THE ROLE IT PLAYS IN THE MANUAL TREATMENT
OF SOFT TISSUE INJURY AND DYSFUNCTION
Dr. Peter Huijing is a Professor of Biomechanics and Physiology at the MOVE Research Institute of Vrije University in Amsterdam (The Netherlands). With over four decades in the field, Dr. Huijing was thinking along the same lines as Schliep when he gave a lecture that was canonized as an article in the January 2009 issue of the Journal of Biomechanics (Epimuscular Myofascial Force Transmission: A Historical Review and Implications for New Research.....). In it he stated that, "Fascia provides structural and functional continuity between the body's hard and soft tissues, as an ubiquitious elastic-plastic, component that invests, supports, and separates, connects, and divides, wraps and gives cohesion, to the rest of the body --- playing an important role in transmitting forces between muscles."
What we see here is what I've been hearing cutting edge "Functional Anatomists" say for quite some time --- that much of the time the "continuity" Huijing speaks of makes it not only difficult to the point of being impossible, to tell where one tissue ends and the other begins, but in most cases it doesn't necessarily matter (HERE). We must think of the body in terms of regional function instead of thinking of it in terms of numerous individual muscles or tendons. If you injure an area you will change both its structure and its function. Whether the injury is traumatic, repetitive, postural, etc (HERE), affected areas have the propensity to become denser, which in turn makes the tissue less elastic.
Dr. Helene Langevin (MD) is a Professor of Neurology at the University of Vermont, who happens to be an Internist, Endocrinologist, Neuroantatomist, and Acupuncturist. In her portion of 2008's book, Integrative Pain Medicine The Science and Practice of Complementary and Alternative Medicine in Pain Management, she shed further light on this topic of Tissue Repair. Revealing that the problem goes beyond "trauma," she said that due to, "inflammation, fascia may shorten and what was previously a pain free range of motion becomes painful and restricted". No one likes pain, but for a moment let's forget about it and realize that ultimately, pain is not our problem, but only a symptom. Did you know that besides a crappy (Inflammatory) diet, the known cause of DEGENERATIVE ARTHRITIS is abnormal joint function --- the most common being loss of normal range of motion?
Think about it like this. A person gets in a car crash and roaches their neck (HERE). There is an INFLAMMATORY RESPONSE (Phase I of the healing process) and the injured Fascia heals with FIBROSIS --- the medical term for what I refer to in my clinic as "MICROSCOPIC SCAR TISSUE" (this is Phase II of the healing process). This "healed" tissue is thicker and less elastic than normal tissue, causing restriction and pain. But none of it shows up using standard imaging techniques such as CT or MRI (HERE). Unfortunately, DIAGNOSTIC ULTRASOUND is not being used much, even though it works quite well for imaging Fascia. And face it, the average doctor is not even looking at simple ROMS. The subsequent cycle of INFLAMMATION / FIBROSIS / DEGENERATION continues to spin, driving the process around and around and around and around in a terribly vicious cycle. This frequently becomes the point where people purchase their ticket to ride the MEDICAL MERRY-GO-ROUND. Unfortunately, things can get even crazier when they find out that getting off said merry-go-round is tougher than they dreamed it might be. And then there's the issue of "Active Scars".
According to any number of experts, "Active Scars" are the elephant in the room that the medical community can no longer choose to ignore. Dr. Karel Lewit, who along with VLADIMIR JANDA, founded the Prague School of Manual Medicine & Rehabilitation over fifty years ago, wrote an article called Clinical Importance of Active Scars: Abnormal Scars as a Cause of Myofascial Pain. Listen to what he tells us about Active Scars. "Scars affect soft tissue in all its layers from the skin to the subcutaneous tissues, the superficial and deep fascias, the muscles, and even the tissues of the abdominal cavity. If the scar is perfectly normal, clinical examination will show no changes whatsoever. But once soft tissue changes occur, we speak of ‘‘active scars.’'" In other words, when scar tissue is present, it has the ability to produce "changes" in the affected area that make it "active". What are these changes? Dr. Lewit says that, "The characteristic findings on the skin are increased skin drag, skin stretch will be impaired and the skin fold will be thicker. If the scar covers a wider area, it may adhere to the underlying tissues, most frequently to bone." I would grossly classify what he is talking about here into TWO SEPARATE AND DISTINCT CATEGORIES, although some people quibble about terminology (HERE).
Dr. Lewit's conclusion shows that dealing with this issue is so critical to helping the patient that failure to do so will result in poor outcomes for large numbers of your patients. "The treatment of active scars can be of importance in a great number of cases; untreated, active scars are an important cause of therapeutic failure." This is echoed by Dr. Alena Kobesova (MD / Ph.D) a neurologist and physiatrist in the Rehabilitation Department of Prauge's School of Medicine at Charles University in the Czech Republic. A 2007 paper published in the medical journal JMPT concluded similarly to Dr. Lewit that, "Assessment and treatment of "active" scar tissue may comprise an important component of the management of locomotor dysfunction and associated pain syndromes" Interesting that we see Scar Tissue, Dysfunction, and Pain Syndromes together in the same sentence. This has been the theme of my website since I started it years ago.
We also know that Willem Fourie --- a South African PT who teaches for Tom Myers' 'ANATOMY TRAINS' program --- said in 2012's book, Fascia: The Tensional Network of the Human Body, that, "Binding may occur among layers that should stretch and glide on each other, potentially impairing motor function." Stop and re-read this sentence. Affecting the sensory side of the Nervous System is one thing (can anyone say "Pain"?), but the fact that this 'Scar Tissue' can affect the motor side of the nervous system is a whole other animal altogether. Fourie's conclusions were backed up by research from Colorado University's Professor of Orthopedic Surgery, Dr. Moshe Slonmonow (MD / Ph.D) when he stated in a 2009 study (Ligaments: A Source of Musculoskeletal Disorders) that dysfunctional soft tissues, "were shown to result not only in mechanical functional degradation but also in the development of sensory-motor disorders with short- and long-term implication on function and disability... Evidence supports the possibility that ligamento-muscular reflexes can have inhibitory effects on muscles associated with that joint. "
WHAT CAN BE DONE TO HELP THESE
SORTS OF SOFT TISSUE PROBLEMS?
One of the things I've figured out in my years of dealing with Soft Tissue Injuries and tissue derangements, is that breaking FASCIAL ADHESIONS takes some humph. What I mean by this is that you might be seriously bruised when you leave my clinic (HERE). This is because it is my opinion that when it comes to breaking these areas of Fibrosis and Microscopic Scar Tissue, you are either breaking them or you aren't (HERE). In other words, a whole lot of sub-threshold treatments do not equal one big treatment (see previous link). To be an "effective" treatment, it has to cause what's known in the peer-reviewed literature as "TISSUE DEFORMATION".
Let me reiterate. The treatment is either over the therapeutic threshold for soft tissue deformation or it's not. Let me put it to you another way; no matter how much sub-threshold treatment you get, you aren't going to see the results you want because it's just that ---- "sub-threshold" ---- below the level of Tissue Deformation required for physiological changes to occur. It's sort of like the old cliche; a whole lot of nothing is still nothing. It's also why in some cases --- particularly when it comes to Forward Head Posture --- current research is saying that stretches need to be held (that's right, "held") for as long as 20 to 30 minutes (HERE).
Think about this in a different way for a moment. If you look at my posts that include detailed information on the three phases of healing (HERE and HERE), you quickly realize that according to the most current research, the Scar Tissue itself is virtually all laid down within a month (most sources say 2-3 weeks), and then REMODELED for the next 18 - 24 months. Where does that leave us with patients who have had their problem for decades (HERE)? The only way to help these patients improve is to play a role similar to that of the surgeon who is going in to "re-break" a mis-healed bone in order to get it to heal the proper way. TISSUE REMODELING is meant to re-initiate the healing process from its beginning (Phase I --- the Inflammatory phase that lasts the first 2-3 days of the process). This is why some forms of bodywork should be thought of along the lines of "CONTROLLED TRAUMA". While we are talking about the Inflammatory Phase of Healing, it would be a good time to dig a bit deeper into the topic of Inflammation in general.
Inflammation was mentioned earlier in this post (Dr. Langevin), and is a big deal. As I've shown you, we need A LOCAL INFLAMMATORY RESPONSE in order to get tissue to heal. However, too much INFLAMMATION in the body for too long a time and you have a catastrophe on your hands (see INFLAMMATION LEADS TO SCAR TISSUE). This is why those of you with CHRONIC PAIN cannot rely on the medical standard of care (PAIN PILLS, NSAIDS, MUSCLE RELAXERS, ANTI-DEPRESSANT medications, and CORTICOSTEROIDS). While a short term local Inflammatory reaction is a necessary and vital part of the healing process, A SYSTEMIC INFLAMMATORY problem leads to any number of health problems including LEAKY GUT SYNDROME, AUTOIMMUNITY, a diminished ability to heal, not to mention CHRONIC PAIN.
As a side note, you need to be aware that your symptoms might change or move after I work on you. This; especially true for those of you who have been dealing with the same old thing for who-knows-how-long, is exactly what we are looking for. However, the change can sometimes (and understandably) cause people to wonder what's going on (or even to freak out a bit). To have a better understanding of what I am talking about here, simply take a look at my post on BULLSEYING. Now; let's look at some studies on the relationship between Manual Therapies and Connective Tissue Healing.
Back in 2003, The Journal of Pathology published a study by Swiss CANCER researchers Ruth Chiquet-Ehrismann and Matthias Chiquet (Tenascins: Regulation and Putative Functions During Pathological Stress) stating that, "Tool assisted treatment produces mechanical deformation that influences extracellular matrix, modulating synthesis of proteoglycans and collagen, apparently influencing connective tissue rehabilitation." Although possible, it can be difficult to produce enough "Mechanical Deformation" of the soft tissues using your hands alone. And if you are, your hands won't last nearly as long as they otherwise would. BTW, tenascins are glycoprotiens of the EXTRACELLULAR MATRIX that are found in and around healing tissue.
In August of 2009, the Scandinavian Journal of Medicine and Science in Sports (From Mechanical Loading to Collagen Synthesis, Structural Changes and Function in Human Tendon) said that, "Load can be used therapeutically to stimulate tissue repair and remodeling in tendon, muscle, cartilage and bone. Exercise and manual methods stimulate tissue repair and remodeling in tendon, muscle, cartilage and bone." Again, this is essentially WOLFF'S LAW in action -- tissue responds / adapts to mechanical stresses put upon it, whether said stresses are normal or abnormal. How do the authors propose remodeling these tissues? The "manual methods" cause the Compressive Deformation required to break down fibrotic tissue adhesions, and the EXERCISE / STRETCHING provides the Elastic Deformation to pull the fibrotic tissue apart --- kind of like combing through and untangling a HAIR BALL or UNTETHERING a tied up animal.
Famed TENDON researcher, Karim Khan (MD / Ph.D) stated in a 2009 study published in the British Journal of Sports Medicine (Mechanotherapy: How Physical Therapists’ Prescription of Exercise Promotes Tissue Repair) that, "Mechanotransduction is the physiological process where cells sense and respond to mechanical loads. This paper presents the current scientific knowledge underpinning how load may be used therapeutically to stimulate tissue repair and remodelling in tendon, muscle, cartilage and bone.... Strictly speaking, mechanotransduction maintains normal musculoskeletal structures in the absence of injury...... clinical therapeutic examples of mechanotherapy–turning movement into tissue healing." Turning movement into healing. These words reckon back to the old and widely used cliches in physical medicine; "move it or lose it", or "motion is lotion".
A moment ago, I spoke of the need for intensive post-treatment stretching protocols, as well as why this is true (Tensile or Elastic Deformation). Dr. Hans Chaudhry --- a biomedical engineer at the New Jersey Institute of Technology --- spoke of this phenomenon in a 2008 study published in the Journal of the American Osteopathic Association (Three-Dimensional Mathematical Model for Deformation of Human Fasciae in Manual Therapy). He said that...
"Fascia is dense fibrous connective tissue that connects muscles, bones, and organs, forming a continuous network of tissue throughout the body. It plays an important role in transmitting mechanical forces during changes in human posture. Several forms of manual fascial therapies—including myofascial release and certain other techniques in osteopathic manipulative treatment (OMT)—have been developed to improve postural alignment and other expressions of musculoskeletal dynamics. The purpose of these therapies and treatments is to alter the mechanical properties of fascia, such as density, stiffness, and viscosity, so that the fascia can more readily adapt to physical stresses.In order to achieve a viscoelastic deformation during manual intervention, without causing tissue damage, … there should be no slow increase in the applied force. Rather it is recommended that a fairly constant force be maintained, for up to 60 seconds, in order to allow for a plastic stress relaxation response of the tissue."
In other words, after going through one form of 'Tissue Deformation' to break down adhesions, you must go through another to pull them apart. Doing one without the other ---- either only breaking tissue or only stretching adhesed tissue (HERE) --- is short-sited, misses the point, and is rarely effective for people struggling with hardcore versions on common CHRONIC PAIN SYNDROMES. As you can see from the quote above, the stretching must be more than a quick now-and-then-when-I-think-about-it sort of thing. It has to be intentional, deliberate, and held for a relatively long time. Take a look at our post-tissue-remodeling stretching protocol for many of those struggling with Chronic Neck Pain (HERE).
Getting this all sorted out is critical because Fascia not only acts as a second Nervous System (HERE), but some believe (Dr. Langevin is one of them) that all --- or at least many / most --- diseases might be related to Fascial Adhesions as well (HERE). If you are interested in a generic protocol that will help many of you return to health, HERE it is.