Defining the fascial system

Physical Conditioning Strategies for the Prevention of Concussion in Sport: a Scoping Review

BACKGROUND

Concussion in sports has received a great deal of media attention and may result in short and longer-lasting symptoms, especially in adolescents. Although significant strides have been made in the identification and management of concussion, less is known about the primary prevention of this condition. The aims of this scoping review are to (1) summarize the current research of physical conditioning strategies to reduce or prevent concussion incidence in individuals participating in sport, especially adolescents, and (2) to identify gaps in the knowledge base. Our research question was what is known from the existing literature about physical preparation strategies to reduce or prevent concussion in adult and adolescent sports?

METHODS

Three literature searches were conducted by information officers at two universities at six-month intervals, using five electronic databases (PubMed; WorldCat.org ; Mendeley; EBSCOHost and Ovid MEDLINE). To increase the search range, subject experts were consulted and articles and reference lists were hand searched. A scoping review methodology identified eligible studies that analyzed physical preparation techniques on modifiable physical risk factors in athletes to reduce the incidence of concussion. The PRISMA-ScR checklist guided the reporting of the findings.

RESULTS

A total of 1414 possible articles were identified, after duplicates removed, and articles analyzed against the inclusion and exclusion criteria, only 9 articles qualified for analysis. Two articles were found from studying reference lists. Thus, a total of 11 articles were included in the final evaluation for the purposes of this study. Data are reported from mostly adolescent subjects participating in nine different sports from three countries. Findings are presented with specific reference to previously recognized modifiable risk factors of concussion which include neck strength, neck size, cervical stiffness, type of sport, and pre-activity exercises.

CONCLUSIONS

There is limited research examining the physical preparation of athletes, especially in adolescents, to reduce or prevent concussion, and conflicting evidence in the few small sample studies that were identified. This scoping review identifies the research gap for a potentially vital modifiable risk factor, notably in the physical preparation of children and adolescents to reduce or prevent sports-related concussion.

The Immediate Effect of Informational Manual Therapy for Improving Quiet Standing and Bodily Pain in University Population

Background: The Informational Manual Therapy (IMT) is a therapeutic touch. This study aims to assess the effect of IMT on quiet standing, pain and health status in university population. Methods: An experiment was conducted on subjects utilizing a comparative paired analysis both before and after the intervention. One IMT session was performed on 57 healthy individuals aged from 18 to 65 years. The primary outcome was quiet standing assessed by the Satel 40 Hz stabilometric force platform. Secondary outcomes were bodily pain assessed by the 36-Item Short Form Survey (SF-36) and health status by EQ-5D-3L. The primary outcome was evaluated before and immediately after treatment. Results: The individuals were divided into 3 age groups, 18–35 (52.6%), 35–50 (29.8%) and 51–65 (17.6%). Statistically significant differences were immediately observed after the session ended when comparing the pre-post quiet stance scores in a number of length parameters: L, Lx, Ly and stabilometry amplitude on Y-axis with eyes open and closed. Significant differences were also found when testing bodily pain (SF-36) and anxiety (5Q-5D-3L). Conclusion: One session of IMT produced positive effects when testing quiet standing with eyes open and eyes closed, as well as a significant reduction in pain and anxiety for those tested. Further research is suggested.

Diagnostic ultrasound assessment of deep fascia sliding mobility in vivo: A scoping review - Part 2: Femoral and crural fasciae

BACKGROUND

Failure of fascial sliding may occur in cases of excessive or inappropriate use, trauma, or surgery, resulting in local inflammation, pain, sensitization, and potential dysfunction. Therefore, the mechanical properties of fascial tissues, including their mobility, have been evaluated in vivo by ultrasound (US) imaging. However, this seems to be a method that is not yet properly standardized nor validated.

OBJECTIVES

To identify, synthesize, and collate the critical methodological principles that have been described in the literature for US evaluation of deep fascia sliding mobility in vivo in humans.

METHODS

A systematic literature search was conducted on ScienceDirect, PubMed (Medline), Web of Science and B-On databases, according to the PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines. The OCEBM LoE was used to evaluate the level of evidence of each study.

RESULTS

From a total of 104 full-text articles retrieved and assessed for eligibility, 18 papers were included that evaluate the deep fasciae of the thoracolumbar (n = 4), abdominal (n = 7), femoral (n = 4) and crural (n = 3) regions. These studies addressed issues concerning either diagnosis (n = 11) or treatment benefits (n = 7) and presented levels of evidence ranging from II to IV. Various terms were used to describe the outcome measures representing fascial sliding. Also, different procedures to induce fascial sliding, positioning of the individuals being assessed, and features of US devices were used. The US analysis methods included the comparison of start and end frames and the use of cross-correlation software techniques through automated tracking algorithms. These methods had proven to be reliable to measure sliding between TLF, TrA muscle-fascia junctions, fascia lata, and crural fascia, and the adjacent epimysial fascia. However, the papers presented heterogeneous terminologies, research questions, populations, and methodologies. This two-part paper reviews the evidence obtained for the thoracolumbar and abdominal fasciae (Part 1) and for the femoral and crural fasciae (Part 2).

CONCLUSION

The US methods used to evaluate deep fascia sliding mobility in vivo in humans include the comparison of start and end frames and the use of cross-correlation software techniques through automated tracking algorithms. These seem reliable methods to measure sliding of some fasciae, but more studies need to be systematized to confirm their reliability for others. Moreover, specific standardized protocols are needed to assess each anatomical region as well as study if age, sex-related characteristics, body composition, or specific clinical conditions influence US results.

A Closer Look at the Cellular and Molecular Components of the Deep/Muscular Fasciae

The fascia can be defined as a dynamic highly complex connective tissue network composed of different types of cells embedded in the extracellular matrix and nervous fibers: each component plays a specific role in the fascial system changing and responding to stimuli in different ways. This review intends to discuss the various components of the fascia and their specific roles; this will be carried out in the effort to shed light on the mechanisms by which they affect the entire network and all body systems. A clear understanding of fascial anatomy from a microscopic viewpoint can further elucidate its physiological and pathological characteristics and facilitate the identification of appropriate treatment strategies.

Diagnostic ultrasound assessment of deep fascia sliding mobility in vivo: A scoping review - Part 1: Thoracolumbar and abdominal fasciae

BACKGROUND

Failure of fascial sliding may occur in cases of excessive or inappropriate use, trauma, or surgery, resulting in local inflammation, pain, sensitization, and potential dysfunction. Therefore, the mechanical properties of fascial tissues, including their mobility, have been evaluated in vivo by ultrasound (US) imaging. However, this seems to be a method that is not yet properly standardized nor validated.

OBJECTIVES

To identify, synthesize, and collate the critical methodological principles that have been described in the literature for US evaluation of deep fascia sliding mobility in vivo in humans.

METHODS

A systematic literature search was conducted on ScienceDirect, PubMed (Medline), Web of Science and B-On databases, according to the PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines. The OCEBM LoE was used to evaluate the level of evidence of each study.

RESULTS

From a total of 104 full-text articles retrieved and assessed for eligibility, 18 papers were included that evaluate the deep fasciae of the thoracolumbar (n = 4), abdominal (n = 7), femoral (n = 4) and crural (n = 3) regions. These studies addressed issues concerning either diagnosis (n = 11) or treatment benefits (n = 7) and presented levels of evidence ranging from II to IV. Various terms were used to describe the outcome measures representing fascial sliding. Also, different procedures to induce fascial sliding, positioning of the individuals being assessed, and features of US devices were used. The US analysis methods included the comparison of start and end frames and the use of cross-correlation software techniques through automated tracking algorithms. These methods had proven to be reliable to measure sliding between TLF, TrA muscle-fascia junctions, fascia lata, and crural fascia, and the adjacent epimysial fascia. However, the papers presented heterogeneous terminologies, research questions, populations, and methodologies. This two-part paper reviews the evidence obtained for the thoracolumbar and abdominal fasciae (Part 1) and for the femoral and crural fasciae (Part 2).

CONCLUSION

The US methods used to evaluate deep fascia sliding mobility in vivo in humans include the comparison of start and end frames and the use of cross-correlation software techniques through automated tracking algorithms. These seem reliable methods to measure sliding of some fasciae, but more studies need to be systematized to confirm their reliability for others. Moreover, specific standardized protocols are needed to assess each anatomical region as well as study if age, sex-related characteristics, body composition, or specific clinical conditions influence US results.

Fascial plane mapping for superficial tumor resection in dogs. Part I: Neck and trunk

OBJECTIVE

To provide qualitative fascial categories and classify the intersections of various fascial planes of the trunk of the dog to facilitate preoperative planning for superficial cancers.

STUDY DESIGN

Qualitative anatomical study.

SAMPLE POPULATION

Two male and three female mixed breed canine cadavers weighing approximately 15 to 35 kg.

METHODS

The skin and subcutaneous fat were excised. Fascial planes were incised and elevated to allow exploration of their quality and borders. Fascia was categorized as type I (discrete sheets), type II (tightly adhered to thin muscles), type III (tightly adhered to thick muscles), or type IV (associated with periosteum). Photographs of specimens were digitally modified with overlays to map tissue types.

RESULTS

Differences between cadavers were largely associated with muscle mass or sex, with only minor anatomical differences and enough subjective similarity among specimens to allow mapping. The fasciae of the neck and trunk were predominantly type I or type II, with type III fascia at the shoulder and type IV fascia at the scapular spine, 13th rib, dorsal spinous processes, and the wing of the ilium.

CONCLUSION

The superficial fasciae of the canine trunk were consistent among the dogs evaluated and can be classified as four broad fascial types. The population used was small, and individual variation should be considered when using these images in a clinical setting.

CLINICAL SIGNIFICANCE

The images and categorization of fascia and transitions between fascial layers detailed here provide a visual and written reference for surgeons to facilitate preoperative planning and excision of superficial cancers.

Injury triggers fascia fibroblast collective cell migration to drive scar formation through N-cadherin

Scars are more severe when the subcutaneous fascia beneath the dermis is injured upon surgical or traumatic wounding. Here, we present a detailed analysis of fascia cell mobilisation by using deep tissue intravital live imaging of acute surgical wounds, fibroblast lineage-specific transgenic mice, and skin-fascia explants (scar-like tissue in a dish - SCAD). We observe that injury triggers a swarming-like collective cell migration of fascia fibroblasts that progressively contracts the skin and form scars. Swarming is exclusive to fascia fibroblasts, and requires the upregulation of N-cadherin. Both swarming and N-cadherin expression are absent from fibroblasts in the upper skin layers and the oral mucosa, tissues that repair wounds with minimal scar. Impeding N-cadherin binding inhibits swarming and skin contraction, and leads to reduced scarring in SCADs and in animals. Fibroblast swarming and N-cadherin thus provide therapeutic avenues to curtail fascia mobilisation and pathological fibrotic responses across a range of medical settings.

Ultrasound and Anatomical Study of Accessing the Nerves in the Knee by Fascial Planes

The fascia is an undifferentiated mesenchymal tissue related to the peripheral nerves. Both can be identified by ultrasound, which is useful when performing peripheral nerve blocks. However, there is no unanimity about the approaching point of each nerve, nor is there a consensus on how to name the appropriate infiltration zone, although the paraneural zone is frequently mentioned. The aims of this study were to determine if ultrasound is accurate for identifying the fascial planes and the paraneural space of the nerves in the knee, infiltrating them, and achieving a correct anatomical diffusion, as well as for establishing access routes to avoid intraneural infiltration. The study was performed in 16 cryopreserved lower extremities of the dissection room of the Faculty of Medicine and Health Sciences, University of Barcelona. Nerves of the knee were injected with colorant guided by ultrasound after they were visualized. Correct location of the nerves by ultrasound was achieved in 98.75% of the cases, correct visualization of the needle by ultrasound in 82.5%, the hypoechogenic image around the nerve after infiltration in 82.5%, and a correct paraneural infiltration in 76.25% of cases. With these results, we can conclude that high-definition ultrasound enables location of the peripheral nerves and adjacent structures as well as the fasciae that surround them, and therefore allows performance of infiltrations in the paraneural spaces.

Integrating mental imagery and fascial tissue: A conceptualization for research into movement and cognition

Mental imagery (MI) research has mainly focused to date on mechanisms of effect and performance gains associated with muscle and neural tissues. MI's potential to affect fascia has rarely been considered. This paper conceptualizes ways in which MI might mutually interact with fascial tissue to support performance and cognitive functions. Such ways acknowledge, among others, MI's positive effect on proprioception, body schema, and pain. Drawing on cellular, physiological, and functional similarities and associations between muscle and fascial tissues, we propose that MI has the potential to affect and be affected by fascial tissue. We suggest that fascia-targeted MI (fascial mental imagery; FMI) can therefore be a useful approach for scientific as well as clinical purposes. We use the example of fascial dynamic neuro-cognitive imagery (FDNI) as a codified FMI method available for scientific and therapeutic explorations into rehabilitation and prevention of fascia-related disabling conditions.

Understanding the Lingual Frenulum: Histological Structure, Tissue Composition, and Implications for Tongue Tie Surgery

Lingual frenotomy has become an increasingly common surgical procedure, performed for a broad range of indications from birth through adulthood. This study utilizes histology to define the structure and tissue composition of the lingual frenulum and floor of mouth (FOM) fascia. En bloc specimens of anterior tongue, lingual frenulum, and FOM tissues were harvested from ten embalmed adult cadavers. An additional three fresh tissue cadaveric specimens were frozen with the tongue supported in an elevated position, to enable harvesting and paraffin embedding of the elevated lingual frenulum as a discrete specimen. All 13 specimens were prepared as ten-micron coronal sections using stains to determine the general morphology of the lingual frenulum, its relationship to neighbouring structures (Mason's Trichrome), presence of elastin fibers (Verhoeff-van Gieson), and collagen typing (Picrosirius Red). Our results have shown a submucosal layer of fascia spanning horizontally across the FOM was present in all specimens, with variability in fascial thickness and histologic composition. This FOM fascia suspends the sublingual glands, vessels, and genioglossus from its deep surface. The elevated lingual frenulum is formed by a central fold of this FOM fascia together with the overlying oral mucosa with variability in fascial thickness and composition. With tongue elevation, the fascia mobilizes to a variable extent into the fold forming the frenulum, providing a structural explanation for the individual variability in lingual frenulum morphology seen in clinical practice.

The feasibility and impact of instrument-assisted manual therapy (IAMT) for the lower back on the structural and functional properties of the lumbar area in female soccer players: a randomised, placebo-controlled pilot study design

BACKGROUND

Myofascial (self-)treatments, such as foam rollers to therapeutic instruments in manual therapy, are utilized increasingly in prevention and therapy in healthy people, athletes, and patients suffering from chronic back pain. However, there is limited knowledge about the effectiveness of treatment and the underlying mechanisms of myofascial therapies, especially for instrument-assisted manual therapy (IAMT). Therefore, this pilot study will investigate the feasibility and impact of IAMT for the lumbar area compared with heat application and placebo treatment as a basis for calculating the sample size for further full studies. The primary outcomes will be a critical analysis of the feasibility of the measurement protocol in terms of time economy and expressiveness and of the short- and long-term effects on shear motion of the single tissue layers of the lower back obtained through ultrasound imaging. Secondary outcomes will include thickness and compressibility of the lumbar structures and flexibility of the dorsal structures, indentometry, and superficial skin temperature.

METHODS

A minimum of 60 healthy, competitive 15-35-year-old female soccer players will be recruited and randomised into three groups. Short-term effects of IAMT on thoracolumbar structures will be compared with heat application and pressure-less placebo treatment. Long-term effects in the IAMT group will be tested after nine further interventions over a 5-week period (2×/week) and compared with the placebo group, which will not receive further treatments but will serve as a control. Intermediate and final testing of both groups will occur in weeks three and five.

DISCUSSION

This pilot study will assess the feasibility and the impact of IAMT for the lower back particularly by examining the structural and functional properties of myofascial tissue using diagnostic ultrasound. These outcomes could evaluate the feasibility of the measurements used, shall build a basis for sample size calculation of further full studies, and might generate a greater understanding of myofascial therapies, especially IAMT, for the lower back and its benefits. If this approach proves to be practicable, next steps will be further full studies with soccer players, other sports, and patients with low back pain.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00012252) 20.06.2018; retrospectively registered.

A Histoarchitectural Approach to Skeletal Muscle Injury: Searching for a Common Nomenclature

In recent years, different classifications for muscle injuries have been proposed based on the topographic location of the injury within the bone-tendon-muscle chain. We hereby propose that in addition to the topographic classification of muscle injuries, a histoarchitectonic (description of the damage to connective tissue structures) definition of the injury be included within the nomenclature. Thus, the nomenclature should focus not only on the macroscopic anatomy but also on the histoarchitectonic features of the injury.

Skeletal Muscle Extracellular Matrix - What Do We Know About Its Composition, Regulation, and Physiological Roles? A Narrative Review

Skeletal muscle represents the largest body-composition component in humans. In addition to its primary function in the maintenance of upright posture and the production of movement, it also plays important roles in many other physiological processes, including thermogenesis, metabolism and the secretion of peptides for communication with other tissues. Research attempting to unveil these processes has traditionally focused on muscle fibers, i.e., the contractile muscle cells. However, it is a frequently overlooked fact that muscle fibers reside in a three-dimensional scaffolding that consists of various collagens, glycoproteins, proteoglycans, and elastin, and is commonly referred to as extracellular matrix (ECM). While initially believed to be relatively inert, current research reveals the involvement of ECM cells in numerous important physiological processes. In interaction with other cells, such as fibroblasts or cells of the immune system, the ECM regulates muscle development, growth and repair and is essential for effective muscle contraction and force transmission. Since muscle ECM is highly malleable, its texture and, consequently, physiological roles may be affected by physical training and disuse, aging or various diseases, such as diabetes. With the aim to stimulate increased efforts to study this still poorly understood tissue, this narrative review summarizes the current body of knowledge on (i) the composition and structure of the ECM, (ii) molecular pathways involved in ECM remodeling, (iii) the physiological roles of muscle ECM, (iv) dysregulations of ECM with aging and disease as well as (v) the adaptations of muscle ECM to training and disuse.

Effect of Osteopathic Manipulative Therapy on Generalized Anxiety Disorder

Context

Traditional management options for generalized anxiety disorder (GAD) have produced low remission rates. As a result, the medical community has turned to complementary and alternative medicine for adjunctive treatment.

Objective

To investigate the efficacy of adjunctive osteopathic manipulative therapy (OMTh; manipulative care provided by foreign-trained osteopaths) in individuals with GAD.

Methods

This open-label, nonrandomized, black-box study took place at a tertiary care mental health clinic in Toronto, Canada. Adult outpatient participants aged 18 to 65 years with a primary diagnosis of moderate-severe GAD (HAM-A score of ≥20) with or without comorbidities were enrolled in the study between June 2014 and January 2015. Patients who qualified and completed the study received 5 individually tailored OMTh sessions over the course of 8 to 9 weeks. A diagnostic psychiatric assessment (Mini International Neuropsychiatric Interview version 6.0.0) was conducted to confirm diagnoses, along with physician-administered and self-reported measures of anxiety, including the Hamilton Anxiety Scale (HAM-A), the Beck Anxiety Inventory, and the Intolerance for Uncertainty Scale.

Results

Significant reductions in total HAM-A scores after OMTh were observed (P<.0001). Significant reductions in total Intolerance for Uncertainty Scale scores were also observed (P<.0001). Beck Anxiety Inventory scores were not found to change significantly with OMTh. Response (defined as 50% reduction of symptoms) and remission (defined as HAM-A score of ≤7) rates were found to be 62% and 26.9%, respectively.

Conclusion

Osteopathic manipulative therapy may be a valuable adjunct to conventional therapy in patients with GAD, thus warranting further investigation using double-blind procedures.

The Intraosseous Dysfunction in the Osteopathic Perspective: Mechanisms Implicating the Bone Tissue

The somatic dysfunction (SD) is a protagonist in the context of theories and practices involving osteopathy and various other manual therapy methods. It is considered an obstacle to the body's inherent self-regulatory capabilities, and several tissues may be involved in this dysfunctional process, including the bone. The so-called intraosseous dysfunction refers to the restriction of natural flexibility of the fibrous components of the bone tissue matrix, or of the nonossified cartilaginous or membranous areas. Bone is a connective tissue composed of inorganic material and specialized cells organized in a hydrated extracellular matrix that provides the mechanical qualities to the tissue. The development of the bone tissue is a continuous process throughout life, and some bones fuse only years or decades after birth. It has microanatomical continuity with other adjacent structures and its different compartments are supplied by fluids, as well as somatic and autonomic innervation. Several studies show the phenomenon of bone tissue sensitization under traumatic, pathological conditions and also movement restriction. The purpose of the article is to review well-established knowledge and recent scientific findings regarding bone tissue anatomy and physiology, in an attempt to offer insights that could be applied to better understand the mechanisms implicating the intraosseus dysfunctions and its local and global repercussions.

Reflections on the Development of Fascial Tissue: Starting from Embryology

A great many articles discuss the histological aspects of fascial tissue in detail, but at the same time, there are many contradictions within the literature. In addition, there is a paucity of scientific data that allow straightforward classification of what tissue the fascia truly is. More precise classification of fascial tissue is essential in improving clinical care and effectively framing patient needs. Embryology is an indispensable starting point for understanding the many functions of the fascial tissue. This scientific discipline allows us to observe the relationships and adaptability of fascia both at local and systemic levels. This article reflects on modern scientific knowledge concerning the classification of fascia from an embryological standpoint with the aim of improving our understanding of connective tissue.

Patch repair of deep wounds by mobilized fascia

Mammals form scars to quickly seal wounds and ensure survival by an incompletely understood mechanism^1-5. Here we show that skin scars originate from prefabricated matrix in the subcutaneous fascia. Fate mapping and live imaging revealed that fascia fibroblasts rise to the skin surface after wounding, dragging their surrounding extracellular jelly-like matrix, including embedded blood vessels, macrophages and peripheral nerves, to form the provisional matrix. Genetic ablation of fascia fibroblasts prevented matrix from homing into wounds and resulted in defective scars, whereas placing an impermeable film beneath the skin-preventing fascia fibroblasts from migrating upwards-led to chronic open wounds. Thus, fascia contains a specialized prefabricated kit of sentry fibroblasts, embedded within a movable sealant, that preassemble together diverse cell types and matrix components needed to heal wounds. Our findings suggest that chronic and excessive skin wounds may be attributed to the mobility of the fascia matrix.

The architecture and spatial organization of the living human body as revealed by intratissular endoscopy - An osteopathic perspective

This article presents an overview of research conducted by Dr Jean-Claude Guimberteau into the architecture and spatial organization of living matter and the relationship between the cells and the extracellular matrix. His research is discussed in the context of previous and current research into fascial anatomy. Andrew Taylor Still, the founder of Osteopathy, did not have access to modern research and yet his observations are proving to be surprisingly accurate in the light of recent findings. This article sets out to highlight the relevance of his insights from a purely anatomical perspective, and to draw parallels with a new way of thinking about the architecture of the living human body that is slowly emerging. Dr Guimberteau's research shows that a force applied to the surface of the skin is transmitted deep into living tissue via a continuous bodywide multifibrillar network. It also confirms the concept of the body as a dynamic functional unit, as proposed by A.T. Still. Still also proposed that structure and function are interrelated at all levels within the living human body. There is a growing body of research to support this. Intratissular endoscopy has highlighted the importance of the quality of the mobility and adaptability of the network of collagen and elastin fibers that structures the ECM in healthy living tissue. Factors such as abnormal stiffness of collagen fibers in the ECM are thought to have adverse effects on local tissue health.

Acupuncture for the Treatment of Animal Pain

Acupuncture is recognized to induce multifactorial changes in the neuroregulatory aspects of pain physiology. Many aspects overlap with known receptor interactions of commonly used analgesic drugs, and acupuncture can increase the efficacy or replace the use of these pharmacologic pain treatments. This article discusses the currently recognized components of the pain pathways that are modified by acupuncture. It introduces the role of fibroblasts and fascia in mechanotransduction and discusses the ways in which this provides a link between the acupuncture needle and the nervous system and is a conduit for extracellular fluid movement, lymphatics, and the immune system.

Fascial neuromodulation: an emerging concept linking acupuncture, fasciology, osteopathy and neuroscience

According to Traditional Chinese Medicine “acupuncture is believed to restore the balance between Yin and Yang” and this can be understood in the Western medicine terminology as a “modulation of the equilibrium between parasympathetic and sympathetic activity”. The vast majority of studies concerning the mechanisms of action of acupuncture have been conducted on its influence on pain, and it has been proposed that acupuncture may indirectly relieve chronic pain by its effects on autonomic nervous system function. Several studies have shown that acupuncture recruits brain networks involved in the integration of multiple other brain functions: for example, the limbic-paralimbic-neocortical network, which plays a major role in modulating the affective dimensions of pain processing and the integration of emotional, sensorimotor, autonomic and immunological functions. It has been recently proposed that mechanical signaling through the connective tissue, along with transmission of the matrix deformation through the fascial system network, can explain the therapeutic effect of acupuncture. This model of acupunture, which involves the transduction of mechanical signals through the connective planes and produces a secondary involvement of neurophysiological mechanism, appears to fit very closely to the ancient model. It is also compatible with the proposed neurophysiological explanation. Furthermore, it appears to be fruitful also in manual therapy approaches. Drawing on the basis of the “Fascial network hypothesis of meridians”, in which there is an overlap between the channels network described by Traditional Chinese Medicine and the newly-defined fascial system, I propose an intervention through a combination of acupoints that have been selected due to their relationship between “extraordinary acupuncture channels”, the myofascial sequences described by Stecco, and the emotional and adaptive function as contemplated by a psychosomatic model used in posturology. This intervention is aimed at treating both stress and postural imbalance.

Interfascial plane blocks

Many novel interfascial plane blocks have been developed in the last 10 years in the effort to improve perioperative pain management that are safe, efficacious, efficient, and inexpensive. These blocks have been widely adopted into clinical practice despite relatively few high-quality clinical investigations of the techniques and how they affect perioperative outcomes. This article defines interfascial plane blocks, discusses the potential benefits, reviews the most common techniques and evidence supporting their indication, and guides clinicians in selecting an appropriate interfascial plane block for different types of surgical procedures.

Fascial nomenclature: Update on related consensus process

The term fascia is increasingly used not only by anatomists but also by other professionals and authors in different health‐oriented fields. This goes along with an inconsistent usage of the term, in which many different tissues are included by different authors causing an increasing amount of confusion. The Fascia Research Society acted to address this issue by establishing a Fascia Nomenclature Committee (FNC) with the purpose of clarifying the terminology relating to fascia. This committee conducted an elaborate Delphi process to foster a structured consensus debate among different experts in the field. This process led to two distinct terminology recommendations from the FNC, defining the terms “a fascia” and “the fascial system.” This article reports on the process behind this proposed terminology as well as the implications for inclusion and exclusion of different tissue types to these definitions. Clin. Anat. 32:929–933, 2019. © 2019 The Authors. Clinical Anatomy published by Wiley Periodicals, Inc. on behalf of American Association of Clinical Anatomists.

Anatomical structures at risk using different approaches for sacrospinous ligament fixation

For 50 years now, sacrospinous ligament fixation (SSLF) has been used to treat pelvic organ prolapse consequent on altered integrity of the pelvic myofascial structures. It is usually performed vaginally, but it has recently been performed laparoscopically through either an anterior or a posterior approach, with the broad ligament as a landmark to differentiate the two. In the present study, these two laparoscopic approaches were assessed using Thiel-embalmed cadavers. The anterior and posterior approaches were compared in terms of the closest distance to anatomical structures at risk, including pelvic viscera, the obturator nerve, and vascular structures. The posterior approach was more often closer to the investigated vessels and the rectum. The obturator nerve and the ureter were close to both the anterior and posterior approaches. The urinary bladder was closer using the anterior approach. From an anatomical standpoint, therefore, the anterior laparoscopic approach for SSLF is more likely to cause injury to the urinary bladder, whereas the posterior approach is more prone to causing rectal and vessel injuries. This study illustrates, from a basic science perspective, the importance of combining fascia research, novel endoscopic or minimally invasive surgical exposures informed by anatomy, and contemporary trends in gynecology in order to improve patient outcomes. Clin. Anat. 33:522-529, 2020. © 2019 Wiley Periodicals, Inc.

Educational avenues for promoting dialog on fascia

If your healthcare professional students have not heard about the importance of fascia they definitely should, and if your residents have not heard about the manifestations of fascia health they definitely will from their patients. While fascia may not be the sexiest of organ systems, it is one of the most influential. Fascia is gaining interest from researchers, physicians, and many subdivisions of manual medicine including massage therapists. The fascial system is now being recognized with roles in pathology, fluid movement, and proprioception. It is also important in skeletal muscle movement, perception of pain, protein regulation and expression, cell signaling, neoplastic growth, and hormone distribution in our body. It can be the reason why we feel chronic pain or why we feel tightness after physical activity. The primary responsibility of fascia is to connect systems so that the body works as a whole, which is what permits this topic to be easily embedded anywhere in our health curricula. Whether you teach students in schools of medical, veterinary, dental, physical therapy, physician assistant studies, or occupational therapy, fascia matters. Whether you teach in an integrated curriculum or a curriculum that is designed for problem-based learning or a classical discipline-based curriculum, connective tissue has a place in academia. So, in our cramped curriculum how do we make sure that our current undergraduate and graduate students understand the complexity of fascia without adding additional time to coursework? To answer this question, this article demonstrates how fascia can fit anywhere in the curriculum because it is found everywhere. Clin. Anat. 32:871-876, 2019. © 2019 Wiley Periodicals, Inc.

Quadriceps foam rolling and rolling massage increases hip flexion and extension passive range-of-motion

Increases in joint range-of-motion may be beneficial for improving performance and reducing injury risk. This study investigated the effects of different self-massage volumes and modalities on passive hip range-of-motion. Twenty-five recreationally resistance-trained men performed four experimental protocols using a counterbalanced, randomized, and within-subjects design; foam rolling (FR) or roller massage (RM) for 60 or 120-s. Passive hip flexion and extension range-of-motion were measured in a counterbalanced and randomized order via manual goniometry before self-massage (baseline) and immediately, 10-, 20-, and 30-min following each self-massage intervention. Following FR or RM of quadriceps, there was an increase in hip flexion range-of-motion at Post-0 (FR: Δ = 19.28°; RM: Δ = 14.96°), Post-10 (FR: Δ = 13.03°; RM: Δ = 10.40°), and Post-20 (FR: Δ = 6.00°; RM: Δ = 4.64°) for all protocols, but these did not exceed the minimum detectable change at Post-10 for RM60 and RM120, and Post-20 for FR60, FR120, RM60, and RM120. Similarly, hip extension range-of-motion increased at Post-0 (FR: Δ = 8.56°; RM: Δ = 6.56°), Post-10 (FR: Δ = 4.64°; RM: Δ = 3.92°), and Post-20 (FR: Δ = 2.80°; RM: Δ = 1.92°), but did not exceed the minimum detectable change at Post-10 for FR60, RM60, and RM120, and Post-20 for FR60, FR120, RM60, and RM120. In conclusion, both FR and RM increased hip range-of-motion but larger volumes (120- vs. 60-second) and FR produced the greatest increases. These findings have implications for self-massage prescription and implementation, in both rehabilitation and athletic populations.

Fascial tissue research in sports medicine: from molecules to tissue adaptation, injury and diagnostics: consensus statement

The fascial system builds a three-dimensional continuum of soft, collagen-containing, loose and dense fibrous connective tissue that permeates the body and enables all body systems to operate in an integrated manner. Injuries to the fascial system cause a significant loss of performance in recreational exercise as well as high-performance sports, and could have a potential role in the development and perpetuation of musculoskeletal disorders, including lower back pain. Fascial tissues deserve more detailed attention in the field of sports medicine. A better understanding of their adaptation dynamics to mechanical loading as well as to biochemical conditions promises valuable improvements in terms of injury prevention, athletic performance and sports-related rehabilitation. This consensus statement reflects the state of knowledge regarding the role of fascial tissues in the discipline of sports medicine. It aims to (1) provide an overview of the contemporary state of knowledge regarding the fascial system from the microlevel (molecular and cellular responses) to the macrolevel (mechanical properties), (2) summarise the responses of the fascial system to altered loading (physical exercise), to injury and other physiological challenges including ageing, (3) outline the methods available to study the fascial system, and (4) highlight the contemporary view of interventions that target fascial tissue in sport and exercise medicine. Advancing this field will require a coordinated effort of researchers and clinicians combining mechanobiology, exercise physiology and improved assessment technologies.

Frontiers in fascia research

Basic sciences are the backbone of every clear understanding of how the body is composed and how different structures and functions are connected with each other. It is obvious that there is a huge variability in human beings - not only in terms of the outer appearance such as measurements of height, weight, muscle mass and other physical properties, but also with respect to metabolic and functional parameters. This article highlights recent developments of research activities in the field of fascia sciences with a special emphasis on assessment strategies as the basis of further studies. Anatomical and histological studies show that fascial tissue is highly variable in terms of density, stiffness, and other parameters such as metabolic and humoral activity. Moreover, it encompasses nerves and harbours a system of micro-channels, also known as the primo vascular system. As ultrasound is a widely available method, its use is appealing not only for imaging of fascial structures, but also for thorough scientific analysis. Unlike most other imaging technologies, US has the advantage of real-time analysis of active or passive movements. In addition, other assessment methods for fascial tissue are discussed. In conclusion, fascial tissue plays an important role not only in functional anatomy, but also in evolutionary and molecular biology, sport, and exercise science as well as in numerous therapeutic approaches. A high density of nerves is found in fascial tissue. Knowledge of individual characteristics, especially by visualizing with ultrasound, leads to personalized therapeutic approaches, such as in pain therapy.

Fasciae of the musculoskeletal system: normal anatomy and MR patterns of involvement in autoimmune diseases

Abstract

The fascial system is a three-dimensional continuum of connective tissues present everywhere throughout the body, from the head to the toes and from the skin to the bone. The current article aims to review the normal anatomy of the fasciae of the musculoskeletal system with macroscopic and microscopic correlations and to describe their appearance at MRI in normal subjects and in patients with autoimmune diseases of the musculoskeletal system.

Key Points

• The fascial system is a three-dimensional continuum of connective tissues.

• It is present everywhere throughout the body, from the head to the toes and from the skin to the bone.

• The normal fascial system is barely visible at MRI.

• MR patterns of fascial involvement in autoimmune diseases reflect the complex anatomy of the fasciae of the musculoskeletal system.

A New Concept of Biotensegrity Incorporating Liquid Tissues: Blood and Lymph

The definition of fascia includes tissues of mesodermal derivation, considered as specialized connective tissue: blood and lymph. As water shapes rocks, bodily fluids modify shapes and functions of bodily structures. Bodily fluids are silent witnesses of the mechanotransductive information, allowing adaptation and life, transporting biochemical and hormonal signals. While the solid fascial tissue divides, supports, and connects the different parts of the body system, the liquid fascial tissue feeds and transports messages for the solid fascia. The focus of this article is to reconsider the model of biotensegrity because it does not take into account the liquid fascia, and to try to integrate the fascial continuum with the lymph and the blood in a new model. The name given to this new model is RAIN—Rapid Adaptability of Internal Network.

Meaning of the Solid and Liquid Fascia to Reconsider the Model of Biotensegrity

The definition of fascia includes tissues of mesodermal derivation considered as specialized connective tissues: the blood and lymph. As water shapes rocks, bodily fluids modify the shape and functioning of bodily structures. Bodily fluids are silent witnesses to mechanotransductive information, allowing adaptation and life, transporting biochemical and hormonal signals. While the solid fascial tissue divides, supports, and connects the different parts of the body system, the liquid fascial tissue feeds and transports messages for the solid fascia. This article reconsiders the model of biotensegrity, by revising the definition of solid and liquid fascia, and tries to integrate the fascial continuum with the lymph and blood in a new model, because in the previous model, these two liquid elements were not taken into consideration. The name given to this new model is Rapid Adaptability of Internal Network (RAIN).

Cervical plexus block

Cervical plexus blocks (CPBs) have been used in various head and neck surgeries to provide adequate anesthesia and/or analgesia; however, the block is performed in a narrow space in the region of the neck that contains many sensitive structures, multiple fascial layers, and complicated innervation. Since the intermediate CPB was introduced in addition to superficial and deep CPBs in 2004, there has been some confusion regarding the nomenclature and definition of CPBs, particularly the intermediate CPB. Additionally, as the role of ultrasound in the head and neck region has expanded, CPBs can be performed more safely and accurately under ultrasound guidance. In this review, the authors will describe the methods, including ultrasound-guided techniques, and clinical applications of conventional deep and superficial CPBs; in addition, the authors will discuss the controversial issues regarding intermediate CPBs, including nomenclature and associated potential adverse effects that may often be neglected, focusing on the anatomy of the cervical fascial layers and cervical plexus. Finally, the authors will attempt to refine the classification of CPB methods based on the target compartments, which can be easily identified under ultrasound guidance, with consideration of the effects of each method of CPB.

New Proposal to Define the Fascial System

At the beginning of the third millennium, we still do not have a definition of 'fascia' recognized as valid by every researcher. This article attempts to give a new definition of the fascial system, including the epidermis, by comparing the mechanical-metabolic characteristics of the connective tissue and the skin. In fact, according to the latest classification deriving from the Fascia Nomenclature Committee, the outer skin layer is not considered as part of the fascial continuum. This article highlights the reasons for taking the functional characteristics of the tissue into consideration, rather than its mere structure. A brief discussion will address the questions as to what is considered as fascial tissue and from which embryonic germ layer the epidermis is formed. The notion that all the layers intersect will be highlighted, demonstrating that quoting precise definitions of tissue stratification in the living organism probably does not correspond to what happens in vivo. What we propose as a definition is not to be regarded as a point of arrival but as another departure.