perception of altered segmental tissue texture and its modification during therapy is a daily experience for most soft tissue therapists. Trauma and injury can apparently alter fascia but further studies are necessary to clarify what actually changes in pathological conditions. Different authors claim that trauma/injury can alter properties of the extracellular matrix due to neurophysiological influences, with water loss in the tissue influencing collagen fiber bundle formation and orientation. Others implicate changes in fibroblasts with their transformation into myofibroblasts. Reduced gliding between layers of collagen fibre bundles within the deep fascia could result in an alteration of the mechanical properties of the fascia.

Fascia demonstrates viscoelasticity, a material property whereby the deformation (strain) that results from a load (stress) will vary with changes in the rate and amount of loading. Loads within the elastic limits of the tissue will deform it but then it gradually returns to its original resting length after the load is removed. Dr. Antonio Stecco is currently researching the role that hyaluronic acid, one of the components of the extracellular matrix, plays in the gliding and the inflammatory response within fascia. It is likely that a modified viscoelasticity of the extracellular matrix, with subsequent misalignment of the endofascial collagen fibres, will affect the fascia’s capacity to elongate and to adapt to stretch from muscle fibres.

By applying localized friction in an area of palpable rigidity, therapists can create local heat and this may increase certain chemical reactions within tissues such as reduced secretion of inflammatory cytokines. In a recent clinical study[4], it was seen that it takes an average of 3.4 minutes of deep friction for a perceptible change to occur in rigid tissues. The redistribution of water from the tissue to the anatomical spaces surrounding the tissue also appears to be involved. This change in viscosity seems to involve an increase in the production of hyaluronic acid, and this acid also has interesting intrinsic anti-inflammatory capacities. Improved drainage of inflammatory mediators and metabolic wastes possibly contribute to the changes we feel under our hands. In addition, by reducing chemical irritation of the various receptors within the tissues our clients can experience a reduction in pain and a renewed freedom in movement.


Hopefully, we will gain a lot more information about all this at the next Fascia Research Congress in Vancouver. 


Padova, Italy, May 2011 




References

1. Stecco A, Masiero S, Macchi V, Stecco C, Porzionato A, De Caro R. The pectoral fascia: anatomical and histological study. J Bodyw Mov Ther. 2009;13(3):255-261.

[2] Stecco A, Macchi V, Masiero S et al. Pectoral and femoral fasciae: common aspects and regional specializations. Surg Radiol Anat. 2009;31: 35-42.

[3] Stecco L, Stecco C. Fascial Manipulation: Practical Part. Padova: Piccin; 2009.

[4] Borgini E, Stecco A, Day JA, Stecco C, How much time is required to modify a fascial fibrosis? J Bodyw Mov Ther. 2010; 14(4) 318-325. 




Julie Day is a physiotherapist originally from Adelaide, and have been living and working in Italy since 1984. She have always used Connective Tissue Massage in her practice and met Luigi Stecco in 1991 in Milan, at a congress about fascia. However, she didn't get around to do Luigi’s course until 1999. She became a Fascial Manipulation teacher since 2003. She has taught courses and workshops in Italy, Poland, and USA. She is the translator of Fascial Manipulation English editions (2004, 2009). She is also a founding member of Fascial Manipulation Association in Italy. She presented a one day workshop with Dr. Carla Stecco at the 2nd Fascia Congress in Amsterdam.

An Interview with Dr. Jean-Claude Guimberteau


 Dr. Jean-Claude Guimberteau is a hand surgeon and the author of the famous film Strolling Under the Skin. The film shows for the first time the most fascinating images of living fascia. Using a special endoscopic camera, Dr. Guimberteau showed that there is a unique architectural system in human and that the tissue continuity is global. He believes that sharing these discoveries will incite people to get into this scientific world exploring living matter organization. His work become well known by bodyworkers when his film  Strolling Under the Skin was shown in The First Fascia Congress in Boston in 2007. He then realised a sequel Skin Excursion at the 2nd Fascia Congress in Amsterdam 2009, and his 3rd film Muscle Attitudes at the 7th Interdisciplinary World Congress on Low Back & Pelvic Pain in LA 2010. Subsequently he released Interior Architectures and Skins, Scars and Stiffness at the 3rd Fascia Congress in Vancouver 2012. Now, we have a privilege to interview him for Terra Rosa e-mag.

Dr. Guimberteau, your work has provided brilliant images of living connective tissues that we haven't seen before, and inspired many of manual therapists who are closely working with the skin and manipulating connective tissues. What led you to the discovery and study of the architecture of the connective tissue. Can you give us a background?

I was seeking a technical procedure to reconstruct flexor tendons, when I came upon the sliding system that I termed the MVCAS (Multimicrovacuolar Collagenic Absorbing System). I first used a microscope to understand how it was working. This tissue, which neatly ensures the efficacy of gliding structures and their independence, is composed of a network of collagen fibrils whose distribution seems to be totally disorganized and apparently illogical at a first sight. This impressed me because my Cartesian mind could not come to terms with the idea of chaos and efficiency co-exists perfectly. This was the starting point for an intellectual voyage that took me far from the beaten track and off into the largely unknown world of fractals and chaos.

* Note: Fractal is a geometric pattern that is repeated at every scale. If you zoom in on a fractal pattern it will look similar or exactly like the original shape. This property is called self-similarity.
Chaos in mathematics is "the irregular, unpredictable behavior of deterministic, non-linear dynamical systems" which is used to describe objects that are apparently disordered, however there is an underlying order in apparently random pattern.




How do you start making film of live connective tissues? Why this is not done previously?

First we start taking pictures during surgical tendon reconstructive procedures. The photos were taken during a planned surgery, thus there is a time limit of 30  minutes so that the surgical team were not disturbed during their work. Surgeries were performed either with a garrot (a stick used for tightening a bandage, in order to compress the arteries of a limb), which allows rather dull observation in terms of colour, or without a garrot which gives more lively images but is disturbed by blood extravasation (leakage). Then after, we extend to skin flaps and abdominal surgeries.

I don’t know why this has not been done previously but some of my experiences can explain that. For many years, I have performed microsurgery transplants and I have used microscope very often. Moreover, surgery is performed without bleeding using a tourniquet, so the observation is easier, and finally I love to understand the processes that have been going on.

What are the challenges in making these pictures using endoscopic camera?

The main challenge is to understand how tendon and skin are sliding, but also all these fascinating images have to be shared. They look so beautiful with their aesthetics, colours, varied and sparse shapes. Sharing them seems to be a good way to arouse the interest of people today.

What is the scale (magnification) we are looking at?
Generally magnification is 25 times. 

In ‘Strolling Under the Skin’, you described the Sliding system and architecture of the connective tissue that looks chaotic in organisation composed of microvacuoles that are able to adapt itself to various stress. Can you briefly describe about this microvacuole form?

All the tissues observed were developed within the framework of multifibrillar architectures and resulting from the intertwining of fibrils : there are the microvacuoles which in fact are intra fibrillar micro volume, and which are the basic elements combining a polyhedral fibrillar frame enclosing multiple micro vacuolar spaces of varying sizes between 10 μm and 100 μm, with a gel inside.
* Note: 1 μm or micro meter is a millionth of a meter.
These microfibrils have a diameter of about ten to twenty microns and are made up predominantly of collagen type I and III. By intertwining, in an irregular fractal manner, they determine the volume of the microvacuole, which is filled with a glycosaminoglycan gel. By accumulation and superposition, these multi microvacuolar polyhedral patterns will build an elaborate form.

In ‘Muscle Attitudes’, you proposed that there is a global tissue continuity around or inside the muscle. Can you tell us the implication of this.

The essential implications of these microsopic and endoscopic observations are the fibrillar continuity. There is no break in the tissue continuity, be it within muscle, tendons, or around the arterial and venous structures and the structures surrounding the adipocytes. All these structures are formed in the same manner and are continuous. We have discovered the same continuity of tissue within the sub-cutaneous tissue in Strolling Under the Skin, the epidermis and dermis and the muscles. The concept of the organisation of living matter into stratified layers, hierarchical layers of sheaths, lamellae and strata cannot satisfy an anatomist who studies precise, endoscopic, functional anatomy. Even though they may be of different colours, textures and shapes, they are all linked to each other. This is a global tissue concept.

Which part of your work would you suggest that could be the most important relevance for manual therapists?

I think that our last movie Muscle Attitudes is the most appropriate for manual therapists, however Skin Excursion gives more detail on the intracutaneous connections. The physical links between these contractile and connective fibrillar structures from the surface of the skin to the deep muscle can explain some of the effects of manual therapy in a rational physiological and noncontroversial manner.

How do you see new technology will bring to the understanding of connective tissues?

I am sure that in the future the intra-body exploration will be one of the new frontier in scientific medical discovery and new technology will be the key point for this development.

What are your current projects?
We continue to explore using HD (high definition) technology and we will soon make a new movie on tendons anatomy and physiology. But for now, we want to show these films and images to all people because we have to share the beauty of human living matter thanks to a book and new videos.

Fascial Unwinding Cancels Torsional Forces


Fascial Unwinding Cancels Torsional Forces

By Dorothea Blostein


 Over the past two years I have undergone a difficult process of large-scale fascial unwinding.  In this article I describe my personal impression of the mechanics and forces in fascial unwinding.  My impressions have been shaped by treatments provided by four manual therapists (who are not to blame for any misconceptions in this article): osteopath Robert Black, chiropractor Brent Helmstaedt, registered massage therapist Kristin Kelly, and Feldenkrais® practitioner Jennifer Payne.


I propose a model of fascial unwinding in which adhesive forces are overcome to allow a torsional force in the fascia network to cancel a countertorsional force.  Unwinding leaves the fascia network in a state of lower energy. This energy reduction is one of the driving forces behind spontaneous body movements associated with fascial unwinding.

At present, my introspection provides the only evidence to support the proposed model. I am publishing these speculative thoughts in case they are useful to others.  Perhaps they will lead to discussion and experimentation.

Fascia forms a connected network that spans the entire body (Myers, 2001). Terminology for fascia varies; standardized terminology is proposed by Langevin and Huijing (2009). Fascia has plasticity, meaning that the structure of the fascia network can change over time (Schleip, 2003).

Pantyhose and wetsuits are suggested as analogies for explaining fascia to patients (Bose and Lesondak, 2009).  Some of us know from personal experience how difficult it is to straighten out twisted pantyhose or a twisted wetsuit! Usually it’s easiest to just take the darn thing off and start over.  Unfortunately, our bodies do not have this option for straightening out the fascia network.  Instead, the body goes through fascial unwinding, a process that can take several years in severe cases.

Fascial unwinding has several definitions.  In a recent survey paper, it is defined as a type of indirect myofascial release technique (Minasny, 2009).  In other circles, fascial unwinding refers to spontaneous movements (for example, see http://www.youtube.com/watch?v=1QM-8_DwArU). Fascial unwinding is closely related to pandiculation (stretching and yawning); Bertolucci (2011) discusses the role of pandiculation in maintaining the myofascial system.




Michelanglo, Atlas Captive, 1520.  Seen statically, this captive figure is endlessly straining against the adhesive forces in the marble. But imagine the marble in motion and you have an inspiring symbol of fascial plasticity, the body emerging to freedom.



A model of a biological system is a simplification: the model characterizes selected aspects of a complex physical system. A model can be used for understanding and teaching, as well as for formulating testable research hypotheses. Tensegrity and viscoelasticity are two well-established models for biological systems. Ingber, Heidemann, Lamoureux and Buxbaum (2000) debate the strengths and weaknesses of tensegrity and viscoelasticity for modeling at the cellular level. Myers (2001) provides a popular and accessible presentation of tensegrity and its use to model bones (under compression) and fascia (under tension). The body’s ground substance can be modeled as a viscoelastic liquid.  Viscoelastic liquids have marvelous properties: if you pull on them suddenly, they are tremendously strong, like a solid, but left on their own, they flow around like a liquid. To experience this for yourself, use this goop recipe to make a viscoelastic liquid out of a mixture of water, white school glue, and borax.

Here is a description of the elements of the proposed model for fascial unwinding.
· The fascia network naturally tends to a configuration that minimizes energy. An idealized initial state is used as a reference. In the initial state, the fascia network is straight, meaning that torsional forces in the fascia network are at a minimum.  Thus the initial state is the configuration of lowest energy.
· Injury can introduce torsional forces into the fascia network.  When a torsional force is introduced, this necessarily introduces an equal and opposite countertorsion elsewhere in the fascia network. A torsional force applied to some part of the fascia network causes twisting in that part of the network. The amount of twist – the angle of rotation – depends on the torsional stiffness of the affected fascia.  Even small angles of twist are damaging in many parts of the body; the body compensates by increasing torsional stiffness of affected fascia and/or by distributing the torsional force to other parts of the fascia network.
· Adhesive forces can prevent a twist and countertwist from meeting and cancelling out. Thus the adhesive forces hold the fascia network in a higher energy state.
· Fascial unwinding is the process of overcoming adhesions to bring together and cancel a twist and countertwist.  This cancelation of torsional forces moves the fascia network from a higher energy state to a lower energy state.
· Fascial unwinding can be facilitated in two ways:
1. Place the body into a position that aligns a twist and countertwist along a straight axis. Applying force along this unwinding axis helps to bridge the adhesion that separates twist and countertwist*.
2. Reduce adhesive forces, by breaking up scar tissue or by increasing circulation to reduce the viscosity of the ground substance.
· Fascial unwinding axes have a fractal organization. This arises because the fascia network has a fractal structure. (Fractal means that a zoomed-in view of a small region of fascia looks similar to a zoomed-out view of a large region of fascia.) During self unwinding the perceived locations of several small unwinding axes can be used to find larger-scale axes along which fascia needs to unwind.
· Positive feedback assists the process of fascial unwinding, with the effect that successful unwinding facilitates further unwinding.  When unwinding succeeds, this reduces torsional forces in some part of the fascia network.  I hypothesize that a reduction in torsional forces triggers a local reduction in the viscosity of the ground substance.  The less-viscous ground substance allows fascia to move more easily, further decreasing the local strain on the fascia, triggering further reduction in ground-substance viscosity. Also, less viscous ground substance allows fluid circulation to improve, thereby encouraging further reduction of viscosity.

Various investigations could be undertaken to refine this model. One problem is to study how the body reacts to torsion.  My hypothesis is that high torsional force triggers an increase in local torsional stiffness (for example, an increase in the viscosity of the ground substance, or a stiffening of the fascia). Such increase in torsional stiffness is advantageous because it reduces the angle of twist for a given torsional force, thereby reducing the degree to which the torsional force impacts mechanical performance of the affected body part.  The entire fascia network responds to a local injury, so a torsional force can be distributed to body parts that are far from the site of injury.

It would be interesting to model injuries and how they introduce torsional forces into a fascia network. An impact injury could create scar tissue and adhesions that cause long-term displacement of fascia, thus giving rise to torsional and countertorsional forces elsewhere in the fascia network. Alternatively, long-term asymmetrical body use might introduce imbalances and twists. Another possibility is that localized proprioception reversals can cause incorrect reflexive responses, increasing torsional forces instead of reducing them.  (Eye movement exercises can be used to correct proprioception problems in the head and neck.  The stability of vision is discussed by Harris (1965): in situations where vision information disagrees with the position sense, the disagreement is resolved by changes in the position sense.)

Computer simulation can be used to investigate the behavior of the model. I propose simulating a tensegrity model that has been extended to include adhesive forces as well as tension and compression forces. A single scale can be used for model elements that are under compression (these represent bone) and fractal structure can be used for model elements that are under tension (these represent fascia). Torsional forces and adhesions can be introduced during the simulation. It would be interesting to develop measures for characterizing a tensegrity structure in terms of its “structural buffering capacity”: how much adhesion and twisting can the tensegrity structure tolerate, while still maintaining a specified level of functionality?  Related work includes the study of tensegrity and adhesions at the cellular level (Stamenovic 2006), tensegrity models of biomechanics (Levin 2002 and 2006), and engineering methods for designing tensegrity structures that minimize construction cost while meeting stated load-bearing requirements (Rhode-Barbarigos, Schmidt, Ali and Smith, 2009).  Computer simulation offers the opportunity to study how localized damage in a tensegrity structure causes a gradual, system-wide degradation of function.

Physical realizations or computer simulation could be used to see whether this model of fascial unwinding can give rise to spontaneous movements as the modeled fascia network undergoes “self unwinding” to return to a lower energy state. If successful, this could offer a mechanical explanation for the spontaneous movements people exhibit during fascial unwinding.  I conjecture that smooth, flowing types of spontaneous movement are due to the body aligning itself along a shifting axis of fascial unwinding.   In contrast, fast oscillatory movements arise when the body is improperly aligned along an axis; the oscillation calms down when alignment is corrected by a manual practitioner or by the patient during self unwinding.  Oscillatory movements can also arise when the body oscillates between several possible unwinding axes; in this case unwinding is unsuccessful and the oscillatory movements can repeat indefinitely.

I conclude with personal observations about self unwinding. Fascial unwinding is mostly sub-conscious and reflexive, but I can consciously take actions to assist unwinding.  Helpful feedback is provided by the amount of spontaneous body movement: if I succeed in lining things up correctly, the external body movement stops.  This reminds me of balancing a spinning basketball on my finger: if I do this correctly, my hand and the ball are stable, whereas if I do it incorrectly my hand and the ball wobble around.

For many months, I found it difficult to react properly to my sensations of the shifting axes of fascial unwinding: an axis moves in an unexpected direction when I (internally) apply a force in a direction that is perpendicular to the axis.  This unexpected response suddenly struck me as familiar when I recalled an earlier experience in which I was holding a spinning bicycle wheel with one hand on each end of the axle. This inspired me to take the front wheel off of a bicycle and use it for more gyroscope practice.  I found that the reflexive movement patterns I developed using the bicycle wheel were transferable to the movement patterns I needed during self unwinding.

This gyroscope analogy seems puzzling because fascia cannot possibly spin fast enough to act like a traditional gyroscope.  The effect might be explained as follows. Imagine looking along the length of a horizontal axis of fascial unwinding: imagine that this section of fascia is under clockwise torsion, so that it needs to unwind clockwise around the horizontal axis in order to reduce torsional forces. (Since torsion and countertorsion are counterbalanced, there is some other part of the axis where fascia is under counterclockwise torsion. For this example, focus on the part of the unwinding axis that is experiencing clockwise torsional forces.)  Now imagine trying to make a fine adjustment in body position to keep this unwinding axis properly lined up. Continuous small adjustments are needed as unwinding occurs, because the axis location shifts in response to asymmetries such as an anisotropic extracellular matrix. Imagine applying a force that pushes on this section of the unwinding axis from the right; the expectation is that this force from the right will move the unwinding axis toward the left.  But because the fascia is under clockwise torsion, the tangential force from the surrounding extracellular matrix may cause the unwinding axis to move upwards rather than toward the left. This might explain the apparently gyroscopic nature of fascial unwinding.




The gyroscope analogy. When you push on a spinning gyroscope it responds by moving in a direction that is at a right angle to the direction of your push. Picture from: http://www.i-am-a-i.org (used with permission).



In summary, during self unwinding I have found it helpful to envision the goal of overcoming adhesive forces to cancel a fascial twist and countertwist. Formal diagnosis is difficult in a case like mine because current medical imaging techniques are limited in their ability to capture fascia. I have heard a prediction that within 2-5 years the rapid advances in ultrasound elastography may make it possible to detect small local changes in fascial stiffness (R. Schleip, personal communication, Dec. 2010).  Such imaging would revolutionize the diagnostic capabilities for fascial unwinding patients.  However, treatment will likely continue to be centered around manual therapy.

References
L. Bertolucci (2011) Pandiculation: Nature's way of maintaining the functional integrity of the myofascial system?  Journal of Bodywork and Movement Therapies, Vol. 15, No. 3, pp. 268–280, July 2011.

A. Boser and D. Lesondak (2009) Helping clients understand their fascial network. Yearbook of Structural Integration, International Association of Structural Integrators (IASI), pp. 78–80. Available from the collection of articles at http://www.somatics.de

C.S. Harris (1965) Perceptual adaptation to inverted, reversed, and displaced vision. Psychological Review, Vol. 72, No. 6, pp. 419–444, Nov. 1965.

D. Ingber, S. Heidemann, P. Lamoureux and R. Buxbaum (2000) Opposing views on tensegrity as a structural framework for understanding cell mechanics. Journal of Applied Physiology, Vol. 89, No. 4, pp. 1663–1678.

H. Langevin and P. Huijing (2009) Communication about fascia: History, pitfalls, and recommendations. International Journal of Therapeutic Massage & Bodywork, Vol. 2, No. 4, pp. 3–8, Dec. 2009.

S. Levin (2002) The tensegrity-truss as a model for spine mechanics: biotensegrity. Journal of Mechanics in Medicine and Biology Vol. 2, No. 3-4, pp. 375–388.

S. Levin (2006) Tensegrity: the new biomechanics, a chapter in Textbook of Musculoskeletal Medicine, M. Hutson and R. Ellis editors; available at http://www.biotensegrity.com/tensegrity_new_biomechanics.php
B. Minasny (2009) Understanding the process of fascial unwinding. International Journal of Therapeutic Massage & Bodywork, Vol. 2, No. 3.

T. Myers (2001) Anatomy Trains : Myofascial meridians for manual and movement therapists, Elsevier.

L. Rhode-Barbarigos, E. Schmidt, N. Bel Hadj Ali and I.F.C. Smith (2009) Comparing two design strategies for tensegrity structures. EG-ICE Workshop: Intelligent Computing in Engineering (ICE09), Berlin, July 2009.

R. Schleip (2003) Fascial plasticity – a new neurobiological explanation, Parts 1 and 2, Journal of Bodywork and Movement Therapies, Vol. 7, No. 1 and 2, January 2003, .

D. Stamenovic (2006) Cells as tensegrity structures: architectural basis of the cytoskeleton. FME Transactions, Vol. 34, No. 2, pp. 57–64.


You can contact the author by email blostein@cs.queensu.ca


Fascia Science Made Simple


Fascia Science Made Simple — and Applicable to your PracticeBy Bethany Ward
 



Readers of the Terra Rosa E-Magazine are well acquainted with Rolfers and their love affair with connective tissue. In recent years, we’ve gotten really excited as serious scientists and academics have caught our enthusiasm for the stuff. Every three years, clinicians like you and me gather with pre-eminent fascia scientists at the International Fascia Research Congress, to share our insights and further each other’s work. These conferences exhibit a passion for learning that is unfortunately all too rare these days; I highly recommend you attend one if you can. You’ll have fun and your brain will get a workout!

But let’s admit it — all that scientific terminology can get a bit daunting. So, I wrote this article to summarize and make sense of the latest fascia research and explain how it applies to massage and bodywork therapists. I hope this discussion puts the latest information about fascia in a context you can use: 1) influencing your work with clients right away; and 2) cluing you in to areas and resources that you may want to explore more in depth on your own.

A brief history of fascia science
The Fascia Research Congress is the brain child of a dear friend of mine, Dr. Thomas Findley—who is a medical doctor, a PhD, and a Certified Advanced Rolfer, Tom tells a story about researching fascia 30 years ago and finding a dearth of information. He explains, “When it came to connective tissue, all we knew was that when you heated a rat tail you could stretch it. There was no other relevant research that I could find.” A scientific discipline couldn’t ask for more humble beginnings. Tom says it was at that moment that he started dreaming of a fascia congress that would “bring together widely separate research disciplines in the service of the clinician.”

Until recently, doctors and scientists alike treated fascia as the webby material you cleared away during a dissection to get to the really interesting parts — the bones, muscles and organs. Fascia was considered pretty much inert stuffing that didn’t do anything. And because connective tissue is everywhere that other stuff is not, it only got named where it was particularly thick, like the plantar or thoracolumbar fasciae.

Watching a positive trend toward fascia research (during three decades, the number of published articles increased over six-fold), Tom organized the first research congress on the Harvard University campus. It was only meant to be one-time event but was so successful that another was held in Amsterdam in 2009, with the next one planned for Vancouver in 2012. Finally, we have a forum to help clinicians understand why myofascial work is so powerful and develop ways to further the work.

Latest research
A lot of fascia research is still answering basic questions: “What is it?” “What are its properties?” and of particular importance to you and me, “How do we affect it?” At the 2009 congress, Jaap van der Waal, MD, PhD spoke about his anatomical studies and explained that a lot of what we take as gospel about the body is just plain wrong (van der Wal, 2009).
Say it isn’t so…
1) Ligaments don’t exist. True ligaments are almost nonexistent; in most cases, ligaments are only “made” with dissection.
2) Tendons don’t insert into bone. There are no discrete tendon attachments as pictured in anatomical drawings. Rather, tendons insert into a connective tissue apparatus, which transmits force across joints. In fact, 15-80% of connective tissue fibres extend past the designated tendon insertion (Stecco, 2009).
3) Muscles are not the prime players. Traditionally, muscles were thought to be active while tendons remained static. Actually, muscles and tendons work as a dynamic system in function, as well as in each other’s development. As it turns out, the term “myofascial” is particularly apt because it communicates this interconnectedness of muscle and fasciae.

A system — greater than the sum of its parts
Connective tissue doesn’t lend itself to reductionism. Although it’s true that anatomists have named fascial structures where the matrix becomes particularly thick, as in tendons or ligaments, these tissues are continuous with different fascial types, which all meld into each other. Perhaps more than any other system in the body, the fascial matrix must be addressed as a complex whole.
And here is the rub: connective tissue’s incompatibility with anatomical separation seems to be at the heart of its incredible ability to simultaneously provide support, containment and freedom of movement.

Connective tissue performs seemingly diametric functions
1) Fascia provides both separation and connection of structures (van der Wal, 2009). By enveloping structures (everything from single muscle and nerve cells, to bundles of cells, to muscle bodies and bones), fascia allows for glide between structures while binding them together and providing form. If we understand this dual role, we can address adhesions to improve glide between structures while also affecting the larger system.

2) Fascia contributes to both support and force transmission in the body. Researchers observed that in most muscles, single muscle fibres do not span the entire length between tendons (Purslow, 2009). So how are forces transmitted through these structures? The connective tissue endomysium keeps fibres tightly in register within the fascicle, which makes it possible to transmit forces between muscle fibres by shear forces. Fascial tension plays a critical role in low back stability. Fascia needs to bear load and the carrying of load needs to vary between muscles and back fascia for healthy function of the low back (Hodges, 2009).  Additionally, crural fascia strongly links the thigh muscles and calcaneus, contributing to propulsion, stability and motor coordination (Nichols, 2009). Crural fascia enhances propulsion by increasing retraction and ankle plantar flexion, while limiting movement of lower limb, providing stability.

3) And now for something really unexpected: Fascia both limits movement and contributes to the fluidity of movement! A study of calf muscles found that as muscle contracts, its tendons actually lengthen a bit, storing energy that is released when the muscle relaxes, which makes gait more efficient (Kawakami, 2009). Does this happen elsewhere? Probably. If so, the interplay between fascia and muscle is important in energy transfer between tissues. Fascia softens the beginning and the end of the muscle movement. It also stores kinetic energy of movement, much as a hybrid car uses regenerative braking to store energy in its batteries.

So fascia separates and unites; supports and communicates; and stores energy and releases it. How is fascia able to possess such inconsistent properties? The answer may be the results of its interconnected system. In addition to enveloping all the structures we can see, fascia extends from the surface of muscle to the interior of the muscle cell. Dr. Ingber at the 2007 congress showed how these connections within the cell extend to the nucleus, with tension of the intracellular fibres directly affecting gene transcription (Ingber, 2007). The fascial matrix reaches even farther than we thought.

So when you work with connective tissue, you need to be thinking about these connections. Even when addressing a specific area of adhesion, your hands and intention must be connecting with the fasciae as a system that crosses all boundaries.

How to address fascia layers
Based on our current knowledge, it is likely that myofascial techniques can restore glide between structures. To do this, we identify places where fascial layers have become stuck together — either due to adhesions or scar tissue —and work to free them up. Assessing range of motion and comfort level during movement, before and after your intervention, can tell you if you’re being effective.

In classes and workshops, I teach students how to “hook into” tissue to create a directed stretch and wait for the tissues to release. From Rolfer-researcher Robert Schleip’s work, we’re understanding that angle of connection really matters. Schleip likens the fascial layers to a layered dessert, the tiramisu, to show how layers are both distinct and interconnected. He proposes that rather than getting tissues to slide, which suggests movement between separate layers, we’re actually attempting to “shear,” or create lateral movement between interconnected strata. To achieve lateral movement, you need to make sure your angle of force is similar to the angle of the layers. Rather than working perpendicularly to the facia layer, you want to hook into the layer and take it in a direction that shears it with respect to the adjacent layer. Robert Schleip has created a library of fascia-related articles for somatic practitioners at http://www.somatics.de/, a treasure trove of information.

In a related study, scientists identified three layers of crural fascial. Collagen fibres within each layer lay parallel, while fibres of different layers form 78-degree angles with other layers. This pattern has been found in thoracolumbar fascia (Stecco, 2009), as well as in bovine neck muscle (Purslow, 2009). While this orientation of collagen fibres within layers makes fascia highly resistant to traction, the oblique fibre orientation between layers makes shearing a viable therapeutic approach.

Using myofascial techniques to relieve pain and restore function
Based on what we currently know about connective tissue, your myofascial interventions should:
1. Target areas that cause tension in fasciae. A study looking at the effects of stretch on areolar (or  “loose”) connective tissue found significant remodelling of the fibroblast cells, which make up fascia, in response to only twenty minutes of tension (Langevin, 2009). Based on this work, it makes sense to direct myofascial therapy at areas (scars, fibrosis, inflammation, etc.) that may be causing chronic tension in the fascia. Areolar connective tissue is the most widespread connective tissue in the body. In addition to filling the spaces between organs and surrounding and supporting blood vessels, this tissue attaches the skin to the underlying tissue. As such, fibrosis can cause strain patterns in the body the same way a seam changes the pull through a piece of cloth. After appropriate preparation, address fibroses and scar tissue early in your sessions, leaving time to integrate these changes throughout the system.

2. Don’t forget the nerves. Dysfunctional fascial tension can affect every structure in the body, including nerves. It is common to find intra-fascial nerves oriented perpendicularly to collagen fibres, suggesting that fascial stretch may stimulate nerves and contribute to certain pain conditions (Stecco, 2009). Like other structures, nerves are sheathed in fascia to allow for glide during movement. Like other structures, nerves can be impeded by adhesions, or “tethered,” causing pain and dysfunction. Learning to feel for nerves and freeing them from surrounding tissues is an important skill for myofascial therapists. If you haven’t explored this area of the work, I strongly encourage it. Just learning to free up the sciatic nerve as it makes its way from the spine down the leg will make you much more effective with common piriformis and sciatic dysfunctions.

3. Work superficial and deep layers. Although it is often tempting to skip superficial layers when you work, don’t. The superficial layers of the thoracolumbar fascia appear to be highly innervated — with over 90% of nociceptive fibres in the superficial fascia and subcutaneous layer, few fibers in the inner layer, and none in the middle layer study (Tesarz, 2009). Nociceptors (pain sensors) are also likely to be found in these tissues as well.
At the 2010 Interdisciplinary World Congress on Low Back and Pelvic Pain in Los Angeles, the role of fascia was described as a very promising area for future research dealing with low back pain. When you address superficial layers, you may be able to affect the remodelling of these tissues, which appear to be caught in chronic pain patterns. When you work deeply, in tendon attachments, where golgi tendon organs are abundant, you may also be influencing muscle patterns. So, consciously working at both superficial and deep levels is warranted when dealing with chronic pain.

A word about terminology
The tendency to use the terms “fascia” and “connective tissue” interchangeably is actually incorrect. It can be confusing because we’re talking about a matrix of material that wraps around every muscle cell and creates envelopes, which compartmentalize and wrap around other structures. There are different fascial layers, which, are interconnected. The more we learn, the more we appreciate fasciae’s different densities, compositions, and unique properties. As such, it’s actually incorrect to lump all these tissues together as “fascia.” Currently, researchers (Langevin and Huijing, 2009) distinguish between a dozen types of fascia: dense connective tissue, areolar (loose) connective tissue, superficial fascia, deep fascia, intermuscular septa, interosseal membrane, periost, neurovascular tract, epimysium, intra- and extramuscular aponeurosis, perimysium, and endomysium. You can read the full article online at http://www.ijtmb.org/index.php/ijtmb/article/view/63/80.


Conclusions
Myofascial therapists know we can create change — we see it everyday when clients experience increased range of motion, reduced pain, and/or smoother, more coordinated movement. But until recently, we didn’t have a lot of places to look to understand the mechanisms for these changes. Fascia has been ignored for a long time so there’s a lot of catching up to do in the research lab. But the latest findings strongly suggest that myofascial therapy is effective because it:
· Improves the glide between the enveloping septa;
· Affects mechanoreceptors (golgi tendon organs); and
· Works with the body as a system, addressing muscle and connective tissue as functional units.

Fascia brings together seemingly opposing functions in the body; working with these tissues demands that we exhibit a similar sophistication. We must be able to sense with our hands and bodies on both a micro- and macro-level. We must be able to identify and address adhesions, scar tissue, and fibroses, which can create tensions through surrounding tissues leading to dysfunction. But at the same time, it is essential that we track how force transmits through larger areas and, ultimately, the entire system.
Empirical studies are confirming what we suspected — bodywork remains an art, as well as a science. In a study involving tendon transfer surgery for patients with cerebral palsy, researchers found the locations of fascia connections varied significantly among subjects (Kreulen, 2009). Every person who walks in your office is as different at his or her fingerprint. Anatomy books, your teachers, and even your own experience can only give you a general sense of where you need to work. Research can inform you of new things to try and new patterns to notice, but the most important skill you have is your touch and your openness to sense what’s there. Only the sensitivity of our hands will tell us what to do and what to do next.

Luckily, the fasciae, once considered inert, replaceable packing material, are turning out to be one pretty smart interconnected cookie. Acupuncture research by Helene Langevin, MD showed that although inserting needles created measurable changes in the fascia, the change was not appreciably different if the needles were placed in traditional points or nearby (Langevin, 2006), introducing the question: “Is the connective tissue a body-wide signalling network?” If so, are we just facilitating healing that the body is trying to do anyway? (Seems plausible to me.) Since fascia connections extend to the nucleus and influence gene transcriptions, what else is possible?
I don’t know, but I’m looking forward to find out.


Sources
All 2009 findings by Hodges, Ingber, Kreulen, Langevin, Nichols, Purslow, Stecco, Tesarz, and van der Wal reference their presentations at the 2009 Fascia Research Congress and are available on DVD, available at http://www.fasciacongress.org.

Hodges P. Fascial aspects of motor control of the trunk and the effect of pain. In: Huijing PA, Hollander P, Findley TW, eds. Second International Fascial Research Congress [DVD]. Vol. 2. Boulder, CO: Ida P. Rolf Research Foundation; 2009.

Ingber D. Tensegrity and mechanoregulation. In: Findley TW, ed. First International Fascial Research Congress [DVD]. Vol. 1. Boulder, CO: Ida P. Rolf Research Foundation; 2007.

Kawakami Y. In vivo ultrasound imaging of fascia. In: Huijing PA, Hollander P, Findley TW, eds. Second International Fascial Research Congress [DVD]. Vol. 4. Boulder, CO: Ida P. Rolf Research Foundation; 2009.

Kreulen M. Myofascial force transmission and reconstructive surgery. In: Huijing PA, Hollander P, Findley TW, eds. Second International Fascial Research Congress [DVD]. Vol. 3. Boulder, CO: Ida P. Rolf Research Foundation; 2009.

Langevin HM. Bouffard NA. Badger GJ. Churchill DL. Howe AK. Subcutaneous tissue fibroblast cytoskeletal remodeling induced by acupuncture: evidence for a mechanotransduction-based mechanism. Journal of Cellular Physiology. 207(3):767-74, 2006.

Langevin HM, Bouffard NA, Fox JR, Barnes WD, Wu J, Palmer BM. Fibroblast cytoskeletal remodeling contributes to viscoelastic response of areolar connective tissue under uniaxial tension. In: Huijing PA, Hollander P, Findley TW, eds. Second International Fascial Research Congress [DVD]. Vol. 1. Boulder, CO: Ida P. Rolf Research Foundation; 2009.

Langevin MH, Huijing PA.  Communicating about fascia: history, pitfalls, and recommendations. International Journal of Therapeutic Massage and Bodywork. 2009;2(4):3-8.

Nichols R. Systems for force distribution in motor coordination: fascia and force feedback. In: Huijing PA, Hollander P, Findley TW, eds. Second International Fascial Research Congress [DVD]. Vol. 4. Boulder, CO: Ida P. Rolf Research Foundation; 2009.  

Purslow P. Fascia and force transmission: structure and function of the intramuscular extracellular matrix. In: Huijing PA, Hollander P, Findley TW, eds. Second International Fascial Research Congress [DVD]. Vol. 2. Boulder, CO: Ida P. Rolf Research Foundation; 2009.

Stecco C. Anatomical study and tridimensional model of the crural fascia. In: Huijing PA, Hollander P, Findley TW, eds. Second International Fascial Research Congress [DVD]. Vol. 2. Boulder, CO: Ida P. Rolf Research Foundation; 2009.

Tesarz, J. The innervation of the fascia thoracolumbalis. In: Huijing PA, Hollander P, Findley TW, eds. Second International Fascial Research Congress [DVD]. Vol. 2. Boulder, CO: Ida P. Rolf Research Foundation; 2009.

van der Wal JC. The architecture of the connective tissue in the musculoskeletal system – An often overlooked functional parameter as to proprioception in the locomotor system. In: Huijing PA, Hollander P, Findley TW, eds. Second International Fascial Research Congress [DVD]. Vol. 2. Boulder, CO: Ida P. Rolf Research Foundation; 2009.


Bethany Ward, MBA is a Certified Advanced Rolfer, Rolf Movement® Practitioner, and faculty member of the Rolf Institute® of Structural Integration. She is President of the Ida P. Rolf Research Foundation and a member of the faculty of Advanced-Trainings.com. She and fellow Rolfing Instructor Larry Koliha presented at the 2011 Association of Massage Therapists Conference in Sydney as well as co-teaching Advanced-Trainings.com’s “Advanced Myofascial Techniques” workshops throughout Australia .