fascia: what, where, why, when, and how?

FASCIA: WHAT, WHERE, WHY, WHEN, AND HOW?

“One has to ask the question: What is the difference between a ‘normal’ muscle injury and a chronic pain response? We first have to understand when any soft tissue (muscle, tendons, nerves, fascia, ligaments) are damaged, the body produces scar tissue (also referred to as adhesions). In the majority of the population this response will stabilize within four to eight weeks, depending on the severity of the injury.

In many patients, especially those suffering from mixed connective tissue disorders (Raynaud’s, Fibromyalgia, Epstein-Barr “mono”, Chronic Fatigue, etc.), the scar response is amplified many times resulting in ‘keloid-type’ scarring almost like cobwebs enveloping the muscles, nerves, and joints of the affected areas. This myofascial- bramble or cob-web suffocates the normal blood flow and nutrition to the area. Consequently, the tissues start to ‘dry-out’, and the lubrication between the different structures decreases.

This results in ‘rubbing’ of the tissues, producing even more scar tissue and adhesions. The patient complains of stiffness, tightness, diffuse-multiple pain and trigger points. Their sleep patterns deteriorate. Consequently the body’s ability to produce pain-killing endorphins and cortisoids is decreased. The patients own ability to modulate and control their own pain is further compromised if the ‘adhesions or cob-webs’ restrict the normal function of the nerve to the muscle.

This can lead to occult neuropathy of the segmental nerves that supply the affected muscle. The muscle will then start to degenerate. Cannon’s Law of Physiology states that nerve damage to a muscle produces an increase sensitivity to pain – i.e. trigger point tenderness. The Chronic pain cycle has begun.” Canadian PT David Moffitt from Chronic Pain – The Adhesion/Scar Tissue Connection

I was recently asked by a prospective LONG DISTANCE PATIENT whether or not there is any science concerning the validity, specificity, and reliability when it comes to identifying fascial adhesions or restrictions.  My answer was simple.  Probably not, and that’s OK.  While I am a huge fan of research, in many ways our fascination with EVIDENCE-BASED MEDICINE has hogtied treating physicians — particularly true with those doing bodywork or FUNCTIONAL MEDICINE (or chiropractic — shhhhhhh). 

Back when I started practice in 1991, the big knock against CHIROPRACTIC was always that we had no “evidence” to back up what we do.  Although it is frequently not the case (HERE), this is an instance where science has lagged behind what’s going on in clinical practice. I treat my patients in an ever-evolving manner, looking constantly at, but never completely relying on EBM (I have attempted to create my own — HERE). 

If I were treating using DANGEROUS DRUGS (including THE BIG FIVE), it would be one thing.  I’m not. What I do in my clinic will either work or it won’t work — there’s not much middle ground (HERE) and to the best of my knowledge, no one has ever gotten worse.  If I were to avoid any sort of treatment that doesn’t have a number of studies to back it up, I wouldn’t be getting the results you can see in the previous link.

The cool thing is, however, studies on fascia are starting to accumulate across the spectrum of peer-review (neurology journals, cellular biology journals, endocrinology journals, biomechanics journals, engineering journals, etc, etc).  A great example of this phenomenon has to do with Tom Meyers’ ANATOMY TRAINS. If he had not chosen to treat patients as he does simply because it works, no one may have ever done the fascia studies seen in the previous link.  Speaking of FASCIA, some of the characteristics of fascia include…..

• FASCIA IS CONTRACTILE:  For the longest time it was believed that fascia was a completely passive tissue — it sat there and held the ‘important’ antatomy together.  Thanks to the work of Dr. Robert Schleip and the Fascia Research Group (part of the Neurosurgical Department of Ulm University in Germany), we know differently.  Their 2014 paper, Clinical Relevance of Fascial Tissue and Dysfunctions states, “The classical concept of its mere passive role in force transmission has recently been disproven. Fascial tissue contains contractile elements enabling a modulating role in force generation and also mechanosensory fine-tuning.”  And although he was talking about this phenomenon back in 2005’s Active Fascial Contractility….., Schleip stated in another 2014 paper, this one from the journal Anesthesia, “Using immunohistochemical staining, α-smooth muscle actin-positive cells (myofibroblasts) were detected in the epi-, endo- and perimysium of human fascial tissue. Force measurements on isolated fascial strips revealed that myofascial tissue is actively regulated by myofibroblasts, thereby influencing the biomechanical properties of skeletal muscle.”  We’ll talk more about FIBROBLASTS shortly, but suffice it to say that fascial contractility can affect both movement and pain via chronic contraction and even spasm.

• FASCIA CONNECTS YOU TO EVERY OTHER PART OF YOU AND TRANSMITS MOVEMENT:  This is not simply cliche.  Listen to what Larry Steinbeck, PT says on Dr. Mike Reinold’s blog post, Fascial Manipulation (Reinold is the PT for the Atlanta Falcons).  “Concepts have moved away from a strictly muscle insertion and origin viewpoint where a muscle moves a bone/joint, towards a function of a myofascial unit. A myofascial unit is described as group of motor units that activate fibers that can move a body segment in a specific direction. This includes the joint moved, the nerves and circulatory system and the fascia that connect it all.  Studies show that up to 40% of force generated by a muscle contraction is not directed toward the origin and insertion of the muscle, but rather is transmitted to agonistic and antagonistic muscles through endo-, epi- and perimysium.”  This means that a chronic contraction of the spinal errectors (low back muscles) can affect the rest of your spine as well as your limbs.  And because it’s all connected, it creates one of those everything-affects-everything scenarios (HERE).

• FASCIA CONNECTS YOU TO EVERY OTHER PART OF YOU AND TRANSMITS MOVEMENT PART II:   Listen to the conclusions of this 2005 study from Germany (The Fascial Network: An Exploration of its Load Bearing Capacity and its Potential Role as a Pain Generator). “Fascial force transmission is an important player in human biomechanics.  While the tensional load bearing function of tendons and ligaments has never been disputed, recent publications revealed that muscles, via their epimysia, also transmit a significant portion of their force to laterally positioned tissues such as to adjacent synergistic muscles and also – more surprisingly – to antagonistic muscles. The reported contribution of transversus abdominis to dynamic lumbar spinal stability has been associated with the load-bearing function of the middle layer of the lumbar fasciae in humans. Similarly, EMG based measurements of the ‘flexion – relaxation phenomenon’ suggest a strong tensional load-bearing function of dorsal fascial tissues during healthy forward bending of the human trunk. This load shifting is reportedly absent in low back pain patients.”  Honestly, most people who have even slightly studies fascia realize this on a general level.

• FASCIA CREATES SLICK SURFACES THAT ALLOW TISSUES TO GLIDE ON EACH OTHER:  We just talked about the epimysim, perimysium, and endomysium (HERE is more information on these tissues), which are all fascia that go by different names.  It is critical that at least on their surface, all tissues have fluidity as opposed to friction (see the video at top of page).  When there is friction (drag), several bad things start happening to fascia.  Firstly, it begins become more solid and less liquid (a dehydrating effect).  Secondly, it becomes thicker (unfortunately this excess thickness makes it weaker instead of stronger).  The thickening and continuous irritation can lead to both adhesion and restriction.  The end result is a “TETHERING EFFECT” not only on the musculoskeletal system, but the nervous system and blood-vascular system as well.

• ADHESIONS ADD UP, RESULTING IN SCAR TISSUE THAT THE MEDICAL COMMUNITY REFERS TO AS FIBROSIS:  SCAR TISSUE is essentially the accumulation of what the medical community refers to as FIBROSIS (some say that this thought process is incorrect and that we should be calling it “DENSIFICATION“).  Regardless of what you call it (HERE), the process is always the same.  INFLAMMATION leads to fibrosis, and fibrosis causes DEGENERATION. Repeat.  This is true of all tissues (organs included), not just fascia.  You’ll see this process in the bullet on proprioception as well.

• FASCIA IS ITSELF CAN GENERATE PAIN:   This bullet is universally held by all except those who say that all pain is solely a function of the brain, and the brain is all we need to deal with to solve CHRONIC PAIN. But for those who aren’t buying, the journal Experimental Brain Research (Increased Pain from Muscle Fascia Following Eccentric Exercise) concluded almost a decade ago that when it comes to post-exercise soreness, “fascia rather than muscle tissue is important.”  Like I said, there are not many debating this bullet point.  In fact, I have been hearing since my days at Kansas State University (class of ’88) that fascia in the form of periosteum, is the most pain-sensitive tissue in the body.  Add this to the next bullet and you have a potential disaster on your hands.

• THIS SCAR TISSUE ITSELF CAN BE EXTREMELY PAIN-SENSITIVE:  While this bullet does not pertain solely to fascia, I felt I needed to included it based on the work of renowned neurologist CHAN GUNN who says that scar tissue is potentially over 1,000 times more pain sensitive than normal tissue.

• BECAUSE OF FASCIA, PAIN IS OFTEN TIMES FELT DISTANT FROM THE ACTUAL ADHESION:  If you understand Anatomy Trains (see earlier link) or concepts like Janda’s UPPER CROSSED and LOWER CROSSED Syndromes, you already grasp this point. THIS POST helps explain this phenomenon as well.

• FASCIA IS A PROPRIOCEPTIVE ORGAN:   A study done by three doctors at the PT department at an Austrian university (Fascia as a Proprioceptive Organ and its Role in Chronic Pain – a Review of Current Literature) and published in the December 2015 issue of Safety in Health, concluded that at least when it comes to the Thoracolumbar Fascia, “The latest research shows that the fascia is highly innervated. Especially the thoracolumbar fascia exhibits a high density of mechanoreceptors. They are responsible for afferent proprioceptive information, i.e. implicit information about joint position and movement. In chronic pain patients, proprioception is impaired and studies indicate that connective tissue structures in painful body parts exhibit pathological changes.  Besides the finding that the thoracolumbar fascia is pathologically altered in a low back pain population, this population displays proprioceptive deficits, measured with joint positioning sense and two-point discrimination, too. Fascia should therefore be considered a cause of pain and proprioceptive deficits and treatment should be applied accordingly. Manual therapy could be used to regain proprioceptive acuity in the region of pain.  The impact of physiotherapeutic treatment on fascia could establish a completely new perspective in clinical reasoning and therapy.”  To really grasp what PROPRIOCEPTION is all about, as well as it’s link to tissue degeneration, just click the link.  Because it is difficult to unwind proprioception from some of these other characteristics of fascia, you’ll see it (mechanoreception) referred to a number of times today.

• FASCIA ACTS AS A SECOND NERVOUS SYSTEM:  Take a listen to what renowned bodyworker, John Barnes said in his article, Myofascial Release Perspective: Therapeutic Insight — Fascia, A Liquid-Crystalline Matrix.  “The brain and every nerve of our body lie within and are profoundly influenced by the liquid/gelatinous ground substance of the fascial system. It is a well-known fact nerves can only transmit signals at slightly over 20 meters per second. Therefore, it is impossible for nerves to stimulate the trillions of cells of our body that each have more than 100,000 reactions per second. The fascial system functions as a fiber-optic network that bathes each cell with information, energy, light, sound, nutrition, oxygen, biochemicals and hormones and flushes out toxins at an enormous speed. The brain and nerves are an important but much slower form of communication. The ion-transfer mechanism of nerve impulses is too slow to account for the massive amount of information necessary for our body-mind to function. Therefore, it is the fascia, your liquid-crystalline matrix, that is the major and most important communication system of our body.”  Try this on for size; impulses in fascia travel at the speed of sound in water — 1,484 meters per second. Almost a decade ago, researchers at Carnegie Mellon University teamed up with Taiwan’s Institute of Biomedical Sciences to publish a study in PLoS One called Understanding Sensory Nerve Mechanotransduction Through Localized Elastomeric Matrix Control.  The authors concluded simply that, “sensory nerve terminals have a specific mechanosensitive response that is related to cell architecture.”  And when we talk about cell architecture, we have to at least mention TENSEGRITY — one of the most important features of fascia that you have never heard of.  MORE on fascia as a second nervous system for those who are interested.

• FASCIA ACTS AS A SECOND NERVOUS SYSTEM PART II:   Remember Robert Schleip?  He wrote an extremely cool scientific paper for the Journal of Bodywork and Movement Therapies clear back in 2003 saying of the nerves found in fascia, “These hidden neurons are much smaller in diameter and are now commonly called interstitial muscle receptors.  A better name would be interstitial myofascial tissue receptors since they also exist abundantly in fascia.  Recent insights into the physiology of pain have shown that several interstitial tissue receptors function both as mechanoreceptors and as pain receptors.  Furthermore the majority of these types III and IV mechanoreceptors have been shown to have autonomic functions , i.e. stimulation of their sensory endings leads to a change in heart rate, blood pressure, respiration, etc.”  Schleip then goes on to make a case for fascia as the interface between our CNS, PNS, and enteric nervous system (THE GUT BRAIN).  In 2014, the ageless and brilliant Warren Hammer — the chiropractic profession’s foremost expert on fascia and other connective tissues — wrote an article called Fascia as a Sensory Organ in which he not only talked a lot about HYALURONIC ACID, but stated, “From a sensory point of view, the  chief proprioceptors for muscles are muscle spin- dles that are localized in the perimysium. eir  capsules connect to the epimysium and fascial  septae.  The chief sensory components of muscles,  the spindle cells, reside in the fascia. Finally, there  is the endomysium, which covers every muscle  fiber and separates fibers from each other to allow  individual fiber gliding.  e fact that spindle cells are in the fascia implies  that if the fascia is altered — restricted or densified — the spindle cells may not function normally, depriving the CNS of necessary information  about joint movement, muscle coordination and  position. Spindle cells represent a common final  pathway, since all proprioceptive input from fascia, ligaments, skin, etc., goes to the dorsal horn.  The dorsal horn has collaterals that synapse on  the gamma motor neurons causing reflex activation of spindle cells. Spindle cells are active even  during sleep, and they must be stretched during  muscle contraction or passive stretch to become  activated. It is therefore probable that if the  spindle cells are embedded in thickened, densified  fascia, its ability to be stretched would be affected and normal spindle cell feedback to the CNS  would be altered.”  Of course Dr. Hammer talks at length about what this does as far as pain and dysfunctional movement patterns are concerned.

• TREATING FASCIA STIMULATES THE PARASYMPATHETIC NERVOUS SYSTEM:  The sympathetic nervous system is your “fight or flight” system, while your parasympathetic system is all about relaxation, regeneration, and digestion.  In a very cool study by Dr Budiman Minasny of the University of Syndey’s Australian Centre for Precision Agriculture (Understanding the Process of Fascial Unwinding), the author states, “Touch is the entrance requirement for the process of unwinding. Touch stimulates the fascia’s mechanoreceptors and, in turn, arouses a parasympathetic nervous system response.  As a result of this latter response, the client is in a state of deep relaxation and calm.  The indirect stimulation of the autonomic nervous system (that is, the parasympathetic nervous system), which results in global muscle relaxation and a more peaceful state of mind, represents the heart of the changes that are so vital to many manual therapies. Gentler types of myofascial stretching and cranial techniques have also long been acknowledged to affect the parasympathetic nervous system.  Touch, stretching, and manual therapy can induce relaxation in the parasympathetic nervous system. They also activate the central nervous system, which is involved in the modulation of muscle tone as well as movement. This activation stimulates the response to stretching: muscles find areas and positions of ease, the client experiences less pain or is more relaxed.”  Because we live in a pedal to the metal society that is plagued by SYMPATHETIC DOMINANCE, this is good news.  BTW, the author spoke numerous times of studies using HRV to test this hypothesis.

• FASCIA ACTS AS ANOTHER IMMUNE SYSTEM:  There was actually a lot of information on this topic (much of it having to do with macrophages), with Dr. Helene Langevin leading the charge.  Dr. L did her postdoctoral work in neurochemisty at Cambridge, her residency in endocrinology at Johns Hopkins, and is currently a researcher and professor at Harvard as well as a Professor of neurology at Vermont College of Medicine.  In other words, she’s smarter than all of us put together.  The following are some notes I jotted down from the February 8, 2016 interview on Liberated Body (Connective Tissue and Inflammation).    “Connective Tissue is part of the immune system — it’s the interface between the musculoskeletal system and the immune system.”  She believes that the mechanical basis for acupuncture is that the connective tissue wraps around the needles (see my work on DRY NEEDLING). She was treating chronic pain patients as an intern and felt like she had little to offer them, so she got into acupuncture in the early 1980’s.  BTW, here is why the needle should be manipulated, not just sit there in the body.  “The needle is sending a mechanical signal through the tissue, pulling, twisting, moving it up and down.  The effects of acupuncture occur via the nervous system.  The connective tissue is the mechanical link between the connective tissue and the nervous system.  Also, fibroblasts respond when you manipulate the needle (they become very large).  Fibroblasts create ATP that has a downstream effect that can affect chronic pain in an analgesic fashion.”  After talking about the difference between systemic inflammation and local inflammation, Dr. Langevin went on to talk about inflammation resolution.  What did she talk about most? FATTY ACID METABOLISM of course.  Dr. L went on to discuss the fact that there is little relationship to the amount of pathology in the spine as seen with imaging, and the amount of pain a person is in (HERE) as well as the tissue she believes is the biggest pain-generator in the spine — fascia.  To top things off, Dr. L stated that, “Cancer is not just a collection of tumor cells growing out of control. They need a base and that base is the connective tissue- the stroma. The cancer takes the connective tissue hostage.”  Why?  Because, “The connective tissue is really the home of the immune system.” Langevin also discussed the fact that stretching not only leads to inflammation resolution but also that movement is known to stimulate the immune system, probably via the connective tissues. This fact was shown via the title of last summer’s study that was published in the Journal of Cellular Physiology (Stretching Impacts Inflammation Resolution in Connective Tissue).  For the record, CANCER is one of the numerous diseases considered to be caused by inflammation.

• THERE ACTUALLY IS A FORM OF ADVANCED IMAGING THAT LETS YOU VISUALIZE FASCIAL ADHESIONS:   Yes, you can actually image fascia (HERE).  Just not with tests that are today’s standard fare such as MRI or CT (HERE).

• FASCIA CAN REVEAL YOUR MEDICAL HISTORY:  Have you had a lot of surgeries that have been giving you issues?  We can often see it in your fascia (HERE)?  Do you eat a crappy diet or have habits that cause unbridled SYSTEMIC INFLAMMATION?   We can see this in your fascia as well (HERE). Poor posture obviously affects your fascia (HERE).  Chronic disease states (HERE), autoimmunity (HERE), and even fibrobyalgia (HERE) also set the table for inflammation.  And what you must remember is that there is a progression — inflammation always leads to fibrosis / Scar Tissue, and fibrosis / Scar Tissue always leads to degeneration.  This is true of every single tissue, cell, and organ in your body, including fascia (HERE).   It also helps explain why Scar Tissue is almost always to some degree hypoxic (does not oxygenate well — HERE).  In many ways, you can think of the aging process as an accumulation of this whole inflammatory mess.

• FASCIAL ADHESIONS SPREAD:  This, folks, is known as compensation.  Once these adhesions occur — especially in a body that is inflamed and either sedentary or overtrained — they get bigger and move to other areas.  It’s the nature of the beast because it’s all connected, and occurs with 100% certainty.  Oh, it might take awhile to occur, but occur it will.  Listen to what the Regenerative Performance website says in their article The Facts on Fascia: Its Role in Chronic and Acute Pain. “Fascia can be a source for pain when it’s ability to effectively create sliding surfaces is impaired.  The location of fascia restriction is often at the site of pain, but this is not a hard and fast rule- often times fascial restrictions occur in areas such as the thoracolumbar fascia resulting in pain localized away from the site of restriction. If injury was present, fascial restrictions can remain even after the acute injury is healed unless the fascial restriction was addressed.  This can translate into impaired ROM in not only the area of injury, but joints both upstream and downstream.”  This goes along with the adhesions-are-not-always-at-the-site-of-pain bullet as well.

• FASCIAL ADHESIONS MAY BE THE HOLY GRAIL OF MEDICAL PRACTICE — THE COMMON CAUSE AND COMMON ‘CURE’ OF ALL SICKNESS, PAIN, AND DISEASE:  Look folks, I’m not the one saying this.  It’s being said by people far smarter than I am (HERE).  

• MOST CASES OF FASCIAL ADHESION AND SCAR TISSUE CAN BE DEALT WITH EFFECTIVELY:   I won’t spend much time here other than to show you THESE POSTS.  Which brings me to the next section — what can you be doing to take care of your own fascia?

TAKING CARE OF YOUR OWN FASCIA

There are a wide array of things you can do to take care of your own fascia.  In most cases, these are mechanical things.  However, first and foremost you must take care of your fascia by addressing it on the biochemical level….

• CONTROL INFLAMMATION:  Unfortunately, most people are not really sure what inflammation is, what drives it, or how to control it (HERE) even though it happens to be the root of most health problems.  This first point is a potential deal-breaker for many of you reading this post.  If you follow every other bullet, but fail to follow this one, you jeopardize your results — especially your long-term results.  For those who are really sick or have multiple issues, HERE is the post you will need to at least look at in order to start figuring out your EXIT STRATEGY from your life of chronic pain and dysfunction.

• CONTROL INFLAMMATION PART II:  Although I provided a link to sugar’s relationship to inflammation earlier in the post, Kinetic Health’s Sugar and Chronic Pain – Is There a Connection? sums it up nicely. “Excess sugar in the blood leads to a pathological process called glycation. One of the effects of glycation is the binding of sugar molecules to fascial proteins, causing them to thicken and become stiff. The body then treats these tangled up molecules as foreign bodies and initiates an inflammatory response in an attempt to get rid of them. Over time this state of inflammation may cause painful symptoms. There are also theories to suggest that glycation speeds up the aging process and may be the primary cause of heart disease and insulin resistance.”  If you are living the HIGH CARB LIFESTYLE and wondering why you still have chronic pain, you may have just solved your own problems.  Make sure to click on the links in the previous bullet because there are any number of things that drive inflammation, and numerous DIY strategies to solve them.

• STRETCH AND EXERCISE:  Here’s the deal folks.  We have just seen over and over again that loss of motion creates problems in the fascia, and that problems in the fascia create loss of motion.  In many cases (CERTAINLY NOT ALL) a simple solution is to get off your butt and EXERCISE or stretch.  For some one you, this may be very (VERY) gentle or at first, even passive, such as seen in WHOLE BODY VIBRATION, EXTENSION THERAPY, or various forms of TRACTION.  For the record, this bullet cannot be understood outside of understanding the difference between segmental motion and sectional motion (HERE).

• USE A LASER:  Although I have a ton of info on LOW LEVEL LASER THERAPY (not to mention THYROID ISSUES), listen to what FUNCTIONAL MEDICINE specialist, Dr. Westin Childs, says in his article How Hypothyroidism Causes Chronic Pain and Fibromyalgia + Treatment.  “Tender points in the muscles are common in fibromyalgia.  These tender points are caused by abnormal contractions in the muscular tissue that stay contracted over long periods of time causing changes in the fascia and potentiating pain.   In order to relieve the pain the tissue MUST relax, and in order for muscular tissue to contract there must be enough energy and ATP.  Remember that thyroid hormone is required for proper ATP production?  In order for muscles to relax your body must produce ATP (the energy currency in your body).  What you may not realize is that contracting your muscles does not use energy, it’s the relaxation portion that requires energy. Consider this as an example:  When someone dies all of their muscles contract and they become “stiff”, this is known as rigor mortis. The reason for this contraction is due to lack of energy production.  The same thing is happening (to a smaller degree) in certain muscles in patients with chronic pain, fibromyalgia and hypothyroidism.”   As the technology improves, the prices of lasers continues to drop, increasingly favoring your ability to purchase your own.

• THERE ARE A WIDE ARRAY OF MECHANICAL SELF-TREATMENT OPTIONS FOR FASCIA:  There are a wide array of FOAM ROLLERS, lacrosse balls or similar, and DIY GIZMOS out there that have been proven to help a lot of people.  My biggest warning with any of these — particularly the later — is simply to start very (VERY) slow and easy, working your way into your protocol over a period of weeks.