An introduction to fascia - PowerPoint Presentation

Slide1

An introduction to fascia

Libby Hinsley, PT, C-IAYT, E-RYT 500

Slide2

Muscle and Fascia terms

Muscle

Fascia

Myofascial system

Myofascial release

Fascial stretching

Slide3

muscle

Muscle is the contractile component of the “myofascial” system

Each muscle has an origin and an insertion.

Muscle contracts via a complex chemical chain of events that leads to actin and myosin proteins found in sarcomeres overlapping and pulling on each other to shorten the sarcomere, and hence shorten the entire muscle.

Slide4

muscle

https://ib.bioninja.com.au/higher-level/topic-11-animal-physiology/112-movement/sarcomeres.html

https://socratic.org/questions/which-type-of-muscle-fibers-contain-sarcomeres

Slide5

muscle

Muscle is “elastic,” meaning muscle tissue generally returns to its original length after stretching.

What we think of a muscle stretch has been shown largely to be the result of stretch tolerance or relaxation of protective muscle reflexes, rather than an actual change in tissue length. This muscle “stretch” effect generally takes somewhere around 20-30 seconds to achieve.

However, muscle can add or subtract sarcomeres through a longer term adaptation process, thus changing the actual length of the muscle.

Slide6

Connective tissue

Connective tissue is a broad term that includes fascia, tendon, ligament, bone, and blood.

Fascia is one type of fibrous connective tissue that envelopes separates and binds together muscles, organs, and other tissues of the body (www.functionalfascia.com)

Most agree there are three or four different kinds of fascia

Some describe superficial, deep, and visceral

Others describe structural, intersectoral or inter-structural, visceral, and spinal

Slide7

Fascia

Fascia is a 3D web consisting of a watery extra cellular matrix (ground substance), elastin, and collagen fibers densely woven in all directions, and fibroblast cells.

Anatomists didn’t much care for or understand fascia for so long because in fixed or preserved tissue, the fascia is collapsed and dry. It has historically been “cleaned off” in order to see what everyone thought was the good stuff. Now we know it’s the watery extracellular matrix that gives fascia its form and function.

https://medium.com/@satiJen/fascia-changes-everything-c81dac9d7e36

Slide8

Fascia

https://www.ashleyblackguru.com/blogs/fascia-blog/fascia

Slide9

Fascia components

Elastin and collagen are the primary proteins that make up fascia, along with the extracellular matrix (mostly very viscous proteoglycans) and fibroblasts (which produce collagen and elastin).

Elastin is like a rubber band. It is an elastic, stretchy protein that is able to stretch and then snap right back to its original length.

Collagen is like a steel cable. It has high tensile strength. It has some give, but not much.

Collagen>elastin in fascia.

Slide10

fascia

https://www.thoughtco.com/connective-tissue-anatomy-373207

Slide11

collagen

The glue that holds the body together.

The primary fibrous protein in connective tissue 

There are >16 (some report 19-25) types of collagen, but 80 – 90 percent of the collagen in the body consists of types I, II, and III. 90% is Type I.

All collagen serves the same purpose - to help tissues withstand stretching.

Molecular Cell Biology, 4

th

Edition.

Lodish H, Berk A, Zipursky SL, et al. New York: W. H. Freeman; 2000.More than 30 different genes encode the proteins and enzymes that form and assemble collagen.

McGraw-Hill Medical. Disorders of Collagen Biosynthesis and Structure. Byers, Peter. DOI:10.1036/ommbid.240

Slide12

collagen

Collagen’s triple helix structure and its assembly are complex.

Each triple helix binds with others at unique angles to create collagen fibrils, which are rod-like tubules. 

Type I collagen fibrils, are stronger than steel gram for gram.

Fibrils are packed side-by-side in parallel bundles- collagen fibers.

https://www.orthobullets.com/basic-science/9013/collagen

Molecular Cell Biology, 4

th

Edition.

Lodish

H, Berk A, Zipursky SL, et al. New York: 

W. H. Freeman

; 2000.

Slide13

fascia

Fascia covers and interpenetrates every muscle belly, muscle fascicle, and muscle fiber cell.

https://deeprecovery.com/understanding-fascia/

Slide14

Fascia

Fascia has no origin and no insertion. It is a continuous structure without interruption.

When we tug on or bend fascia anywhere in the body, the tug spider webs throughout the system, in every plane and at every depth.

Facia distributes strain in all directions.

Fascia maintains separateness and connection between all structures of the body.

Slide15

tensegrity

Tensegrity =

tension+integrity

Tensegrity structures distribute strain in all directions, just like the body does.

Compression structures distribute strain in a straight line.

Compression structures break down where the strain is greatest.

Tensegrity structures break down at their weakest point.

https://www.anatomytrains.com/fascia/tensegrity/

Slide16

Myofascial system

Muscle and fascia are never separate.

The myofascial system is the combination of these two tissues, and how they function in the body.

Active (muscle) and passive (fascia) components work together to provide stability and mobility to each joint of the body.

Fascia transmits force from one muscle to others, making the muscular system more integrated than we have previously thought

Bones are held in position by myofascial tension (serving the tensegrity function)

Bob Fong. Jericho Physio Blog November 28, 2016.

Slide17

Fascia as lymph organ

The type of fascia that is thin, hydrated, and spider-webby, under the skin surface and surrounding vessels and muscle fibers, is also known as the

interstitium

and has recently been recognized as an official organ.

It turns out, this full body networked structure acts as a highway for moving fluid which drains into the lymphatic system. It is the source of lymph, which is vital to immune cell function and inflammation. This may also help explain the mechanism of cancer spread.

The cells that reside in this fascia/

interstitium

are fibroblasts, and they change with age, contributing to skin and joint changes, and the progression of chronic inflammatory diseases.

Petros C. Benias et al. 2018. Structure and Distribution of an Unrecognized Interstitium

in Human Tissues. Scientific Reports 8, article number: 4947; doi: 10.1038/s41598-018-23062-6

Slide18

Fascia as endocrine organ

Some have called the system of fluid-filled tubules under the skin (superficial fascia) as the “primo vascular system” and have and have found that it transports a variety of hormones and neurotransmitters.

J Am Osteopath Assoc

.

 2016 Jan;116(1):12-21.

doi

: 10.7556/jaoa.2016.002.

Primo Vascular System: A Unique Biological System Shifting a Medical Paradigm

.

Chikly B, Roberts P

, 

Quaghebeur

J

.

Some research suggests that the presence of sex hormone receptors in fascial tissue may help explain sex differences in the prevalence of myofascial pain, especially with regard to estrogen and

relaxin

, and that these may play a role in fascial nociceptor stimulation and sensitization.

Eur J

Histochem

.

 2016 Nov 2;60(4):2710.

doi

: 10.4081/ejh.2016.2710.

Hormone receptor expression in human fascial tissue

.

Fede

C

1

, 

Albertin

G

, 

Petrelli

L

, 

Sfriso

MM

, 

Biz C

, 

De Caro R

, 

Stecco

C

.

Other research has also found a strong link between hormonal levels and health of cartilage and ligaments; including that women on oral contraceptives and women post-menopause show significant differences in connective tissue elasticity vs. controls.

Slide19

Fascia as sensory organ

Fascia is the largest sensory organ in the body

Fascia contains 6 times the number of sensory nerves compared with muscle tissue.

Fascia contains four types of sensory nerve endings, which are responsive to mechanical stimulation: Golgi organs, Ruffini receptors,

Pacini

corpuscles, and Interstitial receptors. These sensory nerve endings can be called fascial mechanoreceptors, meaning that they respond to mechanical tension and/or pressure

http://www.fascialfitness.net.au/articles/fascia-as-an-organ-of-communication/

Slide20

proprioception

Fascia has been shown to play a strong role in the body’s overall sense of proprioception- the process of conscious and subconscious sensing of joint position, motion, and posture.

Proprioception is vital to motor control, or the ability to control the body in motion. 

Joint receptors have previous been thought to play the leading role in monitoring joint position or movement, and muscle receptors were relegated to motor functions that operate at a subconscious or reflex level. 

Newer research shows we cannot separate “muscle receptors” from “joint receptors” due to the way fascia transmits force in series (not in parallel) across structures

Int J

Ther

Massage Bodywork

. 2009; 2(4): 9–23.The Architecture of the Connective Tissue in the Musculoskeletal System—An Often Overlooked Functional Parameter as to Proprioception in the Locomotor Apparatus.

Jaap van der Wal, MD, PhD

Slide21

nociception

Nociception is the ability to feel pain, caused by stimulation of a nociceptor. 

Fascia contains lots of nociceptors.

Some research shows fascial tissue to be an important source of pain in patients with nonspecific lower back pain (something also supported by a great deal of research on what does NOT typically cause LBP).

Fascial nociception function may help explain some of the physiological mechanisms of chronic pain.

Med Hypotheses.

 2007;68(1):74-80.

Epub

2006 Aug 21. Pathophysiological model for chronic low back pain integrating connective tissue and nervous system mechanisms.

Langevin HM1, Sherman KJ.

Fascia: The Tensional Network of the Human Body. The Science and Clinical Applications in Manual and Movement Therapy. Edited By Robert

Schleip

, Thomas W. Findley, Leon

Chaitow

, Peter A.

Huijing

.

Slide22

interoception

Interoception

relates to the body’s ability to sense physiological states.

Interoceptive signaling is processed via the insula region in the brain, and is usually associated with an emotional or motivational component

Interoceptive nerve endings are present in the skin, visceral fascia, and muscle

A majority of the nerve endings in fascia transmit information to the insular cortex, rather than the somatosensory cortex where mechanical information and proprioception is processed.

Schleip

, Findley,

Chaitow, et al. Fascia: The Tensional Network of the Human Body. Elsevier 2012.An emphasis on noticing subtle sensations inside the body can boost interoceptionInner spaciousnessInner silence

Inner mindfulnessInner listeningWarmthLightness/heavinessFeeling tone to physical sensation, especially in the viscera, chest and abdomen

Slide23

Fascia as a mind/body link

Fascia is thought to be the location of embodied consciousness, the storage unit for life’s experiences and traumas and our resulting “holding patterns.”

It is structure, physiology, and a postural representation of our habituated thought and behavior patterns and responses to the world

As a huge sensory organ, fascia is very relevant to our relational experience - our ability to sense the self and where it ends, so that we may maintain separateness and connection.

Interoception

points to fascia as the embodiment of HOW WE FEEL

Slide24

Fascia as mind/body link

Some research indicates the superficial fascia is where chi meridians in Chinese Medicine are located and that manipulation of superficial fascia is the mechanism by which acupuncture works.

Langevin HM

, Churchill DL, Fox JR, Badger GJ,

Garra

BS,

Krag

MH. 

Biomechanical response to acupuncture needling in humans. Journal of Applied Physiology. 2001;91(6):2471-8.Langevin HM, Churchill DL,

Cipolla MJ. Mechanical signaling through connective tissue: A mechanism for the therapeutic effect of acupuncture. The FASEB Journal. 2001;15(12):2275-82.Although fascial restriction can be mechanical, it can just as easily be the result of central nervous system guarding.

Fascia, with all its various functions, is a great example of the inherent link between mind and body.

Slide25

Fascial restriction

Physical trauma, emotional trauma, scarring, or inflammation, or sustained postures can cause fascia to become dry and less pliable, sticky, and restricted.

Remember tensegrity and strain distribution? It can be hard to differentiate the “snag” from the “run” in a symptomatic body.

Fascial restrictions be a source of pain and tension to the rest of the body, placing up to 2,000 pounds per square inch of pressure on sensitive tissues

(

www.Myofascialrelease.com

)

Slide26

Fascial stretching

Fascia can have viscoelastic or plastic responses to stretching.

Viscoelastic changes mean fascia might lengthen during a stretch, but then return to its normal length.

A plastic change is a more permanent change of length and occurs under low loads held for long time periods.

How long? Generally it is thought to require minimum 3-5 minutes to achieve plastic change. This is called “tissue creep.”

Fascial length changes can also occur through chronic postural habits, as these are positions held for long periods of time.

Fascia requires movement to stay hydrated, pliable, and healthy.

Slide27

Fascial stretching (stress/strain curve)

Slide28

What we know about

lBp

Research shows that people with chronic low back pain have altered thoraco-lumbar fascia extensibility, with layers up to 30% less able to slide and glide over one another

Langevin HM

, Stevens-Tuttle D, Fox JR, Badger GJ, Bouffard NA,

Krag

MH, Wu J, Henry SM.

 

Ultrasound evidence of altered lumbar connective tissue structure in human subjects with chronic low back pain. BMC Musculoskeletal Disorders

. 2009;10:151.Langevine HM, Fox JR, Koptiuch C, Badger GJ, Greenan-Naumann AC, Bouffard NA, Konofagou EE, Lee WN, Triano JJ, Henry SM. 

Reduced thoracolumbar fascia shear strain in human chronic low back

pain.

 

BMC Musculoskeletal Disorders

. 2011;12:203.

Slide29

Anti-inflammatory stretching

Some animal studies have shown a direct mechanical impact of stretching on inflammation-regulating mechanisms within connective tissue

Stretching connective tissue activates local pro-resolving mechanisms called

resolvins

. They help resolve inflammation.

Berrueta

L,

Muskaj

I, Olenich S, Butler, T, Badger JG, Colas R, Spite M, Serhan CN, Langevine HM. 

Stretching impacts inflammation resolution in connective tissue. Journal of Cellular Physiology. 2016;231(7):1621-7.Other research points to potential for fascial stretching to impact cancer growthBerrueta L, Bergholz J, Munoz D, Muskaj I, Badger JG, Shukla A, Kim HJ, Zhao J, 

Langevine

HM

. 

Stretching reduces tumor growth in mouse breast cancer model

.

 

Scientific Reports

. 2018;8(1):7864

Slide30

Spinal stability example

Some research suggests that long duration spinal flexion stretches, especially in the presence of lumbar muscle fatigue, can alter the mechanical and neuromuscular functions of the lumbar spine and lead to decreased spinal stability and result in the development or exacerbation of low back pain.

Increased muscle activation was required to compensate for the loss of contribution of passive tissues to spinal stability after tissue creep (long passive forward bend at 75% available ROM, knees bent)

Abboud

, Jacques, et al. Muscle Activity Adaptations to Spinal Tissue Creep in the Presence of Muscle Fatigue.

PLoS

One. 2016; 11(2): e0149076.

Slide31

Risk of overstretching injuries to motor function

Researchers have hypothesized that

subfailure

injuries of ligaments may cause chronic back pain due to muscle control dysfunction

Single trauma or cumulative microtrauma causes

subfailure

injuries of the ligaments and embedded mechanoreceptors leading to impaired signals, and in turn, impaired neuromuscular control.

Eur Spine J

. 2006 May; 15(5): 668–676. doi: 10.1007/s00586-005-0925-3. A hypothesis of chronic back pain: ligament

subfailure injuries lead to muscle control dysfunction. Manohar M. Panjabi

Slide32

Myofascial release

In addition to stretching and movement, many techniques claim to offer “myofascial release.”

This term means a lot of different things, depending on who’s using it.

Many claim that releasing myofascial tension can bring about release of deeply held emotional trauma as well.

“Myofascial trigger points” are taut bands of muscle fibers or fascial tissue that are ischemic and pain generating. We think of these as “knots.”

A variety of techniques are used for myofascial release – pressure, suction, taping, scraping, blasting, needling, rolling, etc. All likely support fascial hydration, mobility, and health.

Slide33

Using asana practice

In movement/asana, some goals might be:

Keep fascia hydrated

Allow the body to adapt to a variety of positions

Improve fascia’s ability to handle stress

Increase the length of fascial tissues

Improve the ability of fascial layers to glide and slide along one another

Improve proprioception

Improve interoceptionImprove endocrine, lymph, and immune functionDecrease acute and chronic inflammation De-sensitize our response to body sensation

Slide34

Hypermobility

Libby Hinsley, PT, C-IAYT, E-RYT 500

Slide35

What is hypermobility

Hypermobility means the joints and connective tissues of the body move and can be pulled beyond normal ranges.

Genetic alterations in the structure, function, and/or assembly pathway of collagen fibers = “bad glue.”

The Ehlers-Danlos syndrome: on beyond collagens.

Jau

-Ren Mao and James Bristow. J. Clin Invest. 2001 May 1; 107(9):1063-1069. DOI: 10.1172/JCI12881

Collagenopathy is another broad umbrella term for this.

Collagen can’t hold the body together as well.

Slide36

Types of hypermobility conditions

Ehlers Danlos Syndromes are a group of inherited connective tissue disorders in which joint hypermobility is always a feature. Hypermobility type EDS (

hEDS

) is the most common type.

Hypermobility Spectrum Disorders is a more general term for conditions involving hypermobility and related issues.

Other less common connective tissue disorders also feature hypermobility, including

Marfan

Syndrome and Osteogenesis Imperfecta, infantile hypotonia, and others

Slide37

prevalence

The Ehlers Danlos Society reports research statistics that the total prevalence of EDS Syndromes (13 subtypes) is from 1 in 2,500 to 1 in 5,000 people. Many suspect it may be more common.

hEDS

is the most common type and the most commonly mis-diagnosed.

HSD share many of the same symptoms of

hEDS

and would be treated essentially the same way.

Slide38

How is it assessed?

Beighton

Scale

Maximum score is 9; GHD indicated at > or = 4

http://www.magcloud.com/browse/issue/831426

Slide39

How is it assessed?

hEDS

(Type III Ehlers-Danlos

Syndrom

) is the most common type of EDS and massively underdiagnosed.

Diagnostic criteria:

Based on

Beighton Score in addition to other factors including pain, joint dislocations, umbilical hernia, skin extensibility, pelvic floor dysfunction, fatigue, dental and cardiac issues, and others.

Slide40

How to spot it in yoga

You’ll notice knee and elbow hyperextension

You may also notice an excessive forward or backward bend

https://www.parkeschampionpost.com.au/story/6047994/mobility-is-great-hypermobility-not-so-much

/

https://jewellchiropractic.com/flexibility-vs-mobility

/

Slide41

Associated symptoms

Increased sympathetic nervous system tone = Anxiety disorders, attention disorders

Orthostatic intolerance (orthostatic tachycardia, low blood pressure)

Leaky gut and chronic GI issues, food sensitivities

MAST cell activation issues = increased histamine response

Scoliosis and

sacro

-iliac pain

are very common

Slide42

Associated symptoms

Chronic fatigue

Poor exercise tolerance

Decreased proprioception

Decreased motor control

Chronic musculoskeletal pain (several studies show a STRONG association between HSD and fibromyalgia)

Poor sense of boundaries…literally!

Lots of anecdotal evidence draws association between HSD and HSP (highly sensitive person)

Slide43

We love yoga!

People with HSD and

hEDS

LOVE yoga

Prevalence of these conditions is likely much higher among yogis (and dancers) than the general population because:

Hypermobility is praised in most yoga contexts

Hypermobile people feel “successful” in yoga

Hypermobile people are often in pain and seeking relief from yoga

Hypermobile people are often struggling with anxiety/depression and seeking relief from yoga

Slide44

asana is not helpful when:

Flexibility is praised/glorified

Students are always encouraged to “go deeper” or “find their edge”

Movement is fast paced

Sequences are highly asymmetrical

Stretches are static and passive

Slide45

Asana can be helpful if:

Movement is slow and mindful

Postures are dynamic vs. static

Sequences emphasize symmetry

Range of motion is modified

Emphasis is placed on stability

Pranayama and relaxation are encouraged

Weighted objects can be incorporated