Cellular control of connective tissue matrix tension

Examination of the effect of fascial therapy on some physical fitness parameters in taekwondo athletes

One of the objectives of this study is to determine the effect of the eight-week fascial therapy program on flexibility, vertical jump, standing long jump, speed and anaerobic strength parameters in taekwondo athletes. Another aim of the research is to create a therapy protocol that can be used in athletes related to performance development through the relaxation of the fascial system, which is considered an indicator of physical fitness and has numerous functions in the body. This study included 32 taekwondo players who were licensed, actively attending taekwondo training. In the study, two groups were formed as fascial therapy group (FTG) (n ​= ​16) and control group (CG) (n ​= ​16). After the groups were randomized, fascial relaxation techniques were applied to the fascial therapy group for eight weeks, up to twice a week, and for 30 ​min. According to the findings obtained as a result of the research, FTG ([-0.36 ​± ​0.17] seconds [s]) for the 20 ​m (m) Sprint (T2-T1) had a lower mean time than CG (0.00 ​± ​0.07) s, FTG (0.06 ​± ​1.95) for the Flamingo Balance Test (T2-T1) had a lower mean fall than CG (1.25 ​± ​1.13), FTG ([3.56 ​± ​2.37] centimeters [cm]) for the Sit & Reach Test (T2-T1) had a lower mean fall than CG ([-0.19 ​± ​1.28] cm), FTG ([5.75 ​± ​2.54] cm) had a higher jump distance than CG ([1.88 ​± ​8.11] cm) according to the results of Vertical Jump Test (T2-T1) and finally FTG ([9.13 ​± ​5.56] cm) had a longer distance than CG ([-0.31 ​± ​1.85] cm) according to the results of Standing Long Jump Test (T2-T1). The result of our study has shown that fascial techniques can be used safely by experienced physiotherapists and can be included in the training program. It is recommended that coaches of sports disciplines work with experienced physiotherapists on this subject and include fascial methods in their training programs.

From Muscle to the Myofascial Unit: Current Evidence and Future Perspectives

The "motor unit" or the "muscle" has long been considered the quantal element in the control of movement. However, in recent years new research has proved the strong interaction between muscle fibers and intramuscular connective tissue, and between muscles and fasciae, suggesting that the muscles can no longer be considered the only elements that organize movement. In addition, innervation and vascularization of muscle is strongly connected with intramuscular connective tissue. This awareness induced Luigi Stecco, in 2002, to create a new term, the "myofascial unit", to describe the bilateral dependent relationship, both anatomical and functional, that occurs between fascia, muscle and accessory elements. The aim of this narrative review is to understand the scientific support for this new term, and whether it is actually correct to consider the myofascial unit the physiological basic element for peripheral motor control.

Reconceptualizing Somatic Dysfunction in the Light of a Neuroaesthetic Enactive Paradigm

Background: Palpatory findings are considered a central element of osteopathic practice, especially when associated with a patient's altered regulative functions than with named somatic dysfunctions. Although osteopathic theories for somatic dysfunction could be plausible, the clinical applicability of the concept is debated, especially because it is largely related to simple cause-effect models of osteopathic care. In contrast to a linear kind of diagnosis of a "tissue as a producer of symptoms", this perspective article aims to provide a conceptual and operational framework in which the somatic dysfunction evaluation process is seen as a neuroaesthetic (en)active encounter between osteopath and patient. Subsections relevant to the subject: To summarize all concepts of the hypothesis, the enactive neuroaesthetics principles are proposed as a critical foundation for the osteopathic assessment and treatment of the person, specifically addressing a new paradigm for somatic dysfunction. Conclusions, and future directions: The present perspective article represents a proposition to blend technical rationality informed by neurocognitive and social sciences, and professional artistry clinical experience informed by traditional tenets, to overcome the controversy around somatic dysfunction, rather than dismissing the concept.

Role of fibroblasts in wound healing and tissue remodeling on Earth and in space

Wound healing (WH) and the role fibroblasts play in the process, as well as healing impairment and fibroblast dysfunction, have been thoroughly reviewed by other authors. We treat these topics briefly, with the only aim of contextualizing the true focus of this review, namely, the microgravity-induced changes in fibroblast functions involved in WH. Microgravity is a condition typical of spaceflight. Studying its possible effects on fibroblasts and WH is useful not only for the safety of astronauts who will face future interplanetary space missions, but also to help improve the management of WH impairment on Earth. The interesting similarity between microgravity-induced alterations of fibroblast behavior and fibroblast dysfunction in WH impairment on Earth is highlighted. The possibility of using microgravity-exposed fibroblasts and WH in space as models of healing impairment on Earth is suggested. The gaps in knowledge on fibroblast functions in WH are analyzed. The contribution that studies on fibroblast behavior in weightlessness can make to fill these gaps and, consequently, improve therapeutic strategies is considered.

Tissutal and Fluidic Aspects in Osteopathic Manual Therapy: A Narrative Review

Over the years, several authors have discussed the possibility of considering somatic dysfunction (SD) as a “nosological element” detectable on palpation. There are many aspects to consider regarding the etiology and diagnosis of SD, and the literature on osteopathic issues provides details on physiological signs that characterize it, including tissue texture changes. Recent knowledge suggests that how tissue and, in particular, connective tissue, responds to osteopathic treatment may depend on the modulation of the inflammation degree. Low-grade inflammation (LGI) may act on the extracellular matrix (ECM) and on cellular elements; and these mechanisms may be mediated by biological water. With its molecules organized in structures called exclusion zones (EZ), water could explain the functioning of both healthy and injured tissues, and how they can respond to osteopathic treatment with possible EZ normalization as a result. The relationship between inflammation and DS and the mechanisms involved are described by several authors; however, this review suggests a new model relating to the characteristics of DS and to its clinical implications by linking to LGI. Tissue alterations detectable by osteopathic palpation would be mediated by body fluids and in particular by biological water which has well-defined biophysical characteristics. Research in this area is certainly still to be explored, but our suggestion seems plausible to explain many dynamics related to osteopathic treatment. We believe that this could open up a fascinating scenario of therapeutic possibilities and knowledge in the future.

Evidence-Based Application of Acupuncture for Pain Management in Companion Animal Medicine

The use of veterinary acupuncture for pain relief is expanding among small animal practitioners. Although acupuncture was developed as part of the medical system in Ancient China, research into the scientific basis of its effects is expanding rapidly. Acupuncture is very effective for analgesia on a local, segmental, and suprasegmental level. Many forms of acupuncture can be used independently or as part of a balanced multi-modal approach for the control of acute and chronic pain. In the hands of a skilled practitioner, acupuncture can be a safe and effective modality for treating pain in companion animals. This article outlines the mechanisms of action of acupuncture, its related neurophysiology and provides examples from the literature demonstrating its effectiveness.

Fluid transport in the brain

The brain harbors a unique ability to, figuratively speaking, shift its gears. During wakefulness, the brain is geared fully toward processing information and behaving, while homeostatic functions predominate during sleep. The blood-brain barrier establishes a stable environment that is optimal for neuronal function, yet the barrier imposes a physiological problem; transcapillary filtration that forms extracellular fluid in other organs is reduced to a minimum in brain. Consequently, the brain depends on a special fluid [the cerebrospinal fluid (CSF)] that is flushed into brain along the unique perivascular spaces created by astrocytic vascular endfeet. We describe this pathway, coined the term glymphatic system, based on its dependency on astrocytic vascular endfeet and their adluminal expression of aquaporin-4 water channels facing toward CSF-filled perivascular spaces. Glymphatic clearance of potentially harmful metabolic or protein waste products, such as amyloid-β, is primarily active during sleep, when its physiological drivers, the cardiac cycle, respiration, and slow vasomotion, together efficiently propel CSF inflow along periarterial spaces. The brain's extracellular space contains an abundance of proteoglycans and hyaluronan, which provide a low-resistance hydraulic conduit that rapidly can expand and shrink during the sleep-wake cycle. We describe this unique fluid system of the brain, which meets the brain's requisites to maintain homeostasis similar to peripheral organs, considering the blood-brain-barrier and the paths for formation and egress of the CSF.

Furnishing Wound Repair by the Subcutaneous Fascia

Mammals rapidly heal wounds through fibrous connective tissue build up and tissue contraction. Recent findings from mouse attribute wound healing to physical mobilization of a fibroelastic connective tissue layer that resides beneath the skin, termed subcutaneous fascia or superficial fascia, into sites of injury. Fascial mobilization assembles diverse cell types and matrix components needed for rapid wound repair. These observations suggest that the factors directly affecting fascial mobility are responsible for chronic skin wounds and excessive skin scarring. In this review, we discuss the link between the fascia's unique tissue anatomy, composition, biomechanical, and rheologic properties to its ability to mobilize its tissue assemblage. Fascia is thus at the forefront of tissue pathology and a better understanding of how it is mobilized may crystallize our view of wound healing alterations during aging, diabetes, and fibrous disease and create novel therapeutic strategies for wound repair.

A Complementary Intervention to Promote Wellbeing and Stress Management for Early Career Teachers

The educational climate and culture in our schools present a variety of environmental (contextual) factors that influence teacher wellbeing, job satisfaction, and work-related stress. The magnitude of contextual factors cannot be ignored, and directing attention towards the environment teachers face daily is essential. Primary (organisational)-level interventions are documented in organisational health and wellbeing literature; however, to provide teachers with stress management strategies for promoting wellbeing, attention must also be directed towards secondary (individual)-level interventions. The present study addressed the issue of stress management techniques for early career teachers (n = 24) and aimed to contribute to the research surrounding complementary interventions (CIs) for educators. The intervention was designed to include strategies that operated through cognitive and physiological mechanisms that regulated the stress response and increased awareness of behaviours, emotions, and reactivity. The self-report measures included perceived stress, attention awareness, subjective wellbeing, burnout, and job-related affective wellbeing. The results indicated a statistically significant decrease in perceived stress and increases in attention awareness and subjective wellbeing. The salivary cortisol levels (waking and resting) decreased from baseline to week 6, and the pre- and post-session salivary cortisol levels indicated an immediate decrease in cortisol for weeks 4 to 6.

Fibroblasts as confederates of the immune system

Fibroblastic stromal cells are as diverse, in origin and function, as the niches they fashion in the mammalian body. This cellular variety impacts the spectrum of responses elicited by the immune system. Fibroblast influence on the immune system keeps evolving our perspective on fibroblast roles and functions beyond just a passive structural part of organs. This review discusses the foundations of fibroblastic stromal-immune crosstalk, under the scope of stromal heterogeneity as a basis for tissue-specific tutoring of the immune system. Focusing on the skin as a relevant immunological organ, we detail the complex interactions between distinct fibroblast populations and immune cells that occur during homeostasis, injury repair, scarring, and disease. We further review the relevance of fibroblastic stromal cell heterogeneity and how this heterogeneity is central to regulate the immune system from its inception during embryonic development into adulthood.

Distinct fibroblasts in scars and regeneration

The skin is home to a collection of fibroblastic cell types from varying embryonic origins. These varying fibroblastic lineages display unique genetic programs and in vivo functions. Studying the diversity of fibroblastic cells is emerging as an important area for cutaneous biology, wound repair and regenerative medicine. In this mini-review we discuss the distinct embryonic origins, microenvironments, and transcriptomic profiles of fibroblastic lineages, and how these varying lineages shape the skin's wound response across injury depths, anatomic locations, and developmental time to promote either scarring or regeneration. We outline how the development of single cell sequencing has led to our improved understanding of fibroblastic lineages at the molecular level and discuss existing challenges and future outlook on developing regenerative therapies that are based on this emerging field of eclectic fibroblasts.

Hamstring strains in professional rugby players result in increased fascial stiffness without muscle quality changes as assessed using shear wave elastography

INTRODUCTION

Hamstring strain injury is common among sports injuries. A previous history of this injury is considered a strong predictor of recurrent hamstring strain injury. Fascial tissue reportedly becomes stiffer after hamstring strain injury. However, the association between fascial stiffness and previous hamstring strain injury has not been investigated in clinical studies. We aimed to determine whether a previous history of hamstring strain injury affects fascial tissue and muscle tissues using shear wave elastography.

METHOD

In eleven male professional rugby players, the stiffness as a shear modulus (kPa) of fascial tissue and muscle was measured on the specific injured area measured by magnetic resonance imaging (MRI) at resting position by using shear wave elastography. The side-to-side differences between the injured and the uninjured side were analyzed. The length and area of the muscle scar tissue were evaluated by MRI in relation to fascial stiffness.

RESULTS

The shear elastic modulus of fascia was stiffer in the injured vs. the uninjured side; however, no difference was observed in the muscle. No significant relationship was detected between the length and area of the muscle scar tissue (all P > 0.05).

DISCUSSION

Rugby players with a previous history of hamstring strain injury exhibited passive stiffness of fascial tissues in the injured leg, regardless of the length or area of the muscle scar tissue. However, the passive stiffness of muscles was same between the injured and the uninjured leg.

CONCLUSION

The results can be beneficial to consider future risk for hamstring strain injuries.

The Vegetative Receptor-Vascular Reflex (VRVR) - A New Key to Regeneration

OBJECTIVE

We describe a potentially new physiological reflex path that has so far been neglected but which could be used for a novel therapeutic approach: The vegetative receptor-vascular reflex. This is a physiological response that starts from the connective tissue and influences the whole organism. We cross-fertilized various research areas with each other.

KEY FINDINGS

The matrix or the connective tissue forms a passive reservoir of substrate for the growth and development of cells, and functions as the primordial communication system of all living systems. It contains a continuous network of cells, such as fibroblasts, along with protein bundles made up of collagen that support electrical exchange through piezoelectric effects. This archaic vegetative system surrounds all cells, including neurons, and can thus be viewed as the primordial coordinating system in every organism. It is very likely the basis for a reflex which we describe here for the first time: the vegetative receptor vascular reflex. We also indicate some potential practical applications and test procedures.

CONCLUSION

The vegetative receptor vascular reflex describes the pathway from stimuli that originate in the connective tissue or the extracellular matrix toward organ systems. They might be chemical in nature or electrical via piezo-electric effects stimulating nerve endings, and thus can influence higher order processes such as regeneration or healing of tissue. Thus, this reflex lends itself to a novel therapeutic approach via certain types of manipulation of the connective tissue.

Effect of Lateral Sliding Calcaneus Osteotomy on Tarsal Tunnel Pressure

Background:

Lateral sliding calcaneus osteotomies are common procedures to correct hindfoot varus deformities. Shifting the calcaneal tuberosity laterally (lateralization) can lead to tarsal tunnel pressure increase and tibial nerve palsy. The purpose of this cadaveric biomechanical study was to investigate the correlation of lateralization and pressure increase underneath the flexor retinaculum.

Methods:

The pressure in the tarsal tunnel of 12 Thiel-fixated human cadaveric lower legs was measured in different foot positions and varying degrees of calcaneal lateralization.

Results:

The mean pressure increased from plantarflexion (PF) to neutral position (NP) and from NP to hindfoot dorsiflexion (DF), and with increasing amounts of lateralization of the calcaneal tuberosity. The mean baseline pressure in PF was 1.5, in NP 2.2, and in DF 6.5 mmHg and increased to 8.1 in PF, 18.4 in NP, and 33.1 mmHg with 12 mm of lateralization. The release of the flexor retinaculum significantly lowered the pressure.

Conclusion:

Increasing pressures were found in the tarsal tunnel with increasing lateralization of the tuberosity and with both dorsiflexion and plantarflexion of the ankle.

Clinical Relevance:

A pre-emptive release of the flexor retinaculum for a lateralization of the calcaneal tuberosity of more than 8 mm should be considered, especially if specific patient risk factors are present. No tibial nerve palsy should be expected with 4 mm of lateralization.

Inhibitory Tests as Assessment Tools for Somatic Dysfunctions: Mechanisms and Practical Applications

The capital element in the field of osteopathy and several other manual therapy methods, is the somatic dysfunction (SD), a functional imbalance that can involve different tissues and mechanisms in its genesis and maintenance. The main challenges found in the clinical scope are to understand the interaction, hierarchy, and relevance of the SD. Several manual tests are available to functionally evaluate the SD, each one with its applicability to analyze the different parameters of the SD. The so-called inhibitory tests are a category of functional manual tests that can be added to the diagnostic context of the SD. It is a particular type of test in which the evaluator applies manual mechanical stimuli to dysfunctional tissues and assesses the biological responses that occur simultaneously with the application of the stimulus. Its use can consider biomechanical and neurological principles in such a way that different conditions can be analyzed. The objective of this article is to review well-established knowledge and recent scientific discoveries about the SD and its local and global repercussions, in an attempt to offer ideas that can be applied to better understand the mechanisms that imply the use of inhibitory tests as complementary clinical diagnostic tools. It will be discussed some of the possible mechanisms involved in the physiology of the inhibitory tests, their practical applications in some distinct conditions, as well as new proposals of utilization based on the sensitization of metameric related structures under a dysfunctional state.

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.

Alterations in cellular force parameters and cell projections in Nasal polyps-derived fibroblasts

OBJECTIVE

Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) is a disease that features a mechanical dysfunction involving chronic inflammation and altered tissue remodeling. In this study, we aim to evaluate the fibroblast morphology and its cellular traction force in primary fibroblasts cell cultures obtained from both healthy individuals (n=7) and patients with CRSwNP (n=8).

METHODS

Using a Traction-force Microscopy we analyzed parameters of Force/Tension in fibroblasts cultures in both experimental groups.

RESULTS

The analysis of the Projected Area of Cell revealed that fibroblasts derived from nasal mucosa of healthy individuals have an area on average 39.24% larger than the fibroblasts obtained from the nasal polyp tissue. We also observed that the parameters directly related to the force of the cell, Max Cumulative Force and Net Contractile Moment, presented a high Force/Tension per unit of area in the fibroblasts derived from the healthy nasal mucosa (on average 41% and 52.54% higher than the fibroblasts of the nasal polyp respectively).

CONCLUSION

Our results demonstrate a cellular mechanism that may be associated with the mechanical dysfunction found in the Nasal Polyp tissue. The weak traction force of nasal polyp-derived fibroblast may, in lower dimensions, impact on the remodeling of nasal mucosa in CRSwNP.

Osteopathic Manipulative Treatment in a Paediatric Patient with Oesophageal Atresia and Tracheo-Oesophageal Fistula

This study is aimed to evaluate the effectiveness of osteopathic manipulative treatment (OMT) in dysphagia symptoms and aspiration risk. This is a clinical case report on a 40-day-old infant with a diagnosis of oesophageal atresia and tracheo-oesophageal fistula. The patient received one OMT every 15 days for 7 times. The clinical outcome was the clinical changes in dysphagia symptoms assessed by the Paediatric Eating Assessment Tool-10 (PEDI-EAT-10). At the first osteopathic evaluation (T0), the total score of the PEDI-EAT-10 was 7, at the fourth osteopathic evaluation (T1), the total score was 3, and at the seventh osteopathic evaluation (T2), the total score was 1. OMT was effective and safe in reducing dysphagia symptoms and aspiration risk.

Compressive force induces reversible chromatin condensation and cell geometry-dependent transcriptional response

Fibroblasts exhibit heterogeneous cell geometries in tissues and integrate both mechanical and biochemical signals in their local microenvironment to regulate genomic programs via chromatin remodelling. While in connective tissues fibroblasts experience tensile and compressive forces (CFs), the role of compressive forces in regulating cell behavior and, in particular, the impact of cell geometry in modulating transcriptional response to such extrinsic mechanical forces is unclear. Here we show that CF on geometrically well-defined mouse fibroblast cells reduces actomyosin contractility and shuttles histone deacetylase 3 (HDAC3) into the nucleus. HDAC3 then triggers an increase in the heterochromatin content by initiating removal of acetylation marks on the histone tails. This suggests that, in response to CF, fibroblasts condense their chromatin and enter into a transcriptionally less active and quiescent states as also revealed by transcriptome analysis. On removal of CF, the alteration in chromatin condensation was reversed. We also present a quantitative model linking CF-dependent changes in actomyosin contractility leading to chromatin condensation. Further, transcriptome analysis also revealed that the transcriptional response of cells to CF was geometry dependent. Collectively, our results suggest that CFs induce chromatin condensation and geometry-dependent differential transcriptional response in fibroblasts that allows maintenance of tissue homeostasis.

Neurectomy preserves fast fibers when combined with tenotomy of infraspinatus muscle via upregulation of myogenesis

INTRODUCTION

We evaluated the contribution of denervation-related molecular processes to rotator cuff muscle degeneration after tendon release.

METHODS

We assessed the levels of myogenic (myogenin and myogenic differentiation factor [myoD]) and proadipogenic (peroxisome proliferator-activated receptor γ) transcription factors; the denervation-associated proteins tenascin-C, laminin-2, and calcium/calmodulin-dependent kinase II (CaMKII); and cellular alterations in sheep after infraspinatus tenotomy (TEN), suprascapular neurectomy (NEU), or both (TEN-NEU).

RESULTS

Extracellular ground substance increased at the expense of contractile tissue 16 weeks after surgery, correlating with CaMKII isoform levels. Sheep undergoing NEU and TEN-NEU had exaggerated infraspinatus atrophy and increased fast fibers compared with TEN sheep. The βMCaMKII isoform levels increased with TEN, and myoD levels tripled after denervation and were associated with slow fibers.

DISCUSSION

In sheep, denervation did not affect muscle-to-fat conversion after TEN of the infraspinatus. Furthermore, concurrent NEU mitigated the loss of fast fibers after TEN by inducing a fast-contractile phenotype. Muscle Nerve 59:100-107, 2019.

Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper

Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care have prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies. Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability. The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices.

Optimizing the Bioavailability of Subcutaneously Administered Biotherapeutics Through Mechanochemical Drivers

The subcutaneous route offers myriad benefits for the administration of biotherapeutics in both acute and chronic diseases, including convenience, cost effectiveness and the potential for automation through closed-loop systems. Recent advances in parenteral administration devices and the use of additives which enhance drug dispersion have generated substantial additional interest in IV to SQ switching studies. Designing pre-clinical and clinical studies using SQ mediated delivery however requires deep understanding of complex inter-related physiologies and transport pathways governing the interstitial matrix, vascular system and lymphatic channels. This expert review will highlight key structural features which contribute to transport and biodistribution in the subcutaneous space and also assess the impact of drug formulations. Based on the rapidly growing interest in the SQ delivery route, a number of potential areas for future development are highlighted, which are likely to allow continued evolution and innovation in this important area.

Postsurgical Perforation of the Esophagus Can Be Treated Using a Fully Covered Stent in Children

OBJECTIVES

Surgery and conservative treatment of esophageal or gastric perforations are both often associated with poor results and carry a high morbidity and mortality rate. The aim of the present study was to evaluate the effectiveness and safety of using fully covered self-expending metallic stents (SEMS) in children with upper digestive leaks.

METHODS

This retrospective study reviewed all children with esophageal or gastric perforation who were treated with placement of an SEMS from January 2011 to January 2015. Closure of the perforation was the primary outcome measured. Secondary outcomes were the duration of antibiotic therapy and parenteral nutrition, adverse events, and length of hospitalization.

RESULTS

A total of 19 SEMS were placed in 10 patients (median age: 5.5 years; 5 girls) treated for postanastomotic leaks of esophageal atresia (n = 3), esophagogastroplasty (n = 4), resection of esophageal duplication (n = 1) or perforation during Toupet surgical dismantling (n = 1), and gastric rupture after Nissen surgery (n = 1). The perforation closed in 9 out of 10 patients in a mean of 36 days after stenting (range: 13-158 days). All patients received antibiotic therapy for an average of 17.5 days (3-109 days) and parenteral nutrition for 49 days (17-266 days). During a median follow-up of 8.9 months, 4 out of 9 sealed perforations developed stenosis, which was efficiently treated by endoscopic dilations in 2 patients and surgical redo in 2 patients with dilation-resistant stenosis.

CONCLUSIONS

Covered stents appear to be beneficial in closing esophageal perforations in children and can avoid the high morbidity of a surgical repair. Stenosis, however, occurred frequently after larger leakages.

Macromolecular interactions in alginate–gelatin hydrogels regulate the behavior of human fibroblasts

Due to the presence of tripeptide arginine–glycine–aspartic acid, gelatin is considered a very promising additive material to improve the cytocompatibility of alginate-based hydrogels. Two different strategies, physical blending and chemical crosslinking with gelatin, are used in this study to modify alginate hydrogel. As the intermolecular interactions between the polysaccharide and protein in the resulting physically blended and chemically crosslinked hydrogels are different, significant differences in the properties of these hydrogel types, regarding especially their surface topography, degradation kinetics, mechanical properties, and protein release behavior, are observed. Cellular behavior on both types of alginate–gelatin hydrogels is investigated using primary human dermal fibroblasts to elucidate the effects of the different structural, mechanical, and degradation properties of the produced hydrogels on fibroblast attachment and growth. The hydrogel that is chemically crosslinked with gelatin exhibits the highest degree of cytocompatibility regarding adhesion, proliferation, metabolic activity, and morphology of growing fibroblasts.

Expression of the endocannabinoid receptors in human fascial tissue

Cannabinoid receptors have been localized in the central and peripheral nervous system as well as on cells of the immune system, but recent studies on animal tissue gave evidence for the presence of cannabinoid receptors in different types of tissues. Their presence was supposed also in myofascial tissue, suggesting that the endocannabinoid system may help resolve myofascial trigger points and relieve symptoms of fibromyalgia. However, until now the expression of CB1 (cannabinoid receptor 1) and CB2 (cannabinoid receptor 2) in fasciae has not yet been established. Small samples of fascia were collected from volunteers patients during orthopedic surgery. For each sample were done a cell isolation, immunohistochemical investigation (CB1 and CB2 antibodies) and real time RT-PCR to detect the expression of CB1 and CB2. Both cannabinoid receptors are expressed in human fascia and in human fascial fibroblasts culture cells, although to a lesser extent than the control gene. We can assume that the expression of mRNA and protein of CB1 and CB2 receptors in fascial tissue are concentrated into the fibroblasts. This is the first demonstration that the fibroblasts of the muscular fasciae express CB1 and CB2. The presence of these receptors could help to provide a description of cannabinoid receptors distribution and to better explain the role of fasciae as pain generator and the efficacy of some fascial treatments. Indeed the endocannabinoid receptors of fascial fibroblasts can contribute to modulate the fascial fibrosis and inflammation.

Myofascial techniques: What are their effects on joint range of motion and pain? - A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

This systematic review aimed to determine the evidence for the effect of a single manually applied myofascial technique (MFT) on joint range of motion (JROM) and pain in non-pathological symptomatic subjects.

METHODS

Authors independently searched the following databases: PEDro; Cochrane Library; NLM PubMed; EMBASE; Academic Search Premier; MEDLINE; Psychology and Behavioural Sciences Collection; PsycINFO; SPORTSDiscus; CINAHL Plus from 2003 to 2015. All randomised controlled trials (RCTs) that used JROM as an outcome measure were identified. RCT quality was independently evaluated using PEDro and Cochrane Risk of Bias tools and all reported outcome data were independently abstracted and presented. If post-intervention central tendencies and variance were reported, these were assessed for heterogeneity with a view to performing a meta-analysis.

RESULTS

Nine RCTs (n = 534) were systematically reviewed and outcome data presented; all trials concluded that MFT increased JROM and reduced pain levels in symptomatic patients. Two RCTs (n = 161) were judged 'moderately' heterogeneous (I(2) = 47.2%; Cochran's Q = 5.69; p = 0.128, df = 3) and meta-analysis using a fixed effects model suggested a 'moderate' effect size of MFTs on jaw opening (ES = 0.578; 95%CI 0.302 to 0.853).

CONCLUSION

Although results reported by each RCT indicate that MFT increases JROM and reduces pain scores, there are a number of threats that challenge the statistical inferences underpinning these findings. Only two trials could be meta-analysed, the results of which suggest that applying MFTs to symptomatic patients diagnosed with latent trigger-points in masseter muscle can increase jaw JROM.

Stretching Impacts Inflammation Resolution in Connective Tissue

Acute inflammation is accompanied from its outset by the release of specialized pro-resolving mediators (SPMs), including resolvins, that orchestrate the resolution of local inflammation. We showed earlier that, in rats with subcutaneous inflammation of the back induced by carrageenan, stretching for 10 min twice daily reduced inflammation and improved pain, 2 weeks after carrageenan injection. In this study, we hypothesized that stretching of connective tissue activates local pro-resolving mechanisms within the tissue in the acute phase of inflammation. In rats injected with carrageenan and randomized to stretch versus no stretch for 48 h, stretching reduced inflammatory lesion thickness and neutrophil count, and increased resolvin (RvD1) concentrations within lesions. Furthermore, subcutaneous resolvin injection mimicked the effect of stretching. In ex vivo experiments, stretching of connective tissue reduced the migration of neutrophils and increased tissue RvD1 concentration. These results demonstrate a direct mechanical impact of stretching on inflammation-regulation mechanisms within connective tissue.

Understanding Fibroblasts in Order to Comprehend the Osteopathic Treatment of the Fascia

The osteopathic treatment of the fascia involves several techniques, each aimed at allowing the various layers of the connective system to slide over each other, improving the responses of the afferents in case of dysfunction. However, before becoming acquainted with a method, one must be aware of the structure and function of the tissue that needs treating, in order to not only better understand the manual approach, but also make a more conscious choice of the therapeutic technique to employ, in order to adjust the treatment to the specific needs of the patient. This paper examines the current literature regarding the function and structure of the fascial system and its foundation, that is, the fibroblasts. These connective cells have many properties, including the ability to contract and to communicate with one another. They play a key role in the transmission of the tension produced by the muscles and in the management of the interstitial fluids. They are a source of nociceptive and proprioceptive information as well, which is useful for proper functioning of the body system. Therefore, the fibroblasts are an invaluable instrument, essential to the understanding of the therapeutic effects of osteopathic treatment. Scientific research should make greater efforts to better understand their functioning and relationships.

A unifying neuro-fasciagenic model of somatic dysfunction - Underlying mechanisms and treatment - Part II

This paper offers an extensive review of the main fascia-mediated mechanisms underlying various therapeutic processes of clinical relevance for manual therapy. The concept of somatic dysfunction is revisited in light of the several fascial influences that may come into play during and after manual treatment. A change in perspective is thus proposed: from a nociceptive model that for decades has viewed somatic dysfunction as a neurologically-mediated phenomenon, to a unifying neuro-fascial model that integrates neural influences into a multifactorial and multidimensional interpretation of manual therapeutic effects as being partially, if not entirely, mediated by the fascia. By taking into consideration a wide spectrum of fascia-related factors - from cell-based mechanisms to cognitive and behavioural influences - a model emerges suggesting, amongst other results, a multidisciplinary-approach to the intervention of somatic dysfunction. Finally, it is proposed that a sixth osteopathic 'meta-model' - the connective tissue-fascial model - be added to the existing five models in osteopathic philosophy as the main interface between all body systems, thus providing a structural and functional framework for the body's homoeostatic potential and its inherent abilities to heal.

A unifying neuro-fasciagenic model of somatic dysfunction - underlying mechanisms and treatment - Part I

This paper offers an extensive review of the main fascia-mediated mechanisms underlying various dysfunctional and pathophysiological processes of clinical relevance for manual therapy. The concept of somatic dysfunction is revisited in light of the diverse fascial influences that may come into play in its genesis and maintenance. A change in perspective is thus proposed: from a nociceptive model that for decades has viewed somatic dysfunction as a neurologically-mediated phenomenon, to a unifying fascial model that integrates neural influences into a multifactorial and multidimensional interpretation of dysfunctional process as being partially, if not entirely, mediated by the fascia.

Clinical and symptomatological reflections: the fascial system

Every body structure is wrapped in connective tissue, or fascia, creating a structural continuity that gives form and function to every tissue and organ. Currently, there is still little information on the functions and interactions between the fascial continuum and the body system; unfortunately, in medical literature there are few texts explaining how fascial stasis or altered movement of the various connective layers can generate a clinical problem. Certainly, the fascia plays a significant role in conveying mechanical tension, in order to control an inflammatory environment. The fascial continuum is essential for transmitting muscle force, for correct motor coordination, and for preserving the organs in their site; the fascia is a vital instrument that enables the individual to communicate and live independently. This article considers what the literature offers on symptoms related to the fascial system, trying to connect the existing information on the continuity of the connective tissue and symptoms that are not always clearly defined. In our opinion, knowing and understanding this complex system of fascial layers is essential for the clinician and other health practitioners in finding the best treatment strategy for the patient.

Drowning stars: reassessing the role of astrocytes in brain edema

Edema formation frequently complicates brain infarction, tumors, and trauma. Despite the significant mortality of this condition, current treatment options are often ineffective or incompletely understood. Recent studies have revealed the existence of a brain-wide paravascular pathway for cerebrospinal (CSF) and interstitial fluid (ISF) exchange. The current review critically examines the contribution of this 'glymphatic' system to the main types of brain edema. We propose that in cytotoxic edema, energy depletion enhances glymphatic CSF influx, whilst suppressing ISF efflux. We also argue that paravascular inflammation or 'paravasculitis' plays a critical role in vasogenic edema. Finally, recent advances in diagnostic imaging of glymphatic function may hold the key to defining the edema profile of individual patients, and thus enable more targeted therapy.