Friday, January 11, 2013

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 .  

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