Ultrasound imaging and Fascial Manipulation®: 'Adding a twist' on the ankle retinacula

BACKGROUND

Retinacula of the ankle are thickening of the deep fascia of the leg (crural fascia) and foot i.e. inseparable structures. Recent studies report their crucial role in functional stability and proprioception of the ankle.

CASE PRESENTATION

A 38-yr-old Caucasian man - with a history of lateral malleolus fracture 12 years ago, obesity and right ankle osteoarthritis - was referred to a physiatrist for a right ankle pain that had significantly worsened over the last year. During walking, the patient experienced stinging pain in the area of tibialis anterior and peroneus tertius muscles, and the superior extensor retinaculum. Magnetic resonance imaging and ultrasonography showed clear thicknening (2.05 mm) of the oblique superomedial band of the inferior extensor retinaculum. Sonopalpation was performed to precisely evaluate/confirm the site of maximum pain. Foot function index (FFI) score was 42.

RESULTS

Subsequently, the patient was prescribed fascial manipulation, and he had clinical improvement after the first session (FFI: 21). At 1-month follow-up, the patient was still asymptomatic without any functional limitation (FFI: 24). US imaging confirmed the decreased thickness of the oblique superomedial band of the extensor retinaculum (1.35 mm).

CONCLUSION

Fascial Manipulation® appears to be a useful tool to reduce thickness, stiffness, and pain in this case as displayed by the ultrasound Imaging.

Summaries of the Padua symposium on myofascial pain, fibromyalgia, and fascial pain disorders, June 2023, Aula Falloppio at the Human Anatomy Institute of the University of Padova, Italy

The International Symposium on Myofascial Pain, Fibromyalgia, and Fascial Pain Disorders was held at the University of Padua, Padua, Italy in June of 2023. This report presents a summary of the presentations from scientists and clinicians from around the world who presented to the symposium. The purpose of this symposium and resultant paper is improve health professional's recognition and understanding of the clinical characteristics, co-morbidities, mechanisms, and treatment strategies for these common conditions to better understand and manage their pain, dysfunction, and quality life.

Change in gliding properties of the iliotibial tract in hypermobile Ehlers-Danlos Syndrome

PURPOSE

Fascial changes in hypermobile Ehlers-Danlos syndrome (hEDS), a heritable connective tissue disorder, can be used visualized with sonoelastography. The purpose of this study was to explore the inter-fascial gliding characteristics in hEDS.

METHODS

In 9 subjects, the right iliotibial tract was examined with ultrasonography. Tissue displacements of the iliotibial tract were estimated from ultrasound data using cross-correlation techniques.

RESULTS

In hEDS subjects, shear strain was 46.2%, lower than those with lower limb pain without hEDS (89.5%) and in control subjects without hEDS and without pain (121.1%).

CONCLUSION

Extracellular matrix changes in hEDS may manifest as reduced inter-fascial plane gliding.

The Effect of Mechanical Stress on Hyaluronan Fragments' Inflammatory Cascade: Clinical Implications

It is a common experience, reported by patients who have undergone manual therapy that uses deep friction, to perceive soreness in treatment areas; however, it is still not clear what causes it and if it is therapeutically useful or a simple side effect. The purpose of this narrative review is to determine whether manual and physical therapies can catalyze an inflammatory process driven by HA fragments. The literature supports the hypothesis that mechanical stress can depolymerize into small pieces at low molecular weight and have a high inflammatory capacity. Many of these pieces are then further degraded into small oligosaccharides. Recently, it has been demonstrated that oligosaccharides are able to stop this inflammatory process. These data support the hypothesis that manual therapy that uses deep friction could metabolize self-aggregated HA chains responsible for increasing loose connective tissue viscosity, catalyzing a local HA fragment cascade that will generate soreness but, at the same time, facilitate the reconstitution of the physiological loose connective tissue properties. This information can help to explain the meaning of the inflammatory process as well as the requirement for it for the long-lasting resolution of these alterations.

Effectiveness of Deep Cervical Fascial Manipulation® and Sequential Yoga Poses on Pain and Function in Individuals with Mechanical Neck Pain: A Randomised Controlled Trial

BACKGROUND

This study aimed to investigate the effect of fascial manipulation (FM) of the deep cervical fascia (DCF) and sequential yoga poses (SYP) on pain and function in individuals with mechanical neck pain (MNP).

METHOD

Following the predefined criteria, ninety-nine individuals with MNP were recruited, randomised, and assigned to either the intervention group (IG) (n = 51) or the control group (CG) (n = 48). Individuals in the IG received FM (4 sessions in 4 weeks) and the home-based SYP (4 weeks). The CG participants received their usual care (cervical mobilisation and thoracic manipulation (4 sessions in 4 weeks) along with unsupervised therapeutic exercises (4 weeks). The participants underwent baseline and weekly follow-up measurements of pain using a numerical pain rating scale (NPRS) and elbow extension range of motion (EEROM) during the upper limb neurodynamic test 1 (ULNT1). The baseline and the fourth session follow-up measurements of the patient-specific functional scale (PSFS) and fear-avoidance behavior Questionnaire (FABQ) were also taken.

RESULTS

A repeated-measures ANOVA was performed. There were statistically significant differences between the IG and CG on the NPRS third and fourth sessions, with mean differences (MD) of -1.009 (p < 0.05) and -1.701 (p < 0.001), respectively. Regarding EEROM, there was a 20.120° difference (p < 0.001) in the fourth session between the groups. The MD in FABQ was -5.036 (p < 0.001), but there were no significant differences in PSFS between the groups during the follow-up.

CONCLUSION

FM and SYP can aid in reducing pain and fear-avoidance behaviour and improve the function and extensibility of the upper quarter region.

A model for personalized diagnostics for non-specific low back pain: the role of the myofascial unit

Low back pain (LBP) is the leading cause of disability worldwide. Most LBP is non-specific or idiopathic, which is defined as symptoms of unknown origin without a clear specific cause or pathology. Current guidelines for clinical evaluation are based on ruling out underlying serious medical conditions, but not on addressing underlying potential contributors to pain. Although efforts have been made to identify subgroups within this population based on response to treatment, a comprehensive framework to guide assessment is still lacking. In this paper, we propose a model for a personalized mechanism-based assessment based on the available evidence that seeks to identify the underlying pathologies that may initiate and perpetuate central sensitization associated with chronic non-specific low back pain (nsLBP). We propose that central sensitization can have downstream effects on the "myofascial unit", defined as an integrated anatomical and functional structure that includes muscle fibers, fascia (including endomysium, perimysium and epimysium) and its associated innervations (free nerve endings, muscle spindles), lymphatics, and blood vessels. The tissue-level abnormalities can be perpetuated through a vicious cycle of neurogenic inflammation, impaired fascial gliding, and interstitial inflammatory stasis that manifest as the clinical findings for nsLBP. We postulate that our proposed model offers biological plausibility for the complex spectrum of clinical findings, including tissue-level abnormalities, biomechanical dysfunction and postural asymmetry, ecological and psychosocial factors, associated with nsLBP. The model suggests a multi-domain evaluation that is personalized, feasible and helps rule out specific causes for back pain guiding clinically relevant management. It may also provide a roadmap for future research to elucidate mechanisms underlying this ubiquitous and complex problem.

Evidence for an association of serum microanalytes and myofascial pain syndrome

BACKGROUND

Myofascial Pain Syndrome (MPS) is a common pain disorder. Diagnostic criteria include physical findings which are often unreliable or not universally accepted. A precise biosignature may improve diagnosis and treatment effectiveness. The purpose of this study was to assess whether microanalytic assays significantly correlate with characteristic clinical findings in people with MPS.

METHODS

This descriptive, prospective study included 38 participants (25 women) with greater than 3 months of myofascial pain in the upper trapezius. Assessments were performed at a university laboratory. The main outcome measures were the Beighton Index, shoulder range of motion, strength asymmetries and microanalytes: DHEA, Kynurenine, VEGF, interleukins (IL-1b, IL-2, IL-4, IL-5, IL-7, IL-8, IL-13), growth factors (IGF-1, IGF2, G-CSF, GM-CSF), MCP-1, MIP-1b, BDNF, Dopamine, Noradrenaline, NPY, and Acetylcholine. Mann-Whitney test and Spearman's multivariate correlation were applied for all variables. The Spearman's analysis results were used to generate a standard correlation matrix and heat map matrix.

RESULTS

Mean age of participants was 32 years (20-61). Eight (21%) had widespread pain (Widespread Pain Index ≥ 7). Thirteen (34%) had MPS for 1-3 years, 14 (37%) 3-10 years, and 11 (29%) for > 10 years. The following showed strong correlations: IL1b,2,4,5,7,8; GM-CSF and IL 2,4,5,7; between DHEA and BDNF and between BDNF and Kynurenine, NPY and acetylcholine. The heat map analysis demonstrated strong correlations between the Beighton Index and IL 5,7, GM-CSF, DHEA. Asymmetries of shoulder and cervical spine motion and strength associated with select microanalytes.

CONCLUSION

Cytokine levels significantly correlate with selected clinical assessments. This indirectly suggests possible biological relevance for understanding MPS. Correlations among some cytokine clusters; and DHEA, BDNF kynurenine, NPY, and acetylcholine may act together in MPS. These findings should be further investigated for confirmation that link these microanalytes with select clinical findings in people with MPS.

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

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

Hyaluronan homeostasis and its role in pain and muscle stiffness

Hyaluronan (HA) is a glycosaminoglycan that consists of single-chain polymers of disaccharide units of glucuronic acid and N-acetylglucosamine. It is a chief constituent of the extracellular matrix. About 27% of the total HA in the body is expressed in the skeleton and connective tissue, while 8% is expressed in muscles. In physiological conditions, HA functions as a lubricant and viscoelastic shock absorber. Additionally, HA is part of complex cellular signaling which modulates nociception and inflammation. This study aims to understand the role that HA plays in the musculoskeletal system, specifically in muscles and the surrounding fascia. This review is also intended to further understand HA homeostasis and the process of its synthesis, degradation, and clearance from the local tissue. The authors examined muscle pain and stiffness as pathological conditions associated with HA accumulation.

Ultrasound imaging and Fascial Manipulation® for rigid retinacula in two cases of complex regional pain syndrome

Complex regional Pain Syndrome (CRPS) is a complex disease with articulate impact on the quality of life and its management is challenging. Ultrasound imaging can identify/assess different musculoskeletal structures that might have role in its pathogenesis. We present two cases of CRSP in whom B-mode ultrasonography and sonoelastography showed rigid retinacula associated with the symptomatology. Both patients were also/successfully treated with Fascial Manipulation®.

Densification: Hyaluronan Aggregation in Different Human Organs

Hyaluronan (HA) has complex biological roles that have catalyzed clinical interest in several fields of medicine. In this narrative review, we provide an overview of HA aggregation, also called densification, in human organs. The literature suggests that HA aggregation can occur in the liver, eye, lung, kidney, blood vessel, muscle, fascia, skin, pancreatic cancer and malignant melanoma. In all these organs, aggregation of HA leads to an increase in extracellular matrix viscosity, causing stiffness and organ dysfunction. Fibrosis, in some of these organs, may also occur as a direct consequence of densification in the long term. Specific imaging evaluation, such dynamic ultrasonography, elasto-sonography, elasto-MRI and T1ρ MRI can permit early diagnosis to enable the clinician to organize the treatment plan and avoid further progression of the pathology and dysfunction.

Fascial thickness and stiffness in hypermobile Ehlers-Danlos syndrome

There is a high prevalence of myofascial pain in people with hypermobile Ehlers-Danlos Syndrome (hEDS). The fascial origin of pain may correspond to changes in the extracellular matrix. The objective of this study was to investigate structural changes in fascia in hEDS. A series of 65 patients were examined prospectively-26 with hEDS, and 39 subjects with chronic neck, knee, or back pain without hEDS. The deep fascia of the sternocleidomastoid, iliotibial tract, and iliac fascia were examined with B-mode ultrasound and strain elastography, and the thicknesses were measured. Stiffness (strain index) was measured semi-quantitatively using elastography comparing fascia to muscle. Differences between groups were compared using one-way analysis of variance. hEDS subjects had a higher mean thickness in the deep fascia of the sternocleidomastoid compared with non-hEDS subjects. There was no significant difference in thickness of the iliac fascia and iliotibial tract between groups. Non-hEDS subjects with pain had a higher strain index (more softening of the fascia with relative stiffening of the muscle) compared with hEDS subjects and non-hEDS subjects without back or knee pain. In myofascial pain, softening of the fascia may occur from increase in extracellular matrix content and relative increase in stiffness of the muscle; this change is not as pronounced in hEDS.

Myofascial Injection Using Fascial Layer-Specific Hydromanipulation Technique (FLuSH) and the Delineation of Multifactorial Myofascial Pain

Background and objectives: The aims of this study were to delineate the contribution of specific fascial layers of the myofascial unit to myofascial pain and introduce the use of ultrasound-guided fascial layer-specific hydromanipulation (FLuSH) as a novel technique in the treatment of myofascial pain. Materials and Methods: The clinical data of 20 consecutive adult patients who underwent myofascial injections using FLuSH technique for the treatment of myofascial pain were reviewed. The FLuSH technique involved measuring the pain pressure threshold using an analog algometer initially and after each ultrasound guided injection of normal saline into the specific layers of the myofascial unit (superficial fascia, deep fascia, or muscle) in myofascial points corresponding with Centers of Coordination/Fusion (Fascial Manipulation^®). The outcome measured was the change in pain pressure threshold after injection of each specific fascial layer. Results: Deep fascia was involved in 73%, superficial fascia in 55%, and muscle in 43% of points. A non-response to treatment of all three layers occurred in 10% of all injected points. The most common combinations of fascial layer involvement were deep fascia alone in 23%, deep fascia and superficial fascia in 22%, and deep fascia and muscle in 18% of injected points. Each individual had on average of 3.0 ± 1.2 different combinations of fascial layers contributing to myofascial pain. Conclusions: The data support the hypothesis that multiple fascial layers are responsible for myofascial pain. In particular, for a given patient, pain may develop from discrete combinations of fascial layers unique to each myofascial point. Non-response to treatment of the myofascial unit may represent a centralized pain process. Adequate treatment of myofascial pain may require treatment of each point as a distinct pathologic entity rather than uniformly in a given patient or across patients.

Ultrasound imaging of a scar on the knee: Sonopalpation for fascia and subcutaneous tissues

Persistent scar pain associated with healed surgical incisions after a trauma is a common and potentially debilitating type of fascial pain. At present, there is no universally effective treatment for persistent surgical or post-trauma scar pain. Herein we describe the successful objective diagnosis of debilitating scar pain by Ultrasound (US) imaging. The sonopalpation of the fasciae and subcutaneous tissues seems to be relevant to diagnose the real cause of the pain and why not to monitor the treatment.

Inter and Intra Operator Reliability of Motor and Palpation Evaluation in Fascial Manipulation in individuals with coxarthrosis

OBJECTIVE

An inter and intra rater reliability (INTERR and INTRAR) study was designed.

METHODS

71 subjects, with primary hip coxarthrosis, were included and randomly divided in a study group (SG= 36) and a control group (CG= 35) to assess the efficacy of the Fascial Manipulation® (FM®) method. The primary objective was the assessment of INTERR and INTRAR about movement verification (MV) and palpation verification (PV) of FM® performed by two physiotherapists (PtA and PtB). The secondary objective was evaluate the efficacy of FM® through MV, PV and pain score. Pain was assessed using the Numeric Rating Scale (NRS). SG received three weekly sessions of FM® byPtA. PtB re-evaluated all the subjects at the end of the study.

RESULTS

Results of the INTERR analysis showed for SG: MV (ICC= 0.92, k= 72.7%); PV (ICC= 0.91, k= 75.7%). For CG : MV (ICC= 0.95, k= 84.2%); PV (ICC= 0.90, k= 75%). Results of the INTRAR analysis for SG reported: MV (ICC= 0.82, k= 74,8%); PV (ICC= 0.60, k= 46.8%); for CG: MV (ICC= 0.93, k= 78.7%); PV (ICC= 0.84, k= 53.3%). Statistical significance were reported in NRS (p = 0.001), MV (p = 0.0003) and PV (p < 0.0001) with better results for SG using "Intention To Treat" method.

DISCUSSION

This study demonstrates that FM® assessment procedures have a high reliability even if applied by practitioners with basic experience. Furthermore FM® treatment can improve pain and ROM in individuals with primary coxarthrosis.

Stiffness and echogenicity: Development of a stiffness-echogenicity matrix for clinical problem solving

The assessment of soft tissue stiffness is important to evaluate many neuromusculoskeletal conditions. Several tools have been proposed for the assessment of stiffness, but ultrasonography appears to be most practical. The reflection of ultrasound waves as it travels through tissue enables assessment of tissue echogenicity, which is influenced by the characteristics of the sound wave as well as the characteristics of the tissue through which it passes, such as the amount of fat and fibrous tissue. However, tissue stiffness is not directly proportional to its echogenicity. Hence evaluation of echogenicity, as a stand-alone technique, is inadequate to describe its mechanical properties. The aim of this manuscript is to present a method of combining echogenicity evaluation by ultrasound and stiffness evaluation by palpation to better describe the mechanical properties of muscle using a stiffness-echogenicity matrix.

Fascial entrapment neuropathy

Entrapment neuropathies are debilitating clinical conditions, creating significant morbidity in the upper and lower extremities in terms of pain, sensory abnormalities, and motor weakness, becoming a challenge to diagnose and treat. Because entrapments can have multiple origins, a misinterpretation of anatomy during examination can lead to incorrect diagnosis and treatment. This review addresses understanding of the anatomy of fascia that can play an important role in this syndrome. There is a specific microenvironment around the nerve composed of connective tissues that include deep fascia, intermuscular septa, epineurium, and perineurium. The microenvironmental modifications can be translated into change in mobility with consequence decreasing of the independency of the nerve from the surrounding structures lading to entrapments and "internal stretch lesion." The entrapments reported in this article reinforce the importance of fascia tissue in generating common symptoms that pose more difficult diagnostic challenges and may often be confused with more common clinical conditions. Clin. Anat. 32:883-890, 2019. © 2019 Wiley Periodicals, Inc.

A commentary review of the cost effectiveness of manual therapies for neck and low back pain

BACKGROUND & PURPOSE

Neck and low back pain (NLBP) are global health problems, which diminish quality of life and consume vast economic resources. Cost effectiveness in healthcare is the minimal amount spent to obtain acceptable outcomes. Studies on manual therapies often fail to identify which manual therapy intervention or combinations with other interventions is the most cost effective. The purpose of this commentary is to sample the dialogue within the literature on the cost effectiveness of evidence-based manual therapies with a particular focus on the neck and low back regions.

METHODS

This commentary identifies and presents the available literature on the cost effectiveness of manual therapies for NLBP. Key words searched were neck and low back pain, cost effectiveness, and manual therapy to select evidence-based articles. Eight articles were identified and presented for discussion.

RESULTS

The lack of homogeneity, in the available literature, makes difficult any valid comparison among the various cost effectiveness studies.

DISCUSSION

Potential outcome bias in each study is dependent upon the lens through which it is evaluated. If evaluated from a societal perspective, the conclusion slants toward "adequate" interventions in an effort to decrease costs rather than toward the most efficacious interventions with the best outcomes. When cost data are assessed according to a healthcare (or individual) perspective, greater value is placed on quality of life, the patient's beliefs, and the "willingness to pay."

Successful treatment of rotator cuff tear using Fascial Manipulation® in a stroke patient

Rotator cuff tear is a common disease affecting patients after stroke. It's a cause of pain and dysfunction that may compromise normal stroke rehabilitation. For many cases there is still controversy between whether to use surgical or conservative intervention. Treatment for cuff tears range from physical therapy to surgery. This paper describes for the first time the effect of Fascial Manipulation^® (FM^®) on rotator cuff tear in a post stroke patient. A 69 year old female stroke patient with full absence of distal components of the tendons of the rotator cuff, functional limitations on active movement of shoulder flexion and abduction of the left arm and perceived pain scored 10/10 on the Visual Analogic Scale, was assessed and treat with one session of FM^® A basic theory that explains the healing results of FM^® is that mechanoreceptors, such as spindle cells and other receptors, are located in the deep fascia and activated when movement are performed. Increased viscosity of the deep fascia and muscles due to increased viscosity of hyaluronic acid (HA) molecules prevents the normal gliding of fascia during movement inhibiting normal proprioception and muscle function.

Deformations experienced in the human skin, adipose tissue, and fascia in osteopathic manipulative medicine

CONTEXT

Osteopathic manipulative medicine techniques involve compressive and tangential forces to target the fascia. These forces are transmitted to the skin and adipose tissue before the fascia is encountered. Knowing the extent of deformation of these 2 tissue layers relative to the fascia will assist osteopathic physicians in evaluating techniques for manual therapies and adjusting these therapies to reduce patient discomfort and improve results.

OBJECTIVE

To determine the magnitude of the forces transmitted to the skin, adipose tissue, and fascia, and to determine the magnitude of deformation produced in the skin and adipose tissue relative to the fascia using a mathematical model.

METHODS

The large deformation theory of elasticity, valid for 3-dimensional deformations, was used to evaluate the forces that need to be applied such that a specified deformation is produced in any region of the skin, adipose tissue, or fascia layers. Similarly, if the forces are specified, then the deformation produced can be determined.

RESULTS

The normal and tangential forces required to produce a deformation of 9% compression and 4% shear for the skin were 50 N and 11 N, respectively. Normal and tangential forces of about 100 N and 22 N were found for a similar deformation of fascia. For adipose tissue, these forces were 36 N and 8 N, respectively. In addition, the skin experienced more compression and shear-about 1.5 times as much as the fascia, and the adipose tissue experienced about 2.5 to 3.5 times the deformation of the fascia and 50% more than the skin when a given force was applied to the skin.

CONCLUSION

The forces applied to the surface of the skin were transmitted through this layer and the adipose layer entirely to the fascia. Therefore, the skin and adipose tissue experienced the same magnitude of force as the fascia. However, the skin and adipose tissue experienced more compression and shear than the fascia.

Fascial Manipulation® for chronic aspecific low back pain: a single blinded randomized controlled trial

BACKGROUND

The therapeutic approach to chronic aspecific low back pain (CALBP) has to consider the multifactorial aetiology of the disorder. International guidelines do not agree on unequivocal treatment indications. Recommendations for fascial therapy are few and of low level evidence but several studies indicate strong correlations between fascial thickness and low back pain. This study aims at comparing the effectiveness of Fascial Manipulation® associated with a physiotherapy program following guidelines for CALBP compared to a physiotherapy program alone.

METHODS

24 subjects were randomized into two groups, both received eight treatments over 4 weeks. Outcomes were measured at baseline, at the end of therapy and at a 1 month and a 3 months follow-up. Pain was measured with the visual analogue scale (VAS) and the brief pain inventory (BPI), function with the Rolland-Morris disability questionnaire (RMDQ), state of well-being with the short-form 36 health-survey (SF-36). The mean clinical important difference (MCID) was also measured.

RESULTS

Patients receiving Fascial Manipulation® showed statistically and clinically significant improvements at the end of care for all outcomes, in the short (RMDQ, VAS, BPI) and medium term for VAS and BPI compared to manual therapy. The MCID show significant improvements in the means and percentage of subjects in groups in all outcomes post-treatment, in the short and medium term.

CONCLUSION

Fascial tissues were implicated in the aetiology of CALBP and treatment led to decreased symptomatic, improved functional and perceived well-being outcomes that were of greater amplitude compared to manual therapy alone.

Fascial Manipulation® for chronic aspecific low back pain: a single blinded randomized controlled trial

BACKGROUND

The therapeutic approach to chronic aspecific low back pain (CALBP) has to consider the multifactorial aetiology of the disorder. International guidelines do not agree on unequivocal treatment indications. Recommendations for fascial therapy are few and of low level evidence but several studies indicate strong correlations between fascial thickness and low back pain. This study aims at comparing the effectiveness of Fascial Manipulation® associated with a physiotherapy program following guidelines for CALBP compared to a physiotherapy program alone.

METHODS

24 subjects were randomized into two groups, both received eight treatments over 4 weeks. Outcomes were measured at baseline, at the end of therapy and at a 1 month and a 3 months follow-up. Pain was measured with the visual analogue scale (VAS) and the brief pain inventory (BPI), function with the Rolland-Morris disability questionnaire (RMDQ), state of well-being with the short-form 36 health-survey (SF-36). The mean clinical important difference (MCID) was also measured.

RESULTS

Patients receiving Fascial Manipulation® showed statistically and clinically significant improvements at the end of care for all outcomes, in the short (RMDQ, VAS, BPI) and medium term for VAS and BPI compared to manual therapy. The MCID show significant improvements in the means and percentage of subjects in groups in all outcomes post-treatment, in the short and medium term.

CONCLUSION

Fascial tissues were implicated in the aetiology of CALBP and treatment led to decreased symptomatic, improved functional and perceived well-being outcomes that were of greater amplitude compared to manual therapy alone.

Viscoelastic Properties of Hyaluronan in Physiological Conditions

Hyaluronan (HA) is a high molecular weight glycosaminoglycan of the extracellular matrix (ECM), which is particularly abundant in soft connective tissues. Solutions of HA can be highly viscous with non-Newtonian flow properties. These properties affect the movement of HA-containing fluid layers within and underlying the deep fascia. Changes in the concentration, molecular weight, or even covalent modification of HA in inflammatory conditions, as well as changes in binding interactions with other macromolecules, can have dramatic effects on the sliding movement of fascia. The high molecular weight and the semi-flexible chain of HA are key factors leading to the high viscosity of dilute solutions, and real HA solutions show additional nonideality and greatly increased viscosity due to mutual macromolecular crowding. The shear rate dependence of the viscosity, and the viscoelasticity of HA solutions, depend on the relaxation time of the molecule, which in turn depends on the HA concentration and molecular weight. Temperature can also have an effect on these properties. High viscosity can additionally affect the lubricating function of HA solutions. Immobility can increase the concentration of HA, increase the viscosity, and reduce lubrication and gliding of the layers of connective tissue and muscle. Over time, these changes can alter both muscle structure and function. Inflammation can further increase the viscosity of HA-containing fluids if the HA is modified via covalent attachment of heavy chains derived from Inter-α-Inhibitor. Hyaluronidase hydrolyzes HA, thus reducing its molecular weight, lowering the viscosity of the extracellular matrix fluid and making outflow easier. It can also disrupt any aggregates or gel-like structures that result from HA being modified. Hyaluronidase is used medically primarily as a dispersion agent, but may also be useful in conditions where altered viscosity of the fascia is desired, such as in the treatment of muscle stiffness.

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.

Is the cervical fascia an anatomical proteus?

The cervical fasciae have always represented a matter of debate. Indeed, in the literature, it is quite impossible to find two authors reporting the same description of the neck fascia. In the present review, a historical background was outlined, confirming that the Malgaigne's definition of the cervical fascia as an anatomical Proteus is widely justified. In an attempt to provide an essential and a more comprehensive classification, a fixed pattern of description of cervical fasciae is proposed. Based on the morphogenetic criteria, two fascial groups have been recognized: (1) fasciae which derive from primitive fibro-muscular laminae (muscular fasciae or myofasciae); (2) fasciae which derive from connective thickening (visceral fasciae). Topographic and comparative approaches allowed to distinguish three different types of fasciae in the neck: the superficial, the deep and the visceral fasciae. The first is most connected to the skin, the second to the muscles and the third to the viscera. The muscular fascia could be further divided into three layers according to the relationship with the different muscles.

Conservative treatment of carpal tunnel syndrome: comparison between laser therapy and Fascial Manipulation(®)

The etiopathogenesis of Carpal Tunnel Syndrome (CTS) is multifactorial and most cases are classified as idiopathic (Thurston 2013). A randomized controlled trial was performed to compare the effectiveness of Fascial Manipulation(®) (FM) and Low-Level Laser Therapy (LLLT) for CTS. This prospective trial included 42 patients (70 hands with symptoms) with clinical and electroneuromyographic diagnosis of CTS. The patients were randomly assigned to receive multiple sessions of FM or multiple session of LLLT. The Visual Analogic Scale (VAS) and Boston Carpal Tunnel Questionnaire (BCTQ) were performed at baseline, end of treatment and after three months. The group that received FM showed a significant reduction in subjective pain perception and an increased function assessed by BCTQ at the end of the treatment and follow-up. The group that received LLLT showed an improvement in the BCTQ at the end of the treatment but the improvement level was not sustained at the three month follow-up. FM is a valid alternative treatment for CTS.

Mathematical analysis of the flow of hyaluronic acid around fascia during manual therapy motions

CONTEXT

More research is needed to understand the flow characteristics of hyaluronic acid (HA) during motions used in osteopathic manipulative treatment and other manual therapies.

OBJECTIVE

To apply a 3-dimensional mathematical model to explore the relationship between the 3 manual therapy motions (constant sliding, perpendicular vibration, and tangential oscillation) and the flow characteristics of HA below the fascial layer.

METHODS

The Squeeze Film Lubrication theory of fluid mechanics for flow between 2 plates was used, as well as the Navier-Stokes equations.

RESULTS

The fluid pressure of HA increased substantially as fascia was deformed during manual therapies. There was a higher rate of pressure during tangential oscillation and perpendicular vibration than during constant sliding. This variation of pressure caused HA to flow near the edges of the fascial area under manipulation, and this flow resulted in greater lubrication. The pressure generated in the fluid between the muscle and the fascia during osteopathic manipulative treatment causes the fluid gap to increase. Consequently, the thickness between 2 fascial layers increases as well. Thus, the presence of a thicker fluid gap can improve the sliding system and permit the muscles to work more efficiently.

CONCLUSION

The mathematical model employed by the authors suggests that inclusion of perpendicular vibration and tangential oscillation may increase the action of the treatment in the extracellular matrix, providing additional benefits in manual therapies that currently use only constant sliding motions.

Squeeze film lubrication for non-Newtonian fluids with application to manual medicine

In this paper, we computed fluid pressure and force on fascia sheets during manual therapy treatments using Squeeze Film Lubrication theory for non-Newtonian fluids. For this purpose, we developed a model valid for three dimensional fluid flow of a non-Newtonian liquid. Previous models considered only one-dimensional flows in two dimensions. We applied this model to compare the one-dimensional flow of HA, considered as a lubricating fluid, around or within the fascia during sliding, vibration, and back-and-forth sliding manipulation treatment techniques. The fluid pressure of HA increases dramatically as fascia is deformed during manual therapies. The fluid force increases more during vertical vibratory manipulation treatment than in constant sliding, and back and forth motion. The variation of fluid pressure/force causes HA to flow near the edges of the fascial area under manipulation in sliding and back and forth motion which may result in greater lubrication. The fluid pressure generated in manual therapy techniques may improve sliding and permit muscles to work more efficiently.

The anatomical and functional relation between gluteus maximus and fascia lata

There is not full agreement regarding the distal insertions of the gluteus maximus muscle (GM), particularly the insertions into the iliotibial band and lateral intermuscular septum. 6 cadavers, 4 males and 2 females, mean age 69 yr, were dissected to evaluate the insertions of the GM into the iliotibial band, fascia lata, lateral intermuscular septum and femur. The iliotibial band is a reinforcement of the fascia lata and cannot be separated from it. Its inner side is in continuity with the lateral intermuscular septum, which divides the quadriceps from the hamstring. In all subjects the gluteus maximus presented a major insertion into the fascia lata, so large that the iliotibial tract could be considered a tendon of insertion of the gluteus maximus. The fascial insertion of the gluteus maximus muscle could explain the transmission of the forces from the thoracolumbar fascia to the knee.

Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique

A randomized controlled trial was performed to compare the short-term effectiveness of botulinum toxin injections and physiatric treatment provided by means of Fascial Manipulation techniques in the management of myofascial pain of jaw muscles. Thirty patients with a Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) diagnosis of myofascial pain were randomized to receive either single-session botulinum toxin injections (Group A) or multiple-session Fascial Manipulation (Group B). Maximum pain levels (VAS ratings) and jaw range of motion in millimeters (maximum mouth opening, protrusion, right and left laterotrusion) were assessed at baseline, at the end of treatment, and at a three-month follow-up. Both treatment protocols provided significant improvement over time for pain symptoms. The two treatments seem to be almost equally effective, Fascial Manipulation being slightly superior to reduce subjective pain perception, and botulinum toxin injections being slightly superior to increase jaw range of motion. Differences between the two treatment protocols as to changes in the outcome parameters at the three-months follow-up were not relevant clinically. Findings from the present investigation are in line with literature data supporting the effectiveness of a wide spectrum of conservative treatment approaches to myofascial pain of the jaw muscles. Future studies on larger samples over a longer follow-up span are needed on the way to identify tailored treatment strategies.

Perfusion computed tomography assessments of peri-enhancing brain tissue in high-grade gliomas

PURPOSE

This study was undertaken to identify tumoural infiltration of peri-enhancing brain tissue in patients with glioblastoma by means of perfusion computed tomography (PCT) parameters, cerebral blood volume (CBV) and permeability surface (PS).

MATERIALS AND METHODS

Eight patients with surgically treated glioblastoma who were eligible for radiotherapy and nine patients with brain metastases from lung and breast cancer underwent CT before and after injection of contrast medium. CBV and PS were calculated in the contrast-enhancing lesion area, in the area of perilesional oedema and in the normal-appearing white matter (NAWM), normalised to contralateral symmetrical areas.

RESULTS

No significant differences were found for normalised CBV (nCBV) and nPS in NAWM regions between metastasis and glioma. Significant differences in nPS (p<0.005) were found between the typically vasogenic oedema surrounding the metastases and signal alteration surrounding the glial neoplasm. On the contrary, no significant differences were detected in the same areas for nCBV.

CONCLUSIONS

PCT can analyse the histopathological substrate underlying the hypodense peritumoural halo and differentiate between vasogenic oedema and neoplastic infiltration on the basis of the PS parameter. In our study, PS was more informative than CBV. These findings can be used to integrate plans for radiation therapy and/or surgery.

Predictors of attack severity and duration in multiple sclerosis: a prospective study

Objective:

To evaluate predictors of severity and duration of early Multiple Sclerosis (MS) attacks.

Methods:

We analyzed 248 attacks in 95 patients in a prospective study. Severity: the difference between the EDSS score at the day of maximum worsening and the EDSS score before the onset of the attack. Duration: the time between the date of onset of the first symptom and the date of maximum improvement of the last symptom.

Results:

The number of involved Functional Systems (FS), FS type (brainstem and pyramidal), and total attack duration were linked to severity. Number of FS involved, FS type (sphincteric and sensory), and severity of the attack were related to duration. Neither severity nor duration were correlated to other predictors: gender, age and season at attack onset, speed of onset, infections in the preceding month, age at first attack, season of birth and first attack, CSF examination, first brain MRI, recovery from the first attack. In the multivariate analysis, the Odds Ratio (OR) and Confidence Intervals (CI) for severe attacks was 3.6, 1.7-7.7 for involvement of pyramidal FS, 2.6, 1.2-6.0 for brainstem and 2.5, 1.2-5.3 for long attack duration. Sphincteric (4.4; 1.7-11.0) and sensory FS (1.8; 1.0-3.2) were the only variables explaining duration. The probability of a second moderate/severe or long attack was not influenced by severity or duration of the first.

Conclusion:

FS are predictive of severity and duration of early MS attacks. Severity and duration of the first attack do not predict severity and duration of the second.