I wish every DC could have been exposed to the information disseminated at the first international facial conference, held in October at the Harvard Medical Conference Center. I have considered myself a "fascist" for many years and to hear confirmation about fascia from top researchers from around the world was indeed exhilarating.
A definition of fascia from the Web site is: "Fascia is the soft-tissue component of the connective tissue system that permeates the human body. It forms a whole-body, continuous, three-dimensional matrix of structural support. Fascia interpenetrates and surrounds all organs, muscles, bones and nerve fibers, creating a unique environment for body systems functioning." I rarely think of muscle origins and insertions. For example, the gluteus maximus, iliotibial band (encased in the fascia latae) attached to the knee, is considered as a single structure. Fascial thinking allows easier interpretation of the kinetic chain.
Information about fascial degeneration speaks about fibrosis as an end result. It is important to think of the posterior fascia from the base of the skull down the spine to the sacrum, sacrotuberous ligament and biceps femoris as possible restricted links that restrict motion and result in eventual pain. Posterior lumbar fascia is the furthest away from the spine and has the largest moment arm in generating passive tension in forward flexion of the spine.1 When you ask a patient to flex forward sitting and standing, it helps to ask them exactly where they feel the pain or tension. Often, a patient with cervical pain will flex forward and tell you they feel uncomfortable at the left lower scapula, or even in the lower lumbar area, and not in the cervical area. There is no longer any doubt that the fascia is interconnected, and evaluation of the areas of fascial complaint will elicit restricted, tough, tender areas. All ranges of forward flexion and rotation should be evaluated. Most often, low back patients complain of local pain from L4 to the sacrum or buttock areas.
After checking them in sitting and standing postures that may stress the fascia, it is important to check the hip areas, especially in the supine position. Putting the patient through a range of hip medial rotation (often the most limited), lateral rotation, flexion, extension (patient prone), abduction and adduction will reveal areas of stiffness and pain, often resulting in lumbar pain. These areas relate to interconnected fascial restrictions. Now, of course, other factors such as boney pathology, disc involvement, hip dysplasia, etc., must always be considered, but the fascial fibrosis also must be considered and treated.
An excellent study that corroborates the above concepts was presented at the conference by Stevens-Tuttle, et al.2 They restricted the motion of a group of pigs by using a harness attaching the hind limb to a chest strap. This limited hip extension and created a hobbled gait, causing movement restriction of the pelvis and back, versus another group of pigs without restriction. At the end of a month, both groups were evaluated by C-scan ultrasound. The restricted pig group showed changes in connective tissue architecture (remodeling) in the thoracolumbar fascia. Limited motion can therefore result in connective tissue changes of a fibrotic nature, which can result in initial inflammation, eventual fasciosis and chronic pain.
References
- Barker PJ, Briggs CA. Attachments of the posterior layer of lumbar fascia. Spine, 1999;24(17):1757-64.
- Stevens-Tuttle D, Fox J, Bouffard NA, et al. Perimuscular fascia remodeling in a porcine movement restriction model relevant to human low back pain. In: Fascia Research, Basic Science and Implications for Conventional and Complementary Health Care. Munich Elsevier GmbH, 2007.
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