An introduction to fascia

1. An introduction to fascia Libby Hinsley, PT, C-IAYT, E-RYT 500

2. Muscle and Fascia terms • Muscle • Fascia • Myofascial system • Myofascial release • Fascial stretching

3. muscle • Muscle is the contractile component of the “myofascial” system • Each muscle has an origin and an insertion. • Muscle contracts via a complex chemical chain of events that leads to actin and myosin proteins found in sarcomeres overlapping and pulling on each other to shorten the sarcomere, and hence shorten the entire muscle.

4. muscle https://socratic.org/questions/which-type-of-muscle-fibers-contain-sarcomeres https://ib.bioninja.com.au/higher-level/topic-11-animal-physiology/112-movement/sarcomeres.html

5. muscle • Muscle is “elastic,” meaning muscle tissue generally returns to its original length after stretching. • What we think of a muscle stretch has been shown largely to be the result of stretch tolerance or relaxation of protective muscle reflexes, rather than an actual change in tissue length. This muscle “stretch” effect generally takes somewhere around 20-30 seconds to achieve. • However, muscle can add or subtract sarcomeres through a longer term adaptation process, thus changing the actual length of the muscle.

6. Connective tissue • Connective tissue is a broad term that includes fascia, tendon, ligament, bone, and blood. • Fascia is one type of fibrous connective tissue that envelopes separates and binds together muscles, organs, and other tissues of the body (www.functionalfascia.com) • Most agree there are three or four different kinds of fascia • Some describe superficial, deep, and visceral • Others describe structural, intersectoral or inter-structural, visceral, and spinal

7. Fascia • Fascia is a 3D web consisting of a watery extra cellular matrix (ground substance), elastin, and collagen fibers densely woven in all directions, and fibroblast cells. • Anatomists didn’t much care for or understand fascia for so long because in fixed or preserved tissue, the fascia is collapsed and dry. It has historically been “cleaned off” in order to see what everyone thought was the good stuff. Now we know it’s the watery extracellular matrix that gives fascia its form and function. https://medium.com/@satiJen/fascia-changes-everything-c81dac9d7e36

8. Fascia https://www.ashleyblackguru.com/blogs/fascia-blog/fascia

9. Fascia components • Elastin and collagen are the primary proteins that make up fascia, along with the extracellular matrix (mostly very viscous proteoglycans) and fibroblasts (which produce collagen and elastin). • Elastin is like a rubber band. It is an elastic, stretchy protein that is able to stretch and then snap right back to its original length. • Collagen is like a steel cable. It has high tensile strength. It has some give, but not much. • Collagen>elastin in fascia.

10. fascia https://www.thoughtco.com/connective-tissue-anatomy-373207

11. collagen • The glue that holds the body together. • The primary fibrous protein in connective tissue  • There are >16 (some report 19-25) types of collagen, but 80 – 90 percent of the collagen in the body consists of types I, II, and III. 90% is Type I. • All collagen serves the same purpose - to help tissues withstand stretching. • Molecular Cell Biology, 4th Edition. Lodish H, Berk A, Zipursky SL, et al. New York: W. H. Freeman; 2000. • More than 30 different genes encode the proteins and enzymes that form and assemble collagen. • McGraw-Hill Medical. Disorders of Collagen Biosynthesis and Structure. Byers, Peter. DOI:10.1036/ommbid.240

12. collagen • Collagen’s triple helix structure and its assembly are complex. • Each triple helix binds with others at unique angles to create collagen fibrils, which are rod-like tubules.  • Type I collagen fibrils, are stronger than steel gram for gram. • Fibrils are packed side-by-side in parallel bundles- collagen fibers. https://www.orthobullets.com/basic-science/9013/collagen Molecular Cell Biology, 4th Edition. Lodish H, Berk A, Zipursky SL, et al. New York: W. H. Freeman; 2000.

13. fascia • Fascia covers and interpenetrates every muscle belly, muscle fascicle, and muscle fiber cell. https://deeprecovery.com/understanding-fascia/

14. Fascia • Fascia has no origin and no insertion. It is a continuous structure without interruption. • When we tug on or bend fascia anywhere in the body, the tug spider webs throughout the system, in every plane and at every depth. • Facia distributes strain in all directions. • Fascia maintains separateness and connection between all structures of the body.

15. tensegrity • Tensegrity = tension+integrity • Tensegrity structures distribute strain in all directions, just like the body does. • Compression structures distribute strain in a straight line. • Compression structures break down where the strain is greatest. • Tensegrity structures break down at their weakest point. • https://www.anatomytrains.com/fascia/tensegrity/

16. Myofascial system • Muscle and fascia are never separate. • The myofascial system is the combination of these two tissues, and how they function in the body. • Active (muscle) and passive (fascia) components work together to provide stability and mobility to each joint of the body. • Fascia transmits force from one muscle to others, making the muscular system more integrated than we have previously thought • Bones are held in position by myofascial tension (serving the tensegrity function) • Bob Fong. Jericho Physio Blog November 28, 2016.

17. Fascia as lymph organ • The type of fascia that is thin, hydrated, and spider-webby, under the skin surface and surrounding vessels and muscle fibers, is also known as the interstitium and has recently been recognized as an official organ. • It turns out, this full body networked structure acts as a highway for moving fluid which drains into the lymphatic system. It is the source of lymph, which is vital to immune cell function and inflammation. This may also help explain the mechanism of cancer spread. • The cells that reside in this fascia/interstitium are fibroblasts, and they change with age, contributing to skin and joint changes, and the progression of chronic inflammatory diseases. • Petros C. Beniaset al. 2018. Structure and Distribution of an Unrecognized Interstitium in Human Tissues. Scientific Reports 8, article number: 4947; doi: 10.1038/s41598-018-23062-6

18. Fascia as endocrine organ • Some have called the system of fluid-filled tubules under the skin (superficial fascia) as the “primo vascular system” and have and have found that it transports a variety of hormones and neurotransmitters. • J Am Osteopath Assoc. 2016 Jan;116(1):12-21. doi: 10.7556/jaoa.2016.002. Primo Vascular System: A Unique Biological System Shifting a Medical Paradigm. Chikly B, Roberts P, Quaghebeur J. • Some research suggests that the presence of sex hormone receptors in fascial tissue may help explain sex differences in the prevalence of myofascial pain, especially with regard to estrogen and relaxin, and that these may play a role in fascial nociceptor stimulation and sensitization. • Eur J Histochem. 2016 Nov 2;60(4):2710. doi: 10.4081/ejh.2016.2710. Hormone receptor expression in human fascial tissue. Fede C1, Albertin G, Petrelli L, Sfriso MM, Biz C, De Caro R, Stecco C. • Other research has also found a strong link between hormonal levels and health of cartilage and ligaments; including that women on oral contraceptives and women post-menopause show significant differences in connective tissue elasticity vs. controls.

19. Fascia as sensory organ • Fascia is the largest sensory organ in the body • Fascia contains 6 times the number of sensory nerves compared with muscle tissue. • Fascia contains four types of sensory nerve endings, which are responsive to mechanical stimulation: Golgi organs, Ruffini receptors, Pacini corpuscles, and Interstitial receptors. These sensory nerve endings can be called fascial mechanoreceptors, meaning that they respond to mechanical tension and/or pressure • http://www.fascialfitness.net.au/articles/fascia-as-an-organ-of-communication/

20. proprioception • Fascia has been shown to play a strong role in the body’s overall sense of proprioception- the process of conscious and subconscious sensing of joint position, motion, and posture. • Proprioception is vital to motor control, or the ability to control the body in motion.  • Joint receptors have previous been thought to play the leading role in monitoring joint position or movement, and muscle receptors were relegated to motor functions that operate at a subconscious or reflex level.  • Newer research shows we cannot separate “muscle receptors” from “joint receptors” due to the way fascia transmits force in series (not in parallel) across structures • Int J Ther Massage Bodywork. 2009; 2(4): 9–23.The Architecture of the Connective Tissue in the Musculoskeletal System—An Often Overlooked Functional Parameter as to Proprioception in the Locomotor Apparatus. Jaap van der Wal, MD, PhD

21. nociception • Nociception is the ability to feel pain, caused by stimulation of a nociceptor.  • Fascia contains lots of nociceptors. • Some research shows fascial tissue to be an important source of pain in patients with nonspecific lower back pain (something also supported by a great deal of research on what does NOT typically cause LBP). • Fascial nociception function may help explain some of the physiological mechanisms of chronic pain. • Med Hypotheses. 2007;68(1):74-80. Epub 2006 Aug 21. Pathophysiological model for chronic low back pain integrating connective tissue and nervous system mechanisms.Langevin HM1, Sherman KJ. • Fascia: The Tensional Network of the Human Body. The Science and Clinical Applications in Manual and Movement Therapy. Edited By Robert Schleip, Thomas W. Findley, Leon Chaitow, Peter A. Huijing.

22. interoception • Interoception relates to the body’s ability to sense physiological states. • Interoceptive signaling is processed via the insula region in the brain, and is usually associated with an emotional or motivational component • Interoceptive nerve endings are present in the skin, visceral fascia, and muscle • A majority of the nerve endings in fascia transmit information to the insular cortex, rather than the somatosensory cortex where mechanical information and proprioception is processed. • Schleip, Findley, Chaitow, et al. Fascia: The Tensional Network of the Human Body. Elsevier 2012. • An emphasis on noticing subtle sensations inside the body can boost interoception • Inner spaciousness • Inner silence • Inner mindfulness • Inner listening • Warmth • Lightness/heaviness • Feeling tone to physical sensation, especially in the viscera, chest and abdomen

23. Fascia as a mind/body link • Fascia is thought to be the location of embodied consciousness, the storage unit for life’s experiences and traumas and our resulting “holding patterns.” • It is structure, physiology, and a postural representation of our habituated thought and behavior patterns and responses to the world • As a huge sensory organ, fascia is very relevant to our relational experience - our ability to sense the self and where it ends, so that we may maintain separateness and connection. • Interoception points to fascia as the embodiment of HOW WE FEEL

24. Fascia as mind/body link • Some research indicates the superficial fascia is where chi meridians in Chinese Medicine are located and that manipulation of superficial fascia is the mechanism by which acupuncture works. • Langevin HM, Churchill DL, Fox JR, Badger GJ, Garra BS, Krag MH. Biomechanical response to acupuncture needling in humans.Journal of Applied Physiology. 2001;91(6):2471-8. • Langevin HM, Churchill DL, Cipolla MJ. Mechanical signaling through connective tissue: A mechanism for the therapeutic effect of acupuncture.The FASEB Journal. 2001;15(12):2275-82. • Although fascial restriction can be mechanical, it can just as easily be the result of central nervous system guarding. • Fascia, with all its various functions, is a great example of the inherent link between mind and body.

25. Fascial restriction • Physical trauma, emotional trauma, scarring, or inflammation, or sustained postures can cause fascia to become dry and less pliable, sticky, and restricted. • Remember tensegrity and strain distribution? It can be hard to differentiate the “snag” from the “run” in a symptomatic body. • Fascial restrictions be a source of pain and tension to the rest of the body, placing up to 2,000 pounds per square inch of pressure on sensitive tissues (www.Myofascialrelease.com)

26. Fascial stretching • Fascia can have viscoelastic or plastic responses to stretching. • Viscoelastic changes mean fascia might lengthen during a stretch, but then return to its normal length. • A plastic change is a more permanent change of length and occurs under low loads held for long time periods. • How long? Generally it is thought to require minimum 3-5 minutes to achieve plastic change. This is called “tissue creep.” • Fascial length changes can also occur through chronic postural habits, as these are positions held for long periods of time. • Fascia requires movement to stay hydrated, pliable, and healthy.

27. Fascial stretching (stress/strain curve)

28. What we know about lBp • Research shows that people with chronic low back pain have altered thoraco-lumbar fascia extensibility, with layers up to 30% less able to slide and glide over one another • Langevin HM, Stevens-Tuttle D, Fox JR, Badger GJ, Bouffard NA, Krag MH, Wu J, Henry SM.Ultrasound evidence of altered lumbar connective tissue structure in human subjects with chronic low back pain. BMC Musculoskeletal Disorders. 2009;10:151. • Langevine HM, Fox JR, Koptiuch C, Badger GJ, Greenan-Naumann AC, Bouffard NA, Konofagou EE, Lee WN, Triano JJ, Henry SM.Reduced thoracolumbar fascia shear strain in human chronic low back pain.BMC Musculoskeletal Disorders. 2011;12:203.

29. Anti-inflammatory stretching • Some animal studies have shown a direct mechanical impact of stretching on inflammation-regulating mechanisms within connective tissue • Stretching connective tissue activates local pro-resolving mechanisms called resolvins. They help resolve inflammation. • Berrueta L, Muskaj I, Olenich S, Butler, T, Badger JG, Colas R, Spite M, Serhan CN, Langevine HM. Stretching impacts inflammation resolution in connective tissue.Journal of Cellular Physiology. 2016;231(7):1621-7. • Other research points to potential for fascial stretching to impact cancer growth • Berrueta L, Bergholz J, Munoz D, Muskaj I, Badger JG, Shukla A, Kim HJ, Zhao J, Langevine HM. Stretching reduces tumor growth in mouse breast cancer model.Scientific Reports. 2018;8(1):7864

30. Spinal stability example • Some research suggests that long duration spinal flexion stretches, especially in the presence of lumbar muscle fatigue, can alter the mechanical and neuromuscular functions of the lumbar spine and lead to decreased spinal stability and result in the development or exacerbation of low back pain. • Increased muscle activation was required to compensate for the loss of contribution of passive tissues to spinal stability after tissue creep (long passive forward bend at 75% available ROM, knees bent) • Abboud, Jacques, et al. Muscle Activity Adaptations to Spinal Tissue Creep in the Presence of Muscle Fatigue. PLoS One. 2016; 11(2): e0149076.

31. Risk of overstretching injuries to motor function • Researchers have hypothesized that subfailure injuries of ligaments may cause chronic back pain due to muscle control dysfunction • Single trauma or cumulative microtrauma causes subfailure injuries of the ligaments and embedded mechanoreceptors leading to impaired signals, and in turn, impaired neuromuscular control. • Eur Spine J. 2006 May; 15(5): 668–676. doi: 10.1007/s00586-005-0925-3. A hypothesis of chronic back pain: ligament subfailure injuries lead to muscle control dysfunction. Manohar M. Panjabi

32. Myofascial release • In addition to stretching and movement, many techniques claim to offer “myofascial release.” • This term means a lot of different things, depending on who’s using it. • Many claim that releasing myofascial tension can bring about release of deeply held emotional trauma as well. • “Myofascial trigger points” are taut bands of muscle fibers or fascial tissue that are ischemic and pain generating. We think of these as “knots.” • A variety of techniques are used for myofascial release – pressure, suction, taping, scraping, blasting, needling, rolling, etc. All likely support fascial hydration, mobility, and health.

33. Using asana practice • In movement/asana, some goals might be: • Keep fascia hydrated • Allow the body to adapt to a variety of positions • Improve fascia’s ability to handle stress • Increase the length of fascial tissues • Improve the ability of fascial layers to glide and slide along one another • Improve proprioception • Improve interoception • Improve endocrine, lymph, and immune function • Decrease acute and chronic inflammation • De-sensitize our response to body sensation

34. Hypermobility Libby Hinsley, PT, C-IAYT, E-RYT 500

35. What is hypermobility • Hypermobility means the joints and connective tissues of the body move and can be pulled beyond normal ranges. • Genetic alterations in the structure, function, and/or assembly pathway of collagen fibers = “bad glue.” • The Ehlers-Danlos syndrome: on beyond collagens. Jau-Ren Mao and James Bristow. J. Clin Invest. 2001 May 1; 107(9):1063-1069. DOI: 10.1172/JCI12881 • Collagenopathy is another broad umbrella term for this. • Collagen can’t hold the body together as well.

36. Types of hypermobility conditions • Ehlers Danlos Syndromes are a group of inherited connective tissue disorders in which joint hypermobility is always a feature. Hypermobility type EDS (hEDS) is the most common type. • Hypermobility Spectrum Disorders is a more general term for conditions involving hypermobility and related issues. • Other less common connective tissue disorders also feature hypermobility, including Marfan Syndrome and Osteogenesis Imperfecta, infantile hypotonia, and others

37. prevalence • The Ehlers Danlos Society reports research statistics that the total prevalence of EDS Syndromes (13 subtypes) is from 1 in 2,500 to 1 in 5,000 people. Many suspect it may be more common. hEDS is the most common type and the most commonly mis-diagnosed. • HSD share many of the same symptoms of hEDS and would be treated essentially the same way.

38. How is it assessed? • Beighton Scale • Maximum score is 9; GHD indicated at > or = 4 http://www.magcloud.com/browse/issue/831426

39. How is it assessed? • hEDS (Type III Ehlers-Danlos Syndrom) is the most common type of EDS and massively underdiagnosed. • Diagnostic criteria: • Based on Beighton Score in addition to other factors including pain, joint dislocations, umbilical hernia, skin extensibility, pelvic floor dysfunction, fatigue, dental and cardiac issues, and others.

40. How to spot it in yoga • You’ll notice knee and elbow hyperextension • You may also notice an excessive forward or backward bend https://www.parkeschampionpost.com.au/story/6047994/mobility-is-great-hypermobility-not-so-much/ https://jewellchiropractic.com/flexibility-vs-mobility/

41. Associated symptoms • Increased sympathetic nervous system tone = Anxiety disorders, attention disorders • Orthostatic intolerance (orthostatic tachycardia, low blood pressure) • Leaky gut and chronic GI issues, food sensitivities • MAST cell activation issues = increased histamine response • Scoliosis and sacro-iliac pain are very common

42. Associated symptoms • Chronic fatigue • Poor exercise tolerance • Decreased proprioception • Decreased motor control • Chronic musculoskeletal pain (several studies show a STRONG association between HSD and fibromyalgia) • Poor sense of boundaries…literally! • Lots of anecdotal evidence draws association between HSD and HSP (highly sensitive person)

43. We love yoga! • People with HSD and hEDS LOVE yoga • Prevalence of these conditions is likely much higher among yogis (and dancers) than the general population because: • Hypermobility is praised in most yoga contexts • Hypermobile people feel “successful” in yoga • Hypermobile people are often in pain and seeking relief from yoga • Hypermobile people are often struggling with anxiety/depression and seeking relief from yoga

44. asana is not helpful when: • Flexibility is praised/glorified • Students are always encouraged to “go deeper” or “find their edge” • Movement is fast paced • Sequences are highly asymmetrical • Stretches are static and passive

45. Asana can be helpful if: • Movement is slow and mindful • Postures are dynamic vs. static • Sequences emphasize symmetry • Range of motion is modified • Emphasis is placed on stability • Pranayama and relaxation are encouraged • Weighted objects can be incorporated