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

Effects of Percussive Massage Treatments on Symptoms Associated with Eccentric Exercise-Induced Muscle Damage

Percussive massage (PM) is an emerging recovery treatment despite the lack of research on its effects post-eccentric exercise (post-EE). This study investigated the effects of PM treatments (immediately, 24, 48, and 72 h post-EE) on the maximal isometric torque (MIT), range of motion (ROM), and an 11-point numerical rating scale (NRS) of soreness of the nondominant arm's biceps brachii from 24-72 h post-EE. Seventeen untrained, college-aged subjects performed 60 eccentric elbow flexion actions with their nondominant arms. Nine received 1 minute of PM, versus eight who rested quietly (control [CON]). In order, NRS, ROM, and MIT (relative to body mass) were collected pre-eccentric exercise (pre-EE) and after treatment (AT) at 24, 48, and 72 h post-EE. NRS was also collected before treatment (BT). Electromyographic (EMG) and mechanomyographic (MMG) amplitudes were collected during the MIT and normalized to pre-EE. There were no interactions for MIT, EMG, or MMG, but there were interactions for ROM and NRS. For ROM, the PM group had higher values than the CON 24-72 h by ~6-8°, a faster return to pre-EE (PM: 48 h, CON: 72 h), and exceeded their pre-EE at 72 h by ~4°. The groups' NRS values did not differ BT 24-72 h; however, the PM group lowered their NRS from BT to AT within every visit by ~1 point per visit, which resulted in them having lower values than the CON from 24-72 h by ~2-3 points. Additionally, the PM group returned their NRS to pre-EE faster than the CON (PM: BT 72 h, CON: never). In conclusion, PM treatments may improve ROM without affecting isometric strength or muscle activation 24-72 h post-EE. Although the PM treatments did not enhance the recovery from delayed onset muscle soreness until 72 h, they consistently provided immediate, temporary relief when used 24-72 h post-EE.

Examination of the effect of fascial therapy on some physical fitness parameters in taekwondo athletes

One of the objectives of this study is to determine the effect of the eight-week fascial therapy program on flexibility, vertical jump, standing long jump, speed and anaerobic strength parameters in taekwondo athletes. Another aim of the research is to create a therapy protocol that can be used in athletes related to performance development through the relaxation of the fascial system, which is considered an indicator of physical fitness and has numerous functions in the body. This study included 32 taekwondo players who were licensed, actively attending taekwondo training. In the study, two groups were formed as fascial therapy group (FTG) (n ​= ​16) and control group (CG) (n ​= ​16). After the groups were randomized, fascial relaxation techniques were applied to the fascial therapy group for eight weeks, up to twice a week, and for 30 ​min. According to the findings obtained as a result of the research, FTG ([-0.36 ​± ​0.17] seconds [s]) for the 20 ​m (m) Sprint (T2-T1) had a lower mean time than CG (0.00 ​± ​0.07) s, FTG (0.06 ​± ​1.95) for the Flamingo Balance Test (T2-T1) had a lower mean fall than CG (1.25 ​± ​1.13), FTG ([3.56 ​± ​2.37] centimeters [cm]) for the Sit & Reach Test (T2-T1) had a lower mean fall than CG ([-0.19 ​± ​1.28] cm), FTG ([5.75 ​± ​2.54] cm) had a higher jump distance than CG ([1.88 ​± ​8.11] cm) according to the results of Vertical Jump Test (T2-T1) and finally FTG ([9.13 ​± ​5.56] cm) had a longer distance than CG ([-0.31 ​± ​1.85] cm) according to the results of Standing Long Jump Test (T2-T1). The result of our study has shown that fascial techniques can be used safely by experienced physiotherapists and can be included in the training program. It is recommended that coaches of sports disciplines work with experienced physiotherapists on this subject and include fascial methods in their training programs.

Acute Effects of Percussive Massage Therapy on Thoracolumbar Fascia Thickness and Ultrasound Echo Intensity in Healthy Male Individuals: A Randomized Controlled Trial

Percussive massage therapy (PT) has been widely used by therapists and the fitness population to treat myofascial-related conditions. However, there is no evidence to confirm the effects of PT on the fascia. This study aimed to investigate the effects of PT on thoracolumbar fascia (TLF) morphology and other related outcomes.

METHODS

Sixty-six healthy males participated and were randomly allocated into a percussive massage group (PT group) and a control group. The PT group received 15 min of back percussion massage, while the control group rested prone lying in the same environment for 15 min. Thoracolumbar fascia (TLF) thickness and echo intensity, perceived stiffness, lumbar flexibility, and skin temperature were measured in both groups before and immediately after the intervention.

RESULT

TLF thickness and lumbar flexibility did not change when compared in the two groups. However, the echo intensity (left side, difference -3.36, 95% CI -5.1 to -1.6; right side, difference -4.39, 95% CI -6.1 to -2.7) and perceived stiffness (difference, -1.18, 95% CI -1.84 to -0.52) in the TLF region were significantly lower in the PT group than in the control group and were accompanied by increased skin temperature (difference 0.29, 95% CI 0.11 to 0.48).

CONCLUSION

We suggest that a 15 min PT with 30 Hz on the back region could reduce TLF echo intensity and perceived stiffness and increase skin temperature in healthy men individual.

Thoracolumbar fascia mobility and chronic low back pain: Phase 2 of a pilot and feasibility study including multimodal chiropractic care

BACKGROUND

Thoracolumbar fascia mobility observed with ultrasound imaging and calculated as shear strain is lower in persons with chronic low back pain. This pilot and feasibility trial assessed thoracolumbar shear strain in persons with chronic low back pain following spinal manipulation and over an 8-week course of multimodal chiropractic care.

METHODS

Adults self-reporting chronic low back pain ≥ 1 year participated between September 2019 and April 2021 in a trial using ultrasound imaging to measure thoracolumbar shear strain. Ultrasound imaging occurred 2-3 cm lateral to L2-3 while participants relaxed prone on an automated table moving the lower extremities downward 15 degrees, for 5 cycles at 0.5 Hz. Pain intensity on an 11-point numerical rating scale, disability, pain interference, and global improvement were also collected. Participants received 8-weeks of twice-weekly chiropractic care including spinal manipulation, education, exercise, self-management advice and myofascial therapies. Shear strain was computed using 2 methods. The highest shear strain from movement cycles 2, 3, or 4 was averaged over right and left sides for each participant. Alternately, the highest shear strain from movement cycle 3 was used. All data were analyzed over time using mixed-effects models. Estimated mean changes are reported.

RESULTS

Of 20 participants completing 8-weeks of chiropractic care (female n = 11), mean (SD) age was 41 years (12.6); mean BMI was 28.5 (6.2). All clinical outcomes improved at 8-weeks. Mean (95% confidence interval) pain intensity decreased 2.7 points (- 4.1 to - 1.4) for females and 2.1 points (- 3.7 to 0.4) for males. Mean Roland-Morris disability score decreased by 5 points (- 7.2 to - 2.8) for females, 2.3 points (- 4.9 to 0.2) for males. Mean PROMIS pain interference T-score decreased by 8.7 points (- 11.8 to - 5.5) for females, 5.6 points (- 9.5 to - 1.6) for males. Mean shear strain at 8-weeks increased in females 5.4% (- 9.9 to 20.8) or 15% (- 0.5 to 30.6), decreasing in males 6.0% (- 24.2 to 12.2) or 2% (- 21.0 to 16.8) depending on computational method.

CONCLUSION

Spinal manipulation does not likely disrupt adhesions or relax paraspinal muscles enough to immediately affect shear strain. Clinical outcomes improved in both groups, however, shear strain only increased in females following 8-weeks of multimodal chiropractic care. Trial registration ClinicalTrials.gov registration is NCT03916705.

Fascial Manipulation Method Is Effective in the Treatment of Myofascial Pain, but the Treatment Protocol Matters: A Randomised Control Trial—Preliminary Report

Background: There are many therapeutic methods targeting fascia. However, the only method whose basic assumption is to eliminate the densification of fascia is Fascial Manipulation. Objective: To evaluate the effectiveness of various Fascial Manipulation (FM) protocols in reducing myofascial pain. Design: Randomized control trial. Subjects: A total of 54 individuals, aged 18–29 years, with musculoskeletal pain for at least 1 week. Methods: The patients were divided into four groups subjected to different treatment protocols: group 1—underwent the standard FM treatment protocol (STP), group 2—modified protocol (MTP), group 3—modified protocol 2 (MTP2), and the control group (CG)—did not undergo any therapy. Each protocol involved three treatments at intervals of 7–10 days and a follow-up examination after 30 days. The outcome was pain level measured using the VAS. Results: In the STP, all the measurements showed a significant decrease in pain level—the mean difference was 2.077 after the first treatment, 3.462 after the third treatment and 3.385 in the follow-up. In the MTP, a significant mean difference was noted after the third treatment, 3, and in the follow up, 2.4. In the MTP2, it was noted after the third session, 2, and in the follow up, 2.25. Only the CG group did not display significant changes. Conclusions: FM-based therapy results in pain relief. However, there are differences in the dynamics and durability of the results depending on the chosen protocol.

Quantitative Evaluation of the Movement Distance of Deep Fascia and Change of Muscle Shape Related to Chain Response in Fascia Tissue of Lower Limb

By using ultrasonography, we measured the longitudinal movement distance of the deep fascia (LMDDF), change of the pennation angle (PA) and muscle thickness (MT) in both the tensor fasciae latae muscle (TFL) and the gluteus medius muscle (G-Med) during passive movement of the toes/ankle joints. 21 right lower limbs of 21 healthy males were evaluated in this study. We measured the LMDDF of the TFL and G-Med by measuring distance between the designated landmark on skin and the intersection of the major deep-fascia (D-fascia) and the fascial bundle. We also measured change of the PA and MT of both muscles. Additionally, we also measured the reliability of the measurement and the measurement error. The measurement was performed during three manual positions on the toes/ankle; manual holding of the toes and ankle joint in neutral, toes flexion and ankle plantar flexion/inversion position, toes extension and ankle extension/valgus position. The existence of muscle contraction of both the muscles during passive motion was monitored by active surface electrodes. This study confirmed mobility of the D-fascia in which the TFL's D-fascia moves and change of muscle shape in the distal direction during no muscle contraction due to passive movement. This fact suggests the possibility that passive tension on fascia tissue of the ankle extends to the proximal part of the limb, i.e., to the D-fascia of the TFL.

Hyaluronan and the Fascial Frontier

The buzz about hyaluronan (HA) is real. Whether found in face cream to increase water volume loss and viscoelasticity or injected into the knee to restore the properties of synovial fluid, the impact of HA can be recognized in many disciplines from dermatology to orthopedics. HA is the most abundant polysaccharide of the extracellular matrix of connective tissues. HA can impact cell behavior in specific ways by binding cellular HA receptors, which can influence signals that facilitate cell survival, proliferation, adhesion, as well as migration. Characteristics of HA, such as its abundance in a variety of tissues and its responsiveness to chemical, mechanical and hormonal modifications, has made HA an attractive molecule for a wide range of applications. Despite being discovered over 80 years ago, its properties within the world of fascia have only recently received attention. Our fascial system penetrates and envelopes all organs, muscles, bones and nerve fibers, providing the body with a functional structure and an environment that enables all bodily systems to operate in an integrated manner. Recognized interactions between cells and their HA-rich extracellular microenvironment support the importance of studying the relationship between HA and the body’s fascial system. From fasciacytes to chronic pain, this review aims to highlight the connections between HA and fascial health.

Biology of Lymphedema

Simple Summary

Lymphedema is a chronic, debilitating disease of the lymphatic vasculature. Although several reviews focus on the anatomy and physiology of the lymphatic system, this review provides an overview of the lymphatic vasculature and, moreover, of lymphatic system dysfunction and lymphedema. Further, we aim at advancing the knowledge in the area of lymphatic system function and how dysfunction of the lymphatic system—as seen in lymphedema—affects physiological systems, such as the cardiovascular system, and how those might be modulated by lymphedema therapy.

Abstract

This narrative review portrays the lymphatic system, a poorly understood but important physiological system. While several reviews have been published that are related to the biology of the lymphatic system and lymphedema, the physiological alternations, which arise due to disturbances of this system, and during lymphedema therapy, are poorly understood and, consequently, not widely reported. We present an inclusive collection of evidence from the scientific literature reflecting important developments in lymphedema research over the last few decades. This review aims at advancing the knowledge on the area of lymphatic system function as well as how system dysfunction, as seen in lymphedema, affects physiological systems and how lymphedema therapy modulates these mechanisms. We propose that future studies should aim at investigating, in-detail, aspects that are related to fluid regulation, hemodynamic responses, and endothelial and/or vascular changes due to lymphedema and lymphedema therapy.

Manual Therapies for Posterior Thigh Muscles Enhanced Ten-Repetitions Maximum Test Performance and Hip Flexibility in Young Soccer Players

This study investigated how different manual therapies applied to the posterior thigh muscles affect the ten-repetitions maximum performance test (10 RM) and hip flexion range-of-motion among young soccer players. Seventeen non-professional male soccer players performed the 10RM and range of motion pre-testing, and, in separate laboratory visits, they underwent three different experimental activities presented to each participant in a randomized order: (a) rest control activity with no intervention, (b) manual massage, and (c) muscle energy. Comparing pre-testing performances to repeated tests after each intervention condition, participants increased their maximum load lift on the 10-repeitions maximum test following manual massage and muscle energy interventions (p < 0.05), but not following the control condition. They also increased their hip range-of-motion on flexibility testing following manual massage and muscle energy (p < 0.05), but not following the control condition. Thus, both manual massage and muscle energy therapies applied to the posterior thigh were beneficial to performance. This finding has clear implications when preparing athletes for competition.

Quantitative analysis of gliding between subcutaneous tissue and the vastus lateralis - Influence of the dense connective tissue of the myofascia

INTRODUCTION

The thickness of connective tissue has been shown to be associated with pain (Stecco et al., 2014). However, the relationship between fascial thickness and gliding remains unclear. In addition, the influence between gliding and the motion rhythm and limb position isn't clear.

METHOD

A therapist moved patient's lower leg at one of two constant rhythms (40 or 60bpm). Gliding of both the vastus lateralis (VL) muscle and subcutaneous (SC) tissue were recorded during knee motion using ultrasonography. Particle image velocimetry analysis software was adapted to create the flow velocity from echo imaging. Gliding was calculated using a coefficient of correlation from each flow velocity. Myofascial thickness and SC were measured using Image-J. The ratios of the loose connective tissue (LCT) and dense connective tissue (DCT) thickness to the total myofascial thickness were calculated. Repeated-measures two-way ANOVA was used to compare the two motion rhythms and three positions, with stepwise multiple regression analysis to analyze the predictors that influenced the gliding coefficient at each rhythm.

RESULTS

Repeated-measures two-way ANOVA showed that the effect of rhythm was statistically significant, but the effect of position was not. At a 40 bpm rhythm, stepwise multiple regression analysis selected SC thickness and DCT thickness as significant factors, while at a 60 bpm rhythm, SC thickness and DCT ratio were selected.

CONCLUSION

This study revealed that increased thickness of DCT of the myofascia and SC resulted in decreased gliding between the VL and SC, demonstrating that gliding is related to fascial thickness. Motion rhythm influences gliding between tissues.

Emission of Biophotons and Adjustable Sounds by the Fascial System: Review and Reflections for Manual Therapy

Every body structure is wrapped in connective tissue or fascia, creating a structural continuity that gives form and function to every tissue and organ. The fascial tissue is uniformly distributed throughout the body, enveloping, interacting with and permeating blood vessels, nerves, viscera, meninges, bones and muscles, creating various layers at different depths and forming a tridimensional metabolic and mechanical matrix. This article reviews the literature on the emission of biophotons and adjustable sounds by the fascial system, because these biological changes could be a means of local and systemic cellular communication and become another assessment tool for manual (therapy) practitioners. This is the first article that discusses these topics in a single text, attempting to bring such information into an area of application that is beneficial to osteopaths, chiropractors, and manual therapists.

Fascial manipulation vs. standard physical therapy practice for low back pain diagnoses: A pragmatic study

BACKGROUND

Connective tissue mobility alters motor unit recruitment, but the restoration of fascial mobility allows for optimal motor function. The Fascial Manipulation^® (FM^®) method is a multiplanar approach that assesses and treats the mobility of deep fascia in specific anatomical locations where motor units converge.

OBJECTIVES

To assess the effects of FM^® vs. standard physical therapy treatment (SPT) in patients with low back pain (LBP).

DESIGN

Six-months controlled clinical trial.

METHOD

102 participants with LBP received SPT or FM^®. Numeric Pain Rating Scale (NPRS), 15- point Global Rating of Change (GROC), and Oswestry Disability Index (ODI) were used to monitor progress.

RESULTS

The FM^® group had a significantly lower ODI (p < 0.009) and NPS scores (p < 0.0001) and significantly higher GROC scores (p < 0.003) once their means were adjusted for initial scores. When comparing the SPT to FM^®, the final ODI decreased by at least 1 category in 48.9% of the SPT cases, while in 36.2% of the cases was no change. ODI minimal clinical importance difference (MCID) change of 10% decrease in scores occurred in 70.2% of the SPT group compared to 96% of the FM^® group (p = 0.003). ODI MCID change of 50% decrease in scores occurred in 40% of the SPT group compared to 64.6% of the FM^® group (p = 0.02) 44.7% of the participants in the SPT group had final GROC values above +5 at discharge, compared to 92% of the participants from the FM^® group (p = 0.0001). The FM^® subjects had almost three times the change in NPRS compared to SPT counterparts (-4.3 ± 2.2 to -1.5  ± 2.4, p=0.0001).

CONCLUSIONS

FM^® appears to improve NPRS, GROC, and ODI more than SPT. FM^® may provide an effective treatment technique for LBP.

The indeterminable resilience of the fascial system

The most recent information on fascial tissue indicates that there are not fascial layers, but polyhedral microvacuoles of connective tissue, which connect the body systems and, by hosting specialized cells, permit several functions, such as motor, nervous, vascular and visceral. These microvacuoles (a repetition of polyhedral units of connective fibrils) under internal or external tension change shape and can manage the movement variations, regulating different body functions and ensuring the maintenance of efficiency of the body systems. Their plasticity is based on perfect functional chaos: it is not possible to determine the motion vectors of the different fibrils, which differ in behavior and orientation; this strategy confers to the fascial continuum the maximum level of adaptability in response to the changing internal and external conditions of the cell. The present commentary deals with this concept, providing clinical examples of different disease patterns, providing contrary examples in which this adaptability does not occur, and lastly suggesting considerations for the approach to manipulative therapy of the fascial tissue. The fascial continuum is like a flock of birds flying together without a predetermined logic and maintaining their individuality at the same time.

Investigation of interaction phenomena between crural fascia and muscles by using a three-dimensional numerical model

The focus of this work is the numerical modeling of the anterior compartment of the human leg with particular attention to crural fascia. Interaction phenomena between fascia and muscles are of clinical interest to explain some pathologies, as the compartment syndrome. A first step to enhance knowledge on this topic consists in the investigation of fascia biomechanical role and its interaction with muscles in physiological conditions. A three-dimensional finite element model of the anterior compartment is developed based on anatomical data, detailing the structural conformation of crural fascia, composed of three layers, and modeling the muscles as a unique structure. Different constitutive models are implemented to describe the mechanical response of tissues. Crural fascia is modeled as a hyperelastic fiber-reinforced material, while muscle tissue via a three-element Hill's model. The numerical analysis of isotonic contraction of muscles is performed, allowing the evaluation of pressure induced within muscles and consequent stress and strain fields arising on the crural fascia. Numerical results are compared with experimental measurements of the compartment radial deformation and intracompartmental pressure during concentric contraction, to validate the model. The numerical model provides a suitable description of muscles contraction of the anterior compartment and the consequent mechanical interaction with the crural fascia.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A unifying neuro-fasciagenic model of somatic dysfunction - Underlying mechanisms and treatment - Part II

This paper offers an extensive review of the main fascia-mediated mechanisms underlying various therapeutic processes of clinical relevance for manual therapy. The concept of somatic dysfunction is revisited in light of the several fascial influences that may come into play during and after manual treatment. A change in perspective is thus proposed: from a nociceptive model that for decades has viewed somatic dysfunction as a neurologically-mediated phenomenon, to a unifying neuro-fascial model that integrates neural influences into a multifactorial and multidimensional interpretation of manual therapeutic effects as being partially, if not entirely, mediated by the fascia. By taking into consideration a wide spectrum of fascia-related factors - from cell-based mechanisms to cognitive and behavioural influences - a model emerges suggesting, amongst other results, a multidisciplinary-approach to the intervention of somatic dysfunction. Finally, it is proposed that a sixth osteopathic 'meta-model' - the connective tissue-fascial model - be added to the existing five models in osteopathic philosophy as the main interface between all body systems, thus providing a structural and functional framework for the body's homoeostatic potential and its inherent abilities to heal.