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Creighton D, Fausone D, Swanson B, Young W, Nolff S, Ruble A, Hassan N, Soley E. Myofascial and discogenic origins of lumbar pain: A critical review. J Man Manip Ther 2023; 31:435-448. [PMID: 37503571 PMCID: PMC10642329 DOI: 10.1080/10669817.2023.2237739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/11/2023] [Indexed: 07/29/2023] Open
Abstract
The purpose of this three-part narrative review is to examine the anatomy of, and the research which supports, either the lumbar myofascia or intervertebral disc (IVD) as principal sources of our patient's low back pain. A comprehensive understanding of anatomical lumbar pain generators in combination with the current treatment-based classification system will further improve and enhance clinical decision-making skills. Section I reviews the anatomy of the spinal myofascia, myofascial sources of lumbar pain, and imaging of myofascial tissues. Part II reviews the anatomy of the IVD, examines the IVD as a potential lumbar pain generator, and includes detailed discussion on Nerve Growth Factor, Inflammatory Cytokines, Vertebral End Plates and Modic change, Annular tears, and Discogenic instability. Part III looks at the history of myofascial pain, lab-based research and myofascial pain, and various levels of discogenic pain provocation research including animal, laboratory and human subjects. Our review concludes with author recommendations on developing a comprehensive understanding of altered stress concentrations affecting the posterior annulus fibrosis, neo-innervation of the IVD, inflammatory cytokines, discogenic instability, and how this knowledge can complement use of the Treatment-Based Classification System.
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Kodama Y, Masuda S, Ohmori T, Kanamaru A, Tanaka M, Sakaguchi T, Nakagawa M. Response to Mechanical Properties and Physiological Challenges of Fascia: Diagnosis and Rehabilitative Therapeutic Intervention for Myofascial System Disorders. Bioengineering (Basel) 2023; 10:bioengineering10040474. [PMID: 37106661 PMCID: PMC10135675 DOI: 10.3390/bioengineering10040474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 04/06/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
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.
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Affiliation(s)
- Yuya Kodama
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, 1-10-25 Midorimachi, Minamiku, Okayama 702-8055, Japan
| | - Shin Masuda
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, 1-10-25 Midorimachi, Minamiku, Okayama 702-8055, Japan
| | - Toshinori Ohmori
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, 1-10-25 Midorimachi, Minamiku, Okayama 702-8055, Japan
| | - Akihiro Kanamaru
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, 1-10-25 Midorimachi, Minamiku, Okayama 702-8055, Japan
| | - Masato Tanaka
- Department of Orthopaedic Surgery, Okayama Rosai Hospital, 1-10-25 Midorimachi, Minamiku, Okayama 702-8055, Japan
| | - Tomoyoshi Sakaguchi
- Department of Central Rehabilitation, Okayama Rosai Hospital, 1-10-25 Midorimachi, Minamiku, Okayama 702-8055, Japan
| | - Masami Nakagawa
- Department of Central Rehabilitation, Okayama Rosai Hospital, 1-10-25 Midorimachi, Minamiku, Okayama 702-8055, Japan
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Fascial Innervation: A Systematic Review of the Literature. Int J Mol Sci 2022; 23:ijms23105674. [PMID: 35628484 PMCID: PMC9143136 DOI: 10.3390/ijms23105674] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/13/2022] [Accepted: 05/16/2022] [Indexed: 02/06/2023] Open
Abstract
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.
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Ryskalin L, Morucci G, Natale G, Soldani P, Gesi M. Molecular Mechanisms Underlying the Pain-Relieving Effects of Extracorporeal Shock Wave Therapy: A Focus on Fascia Nociceptors. Life (Basel) 2022; 12:life12050743. [PMID: 35629410 PMCID: PMC9146519 DOI: 10.3390/life12050743] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/14/2022] [Accepted: 05/15/2022] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Larisa Ryskalin
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 55, 56126 Pisa, Italy
- Center for Rehabilitative Medicine "Sport and Anatomy", University of Pisa, 56121 Pisa, Italy
| | - Gabriele Morucci
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 55, 56126 Pisa, Italy
- Center for Rehabilitative Medicine "Sport and Anatomy", University of Pisa, 56121 Pisa, Italy
| | - Gianfranco Natale
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 55, 56126 Pisa, Italy
- Center for Rehabilitative Medicine "Sport and Anatomy", University of Pisa, 56121 Pisa, Italy
- Museum of Human Anatomy "Filippo Civinini", University of Pisa, 56126 Pisa, Italy
| | - Paola Soldani
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 55, 56126 Pisa, Italy
- Center for Rehabilitative Medicine "Sport and Anatomy", University of Pisa, 56121 Pisa, Italy
| | - Marco Gesi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 55, 56126 Pisa, Italy
- Center for Rehabilitative Medicine "Sport and Anatomy", University of Pisa, 56121 Pisa, Italy
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Sinhorim L, Amorim MDS, Ortiz ME, Bittencourt EB, Bianco G, da Silva FC, Horewicz VV, Schleip R, Reed WR, Mazzardo-Martins L, Martins DF. Potential Nociceptive Role of the Thoracolumbar Fascia: A Scope Review Involving In Vivo and Ex Vivo Studies. J Clin Med 2021; 10:jcm10194342. [PMID: 34640360 PMCID: PMC8509394 DOI: 10.3390/jcm10194342] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/09/2021] [Accepted: 09/20/2021] [Indexed: 12/23/2022] Open
Abstract
Nociceptive innervation of the thoracolumbar fascia (TLF) has been investigated over the past few decades; however, these studies have not been compiled or collectively appraised. The purpose of this scoping review was to assess current knowledge regarding nociceptive innervation of the TLF to better inform future mechanistic and clinical TLF research targeting lower back pain (LBP) treatment. PubMed, ScienceDirect, Cochrane, and Embase databases were searched in January 2021 using relevant descriptors encompassing fascia and pain. Eligible studies satisfied the following: (a) published in English; (b) preclinical and clinical (in vivo and ex vivo) studies; (c) original data; (d) included quantification of at least one TLF nociceptive component. Two-phase screening procedures were conducted by a pair of independent reviewers, after which data were extracted and summarized from eligible studies. The search resulted in 257 articles of which 10 met the inclusion criteria. Studies showed histological evidence of nociceptive nerve fibers terminating in lower back fascia, suggesting a TLF contribution to LBP. Noxious chemical injection or electrical stimulation into fascia resulted in longer pain duration and higher pain intensities than injections into subcutaneous tissue or muscle. Pre-clinical and clinical research provides histological and functional evidence of nociceptive innervation of TLF. Additional knowledge of fascial neurological components could impact LBP treatment.
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Affiliation(s)
- Larissa Sinhorim
- Experimental Neuroscience Laboratory (LaNEx), University of Southern Santa Catarina, Palhoça 88137-272, Brazil; (L.S.); (M.d.S.A.); (M.E.O.); (E.B.B.); (G.B.); (V.V.H.); (D.F.M.)
- Postgraduate Program in Health Sciences, University of Southern Santa Catarina, Palhoça 88137-272, Brazil
| | - Mayane dos Santos Amorim
- Experimental Neuroscience Laboratory (LaNEx), University of Southern Santa Catarina, Palhoça 88137-272, Brazil; (L.S.); (M.d.S.A.); (M.E.O.); (E.B.B.); (G.B.); (V.V.H.); (D.F.M.)
- Human Movement Sciences Graduate Program, College of Health and Sport Science at Santa Catarina State University, Florianópolis 88080-350, Brazil
| | - Maria Eugênia Ortiz
- Experimental Neuroscience Laboratory (LaNEx), University of Southern Santa Catarina, Palhoça 88137-272, Brazil; (L.S.); (M.d.S.A.); (M.E.O.); (E.B.B.); (G.B.); (V.V.H.); (D.F.M.)
- Postgraduate Program in Health Sciences, University of Southern Santa Catarina, Palhoça 88137-272, Brazil
| | - Edsel Balduino Bittencourt
- Experimental Neuroscience Laboratory (LaNEx), University of Southern Santa Catarina, Palhoça 88137-272, Brazil; (L.S.); (M.d.S.A.); (M.E.O.); (E.B.B.); (G.B.); (V.V.H.); (D.F.M.)
- Coastal Health Institute, Jacksonville, FL 32224, USA
| | - Gianluca Bianco
- Experimental Neuroscience Laboratory (LaNEx), University of Southern Santa Catarina, Palhoça 88137-272, Brazil; (L.S.); (M.d.S.A.); (M.E.O.); (E.B.B.); (G.B.); (V.V.H.); (D.F.M.)
- Research Laboratory of Posturology and Neuromodulation RELPON, Department of Human Neuroscience, Sapienza University, 00147 Rome, Italy
- Istituto di Formazione in Agopuntura e Neuromodulazione IFAN, 00147 Roma, Italy
| | | | - Verônica Vargas Horewicz
- Experimental Neuroscience Laboratory (LaNEx), University of Southern Santa Catarina, Palhoça 88137-272, Brazil; (L.S.); (M.d.S.A.); (M.E.O.); (E.B.B.); (G.B.); (V.V.H.); (D.F.M.)
- Postgraduate Program in Health Sciences, University of Southern Santa Catarina, Palhoça 88137-272, Brazil
| | - Robert Schleip
- Department of Sport and Health Sciences, Technical University of Munich, 80799 Munich, Germany
- Department for Medical Professions, DIPLOMA University of Applied Sciences, 37242 Bad Sooden-Allendorf, Germany
- Correspondence: ; Tel.: +49-89-346016
| | - William R. Reed
- Department of Physical Therapy, University of Alabama at Birmingham, Birmingham, AL 35294, USA;
- Rehabilitation Science Program, Departments of Physical and Occupational Therapy, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Leidiane Mazzardo-Martins
- Postgraduate Program in Neuroscience, Center of Biological Sciences, Federal University of Santa Catarina, Florianópolis 88040-900, Brazil;
| | - Daniel F. Martins
- Experimental Neuroscience Laboratory (LaNEx), University of Southern Santa Catarina, Palhoça 88137-272, Brazil; (L.S.); (M.d.S.A.); (M.E.O.); (E.B.B.); (G.B.); (V.V.H.); (D.F.M.)
- Postgraduate Program in Health Sciences, University of Southern Santa Catarina, Palhoça 88137-272, Brazil
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