Ultrasound imaging and Fascial Manipulation®: 'Adding a twist' on the ankle retinacula.

BACKGROUND: Retinacula of the ankle are thickening of the deep fascia of the leg (crural fascia) and foot i.e. inseparable structures. Recent studies report their crucial role in functional stability and proprioception of the ankle. CASE PRESENTATION: A 38-yr-old Caucasian man - with a history of lateral malleolus fracture 12 years ago, obesity and right ankle osteoarthritis - was referred to a physiatrist for a right ankle pain that had significantly worsened over the last year. During walking, the patient experienced stinging pain in the area of tibialis anterior and peroneus tertius muscles, and the superior extensor retinaculum. Magnetic resonance imaging and ultrasonography showed clear thicknening (2.05 mm) of the oblique superomedial band of the inferior extensor retinaculum. Sonopalpation was performed to precisely evaluate/confirm the site of maximum pain. Foot function index (FFI) score was 42. RESULTS: Subsequently, the patient was prescribed fascial manipulation, and he had clinical improvement after the first session (FFI: 21). At 1-month follow-up, the patient was still asymptomatic without any functional limitation (FFI: 24). US imaging confirmed the decreased thickness of the oblique superomedial band of the extensor retinaculum (1.35 mm). CONCLUSION: Fascial Manipulation® appears to be a useful tool to reduce thickness, stiffness, and pain in this case as displayed by the ultrasound Imaging.

Physical therapy for acute and sub-acute low back pain: A systematic review and expert consensus.

OBJECTIVE: To review the effectiveness of different physical therapies for acute and sub-acute low back pain supported by evidence, and create clinical recommendations and expert consensus for physiotherapists on clinical prescriptions. DATA SOURCES: A systematic search was conducted in PubMed and the Cochrane Library for studies published within the previous 15 years. REVIEW METHODS: Systematic review and meta-analysis, randomized controlled trials assessing patients with acute and sub-acute low back pain were included. Two reviewers independently screened relevant studies using the same inclusion criteria. The Physiotherapy Evidence Database and the Assessment of Multiple Systematic Reviews tool were used to grade the quality assessment of randomized controlled trials and systematic reviews, respectively. The final recommendation grades were based on the consensus discussion results of the Delphi of 22 international experts. RESULTS: Twenty-one systematic reviews and 21 randomized controlled trials were included. Spinal manipulative therapy and low-level laser therapy are recommended for acute low back pain. Core stability exercise/motor control, spinal manipulative therapy, and massage can be used to treat sub-acute low back pain. CONCLUSIONS: The consensus statements provided medical staff with appliable recommendations of physical therapy for acute and sub-acute low back pain. This consensus statement will require regular updates after 5-10 years.

Factors to consider for fascial plane blocks' success in acute and chronic pain management.

The outcome of fascial plane blocks (FPBs) has a certain variability that may depend on many factors, which can be divided into three main categories: operator-related, patient-related and drug-related. Operator-related factors include personal skills, choice of needle and injection modalities. Patient variables include anthropometric features, the type of targeted fascia, anatomical variants, patient positioning, muscle tone and breathing. Ultimately, efficacy, onset, and duration of fascial blocks may be affected by characteristics of the injected solution, including the type of local anesthetic, volume, concentration, pH, temperature and the use of adjuvants. In this article, we investigated all the factors that may influence the outcome of FPBs from a generic perspective, without focusing on any specific technique. Also, we provided suggestions to optimize techniques for everyday practitioners and insights to researchers for future studies.

Fascial manipulation as an adjunct to physiotherapy management in obstetric brachial plexus palsy: A case report.

The integrity of connective tissue sheaths surrounding the nerves influences both the severity and the potential for recovery of brachial plexus lesions. This study presents an innovative, early onset, multidisciplinary approach to obstetric brachial plexus palsy. This approach is aimed at functional recovery of the nerve lesion and includes mobilization of the fascia using the Fascial Manipulation® method. This case study discusses how, in addition to conventional treatment, interventions aimed at the fascial system can potentially affect tension around the neural sheaths, enhance proprioceptive input and facilitate movement to influence obstetric brachial plexus palsy outcomes.

Integrating mental imagery and fascial tissue: A conceptualization for research into movement and cognition.

Mental imagery (MI) research has mainly focused to date on mechanisms of effect and performance gains associated with muscle and neural tissues. MI's potential to affect fascia has rarely been considered. This paper conceptualizes ways in which MI might mutually interact with fascial tissue to support performance and cognitive functions. Such ways acknowledge, among others, MI's positive effect on proprioception, body schema, and pain. Drawing on cellular, physiological, and functional similarities and associations between muscle and fascial tissues, we propose that MI has the potential to affect and be affected by fascial tissue. We suggest that fascia-targeted MI (fascial mental imagery; FMI) can therefore be a useful approach for scientific as well as clinical purposes. We use the example of fascial dynamic neuro-cognitive imagery (FDNI) as a codified FMI method available for scientific and therapeutic explorations into rehabilitation and prevention of fascia-related disabling conditions.

Defining the fascial system.

Fascia is a widely used yet indistinctly defined anatomical term that is concurrently applied to the description of soft collagenous connective tissue, distinct sections of membranous tissue, and a body pervading soft connective tissue system. Inconsistent use of this term is causing concern due to its potential to confuse technical communication about fascia in global, multiple discipline- and multiple profession-spanning discourse environments. The Fascia Research Society acted to address this issue by establishing a Fascia Nomenclature Committee (FNC) whose purpose was to clarify the terminology relating to fascia. This committee has since developed and defined the terms a fascia, and, more recently, the fascial system. This article reports on the FNC's proposed definition of the fascial system.

Fascial Disorders: Implications for Treatment.

In the past 15 years, multiple articles have appeared that target fascia as an important component of treatment in the field of physical medicine and rehabilitation. To better understand the possible actions of fascial treatments, there is a need to clarify the definition of fascia and how it interacts with various other structures: muscles, nerves, vessels, organs. Fascia is a tissue that occurs throughout the body. However, different kinds of fascia exist. In this narrative review, we demonstrate that symptoms related to dysfunction of the lymphatic system, superficial vein system, and thermoregulation are closely related to dysfunction involving superficial fascia. Dysfunction involving alterations in mechanical coordination, proprioception, balance, myofascial pain, and cramps are more related to deep fascia and the epimysium. Superficial fascia is obviously more superficial than the other types and contains more elastic tissue. Consequently, effective treatment can probably be achieved with light massage or with treatment modalities that use large surfaces that spread the friction in the first layers of the subcutis. The deep fasciae and the epymisium require treatment that generates enough pressure to reach the surface of muscles. For this reason, the use of small surface tools and manual deep friction with the knuckles or elbows are indicated. Due to different anatomical locations and to the qualities of the fascial tissue, it is important to recognize that different modalities of approach have to be taken into consideration when considering treatment options.

Case study: could ultrasound and elastography visualized densified areas inside the deep fascia?

Many manual techniques describe palpable changes in the subcutaneous tissue. Many manual therapists have perceived palpable tissue stiffness and how it changes after treatment. No clear demonstration exists of the presence of specific alterations in the subcutaneous tissue and even less a visualization of their changes following manual therapy. This case study visualizes by ultrasound and elastography an alteration of the deep fascia in a 40-year-old male with subacute pain in the calf area. Ultrasound and elastography permits visualization of gliding, echogenicity and elasticity of deep fascia and their changes, after manual therapy (Fascial Manipulation(©)). This study suggests the possible use of the ultrasound and elastography to furnish a more objective picture of the "sensations" that are commonly reported by manual therapists, and which supports clinicians in the diagnosis of the myofascial pain.

Ultrasonography in myofascial neck pain: randomized clinical trial for diagnosis and follow-up.

OBJECTIVE: A definitive diagnosis of chronic neck pain (CNP) is sometimes not possible. The aim of this study was to understand the possible role of the deep fasciae in CNP and the utility of the ultrasonography in the diagnosis of myofascial neck pain. METHODS: The morphometric and clinical data of 25 healthy subjects and 28 patients with CNP were compared. For all subjects, the active and passive cervical range of motion (ROM) was analyzed and the neck pain disability questionnaire (NDPQ) was administered. The fascial thickness of the sternal ending of the sternocleidomastoid and medial scalene muscles was also analyzed by ultrasonography. RESULTS: There were significant differences between healthy subjects and patients with CNP in the thickness of the upper side of the sternocleidomastoid fascia and the lower and upper sides of the right scalene fascia both at the end of treatment as during follow-up. A significant decrease in pain and thickness of the fasciae were found. Analysis of the thickness of the sub-layers showed a significant decrease in loose connective tissue, both at the end of treatment and during follow-up. CONCLUSIONS: The data support the hypothesis that the loose connective tissue inside the fasciae may plays a significant role in the pathogenesis of CNP. In particular, the value of 0.15 cm of the SCM fascia was considered as a cut-off value which allows the clinician to make a diagnosis of myofascial disease in a subject with CNP. The variation of thickness of the fascia correlated with the increase in quantity of the loose connective tissue but not with dense connective tissue.

The anatomical and functional relation between gluteus maximus and fascia lata.

There is not full agreement regarding the distal insertions of the gluteus maximus muscle (GM), particularly the insertions into the iliotibial band and lateral intermuscular septum. 6 cadavers, 4 males and 2 females, mean age 69 yr, were dissected to evaluate the insertions of the GM into the iliotibial band, fascia lata, lateral intermuscular septum and femur. The iliotibial band is a reinforcement of the fascia lata and cannot be separated from it. Its inner side is in continuity with the lateral intermuscular septum, which divides the quadriceps from the hamstring. In all subjects the gluteus maximus presented a major insertion into the fascia lata, so large that the iliotibial tract could be considered a tendon of insertion of the gluteus maximus. The fascial insertion of the gluteus maximus muscle could explain the transmission of the forces from the thoracolumbar fascia to the knee.

Fascial components of the myofascial pain syndrome.

Myofascial pain syndrome (MPS) is described as the muscle, sensory, motor, and autonomic nervous system symptoms caused by stimulation of myofascial trigger points (MTP). The participation of fascia in this syndrome has often been neglected. Several manual and physical approaches have been proposed to improve myofascial function after traumatic injuries, but the processes that induce pathological modifications of myofascial tissue after trauma remain unclear. Alterations in collagen fiber composition, in fibroblasts or in extracellular matrix composition have been postulated. We summarize here recent developments in the biology of fascia, and in particular, its associated hyaluronan (HA)-rich matrix that address the issue of MPS.

Brachial artery blood flow during submaximal isometric contraction of the biceps brachii and triceps brachii in humans: a preliminary observation.

The purpose of this study was to evaluate brachial artery blood flow changes during submaximal isometric contraction of the biceps and triceps brachii, in order to clarify the influence of the upper arm muscles activity on the local arterial flow. The brachial artery blood flow velocity and diameter were evaluated in twenty healthy men (mean age 29.6 years) at baseline (resting position) and during submaximal isometric contraction of the biceps and triceps brachii by means of ultrasonography (B-MODE and Doppler ultrasound methods). The brachial artery blood flow velocity was significantly higher than resting position during submaximal isometric contraction of the biceps (P < 0.001) and triceps brachii (P = 0.019). As to the brachial artery diameter, no significant change was observed during submaximal isometric contractions of the biceps and triceps brachii. Our preliminary findings suggest that the brachial artery blood flow velocity similarly increases during submaximal isometric contraction of the biceps and triceps brachii.

The muscular force transmission system: role of the intramuscular connective tissue.

The objective of this review is to analyze in detail the microscopic structure and relations among muscular fibers, endomysium, perimysium, epimysium and deep fasciae. In particular, the multilayer organization and the collagen fiber orientation of these elements are reported. The endomysium, perimysium, epimysium and deep fasciae have not just a role of containment, limiting the expansion of the muscle with the disposition in concentric layers of the collagen tissue, but are fundamental elements for the transmission of muscular force, each one with a specific role. From this review it appears that the muscular fibers should not be studied as isolated elements, but as a complex inseparable from their fibrous components. The force expressed by a muscle depends not only on its anatomical structure, but also the angle at which its fibers are attached to the intramuscular connective tissue and the relation with the epimysium and deep fasciae.

Myofascial pain of the jaw muscles: comparison of short-term effectiveness of botulinum toxin injections and fascial manipulation technique.

A randomized controlled trial was performed to compare the short-term effectiveness of botulinum toxin injections and physiatric treatment provided by means of Fascial Manipulation techniques in the management of myofascial pain of jaw muscles. Thirty patients with a Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) diagnosis of myofascial pain were randomized to receive either single-session botulinum toxin injections (Group A) or multiple-session Fascial Manipulation (Group B). Maximum pain levels (VAS ratings) and jaw range of motion in millimeters (maximum mouth opening, protrusion, right and left laterotrusion) were assessed at baseline, at the end of treatment, and at a three-month follow-up. Both treatment protocols provided significant improvement over time for pain symptoms. The two treatments seem to be almost equally effective, Fascial Manipulation being slightly superior to reduce subjective pain perception, and botulinum toxin injections being slightly superior to increase jaw range of motion. Differences between the two treatment protocols as to changes in the outcome parameters at the three-months follow-up were not relevant clinically. Findings from the present investigation are in line with literature data supporting the effectiveness of a wide spectrum of conservative treatment approaches to myofascial pain of the jaw muscles. Future studies on larger samples over a longer follow-up span are needed on the way to identify tailored treatment strategies.