A semiautomatic method for in vivo three-dimensional quantitative analysis of fascial layers mobility based on 3D ultrasound scans

Superficial fascia displacement in cervical flexion: differentiating myofascial pain syndrome, a cross-sectional study

CONTEXT

Myofascial pain syndrome (MPS) is primarily characterized by myofascial trigger points related to fascial adhesions. MPS hinders fascial flexibility and mobility, leading to myofascial limitations, dysfunctional movement, and limitation of motion (LOM).

OBJECTIVES

This study determined the association of age, sex, type of work, symptom chronicity, symptom laterality, cervical LOM, altered direction of fascial displacement, and magnitude of superficial fascial displacement during active cervical flexion with the clinical diagnosis of MPS.

METHODS

A cross-sectional study selectively included MPS and non-MPS participants from different workplaces from January to October 2019. The MPS group exhibited clinical symptoms like tender spots, recognized pain patterns, and local twitch response upon palpation, often accompanied by cervical LOM. The non-MPS group lacked these symptoms, and those with certain pre-existing conditions or recent physiotherapy were not part of the study. Participants performed cervical active range of motion (AROM) while a sonographer recorded superficial fascial displacement utilizing ultrasound, which was later analyzed by three physiotherapists with the Tracker. Aiming for a multiple regression R-squared of 0.2, the target was 384 participants to account for a 20 % dropout, resulting in 307 participants after attrition. To explore the relationships between MPS and various factors, logistic regression models, rigorously tested for reliability and validity, were utilized.

RESULTS

In the study, there were 192 participants with MPS and 137 without MPS. The median ages were 33 years for the non-MPS group and 38 years for the MPS group. The adjusted model found significant links for sex (odds ratio [OR]=2.63, p<0.01), symptom chronicity (OR=8.28, p<0.01), and cervical LOM (OR=3.77, p=0.01). However, age and the presence of nodules/taut bands were not statistically significant (p>0.05). Also, the type of work, the direction of fascial displacement, and the difference in superficial fascial displacement during cervical flexion did not show a significant association with the clinical diagnosis of MPS (p>0.05). The adjusted model had a sensitivity of 73.80 % and a specificity of 81.34 %, correctly identifying 84.66 % of positive cases and 68.99 % of negative ones, resulting in an overall accuracy of 76.95 % in predicting MPS.

CONCLUSIONS

We provided an in-depth examination of MPS, identifying sex, duration of symptoms, and cervical LOM as significant predictive factors in its diagnosis. The study emphasizes the critical role of these variables in the accurate diagnosis of MPS, while delineating the comparatively minimal diagnostic value of other factors such as age, type of occupation, presence of nodules or taut bands, and variations in fascial displacement. This study underscores the imperative for further scholarly inquiry into the role of fascial involvement in musculoskeletal disorders, with the objective of enhancing both the theoretical understanding and diagnostic practices in this medical domain.

Sonographic measurement of deep fascia parameters - Interrater reliability

PURPOSE

The deep fascia has recently been a current topic in many medical fields, including rehabilitation. Some research has already focused on assessing deep fascia, however results of individual authors differ in certain aspects. This study focuses on the inter-rater reliability of ultrasound (US) measurement of the thickness of deep fascia and loose connective tissue (LCT). The aim was to define the causes of any discrepancies in measurement that could contribute to the unification of management of evaluating fascia.

METHODS

An observational study was performed including 20 healthy individuals in whom fascia lata of the anterior thigh was examined by US imaging and then measured in Image J software. Three raters participated in this study: the first with 6 years of US imaging experience, other two were newly trained. The measurement of fascial parameters was conducted in two phases with special consultation between them resulting in an agreement of the research team on the more precise way of measurement.

RESULTS

Results revealed the value of inter-rater reliability ICC3,1 = 0.454 for deep fascia thickness and ICC3,1 = 0.265 for LCT thickness in the first phase and any significant difference in the second phase. This poor inter-rater reliability led to a search for possible causes of discrepancies, which authors subsequently highlighted.

CONCLUSION

The findings of the study show the main pitfalls of deep fascia measurement that should contribute to the unification of evaluation.

Do the fasciae of the soleus have a role in plantar fasciitis?

Plantar fasciitis is a chronic, self-limiting, and painful disabling condition affecting the inferomedial aspect of the heel, usually extending toward the metatarsophalangeal joints. There is compelling evidence for a strong correlation between Achilles tendon (AT) loading and plantar aponeurosis (PA) tension. In line with this, tightness of the AT is found in almost 80% of patients affected by plantar fasciitis. A positive correlation has also been reported between gastrocnemius-soleus tightness and heel pain severity in this condition. Despite its high prevalence, the exact etiology and pathological mechanisms underlying plantar heel pain remain unclear. Therefore, the aim of the present paper is to discuss the anatomical and biomechanical substrates of plantar fasciitis with special emphasis on the emerging, though largely neglected, fascial system. In particular, the relationship between the fascia, triceps surae muscle, AT, and PA will be analyzed. We then proceed to discuss how structural and biomechanical alterations of the muscle-tendon-fascia complex due to muscle overuse or injury can create the conditions for the onset of PA pathology. A deeper knowledge of the possible molecular mechanisms underpinning changes in the mechanical properties of the fascial system in response to altered loading and/or muscle contraction could help healthcare professionals and clinicians refine nonoperative treatment strategies and rehabilitation protocols for plantar fasciitis.

The difference in the upper trapezius deep fascia slides between individuals with and without myofascial pain syndrome: A case-control study

INTRODUCTION

MPS is a chronic disorder caused by myofascial trigger points, leading to pain and limited neck movements due to impacted fascia. Studies have reported reduced fascia slides in chronic low back pain, but limited fascia slides in MPS patients are still unreported.

AIM

We determined differences in upper trapezius' deep fascia slides between MPS and non-MPS participants.

METHODS

Between January-August 2019, participants from diverse work sectors were recruited in Manila. An expert physiotherapist diagnosed MPS, while non-MPS participants performed full painless cervical movements. Participants underwent upper trapezius deep fascia scans on both shoulders while performing six cervical movements. An HS1 Konica Minolta ultrasound recorded the data. Two blinded physiotherapists used Tracker 5.0 © 2018 to analyze videos and quantify deep fascia slides by measuring the distance between two x-axis points. The Multivariate analysis of variance (MANOVA) assessed deep fascia slide differences in six active cervical movements. Pillai's Trace, with a range of 0-1 and a p-value of <0.05, was set. Effect sizes in individuals with and without MPS were calculated using Hedges' g and Cohen's d.

RESULTS

Of the 327 participants (136 non-MPS, 191 MPS), 101 MPS participants had shoulder pain for <1 year and 103 experienced unilateral pain. The study examined 3800 ultrasound videos but found no significant difference in deep fascia slides across cervical movements between MPS and non-MPS groups (Pillai's Trace = 0.004, p = 0.94). Minor differences in deep fascia displacement were observed, with small effect sizes (g = 0.02-0.08).

CONCLUSION

A limited deep fascia slide does not characterize MPS participants from non-MPS participants.

Distinct displacement of the superficial and deep fascial layers of the iliotibial band during a weight shift task in runners: An exploratory study

Motion of the fascial layers of the iliotibial band (ITB), as a reinforcement of the deep fascia lata, is likely to be relevant for its function and mechanical behaviour. This exploratory study aimed to evaluate the ITB fascial layers displacement during a weight shift task. Thirteen pain-free runners performed a 6-second standing weight shift task. B-mode ultrasound imaging using an automated fascicle tracking algorithm was used to measure proximal and distal displacement of superficial and deep ITB layers at the middle region. To study the potential contributors to individual variation of fascial motion, we recorded the activity of five hip/thigh muscles with electromyography (EMG), thigh/pelvis/trunk position with accelerometers, and centre of pressure with a force plate. Linear regressions estimated the relationship between displacement of fascial layers and hip/trunk angles. Independent t-tests or Fisher's exact tests compared EMG and movement-related parameters between participants who demonstrated motion of the fascia in the proximal and distal directions. Thickness of the ITB and the loose connective tissue between its layers were calculated. Proximal displacement was observed in six (-4.1 ± 1.9 mm [superficial]) and two (-6.2 ± 2.0 mm [deep]) participants. Distal displacement was observed for seven participants for each layer (3.1 ± 1.1 mm [superficial]; 3.6 ± 1.3 mm [deep]). Four participants did not show displacement of the deep layer. Trunk lateral flexion and gluteus medius muscle activity were determinants of proximal motion of the superficial layer. Loose connective tissue was thinner in participants without displacement of the deep layer. Displacement of the ITB fascial layers varies between individuals. Variation related to differences in joint movements and muscle activity. This study highlights the complex interaction between fascia and movement.

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.

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.

Influence of female hormones on fascia elasticity: An elastography study

The aim of this study was to examine the influence of hormonal changes during the menstrual cycle on deep fasciae. A total of 29 women, 17 users, and 12 nonusers of hormonal contraceptives were examined clinically and by ultrasound, including shear wave elastography, at two phases of the menstrual cycle. The thickness and elasticity of the fascia lata, thoracolumbar fascia, and plantar fascia were measured, compared between hormonal contraceptive users and nonusers, and correlated with clinical data. There were statistically significant differences between users and nonusers of hormonal contraceptives: the thoracolumbar fascia was thicker in nonusers (P = 0.011), and nonusers had higher maximal and mean stiffnesses of the fascia lata (P = 0.01 and 0.0095, respectively). Generally, nonusers had a higher body mass index (BMI). The elasticity of the thoracolumbar and the plantar fasciae did not differ significantly between the groups. We found no correlation between thickness and elasticity in the fasciae. There were no statistically significant differences in hypermobility, cephalgia, or dysmenorrhea between users and nonusers of hormonal contraceptives. The results of this pilot study suggest that deep fasciae can be evaluated by shear wave elastography. Nonusers of contraceptives had greater stiffness of the fascia lata and higher BMI. Clin. Anat. 32:941-947, 2019. © 2019 Wiley Periodicals, Inc.

Ultrasound assessment of fascial connectivity in the lower limb during maximal cervical flexion: technical aspects and practical application of automatic tracking

Background

The fascia provides and transmits forces for connective tissues, thereby regulating human posture and movement. One way to assess the myofascial interaction is a fascia ultrasound recording. Ultrasound can follow fascial displacement either manually or automatically through two-dimensional (2D) method. One possible method is the iterated Lucas-Kanade Pyramid (LKP) algorithm, which is based on automatic pixel tracking during passive movements in 2D fascial displacement assessments. Until now, the accumulated error over time has not been considered, even though it could be crucial for detecting fascial displacement in low amplitude movements.

The aim of this study was to assess displacement of the medial gastrocnemius fascia during cervical spine flexion in a kyphotic posture with the knees extended and ankles at 90°.

Methods

The ultrasound transducer was placed on the extreme dominant belly of the medial gastrocnemius. Displacement was calculated from nine automatically selected tracking points. To determine cervical flexion, an established 2D marker protocol was implemented. Offline pressure sensors were used to synchronize the 2D kinematic data from cervical flexion and deep fascia displacement of the medial gastrocnemius.

Results

Fifteen participants performed the cervical flexion task. The basal tracking error was 0.0211 mm. In 66 % of the subjects, a proximal fascial tissue displacement of the fascia above the basal error (0.076 mm ± 0.006 mm) was measured. Fascia displacement onset during cervical spine flexion was detected over 70 % of the cycle; however, only when detected for more than 80 % of the cycle was displacement considered statistically significant as compared to the first 10 % of the cycle (ANOVA, p < 0.05).

Conclusion

By using an automated tracking method, the present analyses suggest statistically significant displacement of deep fascia. Further studies are needed to corroborate and fully understand the mechanisms associated with these results.

A 3D sparse motion field filtering for quantitative analysis of fascial layers mobility based on 3D ultrasound scans

In the last few years, there has been an increasing interest in the role of deep fascia mobility in musculoskeletal dynamics and chronic pain mechanisms. In a previous paper we presented an innovative semiautomatic approach to evaluate the 3D motion of the fascia using ultrasound (US) imaging, generating a sparse deformation vector field. This paper presents an improvement of our original method, focusing on the filtering of the sparse vector field and its validation. Moreover, in order to evaluate the performance of the algorithm, a method is proposed to generate synthetic deformation vector fields, including: expansion, rotation, horizontal shear, and oblique shear components. Preliminary tests on the final synthetic deformation vector fields showed promising results. Further experiments are required in order to optimize the tuning of the algorithm.