Natale et. al.'s response to Stecco's fascial nomenclature editorial

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.

Molecular Mechanisms Underlying the Pain-Relieving Effects of Extracorporeal Shock Wave Therapy: A Focus on Fascia Nociceptors

In recent years, extracorporeal shock wave therapy (ESWT) has received increasing attention for its potential beneficial effects on various bone and soft-tissue pathologies, yielding promising outcomes for pain relief and functional recovery. In fact, ESWT has emerged as an alternative, non-invasive, and safe treatment for the management of numerous musculoskeletal disorders, including myofascial pain syndrome (MPS). In particular, MPS is a common chronic painful condition, accounting for the largest proportion of patients affected by musculoskeletal problems. Remarkably, sensory innervation and nociceptors of the fascial system are emerging to play a pivotal role as pain generators in MPS. At the same time, increasing evidence demonstrates that application of ESWT results in selective loss of sensory unmyelinated nerve fibers, thereby inducing long-lasting analgesia. The findings discussed in the present review are supposed to add novel viewpoints that may further enrich our knowledge on the complex interactions occurring between disorders of the deep fascia including changes in innervation, sensitization of fascial nociceptors, the pathophysiology of chronic musculoskeletal pain of MPS, and EWST-induced analgesia. Moreover, gaining mechanistic insights into the molecular mechanisms of pain-alleviating effects of ESWT may broaden the fields of shock waves clinical practice far beyond the musculoskeletal system or its original application for lithotripsy.

Wearable Augmented Reality Application for Shoulder Rehabilitation

Augmented reality (AR) technology is gaining popularity and scholarly interest in the rehabilitation sector because of the possibility to generate controlled, user-specific environmental and perceptual stimuli which motivate the patient, while still preserving the possibility to interact with the real environment and other subjects, including the rehabilitation specialist. The paper presents the first wearable AR application for shoulder rehabilitation, based on Microsoft HoloLens, with real-time markerless tracking of the user’s hand. Potentialities and current limits of commercial head-mounted displays (HMDs) are described for the target medical field, and details of the proposed application are reported. A serious game was designed starting from the analysis of a traditional rehabilitation exercise, taking into account HoloLens specifications to maximize user comfort during the AR rehabilitation session. The AR application implemented consistently meets the recommended target frame rate for immersive applications with HoloLens device: 60 fps. Moreover, the ergonomics and the motivational value of the proposed application were positively evaluated by a group of five rehabilitation specialists and 20 healthy subjects. Even if a larger study, including real patients, is necessary for a clinical validation of the proposed application, the results obtained encourage further investigations and the integration of additional technical features for the proposed AR application.

Review of the Augmented Reality Systems for Shoulder Rehabilitation

Literature shows an increasing interest for the development of augmented reality (AR) applications in several fields, including rehabilitation. Current studies show the need for new rehabilitation tools for upper extremity, since traditional interventions are less effective than in other body regions. This review aims at: Studying to what extent AR applications are used in shoulder rehabilitation, examining wearable/non-wearable technologies employed, and investigating the evidence supporting AR effectiveness. Nine AR systems were identified and analyzed in terms of: Tracking methods, visualization technologies, integrated feedback, rehabilitation setting, and clinical evaluation. Our findings show that all these systems utilize vision-based registration, mainly with wearable marker-based tracking, and spatial displays. No system uses head-mounted displays, and only one system (11%) integrates a wearable interface (for tactile feedback). Three systems (33%) provide only visual feedback; 66% present visual-audio feedback, and only 33% of these provide visual-audio feedback, 22% visual-audio with biofeedback, and 11% visual-audio with haptic feedback. Moreover, several systems (44%) are designed primarily for home settings. Three systems (33%) have been successfully evaluated in clinical trials with more than 10 patients, showing advantages over traditional rehabilitation methods. Further clinical studies are needed to generalize the obtained findings, supporting the effectiveness of the AR applications.

Emission of Biophotons and Adjustable Sounds by the Fascial System: Review and Reflections for Manual Therapy

Every body structure is wrapped in connective tissue or fascia, creating a structural continuity that gives form and function to every tissue and organ. The fascial tissue is uniformly distributed throughout the body, enveloping, interacting with and permeating blood vessels, nerves, viscera, meninges, bones and muscles, creating various layers at different depths and forming a tridimensional metabolic and mechanical matrix. This article reviews the literature on the emission of biophotons and adjustable sounds by the fascial system, because these biological changes could be a means of local and systemic cellular communication and become another assessment tool for manual (therapy) practitioners. This is the first article that discusses these topics in a single text, attempting to bring such information into an area of application that is beneficial to osteopaths, chiropractors, and manual therapists.

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.

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.