Anatomy of the deep fascia of the upper limb. Second part: study of innervation

Effects of lower back foam rolling on the pressure pain threshold and the range of motion of the lumbar spine in healthy individuals

Introduction

The aim of this study was to determine the short- and long-term effects of foam rolling (FR) on the pressure pain threshold and the range of motion of the lumbar spine in healthy subjects.

Methods

43 healthy subjects without back problems were randomly assigned to an experimental group (EG) or a control group (CG). The subjects in the EG underwent a 4-week FR program (12 sessions). The subjects in the CG received no intervention. Range of motion was measured using the modified-modified Schober test for flexion and fingertip-to-floor distance for lateral flexion. The pressure pain threshold was measured with a hand-held pressure algometer. The measurements were taken before and after the first FR, after the 4-week program and at the 1-, 3- and 6-month follow-up. The significance level was set at p ≤ 0.05 and the desired power of the test was 92%.

Results

We found an improvement in flexion (p = 0.03) and lateral flexion (p < 0.001) in the EG after the first FR and recorded a significant improvement in all measured variables (flexion, lateral flexion and algometry: p < 0.001) at the end of the entire 4-week program. The effects were noticeable up to 6 months after the end of the program (p ≤ 0.03) and were statistically significantly better than in the CG (p ≤ 0.04). The calculated Cohen's d value was 1.15 for flexion, 1.06 for lateral flexion and 0.98 for algometry, which represents a large effect size.

Discussion

FR improves the pressure pain threshold and mobility of the lumbar spine in healthy subjects. The effects are noticeable at least 6 months after the end of an FR program.

The median nerve´s system of connective tissue distal to the pronator teres to the carpal tunnel

BACKGROUND

Connective tissue serves a role beyond mere spatial filling. Furthermore, there is increasing evidence that connective tissue plays an important role in the pathogenesis of conditions such as carpal tunnel syndrome (CTS). According to our hypothesis, the median nerve (MN) is surrounded by a system of connective tissue distal to the pronator teres and extending up to, and including, the carpal tunnel.

METHODS

To visualize the connective tissue surrounding the median nerve, we dissected the forearms of 15 body donors from pronator teres to the carpal tunnel, created plastination slices stained with Periodic Acid-Schiff (PAS), and injected ink into the seen spaces. We verified our findings with a segmentational analysis of radiological data of 10 healthy individuals.

RESULTS

We macroscopically describe the median nerve´s system of connective tissue (MC) distal to the pronator teres and up to and including the carpal tunnel. This system creates, connects, and separates spaces. At least from the pronator teres to the carpal tunnel it also creates subspaces from proximal to distal. For the MC, we established a mean cross-sectional area of 153.1 mm2 (SD=37.15) in the carpal tunnel. The median nerve consistently resides at the center of this MC, which further connects to flexor muscles of the forearm, and to the radius bone. In the carpal tunnel, the MC creates subspaces inside. There, it also acts as the outermost internal layer enveloping flexor tendons, and the MN.

DISCUSSION

The term MC does not negate but orders the existence of other "connectives", like subsynovial connective tissue, endo-, epi- or perineuria, epimysia, periostea, or peritendinea, to a hierarchy related to the median nerve. Diseases of the MN are common. Knowing the anatomy of the MC and how it relates to MN function may help clinicians recognize and understand conditions like CTS.

Laparoscopic-Guided Transversus Abdominis Plane (TAP) Block Combined with Port-Site Infiltration (PSI) for Laparoscopic Sleeve Gastrectomy in an ERABS Pathway: A Randomized, Prospective, Double-Blind, Placebo-Controlled Trial

PURPOSE

Patients undergoing laparoscopic sleeve gastrectomy (LSG) commonly experience moderate to severe postoperative pain. We conducted a randomized, prospective double-blind placebo-controlled study to evaluate the analgesic effect of laparoscopic-guided TAP (LG-TAP) block after LSG in a high-volume bariatric center, applying an enhanced recovery after bariatric surgery (ERABS) pathway.

MATERIAL AND METHODS

One hundred ten patients were randomly allocated to receive LG-TAP block with local anesthetic (LA) or saline solution (placebo), both combined with port-site infiltration with LA (LA-PSI). Primary outcome was pain score measured in post-anesthesia care unit (PACU) and at 6, 12, and 24 h after surgery. Secondary outcomes included postoperative nausea and/or vomiting (PONV), analgesic requirement, time to walking, time to flatus, length of hospital stay (LOS), and surgical complications.

RESULTS

No significant differences were observed between LG-TAP and placebo groups in postoperative analgesia, with a median (IQR) NRS of 2 (4.75-0) vs. 2 (5.25-0) in PACU, 5.5 (7-3) vs. 6 (7-4) at 6 h, 2 (6-0) vs. 3 (5.25-1.75) at 12 h, and 2 (3.75-0) vs. 1 (2-0) at 24 h; all p > 0.05. A significant difference was found in PONV in PACU (LG-TAP, 46%; placebo, 25%, p-value, 0.019) and at 6 h postoperatively (LG-TAP, 69%, placebo, 41%, p-value, 0.003). No differences were observed as regards other secondary outcomes.

CONCLUSION

Our results suggest that LG-TAP block is not related to more effective postoperative analgesia compared to placebo when LA-PSI is performed.

From Muscle-Bone Concept to the ArthroMyoFascial Complex: A Pragmatic Anatomical Concept for Physiotherapy and Manual Therapy

BACKGROUND

In physiotherapy, the classic muscle-bone concept is used to translate basic and clinical anatomy. By defining the anatomical structures from superficial to deeper layers which frame the ArthroMyoFascial complex, our aim is to offer clinicians a comprehensive concept of within the muscle-bone concept.

METHOD

This study is a narrative review and ultrasound observation.

RESULTS

Based on the literature and ultrasound skeletonization, the ArthroMyoFascial complex is defined. This model clarifies fascial continuity at the joint level, describing anatomical structures from skin to deeper layers, including superficial fascia, deep fascia, myofascia including skeletal muscle fibers, and arthrofascia all connected via connective tissue linkages. This model enhances the understanding of the muscle-bone concept within the larger ArthroMyoFascial complex.

CONCLUSION

The ArthroMyoFascial complex consists of multiple anatomical structures from superficial to deeper layers, namely the skin, superficial fascia, deep fascia, myofascia including muscle fibers, and arthrofascia, all linked within a connective tissue matrix. This model indicates that it is a force-transmitting system between the skin and the bone. This information is crucial for manual therapists, including physiotherapists, osteopaths, chiropractors, and massage therapists, as they all work with fascial tissues within the musculoskeletal domain. Understanding fascia within the muscle-bone concept enhances clinical practice, aiding in therapeutic testing, treatment, reporting, and multidisciplinary communication, which is vital for musculoskeletal and orthopedic rehabilitation.

A Novel Treatment of Fascial Pain With Glucopuncture: Three Clinical Cases

The fascial system (FS) represents a sophisticated and intricate network within the human body, comprising both superficial and deep fascial layers. Disruptions or dysfunctions within this system have been implicated in a variety of musculoskeletal (MSK) disorders and pain syndromes. Specifically, fascial tightness has been associated with diminished range of motion and localized pain. Glucopuncture, a novel therapeutic approach, involves the administration of 5% dextrose injections directly into the fascial layers, such as the superficial fascia, to address these issues. This article presents a case series involving three patients who underwent palpation/ landmark-guided glucopuncture for the treatment of superficial fascial dysfunction. The first case involves a 45-year-old male with a nine-month history of left groin pain, who experienced significant pain relief following glucopuncture below the inguinal ligament, with complete resolution of symptoms within four weeks. The second case describes a 36-year-old female suffering from left arm and neck pain for two years, who reported gradual pain alleviation over six weeks after receiving multiple injections in the fasciae of the neck, scapula, and lateral aspect of the triceps muscle. The final case involves a 67-year-old female with a six-month history of low back and buttock pain, who showed improvement after four weeks following multiple injections in the fasciae of the low back, lumbar region, and buttocks. These cases highlight the potential of palpation-guided glucopuncture as a simple, cost-effective method for modulating regional pain caused by superficial fascial dysfunction. However, further research is necessary to fully ascertain the efficacy and safety of glucopuncture for treating fascial dysfunction.

Combining Static and Dynamic Myofascial Dry Cupping Therapy to Improve Local and Regional Symptoms in Individuals with Low Back Pain: A Case Series

Introduction

Chronic low back pain is a common musculoskeletal healthcare presentation with an expense of over $100 billion annually. The clinical effect of myofascial cupping on pain and function is not clear, especially when different cupping techniques are combined. The purpose of this case series was to explore changes in pain and function following local static and distal dynamic myofascial dry cupping treatments in patients with chronic low back pain.

Case Descriptions

Three adults from the general population received three ten-minute treatment sessions, 48 hours between each session, of static dry cupping to the low back followed by dynamic myofascial cupping of the quadriceps and hamstring musculature. Outcome measures were taken at two different time points within one-week per participant. Subjective measures included the numeric pain rating scale and the Oswestry Disability Index, objective measures included passive straight leg raise measurements, and pressure pain threshold.

Results and Discussion

Local static combined with distal dynamic myofascial cupping reduced pain, pain sensitivity and perceived disability, and improved hamstring muscle extensibility in all three participants. These encouraging results support the initiation of a larger controlled trial aimed at investigating the efficacy of combined dry cupping interventions to treat musculoskeletal dysfunction and pain.

Level of Evidence

4 (case series).

Effects of Self-Myofascial Release on Athletes' Physical Performance: A Systematic Review

Therapists and strength and conditioning specialists use self-myofascial release (SMR) as an intervention tool through foam rollers or massage rollers for soft tissue massage, with the purpose of improving mobility in the muscular fascia. Moreover, the use of SMR by professional and amateur athletes during warm-ups, cool downs, and workouts can have significant effects on their physical performance attributes, such as range of motion (ROM) and strength. The purpose of this study was to analyse the literature pertaining to these types of interventions and their effects found in different physical performance attributes for athletes. A systematic search was carried out using the following databases: PUBMED, ISI Web of Science, ScienceDirect, and Cochrane, including articles up to September 2023. A total of 25 articles with 517 athletes were studied in depth. SMR seems to have acute positive effects on flexibility and range of motion, without affecting muscle performance during maximal strength and power actions, but favouring recovery perception and decreasing delayed-onset muscle soreness. Some positive effects on agility and very short-range high-speed actions were identified, as well. In conclusion, although there is little evidence of its method of application due to the heterogeneity in that regard, according to our findings, SMR could be used as an intervention to improve athletes' perceptual recovery parameters, in addition to flexibility and range of motion, without negatively affecting muscle performance.

Gender differences on effects of forearm rotation on compressive stiffness of flexor carpi ulnaris during submaximal handgrip contractions

Little is known about gender differences in stiffness of forearm muscles during voluntary actions. This study aimed to investigate the effect of forearm rotation on flexor carpi ulnaris (FCU) stiffness in men and women during submaximal handgrip contractions. During a single session, measurements were made on 20 young participants (9 females). Two positions of the forearm were compared in random order with the elbow flexed 90 degrees: (i) neutral position and (ii) maximal supination. In each position, participants performed two submaximal handgrip contractions at 25% and 50% of maximal voluntary contraction, while compressive stiffness was collected using a hand myometer (MyotonPRO). A mixed repeated measurement ANOVA was applied to assess the interaction between gender, forearm position, and contraction intensity. The FCU stiffness is affected by handgrip contraction intensity (p < 0.001), gender (p < 0.001), BMI (p = 0.009), and forearm rotation (p = 0.007). Only the gender factor was found to have significant interaction with forearm rotation (p = 0.037). Men's FCU was stiffer than women's in both positions and contraction intensities (p < 0.05). Only in men a significant increase in FCU stiffness was observed when comparing contraction intensities at both forearm positions (p < 0.05), as well as when the forearm was rotated from neutral to supine at both intensities (p < 0.05). In conclusion, FCU stiffness during handgrip contraction differed significantly between men and women. Women have fewer stiffness changes in FCU when performing different levels of handgrip contraction. We also observed that only men increased FCU stiffness by changing the forearm position from neutral to supine position for both handgrip intensities.

Low-Intensity Resistance Exercise Based on Myofascial Chains Alters the Lower-Limb Tension and Improves Health Status in Female Individuals With Knee Osteoarthritis

BACKGROUND

Low-intensity resistance exercise therapy (LIRET) based on myofascial chains, applied to both affected and nonlocal joints, is an effective method for knee osteoarthritis (OA) rehabilitation. This study applied LIRET in a comparison of prevalues and postvalues of lower-limb tension in female patients with knee OA and asymptomatic participants.

METHODS

Twenty-four female participants with knee OA and 20 asymptomatic women took part in a 3-month long application of LIRET. Participants' ankle passive torque and ankle range of motion in the sagittal plane were assessed with an isokinetic dynamometer. The collected values were used to estimate the sagittal-plane lower-limb tension.

RESULTS

Compared with the asymptomatic group, participants with knee OA presented decreased maximum ankle dorsiflexion (P < .001), decreased ankle plantar flexion range (P = .023), ankle resting position more inclined to dorsiflexion (P = .017), increased ankle dorsiflexion stiffness (P = .005), and lower ankle plantar flexion stiffness (P = .034). After exercise intervention, the knee OA group self-reported less knee pain (P < .001), improved physical function (P < .001), increased maximum dorsiflexion (P = .021), and increased plantar flexion range (P < .001). While plantar flexion stiffness increased (P = .037), dorsiflexion stiffness decreased (P = .015) and ankle resting position moved toward dorsiflexion (P = .002). Results suggest possible decreased anterior leg tension and possible increased posterior leg tension in patients with knee OA.

CONCLUSIONS

The results supported that knee OA patients present imbalanced myofascial tension of lower limbs. LIRET based on myofascial chains appears to decrease pain, and stiffness, and improve physical function of patients with knee OA and change their lower-limb tension.

The efficacy of sling exercise combined with extracorporeal shock wave on office workers with chronic neck pain

This study aimed to investigate the effect of extracorporeal shockwave therapy on the anterior surface line of the fascia meridian, including the oblique muscle, combined with sling exercise, on the stability of the spine in the neck disability index (NDI), neck joint range of motion (ROM), craniovertebral angle, neck alignment, and posture control. A total of 20 office workers with chronic neck pain were randomly assigned to an experimental group that combined extracorporeal shock wave therapy and sling exercise (n = 10) and a control group (CG) consisting of sling exercise (n = 10) performed twice weekly for 4 weeks. All subjects were evaluated using the NDI, ROM, neck alignment, and spine stability tests. Following the intervention, there were significant differences in the For example, NDI, craniovertebral angle, Cobb's angle, Centaur data, and ROM. Except for Cobb's angle and Centaur data (-90 degrees), all variables showed significant differences in the CG. Comparing changes before and after the intervention, The For example, showed significantly more significant changes in all variables than the CG. The combination of extracorporeal shockwave therapy and sling exercises improved NDI, ROM, and neck and spine alignment in office workers with chronic neck pain more effectively than the sling exercise alone. This study could be recommended as a new approach to enable individuals with chronic neck pain to perform better.

Response to Mechanical Properties and Physiological Challenges of Fascia: Diagnosis and Rehabilitative Therapeutic Intervention for Myofascial System Disorders

Damage to the fascia can cause significant performance deficits in high-performance sports and recreational exercise and may contribute to the development of musculoskeletal disorders and persistent potential pain. The fascia is widely distributed from head to toe, encompassing muscles, bones, blood vessels, nerves, and internal organs and comprising various layers of different depths, indicating the complexity of its pathogenesis. It is a connective tissue composed of irregularly arranged collagen fibers, distinctly different from the regularly arranged collagen fibers found in tendons, ligaments, or periosteum, and mechanical changes in the fascia (stiffness or tension) can produce changes in its connective tissue that can cause pain. While these mechanical changes induce inflammation associated with mechanical loading, they are also affected by biochemical influences such as aging, sex hormones, and obesity. Therefore, this paper will review the current state of knowledge on the molecular level response to the mechanical properties of the fascia and its response to other physiological challenges, including mechanical changes, innervation, injury, and aging; imaging techniques available to study the fascial system; and therapeutic interventions targeting fascial tissue in sports medicine. This article aims to summarize contemporary views.

Effect of Remote Myofascial Release on Lumbar Elasticity and Pain in Patients With Chronic Nonspecific Low Back Pain: A Randomized Clinical Trial

Objective

The purpose of this study was to evaluate the effects of myofascial release technique of a remote area on lumbar elasticity and low back pain (LBP) in patients with chronic nonspecific LBP.

Methods

For this clinical trial, 32 participants with nonspecific LBP were assigned to a myofascial release group (n = 16) or a remote release group (n = 16). Participants in the myofascial release group received 4 sessions of myofascial release to the lumbar region. The remote release group received 4 myofascial release sessions to the crural and hamstring fascia of the lower limbs. Low back pain severity and elastic modulus of the lumbar myofascial tissue were assessed before and after treatment by the Numeric Pain Scale and ultrasonography examinations.

Results

The mean pain and elastic coefficient in each group before and after myofascial release interventions were significantly different (P ≤ .0005). The results showed that the changes in mean pain and elastic coefficient of the 2 groups after myofascial release interventions were not significantly different from each other (F1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 = 1.48, P = .230, 95% confidence interval) (effect size = 0.22).

Conclusion

The improvements in the outcome measures for both groups suggest that remote myofascial release was effective in patients with chronic nonspecific LBP. The remote myofascial release of the lower limbs reduced the elastic modulus of the lumbar fascia and LBP.

Self-Myofascial Release of the Foot Plantar Surface: The Effects of a Single Exercise Session on the Posterior Muscular Chain Flexibility after One Hour

This study evaluated the effects of a single exercise session of Self-Myofascial Release (SMR) on the posterior muscular chain flexibility after one hour from the intervention. Thirty-six participants performed SMR using a rigid ball under the surface of both feet. Participants were tested with the Sit and Reach (S&R) test at four different times: before (T0), immediately after (T1), 30 (T2), and 60 (T3) minutes after the SMR intervention. The sample (n = 36) was categorized into three groups: (1) flexible, (2) average, and (3) stiff, based on the flexibility level at T0 (S&R values of >10 cm, >0 but <10 cm and <0 cm, respectively). For the whole sample, we detected significant improvements in the S&R test between the T1, T2, and T3 compared to T0. The stiff group showed a significant (p < 0.05) improvement between T1−T2 and T1−T3. Results were similar between the average group and the whole sample. The flexible group did not show any significant difference (p > 0.05) over time. In conclusion, this investigation demonstrated that an SMR session of both feet was able to increase posterior muscular chain flexibility up to one hour after intervention. Considering that a standard training session generally lasts one hour, our study can help professionals take advantage of SMR effects for the entire training period. Furthermore, our results also demonstrate that physical exercise practitioners should also assess individuals’ flexibility before training, as the SMR procedure used in this work does not seem necessary in flexible individuals.

The Relationship Between Acute Exercise-Induced Changes in Extramuscular Connective Tissue Thickness and Delayed Onset Muscle Soreness in Healthy Participants: A Randomized Controlled Crossover Trial

Background

The extramuscular connective tissue (ECT) has been shown to play a significant role in mechanical force transmission between musculoskeletal structures. Due to this and owing to its tight connection with the underlying muscle, the ECT may be vulnerable to excessive loading. The present study aimed to investigate the effect of eccentric elbow flexor exercise on the morphology of the biceps brachii ECT. In view of the high nociceptive capacity of the ECT, an additional objective was to elucidate the potential relationship between ECT damage and the occurrence of delayed onset muscle soreness (DOMS).

Methods

Eleven healthy participants (♂ = 7; 24 ± 2 years) performed fatiguing dumbbell elbow flexor eccentric exercise (EE) for one arm and concentric exercise (CE) for the other arm in random order and with random arm allocation. Before, immediately after and 24–96 h post-exercise, maximal voluntary isometric contraction torque of the elbow flexors (dynamometer), pressure pain (algometer), palpation pain (100 mm visual analog scale), biceps brachii ECT thickness and ECT/muscle mobility during passive movement (both high-resolution ultrasound) were examined.

Results

Palpation pain, suggestive of DOMS, was greater after EE than CE, and maximal voluntary isometric contraction torque decreased greater after EE than CE (p < .05). Relative to CE, EE increased ECT thickness at 48 (+ 17%), 72 (+ 14%) and 96 (+ 15%) hours post-exercise (p < .05). At 96 h post-EE, the increase in ECT thickness correlated with palpation pain (r = .68; p < .05). ECT mobility was not different between conditions, but compared to CE, muscle displacement increased at 24 (+ 31%), 72 (+ 31%) and 96 (+ 41%) hours post-EE (p < .05).

Conclusion

Collectively, these results suggest an involvement of the ECT changes in delayed onset muscle soreness.

Fascial Manipulation Method Is Effective in the Treatment of Myofascial Pain, but the Treatment Protocol Matters: A Randomised Control Trial—Preliminary Report

Background: There are many therapeutic methods targeting fascia. However, the only method whose basic assumption is to eliminate the densification of fascia is Fascial Manipulation. Objective: To evaluate the effectiveness of various Fascial Manipulation (FM) protocols in reducing myofascial pain. Design: Randomized control trial. Subjects: A total of 54 individuals, aged 18–29 years, with musculoskeletal pain for at least 1 week. Methods: The patients were divided into four groups subjected to different treatment protocols: group 1—underwent the standard FM treatment protocol (STP), group 2—modified protocol (MTP), group 3—modified protocol 2 (MTP2), and the control group (CG)—did not undergo any therapy. Each protocol involved three treatments at intervals of 7–10 days and a follow-up examination after 30 days. The outcome was pain level measured using the VAS. Results: In the STP, all the measurements showed a significant decrease in pain level—the mean difference was 2.077 after the first treatment, 3.462 after the third treatment and 3.385 in the follow-up. In the MTP, a significant mean difference was noted after the third treatment, 3, and in the follow up, 2.4. In the MTP2, it was noted after the third session, 2, and in the follow up, 2.25. Only the CG group did not display significant changes. Conclusions: FM-based therapy results in pain relief. However, there are differences in the dynamics and durability of the results depending on the chosen protocol.

Fascial Innervation: A Systematic Review of the Literature

Currently, myofascial pain has become one of the main problems in healthcare systems. Research into its causes and the structures related to it may help to improve its management. Until some years ago, all the studies were focused on muscle alterations, as trigger points, but recently, fasciae are starting to be considered a new, possible source of pain. This systematic review has been conducted for the purpose of analyze the current evidence of the muscular/deep fasciae innervation from a histological and/or immunohistochemical point of view. A literature search published between 2000 and 2021 was made in PubMed and Google Scholar. Search terms included a combination of fascia, innervation, immunohistochemical, and different immunohistochemical markers. Of the 23 total studies included in the review, five studies were performed in rats, four in mice, two in horses, ten in humans, and two in both humans and rats. There were a great variety of immunohistochemical markers used to detect the innervation of the fasciae; the most used were Protein Gene Marker 9.5 (used in twelve studies), Calcitonin Gene-Related Peptide (ten studies), S100 (ten studies), substance P (seven studies), and tyrosine hydroxylase (six studies). Various areas have been studied, with the thoracolumbar fascia being the most observed. Besides, the papers highlighted diversity in the density and type of innervation in the various fasciae, going from free nerve endings to Pacini and Ruffini corpuscles. Finally, it has been observed that the innervation is increased in the pathological fasciae. From this review, it is evident that fasciae are well innerved, their innervation have a particular distribution and precise localization and is composed especially by proprioceptors and nociceptors, the latter being more numerous in pathological situations. This could contribute to a better comprehension and management of pain.

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.

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

INTRODUCTION

The deep fascia is a three-dimensional continuum of connective tissue surrounding the bones, muscles, nerves and blood vessels throughout our body. Its importance in chronically debilitating conditions has recently been brought to light. This work investigates changes in these tissues in pathological settings.

MATERIALS AND METHODS

A state-of-the-art review was conducted in PubMed and Google Scholar following a two-stage process. A first search was performed to identify main types of deep fasciae. A second search was performed to identify studies considering a deep fascia, common pathologies of this deep fascia and the associated alterations in tissue anatomy.

RESULTS

We find that five main deep fasciae pathologies are chronic low back pain, chronic neck pain, Dupuytren's disease, plantar fasciitis and iliotibial band syndrome. The corresponding fasciae are respectively the thoracolumbar fascia, the cervical fascia, the palmar fascia, the plantar fascia and the iliotibial tract. Pathological fascia is characterized by increased tissue stiffness along with alterations in myofibroblast activity and the extra-cellular matrix, both in terms of collagen and Matrix Metalloproteases (MMP) levels. Innervation changes such as increased density and sensitization of nociceptive nerve fibers are observed. Additionally, markers of inflammation such as pro-inflammatory cytokines and immune cells are documented. Pain originating from the deep fascia likely results from a combination of increased nerve density, sensitization and chronic nociceptive stimulation, whether physical or chemical.

CONCLUSIONS

The pathological fascia is characterized by changes in innervation, immunology and tissue contracture. Further investigation is required to best benefit both research opportunities and patient care.

Pressure pain threshold mappings of the infraspinatus muscle in chronic unilateral shoulder pain patients do not reflect generalized hypersensitivity

OBJECTIVES

Increased mechanical sensitivity has been observed on the unaffected side in chronic pain conditions, suggesting generalized or widespread hypersensitivity. However, this cannot be considered as a universal response since this hypersensitivity is inconsistent across muscle pain pathologies. The aim of this study was to assess generalized hypersensitivity in chronic unilateral shoulder pain, using pressure pain threshold (PPT) mappings of the infraspinatus muscle. The proposed evaluation is based on the assessment of PPT on a limited subset of sites, reducing potential habituation or sensitization effects.

METHODS

Twenty-nine patients with unilateral shoulder pain (USP) and twenty-seven healthy volunteers were recruited. PPT was assessed using a manual pressure algometer. Six sites distributed over the infraspinatus muscle were assessed, and three repetitions were performed at each site. Mappings were derived using two-dimensional interpolation.

RESULTS

Lower PPT values were found in the symptomatic side in comparison with the asymptomatic side at all assessment sites (estimated difference: 1.42 ± 0.10 kgf/cm², p < 0.001), but there were no differences among the asymptomatic side of USP patients and any of the sides in healthy volunteers (largest estimated difference: 0.17 ± 0.28 kgf/cm², p = 0.927). Furthermore, the medial region of the infraspinatus muscle showed higher mechanical sensitivity in both healthy volunteers and USP patients.

CONCLUSIONS

These results suggest that USP does not induce generalized hypersensitivity, in contrast with previously reported findings. Physiotherapists could take these results into account for the assessment and treatment of patients with USP.

Evaluating the Effectiveness of Soft Tissue Therapy in the Treatment of Disorders and Postoperative Conditions of the Knee Joint-A Systematic Review

The term "soft tissue therapy" (STT) refers to mechanical methods of treatment involving passive kneading, pressing and stretching of pathologically tense tissues in supporting the process of recovery after surgery or trauma to the musculoskeletal system. The objective of this study was to review current scientific reports evaluating the effectiveness of the use of STT in patients with diseases or after surgical procedures of the knee joint. A systematic search of the popular scientific databases PubMed, Scopus and Embase was performed from inception to 15 October 2021. Eight articles met eligibility criteria and were included in the review. Six papers were related to disorders of the knee joint, while the remaining two studies were related to dysfunctions associated with the conditions after surgical intervention. The findings presented confirmed the effectiveness of STT in orthopaedic patients who showed an increase in lower limb functional parameters. The research has shown that the use of various methods of STT has a significant impact on increasing muscle activity and flexibility as well as increasing the range of motion in the knee joint. The physiotherapeutic methods used had a significant impact on reducing pain and increasing physical function and quality of life. The techniques used reduced the time to descend stairs in patients with knee osteoarthritis. This review summarises the effectiveness of STT as an important form of treatment for orthopaedic patients with various knee joint dysfunctions.

Sensory innervation of the human palmar aponeurosis in healthy individuals and patients with palmar fibromatosis

The human palmar aponeurosis is involved in hand proprioception, and it contains different sensory corpuscle morphotypes that serve this role. In palmar fibromatosis (classically referred to as Dupuytren's disease), the palmar aponeurosis undergoes fibrous structural changes that, presumably, also affect the nervous system, causing altered perception. We analysed the various sensory nerve formation morphotypes in the palmar aponeuroses of healthy subjects and patients with palmar fibromatosis. To do this, we used immunohistochemistry for corpuscular constituents and the putative mechanoproteins PIEZO2 and acid‐sensing ion channel 2. Free nerve endings and Golgi‐Mazzoni, Ruffini, paciniform and Pacinian corpuscles were identified in both the healthy and the pathological conditions. The densities of the free nerve endings and Golgi‐Mazzoni corpuscles were slightly increased in the pathological tissues. Furthermore, the Pacinian corpuscles were enlarged and displayed an altered shape. Finally, there was also morphological and immunohistochemical evidence of occasional denervation of the Pacinian corpuscles, although no increase in their number was observed. Both PIEZO2 and acid‐sensing ion channel 2 were absent from the altered corpuscles. These results indicate that the human palmar aponeurosis is richly innervated, and the free nerve endings and sensory corpuscles within the palmar aponeurosis undergo quantitative and qualitative changes in patients with palmar fibromatosis, which may explain the sensory alterations occasionally reported for this pathology.

Deep fascia as a potential source of pain: A narrative review

BACKGROUND

The fascial component of the myofascial pain syndrome and the contribution of the deep fascia to various painful conditions has not been well-described and is still less understood.

OBJECTIVES

The aims of this study were to evaluate the possible role of the deep fascia on musculoskeletal pain, focusing on findings from histological and experimental studies; and to assess the nociceptive and associated responses of the deep fascia to experimentally-induced irritation.

METHODS

Narrative review of the English scientific literature.

RESULTS AND CONCLUSIONS

Different components of the deep fascia, both in humans and animals are richly innervated, with some differences between body segments. These fascial components usually exhibit dense innervation, encompassing amongst others, nociceptive afferents. The application of different types of stimuli, i.e., electrical, mechanical, and chemical to these fascial components produces long-lasting pain responses. In some cases, the intensity and severity of pain produced by the stimulation of fascia were higher than ones produced by the stimulation of the related muscular tissue. These observations may denote that the deep fascia and its various components could be a source of pain in different pathologies and various pain syndromes.

From Neural Command to Robotic Use: The Role of Symmetry/Asymmetry in Postural and Locomotor Activities

This article deepens a reflection on why and how symmetry/asymmetry affects the motor and postural behavior from the neural source, uterine development, child maturation, and how the notion of symmetry/asymmetry has been applied to walking robot design and control. The concepts of morphology and tensegrity are also presented to illustrate how the biological structures have been used in both sciences and arts. The development of the brain and the neuro-fascia-musculoskeletal system seems to be quite symmetric from the beginning of life through to complete maturity. The neural sources of movements (i.e., central pattern generators) are able to produce both symmetric or asymmetric responses to accommodate to environmental constraints and task requirements. Despite the fact that the human development is mainly symmetric, asymmetries already regulate neurological and physiological development. Laterality and sports training could affect natural musculoskeletal symmetry. The plasticity and flexibility of the nervous system allows the abilities to adapt and compensate for environmental constraints and musculoskeletal asymmetries in order to optimize the postural and movement control. For designing humanoid walking robots, symmetry approaches have been mainly used to reduce the complexity of the online calculation. Applications in neurological retraining and rehabilitation should also be considered.

Elastic Fibres in the subcutaneous tissue: Is there a difference between superficial and muscular fascia? A cadaver study

BACKGROUND

In last years the role of fascia in proprioception and pain has been confirmed in numerous papers, but the real structure of fasciae is not still entirely known. To date, many studies have evaluated the elastic fibres in arteries, ligaments, lungs, epidermis and dermis, but only two studies exist about the elastic fibres in the fasciae, and they did not distinguish between superficial (in the subcutaneous tissue) and deep/muscular fasciae. The aim of the study was to assess the percentage of elastic fibres between superficial and deep fascia.

MATERIALS AND METHODS

Three full thickness specimens (proximal, middle and distal respectively) were taken from each of four regions of the thigh of three non-embalmed cadavers: the anterior (Ant), the lateral (Lat), the posterior (Post) and the medial (Med) aspect. Thus, a total of 12 specimens were collected from each analysed thigh and histological Weigert Van Gieson stains was performed. Three sections per specimen were considered for the morphometric analysis.

RESULTS

In all the specimens the superficial and deep fasciae were clearly recognizable. The difference in percentage of elastic fibres between superficial and deep fasciae in same region for all four was highly significant (p < 0.001). They are abundant in the superficial fascia than deep fascia.

CONCLUSIONS

In the light of these findings is evident that the superficial (in the subcutaneous tissue) and deep fasciae have different elasticity. This difference may improve grading of fascial dysfunction in dermatological diseases as burns, scars and lymphedema to better plan treatments.

Fascial plane blocks: a narrative review of the literature

Fascial plane blocks (FPBs) are increasingly numerous and are often touted as effective solutions to many perioperative challenges facing anesthesiologists. As 'new' FPBs are being described, questions regarding their effectiveness remain unanswered as appropriate studies are lacking and publications are often limited to case discussions or technical reports. It is often unclear if newly named FPBs truly represent a novel intervention with new indications, or if these new publications describe mere ultrasound facilitated modifications of existing techniques. Here, we present broad concepts and potential mechanisms of FPB. In addition, we discuss major FPBs of (1) the extremities (2) the posterior torso and (3) the anterior torso. The characteristics, indications and a brief summary of the literature on these blocks is included. Finally, we provide an estimate of the overall level of evidence currently supporting individual approaches as FPBs continue to rapidly evolve.

Evidence of a new hidden neural network into deep fasciae

It is recognized that different fasciae have different type of innervation, but actually nothing is known about the specific innervation of the two types of deep fascia, aponeurotic and epymisial fascia. In this work the aponeurotic thoracolumbar fascia and the epymisial gluteal fascia of seven adult C57-BL mice were analysed by Transmission Electron Microscopy and floating immunohistochemistry with the aim to study the organization of nerve fibers, the presence of nerve corpuscles and the amount of autonomic innervation. The antibodies used were Anti-S100, Anti-Tyrosine Hydroxylase and Anti-PGP, specific for the Schwann cells forming myelin, the sympathetic nerve fibers, and the peripheral nerve fibers, respectively. The results showed that the fascial tissue is pervaded by a rhomboid and dense network of nerves. The innervation was statistically significantly lower in the gluteal fascia (2.78 ± 0.6% of positive area, 140.3 ± 31.6/mm² branching points, nerves with 3.2 ± 0.6 mm length and 4.9 ± 0.2 µm thickness) with respect to the thoracolumbar fascia (9.01 ± 0.98% of innervated area, 500.9 ± 43.1 branching points/mm², length of 87.1 ± 1.0 mm, thickness of 5.8 ± 0.2 µm). Both fasciae revealed the same density of autonomic nerve fibers (0.08%). Lastly, corpuscles were not found in thoracolumbar fascia. Based on these results, it is suggested that the two fasciae have different roles in proprioception and pain perception: the free nerve endings inside thoracolumbar fascia may function as proprioceptors, regulating the tensions coming from associated muscles and having a role in nonspecific low back pain, whereas the epymisial fasciae works to coordinate the actions of the various motor units of the underlying muscle.

Previous hamstring muscle strain injury alters passive tissue stiffness and vibration sense

BACKGROUND

Hamstring strain is one of the most common among sports injuries. A previous history of this injury is considered a strong predictor of recurrent hamstring strain injury. It has been suggested that fascial tissue alters after muscle strain injury. However, the association between previous hamstring strain injury and tissue stiffness and vibration sense detection has not been investigated.

OBJECTIVES

We aimed to determine whether a previous history of hamstring strain injury affects tissue stiffness and vibration sense in professional soccer players.

METHOD

The stiffness (MyotonPRO®) and vibration disappearance threshold (tuning fork) were measured in eight professional soccer players with previous history of hamstring strain and eight uninjured players. The differences between two groups' means were analyzed. Side-to-side differences between injured and uninjured legs were also analyzed.

RESULTS

The tissue stiffness was higher, and the vibration disappearance threshold was lower, in previously injured players when compared to uninjured players. Similar differences were found between injured and uninjured legs. No significant relationship was detected between the age or body mass index (BMI) for both tissue stiffness and vibration disappearance threshold (all P < 0.05).

CONCLUSIONS

Soccer players with a previous history of hamstring strain injury exhibited higher tissue stiffness and lower vibration sensitivity in the injured leg, regardless of the age and BMI. The results that players who have a previous hamstring strain injury with altered tissue stiffness and vibration sense will be useful and feasible evaluation for chronic muscle strain condition.

Tenderness of the Skin after Chemical Stimulation of Underlying Temporal and Thoracolumbar Fasciae Reveals Somatosensory Crosstalk between Superficial and Deep Tissues

Musculoskeletal pain is often associated with pain referred to adjacent areas or skin. So far, no study has analyzed the somatosensory changes of the skin after the stimulation of different underlying fasciae. The current study aimed to investigate heterotopic somatosensory crosstalk between deep tissue (muscle or fascia) and superficial tissue (skin) using two established models of deep tissue pain (namely focal high frequency electrical stimulation (HFS) (100 pulses of constant current electrical stimulation at 10× detection threshold) or the injection of hypertonic saline in stimulus locations as verified using ultrasound). In a methodological pilot experiment in the TLF, different injection volumes of hypertonic saline (50–800 µL) revealed that small injection volumes were most suitable, as they elicited sufficient pain but avoided the complication of the numbing pinprick sensitivity encountered after the injection of a very large volume (800 µL), particularly following muscle injections. The testing of fascia at different body sites revealed that 100 µL of hypertonic saline in the temporal fascia and TLF elicited significant pinprick hyperalgesia in the overlying skin (–26.2% and –23.5% adjusted threshold reduction, p < 0.001 and p < 0.05, respectively), but not the trapezius fascia or iliotibial band. Notably, both estimates of hyperalgesia were significantly correlated (r = 0.61, p < 0.005). Comprehensive somatosensory testing (DFNS standard) revealed that no test parameter was changed significantly following electrical HFS. The experiments demonstrated that fascia stimulation at a sufficient stimulus intensity elicited significant across-tissue facilitation to pinprick stimulation (referred hyperalgesia), a hallmark sign of nociceptive central sensitization.

Immediate effects of myofascial release on neuromechanical characteristics in female and male patients with low back pain and healthy controls as assessed by tensiomyography. A controlled matched-pair study

BACKGROUND

Low back pain (LBP) is a major health issue in most industrialised countries. Lumbodorsal fascia has been advocated as a potential source of pain in the lumbopelvic region. Myofascial release constitutes a manual therapeutic approach focussing on the restoration of altered soft tissue function. No previous study has focused on quantifying neuromechanical effects of myofascial release on LBP patients through tensiomyography. The purpose of this study was to quantify immediate neuromechanical alterations of myofascial release on patients with LBP and healthy controls through tensiomyography parameters.

METHODS

The participants' (n = 30) bilateral lumbar erector spinae muscles were assessed via tensiomyography before and after a 6-min myofascial release treatment of the lumbodorsal fascia to evaluate the muscles' mechanical characteristics. Subjects with LBP (n = 15) were eligible to partake if they reported having had LBP for most days in the past 12 weeks. Muscle displacement (Dm [mm]), velocity of contraction (Vc [mm/s]), and lateral symmetry (Ls [%]) were assessed through tensiomyography testing.

FINDINGS

Statistical analyses revealed a significant increase for velocity of contraction in the right (p = .021) and left (p = .041) lumbar erector spinae for the subjects with LBP but not for the healthy controls (both p > .14).

INTERPRETATION

We suggested that myofascial release alters neuromechanical characteristics in subjects with LBP. Tensiomyography may be implemented in clinical settings to monitor intervention effects of the myofascial system, especially the tensiomyography parameter velocity of contraction.

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.

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

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

Fascia and soft tissues innervation in the human hip and their possible role in post-surgical pain

Persistent symptoms, most commonly pain, may remain after otherwise successful hip replacement surgery. Innervation of fascia and soft tissues has become increasingly important in etiopathogenesis of pain, but the relative importance of the various anatomical structures in the hip region is still not known. Innervation of skin, superficial adipose tissue, superficial fascia, deep adipose tissue, deep fascia, muscles, capsule, capsule ligament, ligamentum teres, and tendon in the human hip from 11 patients and 2 cadavers were quantified by staining with anti-S100 antibody for myelin-forming Schwann cells, to obtain the percentage of antibody positivity, density and mean diameter of the nerve fibers. The skin was the most highly innervated (0.73% ± 0.37% of positive area in patients; 0.80% ± 0.28% in cadavers); the tendon was the least innervated (0.07% ± 0.01% in patients, 0.07% ± 0.007% in cadavers). The muscles (vasto-lateral and gluteus medius) were the second most innervated structure according the percentage (0.31% ± 0.13% in living humans, 0.30% ± 0.07% in cadavers), but with only a few nerves, with large diameters (mean diameter 36.4 ± 13.4 µm). Instead, the superficial fasciae showed 0.22% ± 0.06% and 0.26% ± 0.05% of positive areas in living humans and cadavers, respectively. Fasciae were invaded by networks of small nerve fibers, revealing a possible role in pain. The superficial fascia was the second most highly innervated tissue after the skin, with a density of 33.0 ± 2.5/cm² , and a mean nerve sizes of 19.1 ± 7.2  µm. Lastly, the capsule turned out to be poorly innervated (0.09%), showing that its removal does not necessarily lead to painful consequences. Statement of clinical significance: Deeper knowledge about the innervation of the soft tissue in the human hip joint will enhance study and understanding of the best surgical procedures to follow during hip arthroplasty to reduce post-operative pain.

Overuse Injury: The Result of Pathologically Altered Myofascial Force Transmission?

Overuse injuries are suggested to result from repetitive microdamage eliciting pain in the affected tissue. Therapy commonly focuses on the area of symptom localization; however, such approach may oversimplify the true etiopathology. This review hypothesizes that the development of some sports-related soft tissue disorders, such as plantar fasciitis or lumbago, is promoted by pathologically altered force transmission from anatomically connected structures.

Self-Myofascial Release of the Superficial Back Line Improves Sit-and-Reach Distance

Context: Decreased hamstring flexibility can lead to a plethora of musculoskeletal injuries, including low back pain, hamstring strains, and patellofemoral pain. Lack of flexibility may be the result of myofascial adhesions. The fascia connected to the hamstrings is part of the superficial back line that runs from the cranium to the plantar aspect of the foot. Any disruption along this chain may limit the flexibility of the hamstring. Objective: To investigate if self-myofascial release (SMR) of the plantar surface of the foot in addition to the hamstring group was more effective at improving the flexibility of the hamstrings when compared with either intervention alone. Design: Cross-over study. Setting: Athletic training facility. Participants: Fifteen college students (5 males and 10 females; age: 20.9 [1.4] y, height: 173.1 [10.3] cm, mass: 80.0 [24.9] kg) who were not older than 30, with no history of low back pain or injury within the past 6 months, no history of leg pain or injury within the past 6 months, no current signs or symptoms of cervical or lumbar radicular pain, no current complaint of numbness or tingling in the lower-extremity, and no history of surgery in the lower-extremity or legs. Interventions: Each participant received each intervention separated by at least 96 hours in a randomized order: hamstring foam rolling, lacrosse ball on the plantar surface of the foot, and a combination of both. Main Outcome Measures: The sit-and-reach test evaluated hamstring flexibility of each participant before and immediately after each intervention. Results: There were no significant differences found among the SMR techniques on sit-and-reach distance (F2,41 = 2.7, P = .08, ). However, at least 20% of participants in each intervention improved sit-and-reach distance by 2.5 cm. Conclusions: SMR may improve sit-and-reach distance, but one technique of SMR does not seem to be superior to another.

The effect of treatment regimens on salivary cortisol levels in patients with chronic musculoskeletal disorders

BACKGROUND

Increased levels of circulating cortisol have been associated with pain severity in patients with chronic musculoskeletal disorders (CMD). Little is known about the potential association between pain management and salivary cortisol alterations in CPM patients treated with different regimens.

OBJECTIVES

This prospective feasibility study aimed to determine the effect of two treatment regimens in comparison with sham therapy on pain intensity and disability and salivary cortisol concentration (SCC) in patients with CMD.

METHODS

Thirty patients were randomly assigned to 3 groups of 10: two experimental groups (A and B) and a control group (C). The experimental groups followed physiotherapy treatment (A) or acupuncture (B), while the control group (C) followed a sham therapy for 10 sessions. Pain data were collected using the Chronic Pain Grade (CPG) questionnaire and SCC was measured by enzyme-linked immunosorbent assay at pre- and posttreatment.

RESULTS

Repeated-measures analysis of variance showed that patients treated with acupuncture experienced greater decreases in pain intensity/pain disability (P < 0.05) than the physiotherapy and sham therapy groups. No statistical differences were found between the three groups for the SCC outcome variable. Bonferroni adjustments showed that the mean values of SCC were significantly decreased at posttreatment (P < 0.05) across the three groups.

CONCLUSION

There was a significant decrease in both pain and cortisol outcomes at posttreatment in patients with CMD. Because of the limitations of this study, we cannot draw conclusions regarding whether the lower SCC could be an indication of pain reduction in patients with CMD.

Refining a great idea: the consolidation of PECS I, PECS II and serratus blocks into a single thoracic fascial plane block, the SAP block

The popularity of ultrasound-guided nerve blocks has impacted the practice of regional anesthesia in profound ways, improving some techniques and introducing new ones. Some of these new nerve blocks are based on the concept of fascial plane blocks, in which the local anesthetic is injected into a plane instead of around a specific nerve. Pectoralis muscles (PECS) and serratus blocks, most commonly used for post op analgesia after breast surgery, are good examples. Among the nerves targeted by PECS/serratus blocks are different branches of the brachial plexus that traditionally have been considered purely motor nerves. This unsubstantiated claim is a departure from accepted anatomical knowledge and challenges our understanding of the sensory innervation of the chest wall. The objective of this Daring Discourse is to look beyond the ability of PECS/serratus blocks to provide analgesia/anesthesia of the chest wall, to concentrate instead on understanding the mechanism of action of these blocks and, in the process, test the veracity of the claim. After a comprehensive review of the evidence we have concluded that (1) the traditional model of sensory innervation of the chest wall, which derives from the lateral branches of the upper intercostal nerves and does not include branches of the brachial plexus, is correct. (2) PECS/serratus blocks share the same mechanism of action, blocking the lateral branches of the upper intercostal nerves, and so their varied success is tied to their ability to reach them. This common mechanism agrees with the traditional innervation model. (3) A common mechanism of action supports the consolidation of PECS/serratus blocks into a single thoracic fascial plane block with a point of injection closer to the effector site. In a nod to transversus abdominus plane block, the original inspiration for PECS blocks, we propose naming this modified block, the serratus anterior plane block.

Innervation of the thoracolumbar fascia

The aim of the study was to obtain information on the sensory functions of the thoracolumbar fascia (TLF). The types of nerve fibres present in the TLF were visualized with specific antibodies to neuropeptides and sympathetic fibres. Most data were obtained from the TLF in rats, but some findings from the human fascia are also included. The only receptive nerve ending found was the free nerve ending, i.e. no corpuscular receptors existed in our specimen. An exclusive innervation with free nerve endings speaks for a nociceptive function, but the TLF may also fulfill proprioceptive functions, since many of the free nerve endings have a low mechanical threshold. Most of the fibres could be visualized with antibodies to CGRP [calcitonin gene- related peptide (CGRP)] and SP [substance P (SP)]. The latter ones most likely were nociceptors. The TLF contained a great proportion of postganglionic sympathetic fibres, which may be vasoconstrictors. A comparison between an inflamed and intact fascia showed an increase of the CGRP- and SP-positive fibres in the inflamed TLF. This finding could be one explanation for the low back pain of many patients, since practically all lesions of the fascia are accompanied by a sterile inflammation.

A comparative multi-site and whole-body assessment of fascia in the horse and dog: a detailed histological investigation

Fascia in the veterinary sciences is drawing attention, such that physiotherapists and animal practitioners are now applying techniques based on the concept of fascia studies in humans. A comprehensive study of fascia is therefore needed in animals to understand the arrangement of the fascial layers in an unguligrade horse and a digitigrade dog. This study has examined the difference between the horse and the dog fascia at specific regions, in terms of histology, and has compared it with the human model. Histological examinations show that in general the fascia tissue of the horse exhibits a tight and dense composition, while in the dog it is looser and has non-dense structure. Indeed, equine fascia appears to be different from both canine fascia and the human fascia model, whilst canine fascia is very comparable to the human model. Although regional variations were observed, the superficial fascia (fascia superficialis) in the horse was found to be trilaminar in the trunk, yet multilayered in the dog. Moreover, crimping of collagen fibers was more visible in the horse than the dog. Blood vessels and nerves were present in the loose areolar tissue of the superficial and the profound compartment of hypodermis. The deep fascia (fascia profunda) in the horse was thick and tightly attached to the underlying muscle, while in the dog the deep fascia was thin and loosely attached to underlying structures. Superficial and deep fascia fused in the extremities. In conclusion, gross dissection and histology have revealed species variations that are related to the absence or presence of the superficial adipose tissue, the retinacula cutis superficialis, the localization and amount of elastic fibers, as well as the ability to slide and glide between the different layers. Further research is now needed to understand in more detail whether these differences have an influence on the biomechanics, movements and proprioception of these animals.

The crural interosseous membrane re-visited: a histological and microscopic study

The aim of this study was to characterize the microscopic structure and sensory nerve endings of the crural interosseous membrane (IM). 13 IMs from 7 cadavers were used to analyze the organization of the collagen fibers, IM’s thickness, distribution of elastic fibers and nerve elements. The IM is mainly a two-layer collagen fascicle structure with the collagen fibers of adjacent layers orientated along different directions, forming angles of 30.5 +/- 1.7° at proximal and 26.6 +/- 2.1° at distal part (P>0.05). The percentage of elastic fibers between the two layers and inside the collagen fascicle layer is 10.1 +/- 0.5% and 2.2 +/- 0.1% (P<0.001). The IM’s thickness at proximal, middle, and distal parts is 268.5 +/- 18.6μm; 293.2 +/- 12.5μm; 365.3 +/- 19.3 μm, respectively (Proximal vs Distal: P<0.001; Middle vs Distal: P<0.05). Nerve elements were present and located both inside and on the surface of the IM, whereas the mechanoreceptors are mainly located on the surface of the IM. Free nerve endings (33.3 +/- 5.0/cm²) and Ruffini corpuscles (3.4 +/- 0.6/cm²) were the predominant sensory elements, while Pacinian corpuscles (1.3 +/- 0.7/cm²) were rarely found. The type of mechanoreceptors found suggests that the IM may play a role in proprioception.

Myofascial chains of the upper limb: A systematic review of anatomical studies

The presence of structural in-series continuity between skeletal muscles has been confirmed in the trunk and lower extremity. However, it is not yet clear whether the same architecture can be found in the upper limb. Therefore, the aim of the present study was to review the available literature considering the existence of myofascial chains in the shoulder-arm region. Two independent investigators performed a systematic literature search using MEDLINE (PubMed) and Google Scholar (each 1900-2019). Peer-reviewed anatomical dissection studies reporting myofascial in-series continuity in the upper extremity were included. The methodological quality of the included studies was assessed by the QUACS scale. Thirteen studies were included in the review. Analysis of these papers led to the identification of three myofascial chains: the ventral arm chain (pectoralis major, brachial fascia/biceps brachii, flexor carpi ulnaris/brachioradialis/supinator, based on five studies); the lateral arm chain (trapezius, deltoideus, lateral intermuscular septum/brachialis, brachioradialis, four studies); and the dorsal arm chain (latissiumus dorsi/teres minor/infraspinatus, triceps brachii, anconeus, extensor carpi ulnaris, six studies). There is good evidence for direct serial tissue continuity extending from the neck and shoulder region to the forearm. Despite this intriguing finding, which could have implications for health professionals and the treatment of musculoskeletal disorders, further research is needed to establish the mechanical relevance of the identified myofascial chains. Clin. Anat. 32:934-940, 2019. © 2019 Wiley Periodicals, Inc.

2019 Ejtm Special on Muscle Fascia

For many years the fasciae have been considered by the anatomists only as a "white envelope for the muscles", that is generally removed in anatomical tables, to recognize muscle nerves and vessels. This is one of the reasons that different descriptions of the fasciae exist. On the other hand, in the last years the fasciae and their properties are becoming of central importance to clinicians practicing in various conventional and alternative therapies. The results from the worldwide research activities constitute a body of significant and important data, but this clinical interest is not supported by in-depth comprehension to how integrate the new knowledge about fasciae with the classical biomechanical models based on muscles, tendons and bones. To close this gap an Ejtm Special on "Muscle Fascia" will be published September 30, 2019, but the typescripts will be added to the Ejtm Early Release list as soon as all authors will approve their Epub papers. Deadline for original articles and reviews is June 1st, 2019, but the Editors hope that authors submit their typescripts much earlier.

2019Spring PaduaMuscleDays: Translational Myology and Mobility Medicine

A half-century tradition of skeletal muscles studies, started with a research on fever, is continuing under the auspices of the Interdepartmental Research Centre of Myology (CIR-Myo), Department of Biomedical Sciences, University of Padova, Italy, the A&C M-C Foundation for Translational Myology, Padova, Italy and the European Journal of Translational Myology (EJTM). This year an EJTM Special will be dedicated to Muscle Fascia, an under looked topic, which merits more attention. Furthermore, this year the 2019SpringPaduaMuscleDays: Translational Myology and Mobility Medicine, an International Conference, was held March 28-30, 2019 in Euganei Hills and Padova (Italy). The abstracts of the 2019SpPMD, that are reported in the Myology News of EJTM 29(1), 2019, are excellent examples of translational research. Their excellent contents are at the level needed for approval by Ethical Committees, International Granting Agencies, and Editors of international journals, thanks to the high scientific profiles of researchers and clinicians who are eager to present their results at the PaduaMuscleDays.

Local effects of acupuncture on the median and ulnar nerves in patients with carpal tunnel syndrome: a pilot mechanistic study protocol

Background

While acupuncture’s mechanism of action is not fully understood, there is consensus that the nervous system plays a key role in processing its effects. This research is based on the structural theory of acupuncture, which aims to correlate the location of acupuncture points to peripheral nerves, spinal segments, and spinal plexuses. This mechanistic study explores the close anatomical association between the Pericardium meridian/median nerve and the Heart meridian/ulnar nerve in an attempt to produce electrophysiologic data measuring acupuncture’s direct, nerve-specific effect on the underlying nerves. Specifically, the purpose of this research is to use nerve conduction studies (NCSs) and quantitative sensory testing (QST) to assess for any local, nerve-specific effect of three acupuncture modalities on two anatomically distinct nerves in the forearm — the median and ulnar nerves — in subjects with carpal tunnel syndrome (CTS). The choice of CTS as an injured nerve model allows for comparisons between the response in an injured nerve (median) to that of a healthy one (ulnar).

Methods

Subjects with mild to moderate CTS will be randomized to three intervention groups: manual acupuncture and low- and high-frequency electroacupuncture. Each subject will receive two treatments, 1 week apart, to points in the forearm, which overlay the median nerve (Pericardium meridian) or the ulnar nerve (Heart meridian). Acupuncture will be administered in random order to minimize learning effects in sensory testing. During Week 1, baseline NCS and QST (vibration and cold detection thresholds) will be obtained in both nerve territories, followed by acupuncture and post-acupuncture NCS and QST measurements in both nerve territories. During Week 2, repeat baseline QST and NCS measurements will be obtained, followed by acupuncture to points overlying the nerve not treated in Week 1, followed by post-acupuncture NCS and QST measurements in both nerve distributions.

Discussion

This works aims to capture and characterize the local effects of acupuncture on an underlying nerve and compare them to those on a neighboring nerve. Quantifying acupuncture’s effects using physiologic parameters and discrete values could standardize treatment regimens and help assess their therapeutic effect.

Trial registration

ClinicalTrials.gov, NCT03036657. Registered on 30 January 2017. Retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3094-5) contains supplementary material, which is available to authorized users.

Morpho-functional implications of myofascial stretching applied to muscle chains: A case study

BACKGROUND

Most lesions of the soft tissues, especially those at the muscle level, are due to the lack of elasticity of the connective tissue and fascia. Stretching is one of the most commonly used methods of treatment for such musculoskeletal issues.

OBJECTIVE

This study tracks the effects of stretching on the electromyographic activity of muscle chains, applied to a 24-year-old athlete diagnosed with the Haglund's disease.

METHOD

For the evaluation, we used visual examination and surface electromyography (maximum volumetric isometric contraction). The therapeutic intervention consisted in the application of the static stretching positions, which intended the elongation of the shortened muscle chains. The treatment program had a duration of 2 months, with a frequency of 2 sessions per week and an average duration of 60 minutes.

RESULTS

The posterior muscle chains recorded an increase in the EMG activity, while the anterior muscle chains tended to diminish their EMG activity. As a result of the applied treatment, all the evaluated muscle chains recorded a rebalancing of the electromyographic activity, demonstrating the efficiency of stretching as a method of global treatment of muscle chains.

CONCLUSIONS

By analysing all the data, we have come to the conclusion that static stretching is an effective treatment method for shortened muscle chains.