WHOOPS !

WHOOPS !

www.fascialmanipulationworkshops.com

NUHS 2011 HOMECOMINGSpeaker: Warren I. Hammer DC, MS, DABCO

Winterstein J. Best for the Profession or Best for the Public? Dynamic Chiropractic 29 (12) 2011.• “Chiropractic must be what it has always

been.“ ?????• Optometry, Osteopathy, Psychology (PhD)• Is Chiropractic about what society truly needs

or about what we think society needs?• Is spinal and joint manipulation all society

requires from our profession?

Gross AR et al. Conservative Management of Mechanical Neck Disorders: A Systematic Review. J Rheumatology, 2007;34:3.

• 11 systematic reviews of randomized controlled trials (88 studies).

• Conclusions: Evidence of long term benefit Strong evidence: multimodal including

mobilization/manipulation, stretching/ strengthening exercise.

Evidence of no benefit: manipulation alone.

EFFECT OF SPINAL VS SOFT TISSUE MANIPULATION IN RESTORING CERVICAL LORDOSIS

• STUDY IN JMPT 17(7),1994:454-464.–The use of sustained cervical

traction (10 minutes daily, 10-14 weeks) allowed time for “the soft tissues to stretch past the elastic phase into the viscous-plastic phase”.

Definition of Fascia:1st Fascia Research Congress (Boston 2007)

“Fascia is the soft tissue component of the connective tissue system that permeates the human body”.

“Fascia extends to all fibrous connective tissues, including aponeuroses, ligaments, tendons, retinaculae, joint capsules, organ and vessel tunics, the epineurium, the meninges, the periostea, and all the endomysial and intermuscular fibers of the myofasciae”.

Langevin HM. Connective tissue: A body-wide signaling network? Med Hypoth (2006) 66:1074-1077

• Unspecialized “loose” connective tissue forms an anatomical network throughout the body.

• Fascia may function as a body-wide mechanosensitive signaling network and whole body communication system.

• Possible signals generated by connective tissue due to mechanical forces:– Electrical signals– Cellular signaling– Signals causing tissue remodeling.

Perimysium

MUSCLE BELLY

MUSCLE FIBER

EPIMYSIUM

ENDOMYSIUMMYOFIBRIL

Electron micrograph showing fine collagen fibers (endomysial sheets-fascia) separating adjacent

muscle fibers

Purslow P, Trotter JA, 1994. The morphology and mechanical properties of endomysium in series-fibred muscles; variations with muscle length. J Muscle Res. Cell Motil 15, 299-304

Fascia/Muscle Interactions

• In the early phase of immobilization loss of muscle length is due to shortening of associated fascia before actual muscle shortening.

• Both an absence of stress (hypomobility) or increased stress (hypermobility) cause fibrotic changes in connective tissues.

• TPs, “taut muscle bands”, “muscle spasm” contribute to connective tissue remodeling and fibrosis.

Antonio Stecco M.D. Physical Medicine and Rehabilitation, University of Padova, Italy

PHYSIOLOGY OF THE FASCIA

Ultrasound evidence of altered lumbar connective tissue structure in human subjects

with chronic low back pain*• This study is the first report of abnormal connective

tissue structure in the back in a group of human subjects with chronic or recurrent LBP.

• The LBP group had ~25% greater perimuscular thickness and echogenicity compared with the No-LBP group

• Increased thickness and disorganization of connective tissue layers may be an important and so far neglected factor in human LBP pathophysiology.

* Langevin HM, Stevens-Tuttle D, Fox JR. et al. BMC Musculoskeletal Disorders 2009, 10:151

multi-layered tissue

a c

THE DEEP FASCIAE: from an irregular fibrous tissue to a multilayer organization (Stecco et al, 2008)

Thanks to the different orientations of the collagen fibers in the layers, the fascia has strong resistance to traction even

when it is exercised in different directions. 12

Layer I

Layer II

THE IMAGING OF THE DEEP FASCIAE

• the superficial fascia

• the deep fascia

• superficial layer of hypodermis

(retinacula cutis superficialis)

• deep layer of hypodermis

(retinacula cutis profondus)

13

Innervation of the deep fascia

Pacini corpuscles (S100, 100x)

Ruffini corpuscles (S100, 200x)

In the last years various researches have demonstrated the presence of many free and encapsulated nerve endings, particularly Ruffini and Pacini corpuscles, inside the fasciae

Relationships between nerves and fascia The capsules of the corpuscles and the free nerve endings

are connected to the surrounding collagen fibres

S-100 immunohistochemical stain

Stretching of the deep fascia activates these receptors

NERVE

Large nerve fibres and deep fascia

The larger nerve fibres are often surrounded by different layers of

loose connective tissue that preserves the nerve from traction to which the fascia is subjected.

Layers

From 1975 to 1985: Concepts developed from other methods

that have inspired FM. From 1986 to 2000: Definition of the Fascial Manipulation model

for Musculoskeletal Pain

Short History of Fascial Manipulation© Inspired by Luigi Stecco P.T

Evolution of concepts leading to present day Fascial Manipulation

• 1972-75: PT school: dissatisfied with massage.• 1976: Jt. manipulation: McMennel, Maigne, etc.• 1979: Learned about Connective Tissue Massage:

(works of Elisabeth Dicke) • 1980: Cyriax Orthopaedic Medicine: deep TFM was potent when

administered on correct location.• 1981: Acupuncture: best results came by working over acupuncture points on

the muscle belly, rather than working directly on the tendons and ligaments, as suggested by Cyriax.

Evolution of concepts (continued)

• 1982 Ida Rolf: first introduction to fascia. Realized that joints work better if we modify the fascia. Started to study everything available on the subject.

Evolution of concepts (continued)

1983 J. Travell, Trigger Points, realized that:

• Pressure over active TPs referred pain in a precise distribution.Found that the origin of painful joints came from a “trigger point” over the muscle belly related to that joint. (combining the TP and AP point over the muscle belly)

Evolution of concepts (continued)

1984 Kinetic chains: F. Mézières, Busquet, Souchard.

– Compensations developed along kinetic, or muscular, chains.

– pain (sciatica, brachialgia, back pain …) was often distributed according to these myofascial sequences.

1985 Meridians and Kinetic Chains: KabatParallelisms between motor directions and meridians.

Patterns of flexion-adduction-intrarotation corresponded to the Yin Meridians.

1987 First Book Good results encouraged him

to write down (1983) all that he had learned through 10 years of clinical experience and study.

He wrote first, small book called “Myofascial sequences and acupuncture meridians”. He realized that unidirectional muscles inserted sequentially onto their overlying fascia.

Relationship of Acupuncture Points & Meridians to Connective Tissue Planes*

• Acupuncture meridians tend to be preferentially located along fascial planes between muscles, or between a muscle and bone or tendon.

• Found a greater connective tissue response at acupuncture points than control points.

• The greater the amount of connective tissue at a particular acupuncture point the more powerful the mechanical signaling and down stream effects.

• Langevin H, Yandow JA. Anat Record 2002, 269:257-269

Fascial plane separating the vastus lateralis and biceps femoris muscle. GE-AN

VL

BF

LUNG

1988 Neuroconnective Manipulation • Are acupuncture points all alike?

• Those over muscle belly are centres of coordination whereas those around the joints are centres for motor perception or pain.

• How does manipulation “work”?

• Deep friction loosens the connective tissue that imprisons the free nerve endings (1988).

Giornale della Natura, 12 Maggio, 1988

1990 Pain and the mfu sequences His 2nd Book, published by

IPSA, had indications about the treatment process: data collection, hypothesis, verification, and results.

In this same book, possible research into internal or visceral dysfunctions was postulated. Only this year, 2010, our first book about visceral dysfunctions has been published in Italian.

1994Neuroconnective manipulation performed on backache of myofascial origin provided amazing results.

This treatment does not apply to the single muscle but to the whole fascia located over it.

the point, reference is made to the density of the fascia rather than to the rigidity of the muscle. La Riabilitazione- Vol. 27 – n° 1 - 1994

1996 Neuroconnective Manipulation In this text the six myo-

fascial units (mf units) that move each of the 14 segments (joints) of the body in the three planes of space were defined (re-ge = BL 37).

Each mf unit has: a Centre of Perception (CP)

where pain is felt, in a specific movement test.

a Centre of Coordination (CC), where treatment is performed.

Fascial Manipulation ©

Luigi SteccoFASCIAL

MANIPULATIONInternal Part

1988

1990

1996

2002

2004

2007

2009

I and II levels III level

2011

First course 2008

Numerous Pubmed Articles by Steccos• Application of Fascial Manipulation technique in chronic shoulder pain--

anatomical basis and clinical implications.• Treating patellar tendinopathy with Fascial Manipulation.• RMI study and clinical correlations of ankle retinacula damage and

outcomes of ankle sprain.• How much time is required to modify a fascial fibrosis?• The expansions of the pectoral girdle muscles onto the brachial fascia:

morphological aspects and spatial disposition.• The ankle retinacula: morphological evidence of the proprioceptive role of

the fascial system.• The pectoral fascia: anatomical and histological study.• Anatomical study of myofascial continuity in the anterior region of the

upper limb.• Histological study of the deep fasciae of the limbs.• Historical review of carpal tunnel syndrome.• Tendinous muscular insertions onto the deep fascia of the upper limb.

First part: anatomical study.

HYPOTHESIS

HYPOTHESIS• Both Paoletti (2002) and Stecco (2004) hypothesize that the

deep fascia between two joints is directly involved in safeguarding a perceptive and directional continuity along a specific myokinetic chain or sequence.

• It could be that fascia acts somewhat like a sensitive transmission belt between two adjacent joints and synergic muscle groups.

• Densified fascia is unable to manage the transmission of tension between muscles, bones, and joints*.

Stecco L, Stecco C. Fascial Manipulation:Practical Part. 2009, Piccin Nuova Libraria

S.p.A., Padova. www.piccin.it

When a group of muscle fibers contract together for a particular direction they will tension their overlying and intra fascia and at a particular area there will be a mathematical point where the vector forces will converge in a given movement pattern.

a physiological sliding system in the CC is

necessary to create a correct final vector

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

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

FASCIAL MANIPULATION - BIOMECHANICAL MODEL Simplification of a complexity

an-ge

me ge

an me ge

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

CF can combine along myofascial spirals or diagonals

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

ir ge

CP

CP = Centre of perception , where pain is felt

Spindle Cells (especially in CCs)FUNCTIONS• Specialized proprioceptors that monitor muscle length

(stretch) and signal the rate of change in muscle length. 1) Controls and maintains muscle tone 2) Activates the dynamic stretch reflex mechanism 3) Maintains muscle contraction against the constant

force of gravity (the static stretch reflex mechanism) 4) Controls fine motor movements.

• DYSFUNCTION of fascia surrounding spindle cells alters its ability to fire normally.

Recent e-mail exchange with Siegfried Mense, MD (world’s leading expert on muscle pain & neurophysiology):

• Question: Can fascial adhesions have an adverse affect on spindle cells?

• Answer: “Structural disorders of the fascia can surely distort the information sent by the spindles to the CNS and thus can interfere with a proper coordinated movement”.

• (Spindle cells are within the perimyceum and endomyceum)

Hypothesis Review

• Facial fibrosis at the Center of Coordination (CC).

• Altered motor unit recruitment in MF unit.• Incorrect activation of mechanoreceptors and

proprioceptors.• Uncoordinated movement at joints.• Pain in center of perception (CP) and potential

joint damage.

MF sequence

• Definition: Chain of unidirectional mf units united by the overlying fascia and tensioned by the biarticular muscular fibers.

• Every MFU contains monoarticular and biarticular fibers.

New slide not included

• This spatial organization of the myofascial expansions could be also recognized along the limbs, connecting the different segments.

• This organization could guarantee a perceptive continuity along all the limb, probably representing the anatomical base of the myokinetic chains.

MYOKINETIC CHAINS

44

antemotion

retromotion

mediomotion

Lateral motion

me

extrarotation

intrarotation

ir

MYOFASCIAL SEQUENCESFascial Manipulation © - Luigi Stecco

Antemotion Sequence

Upper Limb

Stecco A, Macchi V, Stecco C, Porzionato A, Ann Day J, Delmas V, De Caro R. J Bodyw Mov Ther. 2009 Jan;13(1):53-62

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

• Dissection of 15 unembalmed cadavers of the upper limb demonstrated an ‘‘anatomical continuity’’ of myofascial expansions, with a nearly constant pattern, which originate from the flexor muscles and extend to the overlying fascia.

• During flexion, as these muscles contract, the anterior portion of the brachial and antebrachial fascia is subject to tension. As the fascia is rich in proprioceptive nerve endings, it is hypothesized that this tension activates a specific pattern of receptors, contributing to perception of a specific motor direction.

• *Stecco A, Macchi V, Stecco C, Porzionato A, Ann Day J, Delmas V, De Caro R. J Bodyw Mov Ther. 2009 Jan;13(1):53-62

• .

AN-HU

AN-CU

AN-CA

AN-DI

MYOFASCIAL CHAIN ALONG THE ANTE SEQUENCE

MFU’S

Di

Sequence of antemotion of the upper limb

CC

cc

cc

cc

4 MFUs OF UPPER LIMB MAKES UP THE UPPER LIMB FASCIAL SEQUENCE

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

• If the muscular fascia is in a nonphysiological state i.e. densified, these mechanisms are altered, and the proprioceptors in the fascia may be incorrectly activated, thus giving rise to extra-articular pain and muscle incoordination.

• *Stecco A, Macchi V, Stecco C, Porzionato A, Ann Day J, Delmas V, De Caro R. J Bodyw Mov Ther. 2009 Jan;13(1):53-62

Hypertonicity of the agonist myofascial unit creates a hypertonicity of the antagonist MFu

• “Evidence of HA aggregation has also been reported: short HA segments have been demonstrated to self-associate in physiological solution, while a variety of intermolecular aggregates were observed when HA was spread on surfaces”.

• “By increasing the concentration of HA, HA chains begin to entangle conferring to the solution distinctive hydrodynamic properties: the viscoelasticity is dramatically increased”.

Matteini P et al;Structural behavior of highly concentrated hyaluronan; Biomacromolecules. 2009 Jun 8;10(6):1516-22.

Etiopathology

Gel-fluid transition

“Extrapolated lines of the travel distance below and beyond these values furnished a gel-like to fluid-like transition at 35-40 °C, in accordance with previous studies which had ascribed it to a destabilization of a postulated HA supramolecular assembly”.

Change of viscosityMatteini P et al;Structural

behavior of highly concentrated hyaluronan; Biomacromolecules. 2009 Jun 8;10(6):1516-22.

The symptoms appear only if the HA's gel phase is present also in the CC!

HA aggregation

Viscoelasticity is dramatically increased

The location is in the CC

Dysfunction: symptoms

The location is NOT in the CC

NO symptoms

Therapy“These chain-chain interactions were reported to be reversibly disaggregated by an increase in temperature or by alkalinization”.

“Recent infrared spectroscopy studies have suggested the formation of three-dimensional superstructures of HA chains stabilized by water bridges. This water-mediated supramolecular assembly was shown to break down progressively when the temperature was increased to over 40 °C, in accordance with ∼ previous NMR observations”.

Matteini P et al;Structural behavior of highly concentrated hyaluronan; Biomacromolecules. 2009 Jun 8;10(6):1516-22.

Scott JE, Heatley F;Biological properties of hyaluronan in aqueous solution are controlled and sequestered by reversible tertiary structures, defined by NMR spectroscopy; Biomacromolecules. 2002 May-Jun;3(3):547-53.

Post Fascial Manipulation effects:

0-15 min •Start of the inflammatory reaction

15min-12h

•Increase in signs and symptoms of inflammatory reaction:•calor, tumor, dolor, functional

loss

12h-24h •Peak of inflammatory reaction

24h-48h •Resolution of the inflammatory

reaction and of the symptoms

“The smallest products of the HA catabolic cascade can turn about and suppress the action of larger predecessors, and thereby mollifying their effects.”

Stern R et al; Hyaluronan fragments: an information-rich system. Eur J Cell Biol. 2006 Aug;85(8):699-715.

“DSC pointed out the existence of a gel-like to fluid-like transition, while it excluded any involvement of strong intermolecular interactions”.

Densification: gel-like phase

Overuse syndrome

retention of HA

Fascial Manipulation Treatment

Resolution of the densification

normal sliding system

cal

Kg

Gel phase Fluid phase

Dysfunction:

CC

CP

ME LA

Symptoms in the Center of Perception

Phase of compensation

Mechanical incoordination in the articulation

The resulting vector becomes faulty

Improper recruitment of muscle fibres

Decrease activation of muscle spindles

Decrease of the sliding system in the CC

Increase of the viscosity of HA in the Centre of Coordination

CCDensifie

d(gel

phase)

Phase of compensatio

n

Assessment Chart1. Complete case history emphasizing all information pertaining to

current complaint.2. Investigation of any concurrent complaints and chronological

order of past injuries, accidents or operations. 3. Relate above to possible sequences or planes

that might be related and resulting in compensations.4. Form an hypothesis regarding segments or planes.5. Functional testing (MoVe) of pertinent segments in all 3 planes.6. Palpation of CCs for areas of positive tests.

Treatment

Friction . . . .

heat develops ? Perception of

change in tissue mobility

patient reports pain reduction

MEAN TIMES 3.24 MINUTES MEAN TIMES 10 SECONDS

MFU cc

MFU cc

MFS

Evaluated by functional tests

FM Evaluation & Treatment of the Upper Extremity Sagittal Plane

MF unit of an-cu

Site of pain or CP: limited ROM of the elbow, often painless, can occur following fractures or dislocation of the radial head.Origin of dysfunction or CC: in the densified brachial fascia that cannot synchronise the monoarticular(brachialis) and biarticular (biceps andbrachioradialis) muscle fibres.

Either test comparatively resisted elbowflexion (bilaterally) or compare elbow flexion ROM by asking patient to touch both shoulders; measurement of the distance between the middle fingertip and the acromion, before and after treatment, can be useful. USEUPPERCUT

MF unit of an-hu

Site of pain or CP: pain in the anterior region of the shoulder that accentuates during antemotion of the shoulder. A diagnosis of capsulitis is common in these cases.Origin of dysfunction or CC: due to lack of coordination of the mf unit, the humerus and scapula movements are asynchronous.

Ask patient to bring arm forward as in shaking hands. At times this is sopainful the patient has to use the other hand to help with the movement.

Patient supine, arm along side, thetherapist uses their knuckle over anterior part of upper deltoid, searching for the most significant fascial alteration that refers pain.

An-cuThe therapist initially uses their knuckleto explore the brachial fascia overthe biceps, at the level of the distaltendon of deltoid, then manipulates withthe elbow.

MF unit of an-caSite of pain or CP: Along the flexor carpi radialis tendon - compensatory cysts may form here due to anomalous muscle tension; sometimes the patient complains of thumbpain, similar to writer’s cramp.Origin or centre of coordination: in the antebrachial fascia, in the point where the monoarticular (flexor carpi radialis) and biarticular (flexor pollicis longus) muscle fibres unite.

Test force of flexor carpi radialis against resistance. Alternatively, ask patient to place both hands palms down on the table and then to push down forcefully - patient is asked to then indicate the most painful area (flexor carpi radialis tendon).

An-caPatient supine, therapist places knuckle,or elbow, over muscle belly of flexorcarpi radialis to manipulate theantebrachial fascia. Here the fascialalteration is often chronic, requiringmore time to dissolve; hence, use of theelbow is advisable.

MF unit of an-di

SSite of pain or CP: the thenar eminence dysfunction manifests mostly in the first metacarpophalangeal joint but, due to fascial continuity, it may also involve the othermetacarpophalangeal joints.Origin or centre of coordination: in the area of densified fascia that unites the monoarticular (flexor pollicis brevis) to the biarticular (flexor pollicis longus) muscle fibres.

Passive stretch of the thenar eminence provokes pain - often the patient inadvertently avoids this movement during daily living activities.

An-diHaving identified the most densifiedpoint of the thenar eminence, thetherapist uses the knuckle tomanipulate this point until tissuefluidity is restored.

MF unit of re-hu

Site of pain or CP: pain is localised in the point where the extensor fibres of deltoid insert.Origin of dysfunction or CC: long head of triceps, latissimus dorsi, teres major and minor all participate in moving the humerus backwards. The fascial alteration is to be found in the point of convergence of these muscles.

Movement verification: Ask the patient to push both arms backwards against resistance placed above the elbows. Note any difference in strength between the two arms.

CC: over muscle belly of teres major behind the posterior axillary wall for RE-HU

Triceps

Deltoid

Myofascial expansion of latissimus dorsi

Teres Major

Teres Minorcc

Monoarticular: teres major, part of the deltoid attached to the scapular spine.Biarticular : latissimus dorsi, long head of triceps.

Stecco L. Fascial Manipulation for Musculoskeletal Pain. Piccin Nuova Libraria, Padova, It; 2004.

Re-huPatient prone, upper limb abducted; thetherapist uses their elbow in the sulcusbetween the long head of triceps andthe scapular part of deltoid. The densifiedfascial fibres can be manipulated byshifting the elbow in different directions.

MF unit of re-cu

Site of pain or CP: a dysfunction of this mf unit determines pain in the olecranon or limited range of elbow extension or flexion.Origin of dysfunction or CC: at times there is incoordination between the various triceps heads and, at other times, the antagonist mf unit (an-cu) provokes hypertonus of the agonist mf unit (re-cu).

Movement verification: Ask patient to extend elbows from 90° flexion, against resistance placed over the forearms; elbow pain may accentuate or a difference in comparative force is noted.

Re-cuPatient prone lying, upper arm resting ontable; therapist uses elbow over muscle bellyof triceps at the level of deltoid’s distaltendon, mobilising the deep myofascial fibres.NB. Avoid compression of radial nerveagainst humerus.

MF unit of re-ca

Site of pain or CP: while tendinitis of extensor carpi ulnaris is relatively rare, hypersensitivity of the ulnar styloid process or the fifth finger may manifest at times.Origin of dysfunction or CC: nflammation of the tendon or the joint is a consequence of anomalous traction of the muscular fibres. Restoration of gliding between these fibres eliminates tendon friction.

Movement verification: Therapist blocks the patient’s forearm with one hand and applies a counter resistance to the extensor carpi ulnaris with the other hand.

Re-caPatient prone with arm along side; thetherapist positions their knuckle overthe myotendinous junction of theextensor carpi ulnaris and manipulatesthis point until the underlying fasciaglides perfectly.

MF unit of re-di

Site of pain or CP: pain in the fifth finger limits certain activities e.g. shaking hands, forming a closed fist.Origin of dysfunction or CC:the small hand muscles perform thefine finger movements; in particular,abductor digiti minimi intervenes inmovements of the V° finger.

Movement verification: Movement verification can be made either actively against resistance or by passive stretch of the fifth finger in different directions. Active contraction is usually proposed to demonstrate mf unit activity.

Re-diPatient prone lying, with arm alongside; the therapist blocks the patient’sfingers with one hand and manipulatesthe lateral part of the hypothenareminence, at the base of the fifthmetacarpal bone, with the other hand.

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