Panel Discussion: Let's get real about fascia!
The research is amazing, the theories incredible, the texts and articles being published undoubtedly important, but… how can we actually affect "fascia"? Let's make a list of credible techniques, their theorized benefit, best-practice guidelines (acute variables), and their place in a routine or treatment session (as in, before lengthening but after mobilization, or as a cool down at the end of a routine.)
I find that when it comes to fascia and practical application the lines between muscle, fascia and joint techniques quickly get blurred, science gets fuzzy, and suggestions get really vague… let's fix that.
Moderated by Brent Brookbush DPT, PT, MS, PES, CES, CSCS, ACSM H/FS
This Panel Discussion was originally posted on my facebook page - https://www.facebook.com/brent.brookbush - on April, 19th 2014
Ryan Crandall Interactor vs Operator…I don't believe there is evidence that we can physically change dense connective tissue. Now, the patients connective tissue can change based on demand depending on direction of forces placed upon the body (multi-planar movement, ground reaction forces, etc) which is SAID principle and also effects bone/muscle/skin.
Massage and joint manipulations can effect mechanoreceptors which can in turn effect sensory input into the brain which effect output…less perceived pain and lowered muscular tone. Schleip himself even said we can't physically change it with our hands…instead out hands can (if the organism finds it not a threat) be a non threatening input into the nervous system which can alter output (feeling and moving better). Feldenkrais has similar thoughts. All stuff, unfortunately, taught in our schools though.
April 19 at 12:08pm
Brent Brookbush Is anybody using Instrument Assisted Soft Tissue Mobilization - is this a fascial technique, does it get deep enough to target the tissues of our larger fascial organs (like the Thoracolumbar Fascia), how often should use the technique, what do you expect to see during re-assessment?
April 19 at 12:09pm
Brent Brookbush Hey Ryan Crandall, I would not go as far as to say there is no evidence, although there is no evidence in-vivo studies that show fascia pre and post treatment. There is some interesting cadaver studies though. I like your points about affecting sensory input via mechanoreceptors to enhance motor output. I do believe many "fascial" techniques are not fascial techniques at all, but rather inhibitory techniques that reduce muscle tone by stimulating various mechanoreceptors (some embedded within fascia).
April 19 at 12:15pm
Steve Middleton A common misconception is that we are "deforming" or "lengthening" the fascia. It takes a couple hundred pounds of force to lengthen fascia. When you "deform" a tissue, you take it beyond its elastic component to the point of failure.
What we are trying to accomplish is an increase in mobility between the layers of tissue. When a myofascial adhesion is present, the skin is adhered to the superficial fascia which is adhered to the deep fascia which is adhered to the muscle. This can compress the nerves and create radicular symptoms as well as compressing the blood vessels furthering local damage by hypoxia.
Fascial manipulation is designed to restore the gliding between these layers of tissue by breaking down the small cross bridges of connective tissue between each layer. It also increases circulation to restore normal oxygen levels. There is also some evidence that the role of lymph is to lubricate these different layers to improve mobility as well.
April 19 at 12:17pm
Brent Brookbush Hey Steve Middleton,
I know you are very experienced clinician - can you give us a technique you would use for a particular case, including the number of strokes, or duration of treatment, force applied, the type of stroke, and what you are feeling for or looking for?
Similar to the way we would say that you can expect hypertrophy in your pectoralis major by doing -
Exercise: Bench Press
Volume: 1 - 5 sets
Reps: 6 - 12 reps
Frequency: 2 times per week
Intensity: 70 - 85% of 1RM
I believe these "acute variables" are grossly missing from manual therapy, and would love your help in filling the gap for this question.
Just one example would be awesome!
April 19 at 1:27pm
Rick Richey I believe that Fascial adhesions are exactly that - fascia stuck to other layers of fascia. This happens via inflammatory processes when fibroblast spread a fibrin and/or collagen matrix. When the fibroclast do not fully reabsorb the fibrin/collagen matrix we are left with adhesions, or simply stated, myofascial bits that stick to other myofascial bits. There is a limited window of treatment with collagen. However, it seems fibrin adhesions can be addressed long after defamation.
April 19 at 1:48pm
Tanya Colucci In order to release fascia first the collagenous liquid/barrier the fascia is bathed in becomes hard and dense like silly putty when it's cold. Most soft tissue techniques aren't applied long enough to create lasting results bc typically they are not held long enough. Collagenous barriers only begin to release after 90+sec w gentle pressure or stretch. Lasting release should be held for a minimum of 2-3 minutes. This essential “time element” has to do with the viscous flow and the piezoelectric phenomenon: a low load (gentle pressure) applied slowly will allow a viscoelastic medium (fascia) to elongate. It literally will feel to the therapist like silly putty and become very soft and pliable. However layer after later of tightness builds up over time so it is imperative that in the beginning a client is repeatedly treated close together and is given self mfr techniques to do daily. Also fascial tissue stores memories of trauma, injury, emotions, etc so these also need to be addressed. I have found with certain chronic pain clients until we work on some mind issues/stressors…sometimes the tissue will be stubborn to release.
April 19 at 2:17pm
Brent Brookbush So Rick Richey,
Can you give me a technique with acute variables as I asked Steve Middleton to do for us. Like I mentioned in the post… our goal in this discussion is to "get real"… as in "real practical."
April 19 at 2:20pm
Grayson Lane Fascia has been put on a pedestal in the recent years.
You cannot affect Fascia alone - period. Doing any passive/active manipulation and claiming to only affect fascia is like trying to use a roller on a big mac and claiming "affecting" the cheese only".
Understanding how to manipulate forces on the entire system is really the key to affecting "fascia".
April 19 at 2:28pm
Rick Richey I wish I had techniques to boast. Without the research to support what works I cannot say. There are modalities that I like, but I don't know if they are working more on fascial adhesions or trigger points or mechanoreceptors. My judgement on modalities are based on if they move better and feel better. I'll leave it to the research (not theoretical assumptions) to fill in the blanks on what is actually happening physiologically.
April 19 at 3:03pm
Brent Brookbush Hey Rick Richey, Lets consider a more complete model of evidence that includes practical application and outcomes. Which technique do you find yourself favoring and what are the acute variables (including what you expect to see during reassessment). Massage technique, static release technique, manual release, whatever… will consider myofascial techniques appropriate for this post.
April 19 at 3:12pm
Brent Brookbush Hey Grayson Lane,
Can you name a technique that you lean towards that includes a potential affect on fascia… sorry to keep harping the same point, but I really want to get some good practical guidelines out of this post.
April 19 at 3:13pm
Brent Brookbush Hey Tanya Colucci,
It sounds like much of what you are describing could be achieved through static release (Foamrolling included) and static stretching… is that accurate?
April 19 at 3:14pm
Leon Chaitow A RANDOM SELECTION OF DOZENS OF STUDIES IN WHICH EITHER COMPRESSIVE, FRICTIONAL OR MANUALLY APPLIED SHEAR FORCES (OR ECCENTRIC STRETCHING) ARE USED TO MODIFY THE BEHAVIOUR OF SUPERFICIAL FASCIA WITH RESULTING ENHANCEMENT OF GLIDE POTENTIAL OF DEEPER STRUCTURES OR REDUCTION IN FIBROSIS. • Borgini E, Stecco A, Day JA, Stecco C, How much time is required to modify a fascial fibrosis? J Bodyw Mov Ther. 2010; 14(4) 318-325.• Langevin, H.M., Bouffard, N., Fox, J., et al., 2009. Fibroblast cytoskeletal remodeling contributes to viscoelastic response of areolar connective tissue under uniaxial tension, as reported in Fascial Research II. Elsevier GmbH, Munich.• Martınez Rodrıguez R et al 2013 Mechanistic basis of manual therapy in myofascial injuries. Sonoelastographic evolution control. Journal of Bodywork & Movement Therapies 17:221-234 • Okamoto T, Masuhara M, Ikuta K, 2013. Acute Effects of Self-Myofascial Release Using a Foam Roller on Arterial Function. J Strength Cond Res: Epub ahead of print. • Parmar S et al 2011 The effect of isolytic contraction and passive manual stretching on pain and knee range of motion after hip surgery: A prospective double-blinded randomized study. Hong Kong Physiotherapy Journal 29:25-30 >>>>>>>>>>>>>>>>>>>>>>> • Stecco A et al 2013. Ultrasonograph in myofascial neck pain: randomized clinical trial for diagnosis & follow-up. Surg. Radiol. Anat. 1-11.
• Pohl H, 2010. Changes in the structure of collagen distribution in the skin caused by a manual technique.J Bodyw Mov Ther 14(1):27-34
April 19 at 3:17pm
Rick Richey Any modality that unbinds the layers of fascia should be considered indicated. Static stretching, friction, active soft tissue release techniques (pinning), myofascial release techniques, IASTM, etc. PNF would not seem to provide fascial release, but most often my favored means of movement reformation.
April 19 at 3:23pm
Steve Middleton Brent: I will get a more thorough response to your question once I am in my computer.
Rick: I disagree with the static stretching. Stretching seems to be more beneficial at maintaining mobility that's creating it.
April 19 at 3:26pm
Leon Chaitow I AM OVERWHELMED WITH DEADLINES AND CANNOT JOIN THIS DISCUSSION, MUCH AS I WOULD LIKE TO…LC
April 19 at 3:26pm
Rick Richey Steve, how so?
April 19 at 3:29pm
Brent Brookbush No problem Leon Chaitow, I think you just gave all of us some homework to do. Flattered by your participation and I will be getting my hands on the studies above. I will also try and add them to our current project to add a research review section to BrentBrookbush.com so that everyone knows where to look for this information.
Thanks again,
B2
(we got our work cut our for us Stefanie DiCarrado, Camron Einerman and Jinny McGivern :-)~)
April 19 at 3:33pm
Mark Jamantoc following…
April 19 at 3:36pm
Tanya Colucci Yes and no..::once a therapist sinks down into the tissue after about 2-3 minutes then the hand/tissue can be stretched or apply a specific technique called cross hand release to open tissue…fascia is 3 dimensional so sometimes doing diaphragm releases w one hand on top & underneath the body can help release global tension if done over areas where a diaphragm exists in pelvic floor, diaphragm, thoracic area and even over joints. Also using the arms and legs as a lever for compression and decompression can cause spontaneous unwinding of fascia and the body w movement…. The body has a way of moving the body to allow tissue to unwind when simple techniques are applied so that the therapist is actually facilitating….some of these techniques would be difficult to do alone or self administered. Also sometimes using standard protocols for issue in the body ie-back pain…sometimes there are restrictions in the cranium, neck or jaw causing dysfunction in back…so it is hard to take a one size fits all approach to the tissue….I might have a client present w similar imbalances in their pelvis etc but they present pain in very different parts of their body….so I tend to take an individualized approach to a clients dysfunction and sometimes that means throughout out all scientific research and going w what I feel under my hands, what the clients feels w referrals while being treated so intuition and other items play a role w successful healing
April 19 at 3:46pm
Leon Chaitow one more paper you should see..a study at Philadelphia College of Osteopathic Medicine, compared effects of 4 modalities with sham in treatment of cervical dysfunction, involving additional assessment of tissue 'stiffness' (using a durometer instrument)….when HVLA manipulation was compared with MET, counterstrain and Balanced ligamentous tension….all showed benefit, but greatest was from counterstrain (measuring hysteresis effect):"
Barnes P et al 2013 A comparative study of cervical hysteresis characteristics after various osteopathic manipulative treatment (OMT) modalities Journal of Bodywork & Movement Therapies 17, 89-94….the implication is that fascial density/stiffness can be modified by various modalities, and this has nothing whatever to do with 'stretching' fascia, but rather with enhancing its functionality.
April 19 at 4:32pm
Ryan Crandall ^Now that I think I can buy (Thanks Leon)
April 19 at 4:46pm
Maurice D. Williams Awesome discussion! I wish I could comment on this topic, but I'm clearly a humble student today!
April 19 at 4:46pm
Jason Erickson I think we need to consider the complexity of what you are proposing, Brent.
From what I've seen, there isn't even agreement on what the various functions of fascia are. Some people believe that fascia is a sensory organ, that it holds emotional memories, that it is related to "bio-energy", that it is capable of moving the body in "unwinding", that it is the primary determinant of health/disease. Others, myself included, think that those concepts are pure fantasy.
For too long, people believed in a "gel/sol" hypothesis of thixotropic change. Science has showed that hypothesis to be without merit, yet it is still cited as the foundation for why certain MFR techniques are to be held/maintained for a longer period of time (2-5 minutes, possibly longer). If we remove the gel/sol explanation, why else might a technique appear to work more effectively by being maintained for longer period of time?
As Ryan Crandall posted, there are other mechanisms which would appear to offer a more likely (read: scientifically plausible) explanation. If we consider those explanations, the rationale for why/how we attempt to work with soft tissues shifts, even if the hands-on techniques are applied in a similar fashion.
To me, the biggest variable in determining how to apply hands-on work is the client's nervous system. If the PNS and CNS don't like what you're doing, it will probably fail.
Since the rationale for the "myofascial" techniques that people use vary so much, they often also have different goals in mind when applying those techniques. Some just want to "warm up" the area before using other methods, while others are seeking some sort of more lasting effect.
If we are going to quantify how to apply techniques, we should do so only in context of what we are hoping to achieve.
Here's an example from my own practice, based on dermoneuromodulation concepts:
In this image, my arms are providing a gentle longitudinal skin stretch between the pieces of blue dycem, as my hands draw the skin of the medial knee area into medial rotation. Though this technique is primary oriented towards addressing pain related to the obturator nerve and medial cutaneous nerve of thigh at the knee, we must recognize that stretching the skin also affects the hypodermis (sometimes referred to as "superficial fascia"), local circulation of blood and lymph, interstitial fluids, skin ligaments, and underlying musculotendinous structures.
The amount of pressure applied is very light and at an oblique angle. It can be held for a shorter or longer period of time, but I tend to stay there for 90 seconds or longer, perhaps 2-5 minutes, to give the CNS and PNS time to respond to the work and enable lasting positive changes. I would only do this once in a session, and hopefully that's the only session I would need to do it.
Jason Erickson's photo.
April 19 at 4:46pm
Brent Brookbush Thanks Jason Erickson,
I totally agree that this is a super complex topic, but I really appreciate you putting your work and methodology out their with specific guidelines. Even if we are unsure of everything that is happening during a technique like the one you are recommending you have given us all the opportunity to try it.
You know me - I am all about practical education… thanks for adding your thoughts but appeasing my want of something applicable.
April 19 at 5:00pm
Tony Susnjara I fully agree that it's a complex topic and it has to be because we are dealing with the most complex organism in the known universe. I have had these discussions with Brent once or twice before and I keep coming back to philosophical questions about the nature of the human organism and the nature of the scientific method.
I often feel that we are trying to impose a 'mechanical' model or conceptual framework onto a highly sophisticated and fully integrated complex organic system. In the body, you cannot touch the part without touching the whole. You cannot touch the fascia without touching the skin, blood vessels, muscle tissue, nerve tissue, lymph ducts, bone etc. as all of these tissues are interwoven or connected on some level.
So if we take that as a given, it is still a worthwhile 'thought experiment' to ask the question in relation to what techniques most positively impact the dense connective tissue because from a mechanical perspective, it is this tissue that limits range of motion because it resists deformation (which is part of its function) and is less extensible than muscle or epithelial tissue and more elastic.
Having said that, dense connective tissue (DCT) simply has to deform to perform certain functions. One of those functions is to act as a spring to generate movement. The body is a sprung system and the elastic recoil of DCT makes humans and animals far more energy efficient. To say that fascia does not deform is to say that fascia does not function. However because the system we are dealing with is so complex, it would be reductionistic to limit the description of the function of any tissues too narrowly.
Another question I would like to raise is in regard to the nature of the scientific research into the adaptive process in relation to DCT. In studying the training effects of say cardio conditioning or strength conditioning, the micro, meso and macro cycles are taken into consideration. There are acute training effects and chronic, long term adaptions. We know we can train someone to become better at running long distances and also at lifting heavy things - can we also training them to become better at stretching? For instance, the stretch reflex is only partly a reflex because it activates the muscle being stretched via the motor neuron. We also have the capacity to consciously relax a muscle or switch that motor neuron off. So if a runner can use their system more efficiently and a lifter can activate more motor units and leverage their power and momentum and other factors better through chronic adaptions and better techniques, can a 'stretcher' (a person who stretches consistently) not learn to override their stretch reflex or use specific techniques to become better at stretching? Are these questions being asked by those who are undertaking the research?
Will someone who regularly gets hands on treatments get a different benefit or result than someone who does not? For instance can a client learn to relax during a technique that causes some degree of physical discomfort? Can the therapist therefore apply more mechanical pressure to the tissues without the client tensing or locking up to activating their stretch reflex? In relation to research on cardio or strength training, I assume that the researches take into consideration the base level of conditioning of their subjects - do they do the same when assessing the DCT of certain subjects? Does the ITB of an elite female gymnast deform in the same manner as the average person? Most likely not.
I think that the quality of the answers we get from scientific research can only at best be as good as the quality of questions that we ask. I feel that stepping back and looking at our paradigm of the human body and also the scientific method will lead to us asking better quality questions. If economists knew exactly how the economy functioned, there would be no more cycles of boom and bust, no inflation and no unemployment, no poverty etc. If stock brokers knew how the stock market really operated, there would be a lot more billionaires in the world. Economists, stock brokers, weather forecasters and environmentalists do not claim to have absolute answers because they systems that they study are way too complex. They can only give indicative advice, not absolute advice. I would like to see researchers into human physiology take a similar stance and not talk about absolutes or science proving anything once and for all.
Economists know the general direction that the economy is likely to move when interest rates are lowered or taxes are raised but they don't know by how much, they don't know all of the complex knock on effects because complex systems are just too complex.
I would like to see scientists in the fields of physiology take a similarly humble approach…”Our research tells us that the most likely outcome of this interventions will be XYZ but we don’t know exactly by how much or when, results will vary from person to person and there is a chance that we will get it wrong” And how about, "We don't know for sure" and "Later research results my disqualify current research results as they have done so many times in the past we will no longer talk in absolutes."
April 19 at 6:11pm
Tony Susnjara Steve Middleton - please get on You Tube and do a search on Iyengar Yoga Demonstration - I can not see how there can be any doubt that static stretching increases flexibility - I have used it successfully for years with a broad cross section of people of different ages, both genders and it has always worked to increase flexibility - on what basis do you say that it does not increase flexibility?
April 19 at 8:29pm
Steve Middleton @Tony:
I utilize a lot of yoga for HEPs; I don't consider it a passive stretch though as the person is fairly active against gravity in the poses.
I've been working on a research study comparing Passive stretching to IASTM on improving ankle DF: 2x30 seconds of stretch increases DF 1-2 degrees where the same amount of IASTM will increase 10-15 degrees (most subjects start with 0-5 degrees). 1 week later, the PROM group has lost their gains while the IASTM group has maintained 5-8 degrees.
April 19 at 9:29pm
Ryan Crandall IASTM…can u define that acronym…
April 19 at 10:19pm
Brent Brookbush Interesting Steve Middleton,
I do use static stretching and the research supports this as an effective means of increasing flexibility, but I think anytime we choose just one technique we are doing a disservice to our clients/patients.
With a fairly recent patient (and a friend who was willing to let me experiment) I used a combination of joint moblization, static release, active release, static stretching, graston, activation, integrated functional task and reinforced with taping (roughly 25 minutes) and the individual achieved 18 degrees of active dorsiflexion with mild overpressure (started with 3 degrees) and maintained 15 degrees a week later. Now, normally I would not just look at one joint, but I was amazed at the outcome and carry over. When you finish your study please keep me in the loop.
April 19 at 10:20pm
Grayson Lane Sure. The Technique I would employe would be called custom tailored and strategic exercise based on an individuals specific goals, tolerances and abilities.
April 19 at 10:27pm
Steve Middleton Brent: if I am actually treating, I use a combination of treatments: IASTM (instrument assisted soft tissue mobilization) for 30-60 seconds followed by either sustained grade III myofascial release or post-isometric relaxation to further increase motion then progress to muscle energy techniques to facilitate proper movement patterning before progressing to active ROM exercises.
I tend to add kinesiology taping (@rocktape) to facilitate the decreased tone/Fascial mobility of the antagonist to the movement.
April 19 at 10:30pm
Brent Brookbush Love it Steve Middleton,
Conversations like the one in this thread are always a little tough because we are taking one tool and dissecting, but I know that all of us use an integrated approach. I look forward adding more to my repertoire as I get to learn from all of the incredible professionals who made this discussion a special one. Continuing our pursuit of optimal practice
April 19 at 10:33pm
Chris Greene I agree with your statement "I think anytime we choose just one technique we are doing a disservice to our clients/patients."
I had my bicep reattached after ripping it off. I had -6% supination and started physical therapy with a ton of static stretching which help to a point but that was not good enough for me. So I found a deep tissue massage therapist that specialized in Rolf technique. I continue to see the physical therapist and deep tissue massage therapist along with doing a ton of active-dynamic stretching exercises that I came up with myself. So I agree that we shouldn't stick to one technique but find multiple techniques to help in recovery.
April 19 at 11:25pm
Steve Middleton Brent:
I agree with the previously referenced treatment time of 90-120 seconds per area and per technique. I do prefer gua aha (instrument assisted soft tissue mobilization) using a thin tool with minimal pressure. The thin tools also have diagnostic properties in the amount of petechaie they form. This is a case study of objective date based on petechiae status post front-impact whiplash:
Top-left: (1 week post-MVA) significant petechae especially on the left upper trapezius from compression by the seatbelt.
Top-right: 1 week later (2 weeks post-MVA), significantly decreased petechaie formation
Bottom-left: 1 week later (3 weeks post-MVA), minimal petechiae
Bottom-right: 1 week later (4 weeks post-MVA), slight increase in petechiae over posterior longitudinal ligament due to falling asleep on a trans-Atlantic flight.
If you don't treat the right area, you will just get an erythemic effect (pink skin) from increased blood flow.
Steve Middleton's photo.
April 20 at 12:39am
Brent Brookbush Great photo Steve Middleton,
We need to see more of this to really help set an expectation when applying these techniques. Adding something like this to a demonstration of the tools and techniques you used would be an incredibly valuable learning tool.