The Deep Fascia and its Role in Chronic Pain & Pathological Conditions: A Review

Effects of Fu's Subcutaneous Needling on Postoperative Pain in Patients Receiving Surgery for Degenerative Lumbar Spinal Disorders: A Single-Blind, Randomized Controlled Trial

Background

Fu's subcutaneous needling (FSN) is a novel acupuncture technique for pain treatment. This study investigated the effects of postsurgical FSN on postoperative pain in patients receiving surgery for degenerative spinal disorders.

Methods

This single-center, single-blind, randomized-controlled study involved patients undergoing surgery for degenerative spinal disorders. Participants were randomized into either an FSN group or a control group that received sham FSN. The primary outcomes were scores on the Brief Pain Inventory Taiwan version (BPI-T) and Oswestry Disability Index before and at 1, 24, and 48 hours after surgery. Secondary outcomes were muscle hardness, pethidine use, and inflammatory biomarker presence.

Results

Initially, 51 patients met the inclusion criteria and were allocated (26 in the FSN group and 25 in the control group). Two patients were lost to follow-up, and finally, 49 patients (25 in the FSN group and 24 in the control group) who completed the study were analyzed. The FSN group had significantly lower pain intensity measured on the BPI-T compared with the control group at 1, 24, 48, and 72 hours after surgical treatment (all p < 0.001). Additionally, pain interference as measured on the BPI-T was lower in the FSN group than in the control group 1 hour (p = 0.001), 24 hours (p = 0.018), 48 hours (p = 0.001), and 72 hours (p = 0.017) after surgical treatment. Finally, the FSN group exhibited less muscle hardness in the latissimus dorsi and gluteus maximus 24, 48, and 72 hours (all p < 0.05) after surgery compared with the control group; patients in the FSN group also exhibited less muscle hardness in the L3 paraspinal muscle 48 hours (p = 0.001) and 72 hours (p < 0.001) after surgery compared with the control group. There were no significant differences in serum CRP, IL-1β, IL-2, IL-6, and TNF-α levels between the FSN and control groups at 24 hours, 72 hours, and 1-month post-surgery (all p > 0.05).

Conclusion

FSN treatment can reduce postoperative pain in patients receiving surgery for degenerative spinal disorders. However, larger sample sizes and multicenter clinical trials are required to verify these findings.

Myofascial release for adults with chronic neck pain and depression

BACKGROUND

Depression affects a significant portion of the global adult population, with chronic pain patients being particularly susceptible to severe depression. Pain and mental illness contribute to an imbalance in the autonomic nervous system, affecting heart function. Myofascial release promises to improve mental and physical health by addressing fascial dysfunctions.

OBJECTIVE

This study aims to investigate the influence of myofascial release on emotional states and autonomic nervous system functioning in individuals with chronic neck pain and depression. Additionally, it seeks to evaluate the myofascial release effect on fascial properties, pain intensity and sensitivity, and cervical spine range of motion.

METHOD

Experimental Study.

RESULT

The study revealed significant enhancements in the myofascial release group, such as a substantial reduction in pain perception and stiffness, increased range of motion of the cervical spine, heart rate variability, positive affect, and pressure pain threshold. The effect sizes of these improvements ranged from small to large. No significant differences were observed in elasticity and tone.

CONCLUSION

The findings suggest that myofascial release has a positive impact on individuals with chronic neck pain and depression, particularly in reducing pain intensity. Integrating myofascial release into treatment approaches may be beneficial. However, further research is needed to confirm and expand upon these findings, explore long-term effects, and better understand the clinical significance of certain outcomes.

TRIAL REGISTRATION

http://www.osf.io, doi.org/10.17605/OSF.IO/6F5RS.

Ultra-High Contrast MRI: Using Divided Subtracted Inversion Recovery (dSIR) and Divided Echo Subtraction (dES) Sequences to Study the Brain and Musculoskeletal System

Divided and subtracted MRI is a novel imaging processing technique, where the difference of two images is divided by their sum. When the sequence parameters are chosen properly, this results in images with a high T1 or T2 weighting over a small range of tissues with specific T1 and T2 values. In the T1 domain, we describe the implementation of the divided Subtracted Inversion Recovery Sequence (dSIR), which is used to image very small changes in T1 from normal in white matter. dSIR has shown widespread changes in otherwise normal-appearing white matter in patients suffering from mild traumatic brain injury (mTBI), substance abuse, and ischemic leukoencephalopathy. It can also be targeted to measure small changes in T1 from normal in other tissues. In the T2 domain, we describe the divided echo subtraction (dES) sequence that is used to image musculoskeletal tissues with a very short T2*. These tissues include fascia, tendons, and aponeuroses. In this manuscript, we explain how this contrast is generated, review how these techniques are used in our research, and discuss the current challenges and limitations of this technique.

Investigation of masticatory muscle thickness and mechanosensitivity of cervical and masticatory muscles in myofascial temporomandibular disorder patients with bruxism: A cross-sectional study

OBJECTIVE

Bruxism is a common problem associated with temporomandibular disorders (TMD). The aim of this study was to compare a patient group with Myofascial TMD and bruxism and a healthy control group in terms of masseter and temporal muscle thickness (clenching and resting), mechanosensitivity of neck and jaw muscles, craniofacial pain, and disability and emotional stress status.

METHODS

The study included 31 patients with myofascial TMD and bruxism (19 females, 12 males) with a mean age of 29.96 ± 8.12 years (range, 18-45 years), and a control group of 31 healthy subjects (19 females, 12 males) with a mean age of 27.58 ± 9.39 years years (range, 18-45 years). Masseter and temporal muscle thicknesses were evaluated with a mobile ultrasound device both at rest and when clenching the jaw. The mechanosensitivity values between the upper trapezius, obliquus capitis inferior, masseter and temporal muscles were measured with a digital algometer device. Craniofacial pain and disability level were evaluated with the Craniofacial Pain and Disability Index (CFPDI), and emotional stress levels with the Perceived Stress Scale-14 (PSS-14).

RESULTS

No difference was determined between the two groups in respect of the clenching and resting ratios of muscle thickness in any muscle (p > 0.05). The mechanosensitivity values in all muscles were lower in the myofascial TMD group than in the healthy group (p < 0.05). The CFPDI and PSS-14 scores were higher in the myofascial TMD group (p < 0.05). There was a moderate positive correlation between CFPDI, PSS-14 and Bruxism Frequency Score (p < 0.05).

CONCLUSION

The difference in mechanosensitivity and CFPDI values between the myofascial TMD patients with bruxism and the healthy control group indicates that the problem in this patient group has effects in the craniocervical and cervical regions. In addition, the correlation between CFPDI, PSS-14 and Bruxism Frequency Score in myofascial TMD patients suggests that this problem may be affected by the interaction of different parameters.

Exploring fascial properties in patients with depression and chronic neck pain: An observational study

BACKGROUND

Depressive disorder and chronic pain are prevalent conditions that often co-occur. The myofascial fascial continuum has been hypothesized to contribute to both conditions. However, limited research exists on the specific association between fascial properties and chronic pain and depression.

OBJECTIVE

This study aims to investigate the properties of the deep fascia of the M. trapezius and their relationship with depression, chronic neck pain, and cervical spine mobility.

METHOD

This study compared fascial properties between two groups: individuals with depression and chronic neck pain, and healthy individuals. Fascial thickness, elasticity, and stiffness were measured as primary outcomes using standardized techniques such as ultrasound imaging and compliance meter. Statistical analyses were conducted to identify potential differences and correlations in fascial properties between the two groups.

RESULT

Significant differences emerge in stiffness, tone, and fascia thickness in the deep fascia, alongside identified correlations between depression, chronic pain, and these variables.

CONCLUSION

The study highlights the impact of depression and chronic pain on fascial properties, emphasizing the need for further research in this domain to unravel the intricate connections and potential implications for treatment strategies.

Fascial Signal Change on the Cervical MRI of a Patient with Systemic Lupus Erythematosus

Here, we present a case of a 53-year-old female patient with chronic neck pain and systemic inflammation who was ultimately diagnosed with systemic lupus erythematosus. Notably, applying fat-suppressed T2-weighted MRI sequences was pivotal in detecting structural fascial changes commonly associated with systemic inflammatory diseases. PET-CT scans further revealed systemic inflammation around multiple joints, providing valuable insights into MRI signal alterations. This case underscores the importance of considering systemic autoimmune pathology as a potential underlying cause of chronic musculoskeletal pain. It also highlights the clinical utility of MRI with fat suppression sequences in identifying inflammation-related fascial changes. This case emphasizes the significance of a comprehensive evaluation, particularly in situations where clinical features overlap between autoimmune and degenerative skeletal pathologies. Fat-suppressed MRI can provide information about fascial pathology related to systemic inflammatory diseases. In this context, it is worth noting that PET-CT and fat suppression MRI complement each other by providing complementary information about inflammation and the underlying causes of a patient's pain.

Myofascial and discogenic origins of lumbar pain: A critical review

The purpose of this three-part narrative review is to examine the anatomy of, and the research which supports, either the lumbar myofascia or intervertebral disc (IVD) as principal sources of our patient's low back pain. A comprehensive understanding of anatomical lumbar pain generators in combination with the current treatment-based classification system will further improve and enhance clinical decision-making skills. Section I reviews the anatomy of the spinal myofascia, myofascial sources of lumbar pain, and imaging of myofascial tissues. Part II reviews the anatomy of the IVD, examines the IVD as a potential lumbar pain generator, and includes detailed discussion on Nerve Growth Factor, Inflammatory Cytokines, Vertebral End Plates and Modic change, Annular tears, and Discogenic instability. Part III looks at the history of myofascial pain, lab-based research and myofascial pain, and various levels of discogenic pain provocation research including animal, laboratory and human subjects. Our review concludes with author recommendations on developing a comprehensive understanding of altered stress concentrations affecting the posterior annulus fibrosis, neo-innervation of the IVD, inflammatory cytokines, discogenic instability, and how this knowledge can complement use of the Treatment-Based Classification System.

A New Player in the Mechanobiology of Deep Fascia: Yes-Associated Protein (YAP)

Recent studies have demonstrated that fascial fibroblasts are susceptible to mechanical stimuli, leading to the remodeling of the extracellular matrix (ECM). Moreover, the extensive literature on Yes-associated protein (YAP) has shown its role in cell mechanics, linking cell properties, such as shape, adhesion, and size, to the expression of specific genes. The aim of this study was to investigate the presence of YAP in deep fascia and its activation after a mechanical stimulus was induced via a focal extracorporeal shockwave (fESW) treatment. Thoracolumbar fascia (TLF) samples were collected from eight patients (age: 30-70 years; four males and four females) who had undergone spine elective surgical procedures at the Orthopedic Clinic of University of Padova. YAP was measured in both tissue and TLF-derived fibroblasts through immunoblotting. COL1A1 and HABP2 gene expression were also evaluated in fibroblasts 2, 24, and 48 h after the fESW treatment. YAP was expressed in all the examined tissues. The ratio between the active/inactive forms (YAP/p-YAP) of the protein significantly increased in fascial fibroblasts after mechanical stimulation compared to untreated cells (p = 0.0022). Furthermore, COL1A1 and HABP2 gene expression levels were increased upon treatment. These findings demonstrate that YAP is expressed in the deep fascia of the thoracolumbar region, suggesting its involvement in fascial mechanotransduction processes, remodeling, regeneration, and fibrogenesis. This study indicates, for the first time, that YAP is a "new player" in the mechanobiology of deep fascia.

Non-Pharmacological Pain Treatment of Patients with Myofascial Pain Syndrome of the Masticatory Muscles-Case Series

Myofascial pain is the most common cause of chronic pain in the masticatory region and can be assessed through clinical analysis and muscle palpation. Generally, it appears with headache and orofacial pain associated with sensitive points (trigger points) due to the excessive contraction of the masticatory muscle fibers. The study aims to evaluate how a correct treatment of myofascial pain can improve the life quality of affected patients. In this case series, 300 patients with myofascial pain were divided into two groups: 150 with intra- and extra-articular disorders and 150 with only extra-articular disorder. Each group included 75 males and 75 females. All the patients were treated with gnathological therapy through passive aligners and biofeedback exercises for four months. They underwent pain assessment (through a visual analogue scale and muscular palpation test) before, during, and after the treatment, as well as nuclear magnetic resonance of the temporomandibular joint before and after the gnathological treatment. The treatment considerably reduced the pain in all patients, without drugs, in four months according to the visual analogue scales and the palpation test. The temporomandibular magnetic resonance in each patient was similar before and after the gnathological treatment. The improvement in pain did not depend on a change in the relationship between the articular condyle and the disc.

Reliability of shear-wave elastography in assessing the stiffness of the nuchal fascia and the thickness of upper cervical muscles

OBJECTIVE

To determine the reliability of shear-wave elastography (SWE)in assessing the stiffness of the nuchal fascia and the thickness of upper cervical muscles in neutral head posture (NHP) or forward head posture (FHP).

METHODS

Sixteen healthy adults (mean age: 21.69 ± 1.01years, 9 females) were included. SWE mode was chosen to measure the nuchal fascia shear modulus and muscle thickness was measured in B-mode. Measurements were collected by two independent investigators on two different days. The intraclass correlation coefficient (ICC) was used to measure the relative reliability, and the standard error of measurement (SEM) were used to measure the absolute reliability.

RESULTS

Intra‑rater (ICC = 0.63-0.89) and inter-rater (ICC = 00.54-0.82) reliability for the nuchal fascia shear modulus were moderate to excellent. Intra‑rater (ICC = 00.64-0.96) and inter-rater (ICC = 00.48-0.86) reliability for upper cervical muscles thickness were moderate to excellent. The SEM percentage oscillated from 3.27% to 13.55%. There were significant differences(P < 0.05) between NHP and FHP on nuchal fascia shear modulus, right side splenius capitis muscle thickness and left side semispinalis capitis muscle thickness, but no significant differences(P > 0.05) were observed between the right and left sides. The upper cervical muscles thickness of males was significantly thicker(P < 0.01) than females while no significant differences were observed (P > 0.05) on the nuchal fascia shear modulus.

CONCLUSIONS

Ultrasound-based SWE may be a reliable tool for assessing the stiffness of the nuchal fascia and the thickness of upper cervical muscles in clinical practice.

REGISTRATION NUMBER

ChiCTR2200055736.

Are fascial strains involved in chronic pelvic pain syndrome? An exploratory matched case-control study

BACKGROUND

Chronic pelvic pain (CPP) and chronic pelvic pain syndrome (CPPS) do not have a definite cause, even if their impact on quality of life was demonstrated. Furthermore, there is evidence of myofascial dysfunctions in a large number of CPP/CPPS, so that the role of fascia can be hypothesized.

METHODS

The aim of this exploratory matched case-control study was to assess whether fascial strains (FS) represent a factor associated with CPP/CPPS. The study followed the "Strengthening the Reporting of Observational Studies in Epidemiology" (STROBE) statement. We collected data from 189 subjects (cases: 58; controls: 131) who attended the clinic. The participants were managed through a 2:1 enrollment ratio. A standardized booklet requested for clinical information, previous FS and the following questionnaires: "National Institutes of Health Chronic Prostatitis Symptom Index" (NIH-CPSI), "Hospital Anxiety and Depression Scale" (HADS), "Fear Avoidance Belief Questionnaire" (FABQ). Each subject underwent a palpatory assessment to detect abnormal palpatory findings in the pelvic area.

RESULTS

The analyses showed that episiotomy, genito-urinary infections and surgery had a significantly increased odds ratio (OR) of 4.13, 3.1 and 3.08, respectively. FS as a whole had a significantly raised OR: 2.22 (1.14 to 4.33). The analysis was adjusted for physical activity and for type of job and OR decreased to 1.94 (0.82 to 4.61), losing its significance (p = 0.129). A strong correlation between symptoms' impact and CPP/CPPS was detected (rpbs = 0.710; p < 0.001) and a moderate one (0.3 < rpbs < 0.7; p < 0.001) was found considering anxiety, depression and abnormal palpatory findings.

CONCLUSION

This exploratory study suggests that FS could represent an etiological factor for developing CPP/CPPS. However, further research on fascial dysfunctions and relative implications in CPP/CPPS is needed for confirmation.

Differential Sensitization of Muscle versus Fascia in Individuals with Low Back Pain

Muscles and the deep fascia surrounding them have been suggested to play an important role in various musculoskeletal pain conditions including low back pain. Both have been shown to host rich nociceptive innervation and to undergo changes in individuals with chronic pain. However, evidence for the respective contribution of muscle and fascia sensitization in humans with myofascial pain syndrome is lacking. Here, we studied the sensitization of muscle and fascia in individuals with myofascial low back pain. Twenty individuals with acute (5) and chronic (15) myofascial low back pain of the quadratus lumborum muscle and a matched control group of twenty healthy individuals were recruited and clinically evaluated. All participants underwent ultrasound-guided needling of their subcutaneous tissue, deep fascia and quadratus lumborum muscle. Reported pain intensity and episodes of muscle twitching were recorded and analyzed. Among pain patients, both muscles and deep fascia demonstrated pain hypersensitivity, but muscles were significantly more sensitized than the deep fascia. No difference between acute- or chronic-pain patients was observed. Results of this study suggest that while both deep fascia and muscle show pain sensitization in both early and chronic stages of low back pain, muscles are more sensitized than fascia.

Comparative Study of the Efficacy of Hyaluronic Acid, Dry Needling and Combined Treatment in Patellar Osteoarthritis-Single-Blind Randomized Clinical Trial

Background: Osteoarthritis of the knee is one of the most common ailments worldwide, and pain management of this condition is critical. Methods: A multicentre randomized controlled trial RCT with three months of follow-up, conducted in parallel groups: hyaluronic acid (HA), dry needling (DN) and ultrasound (US) and isometrics of quadriceps. 60 participants took part in the RCT who were diagnosed with osteoarthritis (Grade 3) of the knee by MRI and active adults (age: 23.41 ± 1.68 years; height: 1.79 ± 0.08 m; body mass: 78.33 ± 9.03 kg; body mass index (BMI): 24.14 ± 1.45 kg/m²). After the assigned intervention, VAS, WOMAC, IPAQ and the Star Excursion Balance test were measured at baseline. At 24 h, 15 days, 30 days, 90 days and 180 days follow-up, all variables were measured again. Results: Comparing statistically significant differences between groups, VAS scores were significant at post-test measurement (HA vs. US + isometric and DN vs. US + isometric) at 24 h (HA vs. DN), at 15 days (HA vs. US + isometric and DN vs. US + isometric) and at 1 month (US + isometric vs. HA and US + isometric vs. DN). Conclusions: There is an improvement in pain intensity in knee osteoarthritis in the short term in patients undergoing DN and conventional US + isometric treatment, but in the long term the HA group shows an improvement in pain intensity. There is also a significant difference in the improvement of knee function at different phases of the study in the various intervention groups. The combination of DN and HA in clinical practice is the best option for the treatment of osteoarthritis.