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Fascial Manipulation

Judy PunPhysiotherapist (KWH)

Fascia

What is fascia ?

“Fascia is an uninterrupted, three-dimensional web of tissue that extends from head to toe, from front to back, from interior to exterior…Fascia can refer to dense plantar fascial sheets (such as the fascia lata) as well as joint capsules, organ capsules, muscular septa, ligaments, retinacula, aponeuroses, tendons, myofascia, neurofascia, and other fibrous collagenous tissues”

First international Fascia Research Congress

Fascia classification

Superficial fascia

Deep/muscular fascia

Visceral fascia

Fascia system-Superficial fascia

Superficial layer

• Retinaculum cutis superficialisformed by vertical septa, superficial adipose tissue, superficial veins , lymphatic vessels, subcutaneous plexus

Deep layer• Loose connective tissue, deep

adipose tissue, oblique septa, Retinaculum cutis profundus

Fascia system- Deep fascia

Deep fascia

Aponeuroticfasciae

Deep fasciae of the limbs

Thoracolumbar fascia/ Rectus

sheath

Epimysialfasciae

Epimysium of muscles/ trunk

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Deep fascia of the limbs Deep fascia/myofascia

Multiple layers of undulated collagen fibre bundles form the deep fascia

Each layer parallel to each other

A thin layer of loose connective tissue separates the different layers (2-3 layers)

Adjacent layers shows different orientation strong resistance to traction

Abundant free and encapsulated nerve endings (Ruffini and Pacinian corpuscles, autonomic nerve fibers, sensory innervation

Various in thickness in different body parts

Evaluation of rectus femoralis muscle and fascia lata with ultrasound. It is evident that the three layers of dense connective tissue forming the fascia lata, are divided by two layers of loose connective tissue

Stecco C et al. (2011)

Histological study of deep fascia

On the left: crural fascia (HE stain), on the right: brachial fascia (Van Gieson stain). Both the fasciae are formed by two to three layers of collagen fibre bundles separated by a thin layer of loose connective tissue (LCT) that permits the different layers to slide one on the other

Stecco C et al (2008)

Presence of Hyaluranic Acid in deep fascia

A. Hyaluronan in loose connective tissue inside and under the deep fascia (Alcian blue 912.5).

B. Hyaluronan (brown color) within the fascia lata as demonstrated with the HA-binding peptide (9400).

Stecco C et al (2011)

Hypothesis- Sliding system

Hyaluronic acid (HA)is a substance that is present to lubricate and facilitate the movements between the muscle fibers

HA is localized to the deep or muscular surface of the deep fascia

The deep fascia produces a gliding interface in conjunction with the epimysial of the muscle and the arelolar tissue plane

Stecco C et al. (2011)

Physiological functions of fascia

1. Muscular force transmission 2. Proprioception and nociception3. Synchronisation of body movement

between body segment

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Can Fascia be a source of PAIN ?

Reaction of fascia to stress

inflammation

repair

Reorganisation of collagen fibres

healing

Repeated inflammation

Collagen fibre hyperplasia

Collagen fibre dysplasia

Ground substance densification

Etiology of overuse syndrome

- Retention of HA

after exercise, in the endomysial location

Trauma or surgery

- HA aggregation has been reported—>the viscoelasticity is dramatically increased fascia adhesion

- damage of proprioception

- movement dysfunction

pain

Manual techniques for myofascial pain

Fascial manipulation

(Stecco, 2004)

–focus to fascia

- role in MSK sys.

Myofascial Release technique (Barnes, 1990)- sustained pressure applied to a restricted tissue barrier 90-120 sec.

Janet Travel (1940)- identified myofascial trigger points (muscle fibres)

Soft tissue modification

- Rolfing (1980) (stretching /pompagetechnique

- Cyriax method (1963)

Acupuncture ( many points have the same body landmark)

Needling request

Fascial manipulation (FM)- a new biomechanical model

Fascial manipulation (FM) is a manual therapy, developed by Italian physiotherapist Luigi Stecco.

Over 40 yrs of clinical practice with vas caseload of MS problems

focuses on the myofascial system , in particular the deep muscular fascia, including the epimysium and the retinacula

Stecco’s Fascial manipulation-Biomechanical Model

14 body segments. Each segment served by six myofascial units (mf units).

CP= centre of perception, where pain is felt

CF

Day J A, 2011

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Each body segment has 6 myofascial units coordinating its movement

78 mf units- trunk and limbs

18 subunits- head

Total of 14 body segments that move in 6 directions(an-re, la-me, ir-er) on 3 planes

Stecco’s Fascial manipulation-Biomechanical Model

14 body segments. Each segment served by six myofascial units (mf units).

Mf unit = monoarticular and biarticular unidirectional muscle fibres, their deep fascia and the joint they move in one direction on one plane.

CP= centre of perception, where pain is felt

CF

Day J A, 2011

The Myofascial (MF) unit

A MF unit is composed of:1. Motor units, innervating fibres in

monoarticular and biarticular muscles, to move a body segment in a specific direction

2. The joint that is moved 3. Nerve and vascular components 4. The fascia that connects these

elements together

Stecco’s Fascial manipulation-Biomechanical Model

Centre of Coordination = point on deep fascia where unidirectional muscular forces converge

14 body segments. Each segment served by six myofascial units (mf units).

Mf unit = monoarticular and biarticular unidirectional muscle fibres, their deep fascia and the joint they move in one direction on one plane.

Centre of fusion= points where vectors from 2 adjacent mf units converge.

CP= centre of perception, where pain is felt

CF

Day J A, 2011

Characteristic of densified point (CCs) Over mm belly,

where traction of unidirectional fibres converge

1 CC for each mfu

Referred pain Prolong, deep Area is densified,

feels stratified

Ultrasonography of the deep fascia of the neck over the sternocleidomastoid muscle. The deep fascia is highlighted with a red arrow. A. Normal fascia, the two fibrous layers (white layers)

and the loose connective tissue (in black) in the middle are visible.

B. Densification of the same fascia: the loose connective tissue is increased, the fibrous layersare normal. The total thickness of the deep fascia is increased.

Pavan PG et al 2014

DysfunctionIncrease of the viscosity of HA in the centre of

coordination

Decrease of the sliding system in the CC

Improper recruitment of muscle fibres

The resultant vector become faulty

Mechanical incoordination in the articulation

Phase of compensation

Symptoms in the Center of perception

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- The pectoral and clavicular part of the pectoral major muscle continues laterally to join the brachial fascia anteriorly.

- The biceps brachii has an expansion to the deep fascia of the forearm: the lacerus fibrosus or bicipital aponeurosis

- Originate from the biceps tendon, distal to its musculotendinous juncture, inserted into the proximal portion of the antebrachial fascia.

- The main group was inserted in an oblique direction, downwards and medially, and then merges with the forearm fascia.

- At the wrist, many collagen fibre bundles forming the flexor retinaculum reinforced the antebrachial fascia.

- Distally continued with the palmar tissue reinforced the aponeurosis of the palmaris longus.

- The palmaris longus sent some myofascial expansions to the flexor retinaculum and to the fascia overlying the thenar muscles.

Anatomical study of myofascial continuity in the anterior region of the upper limb

Stecco C 2009

From MF unit to Myofascial sequences…

Biarticular muscle fibres and myotendinous expansions form an anatomical continuity between body segments-transmission of force and tension

Activation of embedded receptors- specific directional feedback that integrates with other afferents.

New terminology of FM- Head and Trunk

Segment Latin Abbreviation

•Head Caput CP(3 subunits: eye, ear/TMJ, occiput/C1)

•Neck Collum •CL

•Thorax Thorax •TH

•Lumbar Lumbi •LU

•Pelvis Pelvi •PV

New terminology- Upper limb segments

Segment Latin Abbreviation

•Scapula Scapula •SC

•Humerus Humerus •HU

•Elbow Cubitus •CU

•Wrist Carpus •CA

•fingers digiti •DI

New terminology- Lower Limb Segments

Segment Latin Abbreviation

•Hip Coxa •CX

•Knee Genu •GE

•Ankle Talus •TA

•Foot Pes •PE

Movement definition/directions Sagittal planeFlexion-Antemotion (AN)Extension-Retromotion (RE)

Frontal planeAbduction-Lateromotion

(LA)Adduction-Mediomotion

(ME)

Horizontal planeInternal rotation-

Intrarotation (IR)External rotation-

Extrarotation (ER)

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Antemotion (AN)

Forward movement of a body part on the sagittal plane

Neck flexion

Elbow flexion

Hip flexion

Retromotion (RE)

Backwards movement of a body part on the sagittal plane

Knee flexion Shoulder extension

Neck extension

Extrarotation (ER)

Rotation from a neutral position outwards right or left on the horizontal plane

Neck rotation

Hip external rotationWrist supination

Intrarotation (IR)

Return to a neutral position from intrarotation

Hip internal rotation

Trunk rotation

Neck rotation

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Lateromotion (LA)

Movement of a segment on the frontal plane, from the median line outwards

Hip abduction

Trunk sideflexion

Shoulder abduction

Mediomotion (ME)

Medially directed movements on the frontal plane

Adduction of knee

Trunk sideflexion

Scapula adduction (> 90 degrees)

Manual technique

Area of treatment:

Instrument:

Target tissue:

Movement:

Type of pain:

Centre of coordination Small 1-2cm2

elbow (70%), knuckle(28%) fingertips (2%)

Deep fascia, epimysium

80% compression, 20% sliding

Intense, needle-like, can refer elswhere

Principle of Therapy

HA aggregation chain to be reversibly disaggregated by an increase temperature or by alkalinzation

Break down progressively when the temperature was increased to over ~ 40oC

Alter the ground substance of the deep fasciaRestore gliding between collagen fibers

Contraindications

Absolute contraindications

Fever

Skin lesion

Recent thrombosis

Severe immunodepression

Relative contraindications

Edema/acute tendinitis

Lymphedema (III stage or more)

Non-cooperative patient

Recent trauma without diagnosis-red flags?

Oncological patient

Severe bleeding disorder

Corticosteroid therapy

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REFERENCES:1. Day J A. Fascial Anatomy in Manual Therapy: Introducing a New Biomechanical Model.

Orthopaedic Practice, 2011, Vol. 23;2:11.2. Stecco A, Masiero S, Macchi V, Stecco C, Porzionato A, De Caro R. The pectoral fascia:

anatomicaland histological study. J Bodyw Mov Ther. 2009 Jul;13(3):255-61.3. Day JA, Stecco C, Stecco A. Application of Fascial Manipulation technique in chronic

shoulder pain--anatomical basis and clinical implications. J Bodyw Mov Ther. 2009 Apr;13(2):128-35. Epub 2008 Jun 24.

4. Stecco A, Macchi V, S, Porzionato A, Tiengo C, Stecco C, Delmas V, De Caro R. Pectoral and femoral fasciae: common aspects and regional specializations. Surg Radiol Anat. 2009 Jan;31(1):35-42. Epub 2008 Jul 29.

5. Stecco A, Masiero S, Macchi V, Stecco C, Porzionato A, De Caro R. The pectoral fascia: anatomical and histological study. J Bodyw Mov Ther. 2009 Jul;13(3):255-61.

6. Stecco C, Porzionato A, Lancerotto L, Stecco A, Macchi V, Day JA, De Caro R: Histological study of the deep fasciae of the limbs. J Bodyw Mov Ther. 2008 Jul;12(3):225-30. Epub 2008 Jun 13.

7. Stecco A, Macchi V, Stecco C, Porzionato A, Ann Day J, Delmas V, De Caro R. Anatomical study of myofascial continuity in the anterior region of the upper limb. J Bodyw Mov Ther. 2009 Jan;13(1):53-62.

8. Stecco A, Macchi V, Stecco C, Porzionato A, Ann Day J, Delmas V, De Caro R. Anatomical study of myofascial continuity in the anterior region of the upper limb. J Bodyw Mov Ther. 2009 Jan;13(1):53-62. Epub 2007 Jun 28.

9. Stecco C, Masiero Sstern R, Porzionato A, Macchi V, Masiero Stecco A, De Caro R. Hyaluronan within fascia in the etiology of myofascial pain. Surg Radio; Anat. 2011 Oct. doi: 10.1007/s00276-011-0876-9 ·

10. Pavan PG, Stecco A & Stern R: painful connections: densification versus fibrosis of fascia. Curr Pain Headache Rep (2014) 18:441

11. Pedrelli A, Stecco C, Day JA. Treating patellar tendinopathy with Fascial Mnaipulation. J Bodyw Mov Ther 2009; 13(1): 73-80

Books:- Stecco L, Fascial Manipulation for Musculoskeletal Pain, Nuova Piccin, 2004- SteccoL, Stecco C. Fascial Manipulation: Practical Part. Nuova Piccin, 2009

Practical part

Synotic tables of centres of coordiantion (CCs)

Name Address Date of Birth

Occupation Sport Diagnosis

segm locat exacerbate durat intens re-co

SiPa PaMo

PaConc PaMo

PaPrev Examinations, Xrays, Trauma:Paraesthesia cp di pe

Segment

Sagittal Plane Frontal Plane Horizontal Plane CF

ante retro medio latero intra extra An-la Re-la Re-me

An-me

Treatment Results after 1 week

1° 1°

MoVe

PaVe

Assessment Procedure

MoVe (movement verification)

PaVe (palpatory verification)

• Actively• Passively• Stretch• Against resistance

ＰａｉｎReduced ＲＯＭＷｅａｋｎｅｓs

*slight pain and/or deficit** medium pain and/or deficit*** very strong pain(or blocked movement)

* densified tissue* painful tissue

* referred pain/symptomsduring palpation

•Having chosen the plane,segment(s) and MFu(s) : palpate CC of agonist Mfu

•no alteration is found? : palpate CC of the antagonist Mfu (same plane)

• Nothing significant? : palpate other CC(s) along agonist sequence

•Then palpate the other CC(s) of the segment (change plane?)

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Rx logistics:

From data to hypothesis

MoVe altered onlyin one plane

MoVe altered in2 or 3 planes

MoVe aspecific-Generalized unease

Segmental CCsOn one plane

Combination of CC and Cf

Diagnostic Centres of fusion

Demonstration…1. Neck pain: an-cl, re-cl, me-cl,

la-cl, er-cl, ir-cl2. Elbow pain: an-cu, re-cu,

me-cu, la-cu, er-cu, ir-cu3. Back pain: an-lu, re-lu, me-lu,

la-lu, er-lu, ir-lu4. Knee pain: an-ge, re-ge, me-

ge, la-ge, er-ge, ir-ge

CCs of Lu (back)

an-lu ir-lu

me-lure-lu

er-lula-lu

Movement tests of LU (lumbar)

an-lu

re-lu

ir-lu

er-lu

me-lu

la-lu

CCs of Ge (knee)

an-ge

me-ge

ir-ge

re-ge

er-gela-ge

Movement tests of GE (knee)

an-ge

re-ge

ir-ge

er-ge

la-ge

me-ge

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CCs of CL (Neck)

an-clir-cl

me-cl

re-cl

er-cl

la-cl

Movement tests of CL (neck)

an-cl

RECL

IRCL

er-cl la-cl

me-cl

re-cl

ir-cl

CCs of Cu (elbow)

an-cu ir-cume-cu

re-cu

er-cu

la-cu

Movement tests of CU (elbow)

an-cu

re-cu

ir-cu

re-cu

me-cu

la-cu

Thank you