Dermatome and fasciatome

Short-Term Benefits from Manual Therapy as an Adjunct Treatment for Persistent Postural-Perceptual Dizziness Symptoms: A Preliminary Prospective Case Series

Persistent dizziness and balance deficits are common, often with unknown etiology. Persistent Postural-Perceptual Dizziness (3PD) is a relatively new diagnosis with symptoms that may include dizziness, unsteadiness, or non-vertiginous dizziness and be persistent the majority of time over a minimum of 90 days. The purpose of this case series was to investigate short-term outcomes of reducing dizziness symptoms using a manual therapy intervention focused on restoring mobility in the fascia using a pragmatically applied biomechanical approach, the Fascial Manipulation® method (FM®), in patients with 3PD. The preliminary prospective case series consisted of twelve (n = 12) patients with persistent complaints of dizziness who received systematic application of manual therapy to improve fascial mobility after previously receiving vestibular rehabilitation. The manual therapy consisted of strategic assessment and palpation based on the model proposed in the FM® Stecco Method. This model utilizes tangential oscillations directed toward the deep fascia at strategic points. Six males (n = 6) and females (n = 6) were included with a mean age of 68.3 ± 19.3 years. The average number of interventions was 4.5 ± 0.5. Nonparametric paired sample t-tests were performed. Significant improvements were observed toward the resolution of symptoms and improved outcomes. The metrics included the Dizziness Handicap Inventory and static and dynamic balance measures. The Dizziness Handicap Inventory scores decreased (i.e., improved) by 43.6 points (z = -3.1 and p = 0.002). The timed up and go scores decreased (i.e., improved) by 3.2 s (z = -2.8 and p = 0.005). The tandem left increased (i.e., improved) by 8.7 s (z = 2.8 and p = 0.005) and the tandem right increased (i.e., improved) by 7.5 s (z = 2.8 and p = 0.005). Four to five manual therapy treatment sessions appear to be effective for short-term improvements in dizziness complaints and balance in those with 3PD. These results should be interpreted with caution as future research using rigorous methods and a control group must be conducted.

Do the fasciae of the soleus have a role in plantar fasciitis?

Plantar fasciitis is a chronic, self-limiting, and painful disabling condition affecting the inferomedial aspect of the heel, usually extending toward the metatarsophalangeal joints. There is compelling evidence for a strong correlation between Achilles tendon (AT) loading and plantar aponeurosis (PA) tension. In line with this, tightness of the AT is found in almost 80% of patients affected by plantar fasciitis. A positive correlation has also been reported between gastrocnemius-soleus tightness and heel pain severity in this condition. Despite its high prevalence, the exact etiology and pathological mechanisms underlying plantar heel pain remain unclear. Therefore, the aim of the present paper is to discuss the anatomical and biomechanical substrates of plantar fasciitis with special emphasis on the emerging, though largely neglected, fascial system. In particular, the relationship between the fascia, triceps surae muscle, AT, and PA will be analyzed. We then proceed to discuss how structural and biomechanical alterations of the muscle-tendon-fascia complex due to muscle overuse or injury can create the conditions for the onset of PA pathology. A deeper knowledge of the possible molecular mechanisms underpinning changes in the mechanical properties of the fascial system in response to altered loading and/or muscle contraction could help healthcare professionals and clinicians refine nonoperative treatment strategies and rehabilitation protocols for plantar fasciitis.

Could pain change position choice? Comparison of pain level, analgesic requirement and hospitalization time in supine and prone percutaneous nephrolithotomy

PURPOSE

Investigation of how position affects postoperative pain levels and hospitalization in patients undergoing percutaneous nephrolithotomy (PNL) surgery.

METHODS

Between August 2019 and December 2022, a total of 156 patients who underwent prone (pPNL) and supine percutaneous nephrolithotomy (sPNL) due to kidney stones were included in the study. Demographic data, preoperative CT scans, laboratory results, transfusion rates, operation durations, complication rates, stone-free rates, analgesic use, nephrostomy removal time, hospitalization duration, fluoroscopy time, hemoglobin decrease and postoperative Visual Analog Scale (VAS) scores were evaluated for all patients. By comparing these data between the sPNL and pPNL groups, the effect of position selection in PNL on pain control, analgesic requirement, and hospitalization duration was examined.

RESULTS

In the comparison of the pPNL and sPNL groups, there was a significant difference between the two groups in body mass index, hounsfield unit, complication rate, analgesic rate, nephrostomy remove time, hospitalization time, operation time, fluoroscopy time and VAS score (p = 0.025, p < 0.001, p = 0.012, p = 0.012, p < 0.001, p < 0.001, p < 0.001, p < 0.001 and p < 0.001, respectively).

CONCLUSION

The shorter operation and hospitalization time in the sPNL group could be attributed to performing surgeries in a physiological position. Additionally, sPNL seems advantageous in terms of patients' pain levels, hospitalization time and VAS scores. One reason for this could be the different areas of access in sPNL and pPNL, which may correspond to different dermatome regions. Considering the low level of pain and reduced analgesic usage, sPNL appears to be advantageous.

The non-local effects of 7-week foot sole static stretching and foam rolling training on shoulder extension range of motion

Static stretching and foam rolling can increase the range of motion (ROM) of a joint acutely as well as chronically. Although studies have reported ROM increases of a non-stretched heterologous muscle (non-local) following an acute static stretching or foam rolling session, these effects have not been studied for long-term training interventions. Therefore, the purpose of this study was to investigate the effects of a comprehensive 7-week static stretching and foam rolling training program of the foot sole on shoulder extension ROM. A total of 33 healthy, physically active participants (20 male) were assigned to either the intervention (n = 19) or control (n = 14) group. The intervention group performed a 7-week combined static stretching and foam rolling intervention comprising three sessions a week, including three exercises of the foot sole for 5 min each. Before and after the intervention period, the shoulder extension ROM was tested with three-dimensional (3D) motion caption. The level of significance for all statistical analyses was set to ρ ≤ 0.05. There was no significant time (p = 0.70, F1, 31 = 0.157; η2 = 0.005) or time×group effect (p = 0.38, F1, 31 = 0.785; η2 = 0.025) in shoulder extension ROM, indicating no ROM changes in the intervention or the control group. Although previous studies on the acute effects of stretching and foam rolling reported non-local increases in ROM in heterologous muscles, this study could show that such effects do not occur after chronic SS and foam rolling training for 7 weeks. Consequently, if the goal is to chronically increase the ROM of a specific joint, it is recommended to directly treat the muscles of interest.

Effectiveness of ultrasound guided interfascial hydrodissection with the use of saline anesthetic solution for myofascial pain syndrome of the upper trapezius: a single blind randomized controlled trial

Background

Myofascial pain syndrome (MPS) is described as pain that arise from myofascial trigger points (MTrPs) which is a hyperirritable spot within a taut band of skeletal muscle. A newer needling technique called the interfascial hydrodissection (IH), wherein anesthetic saline solution (ASS) is injected between the fascia of the muscles using ultrasound as guide. It is theorized that this technique blocks the nerve branches and improve gliding in between the muscle and fascia.

Objective

To determine the short and long-term effects of interfascial hydrodissection using 2% Lidocaine and saline solution compared to dry needling with MPS of the upper trapezius on pain and quality of life using.

Methods

This study is a single-blind randomized controlled trial where ultrasound guided IH with ASS was compared to dry needling (DN) of the MTrPs. Both groups were taught self-stretch exercises (SSE) to be done everyday after the procedure. Outcome measures were pain using the visual analogue scale (VAS) and quality of life assessment with EQ-5D-5l questionnaire. All participants were assessed by a blinded assessor before the intervention, immediately after, 10 and 30 min, one week, two weeks, four weeks, three months, and six months after the procedure. Data Analysis: Two-way mixed ANOVA and follow-up independent T-test were conducted for the outcome measures across several time points between the 2 groups.

Results

A total of 46 participants with two dropouts were all included during the final analysis. Both groups demonstrated significant differences in VAS scores between baseline and the different time points, the IH + SSE group demonstrated the more significant effect size at as compared to the DN + SSE group. For EQ-5D-5l, no statistical differences were seen in all dimensions but there was a larger effect size for usual activities, pain/discomfort and anxiety/depression.

Conclusion

Interfascial hydrodissection is a technique that can manage both short and long term symptoms of MPS. This could be utilized as an alternative management for those with chronic MPS of the upper trapezius.

Philippine Health Research Registry ID

PHRR221003-005034.

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.

Sonographic guide for botulinum toxin injections for chronic migraine headache: EURO-MUSCULUS/USPRM approach

Application of botulinum toxin A (BoNT-A) into the muscles of the head and neck area has become a widespread and reliable treatment modality for chronic migraine. The mechanism of action for BoNT-A is the inhibition of acetylcholine and local nociceptive peptide release at the terminal nerve endings. Cranial sutures have the highest concentration of nociceptive structures; therefore BoNT-A injection into the suture lines - as opposed to head and neck muscles - has been proposed for the treatment of chronic migraine. Nerve endings in sutures rapidly absorb BoNT-A and transfer it across the afferent nerve fibers in dura mater via orthodromic and antidromic transmission. In this article, ultrasound-guided BoNT-A application around the cranial sutures will be illustrated. It is noteworthy that suture injections would be safer and more efficient when applied with such guidance.

Remote effects of a 7-week combined stretching and foam rolling training intervention of the plantar foot sole on the function and structure of the triceps surae

It is known that a single bout of foam rolling (FR) or stretching can induce changes in range of motion (ROM) and performance in non-directly adjoining areas of the dorsal chain (i.e., remote effects). However, to date, it is not known if such effects exist following long-term interventions. Thus, the purpose of this study was to investigate the remote effects of a 7-week combined stretching and FR training intervention of the plantar foot sole. Thirty-eight recreational athletes were randomly assigned to either an intervention (n = 20) or control (n = 18) group. The intervention group performed stretching and FR exercises of the plantar foot sole for 7 weeks. Before and after the intervention, the dorsiflexion ankle ROM, passive resistive torque at maximum angle (PRTmax) and at a fixed angle, as well as maximum voluntary isometric contraction (MVIC) torque, were measured with a dynamometer. Gastrocnemius medialis and lateralis stiffness was assessed with shear wave elastography. The results showed no interaction effect for any of the parameters. There was a time effect indicating an increase in MVIC and PRTmax, which was more pronounced in the intervention group (+ 7.4 (95% CI 2.5-12.4),  + 4.5 (95% CI - 0.2-9.2)) than the control group (+ 3.6 (95% CI - 1.4-8.6),  + 4.0 (95% CI - 2.2 to 10.2)). The results indicate no or minor remote effects of combined stretching and FR of the foot sole in the ankle joint. Potential non-significant changes in ROM were accompanied with an increase in stretch tolerance, but not with changes in muscle structure.

Concurrent validity of palpation and musculoskeletal ultrasound in evaluating the fascia of individuals with and without myofascial pain syndrome

BACKGROUND AND PURPOSE

Palpation evaluates the fascia, a three-dimensional web of connective tissues. We propose altered fascia system displacement in patients with myofascial pain syndrome. This study determined the concurrent validity of palpation and musculoskeletal ultrasound (MSUS) videos played on Windows Media Player 10 (WMP) when evaluating the direction of the fascia system's displacement at the end of the cervical active range of motion (AROM).

METHODS

This cross-sectional study used palpation as index test and MSUS videos on WMP as reference test. First, three physical therapists palpated right and left shoulders for each cervical AROM. Second, during cervical AROM, PT-Sonographer recorded the fascia system displacement. Third, using the WMP, the physical therapists evaluated the direction of skin, superficial and deep fascia displacements at the end of cervical AROM. MedCalc Version 19.5.3 determined the "exact" Clopper-Pearson Interval (CPI).

RESULTS

We found strong accuracy between palpation and MSUS videos on WMP when determining the direction of skin displacement during cervical flexion and extension (CPI= 78.56 to 96.89). There was moderate agreement between palpation and MSUS videos on WMP when determining the direction of the skin, superficial fascia, and deep fascia displacements during cervical lateral flexion and rotation (CPI= 42.25 to 64.13).

CONCLUSION

Skin palpation during cervical flexion and extension may be useful in evaluating patients with myofascial pain syndrome (MPS). It is unclear what fascia system was evaluated when shoulders were palpated at the end of cervical lateral flexion and rotation. Palpation as diagnostic tool for MPS was not investigated.

Myofascial force transmission between the calf and the dorsal thigh is dependent on knee angle: an ultrasound study

A recent in-vivo experiment has shown that force can be transmitted between the gastrocnemius and the hamstring muscles due to a direct tissue continuity. However, it remains unclear if this mechanical interaction is affected by the stiffness of the structural connection. This study therefore aimed to investigate the impact of the knee angle on myofascial force transmission across the dorsal knee. A randomized, cross-over study was performed, including n = 56 healthy participants (25.36 ± 3.9 years, 25 females). On two separate days, they adopted a prone position on an isokinetic dynamometer (knee extended or 60° flexed). In each condition, the device moved the ankle three times from maximal plantarflexion to maximal dorsal extension. Muscle inactivity was ensured using EMG. High-resolution ultrasound videos of the semimembranosus (SM) and the gastrocnemius medialis (GM) soft tissue were recorded. Maximal horizontal tissue displacement, obtained using cross-correlation, was examined as a surrogate of force transmission. SM tissue displacement was higher at extended (4.83 ± 2.04 mm) than at flexed knees (3.81 ± 2.36 mm). Linear regression demonstrated significant associations between (1) SM and GM soft tissue displacement (extended: R² = 0.18, p = 0.001; flexed: R² = 0.17, p = 0.002) as well as (2) SM soft tissue displacement and ankle range of motion (extended: R² = 0.103, p = 0.017; flexed: R² = 0.095, p = 0.022). Our results further strengthen the evidence that local stretching induces a force transmission to neighboring muscles. Resulting remote exercise effects such as increased range of motion, seem to depend on the stiffness of the continuity.Trial registration: DRKS (Deutsches Register Klinischer Studien), registration number DRKS00024420, first registered 08/02/2021, https://drks.de/search/de/trial/DRKS00024420 .

Ultrasound Imaging and Guidance for Cervical Myofascial Pain: A Narrative Review

Cervical myofascial pain is a very common clinical condition in the daily practice of musculoskeletal physicians. Physical examination is currently the cornerstone for evaluating the cervical muscles and identifying the eventual presence of myofascial trigger points. Herein, the role of ultrasound assessment in precisely localizing them is progressively mounting in the pertinent literature. Moreover, using ultrasound, not only the muscle tissue but also the fascial and neural elements can be accurately located/evaluated. Indeed, several potential pain generators, in addition to paraspinal muscles, can be involved in the clinical scenario of cervical myofascial pain syndrome. In this article, the authors extensively reviewed the sonographic approach for cervical myofascial pain in order to better diagnose or guide different procedures that can be performed in the clinical practice of musculoskeletal physicians.

From Histoanatomy to Sonography in Myofascial Pain Syndrome: A EURO-MUSCULUS/USPRM Approach

ABSTRACT

Myofascial pain is a common clinical condition, whereby accurate physical examination is usually considered as the cornerstone to identify/diagnose the "trigger point complex," that is, the characteristic finding of this syndrome. Considering the emerging role of ultrasound examination as the natural extension of physical assessment for musculoskeletal disorders, we briefly revise the histological/anatomical features of trigger points and propose a standardized, multistep sonographic approach to myofascial pain. We also imply that the integrated clinical-ultrasound evaluation could be considered as a potential tool to discriminate different phases/subsets of this challenging pathology.

Blood supply to the superficial fascia of the abdomen: An anatomical study

The aim of this study was to examine data demonstrating that Scarpa's fascia, a superficial fascia of the anterior abdominal wall, is a vascularized tissue. Specimens of the fascia of seven volunteers undergoing abdominoplasty surgical procedures at the Plastic Surgery Unit of the University of Padova Medical Center were collected. Fractal analysis and quantitative assessment of the vascular network of the fascia was carried out, exploiting the presence of blood in the vessels. Each sample was divided and processed for histological/immunohistochemical analysis (into 5 micron-paraffin embedded sections and cryo-sectioned free-floating samples) as well as for electron microscopy study. A rich vascular pattern forming a fine, dense meshwork with an area percentage of 6.20% ± 2.10% von Willebrand factor stained vessels was noted in all the specimens of the fascia examined; the area percentage of the αSMA-stained vessels was 2.93% ± 1.80%. The diameters of the vessels fell between the 13 and 65 μm range; the network was composed of arteries, veins, capillaries and lymphatic segments. Topological results showed that the vascular network within Scarpa's fascia is well branched (segments: 6615 ± 3070 and 8.40 ± 3.40 per mm² ; crossing points: 3092 ± 1490 and 3.40 ± 1.90 per mm² ). Fractal analysis (fractal dimension = 1.063 ± 0.10; lacunarity = 0.60 ± 0.10) revealed that this particular vascular network has an optimal spatial distribution and homogeneity occupying the entire space of the superficial fascia. These findings could undoubtedly be useful to plastic surgeons as well as to pain management specialists.

Lymph drainage and cervical fascia anatomy-oriented differential nodal CTV delineation at the supraclavicular region for esophageal cancer and nasopharyngeal cancer

PURPOSE

To determine the differences in supraclavicular lymph node metastasis between esophageal cancer (EC) and nasopharyngeal cancer (NPC) and explore the feasibility of differential supraclavicular clinical target volume (CTV) contouring between these two diseases based on the involvement of different fascial spaces.

MATERIALS AND METHODS

One hundred patients with supraclavicular nodes positive for EC or NPC were enrolled, and their pre-treatment images were reviewed. The distribution patterns of nodes between the two diseases were compared in the context of node levels defined by the 2017 Japanese Esophageal Society and 2013 International Consensus on Cervical Lymph Node Level Classification. Grouping supraclavicular nodes based on sub-compartments formed by the cervical fascia was discussed, and the feasibility of differential CTV contouring based on the differences in the involvement of these sub-compartments between EC and NPC was explored.

RESULTS

The 2013 Consensus on cervical node levels and 2017 Japanese Esophageal Society node station could not practically guide supraclavicular CTV contouring. We divided the supraclavicular space into six sub-compartments: the para-esophageal space (PES), carotid sheath space (CSS), sub-thyroid pre-trachea space (STPTS), pre-vascular space (PVS), and vascular lateral space (VLS) I and II. EC mainly spread to the PES, STPTS, CSS, and VLS I, whereas NPC tended to spread to the CSS, VLS I, and VLS II. These combinations of sub-compartments may help constitute the supraclavicular CTVs for EC and NPC.

CONCLUSIONS

The fascia anatomy-based sub-compartments sufficiently distinguished metastasis to the supraclavicular space between EC and NPC, thus facilitating differential CTV contouring between these two diseases.

The Influence of a Single Instrument-Assisted Manual Therapy (IAMT) for the Lower Back on the Structural and Functional Properties of the Dorsal Myofascial Chain in Female Soccer Players: A Randomised, Placebo-Controlled Trial

Background: Instrument-assisted manual therapy (IAMT) is indicated to improve flexibility, reduce pain, and induce hyperaemia locally and along myofascial chains. The underlying effects are largely unclear. This randomised, placebo-controlled pilot study aimed to gain first insights into these effects, primarily on the structural level, through ultrasonography. Methods: 67 healthy female soccer players aged 20.9 (±3.9) years were examined after right lumbar intervention (IAMT: intervention group (IG), heat application: comparison group (CG), pressure-less placebo: placebo group (PG)). Ultrasonography (absolute movement and shear motion), flexibility tests (passive straight leg raise test (PSLR), lumbar and thoracic double inclinometry), and superficial skin temperature were recorded before (t0), immediately (t1) and 45 min after the intervention (t2). Results: IAMT decreased the absolute mobility of the superficial lamina and its shear motion to the superficial fascia compared with the PG (t1; p < 0.05). PSLR improved in the IG compared with the CG (t2) and PG (t1, t2; p < 0.05). The temperature increased in the IG and CG compared with the PG (t1, t2) and in the CG compared with the IG (t1; p < 0.05). Conclusion: IAMT of the lumbar back briefly reduces absolute mobility of the superficial lamina and its shear motion to the superficial fascia, improves flexibility, and increases the temperature.

Inter- and Intra-Rater Reliability of Ultrasound Measurements of Superficial and Deep Fasciae Thickness in Upper Limb

Ultrasound (US) imaging is increasingly the most used tool to measure the thickness of superficial and deep fasciae, but there are still some doubts about its reliability in this type of measurement. The current study sets out to assess the inter-rater and intra-rater reliability of US measurements of superficial and deep fasciae thicknesses in the arm and forearm. The study involved two raters: the first (R1) is an expert in skeletal–muscle US imaging and, in particular, the US assessment of fasciae; the second (R2) is a radiologist resident with 1 year’s experience in skeletal–muscle US imaging. R2, not having specific competence in the US imaging of fasciae, was trained by R1. R1 took US images following the protocol by Pirri et al. 2021, and the US-recorded images were analyzed separately by the two raters in different sessions. Each rater measured both types of fasciae at different regions and levels of the arm and forearm. Intra- and inter-rater reliability was excellent for the deep fascia and good and excellent for the superficial fascia according to the different regions/levels (for example for the anterior region of the arm: deep fascia: Ant 1: ICC_2,2 = 0.95; 95% CI = 0.81–0.98; superficial fascia: Ant 1: ICC_2,2 = 0.85, 95% CI = 0.79–0.88). These findings confirm that US imaging is a reliable and cost-effective tool for evaluating both fasciae, superficial and deep.

Comparative Study of the Efficacy of Hyaluronic Acid, Dry Needling and Combined Treatment in Patellar Osteoarthritis-Single-Blind Randomized Clinical Trial

Background: Osteoarthritis of the knee is one of the most common ailments worldwide, and pain management of this condition is critical. Methods: A multicentre randomized controlled trial RCT with three months of follow-up, conducted in parallel groups: hyaluronic acid (HA), dry needling (DN) and ultrasound (US) and isometrics of quadriceps. 60 participants took part in the RCT who were diagnosed with osteoarthritis (Grade 3) of the knee by MRI and active adults (age: 23.41 ± 1.68 years; height: 1.79 ± 0.08 m; body mass: 78.33 ± 9.03 kg; body mass index (BMI): 24.14 ± 1.45 kg/m²). After the assigned intervention, VAS, WOMAC, IPAQ and the Star Excursion Balance test were measured at baseline. At 24 h, 15 days, 30 days, 90 days and 180 days follow-up, all variables were measured again. Results: Comparing statistically significant differences between groups, VAS scores were significant at post-test measurement (HA vs. US + isometric and DN vs. US + isometric) at 24 h (HA vs. DN), at 15 days (HA vs. US + isometric and DN vs. US + isometric) and at 1 month (US + isometric vs. HA and US + isometric vs. DN). Conclusions: There is an improvement in pain intensity in knee osteoarthritis in the short term in patients undergoing DN and conventional US + isometric treatment, but in the long term the HA group shows an improvement in pain intensity. There is also a significant difference in the improvement of knee function at different phases of the study in the various intervention groups. The combination of DN and HA in clinical practice is the best option for the treatment of osteoarthritis.

Innervation of human superficial fascia

The superficial fascia has only recently been recognized as a specific anatomical structure. Furthermore, whereas it is actually recognized that the innervation of the deep/muscular fascia plays a key role in proprioception and nociception, there are very few studies that have analyzed these characteristics in the superficial fascia. In this work, our group analyzed two different anatomical districts (abdomen and thigh), from volunteer patients, undergoing surgery procedures. Each sample was processed for histological analysis by Hematoxylin&amp;Eosin, and by immunohistochemistry stainings (in 5-micron-paraffin embedded section and in cryosectioned free floating samples), with antibodies specific for nerve fibers: S100 antibody for myelinating and non-myelinating Schwann cells, PGP9.5 antibody as pan-neuronal marker, tyrosine hydroxylase for autonomic innervation. The results revealed a huge innervation: the nervous structures were found above all around blood vessels and close to adipocytes, but they penetrated also in the connective tissue itself and are found in the midst of fibro-adipose tissue. The tissue is pervaded by both thin (mean diameter of 4.8 ± 2.6 μm) and large nerve fiber bundles of greater diameter (21.1 ± 12.2 μm). The ratio S100/TH positivity was equal to 2.96, with a relative percentage of autonomic innervation with of 33.82%. In the light of these findings is evident that the superficial fasciae have a clear and distinct anatomical identity and a specific innervation, which should be considered to better understand their role in thermoregulation, exteroception and pain perception. The knowledge of the superficial fascia may improve grading and developing of different manual approach for treatments of fascial dysfunctions, and the understanding of how some factors like temperature or manual therapies can have an impact on sensitivity of the fascia.

Innovative Treatment Strategies to Accelerate Wound Healing: Trajectory and Recent Advancements

Wound healing is highly specialized dynamic multiple phase process for the repair of damaged/injured tissues through an intricate mechanism. Any failure in the normal wound healing process results in abnormal scar formation, and chronic state which is more susceptible to infections. Chronic wounds affect patients’ quality of life along with increased morbidity and mortality and are huge financial burden to healthcare systems worldwide, and thus requires specialized biomedical intensive treatment for its management. The clinical assessment and management of chronic wounds remains challenging despite the development of various therapeutic regimens owing to its painstakingly long-term treatment requirement and complex wound healing mechanism. Various conventional approaches such as cell therapy, gene therapy, growth factor delivery, wound dressings, and skin grafts etc., are being utilized for promoting wound healing in different types of wounds. However, all these abovementioned therapies are not satisfactory for all wound types, therefore, there is an urgent demand for the development of competitive therapies. Therefore, there is a pertinent requirement to develop newer and innovative treatment modalities for multipart therapeutic regimens for chronic wounds. Recent developments in advanced wound care technology includes nanotherapeutics, stem cells therapy, bioengineered skin grafts, and 3D bioprinting-based strategies for improving therapeutic outcomes with a focus on skin regeneration with minimal side effects. The main objective of this review is to provide an updated overview of progress in therapeutic options in chronic wounds healing and management over the years using next generation innovative approaches. Herein, we have discussed the skin function and anatomy, wounds and wound healing processes, followed by conventional treatment modalities for wound healing and skin regeneration. Furthermore, various emerging and innovative strategies for promoting quality wound healing such as nanotherapeutics, stem cells therapy, 3D bioprinted skin, extracellular matrix-based approaches, platelet-rich plasma-based approaches, and cold plasma treatment therapy have been discussed with their benefits and shortcomings. Finally, challenges of these innovative strategies are reviewed with a note on future prospects.

Ultrasound Imaging of the Superficial Fascia in the Upper Limb: Arm and Forearm

The superficial fascia has received much attention in recent years due to its important role of compartmentalizing the subcutaneous tissue. Ultrasound (US) imaging, owing to its high definition, provides the possibility of better visualizing and measuring its thickness. The aim of this study was to measure and compare, with US imaging, the thickness of superficial fascia in the arm and forearm in different regions/levels. An observational study has been performed using US imaging to measure superficial fascia thickness in the anterior and posterior regions at different levels in a sample of 30 healthy volunteers. The results for superficial fascia thickness revealed statistically significant differences (p < 0.0001) in the arm between the anterior and posterior regions; in terms of forearm, some statistically significant differences were found between regions/levels. However, in the posterior region/levels of the arm, the superficial fascia was thicker (0.53 ± 0.10 mm) than in the forearm (0.41 ± 0.10 mm); regarding the anterior regions/levels, the superficial fascia of the arm (0.40 ± 0.10 mm) was not statistically different than the forearm (0.40 ± 0.12 mm). In addition, the intra-rater reliability was good (ICC2,k: 0.88). US helps to visualize and assess the superficial fascia inside the subcutaneous tissue, improving the diagnosis of fascial dysfunction, and one of the Us parameters to reliably assess is the thickness in different regions and levels.

Effects of Fu's Subcutaneous Needling on Mitochondrial Structure and Function in Rats with Sciatica

To observe the effects of Fu’s subcutaneous needling (FSN) and acupuncture treatment on the mitochondrial structure and function of the skeletal muscle tissue of rats with sciatica. Forty Sprague–Dawley rats were divided into control, model, acupuncture, and FSN groups (10 each) according to a random number table. The control group was left untreated. Rats in the FSN group were treated with FSN once every 2 days for three times, respectively (days 1, 3, 5, and 7), to cooperate with reperfusion approach. The acupuncture group was treated at the same timeline as that of the FSN group. Changes in the mechanical pain threshold, mitochondrial ultrastructure, mitochondrial citrate synthase (CS) activities, mitochondrial respiratory chain complex II, and mitochondrial COX- I protein expression in the skeletal muscle of rats treated with different treatments were compared with those of the model group. The pain thresholds of the rats were remarkably higher after FSN treatment and acupuncture, and the pain threshold of the FSN group was higher than that of the acupuncture group. Compared with the control group, the mitochondria of the model group had a damaged ultrastructure, were arranged in a disorganized manner, accumulated under the basement membrane, and appeared vacuolated with autophagosomes. The state of mitochondria in the FSN group was close to that in the control group and was remarkably better than that in the acupuncture group. The activities of mitochondrial CS and respiratory chain complex II in the skeletal muscle of the treated rats decreased compared with the control group (p < 0.05), and their levels were better in the FSN group than in the acupuncture group (p < 0.05). FSN treatment for 1 week considerably improved the pain thresholds and improved the skeletal muscle mitochondrial ultrastructure and mitochondrial function in rats with sciatica.

Comparison between the Original- and a Standardized Version of a Physical Assessment Test for the Dorsal Chain - A Cohort-Based Cross Sectional Study

This cohort-based cross-sectional study compares the original (OV) and a newly developed standardized version (SV) of the Bunkie Test, a physical test used to assess the dorsal chain muscles. Twenty-three participants (13 females, 10 males; median age of 26 ± 3 years) performed the test, a reverse plank, with one foot on a stool and the contralateral leg lifted. In the SV, the position of the pelvis and the foot were predefined. The test performance time (s) and surface electromyography (sEMG) signals of the dorsal chain muscles were recorded. We performed a median power frequency (MPF) analysis, using short-time Fourier transformation, and calculated the MPF/time linear regression slope. We compared the slopes of the linear regression analysis (between legs) and the performance times (between the OV and SV) with the Wilcoxon test. Performance times did not differ between SV and OV for either the dominant (p = 0.28) or non-dominant leg (p = 0.08). Linear regression analysis revealed a negative slope for the muscles of the tested leg and contralateral erector spinae, with a significant difference between the biceps femoris of the tested (-0.91 ± 1.08) and contralateral leg (0.01 ± 1.62) in the SV (p = 0.004). The sEMG showed a clearer pattern in the SV than in the OV. Hence, we recommend using the SV to assess the structures of the dorsal chain of the tested leg and contralateral back.

Molecular Mechanisms Underlying the Pain-Relieving Effects of Extracorporeal Shock Wave Therapy: A Focus on Fascia Nociceptors

In recent years, extracorporeal shock wave therapy (ESWT) has received increasing attention for its potential beneficial effects on various bone and soft-tissue pathologies, yielding promising outcomes for pain relief and functional recovery. In fact, ESWT has emerged as an alternative, non-invasive, and safe treatment for the management of numerous musculoskeletal disorders, including myofascial pain syndrome (MPS). In particular, MPS is a common chronic painful condition, accounting for the largest proportion of patients affected by musculoskeletal problems. Remarkably, sensory innervation and nociceptors of the fascial system are emerging to play a pivotal role as pain generators in MPS. At the same time, increasing evidence demonstrates that application of ESWT results in selective loss of sensory unmyelinated nerve fibers, thereby inducing long-lasting analgesia. The findings discussed in the present review are supposed to add novel viewpoints that may further enrich our knowledge on the complex interactions occurring between disorders of the deep fascia including changes in innervation, sensitization of fascial nociceptors, the pathophysiology of chronic musculoskeletal pain of MPS, and EWST-induced analgesia. Moreover, gaining mechanistic insights into the molecular mechanisms of pain-alleviating effects of ESWT may broaden the fields of shock waves clinical practice far beyond the musculoskeletal system or its original application for lithotripsy.

Myofascial Treatment Techniques on the Plantar Surface Influence Functional Performance in the Dorsal Kinetic Chain

Prior studies have shown that self- and manual massage (SMM) increases flexibility in non-adjacent body areas. It is unclear whether this also influences performance in terms of force generation. Therefore, this study investigated the effect of SMM on the plantar surface on performance in the dorsal kinetic chain. Seventeen young participants took part in this within-subject non-randomized controlled study. SMM was applied on the plantar surface of the dominant leg, but not on the non-dominant leg. A functional performance test of the dorsal kinetic chain, the Bunkie Test, was conducted before and after the intervention. We measured the performance in seconds for the so-called posterior power line (PPL) and the posterior stabilizing line (PSL). The performance of the dominant leg in the Bunkie Test decreased significantly by 17.2% from (mean ± SD) 33.1 ± 9.9 s to 27.4 ± 11.1 s for the PPL and by 16.3% from 27.6 ± 9.8 s to 23.1 ± 11.7 s for the PSL. This is in contrast to the non-dominant leg where performance increased significantly by 5.1% from 29.7 ± 9.6 s to 31.1 ± 8.9 s for the PPL and by 3.1% from 25.7 ± 1.5 s to 26.5 ± 1.7 s for the PSL. SMM interventions on the plantar surface might influence the performance in the dorsal kinetic chain.

Evaluating the Effectiveness of Soft Tissue Therapy in the Treatment of Disorders and Postoperative Conditions of the Knee Joint-A Systematic Review

The term "soft tissue therapy" (STT) refers to mechanical methods of treatment involving passive kneading, pressing and stretching of pathologically tense tissues in supporting the process of recovery after surgery or trauma to the musculoskeletal system. The objective of this study was to review current scientific reports evaluating the effectiveness of the use of STT in patients with diseases or after surgical procedures of the knee joint. A systematic search of the popular scientific databases PubMed, Scopus and Embase was performed from inception to 15 October 2021. Eight articles met eligibility criteria and were included in the review. Six papers were related to disorders of the knee joint, while the remaining two studies were related to dysfunctions associated with the conditions after surgical intervention. The findings presented confirmed the effectiveness of STT in orthopaedic patients who showed an increase in lower limb functional parameters. The research has shown that the use of various methods of STT has a significant impact on increasing muscle activity and flexibility as well as increasing the range of motion in the knee joint. The physiotherapeutic methods used had a significant impact on reducing pain and increasing physical function and quality of life. The techniques used reduced the time to descend stairs in patients with knee osteoarthritis. This review summarises the effectiveness of STT as an important form of treatment for orthopaedic patients with various knee joint dysfunctions.

Anastomoses (Superficial Cervical Ansa) Between the Cervical Plexus and Peripheral Facial Nerve Branches: Implications for Regional Anesthesia in Carotid Endarterectomies - Anatomical Study

Purpose

Sensory innervation in the carotid triangle involves the cervical plexus, cranial nerves, and the sympathetic trunk. This innervation also applies to skin incision, including various anatomical structures with potentially different innervation, such as the skin (dermatomes), the platysma (myotomes), and the superficial layer of the cervical fascia (fasciotomes), as well as retromandibular retractor insertion (co-innervation: V, VII). The aim of this anatomical study was to develop an injection technique for carotid endarterectomies to additionally block anastomoses between the transverse cervical nerve (TCN), the cervical branch VII (CB VII), and the marginal mandibular branch VII (MMB VII). These anastomoses are also termed superficial cervical ansa (SCA).

Materials and Methods

Preparations (n=16) were performed on unembalmed donor cadavers (n=8). Subplatysmal injections (each using 5 mL of Alcian blue) were performed cranially within the carotid triangle between the anterior margin of the sternocleidomastoid muscle and the submandibular gland.

Results

Anastomoses between the TCN, CB VII, and MMB VII were stained in all preparations (n=16).

Conclusion

This anatomical study presents an ultrasound-guided subplatysmal SCA block to optimize, in addition to a cervical plexus block, the quality of anesthesia for carotid endarterectomies.

Potential Nociceptive Role of the Thoracolumbar Fascia: A Scope Review Involving In Vivo and Ex Vivo Studies

Nociceptive innervation of the thoracolumbar fascia (TLF) has been investigated over the past few decades; however, these studies have not been compiled or collectively appraised. The purpose of this scoping review was to assess current knowledge regarding nociceptive innervation of the TLF to better inform future mechanistic and clinical TLF research targeting lower back pain (LBP) treatment. PubMed, ScienceDirect, Cochrane, and Embase databases were searched in January 2021 using relevant descriptors encompassing fascia and pain. Eligible studies satisfied the following: (a) published in English; (b) preclinical and clinical (in vivo and ex vivo) studies; (c) original data; (d) included quantification of at least one TLF nociceptive component. Two-phase screening procedures were conducted by a pair of independent reviewers, after which data were extracted and summarized from eligible studies. The search resulted in 257 articles of which 10 met the inclusion criteria. Studies showed histological evidence of nociceptive nerve fibers terminating in lower back fascia, suggesting a TLF contribution to LBP. Noxious chemical injection or electrical stimulation into fascia resulted in longer pain duration and higher pain intensities than injections into subcutaneous tissue or muscle. Pre-clinical and clinical research provides histological and functional evidence of nociceptive innervation of TLF. Additional knowledge of fascial neurological components could impact LBP treatment.

Elastic Fibres in the subcutaneous tissue: Is there a difference between superficial and muscular fascia? A cadaver study

BACKGROUND

In last years the role of fascia in proprioception and pain has been confirmed in numerous papers, but the real structure of fasciae is not still entirely known. To date, many studies have evaluated the elastic fibres in arteries, ligaments, lungs, epidermis and dermis, but only two studies exist about the elastic fibres in the fasciae, and they did not distinguish between superficial (in the subcutaneous tissue) and deep/muscular fasciae. The aim of the study was to assess the percentage of elastic fibres between superficial and deep fascia.

MATERIALS AND METHODS

Three full thickness specimens (proximal, middle and distal respectively) were taken from each of four regions of the thigh of three non-embalmed cadavers: the anterior (Ant), the lateral (Lat), the posterior (Post) and the medial (Med) aspect. Thus, a total of 12 specimens were collected from each analysed thigh and histological Weigert Van Gieson stains was performed. Three sections per specimen were considered for the morphometric analysis.

RESULTS

In all the specimens the superficial and deep fasciae were clearly recognizable. The difference in percentage of elastic fibres between superficial and deep fasciae in same region for all four was highly significant (p < 0.001). They are abundant in the superficial fascia than deep fascia.

CONCLUSIONS

In the light of these findings is evident that the superficial (in the subcutaneous tissue) and deep fasciae have different elasticity. This difference may improve grading of fascial dysfunction in dermatological diseases as burns, scars and lymphedema to better plan treatments.

Fascial Manipulation Technique in the Conservative Management of Morton's Syndrome: A Pilot Study

Background and Objective: Morton’s syndrome (MS) is a common cause of neuropathic chronic forefoot pain, characterised by the development of a swelling of the common digital plantar nerve, whose aetiology is not fully known. There is currently no gold standard of treatment; nonoperative management commonly involves manual therapies, orthoses therapy and infiltrative techniques, while surgery is indicated after failure of conservative measures. The present preliminary study prospectively evaluates patients affected by MS treated by Fascial Manipulation technique (FM), a noninvasive manual therapy, focused on the release of the deep fascia, reducing its stiffness. Materials and Methods: Patients with clinical and sonographic diagnosis of MS with at least a 4-month history of neuropathic symptoms underwent a cycle of three weekly FM sessions. Clinical follow-up, including VAS and AOFAS scores, was performed 21 days (T1) and 3 months (T2) after treatment. Results: Nine patients, among 28 recruited initially, completed the manual therapy sessions and relative follow-up points. This noninvasive pain treatment led to significant improvement of VAS (p = 0.0034) and AOFAS scores (p = 0.0240) at the first follow-up (T1). At 3-month follow-up (T2), both scores decreased slightly, remaining however superior to the pre-treatment values. Only VAS was still significant (p = 0.0184). Conclusions: Despite the small size of the case series, this pilot study is unique in supporting Fascial Manipulation in the nonoperative treatment of MS. Further studies are needed with a large cohort of gender balanced patients to confirm the encouraging results obtained.

Fascia Mobility, Proprioception, and Myofascial Pain

The network of fasciae is an important part of the musculoskeletal system that is often overlooked. Fascia mobility, especially along shear planes separating muscles, is critical for musculoskeletal function and may play an important, but little studied, role in proprioception. Fasciae, especially the deep epimysium and aponeuroses, have recently been recognized as highly innervated with small diameter fibers that can transmit nociceptive signals, especially in the presence of inflammation. Patients with connective tissue hyper- and hypo-mobility disorders suffer in large number from musculoskeletal pain, and many have abnormal proprioception. The relationships among fascia mobility, proprioception, and myofascial pain are largely unstudied, but a better understanding of these areas could result in improved care for many patients with musculoskeletal pain.

Pilot Study of Sacroiliac Joint Dysfunction Treated with a Single Session of Fascial Manipulation® Method: Clinical Implications for Effective Pain Reduction

Background and Objectives: Sacroiliac joint dysfunction (SIJD) generally refers to pain in the lower back due to abnormal sacroiliac joint movement, either from hypomobility or hypermobility. It is considered to be the principal cause in up to 40% of low back pain cases. In literature, it emerges that the "fascia", by its anatomical continuity, if altered or densified in different regions of the body with respect to the sacroiliac joint and its surroundings, may have a fundamental role in the genesis of SIJD and low back pain. The purpose of the present study is to evaluate the effectiveness of incorporating a single session of Fascial Manipulation^®-Stecco method^®, treating the muscular fasciae at distance from the painful region. Materials and Methods: Twenty patients with acute and chronic sacroiliac joint dysfunction (SIJD) were recruited (16 males and 4 females, mean age of 46.6 ± 12.98 years). Patients underwent a predefined assessment protocol, followed by an evaluation of myofascial pain and subsequent manipulation of the fascia at points at least 20 cm away from the posterior inferior iliac spines (PIIS). Each patient underwent three pain evaluations: pre-treatment (t0), post-treatment (t1), and at a 1-month follow-up (t2). For the evaluation in t0, t1 the numerical rating scale (NRS) for the intensity of pain and the algometer for the pain threshold at the PIIS were used; in t2 only the NRS scale. Results: The results obtained by comparing the algometer measurements with the NRS values between t0 and t1 were in both cases statistically significant (p < 0.0001), whereas the comparison between the NRS values at t1 and at t2 was not statistically significant (p > 0.05). Conclusions: A single Fascial Manipulation treatment, even when applied at least 20 cm from the PIIS, can potentially decrease pain around the SIJ. The inclusion of this type of approach in SIJD can allow for improved patient management, better tolerance for other treatments and a more rapid application of pain-free exercise programs.

Psychomotor Predictive Processing

Psychomotor experience can be based on what people predict they will experience, rather than on sensory inputs. It has been argued that disconnects between human experience and sensory inputs can be addressed better through further development of predictive processing theory. In this paper, the scope of predictive processing theory is extended through three developments. First, by going beyond previous studies that have encompassed embodied cognition but have not addressed some fundamental aspects of psychomotor functioning. Second, by proposing a scientific basis for explaining predictive processing that spans objective neuroscience and subjective experience. Third, by providing an explanation of predictive processing that can be incorporated into the planning and operation of systems involving robots and other new technologies. This is necessary because such systems are becoming increasingly common and move us farther away from the hunter-gatherer lifestyles within which our psychomotor functioning evolved. For example, beliefs that workplace robots are threatening can generate anxiety, while wearing hardware, such as augmented reality headsets and exoskeletons, can impede the natural functioning of psychomotor systems. The primary contribution of the paper is the introduction of a new formulation of hierarchical predictive processing that is focused on psychomotor functioning.

Wound healing applications of creams and "smart" hydrogels

Although superficial wounds are often easy to treat for healthy individuals, there are some more severe types of wounds (burns, ulcers, diabetic wounds, etc.) that are a challenge for clinicians. A good therapeutic result is based on the delivery of a treatment at the right time, for the right patient. Our goal was to sum up useful knowledge regarding wound healing and wound treatments, based on creams and hydrogels with various active ingredients. We concluded that both preparations have application in preventing infections and promoting healing, but their efficacy is clearly conditioned by the type, depth, severity of the wound and patient profile. However, due to their superior versatility and capability of maintaining the integrity and functionality of the active ingredient, as well as it is controlled release at site, hydrogels are more suited for incorporating different active ingredients. New wound healing devices can combine smart hydrogel dressings with physical therapies to deliver a more efficient treatment to patients if the indications are appropriate.

Myofascial Release Effects in Teachers' Posture, Muscle Tension and Voice Quality: A Randomized Controlled Trial

OBJECTIVE

Myofascial release (MFR) comprises a set of manual therapeutic techniques applied to many conditions, but specific evidence concerning its effects on body posture, muscle tension and voice has been lacking. Thus, the aim of this study was to verify the effects of MFR in teachers' posture, muscular tension and voice quality.

STUDY DESIGN

Randomized controlled trial - crossover.

METHODS

Twenty-four teachers, after completing a Sociodemographic and Clinical Questionnaire and providing written informed consent, were randomly distributed into two groups designated Group 1 (G1; n = 12; received MFR first) and Group 2 (G2; n = 12; belong to control group first). All participants received treatment and were into control group, since, after a 14 day period, procedures were switched between groups. Photogrammetry, muscle tension assessed through palpation, algometry, aerodynamic assessment of voice, acoustic and auditory-perceptual analysis of voice were performed before and after interventions.

RESULTS

Regarding voice, statistically significant differences were found when intervention was applied to both groups for maximum phonation time (MPT) (G1 P = 0.019; G2 P = 0.004). The acoustic variables did not differ. Concerning the auditory-perceptual analysis of voice statistically significant differences were found when intervention was applied in both groups for Grade in G2 (P = 0.046) and for Roughness in G1 (P = 0.025). Regarding the photogrammetry assessment statistically significant differences were found when intervention was applied to both groups in many parameters while as control group they did not. Concerning the algometry and muscle tension assessed through palpation statistically significant differences were found when intervention was applied in all muscles.

CONCLUSIONS

Findings indicated that MFR seems to be an effective therapy in improving MPT, two subscales (Grade and Roughness) of the GRABASH scale, muscle tension assessed through palpation and algometry. Regarding photogrammetry, MFR had an immediately effect in improvement of the posture, especially related with head.

An anatomical comparison of the fasciae of the thigh: A macroscopic, microscopic and ultrasound imaging study

Although the number of Ultrasound (US) imaging studies investigating the fascial layers are becoming more numerous, the majority tend to use different reference points and terminology to describe their findings. The current work set out to compare macroscopic and microscopic data of specimens of the fascial layers of the thigh with US imaging findings. Specimens of the different fascial layers of various regions of the thigh were collected for macroscopic and histological analyses from three fresh cadavers and compared with in vivo US images of the thighs of 20 healthy volunteers. The specimens showed that the subcutaneous tissue of the thigh is made up of three layers: a superficial adipose layer, a membranous layer/superficial fascia, and a deep adipose layer. The deep fascia is composed of an aponeurotic fascia, which envelops all the thigh muscles and is laterally reinforced by the iliotibial tract and an epimysial fascia, which is specific for each muscle. The morphometric measurements of the thickness of the superficial fascia were different (anterior: 153.2 ± 39.3 µm; medial: 128.4 ± 24.7 µm; lateral: 154 ± 28.9 µm; and posterior: 148.8 ± 33.2 µm) as were those of the deep fascia (anterior: 556.8 ± 176.2 µm; medial: 820.4 ± 201 µm; lateral: 1112 ± 237.9 µm; and posterior: 730.4 ± 186.5 µm). The US scans showed a clear picture of the superficial adipose tissue, the superficial fascia, and the deep adipose tissue, as well as the deep fasciae. The epimysial and aponeurotic fasciae of only some topographic areas could be independently identified. The US imaging findings confirmed that the superficial and deep fascia have different thicknesses, and they showed that the US measurements were always larger with respect to those produced by histological analysis (p < 0.001) probably due to shrinkage during the processing. The posterior region (level 1) of the superficial fascia had, for example, a mean thickness of 0.56 ± 0.12 mm at US, while the histological analysis showed that it was 148.8 ± 33.2 µm. Showing a similar pattern, the thickness of the deep fascia was as follows: 1.64 ± 0.85 mm versus 730.4 ± 186.5 µm. Study results have confirmed that US can be considered a valid, non-invasive instrument to evaluate the fascial layers. In any event, there is a clear need for a set of standardised protocols since the thickness of the fascial layers of different parts of the human body varies and the data obtained using inaccurate reference points are not reproducible or comparable. Given the inconsistent terminology used to describe the fascial system, it would also be important to standardise the terminology used to define its parts. The difficulty in distinguishing between the epimysial and aponeurotic/deep fascia can also impede data interpretation.

Embryology of the Fascial System

The fascial system is a link between the various body systems. Understanding the embryonic formation of the fascial system contributes to understanding the development of the whole body, helping to understand clinical phenomena. The text presents the concept of the fascial system and its interactions with the neural system. We describe the formation of musculoskeletal fascia from somites and mesenchymal cells of the cranial neural crest. Differences in the formation of the head, neck, trunk, and limbs and their respective embryonic relationships are presented. We detail the formation of visceral fascia and their corresponding innervations, from the tongue to the final portion of the digestive tract; the development of the genitourinary system that occurs later in the celomic cavity; and the formation of the cardiocirculatory and respiratory systems, with the development of their respective envelopes, associated with the corresponding innervation. The text covers the embryology of neural fasciae, both at the level of the central and peripheral nervous system. Finally, the development of derme and pannicular fascia is presented.

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.

Influence of female hormones on fascia elasticity: An elastography study

The aim of this study was to examine the influence of hormonal changes during the menstrual cycle on deep fasciae. A total of 29 women, 17 users, and 12 nonusers of hormonal contraceptives were examined clinically and by ultrasound, including shear wave elastography, at two phases of the menstrual cycle. The thickness and elasticity of the fascia lata, thoracolumbar fascia, and plantar fascia were measured, compared between hormonal contraceptive users and nonusers, and correlated with clinical data. There were statistically significant differences between users and nonusers of hormonal contraceptives: the thoracolumbar fascia was thicker in nonusers (P = 0.011), and nonusers had higher maximal and mean stiffnesses of the fascia lata (P = 0.01 and 0.0095, respectively). Generally, nonusers had a higher body mass index (BMI). The elasticity of the thoracolumbar and the plantar fasciae did not differ significantly between the groups. We found no correlation between thickness and elasticity in the fasciae. There were no statistically significant differences in hypermobility, cephalgia, or dysmenorrhea between users and nonusers of hormonal contraceptives. The results of this pilot study suggest that deep fasciae can be evaluated by shear wave elastography. Nonusers of contraceptives had greater stiffness of the fascia lata and higher BMI. Clin. Anat. 32:941-947, 2019. © 2019 Wiley Periodicals, Inc.