Myofascial Induction™. An Anatomical Approach to the Treatment of Fascial Dysfunction Volume 1: The Upper Body [1 ed.] 9781913426330, 9781913426347

Table of contents :
Cover
Title Page
Copyright
Contents
Dedication
About the Author
About the Contributors
Foreword by Jan Dommerholt
Foreword by Robert Schleip
Foreword by Andry Vleeming
Preface
Online Videos
Acknowledgments
Glossary
Part 1. The science and principles of Myofascial Induction
Chapter 1. Introduction: Why This Book?
Introduction
Research, development, and innovation (R&D and I)
Searching for a health care model: The conceptual framework
A Systemic approach to therapeutic movement and health care
Metabolic aspects of the fascial system
Fascia and therapeutic movement
Therapeutic touch
What is Myofascial Induction Therapy (MIT) and why this approach?
Conclusion
References
Chapter 2. Definition and characteristics of fascia and the fascial system
Definition of fascia
Definition and characteristics of a system
Fascia as a system
Fascia as a complex biological system
Conclusion
References
Chapter 3. Anatomy and functional aspects of fascia
Introduction
Fascial continuity throughout the body
Fascial layers and their morphological characteristics
Skin and Langer’s lines
Superficial fascia as a system: Its morphology, architecture, and mechanics
Superficial fascia and the circulatory system
Deep fascia as a system: Its morphology, architecture, and mechanics
Conclusion
References and Further Reading
Chapter 4. Embryological aspects of the fascial system With a contribution from Germán Digerolamo
Introduction
Mechanobiology and embryonic development (embryogenesis)
The blastocyst and trilaminar embryonic disc
The ECM and organogenesis
Embryological development of fascial tissue
Integration of the neurocranium and brain
Mechanical control of development of the nervous system
The ECM and mechanobiology of the nervous system
Conclusion
References
Chapter 5. Histological aspects of the fascial system With a contribution from Germán Digerolamo
Introduction
Fascia: The connective, supporting, sustaining tissue?
The living matrix
Conclusion
References
Chapter 6. The concept of tensegrity: Fascia as a tensegrity structure
Origin of the tensegrity concept
Compression-based structures
Tensional tensegrity–integrity
Tensegrity in engineering
Tensegrity in organic chemistry
Tensegrity in biology (biotensegrity)
The concept of tensegrity and the dynamics of the locomotor system
Fascia as a tensegrity system
Conclusion
References
Chapter 7. Movement and force transmission in the fascial system With a contribution from Eduardo Castro-Martín
Introduction: Movement
Force transmission in the myofascial unit
Intramuscular force transmission
Epimuscular force transmission
Adaptation and facilitation of gliding
Conclusion
References
Chapter 8. The neurodynamics of fascia With a contribution from Germán Digerolamo
Introduction
Neurofascial architecture
Nervous tissue as a source of pain
Pain and peripheral sensitization
Pain and central sensitization
Innervation and vascularization of the fascial system
Continuity and transition of the nervous system
The neurovascular tract and lateral transmission of forces
Physiopathology of the nerve and glial response
Allostasis and the fascial system
Interoception and the afferent homeostatic pathway
Interoception, emotion, and behavior
Interoception and central sensitization
Conclusion
References
Chapter 9. Fascial trauma and dysfunction With a contribution from Germán Digerolamo
Introduction
Adaptive response and injury
Trauma to the fascial system
The fascial system and immunomodulation
Immunosenescence
Neuroimmune response, neurogenic inflammation, and remodeling
Scarring: The healing process
Conclusion
References
Chapter 10. The assessment process
Introduction
Global assessment
Specific functional tests
Palpatory tests
Conclusion
References
Chapter 11. The objectives of Myofascial Induction Therapy
General procedures: Recommendations
Complementary treatments
Specific treatment goals
Chapter 12. Scientific evidence relevant to the MIT approach
Introduction
Evidence-based medicine within the framework of the philosophy of science
Scientific evidence for the application of MIT
Examples of clinical research conducted on healthy subjects
Conclusion
References
Part 2. Practical Applications of Myofascial Induction – the upper body
Chapter 13. Myofascial Induction Therapy With a contribution from Mártin Pilat and Eduardo Castro-Martín
Therapeutic Considerations
Introduction: MIT as a manual therapy approach
Treatment objectives
Principles of treatment
Basic techniques and procedures
Introduction
Sliding procedures (direct application)
Sustained systemic procedures (indirect application)
Sustained applications: The four basic modalities
MIT: Indications and contraindications
Other considerations
Conclusion
References
Chapter 14. Upper quadrant assessment With a contribution from Eduardo Castro-Martín
Introduction
Characteristics of the upper quadrant
The assessment process
Conclusion
References
Chapter 15. Craniofacial and neck dysfunctions related to the fascial system With a contribution from Eduardo Castro-Martín
Craniofacial region
Introduction
Craniofacial fascial system
Main features of the fascial system of the craniofacial region
Behavior of craniomandibular and cervical myofascial structures
Craniofacial and cervical innervation
Trigeminocervical complex
Clinical implications
Wound healing processes
Temporomandibular disorder
Pain related to the orofacial area or cervical spine
Cervical, craniomandibular, and ear sisorders (otalgia)
Neural exit foramina
Craniocervical structures
Anatomical considerations related to the continuity of the fascial structures of the neck
Fascial anatomy of the neck
The suboccipital region and myodural connections
Cervical fascial spaces
Triangles of the neck
References
MIT procedures for common craniocervical and neck dysfunctions
Chapter 16. Dysfunctions related to the thorax complex
Introduction
Anatomical considerations related to the thorax complex
Conclusion
References
MIT Procedures for common dysfunctions of the thorax complex
Chapter 17. Upper extremity dysfunctions related to the fascial system
Introduction
Synergy as part of general system theory
Anatomical considerations related to the continuity of the fascial system of the upper extremity
Shoulder complex structures (shoulder girdle fascial system)
Arm and forearm structures
Hand structures
Clinical Features of myofascial dysfunction in the upper extremity
Conclusion
References
MIT Procedures for common upper extremity dysfunction
Permissions and Sources
Index

Citation preview

Myofascial Induction™

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Myofascial ™ Induction An anatomical approach to the

treatment of fascial dysfunction Volume 1 The Upper Body

Andrzej Pilat Forewords

Jan Dommerholt Robert Schleip Andry Vleeming

Edinburgh

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HANDSPRING PUBLISHING LIMITED The Old Manse, Fountainhall, Edinburgh, East Lothian EH34 5EY, Scotland Tel: +44 1875 341 859 Website: www.handspringpublishing.com First published 2022 in the United Kingdom by Handspring Publishing Limited Copyright © Handspring Publishing Limited 2022 All rights reserved. No parts of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without either the prior written permission of the publisher or a licence permitting restricted copying in the United Kingdom issued by the Copyright Licensing Agency Ltd, Saffron House, 6–10 Kirby Street, London EC1N 8TS. The rights of Andrzej Pilat to be identified as the Author of this text have been asserted in accordance with the Copyright, Designs and Patents Acts 1988. ISBN 978-1-913426-33-0 ISBN (Kindle eBook) 978-1-913426-34-7 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress Notice Neither the Publisher nor the Author assumes any responsibility for any loss or injury and/or damage to persons or property arising out of or relating to any use of the material contained in this book. It is the responsibility of the treating practitioner, relying on independent expertise and knowledge of the patient, to determine the best treatment and method of application for the patient. All reasonable efforts have been made to obtain copyright clearance for illustrations in the book for which the authors or publishers do not own the rights. If you believe that one of your illustrations has been used without such clearance, please contact the publishers and we will ensure that appropriate credit is given in the next reprint. Commissioning Editor Mary Law Project Manager Morven Dean Copy Editor Sally Davies Design and cover Bruce Hogarth Photographs of anatomy Andrzej Pilat Indexer Avril Erlich Typesetter Amnet, India Printer Finidr, Czech Republic

The Publisher’s policy is to use paper manufactured from sustainable forests

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CONTENTS Dedication About the author About the contributors Foreword by Jan Dommerholt Foreword by Robert Schleip Foreword by Andry Vleeming Preface Online videos Acknowledgments Glossary

x xi xii xiii xiv xvi xvii xix xx xxi

PART 1

The science and principles of Myofascial Induction

CHAPTER 1

Introduction: Why this book? Introduction Research, development, and innovation (R&D and I) Searching for a health care model: The conceptual framework A systemic approach to therapeutic movement and health care Metabolic aspects of the fascial system Fascia and therapeutic movement Therapeutic touch What is Myofascial Induction Therapy (MIT) and why this approach? Conclusion References

1 1 3 3 6 6 7 9 10 11 12

CHAPTER 2

Definition and characteristics of fascia and the fascial system Definition of fascia Definition and characteristics of a system Fascia as a system Fascia as a complex biological system Conclusion References

15 15 16 21 22 24 25

CHAPTER 3

Anatomy and functional aspects of fascia Introduction Fascial continuity throughout the body Fascial layers and their morphological characteristics Skin and Langer’s lines Superficial fascia as a system: Its morphology, architecture, and mechanics Superficial fascia and the circulatory system Deep fascia as a system: Its morphology, architecture, and mechanics Conclusion References and further reading

27 27 27 28 28 34 60 71 96 97

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CONTENTS continued CHAPTER 4

Embryological aspects of the fascial system With a contribution from Germán Digerolamo Introduction Mechanobiology and embryonic development (embryogenesis) The blastocyst and trilaminar embryonic disc The ECM and organogenesis Embryological development of fascial tissue Integration of the neurocranium and brain Mechanical control of development of the nervous system The ECM and mechanobiology of the nervous system Conclusion References

101 10 1 103 105 105 107 109 109 111 112 1 13

CHAPTER 5

Histological aspects of the fascial system With a contribution from Germán Digerolamo Introduction Fascia: The connective, supporting, sustaining tissue? The living matrix Conclusion References

1 15 1 15 1 16 1 16 136 137

CHAPTER 6

The concept of tensegrity: Fascia as a tensegrity structure Origin of the tensegrity concept Compression-based structures Tensional tensegrity–integrity Tensegrity in engineering Tensegrity in organic chemistry Tensegrity in biology (biotensegrity) The concept of tensegrity and the dynamics of the locomotor system Fascia as a tensegrity system Conclusion References

139 139 139 140 1 41 143 144 148 149 150 151

CHAPTER 7

Movement and force transmission in the fascial system With a contribution from Eduardo Castro-Martín Introduction: Movement Force transmission in the myofascial unit Intramuscular force transmission Epimuscular force transmission Adaptation and facilitation of gliding Conclusion References

153 153 154 157 160 165 166 167

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CHAPTER 8

The neurodynamics of fascia With a contribution from Germán Digerolamo Introduction Neurofascial architecture Nervous tissue as a source of pain Pain and peripheral sensitization Pain and central sensitization Innervation and vascularization of the fascial system Continuity and transition of the nervous system The neurovascular tract and lateral transmission of forces Physiopathology of the nerve and glial response Allostasis and the fascial system Interoception and the afferent homeostatic pathway Interoception, emotion, and behavior Interoception and central sensitization Conclusion References

171 171 171 1 74 1 75 1 75 177 179 180 180 181 182 182 184 185 186

CHAPTER 9

Fascial trauma and dysfunction With a contribution from Germán Digerolamo Introduction Adaptive response and injury Trauma to the fascial system The fascial system and immunomodulation Immunosenescence Neuroimmune response, neurogenic inflammation, and remodeling Scarring: The healing process Conclusion References

189 189 191 191 198 199 199 200 203 205

CHAPTER 10

The assessment process Introduction Global assessment Specific functional tests Palpatory tests Conclusion References

207 207 208 235 235 237 238

CHAPTER 11

The objectives of Myofascial Induction Therapy General procedures: Recommendations Complementary treatments Specific treatment goals

241 241 241 242

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CONTENTS continued CHAPTER 12

Scientific evidence relevant to the MIT approach Introduction Evidence-based medicine within the framework of the philosophy of science Scientific evidence for the application of MIT Examples of clinical research conducted on healthy subjects Conclusion References

243 243 244 247 2 51 252 254

PART 2

Practical applications of Myofascial Induction – the upper body

259

CHAPTER 13

Myofascial Induction Therapy With a contribution from Mártin Pilat and Eduardo Castro-Martín Therapeutic considerations Introduction: MIT as a manual therapy approach Treatment objectives Principles of treatment Basic techniques and procedures Introduction Sliding procedures (direct application) Sustained systemic procedures (indirect application) Sustained applications: The four basic modalities MIT: Indications and contraindications Other considerations Conclusion References

26 1 26 1 26 1 262 262 266 266 266 273 283 289 289 290 291

CHAPTER 14

Upper quadrant assessment With a contribution from Eduardo Castro-Martín Introduction Characteristics of the upper quadrant The assessment process Conclusion References

293 293 295 296 322 323

CHAPTER 15

Craniofacial and neck dysfunctions related to the fascial system With a contribution from Eduardo Castro-Martín

Craniofacial region Introduction Craniofacial fascial system Main features of the fascial system of the craniofacial region Behavior of craniomandibular and cervical myofascial structures Craniofacial and cervical innervation Trigeminocervical complex Clinical implications Wound healing processes

327 327 327 328 331 336 340 340 340 341

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Temporomandibular disorder Pain related to the orofacial area or cervical spine Cervical, craniomandibular, and ear disorders (otalgia) Neural exit foramina Craniocervical structures Anatomical considerations related to the continuity of the fascial structures of the neck Fascial anatomy of the neck The suboccipital region and myodural connections Cervical fascial spaces Triangles of the neck References MIT procedures for common craniocervical and neck dysfunctions

CHAPTER 16 Dysfunctions related to the thorax complex Introduction Anatomical considerations related to the thorax complex Conclusion References MIT procedures for common dysfunctions of the thorax complex

CHAPTER 17 Upper extremity dysfunctions related to the fascial system

341 342 343 346 347 347 348 36 1 380 380 384 393 427 427 427 454 455 457

Introduction Synergy as part of General System Theory Anatomical considerations related to the continuity of the fascial system of the upper extremity Shoulder complex structures (shoulder girdle fascial system) Arm and forearm structures Hand structures Clinical features of myofascial dysfunction in the upper extremity Conclusion References MIT procedures for common upper extremity dysfunction

467 467 467 473 486 494 499 503 507 508 513

Permissions and sources Index

555 559

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DEDICATION

In May 2016 I had the opportunity to show a sample chapter of this book to Dr. Leon Chaitow. On reviewing it carefully, he exclaimed: “I want this book!” He also generously agreed to my request to write the book’s foreword. I promised he would be the ÿ rst to read the book. Sadly, his sudden passing did not allow me to fulÿ ll my promise. I am honored to dedicate the book to the memory of this great person, clinician, researcher, writer, lecturer, educator, editor, and visionary. Andrzej Pilat

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ABOUT THE AUTHOR

Andrzej Pilat is a physical therapist. Born in Poland, throughout his professional life he has practiced across continents. ° is has given him the opportunity to be involved in a variety of aspects of physical therapy: health care (a bustling hospital environment; the mystery of an operating room; the adrenaline of intensive care units; and the intimacy of a private practice); teaching (in a university setting, tutoring graduate and undergraduate students); research (decoding the human body’s enigma by dissecting unembalmed cadavers); management (he has been chair of domestic professional associations and international organizations); publishing (he was an editor for the Venezuelan Manual ° erapy journal); and information dissemination (he is the author of several papers and books). ° ese experiences have led him to a better understanding of people’s culture, customs, and attitudes towards diseases, thus awakening his interest in therapeutic approaches and treatments that will adapt as e˛ ectively as possible to the individual, as opposed to the disease. In his quest, Andrzej has experienced a fruitful array of di˛ erent approaches to physical therapy, with a wide range of exercises, modalities, applications (devices), manual applications, and concepts – learned from well-known masters, such as Maitland, Mulligan, McKenzie, Upledger, Barnes, Greenman, and others. ° e study of di˛ erent concepts of manual therapy has occupied the last 35 years of his career and he

has become intensely interested in fascia in the search for answers to the (always) global response of the body to disease and healing. Andrzej’s experience as a photographer has allowed him to immerse himself in the intimacies of the unembalmed cadaver, capturing in pictures the beauty of the inner body architecture. ° e pages of this book re˝ ect these experiences by taking the reader on a fascinating journey through the puzzle of the fascia, from a microbiological, anatomical, biomechanical, neuroscientiÿ c, and even psychological and philosophical approach. Today Andrzej leads the Myofascial ° erapy School, Tupimek, in El Escorial (Madrid), Spain, where he gives instruction in Myofascial Induction ° erapy (MIT) , in collaboration with certiÿ ed teachers both in Spain and worldwide. Andrzej lectures in specialized workshops and teaches for di˛ erent master’s programs in local universities and abroad. He has participated in numerous international congresses about fascia, manual therapy, and physical therapy in general. In recent years, his participation in webinars has resulted in a growing international following. Myofascial Induction™: An anatomical approach to the treatment of fascial dysfunction is the result of ÿ ve years of intense research through a vast amount of scientiÿ c evidence about the fascia’s increasing importance to people’s health and illnesses.

™

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CONTRIBUTORS Eduardo Castro-Martín PT, MSc, CO Physiotherapist, Vértex Centro, Granada, Spain International Lecturer Academic Coordinator and Certiÿ cated Teacher, Tupimek Myofascial ° erapy School, Madrid, Spain Assistant Professor, Department of Physiotherapy, Granada University, Granada, Spain Germán Digerolamo BS(Kin), MNeuro Kinesiologist and Physiotherapist International Lecturer Academic Coordinator and Certiÿ cated Teacher, Tupimek Myofascial ° erapy School, Madrid, Spain Director of the Institute of Neuroscience and Physiotherapy, Segovia, Spain Mártin Pilat PT, MSc, CO Physiotherapist and Manual ° erapist, Tupimek Physiotherapy Center, El Escorial, Spain International Lecturer Sub-Director and Certiÿ cated Teacher, Tupimek Myofascial ° erapy School, Madrid, Spain

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FOREWORD by JAN DOMMERHOLT I do not recall when and where I ÿ rst met Andrzej Pilat, but I suspect it was at either a myofascial pain congress, a fascia congress, or a physiotherapy course or conference somewhere in the world. O˙ en Andrzej’s travels coincided with mine, and every time I attended his lectures several thoughts and associations came to mind. It was clear to me that this man is an innovator in the ÿ eld of physiotherapy and beyond – someone who follows in the footsteps of other innovators from many di˛ erent ÿ elds, dispelling the many erroneous belief systems so common in our discipline. I have a feeling that already, during his time as a physiotherapy student, young Andrzej would have been questioning his tutors and challenged their teachings and convictions about physiotherapy treatment methods. In a time when the terms evidence-based and evidenceinformed physiotherapy had not been invented, Andrzej was probably way ahead of many of his professors in his critical thinking skills and vision for the profession. During our lifetime, physiotherapy has evolved from a tradition-based therapy to an evidence-informed approach. Charles Kettering is quoted as saying “If you have always done it that way, it is probably wrong” – words that could easily have been uttered by Andrzej Pilat. During a myofascial pain conference in Bangalore, India several years ago, Andrzej and I had numerous opportunities to re˝ ect, share ideas, admire each other’s creative presentation styles, share a beer or two, and ponder about the future of physiotherapy. His attention to detail, his phenomenal dissection videos, animations, and photographs were most impressive, not to mention his good nature and willingness to share his perspective with anyone willing to listen. Attendees of the congress recognized his brilliant mind, creativity, and tenacity, and our chats were frequently interrupted by requests to take selÿ es with Andrzej! In a time where many physiotherapists have adopted a mindset that because “pain is in the brain” and “the issues are not in the tissues,” so “hands-on therapies are a thing of the past,” Andrzej continued to defy such developments and instead explored new developments beyond what most of us could ever have imagined. Albert Einstein reportedly stated that “You can’t solve a problem on the same level that it was created. You have to rise

above it to the next level.” ° at observation is applicable to Pilat at many levels. Myofascial Induction™: An anatomical approach to the treatment of fascial dysfunction is the ultimate proof of the innovative pathway which Andrzej has carved out, o˙ en against the contemporary viewpoints of other scientists, social media in˝ uencers, and established traditions. At the time I was preparing this foreword, Colleen Kigin, PT, PhD, FAPTA was presenting the 52nd Mary McMillan Lecture as part of the centennial celebration of the American Physical ° erapy Association. By pure coincidence the title of her lecture was “Innovation: It’s in our DNA.” Although I am personally not convinced that “the [physical therapy] profession is rich with innovators,” Dr Kigin hit the nail on the head when she summarized, that physical therapy innovators have the ability to connect the dots, accompanied by intense questioning, observing, networking, and experimenting. I have read several older chapters about myofascial induction written by Pilat in other textbooks, but this book goes far beyond anything I have read before or seen during Pilat’s lectures. It was such a pleasure and enrichment to learn about tensegrity, the embryological development of the extracellular matrix, fascial anatomy, pain sciences, allostasis, interoception, and additionally, myofascial induction – all in one book! ° e many outstanding illustrations, including line drawings, exquisite anatomy photographs, and diagrams complement the text together with links to supporting videos online showing Andrzej at work. While at times, Pilat becomes rather philosophical, he never loses track of educating clinicians and scientists across a wide spectrum in the current knowledge of fascia. I admire and congratulate Andrzej Pilat for this phenomenal book. It is such an honor to introduce you, the reader, to this outstanding publication. Jan Dommerholt PT, DPT Bethesda Physiocare, Inc. Myopain Seminars Lecturer, Department of Physical ° erapy and Rehabilitation Science, University of Maryland Bethesda, MD, USA, September 2021

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FOREWORD by ROBERT SCHLEIP Fascia is a connecting (t)issue. While Western conventional medicine underestimated it for centuries as a mere packaging organ, recent advances in assessment methods – such as shear wave ultrasound elastography or harmonic generation microscopy – have triggered an avalanche of new discoveries and insights into the collagenous tissue network that keeps many researchers and clinicians around the world on their toes. Although many aspects remain to be explored, recent publications have shown that this network not only in˝ uences muscular force transmission in a signiÿ cant manner but also constitutes our richest sensory organ. One of the fascinating aspects of the fascial network is its connective nature, which makes it diˆ cult for precision-minded thinkers to describe its clear boundaries and distinctions in a satisfactory manner. While this fact is frustrating to some, it has also piqued the interest of esoteric healing practitioners who wish to project far-reaching hypothetical abilities, such as telepathic intuition or cosmic resonance transmission, into this elusive tissue network. Indeed, among the many di˛ erent scientiÿ c and therapeutic congresses I have attended, I have never seen such a diverse and interdisciplinary audience as at fascia-oriented congresses, ranging from biomechanical engineers, plastic surgeons, meat scientists, matrix biologists, and orthopaedic researchers to osteopaths, yoga teachers, meditation instructors, martial arts gurus, and Reiki practitioners. What does this aspect have to do with the excellent book you are holding in your hands right now? Let me explain a˙ er completing the next two paragraphs. Having been a holistic therapy practitioner and missionary myself for several decades, my personal path has led me more and more to the humble, questioning approach of those scientists who are interested in unraveling the mysteries of the human body in many small and careful steps. When it comes to drawing conclusions about cause-and-e˛ ect relationships in the fascia-oriented ÿ eld I personally tend to side with those researchers who work with a curious “we don’t know” attitude. ° is approach can be frustrating as it is often less exciting and less charismatic than allowing our wishful thinking to generate broad assumptions and easy explanations about the implications of a perceived fascial phenomenon.

On the other hand, I must confess that for therapeutic treatment of myself or my family members, I continue to appreciate the healing attention of therapists who work with a more holistic and intuitive approach. In my experience, their quality of touch, loving presence, and wonderful enthusiasm are priceless components of a healing relationship. ° ese qualities are less o˙ en found – at least not with the same depth – among my respected scientiÿ c colleagues. Or to put this observation the other way around: When listening to the personal explanations of the best therapists in our ÿ eld about the healing mechanisms involved in their work, one must o˙ en be prepared to hear interpretations that any of my undergraduate Life Science students would easily recognize as premature logical conclusions. If you have already guessed how this situation relates to the author of this book and the brilliant book he has written, you have my collegial applause. Yes, the author, Andrzej Pilat, is indeed a very rare exception to the common disparity described here. I consider him one of the best manual therapists I know, and I do not say that lightly. When I see Andrzej at work, I feel as if I am watching a master artist, like Michelangelo as a painter or like a Butoh dancer in slow motion. But the most impressive aspect for me is his connection with the client: Both seem to be united in a joyful and almost hypnotic process of discovery. Nevertheless, when Andrzej describes his work in terms of suggested fascia changes, I feel like asking all my students to join me in listening to him with eager attention. ° e way he weaves together various ÿ ndings and issues of the latest international research is truly outstanding. ° e author of this brilliant book has not only been a passionate manual therapist for many decades but has also been actively involved in academic fascia research, including the ÿ rst Fascia Research Congress (Harvard Medical School Conference Center, Boston, 2007), all subsequent such events, and in several similar congresses which he hosted himself and used to interact personally with the leading scientists in our ÿ eld. ° ose of you who have had the pleasure of attending one of the international Fascia Research Congresses know that Andrzej Pilat’s presentations tend to be absolute highlights. A˙ er his presentation, he is usually surrounded by a crowd of enthusiastic attendees who

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want to collaborate with him in one way or another, or to ÿ nd out how they can get their hands on the fantastic photos and videos of fascia anatomy that he has shown. For many years, his constant response to the latter request has been, “Give me a little more time to ÿ nish my book, which will contain all of this and much more.” Here it is, dear friends and companions in the ÿ eld of fascia research: the long-awaited – and I think truly historic – contribution of Andrzej Pilat to our common ÿ eld of fascination. Many of the fascial images, based on fresh tissue dissections, are the best presented outside of professional conferences. One cannot help but admire the beauty of the complex architecture of the wonderful connecting tissue called fascia. ° e book also provides an up-to-date overview of what is

currently known about the many functions of this tissue. Finally, this masterpiece in print introduces you to a fascia-oriented manual treatment method that you will surely want to experience yourself a˙ er reading the ÿ rst few chapters. I congratulate the author for this fantastic achievement. Myofascial Induction™: An anatomical approach to the treatment of fascial dysfunction is a milestone contribution to the literature on fascia. Robert Schleip Dr biol.hum., Dipl.Psych. Visiting Professor, IUCS Barcelona, Spain Director, Fascia Research Group, Ulm University, Germany Research Director, European Rolÿ ng Association Munich, Germany, September 2021

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FOREWORD by ANDRY VLEEMING ° e complexity of fascia and its functions has been well documented, and it is evident that some of its secrets are yet to be unfolded. As this information expands, it is convenient to have a go-to source to help us bring this knowledge together and explore tools useful in applying this information in the clinical setting.ˇ

currently known in the ÿ eld. ° is includes an in-depth description of fascial topographical anatomy, its layers and architecture. ° e book then explores embryological development, histological characteristics, neurodynamics and the role of force transmission relating to the fascia.ˇ

Developed over years of dedication and enthusiasm this book delivers exactly that. It is systematically organiszed to take the reader through the relevant clinical research and literature. It does so in a way that enables us to gain a greater understanding of this threedimensional sensory organ. Let me explain why ...

° e later part of the book invites the reader to explore the clinical applications of Myofascial Induction ° erapy. ° is section is neatly categorized into treatment regions – craniofacial, craniocervical, the thorax, upper and lower extremities – with each region providing detailed information regarding clinical assessment and dysfunction. ° e relevant manual techniques are clearly described in a format that is easy to follow. Evidently much thought has been given to the layout of this book, employing wonderful photography and well-designed diagrams, enabling us to get a deeper understanding of the fascial system. If you wish to expand your knowledge of the anatomical approach to the treatment of fascial dysfunction Myofascial Induction™: An anatomical approach to the treatment of fascial dysfunction will be a very welcome addition to your collection.ˇˇ

Because it is a continuous matrix fascia is not easy to map. It reaches out to all corners of the body and to every cell. It provides the framework that helps support and envelop muscles, organs, blood vessels and neurons, enabling the body to function as a whole.ˇ Its various mechanical properties are intriguing and complex. Addressing this complexity, this book does a wonderful job of bringing us up close and personal to the topographical anatomy. It also helps us explore, through illustration, the anatomical continuity of the fascia and how it relates to other body systems. ° is is achieved through the use of wonderful photographs and diagrams that help the reader visualize what lies beneath the skin. To start you o˛ in this exploration, the opening chapters provide the reader with an overview of what is

My warmest congratulations to you, Andrzej Pilat. Professor Andry Vleeming PhD Chairman, Interdisciplinary World Congress on Low Back and Pelvic Girdle Pain Antwerp, Belgium, September 2021

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PREFACE In 2003 I published my ÿ rst book on fascia and Myofascial Induction ° erapy: Terapias miofasciales: Inducción miofascial. ° is was based on the limited scientiÿ c information then available and at that time images of fascial anatomy were very scarce. I had to undertake a detailed search for evidence to corroborate the criteria presented in that book. Today, 18 years later, the picture is very di˛ erent. ° e problem now is how to make the best selection from the mass of high-quality scientiÿ c information on fascia that is available today. ° is detailed and richly illustrated book distils that information, and puts it into the context of my own extensive study of human tissue, creating a unique textbook and manual on the fascia and on how to manage its dysfunctions. Over the past 15 years I have undertaken many dissections of unembalmed cadavers and this work has allowed me to open up new perspectives in the ÿ eld of fascia research. ° rough these anatomical explorations I discovered the harmony, omnipresence, architectural complexity, diversity, and continuity of this amazing fascial system. No less fascinating (although complicated and laborious) was the photographic e˛ ort necessary to capture this inÿ nite, diversiÿ ed, and colorful network. ° rough macrophotography I discovered the hidden beauty that is the continuum of the endless fascial web. As a result of this detailed research, the extensive approach to fascial anatomy presented in the book (with the support of numerous full-color photographs and videos) encompasses not only the topography of the fascial tissue but also shows its elegance, structural continuity, and coherence within the chaos. It invites the reader to explore its microstructure and to recognize its essential role and active participation in body movement. Within the contemporary conceptual framework new terminology di˛ erentiates between anatomical structure (fascia) and function (fascial system) – a complex biological system responsible for communication (transmission of information) between body components and with the environment. ° e movement of each human (for example walking) is personal and almost impossible to duplicate. ° e uniqueness in the conÿ guration of each individual’s fascial system is part of this process. In order to

achieve the desired movement our brain manages its complex neural network, selecting for activation those motor units that enable optimal performance for the task in hand. It is obvious that in this process the muscles (muscle tissue) are the main engines of movement. However, it should be remembered that none of the muscle ÿ bers acts in isolation. ° ey are fascial structures that transmit dynamic adjustments according to demands. Following this reasoning, the question is: What is the signiÿ cance of fascia for body movement and what is its relevance in the therapeutic processes? In this context, the book deals with fascia and kinesis, the latter deÿ ned in the Merriam-Webster dictionary as “a movement that lacks directional orientation and depends upon the intensity of stimulation.” A human being can choose his movement at will. ° is attribute is guided by the brain. ° e brain uses past experiences to anticipate movements. ° e brain does not see the future, but makes intelligent predictions about what will happen in the immediate future. It is a learning process that involves the senses (exteroception). In this way we perceive the world. In parallel, the same senses are in˝ uenced by body condition (interoceptive messages) based on experience, which is personal. ° e plasticity of the nervous system allows body movement to accommodate to diverse circumstances (for example, facing dangerous situations) based on experience and current information. ° e nervous system and the fascial system share the principles of plasticity, and adjust movement in an anticipatory and individual way for each person. ° is process facilitates the ability to easily recover or adapt to misfortunes or changes (resilience). Myofascial Induction™: An anatomical approach to the treatment of fascial dysfunction describes the properties of the endless and omnipresent fascial network and provides therapeutic solutions for di˛ erent types of fascial dysfunction. ° e material is presented in two volumes: Volume 1 analyzes in depth the theoretical aspects related to fascia and focuses on the therapeutic procedures of Myofascial Induction ° erapy (MIT™ ) for the upper body; Volume 2 summarizes and expands on the theoretical aspects and explains the therapeutic procedures of MIT™ for the lower body.

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PREFACE continued Volume 1 is divided into two parts: Part 1 – ° e Science and Principles of Myofascial Induction Part 2 – Practical Applications of Myofascial Induction – the Upper Body. In Part 1, a˙ er deÿ ning the fascia as a complex biological system, its multiple characteristics are broadly discussed:

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fascial embryology (with the importance of movement throughout its development),

•

anatomy of the fascia (with extensive photographic and video recording of dissections of unembalmed cadavers, showing its continuity and integrity),

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ultrastructure of the fascia (discussing the behavior of the extracellular matrix with its essential components – cells, ÿ bers and receptors), giving the reader an understanding of the importance of cells with their contractile capacity and control of the gliding process,

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biomechanics (with a special focus on myofascial force transmission),

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neurodynamics (mechanoreception, proprioception, interoception, and nociception),

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trauma and consequent myofascial dysfunction and its assessment.

Part 2 is the practical part. Here the reader will ÿ nd a wide range of manual therapeutic procedures which can be selected and used in combination to build up the MIT treatments. ° ese processes are explained in detail and are richly illustrated with diagrams and photographs of their practical application on the body and of hand contacts on samples of dissected tissues. ° e introduction to each chapter o˛ ers the reader some philosophical background as a reminder that philosophy allows us to relate the strictly scientiÿ c with the empirical. Praxis and empiricism are the basis of science. I invite you to join the scientiÿ c fascial adventure that allows us to uncover areas of knowledge which may have been forgotten or which are not yet recognized as being related and which might still reveal relevant information. Once discovered, these facts can help us to better understand the kinesis of our body and so help the individual to change their body image and to improve their quality of life. Andrzej Pilat Madrid, Spain July, 2021

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ONLINE VIDEOS Chapter 3 Video 3.1 Movement of superficial fascia in conjunction with the skin Video 3.2 Movement of the superficial layer of the superficial fascial system Video 3.3 Movement of the deep layer of the superficial fascial system Video 3.4 Blood flow through the great saphenous vein Chapter 7 Video 7.1 Dynamic ultrasound imaging of the ventral aspect of the forearm in a living subject Chapter 16 Video 16.1 Mechanical links between the trapezius and scapula Video 16.2 Scapular and rhomboid dynamics

Chapter 17 Video 17.1 Cubital fossa neurovascular tract components and their links to the brachial and antebrachial fascia Video 17.2 Cubital fossa induction procedure

Video 17.3 Biceps brachii induction: Hand position and performance of the procedure Video 17.4 Bicipital groove induction procedure

Video 17.5 Infraspinatus fascia induction

Video 17.6 Performance of pectoralis major fascia induction

Video 17.7 Clavipectoral fascia induction

Video 16.3 Longitudinal stroke applied to the intercostal spaces

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ACKNOWLEDGMENTS ° e discovery of the double helix of DNA, whose structural coherence hides in code the morphogenetic and informational potential of life, opened the way to modern biology. It also marked the beginning of the close collaboration between biology, physics, and progressively other disciplines such as computing. ° e relatively simple interactions between di˛ erent pairs of nucleotides reveal the almost inÿ nite capacity to store information in the DNA heteropolymer. It is the intimate connection between interaction and information that constitutes the fabric of living matter. Biological complexity is based on speciÿ c interactions between molecules. ° ese interactions create complex networks that are balanced by their interconnection. ° ese networks control and regulate the exchange of signals that govern intracellular functions and multicellular behavior throughout the development and functioning of the organism. ° is fascinating advance of science forced the change of paradigms and integration of scientiÿ c streams. ° e analysis of the behavior of the fascia, as the integrating structure of the body, did not escape these requirements. ° us, the act of writing this book on fascia turned into a long and fascinating scientiÿ c adventure. Although not an expert in the aforementioned disciplines, I was fortunate to have the advice and help of friends who made this trip possible and enabled me to ÿ nally dock at the destination harbor. My sincere thanks to all listed below for having accompanied me on this long and winding journey.

•

•

First of all, I would like to thank the editorial team at Handspring Publishing, especially Mary Law and Andrew Stevenson as well, Sally Davies, Bruce Hogarth, Morven Dean, and Hilary Brown for their dedication, patience, professionalism, and attention to detail in search of editorial perfection. I would like to thank my family for allowing me the long months (years) dedicated to writing the book, especially my wife Yulita for her unconditional support and her contribution to so many tasks, and also my children Eva, Mártin, and Kamil.

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° ank you to my friend, architect Michele Testa, for teaching me to select and synthesize the avalanche of scientiÿ c information to solve seemingly insoluble problems.

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I would like to thank the ETM Tupimek team, particularly my son Mártin Pilat, Germán Digerolamo, and Eduardo Castro-Martín for their extensive help, reviews, and critical reading of the manuscript as well as their contributions on issues that I was unaware of. Also, I am grateful to Javier Rodríguez and Jorge Sánchez for their help in preparing the illustrative material and to Rafael García for his help in the search for scientiÿ c information.

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° ank you to the PROMPT team, especially Francesco Testa, Iván Arellano, and Andrea Fiorucci for developing the illustrative material for the book and re˝ ecting my thoughts in the drawings.

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I am extremely grateful to the late Professor Dr. Horacio Conesa for allowing me to live the adventure of discovering the enigmas of the fascia in anatomical dissections.

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I would like to thank Dr. Nicolás Barbosa for his art of dissecting fascia during the long hours of anatomical work that we shared.

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I would also like to thank Professor Dr. Maribel Miguel-Pérez and Dr. Albert Perez-Bellmunt for their critical review of my anatomical interpretations.

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° ank you to Dr. Ramón Gassó for his analysis and helpful opinions on fascial physiology.

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I thank the photographer Óscar Ruiz for his art of capturing therapeutic applications in photographic subtlety.

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° ank you to Ailén Botta Mazzone for her patience and grace in modeling the applications of therapeutic procedures.

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I would like to thank Javier Álvarez for introducing me to the world of the analysis of fascia through images and for obtaining the samples for the book.

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Finally, my special thanks to Venezuela and all who have been part of this adventure.

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GLOSSARY acid-base balance balance of acidity and alkalinity in the body actin a family of globular proteins that form microfilaments which are one of the three main components of the cytoskeleton of a cell

actin microfilaments thin, globular protein fibers composed predominantly of a contractile protein called actin

adventitia

Cajal–Retzius cells a heterogeneous population of morphologically and molecularly distinct reelin-producing cell types in the marginal zone or layer of the developmental cerebral cortex

catabolic enzymes enzymes that control the cellular reactions that take place within a cell

catabolic response the part of the metabolic process that consists of the transformation of complex biomolecules into simple molecules

the outermost layer of the arterial wall composed of collagen and elastic fibers

catastrophizing

anabolic response

cell differentiation

exaggeration or distortion of reality that causes great stress

the set of metabolism processes that result in the synthesis of cellular components from molecular precursors

a process by which a less specialized cell becomes different (more specialized)

angiogenesis

cell migration

formation of blood vessels

anterior cingulate cortex

a process by which a cell moves through tissue or on the surface of a culture plate

located in the anterior part of the brain, it plays a role in autonomic functions (regulation of blood pressure and heart rate) and cognitive functions (decision making, empathy, emotions)

cell proliferation

antidromic

amplification of neural signaling within the CNS that causes hypersensitivity to pain

describes a type of nerve conduction that runs in the opposite direction to the usual (orthodromic) conduction

apoptosis a genetically directed, normal cellular self-destruction process that controls cell development and growth. It can be physiological in nature and is triggered by genetically controlled cellular signals

increase in the number of cells through cell division

central sensitization

chemoattractant signals or chemoattractants organic or inorganic substances that have a chemotaxis-inducing effect on mobile cells

chemokines

a group of transmembrane proteins responsible for transporting water through cells

belonging to the cytokine family, chemokines are small proteins best known for their role in controlling the migration of diverse cells. They have the ability to activate, attract, and direct various families of circulating leukocytes to damaged sites

areolar or loose connective tissue

chemotaxis

the most abundant of the connective tissues. It is widely distributed and fills both internal and inter-organ spaces. It is found in areas that do not need to be highly resistant to mechanical stress

the phenomenon through which the cells of unicellular or pluricellular organisms direct their movements according to gradients of concentration

cingulate gyrus

astrocyte

an area of the brain that is located above the corpus callosum (a structure that connects the left and right sides of the brain allowing for communication between both hemispheres)

aquaporins

a non-neuronal cell of the nervous system responsible for performing tasks complementary to neurons which are linked to the transmission of information, metabolic support, and mechanical activity

attitude a bodily state of readiness

axonopathy a neurotoxic process that affects the axon

cadherins a group of transmembrane glycoproteins that mediate cell-to-cell adhesion

cognition the capacity of some living beings to obtain information about their environment, which is processed by the brain, to interpret the information and give it a meaning

cognitive processes the mental processes through which the brain captures the different aspects of reality through the sensory organs in order to understand reality. Cognitive processes enable an individual to gather, integrate, relate, and modify the information from the world around them

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GLOSSARY continued collagenase

electrolyte

an enzyme, more specifically a matrix metalloproteinase, that breaks down the peptide bonds of collagens

a substance that conducts electric current as a result of a dissociation into positively and negatively charged particles called ions

concentration gradient

electronic microscope

the gradual difference in concentration of a dissolved substance in a solution between a region of high density and a region of lower density

connexins a family of transmembrane structural proteins that join together to form gap junctions

covalent bonding or molecular bonding a chemical link between two atoms or ions where the electron pairs are shared between them. It is the most stable kind of bonding

cross-linking bonding that links one chain to another

cytokines proteins that regulate the functions of cells that produce them in other cell types. They are agents responsible for intercellular communication, inducing the activation of specific membrane receptors, cell proliferation and differentiation functions, chemotaxis, growth, and modulation of immunoglobulin secretion. They promote inflammation (proinflammatory) or act as anti-inflammatory

cytoskeleton a network of filaments that is present in the cytoplasm of the cell

degranulation a process by which the cytoplasmic granules of some cells are fused with the cell membrane to release their contents

uses electrons instead of photons or visible light to form images of tiny objects. Electronic microscopes can achieve higher magnifications than the best optical microscopes, because the wavelength of electrons is much shorter than that of “visible” photons

electrophysiology the study of the electrical behavior of neurons

embryogenesis a process that begins after fertilization, in the early stages of the development of multicellular living beings, that gives rise to the embryo

embryonic induction the process by which a group of cells changes the behavior of another group of cells, causing a change in their shape, mitotic rate or destiny

empiricism the epistemological theory that the only source of human knowledge is sensory experience, with the assumption that the human spirit by nature is devoid of all knowledge and therefore has no kind of innate knowledge

epicritic sensitivity sensitivity that allows for correct discrimination both in terms of quality and the anatomical location of the stimulus

epistemology

replacement of extracellular matrix (collagen) by new components

the philosophical study of the principles, foundation, extent, and methods of human knowledge and the distinction between justified belief and opinion

developed plasticity

evidence-based medicine

deposition

occurs in the case of individuals with preserved or recovered plasticity who have exercised the fascial system to enhance the adaptive response to mechanochemical stimuli

an approach to medical practice aimed at optimizing decision making, emphasizing the use of scientific evidence from properly designed and correctly carried out research

differentiation

evidence-based practice

the process by which a less specialized cell becomes a more specialized cell type

the application of evidence-based medicine by the health professions

ex vivo

durotaxis

refers to experiments or measurements performed in or on biological tissues of an organism in an artificial environment outside the organism with minimal alteration of natural conditions

a form of cell migration in which cells are guided by rigidity gradients. Most normal cells migrate up rigidity gradients (in the direction of greater stiffness)

ECA epidemiologic catchment area

echogenicity the ability of tissues to reflect (echo) ultrasound waves

ectomeninx the layer of mesoderm from which the dura mater and much of the membrane bone of the skull develop in the higher vertebrate embryo

excision (fragmentation or splitting) is a method of asexual animal division by which an individual is divided into two or more pieces, each of which is capable of reconstructing an organism completely

excitation threshold the level of neural depolarization that is necessary to generate an action potential. In simpler terms, this means the level of excitation (through neurochemical stimulation) that is needed for a muscle to react appropriately to a stimulus

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excitatory synaptic transmission

glycoproteins

a type of nerve impulse that increases the possibility of producing a potential action (electric impulse)

molecules composed of a protein bound to one or more simple or complex carbohydrates

fibrillin

glycosaminoglycans

an essential glycoprotein for the formation of elastic fibers in connective tissue

fibronectin an adhesion glycoprotein that participates in blood clotting

filopodia thin cytoplasmic cell projections that extend from the directive end of migrating cells

focal adhesions anchorage points (fi xations) of the cell to an acellular substrate

free radicals very unstable and highly reactive molecules that are produced during normal cell metabolism They are indispensable to the body’s physiology, but at high concentrations they are harmful and can increase the risk of cancer and other diseases

functional remodeling refers to the “replacement” of ECM components in order to adapt to a mechanochemical demand. Connective tissue can be remodeled to adapt its cellular and subcellular properties (fibroblast dynamics and collagen matrix synthesis) to the stimuli it receives

gap junctions intercellular channels that allow the passage of water, ions, and small molecules and which are observed in animal tissues. They are found between all cells that are directly touching other cells. A gap junction may also be called a macula communicans or nexus

gastrulation

biomolecules that make up the extracellular matrix and have a great capacity to attract water molecules and positively charged ions

growth cone a conical expansion of the distal end of axons and dendrites in the development stage, described for the first time by Ramón y Cajal. It is a sensory motor structure that recognizes indicative signals and responds to them by directing axonal growth

growth factors a group of substances, most of them of a protein nature, which together with hormones and neurotransmitters play an important role in intercellular communication

hermeneutics a branch of philosophy concerned with interpretation. Hermeneutics supports the nonexistence of an objective, transparent or disinterested knowledge of the world and considers that the human being is not an impartial spectator of phenomena. Rather, any knowledge of things is mediated by a series of prejudices, expectations, and assumptions received from traditions that determine, guide, and limit our understanding. Hermeneutics accepts the finitude of human will and cognition

heterocellular contacts contacts between cells of different populations

homeostasis the capacity of an organism to maintain a stable internal condition to compensate for changes in its environment

homocellular contacts contacts between cells of the same population

the process during embryonic development that changes the embryo from a blastula with a single layer of cells to a gastrula containing multiple layers of cells

hyaluronan (hyaluronic acid)

gene expression

hyperglycemia

the process by which eukaryotic cells transform information encoded by deoxyribonucleic acid (DNA) into the proteins necessary for their development, functioning, and reproduction

hypo-osmolality

genotype the genetic information, in the form of DNA, that belongs to a particular organism

glia or glial cells

a polysaccharide present in connective tissue that participates in its mechanical and hydrophilic behavior an increase of the existing quantity of glucose in the blood a decrease in the concentration of solutes (dissolved substances) in the blood or other body fluids

hypoxia a state of oxygen deficiency in the blood and consequently a deficiency in the amount of oxygen reaching the tissues

a set of cells whose main function is to support neurons and control the neuronal microenvironment, especially ionic composition, levels of neurotransmitters, and the biochemical factors of cell growth

IL1β (interleukin 1 beta)

glutamate

imbricate structure

an excitatory neurotransmitter involved in many neurobiological processes including pain

a structure of partially overlapping layers, that is, arranged in the manner of tiles on a roof or the scales of fish

a cytokine produced by multiple cell lines, mainly by activated macrophages. It is a key mediator of the inflammatory response

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GLOSSARY continued immunodermatosis

mechanistic vision

the general term used to describe any abnormality or injury to the skin of immune origin

the belief that reality is composed of basic or elementary pieces that interact mechanically to carry out a process, as in the mechanism of a clock

immunogenicity

mechanosensitivity

the ability of the immune system to react to an antigen

sensitivity to mechanical stimuli

immunoglobulins

mechanotransduction

proteins that circulate in the bloodstream to perform immunological tasks. They act in defense of the body against bacteria, viruses, and other pathogens

the process of transduction of cellular signals in response to mechanical stimuli

immunohistochemistry

multipotent cells that can give rise to the various specialized cells found in skeletal tissue

a histopathological process based on the use of antibodies that selectively bind to a substance you want to identify (primary antigen). This immunostaining technique allows identification of the location of the tissue or cytological substance

immunosenescence the gradual deterioration of the immune system caused by aging

mesenchymal cells

meta-analysis a systematic review in which statistical procedures are applied to quantitatively analyze the results of a compilation of different studies

metacognition

experimentation carried out in or on the living tissue of a living organism

the ability to self-regulate learning processes. As such, it involves a set of intellectual operations associated with knowledge, control, and regulation of the cognitive mechanisms that intervene in an individual’s collection, evaluation, and processing of information

integrins

metalloproteinases

a superfamily of glycoproteins that participate mainly in the union of cells with the extracellular matrix, forming part of the process of cellular mechanotransduction

enzymes that can break down collagen. They are found in the spaces between tissue cells and are involved in processes such as wound healing, angiogenesis, and tumor cell metastasis

interleukin

microgliosis

a cytokine produced by multiple cell lines, mainly by activated macrophages. It occurs in large quantities in response to infection or any type of injury or stress

an increase in the proliferation and reactive activity of microglial cells as a response to an injury to the nervous system

intermediate filaments

cellular structures formed by protein polymers that together with actin microfilaments form the cytoskeleton

in vivo

components of the cytoskeleton formed by clusters of fibrous proteins of intermediate size between actin microfilaments and microtubules

ion channels a type of transmembrane protein that allows specific ions or water to pass through the cell membrane

kinesiophobia fear of movement

kinetic energy

microtubules

morphogenesis the process by which a group of embryos determines the development of organs, tissues or individual cells of the organism of living beings, as well as the particular characteristics and functions of each of these components

morphogenetic control the biological process that causes an organism to develop its shape

an energy of movement, which implies the force (of gravity, friction, or muscular or internal resistance) that is needed to cause the acceleration of a body that is in a state of rest and to set it in motion

myoblasts

laminins

a manual therapy approach characterized by the application of gentle force sustained over time

a group of glycoproteins that are part of the basal layer of cells that anchors collagen proteins

lipid bilayers a component of all cell membranes that provides the barrier that marks the boundaries of a cell. It is composed of two layers of fat cells organized in two sheets

cells that are the precursors of muscle fibers

myofascial therapy

myofibroblasts specialized fibroblasts possessing characteristics between those of fibroblasts and smooth muscle cells. They play a very important role during inflammation, repair, healing, and regeneration of the tissues of different organs

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negative adaptability

orthodromic

occurs when the fascial system responds in an excessive or disproportionate way to a stimulus, establishing a proinflammatory state and increasing its pre-tension and/or state of quiescence (kinesiophobia)

describes the normal conduction direction of nerve impulses which runs from the center to the periphery

nervi nervorum a set of unmyelinated or poorly myelinated nerve fibers that innervate the nerve sheaths of peripheral nervous system structures

neurite is a neuronal process that projects from the cell body of a neuron during growth of an axon

neuroeffector junction a synapse between a neuron (presynaptic) and an effector cell that is not a neuron (postsynaptic). Neuroeffector junctions include synapses in the muscles and in the secretory cells

neuro–endocrine–immune the major regulatory systems responsible for coordinating and integrating the functions of different tissues and organs. The endocrine system synthesizes and releases hormones into the circulation, the nervous system coordinates responses to stimuli, and the immune system can modify endocrine function and in turn is subject to nervous and hormonal modulation through cytokines produced by lymphocytes

neuroethics a research area that focuses on ethical analysis in the interpretation of research results in the area of neuroscience

neurogenic differentiation when mesenchymal (immature) stem cells differentiate into neurons

neuropathic pain pain generated in the central nervous system (brain and spinal cord) or in the peripheral nervous system (nerves, plexus, microscopic nerve endings) that appears in the absence of real threat

neuropeptides small proteins or polypeptides that function as neurotransmitters in the nervous system and modulate neural activity

neuroplasticity the ability of the nervous system to create new synaptic connections. This dynamic leaves a time stamp that modifies the efficiency of the transfer of information

neurotrophins (also called neurotrophic factors) a family of proteins that promote the survival of neurons

nociceptive describes pain that results from the activation or sensitization of nociceptors with a protective function

notochord an embryonic structure that represents the axial skeleton of the embryo until such time as the other elements such as the vertebrae have formed

osteoarthritis a heterogeneous group of conditions that lead to symptoms and signs associated with a loss of articular cartilage integrity in a joint combined with changes to the bone margins and underlying joints

osteogenic cells nonspecialized cells that originate osteoblasts

osteogenic differentiation when mesenchymal (immature) stem cells differentiate into bone cells

paracrine signaling a form of cell-to-cell communication in which a cell produces a signal to induce change in nearby cells

pathogenesis the sequence of cellular and tissue events that occurs from the initial contact with an etiologic agent to the final expression of disease

pattern or profile of expression the measurement of the activity (of gene expression) of thousands of genes simultaneously in order to create a global image of cellular function

peptidergic refers to neurons capable of synthesizing neuropeptides, such as substance P, which act as neurotransmitters or neuromodulators

peptides short chains of several different amino acids held together by peptide bonds. For example, neuropeptides act by modulating neurobiological processes related to pain, sleep, stress, inflammation, etc.

phenomenology an approach that appears to rethink the principles of empiricism giving them new life and meaning. The concept is that knowledge is not the product of simple experimentation nor is it the result of sensory impressions. The observer is not a passive entity, dedicated to the simple measurement and collection of data; he is part of the object of study and the experience of this is part of the process of understanding the phenomenon

phenotype an organism’s final appearance which is the result of the interaction of the information held in its genotype (set of genes) and the effects of the environment

phenotypic of the phenotype or related to it

plasticity the ability of an organism to adapt to a changing environment. This property emerges from the nature and functioning of neurons when they establish communication and modulates the perception of stimuli entering and leaving the environment. This dynamic leaves an imprint while modifying the efficiency of the information transfer

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GLOSSARY continued polypeptide a molecule formed by the union of a long chain of multiple peptides. Polypeptides are usually part of proteins when they do not form them in their entirety

treatment is assigned. Simple randomization does not always produce the desired effects, particularly when the sample sizes are small

rationalism

is present when the fascial system adapts while improving its response (supercompensation)

the epistemological theory that maintains knowledge has its origin in reason and asserts that knowledge is only really knowledge when it has logical necessity and universal validity. It asserts that human beings are born with innate ideas that are part of their rational nature

positron emission tomography (PET)

RCT

positive adaptability

a neuroimaging technique that allows cerebral function to be identified

preserved plasticity refers to when the fascial system has preserved its wide range of adaptive responses (its original biological attributes) and occurs in individuals who possess or acquire sustained body behavior based on consciousness, balanced kinetic energy, and maintenance of a healthy diet and lifestyle

procollagen a precursor of collagen

proliferative rapidly increasing the number or quantity of cells

proteases enzymes that break down peptide bonds in proteins

proteoglycans the fundamental component of the animal extracellular matrix, constituting the main substance that “fills” the spaces that exist between the cells of the organism (extracellular matrix). Their major biological function derives from the physicochemical characteristics of the glycosaminoglycan component of the molecule, which provides hydration and swelling pressure to the tissue enabling it to withstand compressional forces

proteolysis or proteolytic activity a process performed by enzymes that facilitate the digestion of proteins

protopathic sensitivity sensation with low discriminative capacity, especially in relation to the stimulated area

protoplasmic expansions

randomized controlled trial

reactive gliosis increased astrocyte proliferation in injured regions of the central nervous system

remodeling a process of destruction and subsequent aggregation of the cellular matrix, orientation and arrangement of the collagen fibers (this process can occur without tissue damage, e.g, as in the embryo)

repair process of sealing the tissue lesion and removing necrotic remains

resilience ability of the tissue to cope with and overcome overload (repetitive stress)

rubber hand illusion a process that gives a healthy subject the sensation that a fake hand is his own

selectins glycoproteins that act as receptors for cell adhesion

self: the self from a cognitive-constructionist point of view the self is the bodilyemotional sense of oneself, felt from moment to moment

senescent beginning to get old (biologically aging)

soluble morphogens soluble molecules that diffuse during embryogenesis to control the decisions in cell differentiation and migration

substance P

very long and very thin prolongations of the telocyte

a neuropeptide that acts as a neuromodulator and neurotransmitter in processes related to pain and inflammation

radial glia

sucking feet

glial cells that serve as “scaffolding” to immature neurons in the process of migration to their final destination

randomization consists of randomly assigning participants in a trial to two or more treatment or control groups. It is one way of avoiding selection biases; its purpose is to enable comparisons in the treatment allocation groups. Its main advantage is that it allows patients to be masked in the assignment of treatment before the start of a clinical trial, so that it is not known who the patients are, in which order they appear, or what

a term coined by Nicolás Achúcarro (1880–1918), a disciple of Ramón y Cajal, referring to the cytoplasmic extensions of astrocytes

supercompensation improvement of the biological response after a stress stimulus due to overloading (without having reached the threshold of tissue injury)

Sylvian fissure (also known as the lateral sulcus) separates the frontal and parietal lobes superiorly from the temporal lobe inferiorly

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talin

transduction

a protein found in high concentrations in focal adhesions

the conversion of a stimulus into a nerve signal

telopods

transition zone

cytoplasmic prolongations of telocytes

tenascin an adhesion glycoprotein with functions similar to fibronectin

tensotaxis a form of cell migration in which cells are guided by strain gradients. Most normal cells migrate up strain gradients (in the direction of greater strain)

TGFβ (transforming growth factor beta)

refers to the area where the spinal nerve root “penetrates” the spinal cord

triple-helical glycoprotein the structure of various types of fibrous collagen, including type I collagen. It consists of a triple helix made of the repetitious amino acid sequence

viability the capacity of the fascial system to occupy clearly different states (high or low pre-tension states) and to move flexibly between them

a protein involved in cellular processes such as cell proliferation, angiogenesis, differentiation, migration, and cell apoptosis, which is essential to embryogenesis and development

vinculin

TNF (tumor necrosis factor)

Young’s modulus or modulus of elasticity

a protein in the group of cytokines released by the immune system cells involved in inflammation

topognosia identification of the location of a stimulus applied to the skin

transcription the first process of gene expression through which the information contained in the DNA sequence is transferred to the protein sequence using various RNAs as intermediaries

a protein located in the plates of focal adhesions and involved in the anchoring of integrin molecules to the actin cytoskeleton a type of elastic constant that involves a measurement related to stress and a measurement related to deformation. It is the ratio between the increase in stress applied to a material and the change corresponding to the unit deformation it undergoes in the direction of stress application. Elastic isotropic materials (such as collagen and elastin) are characterized by an elastic modulus and an elastic coefficient (or ratio between two deformations)

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PART 1

The science and principles of Myofascial Induction CHAPTER 1 Introduction: Why this book?

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1

CHAPTER 2 Definition and characteristics of fascia and the fascial system

15

CHAPTER 3 Anatomy and functional aspects of fascia

27

CHAPTER 4 Embryological aspects of the fascial system

101

CHAPTER 5 Histological aspects of the fascial system

115

CHAPTER 6 The concept of tensegrity: Fascia as a tensegrity structure

139

CHAPTER 7 Movement and force transmission in the fascial system

153

CHAPTER 8 The neurodynamics of fascia

171

CHAPTER 9 Fascial trauma and dysfunction

189

CHAPTER 10 The assessment process

207

CHAPTER 11 The objectives of Myofascial Induction Therapy

24 1

CHAPTER 12 Scientific evidence relevant to the MIT approach

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Introduction: Why this book?

1

KEY POINTS •

Outline of the concept of this book

•

The conceptual framework for health care

•

Definition of the movement system

•

Definition of fascia as the body’s communication network

•

Importance of fascia's role in body movement

•

The principles of therapeutic touch

•

Definition of Myofascial Induction Therapy and its relation to other myofascial approaches

Introduction ° e fascial structure constitutes a complex network which links all the systems of the body (Fig. 1.1). In the past 10 years we have witnessed a dizzying increase in research related to fascial tissue. ° is research is bringing together more and more scientiÿ c disciplines, such as biology, physics, biochemistry, and neuroscience. Simultaneously, systemic reasoning is becoming more evident in health care. Clinical trials increasingly support the need to include fascial approaches in treatment protocols. Before carrying out research on biological structures like the human body we have to study anatomy. Nothing that happens in the body can be “antianatomical.” We always look at the anatomy for conÿ rmation of the clinical diagnosis. Gross anatomy, which is usually performed on embalmed cadavers, allows anatomical structures to be topographically located; however, the interrelation between structures is o˙ en distorted or broken. ° e opportunity to carry out anatomical dissections of unembalmed cadavers, which have been preserved only at low temperatures, has allowed us to approach the construction of the body from a di˛ erent perspective – the perspective of continuity and

Pilat_Myofascial Induction.indb 1

integration (see Chapter 3). ° is knowledge is re˝ ected in the analysis of body movement at all levels of construction, from microstructures to macrostructures, which brings clinical reasoning closer to the totality of the body’s response to each movement requirement (see Chapters 5 and 6). ° e presence of unspecialized connective tissue – the connective tissue located between anatomical structures (e.g., between muscle ÿ bers, between fascicles, between muscle epimysia, and between muscles and neurovascular tracts) – that links anatomical components to create an uninterrupted communication network has necessitated a change in movement paradigms (see Chapter 7). We now know that this tissue is richly innervated, has contractile capacity, and actively participates in movement (see Chapter 8). For example, to drink a cup of co˛ ee we activate 32 muscles controlled by the stimuli of numerous mechanoreceptors, which act with great precision and, in sequences, adjust to interoceptive and exteroceptive information. By grasping the cup, Merkel’s receptors act, recognizing the texture and shape of the cup. ° e deformation (stretching) of the skin of the hand is detected by Ruˆ ni receptors; Meissner’s corpuscles respond when the ÿ ngers slide slightly to improve the grip; and Pacinian corpuscles control the degree of pressure created by holding the cup. ° e process is carried out with

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1 B

A

C

Figure 1.1 Continuity of the superficial and deep fascia of the thigh. A Cross-section of the thigh. Note the compartmental structures that create space for the movement of the muscles, bones, and neurovascular tracts. B Anterolateral aspect of the knee and thigh. C Cross-section of a loofah. The fibrous distribution resembles fascial architecture

extreme precision which allows the brain to choose the motor units of the muscles involved to perform the task eˆ ciently without excessive expenditure of energy. Van der Wal (2009) states that mechanoreceptors do not understand muscles or ligaments or capsules, but rather the strain of their deformable environment (meaning the fascial tissue). ° erefore, the activity and role of a mechanoreceptor is deÿ ned not only by its functional properties but also by the architecture of its environment. ° is means that it is the architecture of the fascial system that encodes the mechanoreceptive information. ° erefore, whether an A˘ ÿ ber or a type C ÿ ber encodes nociceptive information or other interoceptive information will depend on the architecture

of the tissue environment (see Chapter 8). It should be noted that mechanoreceptors are not exclusively subject to their mechanical environment but also to the experiential environment, expectations, and the experience of other sensory systems such as vision. ° e scientiÿ c discoveries and clinical experiences outlined above have led to the need to review and update our knowledge of the fascial system. ° is book brings the reader closer to fascial architecture, which is demonstrated and discussed based on numerous photographs and videos of dissections of unembalmed cadavers. ° e objective of this book is not only to focus on the topographic anatomy of the fascia, although this is widely illustrated and discussed, but

2

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Introduction: Why this book?

•

Development (D): application of the results of research or any other type of scientiÿ c knowledge.

° ese observations invite us to change the existing paradigms related to body movement and to relate them to clinical procedures. In Part 2 of the book a wide range of clinical procedures is extensively discussed and is supported by graphic materials.

•

Innovation (I): activity that results in advances leading to completely new horizons or substantial improvements in existing horizons, di˛ ering substantially from what already exists and leading to something novel.

Research, development, and innovation (R&D and I)

Searching for a health care model: The conceptual framework (Fig. 1.2)

rather to demonstrate the continuity of the fascial system and its dynamic links with the other systems of the body.

The best way to predict the future is to create it. Abraham Lincoln ° e last decade has been characterized by extensive and rapid changes in all areas of our lives. ° e amazing and vertiginous advances in the ÿ eld of communications are obvious examples of this process. ° ese innovations deÿ ne our lifestyle – our employment, leisure, and personal relationships. ° is progress can be deÿ ned by three words (and letters):

•

Research (R): creation of new knowledge and/or the use of existing knowledge in a new and creative way so as to generate new concepts, methodologies, and understanding.

Environmental factors

Psychological factors

1

Health conditions in all ÿ elds of health sciences, particularly in medicine, do not escape the R&D and I process. ° e spectacular development of high technology and the discovery of new drugs allow medicine to prolong our lives and optimize our quality of life. ° e World Health Organization deÿ nes health as: “A complete state of physical, social and mental wellbeing, and not merely the absence of disease or inÿ rmity” (WHO [1946] 2012). It is worth asking if the current health model addresses this deÿ nition. ° is is diˆ cult to answer due to the fact that there is no universal model of health care that is speciÿ cally associated with the chronic processes of pain and dysfunction.

Biology

Psychology Health

Biological susceptibility

A

Previous disease

Clinical outcome

Social context

B

C

Figure 1.2 Conceptual models of health (care). A The biomedical model (Abdelnour & El-Nagi 2017). B The biopsychosocial model. Each domain has some shared features related to health: • Biology: gender, illness, disability, genetics, immunology, medication, and neurochemistry • Psychology: learning and memory, attitudes, personality, behavior, emotions, post-traumatic stress • Social context: social support, family background, cultural traditions, socioeconomic status, and education C The enactive model. This concept is based on the experience of the person in their environment (outer circle). The inner circle represents the organism. The orange band represents the organism’s nervous system which is inseparable from a changing environment (purple band)

3

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1 A biomedical model is a surrogate for a human being, or a human biologic system, that can be used to understand normal and abnormal function from gene to phenotype and to provide a basis for preventive or therapeutic intervention in human diseases. (National Academies Press 1998)

The biomedical model ° e biomedical model (with its reductionist or dualist reasoning which endorses a linear relationship between stimuli and disease) was (is?) very successful in medicine and, in only a 100 years, has allowed us to double life expectancy for our species in a time when most human deaths have been caused by infectious diseases (caused by agents such as fungi, viruses, germs, bacteria, parasites, or toxins), trauma, or genetic defects. According to this model, a biological predisposition in the presence of environmental factors or tissue insults produces diseases, i.e., “a veriÿ able evidence of a pathological state, evidenced by medical investigations” (Abdelnour & El-Nagi 2017). Medicine studies these agents with precision and categorizes them. ° rough research it discovers their nature and identiÿ es signs and symptoms. Once the main cause of a disease was determined, medicine knew how to attack the agent with drugs or the routes of infection with preventive measures such as hygiene or vaccination. With the help of high technology, medicine studies the a˛ ected organs and the nature of the disorder and establishes therapeutic protocols. And then, medicine succeeds! Medicine has this amazing knowledge and the means to repair or even replace a˛ ected organs and maintain their function with the help of drugs. Medicine applies the same reasoning to pain. According to Cartesian reasoning (the dualistic perspective), “pain occurs in an immaterial mind,” and according to reductionist reasoning, “the pain is o˙ en considered to be in the brain” (Stilwell & Hartman 2019). ° e biomedical model of health focuses on biological factors and usually excludes psychological, environmental, and social in˝ uences. “° is model does not recognize illness, which is the patient’s own perception of health” (Abdelnour & El-Nagi 2017), nor are the reasons for the

illness at the center of the biomedical model (Stilwell & Hartman 2019). Reductionism was (is?) necessary for the development of science; however, it has its limitations.

At the present time, however, the highest mortality occurs due to chronic or degenerative diseases, such as cardiovascular, hepatic, and immune deÿ ciencies, cancer, metabolic disturbances, connective tissue diseases, or ulcers. Reductionist reasoning (the biomedical model) has limited possibilities to deal with these complex diseases since they have multiple causes and it is necessary to consider how one cause is related to another and to the individual patient (requiring systemic reasoning from the perspective of the behavior of complex systems). A complex biological system – such as the human body which is the opposite of a simple system – manifests itself as an entity of global behavior (each component relates to the other), and the total is more than the sum of its parts. Of greater relevance is the interrelation between the components, rather than the individual properties of a single component. ° e systemic properties are destroyed when the system is sectioned into isolated elements. ° erefore, complex systems are not fragmentable and are characterized by irreducibility (see Chapter 2). At present it is well known that psychosocial factors may in˝ uence most biological treatments. In recent years the biopsychosocial model has gained in popularity and has become the mainstream ideology of contemporary health care.

The biopsychosocial model As the biomedical model could not explain the complex nature of health conditions, Engel proposed the biopsychosocial model (Engel 1960, 1977, 1980). ° is model considers three domains in its understanding of health, diseases, and health care: biological (age, gender, genetics), psychological (mental and emotional factors), and sociocultural (interpersonal relationships). Following the principles of von Bertalan˛ y’s General System ° eory (see Chapter 2), Engel focused on the close interrelation or interaction of the individual with

4

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Introduction: Why this book?

behavioral, psychological, and social dimensions. ° ese three domains faced the same demand for scientiÿ c veriÿ cation of their role in health care. Engel’s proposal was initially related to psychiatry. However, because it did not separate the individual and their personal circumstances from the medical condition, it was well received and extended to other medical specialties. ° e utility of the model was validated in clinical trials (Chen et al. 2015, Drossman 1998, Greenberg 2005). Over the last 40 years it has become an increasingly accepted model and is currently considered the clinical standard for medicine, physiotherapy, and other health science care (Gatchel et al. 2007, Daluiso-King & Hebron 2020). ° e introduction of the biopsychosocial model to the ÿ eld of musculoskeletal disorders was initiated by Waddell (1987, 2004), and this introduced a new concept into the treatment of low back pain (Jull 2017). ° e model allowed for the conceptualization of holistic evaluation and linked science and humanism (Beilock 2017). However, authors claimed that greater precision was needed to achieve an accurate biopsychosocial understanding of the patient. Jull (2017) states that the “biopsychosocial model does not provide any speciÿ c guidance to what interventions should be implemented.” “° is is a weakness as domains can feasibly be interpreted as interventional models” (Ghaemi et al. 2009 cited in Jull 2017). An example of a biopsychosocial model distortion can be seen in the interpretation of pain, particularly of chronic pain. Frequently, attention is focused “on pathoanatomical (biological) causes of pain, while psychosocial factors are neglected, ignored” (Stilwell & Hartman 2019). At the same time, the requirement to determine a speciÿ c diagnosis notably increases the tendency to relate the painful processes to psychosocial factors to the point of triggering a kind of stigmatization of patients who su˛ er from them (Jepsen 2018, Synnott et al. 2015) (see Chapter 17). “Fragmenting a patient’s pain into components inappropriately considers humans as linear and dissociable (i.e., able to mechanistically separate into distinct parts) and is contrary to the intent of Engel’s proposition” (Stilwell

1

& Hartman 2019). ° e biopsychosocial model continues to be dominated by the biological component. An important contribution in the development of the biopsychosocial model is linked to the interpretation of pain and focuses on the central nervous system and its bioplasticity. ° e motto “all pain is in the brain” was coined by Butler and Moseley (2003). ° is concept deeply in˝ uenced health care providers, particularly in physical therapy. ° e concept focuses on the leading role of the brain in the perception and experience of pain (Moseley & Butler 2017). However, over the last few years, authors have been questioning if attributing the perception of pain exclusively to the brain (neurocentrism) will lead to a return to dualistic reasoning. ° acker (2015) points out “that pain is not an a˛ erent input” and “the only entity suˆ cient for the experience and perception of pain is the person.” Clinical experiences invite the enlargement of the biopsychosocial model toward the patient-centered model.

Beyond the biopsychosocial model Any aspect of cognition, ranging from attention onwards, cannot be understood exclusively by studying the brain.

The enactive approach In previous models clinical reasoning and outcomes have focused mainly on the biomechanical body, disregarding the mind/consciousness as a by-product of the brain without causal importance (Gallagher 2012 cited in Øberg et al. 2015). Following the principles of General System ° eory, Stilwell & Hartman (2019) suggest updating the biopsychosocial model by focusing on the fact that the person is a “dynamic whole – embedded in an environment.” ° e authors state that “the mind is not only connected to the body, but the body in˝ uences the mind.” In their analyis of pain behavior, they suggest evolving the biopsychosocial model toward the enactive approach. ° e enactive approach to cognition was ÿ rst proposed by Varela, ° ompson, and Rosch in 1991 (Weber & Varela 2002, Di Paolo & ° ompson 2017).

5

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1 ° e authors consider that cognition comes from bodily action and serves bodily action; that is, cognition is an embodied action. It should be understood as a means of obtaining an internal representation of a corresponding external reality. Cognition is thus best understood as “enactive”; that is, as a form of practice itself (Ye et al. 2019). Although of great interest, a more extensive discussion of this topic is beyond the scope of this book.

Body perception and movement (body schema – body image) ° ere is a tradition of ambiguous terminological usage and conceptual misusage of body schema and body image in clinical studies (Gallagher 1986). Body schema is deÿ ned as system of preconscious, subpersonal processes that play a dynamic role in governing posture and movement (Head 1920). Body image is a “conscious idea or mental representation” (an intentional state) that “one has of one’s own body” and includes perceptions, mental representations, beliefs, and attitudes (Gallagher & Cole 1995). In the therapeutic process we focus on changes in body image thus in˝ uencing the body schema. A wide range of intrinsic and extrinsic input can alter a individual’s body image state. Beyond the biomechanical construction of the body, touch can improve the patient’s perception of the body by promoting the reorganization of the body image (Longo & Haggard 2012). ° erapeutic processes that involve sustained touch (such as movement induction in the MIT approach) can cause signiÿ cant e˛ ects on functional connectivity patterns (brain plasticity) in cortical areas that process the interoceptive and attentional value of touch (such as the right insular cortex) and the posterior cingulate cortex. ° us, touch can be a fundamental element in “learning or relearning processes” (Cerritelli et al. 2017).

A systemic approach to therapeutic movement and health care Transforming society by optimizing movement to improve the human experience. (APTA 2015) In health care in recent years the inclusion of movement approaches has been observed to be an essential factor in well-being. It should be emphasized that in a

biological structure, such as the human body, movement should be carried out on the basis of interconnection and integration of neuromuscular and neurocognitive processes (Pilat 2018). APTA (2015) deÿ nes movement as “the activity that involves metabolic changes, structural increases, morpho-functional changes, maturation, physical dimensions, motor, cognitive, psychological, a˛ ective and social activity.” Sahrmann deÿ nes movement system as “a system of physiological organ systems that interact to produce movement of the body and its parts” (Sahrmann 2017, Sahrmann et al. 2017). To achieve this goal, it is essential – again – to apply systemic reasoning in order to facilitate the integration of and interaction between the aforementioned bodily components (Voight & Hoogenboom 2017, Pilat 2017). Farina et al. (2019) state that: “° e integration is an essential feature of complex biomechanical systems, with coordination and covariation occurring among and within structural components at time scales that vary from microseconds to deep evolutionary time.” Integration exists at multiple levels of organization of the living organism in such a way that levels can interact with adjacent levels to result in complex patterns of structural and functional phenotypes. ° ese ÿ ndings justify the need to focus on systemic reasoning in relation to body movement.

Metabolic aspects of the fascial system As discussed above, research shows that the fascial system has an obvious impact on body movement. ° is also involves the management of substances that inhabit the circulatory system and are elemental to the metabolic behavior of the body. It is suggested that the condition of mechanical tissue (including the behavior of fascia) can modulate endocrine and immunological responses. ° e biomechanical behavior of fatty tissue and its relation to fascia is an example of the systemic behavior of the fascial system (Abuhattum et al. 2015). ° e superÿ cial fascia develops ÿ brous septa, which deÿ ne the continuity, shape, length, diameter, quantity, disposition, and dynamics of the adipose lobes.

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Introduction: Why this book?

° e increased rigidity of the extracellular matrix generates a kind of physical barrier that prevents the expansion of adipocytes. Consequently, lipids ingested in the diet cannot be absorbed and deposited in fatty tissue and instead circulate in the blood (hyperlipidemia) and are deposited in other tissues (Hara et al. 2011). It should be noted that the constraints on the adipocyte’s ability to expand (therefore limiting its accumulation of lipids), as a result of the rigidity of its environment (fascial compartments), “increases collagen deposition and consequently the risk for many clinical conditions, including diabetes, hypertension, coronary atherosclerotic heart disease, and some forms of cancer” (Hausman et al. 2001).

Fascia and therapeutic movement Fascia as a system A system can be deÿ ned as a group of interrelated elements, consisting of both structural aspects (elements, ranges, communication networks, and information) and functional aspects (the ability of the system to perform the task for which it was intended). In order to function properly a system requires the interdependency of all of its components through the nonlinearity of its interrelations (von Bertalan˛ y 1968). Each system is made up of subsystems and at the same time it is embedded within a suprasystem. For the system to function properly coordinated reciprocal action between the three levels is essential (see Chapter 2). In anatomical research, in the topographical approach applied to embalmed cadavers, the concept of fascia relates mainly to some anatomical structures, for example, the tensor fasciae latae, palmar fascia, plantar fascia, thoracolumbar fascia, etc. ° is nomenclature (and its analysis) suggests a series of unrelated elements instead of a unique and continuous conÿ guration that links the body structure (Pilat et al. 2016). Moreover, such an approach makes it diˆ cult to analyze the morphology and function of the dissected elements when integrated into a higher level of organization (Huijing 2009). Anatomical studies of unembalmed cadavers (fresh cadavers) have allowed a di˛ erent vision and a more thorough analysis of anatomical connections. While

1

preserving the natural appearance of the latter (“inside the body”), these studies have also permitted the linking of clinical ÿ ndings (° iel 2000, van der Wal 2009), thus creating a new vision of the fascia di˛ erent to the traditional “ÿ brous sheet” that “hides” the muscle (Pilat et al. 2016). It has been proposed that fascia be deÿ ned as a functional and structural (anatomical) continuity system, characterized by the integration and interconnection of its components (see the extensive discussion of this topic in Chapter 3). ° us, fascia can be considered to be a continuous and uninterrupted communicational network through which information related to movement ˝ ows between and within the muscular, vascular, visceral, and neural structures. ° is system brings together di˛ erent types of cells with diverse activities (in a similar manner to, for example, the cardiovascular or nervous systems) and is associated with other body systems through an uninterrupted and innervated structure of functional stability formed by the tridimensional collagenous matrix.

Fascia as a continuous network: From micro- to macrostructure DNA: The beginning of the journey ° e discovery of the DNA double helix, the structural coherence of which conceals the morphogenetic and informational potential of life, opened the way to modern biology. It also marked the beginning of close collaboration between biology and physics. ° e relatively simple interactions between di˛ erent nucleotide pairs reveal the almost inÿ nite capacity to store information in the DNA heteropolymer. It is the intimate connection between interaction and information that constitutes the factory of living matter. Biological complexity is based on speciÿ c interactions between molecules. ° ose interactions create complex networks that are balanced by their interconnection. ° ese networks control and regulate the exchange of signals that govern intracellular functions and multicellular behavior during the development of the organism (see Chapter 5).

Functions of the extracellular matrix To comply with the role outlined above, an eˆ cient communication system is essential. Information must

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1 ˝ ow eˆ ciently between di˛ erent layers of construction, from micro- to macrostructures, which are integrated into the systemic dynamics. ° e essential structure in this process is the extracellular matrix (ECM) and its protein behavior. ° e mechanical and biochemical behavior of the ECM depends on the balance of its constituent components (water, proteins, and polysaccharides) which fulÿ lls the functional requirements of the tissues. Mechanosensitive cells immersed in the ECM (e.g., ÿ broblasts and their phenotypes) secrete collagen and elastin proteins. ° ese cells form a continuous communication network and through their membranous proteins (integrins) control the intrinsic tension of the matrix. By activating the actin ÿ laments within its cytoskeleton, some of the ÿ broblast phenotypes (e.g., myoÿ broblasts) can contract, especially in emergent and/or pathological conditions. Alterations in the mechanical properties of the matrix are interpreted and may a˛ ect the motility, proliferation, differentiation, and apoptosis of cells. Within the ECM, the structure and function complement each other in the search for its optimal behavior (McKee et al. 2019). ° e collagenous network of the ECM is linked to the dynamics of the ÿ broblasts (that are anchored in the network) and ensures the plasticity (adaptability) of the system. ° is intercellular communication system is essential to maintain optimal conditions in the body. Using an unconventional approach, some authors have studied the topic of the interconnection of biological networks. Mae-Wan Ho (1993) and Hamero˛ and Penrose (2014) have proposed a reading of the living organism as a closely related set, by virtue of a quantum coherence that governs the hierarchy, relationships, and intercommunication of all components. In this set each part communicates in a nonlocal (instantaneous) way with the whole, guaranteeing a ˝ uid harmony of development (due to the communicational interpenetration of many levels of structure), being much more than the Cartesian “vital principle.” It is tempting to use nonlinear principles to explain (justify) how systems work – and hence how the fascial network works. However, we must be cautious, since this way of understanding the universe is “novel” and there is still a lot of room for error in its interpretation.

Mechanical properties of the fascial network (see Chapter 7) ° e universal model of muscular contraction based on the gliding of ÿ laments of actin and myosin, described over 50 years ago by Huxley & Simmons (1971), has supported the Newtonian analysis of body movement characterized by the action of levers. In this model myoÿ brils, arranged in series, act as independent motors that approximate myotendinous or myoaponeurotic junctions therefore triggering movement. However, the discovery of the ultrastructure and mechanobiology of the sarcomeral unit has given shape to a new model of myoÿ brils embedded inside the extracellular matrix, which at the same time participates (via its own dynamics) in the contractile phenomenon (Yucesoy 2010, Maas & Sandercock 2010). ° e shortening of the myoÿ bril exerts a force from within the myofascial structure (endomysium, perimysium, and epimysium) and resembles more the principles of the tensegrity model (see Chapter 6) (Gillies & Lieber 2011) than a simple linear analysis (movements arranged in series). Most contractile forces are directed to myotendinous units, but approximately 30ˇpercent of them use “epimysial” (lateral) transmission paths which are parallel to the tendinous paths (Huijing 2007). ° e muscle does not act as an isolated and independent entity. Instead, collagenous linkages between epimysia of adjacent muscles, such as the neurovascular tracts, provide indirect intermuscular connections. Usually, these lateral connections and the consequences of their presence are not taken into consideration in most researchers’ designs related to body movement. However, in recent years, several studies have indicated mechanical interactions between adjacent muscles, including myofascial force transmission, in research models and clinical trials. ° ere are three main areas of research:

•

Alterations in movement patterns due to the existence of pathological conditions, i.e., spasticity or the presence of post-traumatic and postsurgical scars (Smeulders & Kreulen 2007, de Bruin et al. 2011, Abdollahi et al. 2014).

•

Analysis of muscular dynamics in healthy subjects, focused on muscular synergisms (Yu et al. 2007, Yaman et al. 2013, Carvalhais et al. 2013).

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Introduction: Why this book?

•

Analysis of the muscular microstructure (ÿ bers) related to the participation of the intrinsic connective tissue (fascial system) (Huijing & Jaspers 2005, Huijing 2007, Purslow 2010, Zhang 2012).

It should be pointed out that the concept of myofascial force transmission implies any kind of transmission from the full surface of a myoÿ bril, excluding direct participation in the myotendinous or myoaponeurotic unit where force is transmitted in the aponeurosis or tendon and myomyonal continuum – in other words, through the connections between myoÿ brils arranged in series (Huijing 2002).

interstitial mechanoreceptors (group III and group IV free nerve endings), each of which has two subgroups with low and high levels of mechanosensitivity related to cell architecture, as described below:

•

Group III muscle a˛ erents are found, for example, in perimuscular fascia and the adventitia of muscle blood vessels and respond to deforming stimuli such as pressure and stretch (Lin et al. 2009). Neural action potential ÿ ring through nerve terminals is linked to speciÿ c mechanical deformation and extracellular matrix interaction. Stimulation of group III and IV muscle a˛ erents has re˝ ex e˛ ects on both the somatic and autonomic nervous systems, including an inhibitory e˛ ect on alpha motoneurons, an excitatory e˛ ect on gamma motoneurons, and an excitatory e˛ ect on the sympathetic nervous system (Kaufman et al. 2002).

•

° rough the mechanoreceptors the fascial system is in a continuous process of internal communication (Vaticon 2009):

° e most signiÿ cant ÿ ndings obtained from dissections of unembalmed cadavers are described below (Pilat et al. 2016):

• •

° ere is continuity of the fascial structure both at extrinsic and intrinsic levels of the construction of the body. ° ere are parallel “epimysial” paths for the transmission of contractile force. An example of this phenomenon is the aponeurotic expansion (lacertus ÿ brosus) of the biceps brachii muscle of the forearm or the continuity between the pectoral and brachial fasciae.

•

° e epimysium and perimysium may act as pathways for the transmission of muscular force.

•

Numerous ÿ bers in long muscles terminate their path without reaching the extremities of the tendon or aponeurosis.

•

Muscles are laterally connected to adjacent structures such as blood vessels or peripheral nerves.

•

° e neurovascular tracts wrap around and reinforce the blood and lymph vessels and the peripheral nerves; they are strong candidates for being an important route in force transmission (Huijing 2009).

•

Intramuscular and perimuscular connective tissue acts as a protective net in the case of trauma related to the tendon or muscular belly (Bernabei et al. 2016).

Fascia as a mechanosensitive structure A strong connection between fascia and the autonomic nervous system has been identiÿ ed (Haouzi et al. 1999). ° is involves a network of mechanoreceptors known as

1

▶ somatosomatic ▶ somatovisceral ▶ viscerovisceral ▶ viscerosomatic ▶ psychovisceral ▶ visceropsychic.

Therapeutic touch “Several studies demonstrated that the stimulation of C-tactile a˛ erent ÿ bers, essential neuroanatomical elements of a˛ ective touch, activates speciÿ c brain areas and the activation pattern is in˝ uenced by [the] subject’s attention” (Cerritelli et al. 2017). ° erefore, touch cannot be understood solely in terms of proprioceptors, rather it is a very powerful form of communication that requires the participation of both the practitioner and the patient. It is the only reciprocal, bidirectional sense: When you touch you are touched. ° e therapeutic impulse received by the patient will be received as feedback by the practitioner consciously or unconsciously. “Touch has been always regarded as a powerful communication channel playing a key role in governing our emotional wellbeing and possibly perception of

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1 self” (Cerritelli et al. 2017). It is a genuine communication in which the practitioner’s intention (optimal state of mind) has a clear relevance. In order to achieve an evaluative and therapeutic touch it is not enough to be familiar with anatomy and physiology; the practitioner must master the “intention” of touching. “Intention” means focusing one’s attention on listening to the condition and needs of the tissue. ° e practitioner has to facilitate the changes resulting from the therapy to attain healing at a more holistic level. ° is is explained by the following question: What do we touch – the body or the individual person? Touch is understood, humanistically and interpersonally, as being able to calm and heal (Carter & Drew 2012).

action concentrates on the provision of resources for the adjustment of homeostasis. ° e ÿ nal objective is not the establishment of stable hierarchies but rather the facilitation of an optimal adaptation to the demands of the environment (Pilat 2018) in order to change the painful symptoms and recover the altered function. ° e main objective of treatment through the MIT approach is to allow the patient a prompt and, as far as possible, optimum restoration of the body’s homeostasis and its resilient capacity (see Chapter 13). ° e result (change in body image, improvements in functional abilities) should be evaluated and appreciated not only by the practitioner but also by the patient. MIT is intended to be a patient-centered focused treatment (Pilat 2015).

What is Myofascial Induction Therapy (MIT) and why this approach?

MIT and other myofascial approaches

MIT is a therapeutic concept in manual therapy that is aimed at the functional restoration of the altered fascial system. MIT is a process of evaluation and treatment in which the practitioner transfers a slight force (traction and/or compression) to the target tissue (Pilat 2012), facilitating the recovery of the dynamics of the fascial system. ° e application of the procedures can be deÿ ned as a combination of sustained pressure, speciÿ c positioning, and very smooth gliding. ° e term “induction” is related to the facilitation of movement rather than a passive stretching of the fascial system. ° e result is a reciprocal reaction from the body involving a biochemical, metabolic signaling reaction and, ultimately, physiological responses. ° is process aims to reshape the quality of the extracellular matrix of the connective tissue to facilitate and optimize the transfer of information to and within the fascial system (see Chapter 5) (Chiquet et al. 2003, Wheeler 2004, Pilat 2017). It is a process controlled by the patient’s central nervous system in which the practitioner acts as a facilitator. In general, MIT is recommended mainly for patients with orthopedic, neuro-orthopedic, post-traumatic, and degenerative dysfunctions related to the myofascial system. ° e remodeling of restrictions and recovery of tensional equilibrium allows the fascial dynamics (communication) to be re-established. ° e therapeutic

It is not an easy task to locate MIT in a historical context. Adstrum and Nicholson (2019), in their paper “A history of fascia,” provide a comprehensive analysis of the development of knowledge related to fascia through the centuries and its clinical context. Listed below are the therapeutic approaches that are most relevant to MIT and their proponents:

•

Andrew Taylor Still (1899) – holistic treatment of so˙ tissue, based on manipulation and stretching

• •

Ida Rolf (1990) – Rolÿ ng®

•

John F. Barnes (1970) – John F. Barnes’ Myofascial Release Approach®

• • •

Carol Manheim (2001) – Myofascial Release

• •

° omas Myers (2009) – Anatomy Trains®

Robert Ward (1997) – was the ÿ rst person to coin the term “Myofascial Release” in the 1960s

Pilat (2003) – Inducción Miofascial Cantu, Grodin and Stanborough (2012) – Myofascial Manipulation Luigi Stecco (Stecco & Stecco 2019) – Fascial Manipulation®.

From this brief summary we can conclude that there is a wide range of approaches to clinical work with fascial tissue. And what about MIT?Its roots can be found in the concepts of di˛ erent manual therapy approaches. Its practical applications share many elements of the

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Introduction: Why this book?

other models of fascial work mentioned above, such as Myofascial Release (e.g., Ward 1997, Manheim 2001, Barnes 1970, Cantu et al. 2012). ° en what is the di˛ erence between MIT and other myofascial approaches? ° e following text published by Leon Chaitow in an Editorial in the Journal of Bodywork and Movement ˜ erapies (2017) explains: Recent reviews of current research into the use of Myofascial Release (MFR) (Leahy and Mock 1992, Manheim 2008) – also described in many studies as Myofascial Induction Therapy (MIT) (Pilat, 2014, Pilat, 2017, Fernández-Pérez et al. 2008) – strongly suggest that this gentle soft tissue manipulation approach is clinically effective – whether self-applied, or provided as part of a therapeutic interventions [sic]. Since the two approaches (see below) are virtually identical, the question arises as to which name is more appropriate? As Pilat (2014) has explained, in relation to his preferred term, Myofascial Induction, this has implications beyond a local tissue response (i.e. “release”): The term “induction” relates to the correction of movement facilitation, and not a passive stretching of the fascial system. This is primarily an educational process, in the search for restored optimal homeostatic levels, recovering range of motion, appropriate tension, strength, and coordination. The final aim of the therapeutic process is not establishment of stable hierarchies, but facilitation of optimal and continuous adaptation to environmental demands, with maximum efficiency. Pilat (2018) explains the subtle difference between induction, and release, as follows: Clinicians familiar with myofascial release (MFR) note the many similarities between it and MIT. With different

1

nuances, they are based on the same concept of clinical reasoning and complement each other. MIT is characterized as manual tissue remodeling, always avoiding arbitrary stimulus application (altered force intensity and direction), focusing on the intrinsic natural tissue response … MFR (MIT) appears to have increasing degrees of evidence, as safe and effective manual therapy approaches, in management of musculoskeletal pain and dysfunction. CONCLUSION: Returning to the question in the title of this editorial as to whether the method should be called Myofascial Release or Myofascial Induction? – the latter would seem to be more appropriate.

Conclusion ° e abundant scientiÿ c information that has been made available in recent years, as well as the needs and demands of patients, reinforces the requirement for a contemporary model of health care. ° e MIT approach searches for a systemic perspective and allows treatment to be focused on the patient (person). ° is global perspective facilitates the improvement of the patient’s body image. In the pages of this book the reader will ÿ nd details on the topics outlined in this chapter accompanied by an extensive array of illustrations, among which are photographs of fascia obtained from dissections of unembalmed cadavers. ° is experience of anatomical and photographic work enriched the author’s knowledge of fascial tissue and allowed him to understand its relevance to body movement. ° e reader is invited to join this fascial adventure.

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1

REFERENCES

Abdelnour LH, El-Nagi F (2017) Functional neurological disorder presenting as stroke: A narrative review. J Psychol Abnorm 6(1):159. Abdollahi I, Taghizadeh A, Shakeri H, Eivazi M, Jaberzadeh S (2014) ° e relationship between isokinetic muscle strength and spasticity in the lower limbs of stroke patients. J Bodyw Mov ° er 19(2):284–290. Abuhattum S, Gefen A, Weihs D (2015) Ratio of total traction force to projected cell area is preserved in di˛ erentiating adipocytes. Integr Biol 7(10):1212–1217. Adstrum S, Nicholson H (2019) A history of fascia. Clin Anat 32(7):862–870. APTA – American Physical ° erapy Association (2015) Physical therapist practice and the human movement system [White paper]. Alexandria, VA. Barnes JF (1990) Myofascial Release: ° e Search for Excellence. 10th ed. Paoli, PA: Rehabilitation Services, Inc. Beilock S (2017) How the Body Knows Its Mind: ° e Surprising Power of the Physical Environment to In˝ uence How You ° ink and Feel. New York, NY: Atria Books, Simon & Schuster, Inc. Bernabei M, Maas, H, van Dieën JH (2016) A lumped sti˛ ness model of intermuscular and extramuscular myofascial pathways of force transmission. Biomech Model Mechanobiol 15(6):1747–1763. Butler DS, Moseley GL (2003) Explain Pain. Adelaide City West: NOI Group Publications. Cantu RI, Grodin AJ, Stanborough RW (2012) Myofascial Manipulation: ° eory and Clinical Practice. Austin, Texas: Pro Ed International Publishers. Carter S, Drew L (2012) Touch in the consultation. Br J Gen Pract 62(596):147–148. Carvalhais VOD, Ocarino JD, Araujo VL, Souza TR, Silva PLP, Fonseca ST (2013) Myofascial force transmission between the latissimus dorsi and gluteus maximus muscles: An in vivo experiment. J Biomech 46(6):1003–1007.

Cerritelli F, Chiacchiaretta P, Gambi F, Ferretti A (2017) E˛ ect of continuous touch on brain functional connectivity is modiÿ ed by the operator’s tactile attention. Front Hum Neurosci 11:368. Chaitow L (2017) What’s in a name: Myofascial Release or Myofascial Induction? J Bodyw Mov ° er 21(4):749–751. Chen L, Pei JH, Kuang J, Chen HM, Chen Z, Li ZW, Yang HZ (2015) E˛ ect of lifestyle intervention in patients with type 2 diabetes: A meta-analysis. Metabolism 64(2):338–347. Chiquet M, Renedo AS, Huber F, Flück M (2003) How do ÿ broblasts translate mechanical signals into changes in extracellular matrix production? Matrix Biol 22(1):73–80 Daluiso-King G, Hebron C (2020) Is the biopsychosocial model in musculoskeletal physiotherapy adequate? An evolutionary concept analysis. Physiother ° eory Pract 1–17; doi: 10.1080/09593985.2020.1765440. de Bruin M, Smeulders MJC, Kreulen M (2011) Flexor carpi ulnaris tenotomy alone does not eliminate its contribution to wrist torque. Clin Biomech (Bristol, Avon) 26(7):725–728. Di Paolo E, ° ompson E (2017) ° e Enactive Approach. MindRxiv Papers. Available: https:// mindrxiv.org/3vraf/ [accessed February 2, 2021]. Drossman DA (1998) Presidential address: Gastrointestinal illness and the biopsychosocial model. Psychosom Med 60(3):258–267. Engel GL (1960) A uniÿ ed concept of health and disease. Perspect Biol Med 3(4):459–485.

Fernández-Pérez AM, Peralta-Ramírez MI, Pilat A, Villaverde C (2008) E˛ ects of myofascial induction techniques on physiologic and psychologic parameters: A randomized controlled trial. J Altern Complement Med 14(7):807–811. Gallagher S (1986) Body image and body schema: A conceptual clariÿ cation. JMB 7(4): 541–554. Gallagher S (2012) Phenomenology. London: Palgrave Macmillan. Gallagher S, Cole J (1995) Body image and body schema in a dea˛ erented subject. JMB 16(4):369–390. Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC (2007) ° e biopsychosocial approach to chronic pain: Scientiÿ c advances and future directions. Psychol Bull 133(4):581–624. Ghaemi S (2009) ° e rise and fall of the biopsychosocial model. Br J Psychiatry 195(1):3–4. Gillies A, Lieber R (2011) Structure and function of the skeletal muscle extracellular matrix. Muscle Nerve 44(3):318–331. Greenberg W (2005) ° e Biopsychosocial Approach: Past, Present, Future. Am J Psychiatry 162(7):1398–1398. Hamero˛ SR, Penrose R (2014) Consciousness in the universe: A review of the ‘Orch OR’ theory. Phys Life Rev 11(1):39–78. Haouzi P, Hill JM, Lewis BK, Kaufman MP (1999) Responses of group III and IV muscle a˛ erents to distension of the peripheral vascular bed. J Appl Physiol 87(2):545–553.

Engel GL (1980) ° e clinical application of the biopsychosocial model. Am J Psychiatry 137(5):535–544.

Hara Y, Wakino S, Tanabe Y Saito M, Tokuyama H, Washida N, Tatematsu S, Yoshioka K, Homma K, Hasegawa K, Minakuchi H, Fujimura K, Hosoya K, Hayashi K, Nakayama K, Itoh H (2011) Rho and Rho-kinase activity in adipocytes contributes to a vicious cycle in obesity that may involve mechanical stretch. Sci Signal 4(157):ra3; doi: 10.1126/scisignal.2001227.

Farina S, Kane E, Hernandez L (2019) Multifunctional structures and multistructural functions: Integration in the evolution of biomechanical systems. Integr Comp Biol. 59(2):237–242.

Hausman DB, DiGirolamo M, Bartness TJ, Hausman GJ, Martin RJ (2001) ° e biology of white adipocyte proliferation. Obes Rev 2(4):239–254.

Engel GL (1977) ° e need for a new medical model: A challenge for biomedicine. Science 196(4286):129–136.

12

Pilat_Myofascial Induction.indb 12

03/12/21 3:33 PM

REFERENCES

Head H (1920) Studies in Neurology, Volume 2. Oxford: H. Frowde, Oxford University Press; London: Hodder & Stoughton Ltd. Ho MW (1993) ° e Rainbow and the Worm. Singapore: World Scientiÿ c Publishing Co. Pte. Ltd. Huijing PA (2002) Intra-, extra- and intermuscular myofascial force transmission of synergists and antagonists: E˛ ects of muscle length as well as relative position. J Mech Med Biol 2(03n04):405–419. Huijing PA (2007) Epimuscular myofascial force transmission between antagonistic and synergistic muscles can explain movement limitation in spastic paresis. J Electromyog and Kinesiol 17(6):708–724. Huijing PA (2009) Epimuscular myofascial force transmission: A historical review and implications for new research. International Society of Biomechanics Muybridge Award Lecture, Taipei. J Biomech 42(1):9–21. Huijing PA, Jaspers RT (2005) Adaptation of muscle size and myofascial force transmission: A review and some new experimental results. Scand J Med Sci Spor 15(6):349–380. Huxley AF, Simmons RM (1971) Proposed mechanism of force generation in striated muscle. Nature 233(5321):533–538.

Leahy P, Mock L (1992) Myofascial release technique and mechanical compromise of peripheral nerves of the upper extremity. Chiropr Sports Med 6:139. Longo M, Haggard P (2012) What is it like to have a body? Curr Dir Psychol Sci 21(2):140–145. Maas H, Sandercock TG (2010) Force transmission between synergistic skeletal muscles through connective tissue linkages. J Biomed Biotechnol 2010:575672; doi: 10.1155/2010/575672. Manheim C (2001) ° e Myofascial Release Manual. 3rd ed. SLACK Incorporated.

Dommerholt J (Eds.) Manual ° erapy for Musculoskeletal Pain Syndromes: An Evidence- and Clinical-Informed Approach. London: Elsevier. Pilat A (2017) Myofascial induction therapy. In: Liem T, Tozzi P, Chila A (Eds.) Fascia in the Osteopathic Field. Edinburgh: Handspring Publishing. Pilat A (2018) Myofascial Induction ° erapy. In: Chaitow L (Ed.) Fascial Dysfunction: Manual ° erapy Approaches. 2nd ed. Edinburgh: Handspring Publishing.

Manheim CJ (2008) ° e Myofascial Release Manual. 4th ed. ° orofare, NJ: SLACK Incorporated.

Pilat A, Salom-Monreno J, Castro E, Fernándezde-las-Peñas C (2016) Myofascial force transmission. Evidence from unembalmed cadavers dissections. Man ° er 25:e134.

McKee TJ, Perlman G, Morris M, Komarova S (2019) Extracellular matrix composition of connective tissues: A systematic review and meta-analysis. Sci Rep 9(1):10542.

Purslow P (2010) Muscle fascia and force transmission. J Bodyw Mov ° er 14(4):411–417.

Moseley GL, Butler DS (2017) Explain Pain Supercharged: ° e Clinician’s Manual. South Australia: Noigroup Publications. Myers TW (2009) Anatomy Trains: Myofascial Meridians for Manual and Movement ° erapists. 2nd ed. Edinburgh: Churchill Livingstone.

Rolf IP (1990) Rolÿ ng and Physical Reality. Ed. Rosemary Feitis. Rochester, VT: Healing Arts Press. Sahrmann S (2017) ° e how and why of the movement system as the identity of physical therapy. Int J Sports Phys ° er 12(6):862.

National Academies Press (1998) 2, Biomedical Model Deÿ nition. Available: https://www. ncbi.nlm.nih.gov/books/NBK230283/ [accessed February 2, 2021].

Sahrmann S, Azevedo DC, Van Dillen L (2017) Diagnosis and treatment of movement system impairment syndromes. Braz J Phys ° er 21(6):391–399.

Øberg GK, Normann B, Gallagher S (2015) Embodied-enactive clinical reasoning in physical therapy. Physiother ° eory Pract 31(4):244–252.

Singh C, Leder D (2012) Touch in the consultation. Br J Gen Pract. Journal of the Royal College of General Practitioners 62(596):147–148.

Jull G (2017) Biopsychosocial model of disease: 40 years on. Which way is the pendulum swinging? Br J Sports Med 51(16):1187–1188.

Pilat A (2003) Terapias miofasciales: Inducción miofascial. Madrid: McGraw Hill Interamericana de España.

Kaufman MP, Hayes SG, Adreani CM, Pickar JG (2002) Discharge properties of group III and IV muscle a˛ erents. In: Gandevia SC, Proske U, Stuart DG (Eds.) Sensorimotor Control of Movement and Posture. Advances in Experimental Medicine and Biology, Volume 508. Boston: MA: Springer, pp. 25–32.

Pilat A (2012) Myofascial induction approaches. In: Schleip R, Findley TW, Chaitow L, Huijing PA (Eds.) Fascia: ° e Tensional Network of the Human Body. Edinburgh: Churchill Livingstone Elsevier.

Smeulders MJ, Kreulen M (2007) Myofascial force transmission and tendon transfer for patients su˛ ering from spastic paresis: A review and some new observations. J Electromyog Kinesiol 17(6):644–656.

Jepsen JR (2018) Studies of upper limb pain in occupational medicine, in general practice, and among computer operators. Dan Med J 65(4):B5466.

Lin YW, Cheng CM, Leduc PR, Chen CC (2009) Understanding sensory nerve mechanotransduction through localized elastomeric matrix control. PLOS ONE 4(1):e4293.

Pilat A (2014) Myofascial Induction ° erapy. In: Chaitow L (Ed.) Fascial Dysfunction: Manual ° erapy Approaches. Edinburgh: Handspring. Pilat A (2015) Myofascial induction approaches. In: Fernández-de-las-Peñas C, Cleland JA,

1

Stecco L, Stecco C (2019) Fascial Manipulation. Padua: Piccin. Still AT (1899) Philosophy of Osteopathy. Kirksville MO: A.T. Still. Stilwell P, Harman K (2019) An enactive approach to pain: Beyond the biopsychosocial model. Phenomenol Cogn Sci 18: 637–665.

13

Pilat_Myofascial Induction.indb 13

03/12/21 3:33 PM

1

REFERENCES

Synnott A, O’Kee˛ e M, Bunzli S, Dankaerts W, O’Sullivan P, O’Sullivan K (2015) Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that in˝ uence recovery: A systematic review. J Physiother 61(2):68–76. ° acker M (2015) Is pain in the brain? Pain Rehabil. J Physiother Pain Assoc 201(39):3. ° iel W (2000) Atlas fotográÿ co de anatomía práctica. Volumen I, abdomen y extremidad inferior. Springer-Verlag Ibérica, Barcelona.

Voight ML, Hoogenboom BJ (2017) What is the movement system and why is it important? Int J Sports Phys ° er 12(1):1–2. von Bertalan˛ y L (1968) General System ° eory: Foundations, Development, Applications. New York: George Braziller. Waddell G (1987) 1987 Volvo award in clinical sciences. A new clinical model for the treatment of low-back pain. Spine (Phila Pa 1976) 12(7):632–644. Waddell G (2004) ° e Back Pain Revolution 2nd ed. Edinburgh: Churchill Livingstone.

van der Wal J (2009) ° e architecture of the connective tissue in the musculoskeletal system—an o˙ en overlooked functional parameter as to proprioception in the locomotor apparatus. Int Int J ° er Massage Bodywork 2(4):9–23.

Ward R (1997) Integrated neuromusculoskeletal release and myofascial release: An introduction to diagnosis and treatment. In: Ward RC, Hruby JR, Jerome JA, Jones JM, Kappler RE (Eds.) Foundations for Osteopathic Medicine. Baltimore, MD: Williams & Wilkins.

Varela FJ, ° ompson E, Rosch E (1991) ° e embodied mind: Cognitive science and human experience. Cambridge, MA: MIT Press.

Weber A, Varela FJ (2002) Life a˙ er Kant: Natural purposes and the autopoietic foundations of biological individuality. Phenomenol Cog Sci 1:97–125.

Vaticon D (2009) Sensibilidad miofascial libro de ponencias XIX. Jornadas de Fisioterapia EUF ONCE, Madrid 24–30.

Wheeler AH (2004) Myofascial pain disorders: theory to therapy. Drugs 64(1):45–62.

WHO (World Health Organization) ([1946] 2012) Cited in: Kim R WHO AND wellbeing at work. Available: https://www.hsl.gov.uk/media /202146/5_kim_who.pdf [accessed February 2, 2021]. Yaman A, Ozturk C, Huijing PA, Yucesoy CA (2013) Magnetic resonance imaging assessment of mechanical interactions between human lower leg muscles in vivo. J Biomech Eng 135(9):91003. Ye H, Zeng H, Yang W (2019) Enactive cognition: ° eoretical rationale and practical approach. Acta Psychologica Sinica 51(11):1270–1280. Yu WS, Kilbreath SL, Fitzpatrick RC, Gandevia SC (2007) ° umb and ÿ nger forces produced by motor units in the long ˝ exor of the human thumb. J Physiol 583(3):1145–1154. Yucesoy C (2010) Epimuscular myofascial force transmission implies novel principles for muscular mechanics. Exerc Sport Sci Rev 38(3):128–134. Zhang C (2012) Finite element analysis of mechanics of lateral transmission of force in single muscle ÿ ber. J Biomech 45(11):2001–2006.

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Definition and characteristics of fascia and the fascial system

2

KEY POINTS •

The anatomical evidence relating to fascial nomenclature

•

The local (topographic) approach and the systemic approach

•

Definition and characteristics of the fascial system

•

Discussion of the attributes of the fascial system

•

Differentiation and comparison of closed and open systems

•

Definition of a complex biological system

•

The systemic approach to fascial structures

•

Fascia as a complex biological system

Definition of fascia What is fascia? Everything that exists is within. Answering this question correctly is quite a challenge. ° e term “fascia” comes from the Latin term for “a band, bandage, swathe, ribbon” (Merriam-Webster Dictionary 2017). ° e Federative Committee on Anatomical Terminology (later renamed the Federative International Committee on Anatomical Terminology) (2008) deÿ nes it as follows: “ fascia consists of sheaths, sheets or other dissectible connective tissue aggregations … It includes not only the sheaths of muscles but also the investments of viscera and dissectible structures related to them.” In light of this a broad deÿ nition of fascia is needed in order to fully explain the body’s biomechanics and pathomechanics. Providing this deÿ nition is not an easy task, since even among researchers there is a wide range of views on what fascia is and what nomenclature we should use to classify it (Langevin & Huijing 2009, Schleip et al. 2012, Kumka & Bonar 2012, Swanson 2013). In the opinion of this author, fascia can be described as the unifying structure of body dynamics, which is

Pilat_Myofascial Induction.indb 15

a continuum of ÿ bers embedded in the fundamental (ground) substance, connecting the components of the body without interruption (Pilat 2003). Recently, Adstrum et al. (2017) published a proposal from the Fascia Nomenclature Committee in the form of a request to the Federative International Committee on Anatomical Terminology. Since fascia is mostly perceived in two ways, and following the earlier proposal from Stecco & Schleip (2016), the authors suggest two deÿ nitions for fascia based on its morphology and functionality. Morphological deÿ nition: A fascia is a sheath, a sheet or any other dissectible aggregation of connective tissue that forms beneath the skin to attach, enclose and separate muscles and other internal organs. Functional deÿ nition: The fascial system consists of the three-dimensional continuum of soft, collagen-containing, loose and dense fibrous connective tissues that permeate the body. It incorporates elements such as adipose tissue, adventitiae and neurovascular sheaths, aponeuroses, deep and superficial fasciae, epineurium, joint capsules, ligaments, membranes, meninges, myofascial expansions, periostea, retinacula,

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2 septa, tendons, visceral fasciae, and all the intramuscular and intermuscular connective tissues including endo-/peri-/ epimysium. The fascial system interpenetrates and surrounds all organs, muscles, bones and nerve fibers, endowing the body with a functional structure, and providing an environment that enables all body systems to operate in an integrated manner.

in a system, and at the same time we represent a system made up of many systems. ° erefore, a systemic approach to fascial tissue, analyzing it as a complex biological system, is recommended.

In order to understand the concept of fascia as a system, the terms related to it must be deÿ ned. It is recommended that fascia be analyzed as a complex biological system composed of a group of elements (a system), in˝ uenced by extrinsic factors (a suprasystem), and in relation to internal components (subsystems).

Systemic analysis requires the deÿ nition of the following terms: element, pattern, object, event, system, acting system, component, interaction, mutual interaction, pattern system, and interdependency. See Table˜2.1 for the full list of deÿ nitions.

Definition of terms

Definition and characteristics of a system

Table 2.1

A system can be defined as a group of interrelated elements, consisting of both structural aspects (elements, ranges, communication networks, and information) and functional aspects. In order to function properly a system requires the interdependency of all of these elements.

° e systemic approach began to dominate in the second half of the twentieth century, initially through the work of biologist Ludwig von Bertalan˛ y (1901–1972). Since Descartes a scientiÿ c method has evolved based on two related hypotheses:

•

that a system can be divided up into its components in such a way that each component can be analyzed as a separate entity, and

•

that components can be added to the system in a linear fashion to understand the whole system. GST establishes that the properties of a system cannot be described in terms of its separate elements. A system can only be understood when it is studied as a whole, involving all of the interdependencies of its parts. The information content of a “piece of information” is proportional to the amount of information that can be inferred from the information (Kuhn 1974).

Definition of terms (according to Kuhn, 1974)

Term

Definition

Element

Any identifiable entity

Pattern

Any relationship of two or more elements

Object

A pattern as it exists at a given moment in time

Event

A change in a pattern over time

System

Any pattern whose elements are related in a sufficiently regular way to justify attention

Acting system

A pattern where two or more elements interact

Component

Any interacting element in an acting system

Interaction

A situation where a change in one component induces a change in another component

Mutual interaction

A situation where a change in one component induces a change in another component, which then induces a change in the original component

Pattern system

A pattern where two or more elements are interdependent

Interdependent

A situation where a change in an element induces a change in another element

Conceptual basis of a system ° e conceptual basis of a system is described below.

In his General System ° eory (GST) von Bertalan˛ y (1968) aˆ rmed that both hypotheses are false and that, on the contrary, a system is characterized by the interrelations (interactions) of its components and by the nonlinearity of these interrelations. We are embedded

•

A system is a group of interacting elements organized to achieve a speciÿ c objective or speciÿ c objectives.

•

° e objectives are the system’s raison d’être that integrate all of its parts.

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Definition and characteristics of fascia and the fascial system

•

Variation in or alteration of one of the system’s parts a˛ ects the other parts and, for that matter, the entire group.

•

° e level of complexity of the system depends on the quantity of elements included in it, as well as the quantity and the variety of relationships that exist among them.

•

° e specialized functions (parameters) of the system are:

Subsystem

System

2

Suprasystem

▶ entries or input (coming into the system: energy, material resources, information) that are:

° serial (emanating from the previous system directly associated with the system in question)

° random (potential input that may randomly

Figure 2.1

activate)

Levels of system complexity

° feedback-based (feeding the system with products created through its own output);

▶ processes or transformations (conversion, transformation, ˝ ow); ▶ output or results (obtained by processing the input; this is the result of the operation of the system):

° the output of one system can be converted into in-

put for another, which will process it by converting it to other output, repeating this cycle indeÿ nitely

° when di˛ erent combinations of input are pres-

ent, or if they are combined in di˛ erent sequential orders, di˛ erent output situations may result;

▶ boundaries of a system – deÿ ned as the group of its interacting components.

•

All of these (system, subsystem, and suprasystem) are systems.

Classification of systems A system can be classiÿ ed according to the following criteria: type, make-up, response, internal mobility, predetermination of its operation, and level of dependency. For details on classifying a system according to its characteristics see Table 2.2. ° e main criteria to consider when analyzing the human body as a complex system are the types of systems. Systems can be divided into closed and open systems:

•

Closed system (Fig. 2.2). A system is considered to be closed when its interactions occur only with

Levels of complexity of a system (Fig. 2.1) Analysis of a complex system involves all the component parts (system), the in˝ uence of extrinsic factors (suprasystem), and the interaction of the internal components (subsystem). ° e parts are deÿ ned as follows:

•

System. A group of elements that interact in order to achieve a common objective.

•

Subsystem. A group of parts and interrelations that are found, structurally and functionally, within a major system.

•

Suprasystem. ° e group of processes that provides the system with resources from outside its environment.

Table 2.2 Classification of systems Classification parameters

Characteristics

Constitution

Physical or abstract

Nature

Closed or open

Response

Passive, active, or reactive

Internal mobility

Static, dynamic, or homeostatic

Predetermination of its behavior

Probabilistic or deterministic

Grade of dependency

Dependent, independent, or interdependent

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2 its components and not with its environment; no outside element enters or exits the system. A closed system reaches its maximum state (equilibrium) once it is balanced with the external environment. Its systems can be fixed, rhythmic, or

constant, as would be the case with closed electrical circuits.

•

Open system (Fig. 2.3). All living systems are characterized as open. An open system is one that receives

Matter

Closed system Process

Information Matter Energy

Conversion Input

Transformation flows

Output

New resources Modified information

Feedback A

Energy

Figure 2.2 A The closed system model and its specialized functions (parameters). A system’s input is defined as the movement of information or matter–energy from the environment into the system. Output is the movement of information or matter–energy from the system to the environment. B A pressure cooker is an example of a closed system

B

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2

Definition and characteristics of fascia and the fascial system

Homeostasis

Feedback

Information

SYSTEM

Matter Energy

Subsystem

Environment

Subsystem

Subsystem

Information

Environment

Subsystem

Subsystem

Information

Subsystem

Entropy

Matter Energy

Information Information

Information

A

Interrelationships

Figure 2.3 A The open system model and its specialized functions (parameters) showing the exchange of information between the subsystems, the system and its environment. B A cooking pot is an example of an open system

B

input from the environment and/or outputs into the environment. ° is includes systems that bring in and process elements (energy, material, information) from their surroundings. An open system continually interacts with and feeds itself from its environment in a dual manner, meaning that it in˝ uences and is

in˝ uenced. ° is ensures its continuity (viability, negative entropy, teleology, morphogenesis, equiÿ nality). If these actions cease to occur, the sustainability of the system is jeopardized. In order to avoid confusion, two basic terms should be deÿ ned: entropy and negative entropy. System entropy is how the system wears

19

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2 either over time or through its operation. Highly entropic systems tend to wear out due to their own systemic processes. ° ese systems must have rigorous control systems and mechanisms for review and reworking and must continually adapt to avoid wearing out over time. In a closed system, entropy is constantly increasing and is positive. Conversely, in open biological systems, entropy can be reduced or transformed into negative entropy, meaning that a more complete and organized condition can be created with a greater capacity for transforming resources. ° is is possible because in open systems the resources used to reduce entropy are taken from the external environment. In this way, living systems maintain a stabilized state and can avoid increasing entropy, improving their order and organization. ° us, open systems can reach higher levels of organization (negative entropy), while the organization of closed systems can only be sustained or deteriorate. In an open system, output returns to the system as resources or information, which allows the system to self-monitor and correct based on the feedback. For a comparison of the advantages of open systems over closed systems see Table 2.3.

Table 2.3

Comparison of open and closed systems

Open systems gravitate toward higher levels of organization (negative entropy), while closed systems can only sustain or decrease their levels of organization.

Table 2.4 The main characteristics and activities of a system (according to von Bertalanffy, 1968) Characteristic

Activity

Totality

System modifications are independent of the initial conditions

Entropy

Systems tend to retain their identity

Synergy

The whole is greater than the sum of its parts Any change to any part affects all others and sometimes the entire system

Purpose

Systems share common goals

Equifinality

System modifications are independent of the initial conditions

Equipotentiality

Allows the remaining parts to assume the functions of extinct parts

Feedback

Constant exchange of information

Homeostasis

Tendency to remain stable

Morphogenesis

Tendency to change

Adaptability

Open system

Closed system

Constantly adjusts its stability Is in a constant process of adaptation to the requirements and flow of energy

Remains in equilibrium

Have a fluid exchange with the environment in which it develops

Absence of entropy

Learn and modify a process

Interacts continually with the environment in a dual manner

Does not interact

Respond to internal and external changes over time Stability

Influences and is influenced Can grow, change, and adapt to the environment, and even reproduce under certain environmental conditions

Does not react

Competes with other systems

Does not compete

Collects information on the environment that surrounds it to be able to satisfy its demands

Does not act

Absorbs supplies (input) and converts them into products, particularly if the environment demands rapid or extensive changes

Does not react

Maintains only its own balance

Cannot survive due to lack of adaptation

Maintenance of balance through the continuous flow of energy and information A system is said to be stable when it can be maintained in optimal condition through the continuous flow of materials, energy, and information The stability of a system occurs when it can maintain its operation and work effectively (maintainability)

Maintenance

Property of being able to perform constantly A system uses a mechanism of maintenance to ensure that the various subsystems are balanced and the whole system is in equilibrium with its environment

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Definition and characteristics of fascia and the fascial system

Primary characteristics of a system ° e study of systems can follow two general approaches. A cross-sectional approach addresses the interactions among various systems, while a developmental approach addresses the changes in a system over time. When all of the forces of a system are balanced to the point that changes no longer occur, the system is considered to be stable or in a steady state. Dynamic equilibrium is considered to exist when the system components are in a state of change, but at least one system variable is within a speciÿ ed range. Homeostasis is the condition of dynamic equilibrium between at least two system variables. Kuhn (1974) asserts that all systems gravitate toward equilibrium, and that a prerequisite for the longevity of a system is its ability to maintain a stationary state or a steadily oscillating state. ° e characteristics of systems are described in Table 2.4.

Hypothesis for considering the human body as a system

•

Each system carries out tasks with the purpose of fulÿ lling set objectives in accordance with its dependence on the superior system to which it belongs. For example, the cellular dynamic determines how a tissue functions.

•

Living organisms are open systems (all of the system components, at each level of the organism’s structure, can receive the beneÿ ts provided by the surroundings and return transformed resources to the surroundings).

•

A system’s functions depend on the interrelation of its parts. Feedback is one of the primary aspects of the development of the system (for example, variations in respiratory rate depend on the level of oxygenation of the blood).

Fascia as a system Characteristics of organization, whether of a living organism or a society, are notions like those of wholeness, growth, differentiation, hierarchical order, dominance, control, and competition. von Bertalanffy (1968)

It has been proposed that fascia could be described as a functional and structural (anatomical) continuity system characterized by the integration and interconnection of its components. To that end, fascia can be considered to

2

be a continuous and uninterrupted communication network through which information travels that is related to movement generated between and within the muscles and vascular, visceral, and neural structures. ° is system brings together di˛ erent types of cells with diverse activities (for example, in a similar manner to the cardiovascular or nervous systems), and is associated with other body systems through an uninterrupted and innervated structure of functional stability formed by the tridimensional collagenous matrix (Fig. 2.4). An organism is more than the sum of its parts by virtue of the new properties that emerge from the relationships between its parts.

° e fascial system represents a complex communication structure that provides mechanoreceptive information (Kapandji 2012). ° is process occurs not only as a result of its topographical distribution, but also because of the manner in which it interrelates with the other organs, speciÿ cally the muscles (Lancerotto et al. 2011, Pilat 2010). Its ÿ brous construction allows it to adapt to the body’s tension requirements, both intrinsic and extrinsic (Langevin et al. 2011, Swanson 2013). ° e tension paths created from appropriate (optimal) biomechanical frameworks can in this way redirect the body’s dynamics. ° e density, distribution, and organoleptic characteristics of the system di˛ er depending on the path (Benjamin 1995), but continuity is essential because it drives the fascia to function as a single, synergistic entity that absorbs local stimuli and redistributes them to the entire system. ° e inherent synergy of the fascial system helps the human body to be relatively independent of gravitational pull and also provides a great capacity to adapt in accordance with external and internal requirements or in relation to the energy and nutrients available in the environment (Nakajima et al. 2004). Aside from its structural role, fascia distributes the stimuli that the body receives. Its sensory network registers thermal, chemical, pressure, and movement impulses. In addition, it analyzes, categorizes and transmits them to the central nervous system (Craig 2003). In turn, the central nervous system redirects the impulses and sends instructions to the organs. In conclusion, fascia should not be described just as a passive support structure but rather as a “dynamic and adaptable system” (Swanson 2013) with a great potential for action.

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2

Skin

Langer’s lines

Superficial fascia with adipose lobes

Lymphatic system

Deep fascia

Figure 2.4 Fascial continuity throughout the body. All body systems are surrounded and interpenetrated by fascia and communicate with each other through the continuous fascial network

Fascia as a complex biological system A biological (or organic) system is a complex network of biologically relevant entities that work together to carry out physiological functions in a living being.

•

° e classic orthodox model used in biology has frequently led to reductionist (mechanism) approaches through which biological components can be analyzed individually and which are governed by linear aggregation laws.

•

Biological entities are complex systems (multicellular organisms) in which the total is not equal to the sum of its parts, and therefore they are not able to be separated and broken down.

•

In biological entities, the cause–e˛ ect relationship is linked to multiple variables, meaning an e˛ ect may not always have the same cause and the same cause does not always have to have the same e˛ ect.

•

Biological systems (and speciÿ cally the fascial system) are self-regulating and use decentralized control

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Definition and characteristics of fascia and the fascial system

Muscular system (myofascia)

Nervous (neuroconnective) system

Circulatory system

Digestive system (viscerofascia)

2

Skeletal system

Figure 2.4 (continued)

•

mechanisms in which various subunits (for example, molecules of a cell, cells of an organism, or organisms of a group) adapt their activities themselves, based on limited local information (intercellular communication). As an evolutionary feature, the human organism, like other complex biological systems, has developed a centralized control (central nervous system, CNS). Clearly self-regulation is not always the best method to coordinate subunits in a system.

•

•

° e absence of a central authority leaves a system (molecules, cells, or organisms) open to opposing actions among its subunits, because they are responding to di˛ erent local conditions rather than the shared situation of the entire system (for example, cancer). ° e ability of the subunits to communicate is essential for the evolution of the centralized control, since without such abilities this control paradigm cannot be implemented.

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2 •

° is task is only possible through the appropriate ˝ ow of information, with the purpose of obtaining optimal system performance, in other words, functional (dynamic) stability (Taleb 2013).

Conclusion We are far from a consensus on the nomenclature relating to fascia. ° e diˆ culty is that international,

interdisciplinary, and transdisciplinary consensus is required. It has been recommended that the terms fascia and fascial system be widely adopted and used in communications in the bioscientiÿ c areas. Subsequent chapters will focus on fascia as a system and attempt to analyze it using anatomical, histological, embryological, architectural, and neurological approaches.

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REFERENCES

Adstrum S, Hedley G, Schleip R, Stecco C, Yucesoy CA (2017) Deÿ ning the fascial system. J Bodyw Mov ° er 21(1):173–177. Benjamin M (1995) Fibrocartilage associated with human tendons and their pulleys. J Anat 187(Pt. 3):625–633. Craig AD (2003) Interoception: ° e sense of the physiological condition of the body. Curr Opin Neurobiol 13(4):500–505. Kapandji AI (2012) Le système conjonctif, grand uniÿ cateur de l’organisme. Ann Chir Plast Esthet 57(5):507–514. Kuhn T (1974) Second thoughts on paradigms. In Suppe F (Ed.) ° e Structure of Scientiÿ c ° eories. Urbana: University of Illinois Press, pp. 459–482. Kumka M, Bonar J (2012) Fascia: A morphological description and classiÿ cation system based on a literature review. J Can Chiropr Assoc 56(3):179–191.

Lancerotto L, Stecco C, Macchi V, Porzionato A, Stecco A, De Caro R (2011) Layers of the abdominal wall: Anatomical investigation of subcutaneous tissue and superÿ cial fascia. Surg Radiol Anat 33(10):835–842. Langevin HM (2011) Fibroblast cytoskeletal remodeling contributes to connective tissue tension. J Cell Physiol 226(5):1166–1175. Langevin HM, Huijing PA (2009) Communicating about fascia: History, pitfalls, and recommendations. Int J ° er Massage Bodywork 2(4):3–8. Nakajima H, Imanishi N, Minabe T, Kishi K, Aiso S (2004) Anatomical study of subcutaneous adipofascial tissue: A concept of the protective adipofascial system (PAFS) and lubricant adipofascial system (LAFS). Scand J Plast Reconstr Surg Hand Surg 38(5):261–266. Pilat A (2003) Terapias miofasciales: Inducción miofascial. Madrid: McGraw Hill Interamericana de España.

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Pilat A (2010) Myofascial induction approaches for headache. In: Fernández-de-las-Peñas C, Arendt-Nielsen L, Gerwin RD (Eds.) TensionType and Cervicogenic Headache: Pathophysiology, Diagnosis, and Treatment. Sudbury, MA; London: Jones & Bartlett Publishers. Schleip R, Jäger H, Klinger W (2012) What is ‘fascia’? A review of di˛ erent nomenclatures. J Bodyw Mov ° er 16(4):496–502. Stecco C, Schleip R (2016) A fascia and the fascial system. J Bodyw Mov ° er 20(1):139–140. Swanson RL (2013) Biotensegrity: A unifying theory of biological architecture with applications to osteopathic practice, education, and research. J Am Osteopath Assoc 113(1):34–52. Taleb NN (2013) Antifrágil: Las cosas que se beneÿ cian del desorden. Paidós. von Bertalan˛ y L (1968) General System ° eory: Foundations, Development, Applications. New York: George Braziller.

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Anatomy and functional aspects of fascia

3

KEY POINTS •

Exploration of the anatomical evidence relating to the fascial system

•

Illustration of the anatomical continuity of fascia throughout the body

•

Discussion of fascial architecture

•

How the fascial system relates to other body systems (neural, muscular, visceral, vascular systems)

•

How fascial anatomy is linked to body movement

Introduction The anatomical samples presented in this chapter were taken during dissections of unembalmed cadavers. In some respects, for example, in relation to fascial planes and layers, the anatomical analysis may differ slightly from the viewpoint of experts in gross anatomy and histology. For a detailed topographic analysis the reader is advised to consult the classic anatomy texts. In anatomical research carried out on embalmed cadavers the concept of fascia is mostly related to only some anatomical structures, which has led to speciÿ c names being designated topographically for fascia. ° ese are mostly the names of muscles (for example, latissimus dorsi fascia, deltoid fascia, bicipital fascia, palmar fascia, or plantar fascia) or particular areas (pectoral fascia, fascia of the back). Although this analysis is topographically accurate, at the same time it is abstract and isolated, and shows limited functional correlation between anatomical components. It suggests a series of independent items instead of a single and continuous conÿ guration and also complicates the analysis of morphology and function when these elements are integrated into a higher level of organization (Huijing 2009). In this process, tissue characteristics could have been altered by chemical ÿ xation, freezing, or thawing, which prevent the researcher from fully exploring and understanding fascial conditions and also the continuity, biomechanical links, and behavior of fascia.

Pilat_Myofascial Induction.indb 27

Anatomical studies of unembalmed cadavers (“fresh cadavers”) have allowed for a di˛ erent view and a more thorough analysis of anatomical links. While preserving the natural appearance (“inside of the body”) (Huijing & Baan 2008), they have enabled the linking of clinical ÿ ndings. ° is process has allowed for the creation of a new view of fascia, which is di˛ erent from the traditional description of a ÿ brous sheet that hides the muscle.

Fascial continuity throughout the body As mentioned in Chapter 2, the debate on the deÿ nition of fascia is very dynamic. Similarly, classiÿ cation of fascia also leads to many discrepancies between researchers who may refer to the topographical, structural, functional, or linguistic aspects of fascia. ° e two most widely used terminologies are: 1) the recommendations of the Federative Committee on Anatomical Terminology (FCAT 1998) and 2) the terminology according to Gray’s Anatomy (Standring 2008). ° e ÿ rst distinguishes fascial structure by its histology (this deÿ nition of fascia includes structures of dense connective tissue, while excluding those of loose connective tissue). ° e second terminology, which deÿ nes fascia according to its ÿ ber arrangement, includes the interwoven structures, while excluding ligaments, tendons, and aponeuroses (Pilat 2017). Another problem is the fact that this is an anglocentric nomenclature and

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3 it has not been completely taken up in other languages. ° erefore, in the interests of international understanding, the recommended terms are now tela subcutanea (subcutaneous tissue), fascia musculorum, and fascia visceralis. ° e problem was that fascia superÿ cialis in English described the whole of the tela subcutanea. In Italian it excluded the panniculus adiposus. In French it excluded both the panniculus adiposus and the textus connectivus laxus beneath the stratum membranosum, whereas in German it described the superÿ cial layer of the fascia musculorum and thus excluded the panniculus adiposus, the stratum membranosum, and the textus connectivus laxus (Wendell-Smith 1997). ° e discussion remains open.

Fascial layers and their morphological characteristics In the functional analysis of the fascial system, we recognize the presence of superÿ cial and deep fascia, according to the most widely used classiÿ cation system (Figs. 3.1 and 3.2) as follows:

•

superÿ cial fascia (tela subcutanea – subcutaneous tissue)

•

deep fascia: ▶ myofascia (fascia musculorum) ▶ visceral fascia (fascia visceralis) ▶ neurofascia (epineurium and meninges).

Analysis of the continuity of the fascial system begins at the level of the skin as there is no movement between the skin and the superÿ cial fascia; both structures move together (see below).

Skin and Langer’s lines The skin envelops the whole body. • Is the skin just a superficial unit? • Is it possible that tensional changes in the skin influence muscle dynamics and perhaps other underlying structures?

C

Figure 3.1

B B1 A

E

Fascial continuity in a transverse section of the thigh A Skin B Superficial fascia (note the variable thickness – see arrows) B1 Superficial fascia with adipose lobes, dissected from the deep fascia and pulled back C Deep fascia D Myofascia E Thickening of the deep fascia (in this case the iliotibial band) F Compartments formed by the retinacula cutis, creating spaces for adipose lobes

D

Anterior

F Lateral

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Anatomy and functional aspects of fascia

A

Figure 3.2

B

Fascial continuity in a transverse section of the forearm A Skin B Adipose lobe C Compartments formed by the retinacula cutis, creating spaces for adipose lobes D Superficial fascia E Deep fascia (note the fibrous construction) F Intermuscular septa (note the continuity between the septa and the deep fascia)

C D

E F

•

° e epidermis, which:

▶ provides oxygen and nutrients ▶ removes waste

•

▶ contains sensitive and sympathetic innervation. ° e hypodermis (subcutaneous tissue, superÿ cial fascia), which:

▶ is a keratinized squamous epithelium

▶ is located deep under the dermis

▶ provides the outer surface (the basal layer)

▶ acts as a shock absorber

▶ does not contain blood or lymphatic vessels

▶ connects skin to underlying structures

▶ contains receptors which are sensitive to touch, temperature, and vibration (see Table 3.2).

•

Reproduced with permission from Pilat A. (2012) Myofascial Induction Approaches. In: Schleip R., Findley T.W., Chaitow L., Huijing P.A. (Eds.) Fascia: The Tensional Network of the Human Body. Churchill Livingstone Elsevier

▶ contains blood and lymph vessels which control body temperature

Characteristics of skin ° e skin is not just a simple and inert body wrapper but rather a complex anatomical and functional organ. It is the second heaviest and largest organ in the human body. Only the alveoli of the lungs create a surface area that exceeds that of the skin. ° e skin consists of:

° e dermis, which: ▶ links together ÿ bers of elastin and collagen, which are secreted by ÿ broblasts. ° e ÿ bers:

° are immersed in the gelatinous matrix, giving skin turgor and elasticity

° are arranged randomly, giving the dermis its resistance and distensibility

° note, however, that the collagen ÿ bers are distributed mainly as transverse lines on the neck and trunk and longitudinally or spirally in the extremities. ° ey are named Langer’s lines (see below)

3

▶ is made up of lobe-like adipocytes separated by connective tissue septa ▶ represents between 18–23ˇpercent of body weight in a nonobese adult ▶ is a source of insulation and thermal regulation ▶ is the organism’s energy reserve. In conclusion, the skin can be considered to be a sensitive structure which acts as a biological defense system (Bloom & Fawcett 1975). ° e purposes and functions of the skin are summarized in Table 3.1.

Skin receptors ° e skin’s receptors are distributed all over the body rather than concentrated in speciÿ c areas and are responsible for touch sensations. Each receptor is

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3 Table 3.1 Purposes and functions of the skin Purposes

Functions

Protective barrier

Protects against dehydration (regulation of loss of water and electrolytes) Protects against biological, chemical, and physical agents (infections)

Sensitivity

Detects sensations such as: temperature (heat or cold) (free nerve endings) pain (free nerve endings) itching (unmyelinated C fibers and thinly myelinated Aδ nerve fibers) pressure (Merkel receptors) vibrations (Pacinian corpuscles)

(see Fig. 3.3)

Temperature regulation

Insulation control Change in blood flow Sweating

Hemodynamic monitoring

Peripheral vascular changes

Secretion and excretion

Gland function Hair and epidermis growth Disposal of percutaneous gases, solutes, and liquids

Synthesis

Synthesis of vitamin D

Immune function

Surveillance Responses

A

B

C

D

E

specialized to convey certain information. Mechanoreceptors respond to speciÿ c mechanical stimuli, such as pressure, stretching, and vibration. ° rough them is produced the detection of harmless and harmful mechanical stimuli which determine our sense of touch and pain. If deformation of the tissue which covers the nerve endings is considerable it can produce an action potential that is transmitted to the central nervous system. ° us, skin receptors, along with the peripheral nerves and brain, constitute the somatosensory system. ° ey also interact with the autonomous nervous system. Skin mechanoreceptors di˛ er according to their location, the type of mechanical stimuli, the speed of adaptation to each stimulus, and the receptive area (Delmas etˇal. 2011, Kandel etˇal. 2000) (Fig. 3.3). ° e characteristics of cutaneous somatosensory receptors are summarized in Table 3.2.

Tensional changes on and within the skin ° e skin remains in a state of continuous pre-tension. ° e proper condition of tension becomes distorted during pathological processes, such as in the presence of a scar or elastosis. Regarding wound and scar formation, Hamed et al. (2011) reported that neuroanatomical changes relating to a scar are not simply local but could also be present in uninjured areas peripheral to the wound. ° ey concluded that the response to injury is systemic (Fig. 3.4). Meanwhile elastosis is deÿ ned F

G

Figure 3.3 Cutaneous somatosensory receptors A Hair follicles B C fibers C Polymodal receptors: C fibers and Aδ fibers D Merkel receptor E Ruffini corpuscle F Meissner corpuscle G Pacinian corpuscle

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3

Table 3.2 Characteristics of cutaneous somatosensory receptors

Receptor

Hair follicles

Location

Dermis (individual hairs) apart from glabrous skin

Subepidermal

Subepidermal

Epidermis (basal layer, closest to the dermis)

Dermis

Dermis (just below the epidermis)

Dermis (deep in subcutaneous adipose tissue)

Response to mechanical stimuli

Rapid1

Slow2

Slow2 or rapid1

Slow2

Slow2

Rapid1

Rapid1

Frequency

200–1000 Hz4

0.5 Hz

0.5 Hz

0.3–3 Hz

15–400 Hz

3–40 Hz

10–500 Hz

Perception

Light touch Brush stimuli Hair movement Pleasant touch Skin movement

Light (pleasant) touch

Skin injury Pain

Gentle pressure Form and texture perception

Stretching Direction of object motion Hand shape and position of fingers

Flutter Detecting slipping objects Sharp edges

Vibration (200–300 Hz at 1 μm) Contact with the body when holding an object

Receptive field size

Small or large3

Small

Small

Small

Large

Small

Large Distant events

Responds best to

Skin movement (distension) Vibratory stimuli

Pressure and stretching

Pressure and stretching Burning pain Acute pain

Steady pressure from small objects

Steady pressure and stretching of the skin for example, joint movement)

Rubbing against the skin or skin movement across a surface

Changing stimulation Vibration

C fibers

Polymodal receptors, C fibers, Aδ fibers

Merkel receptor

Ruffini corpuscle

Meissner corpuscle

Pacinian corpuscle

1Rapid adaptation: the receptor's response to changes in pressure (an increase or decrease). There is no response to sustained pressure. 2Slow adaptation: the receptor continues to respond to pressure for as long as it is sustained. 3The receptive fields of hair follicles vary in size being small on the distal part of the limb and larger on the proximal part. 4Gottschaldt (1973).

Figure 3.4 Skin injuries: a postsurgical scar in the abdominal area. Note the tensional deformation of the skin. It should be remembered that the scar is not only an observable structure on the skin. Its continuity at the deep levels affects the consecutive fascial planes generating dysfunctions that over time can transform into pathologies. For example, the postcesarean scar affects the abdominal fascia (particularly its link with the external oblique muscle of the abdomen) and over time it can generate disturbances in the mechanics of the thoracolumbar fascia with consequent low back pain. Consequently, it also affects the dynamics of the pelvic floor structures

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3 as degeneration of the elastic subdermal tissue by prolonged exposure to solar radiation, causing deformations (wrinkles) of the skin. ° ese deformations on the surface (epidermis) expand and deform the underlying structures (Tsukahara etˇal. 2012) (Fig. 3.5). ° e consequences of these pathological processes can alter the skin’s tensional behavior and a˛ ect the dynamics of subdermal components and the passage of cutaneous nerves, blood, and lymph vessels.

Langer’s lines ° e tensional lines of the skin are of interest to anatomists and surgeons – particularly plastic surgeons – and various tensional lines have been described over the years. It can be seen that wounded skin will gape, becoming elliptical instead of round (Dupuytren 1834). ° e directions of these ellipses vary according to the area of the body (Malgaigne 1838). Karl Langer (1861) studied the direction of these ellipses extensively and was able to observe patterns determining “line directions” beside the longer axes of the ellipsoidal holes and lines. Langer’s lines is “a term used to deÿ ne the direction within the human skin along where the skin has maximum tension” (Gibson 1978). ° e images in Figure 3.6 show the paths of Langer,s lines along the body. ° ese lines, also known as “cleavage lines,” coincide with the dominant axis of mechanical tension

in the skin (Seo etˇal. 2013). Previously, the lines were considered to be a static feature; however, in recent years it has been proved that Langer’s lines have a dynamic behavior (Bush etˇ al. 2007). Researchers extracted 175 nevi using circular dermal punch biopsies. Prior to surgery a vertical line was marked on the skin through the center of each nevus. ° e aim was to measure the orientation of the long axis of the wound at rest and subsequent rotation of the wound with movement. A˙ er excision distortions of the resulting wounds were observed. ° e researchers concluded that Langer’s lines are not a static feature but rather dynamic with rotation of up to 90 degrees (Bush etˇal. 2007). Meanwhile, Byard etˇal. (2005) demonstrated that skin tension lines “may transform round skin defects into slit-like wounds resembling knife stab wounds.” Langer’s original studies reveal the paths of the lines when crossing joints is longitudinal and parallel to the paths of the underlying muscle ÿ bers. Surgeons, particularly plastic surgeons, use the map of Langer lines to determine the direction of the skin incision, following the route of the lines and not crossing over them. It is considered that crossing the lines facilitates the formation of keloid scars. ° ese are only clinical observations, and there is no clear scientiÿ c evidence on this subject. Recently three studies were published that veriÿ ed the paths of Langer lines. Carmichael (2014) considers they are not an accurate

Figure 3.5

A

B

C

D

Solar elastosis A Skin wrinkles resulting from excessive sun exposure B Superficial fascia C Dermis D Epidermis

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Figure 3.6 Distribution of Langer’s lines. Redrawn from Langer K. (1908) [1978] On the anatomy and physiology of the skin. British Journal of Plastic Surgery 31(1):3–8

map for decision making on the skin incisions for surgery, particularly on the neck and face. He also states that Langer completed his work on cadavers and the paths of the lines are not accurate for living people. Meanwhile, using laser scanning technology, Seo et al. (2013) measured the dynamic skin strain lines (the direction of skin stress caused by muscle actions) in the lower extremity. ° ey found a correspondence with Langer,s lines at the popliteal fossa and upper posterior thigh; however, at the patella there was no correspondence. On the thigh, Langer drew diagonal lines, but Seo etˇal. (2013) found lines with a rather perpendicular

orientation. In conclusion, they recommended the use of their method “to measure the dynamic skin tension lines, i.e. the direction of skin tension caused by muscle actions such as knee ˝ exion.” AlHamdi (2015) reports that “skin tension lines are formed by the interrelation between elastic and collagen ÿ bres as well as ÿ xed attachments between collagen ÿ bres.” (Langer claimed “that there was no elastin in the skin during his investigations” [Piérard & Lapière 1987]). Although the decision to use the Langer,s lines map in surgical procedures is unsubstantiated, all the studies agree on the existence of the interrelationship between tensional

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3 skin lines and the dynamics of subdermal structures. Researchers have reported the relevance of the quality of movement of the skin–subcutaneous complex relative to the mobility of underlying tissue (Li & Ahn 2011, Ahn & Kaptchuk 2011, Guimberteau etˇal. 2010). It is suggested that e˛ ective skin movement facilitates eˆ cient muscle output, pain reduction, and functional improvement (Ishida etˇal. 2015). In this way the skin can assist muscular movement (Ottenio etˇal. 2015). ° ese observations indicate the need to explore the relationship between the skin and the underlying structures linked to body movement. Figure 3.7 shows the links between the dermis and superÿ cial fascia. Watch the video demonstrating the inseparable movement of superÿ cial fascia in conjunction with the skin (Video 3.1)

Video 3.1 Movement of superficial fascia in conjunction with the skin

During the assessment process, it is recommended that the practitioner explores the skin’s movement as a preliminary step before addressing the applications for the deeper tissues. However, more studies are needed to determine in detail the in˝ uence of the tensional skin lines in the dynamics of the myofascial system.

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Superficial fascia as a system: Its morphology, architecture, and mechanics Key features of the superficial fascial system • It is located under the dermal layer of the skin and is firmly attached to it. • Its anatomy differs according to gender, the amount of fat, and the region of the body. • It supports the weight of the skin. • As a continuous network (interconnected septa) it extends from the subdermal layer and connects the skin to the deeper layers, such as the epimysium– aponeuroses, neurovascular tract, and bones. • Its pattern of distribution demonstrates regional specificity. • It forms a functional whole of protection, lubrication, and motion control in relation to the deeper tissues and organs. • It contains and controls superficial adipose tissue. • It may contain muscle fibers (for example, platysma, palmaris brevis, some muscles of the face). • The mammary glands are located within its structure. • It stores nutrients in the fat nodes. • It is the transit zone to the skin for vessels and nerves. • It fills out irregularities in the subcutaneous tissue (wrinkles, cellulitis).

D Figure 3.7 Skin attached to superficial fascia A Skin B Superficial fascia with adipose lobes C Skin (inner view) D Skin ligaments (retinacula cutis)

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Anatomy and functional aspects of fascia

Morphology of the superficial fascia All paths from within the body lead to the subdermis. To avoid any confusion the term superficial fascia is used, although the latest edition of the Terminologia Anatomica (FCAT 1998) suggests the use of the term hypodermis. Superÿ cial fascia is the major anatomic structure located under the skin and is ÿ rmly attached to it. It consists of horizontal membranes (stratum membranosum) that are connected together by vertical or oblique ÿ brous septa – skin ligaments (retinacula cutis) – which are separated by adipose lobes (Fig. 3.8). However, superÿ cial fascia is not just a fat deposit, but rather a multifunctional system with a complex internal architecture. Along its path, superÿ cial fascia envelops the entire body (Figs. 3.9–3.11) and expands, as a complex network, from the subdermal level to the deep level, reaching the deep fascia (Fig. 3.12). It also facilitates the transit of cutaneous nerves, as well as blood and lymph vessels, and may indirectly mediate blood ˝ ow (Figs. 3.13 and 3.14) (Li & Ahn 2011).

Behavior of the superficial fascial system ° ere are controversial descriptions relating to the anatomical location of superÿ cial fascia. Its characteristics

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are mostly analyzed in relation to plastic surgery and the skin healing process (Congdon etˇal. 1946, Markmann & Barton 1987, Avelar 1989) and limited to speciÿ c areas such as:

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the lower abdomen focusing on two layers: Camper’s fascia and Scarpa’s fascia (Enevoldesn etˇal. 2001);

•

the perineum, where it forms a well-deÿ ned and smooth sheet: Colles’ fascia (Colles 1811);

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the pectoral area (suspensory ligaments – Cooper’s ligaments) (Nash etˇal. 2004); and

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the face (zygomatic ligaments) (Rossell-Perry & Paredes-Leandro 2013).

Perhaps the most common terms for fascia, which are no longer recommended, were for parts of the tela subcutanea of the anterior abdominal wall (Camper’s fascia, now panniculus adiposus abdominis; Scarpa’s fascia, now stratum membranosum abdominis), the penis (Colles’ fascia, now stratum membranosum penis), and the perineum (Colles’ fascia, now stratum membranosum perinei) (Wendell-Smith 1997). However, although research linked to plastic surgery has provided new scientiÿ c data related to the construction and behavior of superÿ cial fascia, its relation to body movement is not usually considered.

F

Figure 3.8 Connection of the skin to superficial fascia and deep fascia in a cross-section of the thigh A Skin B Muscle C Fascial net (superficial fascia) D Deep fascia E Adipose lobes F Femur

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3 C

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Figure 3.9 Vascularization and mechanical continuity of the superficial fascia of the trunk. The skin has been dissected and turned down. 1 Posterolateral aspect of the trunk. Note the blood supply to each area; it is abundant in the interscapular and lumbar region. The opposite occurs in the back and gluteal regions. Note also the “mirroring” in the vascularization of the skin and superficial fascia A Superficial fascia in the interscapular area B Superficial fascia in the dorsal area C Incision line separating the skin from the superficial fascia D Skin (inner view) E Superficial fascia in the lumbar area F Superficial fascia in the gluteal area 2 Close-up of the incision area G Adipose lobules H Fascial net I Line of incision J Skin (inner view)

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Anatomy and functional aspects of fascia

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Figure 3.10

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CAPTION NEEDS TO BE REORDERED

Continuity of superficial fascia in the lower quadrant. Note that fascia looks like pantyhose enveloping consecutive anatomical areas of the lower limb structure without interruption. A Adipose lobes. B Superficial vessels embedded in superficial fascia. Transverse section of the lower extremity. C Knee. D Knee and upper leg. E Foot. F Proximal aspect of the thigh. G Distal aspect of the thigh. H Medial aspect of the leg

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Figure 3.11 Continuity of superficial fascia in the upper quadrant. Note the continuity of the superficial fascia which envelops the consecutive anatomical structures like a sweater A Superficial fascia of the neck, arm, and pectoral areas B Skin (inner view). The skin has been separated from the superficial fascia using a scalpel

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3 B

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Figure 3.14 F

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The venous network embedded in superficial fascia in the abdominal area. Note how the tension applied to the fascia modifies the positioning of the veins. Excessive pressure on the fascial system can influence the mechanics of the veins A Skin B Pubis C Superficial fascia with adipose lobes D Navel E Superficial epigastric vein

Figure 3.12 Cross-section of the thigh A Skin C Honeycomb fascia B Vein D Cuboidal adipose lobes

E Flat adipose lobes F Deep fascia

Figure 3.13

G Aponeurosis H Muscle

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The elbow area. Note that the cutaneous nerves and veins are embedded in the superficial fascia A Skin of the arm (A1) and forearm (A2) B Superficial fascia with adipose lobes showing the outer surface (B1) and the inner surface (B2). Note the high level of hydration of the superficial fascia C Cutaneous nerve D Cutaneous vein E Deep fascia Reproduced with permission from Pilat A., Fascial anatomy of the limbs. In: Liem T., Tozzi P., Chila A. (Eds.) Fascia in the Osteopathic Field. Edinburgh: Handspring Publishing

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Anatomy and functional aspects of fascia

Nevertheless, research carried out with dissections of unembalmed cadavers, assessment using high deÿ nition imaging, and also the application of theoretical models that simulate the anatomy of the skin–subcutaneous complex have provided new information that allows us to predict the behavior of the fascial tissue in relation to the motion of the body. According to Herlin etˇal. (2015), superÿ cial fascia can be involved “in the dissipation of mechanical loads and in proprioceptive processes.” Recently, a study conducted with sonoelastography (Yoshitake etˇal. 2015) suggests “that the skin is a main contributor for maintaining the muscle mechanical properties among tissues covering the skeletal muscle.”

Terminology and classification of superficial fascia For a long time, anatomists and surgeons denied the existence of superÿ cial fascia as a speciÿ c entity, although it was described for the ÿ rst time about 180 years ago (Lockwood 1991). Even now there is no unanimity in the classiÿ cation of superÿ cial fascia over the entire body and there are many controversial descriptions of the anatomical context in particular areas. ° erefore, the same structure can be identiÿ ed by di˛ erent names, for example: hypodermis (Lionard 1986), subcutaneous fascia (Rouvière & Delmas 2005), subcutaneous adipofascial tissue (Nakajima etˇ al. 2004, Avelar 1989), cellular cutaneous tissue (Testut & Latarjet 1996), subcutaneous tissue (MarquartEibaz etˇal. 2001), tela subcutanea (Standring 2008), microvacuolar system (Guimberteau 2010), subcutaneous fascia (Wendell-Smith 1997), skin/subcutaneous complex (Herlin etˇal. 2015), etc. Historically, there are also marked di˛ erences of opinion between researchers as to the number of layers in superÿ cial fascia structures. ° ese range from the presence of one layer (Markman & Barton 1987), two layers (Borley 2008), three layers (Illouz 1989), or even more than three (Lockwood 1991). ° e absence of a consensus on translations of the terminology, in di˛ erent languages and countries, further complicates agreement on a single deÿ nition and proper communication between researchers. Discrepancies in the analysis of anatomical ÿ ndings are perhaps related also to the di˛ erent processes of exploration (through

3

dissections of embalmed, unembalmed, frozen, or plastinated cadavers, during surgery, through ultrasound imaging or in histological samples) and additionally are related to the focus of the research. In dissections conducted on embalmed cadavers, the clear identiÿ cation of superÿ cial fascia and its layers is not an easy task. Generally, dissection of the superÿ cial fascia is hindered by the drying process and this creates a technical diˆ culty in separating it from deep fascia, especially since in some body regions superÿ cial fascia is very thin. Abu-Hijleh etˇal. (2006) relate the thickness of the fascia to gender and the speciÿ c fascial morphology in each body region. Focusing on the subdermal layer, in recent years most researchers have agreed on the presence of a clear separation of two adipose layers by a layer of ÿ brous membrane. ° e names assigned to this membrane, its description, architecture, and relevance vary according to the researcher. Ferreira etˇal. (2006) named this structure, which extends throughout the body, superÿ cial fascia. According to this research, a network of septa (retinaculum cutis superÿ cialis) extends from the subdermal plane to a deeper level to reach a ÿ brous sheet – the superÿ cial fascia. ° e fat trapped between these ÿ bers is superÿ cial adipose tissue (SAT). ° e ÿ bers that connect superÿ cial fascia with deep fascia are retinaculum cutis profundus and adipose tissue is known as deep adipose tissue (DAT) (Lancerotto etˇal. 2011). ° e research of Herlin etˇal. (2015), conducted with MRI scans, conÿ rms these observations. ° ey conclude that “the superÿ cial and deep adipose tissue was found to be clearly separated by an intermediate layer called stratum membranous or superÿ cial fascia” which “covered all the anatomical parts of the body.” Regarding the skin ligaments, they suggest that morphologically they are densiÿ cations of septa to ensure that the skin is held in place. ° ese researchers suggest the use of the term “skin ligaments” exclusively for the ÿ brils that are not involved in organizing the fat lobules. Nakajima etˇal. (2004) call this dividing sheet “membranous fascia” or “superÿ cial fascia.” However, they emphasize that it is not present throughout the body. Gardetto etˇal. (2003) examined fascial relations in the face and neck in fetuses, newborn, and adult specimens using the technique of plastination histology. ° ese researchers reported the presence of a superÿ cial

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3 Table 3.3

Purposes and functions of the superficial fascial system

Purposes

Functions

Formation and definition of the shape of the body

Contributes to the final shape of the body, particularly in the facial region and torso region

Connection to underlying structures

Connects the skin with the underlying structures, such as muscles, bones, viscera, or neurovascular bundles

Support

Supports the weight of the skin Acts as a supporting structure for subcutaneous fat

Force absorption

Provides the necessary cushioning for the fragile epidermis Provides protective padding to cushion gait (calcaneus) Allows tissue to retain or regain its natural spring

Direct energy transfer

Superficial septa and their oblique and vertical orientation disperse energy in a direction perpendicular to the tension of the wound

Posture recognition and interaction with autonomous nervous system

Mechanoreception and mechanotransduction, nociception, proprioception

Subcutaneous muscle dynamics

Influences muscle dynamics (platysma, external anal sphincter, palmaris brevis, and facial muscles)

Gland positioning

Is the location for mammary glands Is the location for sweat glands

Superficial movement

Facilitates skin movement

Elasticity

Has the ability to reverse deformation

Deformation

Has the ability to stretch to accommodate the deposit of fat from ordinary and pregnancy weight gain or weight loss; superficial fascia slowly reverts to its original level of tension

Active participation in movement

Controls tensional changes related to the dynamics of myofibroblasts

Scar formation

Creates an environment for tissue repair and the activities of fibroblasts/myofibroblasts

Heat insulation

Controls the behavior of fat (which is a good insulator)

Sensitivity to variations of temperature and pressure

Continually changes its intrinsic tension according to the surrounding environment

Chemical protection

Defends against pathogenic agents and infections

Lymphatic system protection

Is the location for groups of lymph nodes Acts as a dynamic passageway for lymph fluid

Protection of nerves and vessels

Is a soft medium for the passage of nerves and vessels to the skin

Energy reserve

Fat storage

Detoxification

Expels toxins through the pores of the skin

Fast adaptation

Its receptors respond to changes in pressure

musculoaponeurotic system and concluded that the architecture of subcutaneous connective tissue is a characteristic of all regions of the face and neck. Other authors identiÿ ed “the thin horizontal branches that subdivide the subcutaneous tissue into two or three layers” (Nash etˇal. 2004). Abu-Hijleh etˇal. (2006) consider that the membranous sheet is present in many regions of the body. ° ey also demonstrate that in some places there is more than one membranous layer separating the adipose tissue. Kumar etˇal. (2011) state

that “superÿ cial fascia consists of one to several thin, horizontal membranous sheets separated by varying amount of fat with interconnecting vertical or oblique ÿ brous septae.”

Experience with dissection of unembalmed cadavers Based on the experience of numerous dissections of unembalmed cadavers, the author suggests that superÿ cial fascia:

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Anatomy and functional aspects of fascia

•

extends from the subdermal layer and reaches the deep fascia as an uninterrupted network;

•

is attached ÿ rmly to the skin and supports the superÿ cial adipose tissue;

• •

meets the mechanical demands of vessels and nerves;

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has changing morphology along its path and consists of mechanically joined layers, which provide an uninterrupted system of communication. However, the division between the layers is not clear.

di˛ ers in its anatomy according to gender, age, the amount of adipose tissue, and the region of the body;

° is chapter proposes a systemic analysis with a focus on the morphology and dynamic continuity of superÿ cial fascia. In this analysis the author will use the expression proposed by Lockwood (1996) – “superÿ cial fascial system” (SFS) – as an umbrella term to include all connective tissue structures that mechanically link the skin with the deep fascia. ° is provides a model for

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clinical analysis and is widely used in di˛ erent therapeutic concepts and research, such as in plastic surgery or the wound healing process (Song etˇal. 2006).

Architecture of the SFS As mentioned earlier, the SFS is not just a fat deposit that behaves passively, rather it represents a dynamic, viscoelastic architecture that has a variety of functions and also maintains body surface contours (Lockwood 1991, Gasperoni & Salgarello 1995). ° e functions and activities of the SFS are summarized in Table 3.3. ° is author proposes the existence of two adipofascial layers, superÿ cial and deep, that connect the dermis to the deep fascia. ° e superÿ cial layer (SL), located just under the skin, contains the cuboid-shaped adipose lobes. ° e deep layer (DL) encloses ˝ at adipose lobes (Fig. 3.15). Di˛ erentiating the two layers is diˆ cult in the cadavers of very thin people. ° ere are also di˛ erences in the morphological characteristics (distribution, density, pattern) of the layers from one person

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Figure 3.15 The superficial fascial system in the anterior aspect of the leg. This sample is a specimen from a fresh cadaver of an obese person A Skin E Fascial net B Cuboid adipose lobule F Flat adipose lobule C Septa 1 Superficial layer of the superficial fascial system D Deep fascia level 2 Deep layer of the superficial fascial system

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3 to another in distinct body regions, and depending on gender, age, and the amount of body fat (Fig. 3.16, Table 3.4). For example, in the perineum, the fat is almost nonexistent; the opposite is true in the axillary fossa (Fig. 3.17). ° is phenomenon is related to the function of each area, for example, protection or shock absorption. ° e volume of adipose lobes in both the superÿ cial and deep layers is not equal and can change along its path; therefore, the adipofascial layers can delimit the depth of adipose tissue in any body area. In some areas fusion can occur between both layers, or both layers can be transformed directly into another structure, for example the periosteum (Fig. 3.18). ° e morphology of the SFS clearly varies with gender. In the female body there is more cuboidal adipose tissue organized into multiple layers and the suspension ligaments are thinner. ° e adipose tissue distribution tends to accumulate above the belt and over the abdomen and shoulders in men and below the waist around the thighs, hips, and gluteal area in women (Fig. 3.19).

Links between the skin and superficial fascia In the description of Langer’s lines earlier in this chapter the author analyzed the in˝ uence of the restriction of skin movement on the dynamics of subcutaneous structures. Although there is no movement between the skin and the SL of the SFS, the skin is not mechanically isolated or independent from the underlying network. ° e honeycomb fascia is anchored to the dermis through the ÿ brils that irregularly emerge from it “with gaps ranging from 4 to 9 mm” between them (Song etˇal. 2006). ° ese ÿ brils, known as skin ligaments (retinacula cutis), determine the mobility of the skin over the deep structures (Nash etˇal. 2004) and also provide anchorage of the skin to resist tensile, rotational torque and gravitational forces (Gratzer etˇal. 2001) (Fig. 3.20). ° e pattern (distribution, orientation, density, and mobility) of skin ligaments changes according to the body area. ° eir orientation is mainly perpendicular to the skin; however, it varies according to the location or amount of adipose tissue. Usually, skin ligaments

Figure 3.16 Posterior aspect of the lower extremity in the unembalmed cadaver of an obese person A Fibrous attachments (adhesions) between the superficial and deep fascia B Thickness of fat at hip level

A B

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Anatomy and functional aspects of fascia

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Table 3.4 Differences in the distribution of adipose tissue within the superficial fascia system Adipose tissue density

Abundant

Scarce or absent

Anatomical areas

Cheeks Breasts Waist Buttocks Ischioanal (ischiorectal) fossa Hips Thighs Palms of the hands Soles of the feet

Eyelids External nose Pinna Lips Labia minora Penis Scrotum

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3 A

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E Figure 3.17 The axillary fossa. Note the large amount of adipose tissue and the anchoring of the superficial fascia to the deep fascia. This system acts as a mechanical protector of the neurovascular tract (axillary artery and vein and brachial plexus) and also of lymph nodes (pectoral, subscapular, humeral, central, and apical) A Ventral aspect of the arm B Axillary fossa C Skin at the pectoral area (view from above) D Skin with pectoral superficial fascia (view from below) E Pectoralis major muscle belly

Figure 3.18 Section of the knee joint in the sagittal plane A Superficial fascia B Superficial to deep fascia attachment C Patella D Skin

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Anatomy and functional aspects of fascia

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Figure 3.19 Adipose tissue distribution by gender. The shading indicates areas with the greatest accumulation of fat. A Female body. B Male body

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Figure 3.20 Skin ligaments over the pectoral area A Skin B Superficial fascia with adipose lobes C Skin lifted from the superficial fascia D Skin ligaments

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are plentiful over the breasts, where they are known as suspensory ligaments (Cooper’s ligaments), and also on the palms and soles (Nash etˇal. 2004) and on the face (zygomatic ligaments) (Rossell-Perry & ParedesLeandro 2013). Nash etˇal. (2004) demonstrated the presence of the extensive ÿ brous network systems of skin ligaments not just on the areas mentioned above but also in the subcutaneous tissue of the upper limbs, lower limbs, and trunk. According to their research the highest density of skin ligaments is present in the head, neck, upper and lateral trunk, and upper and lower limbs. ° ey relate it to the need for stability in these areas. ° e opposite occurs in the abdomen, gluteal area, and perineum, where the density of the ligaments is lower or they are absent. ° ese are areas that require elasticity in order to eˆ ciently adapt to mechanical demands, for example during pregnancy or according to the amount of subcutaneous fat and in relation to the neurovascular tract and intermuscular septa. ° ey also observed that the pattern of skin ligaments “appeared more organized when the number of fat cells in the subcutaneous tissue is low” and concluded that the “increased subcutaneous fat appeared to distort the ÿ brous network structure, resulting in a more random

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3 appearance, with reduced numbers of skin ligaments observed” (Nash etˇal. 2004). Along its path the SFS develops ÿ brous septa, which deÿ ne the continuity, shape, length, diameter, quantity, disposition, and dynamics of the adipose lobes. ° ese septa are connected to adjoining septa and skin ligaments, creating a dynamic branching system. ° rough this interconnected system the communication between the skin and muscle epimysium is maintained. ° e architecture of the ÿ brous septa of the SFS has some regional variations, according to the location and also the movement requirements of each region. In the SL, fascia is characterized by cuboid-shaped compartments, similar to honeycomb. It represents a solid structure with some amount of intrinsic movement between the fat nodes (Fig. 3.21, Video 3.2).

Video 3.3 Movement of the deep layer of the superficial fascial system

Mechanically, it can be considered that the SL of the SFS is an extension of the skin. Changes in the body outline relating to speciÿ c pathological processes, and observable in the skin, may be associated with dysfunction of the SFS. For example, wrinkles, cellulite, edema, in˝ ammation, pregnancy or obesity, and rapid weight loss mechanically a˛ ect the dynamics of the whole dermofascial unit. See Figure 3.23 for illustrations of the aforementioned alterations. ° e pathological changes in the structure of superÿ cial fascia mentioned earlier

Video 3.2 Movement of the superficial layer of the superficial fascial system

At the DL fascia displays as an extraordinarily mobile, striated structure (Fig. 3.22, Video 3.3).

Figure 3.21 The superficial layer of the superficial fascial system. Note the cuboid-shaped compartments, similar to honeycomb

Figure 3.22 The deep layer of the superficial fascial system: the extraordinarily mobile, striated fascia. Note the web-like collagen tendrils. These webs encase flat adipose lobes

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3

Anatomy and functional aspects of fascia A

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Figure 3.23-1 Photomontage of the superficial fascial system: normal tissue

Figure 3.23-2 Photomontage of the superficial fascial system

A Epidermis B Dermis C Superficial layer: cuboidal adipose lobule

A Wrinkles

D Membranous layer E Skin ligaments F Deep layer: flat adipose lobule

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G Deep fascia H Subcutaneous vein I Muscle

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Figure 3.23-3 Photomontage of the superficial fascial system: cellulite

Figure 3.23-4 Photomontage of the superficial fascial system A Edema (circled area) with short-term elongation of the skin ligaments

A Skin depression C Retracting skin ligaments B Hypertrophic fat lobules

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Figure 3.23-5 Photomontage of the superficial fascial system A Inflammation (circled area) with overstretched skin ligaments

Figure 3.23-6 Photomontage of the superficial fascial system: obesity

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A Overstretched skin ligaments C Ptosis B Hypertrophic fat lobules

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3 muscle, the platysma (Gardetto etˇal. 2002) (Fig. 3.26), and also the mammary gland (Stecco etˇal. 2009) (Fig. 3.27).

are observable in ultrasound scans (see the examples in Fig. 3.24). ° e SFS illustrates the variability of fascial thickness. In some areas the DL can completely disappear, leaving only the striated fascia (Nakajima etˇal. 2004). It is also possible to observe sporadic isolated muscle ÿ bers (panniculus carnosus) (Fig. 3.25). Some muscles correspond to the superÿ cial fascial system, for example some muscles of facial expression, the dartos

Links between the superficial fascia and deep fascia ° e DL of the SFS contains ˝ at adipose lobes surrounded by a loose fascial network, which is characterized by a great capacity for movement (Fig. 3.28). See also Video 3.3.

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Figure 3.24 Longitudinal ultrasound images of the subcutaneous tissue of the subumbilical region.

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1 Normal tissue

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2 Cellulite A Skin depression B Hypertrophic fat lobule

A Epidermis fascia B Dermis C Superficial fascia: cuboidal adipose lobule D Skin ligaments

3 Obesity

A Skin B Overstretched skin ligaments

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E Rectus abdominis muscle F Rectus abdominis muscle G Peritoneum H Small intestine

C Retracting skin ligaments

C Hypertrophic fat lobules

Images courtesy of Javier Álvarez González

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3

Anatomy and functional aspects of fascia A Figure 3.27 X-ray showing a normal mammogram result. Note the distribution of the fascial net. Image courtesy of Javier Álvarez González

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Figure 3.25 Superficial fascia in the pectoral area A Muscles fibers (panniculus carnosus) B Sternum

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Figure 3.26

RUN LABELS ALPHABETICALLY Platysma A Angle of the mandible B Chin C Platysma D Skin, lifted from the neck E Clavicle

Figure 3.28 Close-up of the three-dimensional network of the deep layer of the superficial fascial system of the thigh A Flat adipose lobes

Image courtesy of Prof. Dr. Horacio Conesa

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3 In the SL the orientation of the ÿ brils that make up the network is mostly perpendicular to the skin. In the DL the ÿ brils run mostly obliquely or even horizontally (Fig. 3.29). ° ese morphological di˛ erences are related to the respective mechanical functions. In the SL the ÿ bers are associated with maintenance of skin weight. Depending on the body area the thickness of the ÿ bers di˛ ers; it is greater in the lower limbs, and is thus associated with antigravity control. In the DL, the oblique orientation of the ÿ bers facilitates the sliding process of the SFS over the deep fascia and helps in the lubrication of musculoskeletal movement (see Video 3.3). It also fulÿ lls the mechanical requirements for the conduction of lymph vessels, nerves, and vascular bundles (Fig. 3.30). Additionally, according to Sommer etˇal. (2013), the oblique orientation of the ÿ bers has a pressure resistance role. ° e morphology of the DL is not uniform across the body. For instance, it is thinner

over the front of the trunk than over the back, and also the volume of fat is usually thicker in the lower segment of the trunk (Kumar etˇal. 2011). Other ÿ ndings of interest in the analysis of dissections of unembalmed cadavers were recorded in di˛ erent areas of the body (Fig. 3.31):

•

° e adipose lobes may overlap several fascial planes making their path unclear (Fig. 3.32).

•

In some areas multiple fascial layers were found, which then merged into a single layer and subsequently transformed again into a multilayered structure (Fig. 3.33).

•

° e presence of areas where the skin–fat envelope is tethered to the underlying musculoskeletal anatomy, restricting either descent or elevation, which can occur with aging, weight ˝ uctuation or surgical

B C

Figure 3.29 Lateral aspect of the leg A Superficial fascia with fat (inner view). The superficial fascia and skin have been separated from the deep fascia B Superficial to deep fascia anchorage. Note the oblique or even horizontal orientation of the anchoring fibers C Deep fascia of the leg

A

A

B

C

D Figure 3.30 Superficial fascial system at the inner aspect of the forearm A Skin B Cuboidal adipose lobes C Cutaneous nerve and vein D Deep fascia

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3

Anatomy and functional aspects of fascia

C

B

D

C

C

B

D D

C

Figure 3.31

B

C

Examples of areas of incisions performed in the analysis of morphology of superficial fascia

A

D Figure 3.32 Superficial fascia of the gluteal area. The adipose lobules may overlap fascial planes A Fat lobule embedded in the superficial fascia B Superficial fascia C Dimples after the removal of an adipose lobule D Deep fascia

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3 A

C

B

A

D

B

1 A

Figure 3.33 Anterior aspect of the thigh. At the superficial layer (honeycomb-like fascia) the adipose tissue can be distributed in several spaced layers, then it can merge into a single layer and subsequently be converted again into a multilayered structure A Deep fascia B Multiple layers of superficial fascia

2 Figure 3.34 1 Posterior aspect of the middle third of the leg A Skin B Deep fascia of the leg C Superficial fascia (inner view) D The large fluid and fat deposit. A derivation of the superficial fascia creates a type of compartment to hold the excess fluid and fat 2 Posterior aspect of the middle third of the leg A Large fluid and fat deposit sectioned with a scalpel

manipulation. ° ese areas are called zones of adherence and act like “hooks” for the skin–fat envelope to hang onto as it falls down, especially a˙ er the skin has been stretched by excess weight and then de˝ ated by weight loss (Fig. 3.34).

•

° e morphological variations that were found mostly match with those reported by Nakajima etˇal. (2004). Table 3.5 and Figure 3.35 summarize the di˛ erences in the architecture and functions of the superÿ cial fascia throughout the body.

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3

Table 3.5 Morphological pattern of the superficial fascial system Morphological pattern

Distribution

Two adipofascial layers

Function

Superficial layer Protection Maintaining the position of the skin Transmission of muscle action directly to the skin

Superficial layer Honeycomb fascia Cuboid-shaped adipose lobes Deep layer Striated loose fascia Flat adipose lobes

Deep layer Transmission of muscle action directly to the skin Wide range of motion Control of the sliding process Autonomy of superficial nerves and vessels from muscle contraction Pressure resistance role

Membranous lamina Characteristics Two-layered structure Obvious presence of membranous lamina Head Face Neck Trunk Dorsal regions of the wrist and ankle joints

Allows ease of movement of the thorax during breathing

Two adipofascial layers with no evident membranous lamina between them

Chest Upper arm Elbow joint Lower extremity (with the exception of the posterior thigh and knee joints)

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3 Table 3.5 continued Morphological pattern

Distribution

Function

Presence of only cuboid adipose tissue and honeycomb fascia penetrating the deep fascia. Absence of flat adipose lobes

Protects vulnerable structures in weight-bearing areas Participates in antigravity action Ensures that objects can be safely held in the hands

Some parts of the face Palms of the hands Soles of the feet Posterior neck

Shoulder Posterior deltoid area Buttocks Posterior thigh

Anchoring structure

The anchoring structure makes large cutaneous vessels and nerves resistant to slippage by:

Subcutaneous fascia is anchored to the deep fascia or to the periosteum*

providing adhesions along the courses of nerves providing adhesions to bony prominences dividing compartments

Adipose tissue is scarce or absent

Nasolabial folds Zygomatic arch Infrahyoid line Sternum Axillary region Inframammary folds Antecubital fossa Linea alba Groin

Tibial crest Galea aponeurotica Occipital protuberances Nuchal ligament Midline of the spine Iliac crests (L4 level) Folds of the buttocks Popliteal fossa

* Subcutaneous fasciae were found to be anchored to a relatively narrow area of the underlying deep fascia or periosteum forming skin creases, cleavage, and fossae (Nakajima et al. 2004, Herlin 2015, Pilat 2015).

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1

3

Figure 3.35 A Morphological differences of the superficial fascial system: front view. 1 Abdominal area. Two adipose layers with membranous lamina. 2 Anterior aspect of the thigh. The structure consists of two adipose layers with no clear membranous lamina. 3 Infrapatellar area: docking structure with no adipose tissue. B Morphological difference of the superficial fascial system: rear view. 1 Occipital protuberances: docking structure. 2 Lumbar area with cuboidal adipose nodules and membranous lamina. The fat is flat. 3 Plantar fascia with only cuboidal fat and without flat lobules

2

3 A

MAIN PART ‘A’ SO SUBPARTS SHOULD BE NUMBERS (ALSO APPLIES TO PART ‘B’)

1

2 3

B

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3 •

° e morphological characteristics of each area can be described as follows: ▶ Presence of two adipofascial layers (SL and DL) and evident membranous lamina between them (Fig. 3.36). ▶ Presence of two adipofascial layers with no obvious dividing sheet (Fig. 3.37).

B

C

D

▶ Presence of only honeycomb fascia with cuboidshaped adipose tissue. Flat adipose lobes are missing (Figs. 3.38 and 3.39). ▶ Docking structures (adhesions). In these areas subcutaneous fascia develops folds, segmentations, and fossa and is almost missing the adipose tissue. ° e superÿ cial fascia attaches directly to the deep fascia or to the periosteum. ° ese anchors keep the skin in a ÿ rm position at strategic points for protection and/or movement control (distribution). ° e pattern of the docking structure is related to the mechanical requirements of the speciÿ c body region and can occur in di˛ erent arrangements, for example:

° Creation of divisions as in the ÿ rm attachment

A

of the superÿ cial and deep fascia along the line of the spinous processes which divides the two sides of the back (Fig. 3.40) or the attachment at the body of the sternum dividing the two sides of the thorax (Fig. 3.41). In both locations, the superÿ cial fascia merges with the deep fascia and subsequently both fuse in the periosteum.

D

A

A

E

Figure 3.36 Cross-section of the internal compartment of the thigh A Cuboidal adipose lobules B Adductor muscles compartment C Flat adipose lobules D Membranous lamina. (This dividing sheet is not always well defined and in some segments may bifurcate.) E Skin

D

A A

C

D

E

B

C

C A

A

B Figure 3.38 Figure 3.37 Fascial layers on the anterior aspect of the thigh. Note the absence of a dividing membrane between the superficial layer and the deep layer A Skin C Superficial layer of the superficial E Deep fascia fascial system B Skin (inner view) D Deep layer of the superficial fascial system

Posterior aspect of the thigh. Note the absence of flat adipose lobes and the direct insertion of superficial fascia into deep fascia A Superficial fascia with adipose honeycomb-like lobes: view from above B Superficial fascia: view from below (the superficial fascia has been sectioned and lifted) C Deep fascia D Superficial to deep fascia anchorage

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3

B

1 A

A B

B A 2 D D

C

C Figure 3.40

Figure 3.39 Palmar aspect of the hand. Note the absence of flat adipose lobes and the direct insertion of superficial fascia into deep fascia A Skin B Cuboidal adipose lobules C Palmar fascia

D

1 Posterior aspect of the trunk. The incision has been carried out along the line of the spinous processes A Incision line B Anchoring of the superficial fascia to the periosteum at the level of the spinous processes 2 Image on the longitudinal axis of the line of the spinous processes A Skin B Superficial fascia C Spinous processes D Anchoring of the superficial fascia to the periosteum at the level of the spinous processes

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3 ▶ Fusion of the fascial layers with the underlying so˙ tissue, as in the linea alba. Figure 3.42 shows the progress of the dissection at the abdominal area from the skin level to the linea alba.

A

▶ Adhesions around the joints. Fascia merges with the periosteum (at the bony prominence), ligaments, or joint capsule increasing movement stability (Figs. 3.43 and 3.44). ° us, the skin can directly follow the joint movement.

B

C

▶ Subcutaneous bursae. ° ese arise within the superÿ cial fascia or between the superÿ cial and deep fascia. ° ey are present in areas susceptible to repetitive friction from unusual shearing stresses, particularly over bony prominences. For example, the subcutaneous prepatellar bursa lies between the skin of the knee and the patella, facilitating the movement of the skin (Fig. 3.45). Knee bursitis (Fig. 3.46) can be produced by trauma (for example, prolonged and frequent kneeling) or medical conditions like rheumatoid arthritis and gout.

D

Figure 3.41 Anchoring of the deep layer of the superficial fascial system to the deep fascia at the sternal line A Superficial fascia: view from above B Superficial fascia with adipose honeycomb-like lobes: view from below C Deep fascia D Superficial to deep fascia anchoring

▶ Protection of neurovascular tracts (see below for details). B

C

D

E

C B

A

A 1

2

Figure 3.42-1 Skin incision along the midline of the abdominal region between the navel and the pubis

Figure 3.42-2 Abdominal fascia. The incision was made along the linea alba down to the level of the deep fascia

A Navel B Superficial fascia with adipose lobes C Pubis

A Navel B Superficial fascia with adipose lobes C Subcutaneous vessels embedded in the superficial fascia D Deep fascia E Skin

58

H

G

C Pilat_Myofascial Induction.indb 58

E

A

B

B D

D

E

F

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1

2

Figure 3.42-1 Skin incision along the midline of the abdominal region between the navel and the pubis

Figure 3.42-2 Abdominal fascia. The incision was made along the linea alba down to the level of the deep fascia

A Navel B Superficial fascia with adipose lobes C Pubis

A Navel Anatomy and functional aspects of fascia B Superficial fascia with adipose lobes C Subcutaneous vessels embedded in the superficial fascia D Deep fascia E Skin

E

A

B

3

H

G

C

B

D

D

E

F

D

E

A

C

3

4

Figure 3.42-3 Abdominal fascia

Figure 3.42-4 An incision in the fascial layers along the midline of the

A Navel B Superficial fascia, separated from deep fascia and lifted C Line of adhesion between the superficial and deep fascia D Deep fascia. Note the fibrous appearance and deformation of the fibers when the superficial fascia is pulled E Linea alba

abdominal region between the navel and the pubis A Navel B Skin C Skin, dissected and turned down D Superficial fascia (superficial layer) with fatty lobes E Superficial fascia (deep layer) F Adipose lobes G Deep fascia H Pubis

A

C

B

D 1

C A

B A

C

D B 1

2

Figure 3.43-1

Figure 3.43-2

Anterior aspect of the knee joint. The adhesion allows continuity of movement between the skin and the joint A Tibial crest B Adherence C Patella D Superficial fascia with adipose lobules

Close-up of the anterolateral aspect of the leg at the level of the patella. Note the large area of adherence of the superficial fascia and the deep fascia A Adherence of the superficial and deep fascia B Superficial fascia with adipose lobules (inner view) C Fibrous attachment between the superficial and deep fascia

A

C B

2

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3 C

B

D

E

B

A

Figure 3.44 Posterolateral aspect of the leg and foot. A Skin (inner view) B Superficial fascia (inner view) C Calcaneus D Superficial to deep fascia insertion E Plantar fascia

A

B

C

D

E

Figure 3.45 Sagittal section of the knee. The presence of the bursa allows for a better gliding movement A Tibia C Hoffa’s fat pad E Femur B Subcutaneous prepatellar bursa D Patella

B C

A

B 1

D

2

Figure 3.46 Severely inflamed subcutaneous prepatellar bursa. 1 Subcutaneous prepatellar bursa in the left knee joint. 2 An MRI scan of the knee joint in the sagittal plane A Tibia B Subcutaneous prepatellar bursa C Patella D Femur

Superficial fascia and the circulatory system Fascia actively participates in the hemodynamic stability of the body by maintaining the intrinsic and extrinsic pressure in the circulatory system and may indirectly mediate blood ˝ ow (Li & Ahn 2011). Subcutaneous blood

Figure 3.47 The vascular system in the ulnar fossa. Note the vascular structures embedded in the superficial fascia

vessels are extensively integrated into the fascial network which wraps around vascular structures, providing both mechanical support and protection (Fig. 3.47). ° e fascial network prevents excessive expansion of the circulatory system, but it also does not allow its collapse. ° e functionality of the venous and lymphatic systems is inseparable from fascial dynamics. ° e pressure

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in both systems di˛ ers (is lower) from that of the arterial system which is controlled by the powerful pumping of the heart. In parallel, the construction of the walls of the veins and lymphatic vessels is more fragile, with less resistance to deformation, compared to the walls of the arteries. ° is “deÿ ciency” is compensated for by fascial dynamics, allowing an eˆ cient process of blood return to the heart.

3

Fascia and the lymphatic system ° e lymphatic system is a network of tissues and organs which helps the body to drive out toxins, waste, and other unwanted materials (Fig. 3.48). ° e ÿ ne network of fascial ÿ laments, together with adipose lobules, protects the fragile lymphatic vessels and lymph nodes and facilitates the movement of lymph. Simultaneously, it facilitates their adaptation to the mechanical

B

C A B A

C

A C

A

Anterior view

Posterior view

Figure 3.48 Schematic representation of the lymphatic system A Lymphatic vessels B Lymph nodules C Lymph nodes

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3 requirements for the transport of lymph from peripheral tissues to the veins. ° e superÿ cial (small) lymphatic vessels and nodes are embedded in the SL of the SFS. ° e deep nodes are located in the DL of the SFS. ° is extensive system takes care of four major body functions (Cueni & Detmar 2008):

•

drainage of excess interstitial ˝ uid (regulation of tissue pressure) and proteins back to the systemic circulation;

• •

maintenance of hydric balance in the body;

•

absorption of lipids from the digestive system.

Caudal Lateral Medial Cranial

regulation of immune responses by both cellular and humoral mechanism;

In inflammatory disease, by increasing the volume of the lymphatic nodules, the fascial network hardens and its movement can be distorted. The lymphatic system can also contribute to the development of diseases such as lymphedema, metastatic cancer, and inflammatory disorders (Mallick & Bodenham 2003).

A

B

•

° e thoracic duct (le˙ lymphatic duct) is the largest of the body’s lymphatic ducts. It collects almost all of the lymph that circulates throughout the body. It is located in the mediastinum of the pleural cavity which drains lymph ˝ uid from everywhere except the upper right quarter of the body above the diaphragm and down the midline.

E

Figure 3.49 The left inguinal area A Inguinal ligament B Superficial inguinal lymph nodes C Superficial fascia with adipose nodules D Pubis E Superficial epigastric vein

Essential anatomy and behavior of the lymphatic system In the human body the lymphatic system is organized by lymphatic vessels, lymph nodules, and lymph nodes (Fig. 3.49). Humans have approximately 500–600 lymph nodes distributed throughout the body with bundles found in the underarms, groin (Fig. 3.50), neck, chest, and abdomen. Lymphatic capillaries join to form lymph venules and veins that drain via regional lymph nodes into the thoracic duct on the le˙ side or into the right lymphatic duct; from there, the lymph ˝ ows back into the bloodstream (Fig. 3.51). (Mallick & Bodenham 2003, Hematti & Mehran 2011).

D

C

Cranial

Caudal

A

C

B B

F

D

E

Figure 3.50 Left inguinal area with lymph nodes A Pubis B Deep lymph inguinal nodes C Deep abdominal fascia D Inguinal ligament E Fascia lata F Anterior superior iliac spine (ASIS)

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A

B

3

C

D

Anterior view

Posterior view

Figure 3.51 Diagram of lymphatic drainage areas. Arrows indicate the direction of lymphatic drainage A Area drained by the lymphatic duct B Area drained by the thoracic duct C Location of the lymphatic duct D Location of the thoracic duct

•

° e lymphatic duct (right thoracic duct) drains lymphatic ˝ uid from the right thoracic cavity, the right arm, and from the right side of the neck and the head. ° is duct is located near the base of the neck, and passes along the medial border of the anterior scalene muscle at the side of the neck.

Essential to the provision of continuous local lymph drainage is the presence of intermittent external forces that act on lymphatics. According to Mallick & Bodenham (2003), these forces come from:

• • • •

muscle contractions (reinforced by fascial dynamics) activities of the body (for example, breathing patterns) arterial pulsations external forces acting on the body.

Fascia and the venous system ° e main function of the venous system is to allow the return of the deoxygenated blood from the capillary bed to the heart. ° is process, that has to transport

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3 around 7,000 liters of blood daily, begins in the capillaries and ends in the vena cava. Superÿ cial veins are submerged in the structure of superÿ cial fascia and their activity widely depends on the degree of tension that the fascia exerts on them (Fig. 3.52).

Essential anatomy and behavior of the venous system ° e venous system consists of two distinct parts (Fig. 3.53) (Ricci & Georgiev 2002, Caggiati & Franceschini 2010):

•

•

° e superÿ cial or epifascial system located under the skin, which is responsible for carrying the blood away from the subcutaneous tissue. Some veins may be accompanied by superÿ cial or sensory nerves (e.g., the musculocutaneous nerve follows the path of the cephalic vein along the forearm). ° e veins between the muscles and the skin are assigned to the superÿ cial system. ° e deep or subfascial system is responsible for draining the muscles and bones. ° is is also the

primary network and is located in the deep compartment, under the deep fascia, and follows a path parallel to the arteries. ° e veins inside the muscles are associated with the deep system. Both the epifascial and subfascial systems are separated anatomically by the deep fascia. However, they communicate with each other through perforating veins known as transfascial veins. ° e system is constituted hierarchically. From the smallest to the largest, according to their caliber and position, the components are venous capillaries, venules, tributaries, and saphenous trunks, which together form an interconnecting drainage network. ° e most complex movement of venous blood is performed in the veins of the legs. ° e veins, acting against gravitational forces, must carry blood to a great height which can be up to a meter and a half. As a consequence, a particular construction is required to incorporate the valves into the large veins. ° e valves are types of wings of intraluminal connective tissue

A

Figure 3.52 Posterior aspect of the leg. Superficial veins embedded in the superficial fascia

B

C

D

E

F

Figure 3.53 Photomontage of the anatomical distribution of the venous system Circles – locations of the veins Dotted lines – indicate the thickness of the structure A Subcutaneous compartment (location of collateral or tributary veins) B Interfascial compartment (saphenous compartment) C Deep compartment (the deep venous system) D Skin E Superficial fascia F Deep fascia

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3

Figure 3.54 The venous valves in the leg

A

Normal valve

The valve opens with upward flow

The valve opens with upward flow

When there is return flow, the healthy valve prevents reverse blood flow

When there is return flow, the valve fails to close resulting in backflow and pooling

B

Venous valve insufficiency

(Fig. 3.54). ° ese valves divide the long veins into segments. ° e valves open as soon as the blood is pushed up and they close the instant the blood stops pushing up and begins to ˝ ow backwards. Healthy valves prevent blood from pooling around the periphery (especially when standing) and absorb the forces acting on the veins under stress (walking, running, and jumping). If the valves’ functioning is impaired or even destroyed due to injury or in˝ ammation, sometimes the blood going to the heart is pushed into the subcutaneous veins instead of the deep veins by the actions of the muscles of the legs. ° is produces excessive tension in the superÿ cial venous system, the symptoms of which are stasis and edema. In the long term this can lead to chronic venous insuˆ ciency (CVI). To protect the superÿ cial veins and optimize return of venous blood,

the superÿ cial fascia has developed an anatomical set of sheets of di˛ erent thicknesses that form compartments that act as routes for the pathways of the veins. ° ese compartments, according to the demands of the speciÿ c zone, form tunnels providing passages for vascular structures. ° e most important fascial compartments surround the following structures in the leg (Caggiati 2001):

• •

the great and small saphenous veins (Fig. 3.55);

•

the proximal section of the anterior accessory saphenous vein;

the vein loops on the dorsum of the foot connecting the great and small saphenous veins;

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3 Figure 3.55 A The course of the great saphenous vein. B The territory and the zone of influence of the saphenous vein

Femoral vein

Great saphenous vein

Small saphenous vein

A

•

B

the proximal section of the posterior accessory saphenous vein and occasionally along its entire course up to the con˝ uence with the small saphenous vein.

° e great saphenous vein and small saphenous vein run in their own fascial compartment (Figs. 3.56 and 3.57). ° e saphenous fascia wraps the saphenous trunks providing them with a certain independence from surrounding structures and fat content in order to facilitate the venous function (Fig. 3.58) (Soler etˇal. 2012). Video 3.4 shows blood ˝ ow through the great saphenous vein. Superÿ cial fascia makes up the superÿ cial sheet of this compartment, which is called saphenous fascia and which is both thick and thin. ° e deep sheet is composed of deep fascia and it is

positioned close to the muscle ÿ bers (Figs. 3.59 and 3.60). ° us, muscle contraction can alter the size of the vein and mechanically in˝ uence varicose processes (Fig. 3.61) (Caggiati 2001, Cagiatti & Franceschini 2010, Bergan etˇal. 2006). And, conversely, the tension of the fascial system (depending on local and functional requirements) will a˛ ect the state and behavior of the vessels of venous circulation, in˝ uencing the varicose processes.

Video 3.4 Blood flow through the great saphenous vein

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T A

F D

B

C

Figure 3.56 Transverse view of the proximal third of the right thigh T Tibia F Fibula Red circle – great saphenous vein White circle – small saphenous vein A Interosseous membrane B Medial gastrocnemius muscle C Lateral gastrocnemius muscle D The course of the small saphenous vein. In the upper segment, it runs in the recess between the medial and lateral gastrocnemius muscles and further down directly on the soleus muscle. In the ankle region, it runs lateral to the Achilles tendon and posterior to the lateral malleolus

A

Figure 3.57 The saphenous vein protected by the saphenous compartment. The lines indicate the path of the saphenous vein Image courtesy of Dr. Maribel Miguel-Pérez

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3 A B

D

C

E

Figure 3.58 Longitudinal view of the thigh showing the great saphenous vein. The membranous layer (tunic) along the saphenous veins is seen as a white layer on ultrasound and can be distinguished easily from the surrounding fat and muscle A Skin C Tunics of the vein E Muscle B Superficial fascia D Blood stream Image courtesy of Javier Álvarez González

Figure 3.60 Transverse view of the thigh showing the great saphenous vein. Note the overlay highlighting the “saphenous eye” where the upper lid is the saphenous fascia, the lower lid is the muscle fascia, and the iris is the great saphenous vein (Caggiati & Franceschini 2010). Image courtesy of Javier Álvarez González

A

B A B

A1

C D E F

G

1

Figure 3.59 Photomontage of a transverse view of the thigh showing the great saphenous vein A Skin D The great saphenous vein B Adipose lobule E Deep fascia C Superficial fascia compartments support F Epimysium the adipose lobules G Muscle

2

Figure 3.61 Transverse view of the thigh showing the great saphenous vein (A and A1). 1 Without compression. 2 With compression applied by the ultrasound probe at the cutaneous level. The structure of the lax subcutaneous connective tissue can be seen as a white pattern in the grey fatty tissue (Cagliattti, 2010). Images courtesy of Javier Álvarez González

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Fascia and arterial vascularization

3

A

° e arterial system in the superÿ cial fascia participates in the vascularization of the skin and thermoregulation.

C

Essential anatomy and behavior of the arterial system Arterial vascularization at the subcutaneous layer is not uniform (Fig. 3.62). It is usually associated with the requirements of each area. Note how the arteries border the contours of the adipose lobules in Figure 3.63. ° is sinuous pathway allows the fascial network to ensure the arteries mechanical independence from movements of the skin. Perforating arteries pass through the superÿ cial fascia to the skin, in two di˛ erent ways; they can take the longitudinal pathway and progressively reach the consecutive planes or advance perpendicularly. According to Taylor and Palmer (Fernández-Samos Gutiérrez 2012) the arteries are organized in three-dimensional territories called angiosomes (Fig. 3.64). ° e arterial system resembles a tree with a trunk (arteries) which divides into branches (arterioles) down to the smallest twig (arterial capillaries)

B

Figure 3.63 Fascial layers on the anterior aspect of the thigh A Perforating artery embedded in the superficial fascia of the thigh B Skin (inner view) C Superficial fascia with adipose lobules

C

D

B

E

A Figure 3.62

Figure 3.64 Anterior aspect of the thigh: branches of the superficial arterial system

Surface blood vessels in the lumbar and gluteal area. Note a marked difference in arterial vascularization between the lumbar and gluteal areas A Linea of dissection B Superficial fascia in the lumbar area C Superficial vascularization D Superficial fascia in the gluteal area E Skin (inner view)

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3 (Fig. 3.65). ° e fascial system can participate in modiÿ cations of this territory, depending on certain physiological or pathological conditions. ° e angiosome theory explains the variations that exist in the contributions of arterial blood to the skin and adjacent structures between the di˛ erent regions of the body. ° us, distension or narrowing of the arteries is associated with variations in the temperature of the skin.

Circulatory deficiencies related to superficial fascia According to Beyer etˇal. (2009) vascular alterations and reduced capillary density lead to ischemia. In chronic fascia densiÿ cation, obstruction and favoring of stasis occurs with the consequent ÿ brosis. Tissue ÿ brosis might further aggravate tissue malnutrition and lead to chronic hypoxia (Fig. 3.66). In relation to lymphatic vessels and perforating veins, fascial hardening can create traps in the form of “turnstiles.”

Vasculopathy

A

Fibrosis

B Reduced blood flow

Impaired diffusion

Hypoxia

C

Figure 3.65

Accumulation of ECM proteins

Activation of fibroblasts

The angiosome concept. A An angiosome. B Coupling of angiosomes as puzzle pieces. C Revascularization of an ischemic angiosome by “shock vessels” from adjacent angiosomes (Fernández-Samos Gutiérrez 2012) Stimulation of ECM production

Figure 3.66 Hypoxia formation

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Deep fascia as a system: Its morphology, architecture, and mechanics Key features of the deep fascial system • It is located directly beneath the superficial fascial layer and attached to it. • It has a dense and fibrous structure. • It expands deep into the body reaching the periosteum and the bone. • In some body regions, the superficial and deep fascial layers can be merged. • Its morphology and pattern of distribution demonstrate regional specificity. • It forms a communication network between different body systems, such as the muscular, nervous, or vascular systems. • It is involved in myofascial force transmission interacting with muscles. • It develops septa and communicates with the interosseous membranes. • It contains an extensive network of mechanoreceptors. • It participates in proprioception and also motor control. • It is characterized by plasticity (plasticity is defined as the strengthening and weakening of connections in response to stimuli).

A

*

*

*

B

C

Figure 3.67 Anterior aspect of the thigh: adhesions between the superficial and deep fascia A Superficial fascia B Deep fascia C Skin * Adhesions

A

B

C

Morphology of the deep fascia According to research, deep fascia is a dynamic communication network between (and within) different body systems, for example, the muscular, circulatory, nervous, and vascular systems.

3

Figure 3.68 The path of the deep fascia of the thigh A Femur B Femoral artery C Sciatic nerve

Deep fascia is attached beneath superÿ cial fascia (Fig. 3.67) and expands deep into the body, blending with the periosteum until it reaches the bone (Fig. 3.68). It is devoid of fat, usually inelastic, tough, and never crosses a subcutaneous edge.

are dealing with an entire structure with an uninterrupted path (Fig. 3.69).

Di˛ erent names are assigned to deep fascia that are usually linked to certain body areas (thigh fascia, arm fascia) or certain muscles, (pectoral fascia, bicipital fascia, gluteal fascia). However, it should be noted that we

Its morphology (thickness, number of layers, orientation of ÿ bers) varies according to its regional specialization. It is denser in areas requiring stability and resistance, but it is scattered in areas where extensive movement is

Deep fascia is a ÿ brous structure of dense connective tissue sheets which contain plenty of closely packed collagen ÿ bers (Fig. 3.70).

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3

B

C

D

E

A

Figure 3.69

IMAGE CUT OFF ONLY WAY TO INCLUDE CHIN/STERNUM (NOT MENTIONED IN CAPTION)

Continuity of the deep fascia along the upper limb (from the chin to the palm of the hand). A Deep fascia on the upper quadrant. B Deep fascia on the shoulder area. Note the continuity between pectoral, deltoid, and bicipital fasciae. C Cubital fossa area. Note the continuity between the brachial and antebrachial fasciae. D Carpal tunnel and the continuity of the deep fascia fibers in the forearm and the hand. E Palmar fascia

required (Fig. 3.71). It has been suggested that its structure, like a sleeve, shapes itself around the muscles (also groups of muscles) and tendons (Fig. 3.72). For some anatomists and surgeons this is the true fascia. However, recent research expands on this view, emphasizing the dynamic role of deep fascia and focusing on its innervation and the relevance of functional links between microfascial and macrofascial structures. It

suggests that deep fascia is associated with protection, myofascial force transmission, proprioception, nociception, interoception, and posture control (see Chapter 8). Deep fascia, because of these characteristics, is emerging as a system with the potential to inform, joined as it is to the whole structure for a speciÿ c purpose (Pilat 2014). ° e purposes and functions of the deep fascial system are summarized in Table 3.6.

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B

C

3

A

1

Figure 3.70 Lateral aspect of the thigh. 1 Superficial and deep fascia of the thigh. Note the difference in morphology of both structures. 2 Close-up of deep fascia. Note the fibrous structure. The fibers are distributed in different layers and have a different orientation in each layer A Deep fascia of thigh B Superficial fascia of the thigh was dissected and separated from the thigh. C Patella

NEW SIZE MAY HAVE UNACCEPTABLE EFFECTS TO SETTING OF REST OF CH

2

Behavior of the deep fascial system ° is system consists of a complex communicational architecture (Kapandji 2012) which assures extensive mechanoreceptive information, not only through its topographic distribution, but mainly through the patterns of interrelation with other structures of the body (Lancerotto etˇal. 2011), especially the muscles. In its dynamic and ÿ brous construction the property of continuous remodeling (fascial plasticity) (Langevin 2010) is signiÿ cant. It serves to align and accommodate the intrinsic and extrinsic tensional body requirements

(Swanson 2013). Tensional accommodations, created outside physiological movement patterns, can reorganize the body dynamics through excessive extracellular matrix retraction (for example, through the dynamics of myoÿ broblasts or telocytes) (Tomasek 2002, Dawidowicz etˇal. 2016) that a˛ ects the freedom (coordination, synergisms, range of motion) of the movement (Hinz etˇal. 2007). ° e density, distribution, and organoleptic characteristics of the deep fascia di˛ er along its path, which allows it to adapt and respond to the demands of the movement (Benjamin 1995); however,

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3

Figure 3.71 The arrangement of deep fascia throughout the body. Note its fibrous structure

C B

B A

Figure 3.72 Deep fascia of the lower limb. Note the fibrous structure which is adjusted to the contents and also the continuity of the deep fascia between the thigh and the lower leg A Superficial fascia B Deep fascia C Patella

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Table 3.6 Purposes and functions of the deep fascial system Purposes

Functions

Formation or definition of the shape of the body

Keeps the underlying structures in position and preserves the surface contours of the limbs and neck

Distribution

Provides an enclosure (compartments) for muscle groups

Protection

Supports and protects muscles and other soft-tissue structures

Targeting of muscle force

Provides a broad surface for muscular attachment. Assists muscles in their action by the degree of tension and pressure it exerts upon their surfaces

Terminology and classification of deep fascia Following on from the analysis of the features and functions of superÿ cial fascia, this chapter will now focus on the anatomy and dynamics of deep fascia. ° ere is no consensus on the deÿ nition and classiÿ cation of deep fascia:

Creates a barrier against the spread of infection from the skin and superficial fascia into muscle compartments

° e Terminologia Anatomica (FCAT 1998) has recommended that the terms “superÿ cial fascia” and “deep fascia” not be used generically or in an unqualiÿ ed way because of variation in their meanings internationally. ° e recommended terms are “subcutaneous tissue” or “tela subcutanea” in place of superÿ cial fascia and “muscular fascia,” “parietal fascia,” or “visceral fascia” (fascia musculorum, fascia parietalis, or fascia visceralis) in place of deep fascia (Stedman’s Medical Dictionary 2005).

•

Its omnipresence in muscular architecture (the endomysium, perimysium, and epimysium) places it in a privileged location for interacting with muscle fibers

Merriam-Webster’s Medical Dictionary (2016) deÿ nes it as “a ÿ rm fascia that ensheathes and binds together muscles and other internal structures.”

•

Lee etˇal. (2011) deÿ ne deep fascia as comprising an intricate series of connective sheets and bands that hold the muscles and other structures in place throughout the body, wrapping the muscles in gray, felt-like membranes.

•

Stecco etˇal. (2008) states that the deep fascia of the limbs is a sheath formed by two to three layers of parallel collagen ÿ ber bundles and in the adjacent layers they show di˛ erent orientations.

•

˜ e Great Soviet Encyclopedia (2010) states: “the deep fascia invests individual muscles or [a] muscle group. Outgrowths of the deep fasciae form intermuscular barriers, which may serve as points of muscle termination and attachment. In many parts of the body, especially in the extremities, the fascial system acts as a spring. When muscles contract, the fasciae shi˙ their position, compressing or relaxing

Allows two bones to be connected at an optimum distance Increases the surface area for attachment of muscles Transfers weight from one bone to another

Prolongations

Forms the intermuscular septa which divide the limb into compartments Forms fibroareolar sheaths for muscles, vessels, and nerves

Safety

Muscle force transmission

° is new approach to the deep fascial system facilitates the linking of scientiÿ c and clinical ÿ ndings and o˛ ers a di˛ erent, widespread perspective for the analysis of body mechanics and pathomechanics through the behavior of the deep fascia.

•

Interosseous membrane formation

Preservation

Encloses neurovascular structures, glands, and muscles (e.g., in the neck)

Mechanoreception

Due to its innervation, it participates in proprioception and also motor control

Mechanical advantage through the retinacula

The retinacula act as pulleys and serve to prevent the loss of power

Circulation control

Helps with venous and lymphatic return

its continuity is fundamental. ° rough this it can act as a synergistic whole, absorbing and distributing a local stimulus to all the other components of the system (Ingber 2008).

3

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3 Epineuron

Perineuron

Endoneuron

Meninges

Dura mater

Arachnoid mater

Neurofascia

Pia mater

Epimysium of the limb muscles Epimysium Deep fascia of the trunk

Deep fascia

Myofascia Deep fascia of the limbs Aponeurotic fascia Deep fascia of the trunk

Visceral fascia

Figure 3.73 Distribution of deep fascia

connect muscles with other structures. Its structure is ÿ brous, dense, and nonextendable.

the neural and vascular sheets, thus facilitating the ˝ ow of blood toward the heart.” Following on from the classiÿ cations of fascia proposed earlier in relation to superÿ cial fascia, the following classiÿ cations for deep fascia are proposed (Fig. 3.73):

•

Myofascia wraps the muscles at each level of its construction (epimysium, perimysium, endomysium) (Figs. 3.74 and 3.75). It develops extensions that

•

Neurofascia covers each nerve as epineurium, each nerve fascicle as perineurium, and individual nerve ÿ bers as endoneurium (Fig. 3.76). It also supports the nerve ÿ bers and carries capillaries and lymphatics.

•

Visceral fascia envelops and supports the organs and allows them to be mobile.

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A

B

C

D

E

4

5

3

Figure 3.74 The internal structure of muscle A Tendon B Epimysium C Perimysium D Endomysium E Sarcolemma 1 Muscle belly 2 Muscle fascicle 3 Muscle fiber 4 Myofibril 5 Filaments

1 2

3

Figure 3.75 Fascial structures in the pectoral area A Skin B Superficial fascia C Deep fascia D Sternum

A B D

C

° e following classiÿ cation of myofascia is proposed:

Classification and morphology of myofascia Muscular and connective tissues are separable anatomically and histologically. However, they act as an indivisible functional unit during a movement. For this reason, the term “myofascia” is an accurate description of this tissue. ° e morphology of myofascia changes along its path. It manifests clearly in the extremities in the form of a sleeve and in the neck as a kind of collar. Its deÿ nition on the face is not clear.

• •

aponeurotic fascia epimysium ▶ deep fascia of the trunk ▶ epimysium of the limb muscles.

° ese two forms of deep fascia complement each other in their tasks, and in some areas it is even diˆ cult

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3 Axon

A Myelin

C

Endoneurium

D B

Nerve fibers

Fascicle

Figure 3.77 Posterior aspect of the trunk. Fusion of the aponeurotic and epimysial fascia A Trapezius muscle B Infraspinatous fascia C Inferior angle of the scapula D Fascial link between the trapezius and the aponeurosis of the infraspinatus

Epineurium Blood vessels

Figure 3.76 Schematic representation of nerve assembly. Reproduced with permission from Lesondak D. (2017) Fascia: What It Is and Why It Matters. Edinburgh: Handspring Publishing

to identify a clear anatomical division between them (Fig. 3.77).

Aponeurotic fascia Dorland’s Illustrated Medical Dictionary (2003) deÿ nes the aponeurotic fascia as “a dense, ÿ rm, ÿ brous membrane investing the trunk and limbs and giving o˛ sheaths to the various muscles” (Figs. 3.78 and 3.79).

Studies have demonstrated the importance of aponeurotic fascia in human movements. ° e aponeurosis provides an extra surface for muscular attachments known as regional fascial specializations (RFS) (they are also referred to: myofascial expansions, extensions, prolongations, modiÿ cations, or excrescences). Force transmission from a contracting muscle to neighboring muscles via aponeuroses (Jaspers etˇal. 1999) can expand throughout the entire system of aponeurotic connections and thus aponeuroses participate actively in movement coordination. ° e aponeurotic system seems to provide complementary pathways for muscle force transmission, stabilization, and protection. ° ese myofascial paths have a precise orientation and may participate in selecting the bundle of muscle ÿ bers according to the demands of each movement. In addition, the force management properties of muscle ÿ bers in a muscle–tendon complex are also considerably in˝ uenced by the aponeurotic fascia (Oda etˇal. 2007). Due to their viscoelastic properties, aponeuroses contribute to power enhancement through elastic energy reuse in locomotion and postural control (Maeda etˇal. 2015). Partial deformation of aponeuroses due to mechanical stresses can restrict

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Figure 3.78 Examples of aponeurotic fascia at the front of the body. A Pectoral fascia (continuity of the deltoid fascia with the fascia of the arm). B Abdominal fascia. C Fascia of the thigh

A

B

C

Figure 3.79 Examples of aponeurotic fascia at the back of the body. A Trapezius aponeurosis. B Latissimus dorsi aponeurosis. C Fascia lata. * Thoracolumbar fascia

A

* B

C

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3 length changes in connecting muscle ÿ bers and be the basis for the compensatory process and subsequent dysfunctions. ° e architecture of the aponeurotic fascia in the trunk di˛ ers from that of the limbs. Although both consist of a dense ÿ brous structure, mechanically they operate in a di˛ erent manner. In the trunk, the aponeurotic fascia allows the surface of insertion of the muscles to extend. For example, there are extensive connections between the latissimus dorsi muscle, the contralateral gluteus maximus muscle, and the thoracolumbar fascia (Fig. 3.80), which suggest a possible pathway for myofascial force transmission. Carvalhais etˇal. (2013), demonstrated that manipulation of the tension of the

latissimus dorsi modiÿ ed the passive contralateral hip variables, providing evidence of a myofascial pathway for force transmission in vivo. Another example is the interconnection of the abdominal muscles; the force generated by the internal oblique muscle is received by the external oblique muscle on the contralateral side (Fig. 3.81). In the limbs, the aponeurotic fascia covers the epimysium of the underlying muscles (Fig. 3.82). It forms a multilevel sheath of protection and force transmission. At each level of the construction of the aponeurotic fascia the orientation of the collagen ÿ bers is parallel, however, their direction is modiÿ ed in the consecutive layers (Fig. 3.83). In this way, this complex system can assist muscles in their actions by the degree of tension and pressure it exerts upon their surfaces and it also provides a strong resistance to traction. ° e epimysium envelops the muscle and is ÿ rmly attached to it. ° ere is no gliding between the

A

B

Figure 3.80 The thoracolumbar fascial system. The lines show the force transmission between the gluteus maximus and latissimus dorsi muscles through the thoracolumbar fascia

Figure 3.81 The abdominal fascial system. The arrows show the force transmission between the abdominal muscles through the abdominal fascia A External oblique muscle B Internal oblique muscle

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3

muscle and its epimysium and, for this reason, this zone lacks fat (Fig. 3.84). At the tendon/aponeurotic ends of the muscle the presence of fat and loose connective tissue can be observed. ° ese are also highly hydrated zones. ° is design allows for a better and faster adaptation to the movement and transmission of force generated by muscular contraction (Fig. 3.85). Arising from superÿ cial fascia, aponeurotic fascia continues on its path, becoming periosteum (Fig. 3.86). Subsequently it creates a ÿ rm attachment to the bone (Fig. 3.87). Figure 3.82 Anterior aspect of the thigh. The aponeurotic fascia has been sectioned. Note the continuity between the epimysium and the aponeurosis

Figure 3.83

Figure 3.84

Anterolateral aspect of the fascia of the leg. Note the density and fibrous structure of the fascia. Its function is to cover the anterior compartment of the leg

Anterior aspect of the thigh. Note the firm attachment of the muscle to the fascia which provides an efficient mechanism for transmission of contractile forces from muscles

Figure 3.85 Lateral aspect of the left knee. There is a marked difference between the epimysium and the aponeurotic fascia close to the joints in relation to the course of the muscle belly. The presence of loose connective tissue, abundant hydration, and the presence of fat in the vicinity of the joint facilitate an efficient accommodation to joint movement

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3 A

A

B

B

C Figure 3.86 Lateral aspect of the arm. Fascial continuity from the superficial fascia to the surface of the bone. Note the presence of the intermuscular septa that join the superficial fascia to the surface of the bone A Deep fascia B Intermuscular septa C Humerus

C

C

C

D

Epimysial fascia ° e discovery of the ultrastructure and mechanobiology of the sarcomeral unit has given shape to a new model of myoÿ brils, embedded inside the extracellular matrix, which, at the same time, participates (through its own dynamic) in the contractile phenomenon (Yucesoy 2010, Maas & Sandercock 2010). In the contemporary model of muscle contraction, the muscle does not act as an isolated and independent entity. ° e shortening of the myoÿ bril exerts a force from within the myofascial structure (endomysium, perimysium, and epimysium) and the muscle contraction resembles more the principles of the tensegrity model (see Chapter 6) (Gillies & Lieber 2011) rather than a simple linear analysis (movements arranged in series). Most contractile forces are destined for myotendinous units; however, approximately 30– 40ˇpercent of them use “the epimismal” transmission pathways, i.e., that are parallel to the tendinous ones (Huijing & Jaspers 2005, Huijing 2007). In this design, it can be observed that contractile force acts in both a linear direction and in multiple directions. Epimysial fascia is a multilayered ÿ brous structure which covers all layers of muscle architecture and deÿ nes its form and structure (Figs. 3.88 and 3.89). It connects muscles laterally with each other and also to tendons (Fig. 3.90) and neurovascular tracts (Fig. 3.91).

Figure 3.87 Pectoral region A Clavipectoral fascia B Pectoralis minor muscle C Ribs D Pectoralis minor muscle aponeurosis integrating into the periosteum of the ribs

° e neurovascular tracts wrap around and reinforce the blood and lymph vessels, as well as the peripheral nerves. ° ese tracts are strong candidates for an important route in force transmission (Huijing & Jaspers 2005, Huijing 2007, Purslow 2010, Chi Zhang 2012, Pilat etˇal. 2017). In recent research Bernabei etˇal. (2016) asserted that intramuscular and perimuscular connective tissue could act as a protective net in the case of a traumatic event related to the tendon or muscle belly. ° ey concluded that, in the dysfunction process, motor deÿ ciencies are mainly due to alterations of lateral connectivity between muscles rather than to speciÿ c alterations of the musculotendinous pathway. During each body movement all layers of epimysial fascia act in a coordinated manner, according to

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A

B

3

C

Figure 3.88 The epimysial fascial system. A Anterior view. B Lateral view. C Posterior view

NO COLOUR CHANGE A WAS SET AT WRONG SIZE SHOULD BE @100%

Figure 3.89 The multilayered structure of the fascia of the thigh A Pathways of the nerves and perforating veins

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3

Figure 3.90 Ventral aspect of the forearm. Note the epimysial connections (extramuscular connective tissue) between the tendons and muscle belly of the flexors of the wrist and finger muscles

A

tensegrity principles (see Chapter 6 for more details). ° e reader is referred to the schematic representation of muscle assembly in Figure 3.74, consisting of:

•

endomysium, which ensheathes each individual muscle ÿ ber;

•

perimysium, which wraps up muscle ÿ bers into bundles (fascicles);

•

epimysium, which surrounds the entire skeletal muscle structure.

One of the clearest examples of this muscle assembly is the pectoral fascia (Fig. 3.92) which covers and gives shape to the pectoralis major muscle. It can be observed that the epimysium launches septa that penetrate and

Figure 3.92 Epimysial fascia over the pectoralis major A Intermuscular septa separating the fascicles

compartmentalize the muscle, creating spaces for muscle fascicles or bundles. ° e muscle contraction locally tightens the septa; however, the contractile force is not just transmitted locally, but rather expands to the whole system. ° e epimysium architecture consists of three layers. ° e arrangement of ÿ bers varies in each layer. Purslow Figure 3.91 Ventral projection of the right upper extremity. Note the epimysial links between the vascular structures of the forearm

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Figure 3.93 Fascial entrapment. Note the disorganized pathway of the epimysial fibers

(2010) shows that in the deepest layer the pathway of the ÿ bers is chaotic, in the intermediate layer the ÿ bers shape a complex network, and in the superÿ cial layer the ÿ bers are thicker, ˝ attened, and follow a speciÿ c path. It should be noted that the epimysium is a richly hydrated structure. ° is hydration ensures gliding between the muscle ÿ bers, as well as maintaining their proper organization (the correct separation between them and their path). In dysfunction processes, disorganization of the paths of the ÿ bers occurs with the consequent formation of cross-linkages (Fig.˜3.93). ° rough all these connective tissue components, the arterioles, capillaries, venules, lymphatics, and nerves traverse to reach each muscle ÿ ber (Fig. 3.94). Numerous ÿ bers

in long muscles terminate their path without reaching any of the extremes of the tendon or aponeurosis. In this design, the tendon structure emerges as the continuity of the intramuscular fascial components, with a clear densiÿ cation and a parallel organization between the collagenous ÿ bers along its path (Fig. 3.95) (ChiZhang & Gao 2012).

Experience with unembalmed cadaver dissection As mentioned above, deep fascia can modify its morphology according to regional mechanical demands. Modifying its pattern develops regional fascial

Figure 3.94 Arterial vascularizaion of deep fascia. 1 Posterior aspect of the back. 2 The complex system of capillaries is embedded in the epimysial fascia A Inferior angle of the left scapula B Trapezius muscle

B A

2 Medial Anterior

1

Posterior Lateral

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3 Figure 3.95 The musculotendinous junction. Numerous fibers in long muscles terminate their paths without reaching any of the extremes of the tendon, thus force generated in fibers has to be transmitted laterally. The tendinous structure manifests as continuity of the fascial system of the intramuscular belly

specializations. ° e function of these structures is related to important tasks such as: protection, force transmission, friction minimization, muscle isolation, tendon positioning and stabilization, transmission of weight from one bone to another, improvement in venous and lymphatic return, formation of tendon sheaths, and an increase in the muscular insertion surface. Based on the experience of numerous dissections of unembalmed cadavers, the author suggests that the anatomy of deep fascia and its behavior have the functions described below.

•

Force transmission Deep fascia actively participates in the movement generated by contraction of musculoskeletal ÿ bers.

•

One example is (again) the lacertus ÿ brosus of the biceps brachii muscle. ° e precise orientation of its ÿ bers is important. When the elbow is in full extension the orientation of the ÿ bers in the forearm is oblique (Fig. 3.100A). However, in ˝ exion at about 90 degrees the ÿ bers are oriented transversely relative to the axis of the forearm (Fig. 3.100B). ° us, the ÿ bers are stretched and oriented in a straight line in the arm and forearm. It is suggested that this creates a mechanical advantage for the biceps brachii muscle. It is probably, one of the reasons why the biceps brachii develops maximum force from 90 degrees of ˝ exion. Additionally, Eames etˇal. (2007) suggest the stabilizing function of the lacertus ÿ brosus in relation to the distal end of the biceps’ tendon.

•

° e deep fascia creates connections between diverse structures. As mentioned above, the mechanical

Protection Deep fascia protects the underlying structures, i.e., vessels and nerves, in the event of trauma to the tendon, muscle belly or neurovascular tract (Bernabei etˇal. 2016).

•

One example of this function is the bicipital aponeurosis, also known as the lacertus ÿ brosus, of the biceps brachii muscle. It consists of a fascial expansion arising from the tendon of the short head of the biceps brachii which merges into the antebrachial fascia and protects the underlying vessels (Fig. 3.96).

•

Another example is the palmar (Fig. 3.97) and plantar (sole) (Fig. 3.98) aponeuroses, which serve to protect vessels and nerves.

It should also be mentioned that aponeurotic fascia can create routes for the transit of the nerves going through the consecutive fascial layers. Fascia is able to facilitate the correct positioning of nerves while ensuring the independence of muscular contractions (Fig. 3.99).

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Figure 3.96 Bicipital aponeurosis. 1 The cubital fossa of the left upper limb. 2 Bicipital fascia (lacertus fibrosus of biceps brachii muscle) A Cubital nerve B Median nerve C Tendon of the biceps brachii muscle D Medial epicondyle E Lacertus fibrosus F Antebrachial fascia Reproduced with permission from Pilat A., Fascial anatomy of the limbs. In: Liem T., Tozzi P., Chila A. (Eds.) Fascia in the Osteopathic Field. Edinburgh: Handspring Publishing

1

Anterior

2

l

A

B

C

D

E

F

Figure 3.97 Palmar fascia of the right hand. 1 Structure of the palmar fascia. 2 Carpal tunnel area with sectioned palmar fascia A Tendon of the palmaris longus muscle B Palmar fascia C Sectioned palmar fascia

A C B

1

2

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3 changes in muscles or muscle groups during the contraction are not just performed on the pathway between two tendons or aponeuroses. ° e force is also transmitted laterally through the epimysium and perimysium, which could act as pathways for the transmission of muscle forces. ° e regional fascial specializations may interrelate muscle ÿ bers or tendons with adjacent structures, as in the: ▶ muscle belly to muscle belly fascial link (Fig. 3.101); ▶ epimysial to aponeurotic fascia link (Fig. 3.102); ▶ adhesion between the muscle and epimysial fascia (Fig. 3.103); ▶ adhesion between the muscle and several layers of the epimysial fascia (Fig. 3.104); ▶ tendon to periosteum fascial link (Fig. 3.105); ▶ aponeurotic fascia to aponeurotic fascia link (Fig. 3.106); ▶ epimysial fascia to tendon link (Fig. 3.107); ▶ epimysial fascia–tendon–muscle ÿ bers link (Fig. 3.108);

Figure 3.98 Structure of the plantar fascia. Note the thick layer of superficial fascia with abundant adipose tissue

▶ epimysial fascia to the neurovascular tracts (Fig. 3.109). ° is is not just a passive connection but rather a dynamic link involving reciprocal action between the fascia, muscles, and neurovascular bundles. ° e neurovascular tracts wrap around and reinforce the blood and lymph vessels and also the peripheral nerves; they are strong candidates for an important route in force transmission.

Figure 3.99 Lateral aspect of the leg A Superficial peroneal nerve

A

Cranial

Caudal

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B

A Figure 3.100

The mechanism of the lacertus fibrosus. Note the direction of the fibers in extension (A) and in flexion at nearly 90 degrees (B)

Figure 3.101 Anterior aspect of the thigh A Fascia lata B Rectus femoris C Vastus medialis D Fascial link

Caudal Lateral

A

B

C

D Figure 3.102 Anterior aspect of the thigh: link between the aponeurotic and epimysial fascia A Fascia lata B Rectus femoris covered by epimysial fascia C Fascial link

B

A

Caudal

C Lateral

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3 C

D

Figure 3.103 Tensor fasciae latae muscle. There is a direct insertion of muscle fibers into the fascia. There is no fat or loose connective tissue between the fascia and muscle fibers A Fascia lata B Tensor fasciae latae muscle C Tensor fasciae latae muscle fibers firmly attached to the fascia lata D Adhesion between muscle and epimysial fascia

A B

A

B

C

E A B C D

D

Figure 3.105 Posterior aspect of the pelvis and thigh (the gluteus maximus muscle has been A removed) A Sacrotuberous ligament B Biceps femoris (long head) tendon insertion C Biceps femoris (long head) tendon D Biceps femoris (long head) belly E Ischial tuberosity

Reinforcement

Figure 3.104 The back A Trapezius muscle B Spine extensor muscles C Thoracolumbar fascia D Multilayered epimysial connections

Fascia reinforces underlying structures, such as tendons or even joints in areas susceptible to repetitive stress.

•

Retinaculum is one such example. Retinaculum is a broad band of dense crisscrossed ÿ bers that keeps tendons and bones in an optimal relation and stabilizes them. Retinacula are present at the wrists (Fig. 3.110) and ankles (Fig. 3.111) and act as pulleys that

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3

Figure 3.106 Posterolateral aspect of the leg: interconnection of the aponeurotic fasciae (circled area)

Caudal

Proximal

Cranial

Distal

A

C

2 B Figure 3.107 Ventral aspect of the forearm, showing the epimysium linked to a tendon

D

1 Figure 3.109

Figure 3.108 Ventral aspect of the forearm. The circled area clearly shows the unifying function of the epimysial fascia which connects muscle, tendon, and epimysium

Anterior aspect of the cervical area and upper limb. 1 The path of the brachial plexus. 2 The branches of the brachial plexus are protected by adipose tissue and loose connective tissue. Simultaneously the brachial plexus creates lateral links, which ensure a more efficient stabilization A Branches of the brachial plexus B The fascial links of the neurovascular tract C Shoulder joint D Medial epicondyle

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A A

B

B Figure 3.110 Antebrachial fascia. A The dorsal retinaculum of the wrist. B Dorsal fascia of the hand

A

B Figure 3.112 A Anterior aspect of the right leg. B The tendinous sheath surrounding the tendon

Figure 3.111 Dorsal aspect of the foot. The retinacula structure of the ankle

Figure 3.113 Ventral aspect of the left forearm: the paratenon

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Anatomy and functional aspects of fascia

allow smooth longitudinal sliding of the tendons. In the histological literature, Klein etˇal. (1999) recognize three distinct layers in the construction of retinacula: the inner, gliding layer, with hyaluronic acid-secreting cells; the thick middle layer containing collagen bundles, ÿ broblasts, and interspersed

elastin ÿ bers; and the outer layer consisting of loose connective tissue containing vascular channels. Unlike ligaments, it is doubtful that retinacula have a role in articular stabilization as their structure is relatively thin and lax. It should be noted that retinacula are not isolated structures, rather they are integrated with fascia through multiple insertions

C A A

D B C

Caudal

D

Cranial

Figure 3.114 Anterior aspect of the knee A Patella B Fascial expansions linking superficial fascia to deep fascia C Superficial fascia with fatty lobules (inner view) D Deep fascia

B Figure 3.115 Anterior aspect of the knee joint A Patella B Patellar ligament C Quadriceps femoris D The expansions of the deep fascia with the epimysium, ligaments, and the joint capsule

A

D B A B

C

Cranial

Figure 3.116 Transverse section of the knee joint. The aponeurotic fascia stabilizes the patella in the patellar groove A Patella B Femur C Popliteal space D Fascia lata

Caudal

Figure 3.117 Anterolateral aspect of the knee A Patellar ligament B Links of the patellar tendon to the deep fascia of the leg (circled area)

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3 in adjacent tendons or muscles. It is likely they act more as a local spatial proprioceptive structure and not so much as a mechanical joint stabilizer. ° eir structure and behavior conÿ rms the relevance of fascia in the process of peripheral coordination of articular movement (Stecco & Day 2010).

•

° e tendinous sheath (paratenon) is another tendon reinforcement and protection structure. It is a membrane which surrounds or overlies the tendon body, allows the tendon to stretch, and prevents it from adhering to the overlying fascial structures (Figs. 3.112 and 3.113). ° e paratenon wraps and nourishes the tendon. It plays an important role in tendon healing (Müller et al. 2018).

Stabilization Modifying its shape, deep fascia is integrated into the joint capsule, synovial membrane or bursae and is thus associated with joint dynamics. Figures 3.114 to 3.117 show the sequence of fascial structures associated with dynamic stabilization of the knee. ° ese are:

•

Fascial expansions which link superÿ cial fascia to deep fascia (Fig. 3.114);

•

Expansions which link deep fascia to the epimysium, ligaments and joint capsule (Fig. 3.115);

•

Aponeurotic fascia which stabilizes the patella in the patellar groove (Fig. 3.116);

•

° e links of the patellar tendon to the deep fascia of the leg (Fig. 3.117).

Increase in the muscular insertion surface ° e aponeurotic fascia of the trunk is like a ˝ attened tendon and is di˛ erent in its distribution compared to the fascia of the limb. It is distributed in several layers and brings together, anatomically and functionally, various muscles. ° e thoracolumbar fascia is an example of this dynamic (Fig. 3.118) (see also Fig. 3.80).

Muscle separation (isolation): Compartments and interosseus septa In the extremities, joining folds of deep fascia (intermuscular septa) separate functionally di˛ erent groups of muscles into compartments and frequently become continuous with the periosteum.

•

° e best example of this are the compartments in the leg. ° e deep fascia wraps around the leg; however, on the anterior aspect of the leg it disappears, merging with the periosteum (Figs. 3.119 and 3.120).

Figure 3.118

B

The thoracolumbar fascia connections A Thoracolumbar fascia B Trapezius C Latissimus dorsi D Gluteus maximus

C

C A

D D

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Anatomy and functional aspects of fascia

P A

1

J

B

B G

F

D I

C

C

H

E

2

23 J

P

24 Figure 3.119 Cross-section of fascial compartments in the leg. 1 Anterolateral aspect of the deep fascia of the leg. 2 Cross-section in a cadaver dissection. 3 Diagram of the crosssection. 4 Interior aspect of the deep fascia of the leg A Cross-section marker B Tibia C Fibula D Interosseus membrane E Crural fascia F Superficial posterior compartment G Deep posterior compartment H Anterior compartment I Lateral compartment J Deep fascia blended with the periosteum of bone P Patella

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3 B

A

Figure 3.120 Arrangement of the fascial compartments in the leg. Note the continuity of this system in relation to the behavior of the deep fascia. Image courtesy of Dr. Albert Pérez-Bellmunt

Figure 3.121 Cross-section of the arm A Humerus B Brachial intermuscular fascia

•

° e deep fascia extends the septa that merge into the periosteum. In this way, it creates compartments (spaces) for selective muscle activity (Fig. 3.121).

Friction reduction Deep fascia forms tendon sheaths wherever tendons cross over a joint. ° is mechanism prevents wear and tear of the tendons and it also helps in venous and lymphatic return from the lower limb. For example, the contraction of calf muscles in the tight sleeve of deep fascia helps to push the venous blood and lymph towards the heart.

Conclusion Considering that, anatomically, muscle ÿ bers do not connect directly with bones and therefore require a “middle man” to develop their work and create movement, the classic model of body movement based on Newton’s laws and the conceptualization of lever action to create body dynamics requires revision. Including fascia in the concept of movement makes the task diˆ cult. However, it simultaneously opens up new horizons, allowing us to unite in a conceptual model fascial dynamics integrated into the performance of other systems (mainly the nervous system) in the creation of movement.

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REFERENCES AND FURTHER READING

Abu-Hijesh MF, Roshier AL, Al-Shboul Q, Dharap AS, Harris PF (2006) ° e membranous layer of superÿ cial fascia: Evidence for its widespread distribution in the body. Surg Radiol Anat 28(6):606–619. Ahn AC, Kaptchuk TJ (2011) Spatial anisotropy analyses of subcutaneous tissue layer: Potential insights into its biomechanical characteristics. J Anat 219(4):515–524. AlHamdi A (2015) Facial skin lines. Iraqi JMS 13:103–107. Avelar J (1989) Regional distribution and behavior of the subcutaneous tissue concerning selection and indication for liposuction. Aesthetic Plast Surg 13(3):155–162. Benjamin M (1995) Fibrocartilage associated with human tendons and their pulleys. J Anat 187(Pt. 3):625–633. Benjamin M (2009) ° e fascia of the limbs and back--a review. J Anat 214(1):1–18. Bergan JJ, Schmid-Schönbein GN, Coleridge Smith P (2006) Chronic venous disease. N Engl J Med 355(5):488–498. Bernabei M, van Dieën JH, Maas H (2016) Altered mechanical interaction between rat plantar ˝ exors due to changes in intermuscular connectivity. Scand J Med Sci Sports 27(2): 177–187. Beyer C, Schett G, Gay S, Distler O, Distler JHW (2009) Hypoxia. Hypoxia in the pathogenesis of systemic sclerosis. Arthritis Res ° er 11(2):220. Bloom W, Fawcett D (1975) A Textbook of Histology. WB Saunders. Borley NR (2008) Anterior abdominal wall. In: Standring S (Ed.) Gray’s Anatomy: ° e Anatomical Basis of Clinical Practice, 40th ed. Philadelphia: Churchill Livingstone, p. 1060. Bush J, Ferguson MW, Mason T, Mc Grouther G (2007) ° e dynamic rotation of Langer’s lines on facial expression. J Plast Reconstr Aesthet Surg 60(4):393–399. Byard RW, Gehl A, Tsokos M (2005) Skin tension and cleavage lines (Langer’s lines) causing distortion of ante- and postmortem wound morphology. Int J Legal Med 119(4):226–230.

Caggiati A (2001) Fascial relationships of the short saphenous vein. J Vasc Surg 34(2):241–246. Caggiati A, Franceschini M (2010) Stroke following endovenous laser treatment of varicose veins. J Vasc Surg 51(1):218–220. Carmichael S (2014) ° e tangled web of Langer’s lines. Clin Anat 27(2):162–168. Carvalhais VO, Ocarino Jde M, Araújo VL, Souza TR, Silva PL, Fonseca ST (2013) Myofascial force transmission between the latissimus dorsi and gluteus maximus muscles: An in vivo experiment. J Biomech 46(5):1003–1007. Chi-Zhang C, Gao Y (2012) Finite element analysis of mechanics of lateral transmission of force in single muscle ÿ ber. J Biomech 45(11):2001– 2006. Colles A (1811 [1949]) A Treatise on Surgical Anatomy: Anatomy of the Perineum. Gilbert and Hodges, Dublin (Tobin CE, Benjamin JA). Congdon ED, John Edson J, Yanitelli S (1946) Gross structure of subcutaneous layer of anterior and lateral trunk in the male. Am J Anatomy 79:399–429. Cueni LN, Detmar M (2008) ° e lymphatic system in health and disease. Lymphat Res Biol 6(3–4):109–122. Dawidowicz J, Matysiak N, Szostek S, Maksymowicz K (2016) Telocytes of fascial structures. Adv Exp Med Biol 913:403–424. Delmas P, Hao J, Rodat-Despoix K (2011) Molecular mechanisms of mechanotransduction in mammalian sensory neurons. Nat Rev Neurosci 12(3):139–153. Dorland’s Illustrated Medical Dictionary, 30th ed. (2003) Saunders. Dupuytren G (1834) Clinical lectures on surgery. ° e Lancet 22(558):222–225.

3

Federative Committee of Anatomical Terminology (FCAT) (1998) Terminologia Anatomica: International Anatomical Terminology. Stuttgart, New York: Georg ° ieme Verlag, pp. 1–292. Fernández-Samos Gutiérrez R (2012) El modelo angiosoma en la estrategia de revascularización de la isquemia crítica [° e angiosome model in the revascularization strategy of critical limb ischemia]. Angiologia 64(4):173–182. Ferreira, LM, Hochman, RF, Locali LM, Rosa-Oliveira M (2006) A stratigraphic approach to the superÿ cial musculoaponeurotic system and its anatomic correlation with the superÿ cial fascia. Aesthetic Plast Surg 30: 549–552. Gardetto A, Dabernig J, Rainer C, Piegger J, Piza-Katzer H, Fritsch H (2003) Does a superÿ cial musculoaponeurotic system exist in the face and neck? Plast Reconstr Surg 111(2):664–72. Gasperoni C, Salgarello M (1995) Rationale of subdermal superÿ cial liposuction related to the anatomy of subcutaneous fat and the superÿ cial fascial system. Aesthetic Plast Surg 19(1):13–20. Gibson T (1978) Karl Langer and his lines. Br J Plast Surg 31:1–2. Gillies A, Lieber R (2011) Structure and function of the skeletal muscle extracellular matrix. Muscle Nerve 44:318–331. Gottschaldt KM, Iggo A, Young DW (1973) Functional characteristics of mechanoreceptors in sinus hair follicles of the cat. J Physiol 23(2):287–315. Gratzer J, Vokt CA, Brenner P (2001) Morphological and functional interface between palmar plates of metacarpophalangeal joints and intrinsic muscles of the hand. Handchir Mikrochir Plast Chir 33:299–309.

Eames MH, Bain GI, Fogg QA, van Riet RP (2007) Distal biceps tendon anatomy: A cadaveric study. J Bone Joint Surg Am 89(5):1044–1049.

Guimberteau JC, Delage JP, McGrouther DA, Wong JK (2010) ° e microvacuolar system: How connective tissue sliding works. J Hand Surg Eur 35(8):614–622.

Enevoldesn L, Simonsen L, Stallknecht B, Galbo H, Bulow J (2001) In vivo human lipolytic activity in preperitoneal and subdivisions of subcutaneous abdominal adipose tissue. Am J Physiol Endocrinol Metab 281:E1110–E1114.

Hamed K, Giles N, Anderson J, Phillips JK, Dawson LF, Drummond P, Wallace H, Wood FM, Rea SM, Fear MW (2011) Changes in cutaneous innervation in patients with chronic pain a˙ er burns. Burns 37(4):631–637.

97

Pilat_Myofascial Induction.indb 97

03/12/21 3:55 PM

3

REFERENCES AND FURTHER READING

Hematti H, Mehran RJ (2011) Anatomy of the thoracic duct. ° orac Surg Clin 21(2):229–238. Herlin C, Chica-Rosa A, Subsol G, Giles B, Macri F, Beregi JP, Captier G (2015) ° ree-dimensional study of the skin/subcutaneous complex using in vivo whole body 3T MRI: Review of the literature and conÿ rmation of a generic pattern of organization. Surg Radiol Anat 37(7):731–741. Hinz B, Phan SH, ° annickal VJ, Galli A, Bochaton-Piallat, Gabbiani G (2007) ° e myoÿ broblast: One function, multiple origins. Am J Pathol 170(6):1807–1816. Huijing PA (2007) Epimuscular myofascial force transmission between antagonistic and synergistic muscles can explain movement limitation in spastic paresis. J Electromyogr Kinesiol 17(6):708–724. Huijing PA (2009) Epimuscular myofascial force transmission: A historical review and implications for new research. International Society of Biomechanics Muybridge Award Lecture, Taipei, J Biomech 42(1):9–21. Huijing P, Baan GC (2008) Myofascial force transmission via extramuscular pathways occurs between antagonistic muscles. Cells Tissue Organs 188(4):400–414. Huijing PA, Jaspers RT (2005) Adaptation of muscle size and myofascial force transmission: A review and some new experimental results. Scand J Med Sci Sports 15(6):349–380. Illouz YG (Ed.) (1989) Body Sculpting by Lipoplasty. Edinburgh: Churchill Livingstone. Ingber DE (2008) Tensegrity-based mechanosensing from macro to micro. Prog Biophys Mol Biol 97(2–3):163–179. Ishida T, Takeuchi K, Hayashi S, Kawata S, Hatayama N, Qu N (2015) Anatomical structure of the subcutaneous tissue on the anterior surface of human thigh. Okajimas Folia Anat Jpn 92(1):1–6. Jaspers RT, Brunner R, Pel JJ, Huijing PA (1999) Acute e˛ ects of intramuscular aponeurotomy on rat gastrocnemius medialis: Force transmission, muscle force and sarcomere length. J Biomech 32(1):71–79.

Kandel ER, Schwartz JH, Jessell TM (2000) Principles of Neural Science, 4th ed. New York: McGraw-Hill.

dynamic postural control ability in the presence of sensory perturbation. J Medical Biol Eng 35(1):86–93.

Kapandji A (2012). Le système conjonctif, grand uniÿ cateur de l’organisme. Annales de Chirurgie Plastique Esthetique.

Malgaigne JF (1838) Traité d’anatomie chirurgicale et de chirurgie expérimentale. Vols 1 and 2. Paris: J.-B. Baillière.

Klein DM, Katzman BM, Mesa JM, Lipton JF, Caligiri DA (1999) Histology of the extensor retinaculum of the wrist and the ankle. J Hand Surg Am 24(4):799–802.

Mallick A, Bodenham AR (2003). Disorders of the lymph circulation: ° eir relevance to anaesthesia and intensive care. Br J Anaesth 91(2): 265–272.

Kumar P, Pandey AK, Kumar B, Aithal SK (2011) Anatomical study of superÿ cial fascia and localized fat deposits of abdomen. Indian J Plast Surg 3:478–483.

Markmann B, Barton FE (1987) Anatomy of the subcutaneous tissue of the trunk and lower extremity. Plastic Reconst Surg 80:248–254.

Lancerotto L, Stecco C, Macchi V, Porzionato A, Stecco A, DeCaro R (2011) Layers of the abdominal wall: Anatomical investigation of subcutaneous tissue and superÿ cial fascia. Surg Radiol Anat 33(10):835–842. Langer K (1861 [1978]) On the anatomy and physiology of the skin. Br J Plast Surg 31(1):3–8 [Translated from Langer K (1861) Zur Anatomie und Physiologie der Haut. I. Über die Spaltbarkeit der Cutis. Sitzungsbericht der Mathematisch-naturwissenscha˙ lichen]. Langevin, HM (2010) Tissue stretch induces nuclear remodeling in connective tissue ÿ broblasts. Histochem Cell Biol 133:405–415. Lee S, Joo KB, Song S-Y (2011) Accurate deÿ nition of superÿ cial and deep fascia. Letters to the Editor. Radiology 261(3). Li W, Ahn AC (2011) Subcutaneous fascial bands—a qualitative and morphometric analysis. PLoS One 6(9):e23987. Lionard MD (1986) ° e fasciae of the face: An anatomical and hystological analysis. J Am Acad Dermatol 14:502–507. Lockwood TE (1991) Superÿ cial fascial system (SFS) of the trunk and extremities: A new concept. Plast Reconstr Surg 87(6):1009–1018.

Marquart-Elbaz, C, Varnaison E, Sick H, Grosshans E, Cribier B (2001) Le tissu cellulaire sous-cutané. Annales de Dermatologie et de Vénéréologie 128:1207–1213. Merriam-Webster’s Medical Dictionary (2016) Merriam-Webster, Inc. Müller SA, Evans CH, Heisterbach PE, Majewski M (2018) ° e role of the paratenon in Achilles tendon healing: A study in rats. Am J Sports Med 46(5):1214–1219. Nakajima H, Imanishi N, Minabe T (2004) Anatomical study of subcutaneous adipofascial tissue: A concept of the protective adipofascial system (PAFS) and lubricant adipofascial system (LAFS). Scand J Plast Recons 38(5):261–266. Nash LG, Phillips M, Nicholson H, Barnett R, Zhang, M (2004) Skin ligaments: Regional distribution and variation in morphology. Clin Anat 17(4):287–293. Oda T, Kanehisa H, Chino K, Kurihara T, Nagayoshi T, Fukunaga T, Kawakami Y (2007) In vivo behavior of muscle fascicles and tendinous tissues of human gastrocnemius and soleus muscles during twitch contraction. J Electromyogr Kinesiol 17(5):587–595.

Maas H, Sandercock TG (2010) Force transmission between synergistic skeletal muscles through connective tissue linkages. J Biomed Biotechnol 2010:575672.

Ottenio M, Tran D, Ní Annaidh A, Gilchrist MD, Bruyère K (2015) Strain rate and anisotropy e˛ ects on the tensile failure characteristics of human skin. J Mech Behav Biomed Mater 41:241–50.

Maeda Y, Tanaka, T, Nakajima Y, Miyasaka T, Izumi T, Kato N (2015) Age-related changes in

Piérard GE, Lapière CM (1987) Microanatomy of the dermis in relation to relaxed skin tension

98

Pilat_Myofascial Induction.indb 98

03/12/21 3:55 PM

REFERENCES AND FURTHER READING

lines and Langer’s lines. Am J Dermatopathol 9:219–224.

lines in vivo using 3D scans. Comput Aided Des 45:551–555.

Pilat A (2014) Myofascial induction approach. In: Chaitow L (Ed.) Fascial Dysfunction. Manual ° erapy Approaches. Edinburgh: Handspring Publishing.

Soler M, Morand J, Mele F, Ovelar M, Ovelar A, Cedola J, Villardel D, Coscarelli L, Michelini C (2012) Estudio del compartimento safeno como estructura de ÿ jación, conexión y protección del sistema venoso superÿ cial de miembros inferiores. Tercera Epoca 2(5):1–2.

Pilat A (2015) Myofascial induction approaches. In: Fernández-de-las Peñas C, Cleland JA, Dommerholt J (Eds.) Manual ° erapy for Musculoskeletal Pain Syndromes of the Upper and Lower Quadrants: An Evidence- and ClinicalInformed Approach. London: Elsevier. Pilat A (2017) Fascial anatomy of the limbs. In: Liem T, Tozzi P, Chila A (Eds.) Fascia in the Osteopathic Field. Edinburgh: Handspring Publishing. Pilat A, Salom-Monreno J, Castro E, Fernándezde-las-Peñas C (2016) Myofascial force transmission. Evidence from unembalmed cadavers dissections. Man ° er 25:e134. https://doi. org/10.1016/j.math.2016.05.253. Purslow PP (2010) Muscle fascia and force transmission. J Bodyw Mov ° er 14(4):411–417. Ricci S, Georgiev M (2002) Ultrasound anatomy of the superÿ cial veins of the lower limb. J Vasc Technol 26(3):183–199. Rossell-Perry P, Paredes-Leandro P (2013) Anatomic study of the retaining ligaments of the face and applications for facial rejuvenation. Aesthetic Plast Surg 37(3):504–512.

Sommer G, Eder M, Kovacs L, Pathak H, Bonitz L, Mueller C, Regitnig P, Holzapfel GA (2013) Multiaxial mechanical properties and constitutive modeling of human adipose tissue: A basis for preoperative simulations in plastic and reconstructive surgery. Acta Biomater 9(11):9036–9048. Song AY, Askari M, Azemi E, Alber S, Hurvitz DJ, Marra KG, Shestak KC, Debski R, Rubin JP (2006) Biomechanical properties of the superÿ cial fascial system. Aesthet Surg J 26(4):395–403. Standring S (Ed.) (2008) Gray’s Anatomy: ° e Anatomical Basis of Clinical Practice. 40th ed. Edinburgh: Churchill Livingstone. Stecco A, Masiero S, Macchi V, Stecco C, Porzionato A, De Caro R (2009) ° e pectoral fascia: Anatomical and histological study. J Bodyw Mov ° er 13(3):255–261. Stecco C (2010) ° e ankle retinacula: Morphological evidence of the proprioceptive role of the fascial system. Cells Tissues Organs 192(3): 200–210.

Rouvière H, Delmas A (2005) Anatomía Humana. Barcelona: Masson.

Stecco C, Day JA (2010). ° e fascial manipulation technique and its biomechanical model: A guide to the human fascial system. Int J ° er Massage Bodywork 3(1):38–40.

Seo H, See-jo K, Cordier F, Jiyoung C, Kyunghi H (2013) Estimating dynamic skin tension

Stecco C, Porzionato A, Macchi V, Stecco A, Vigato E, Parenti A, Delmas V, Aldegheri R, De

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Caro R (2008) ° e expansions of the pectoral girdle muscles onto the brachial fascia: Morphological aspects and spatial disposition. Cells Tissues Organs 188(3):320–329. Swanson RL (2013) Biotensegrity: A unifying theory of biological architecture with applications to osteopathic practice, education, and research. J Am Osteopath Assoc 113(1):34–52. Stedman’s Medical Dictionary, 28th ed. (2005) Philadelphia, PA: Lippincott Williams & Wilkins. Testut L, Latarjet A (1996) Compendio de anatomía descriptiva. Madrid: Masson. ° e Great Soviet Encyclopedia, 3rd ed. (2010 [1970–1979]) ° e Gale Group. Tomasek J, Gabbiani G, Hinz B, Chaponnier C, Brown RA (2002) Myoÿ broblasts and mechanoregulation of connective tissue remodelling. Nat Rev Mol Cell Biol 3:349–363. Tsukahara K, Tamatsu Y, Sugawara Y, Shimada K (2012) Relationship between the depth of facial wrinkles and the density of the retinacula cutis. Arch Dermatol 148(1):39–46. Wendell-Smith CP (1997) Fascia: An illustrative problem in international terminology. Surg Radiol Anat 19:273–277. Yoshitake K, Miyamoto N, Taniguchi K, Katayose M (2015) ° e skin acts to maintain muscle shear modulus. Ultrasound Med Biol 42(3):674–682. Yucesoy C (2010) Epimuscular myofascial force transmission implies novel principles for muscular mechanics. Exerc Sport Sci Rev 38(3): 128–134.

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Embryological aspects of the fascial system With a contribution from Germán Digerolamo

4

KEY POINTS •

Relevance of mechanical factors in the arrangement and development of the fetus

•

The close structural and functional relationship between the germinative layers

•

Importance of the extracellular matrix (ECM) in embryonic growth and development

•

Identification and discussion of the embryological arguments for the systemic behavior of the mature fascial system

•

Analysis of the development of the neurocranium and identification of the variables that can condition the adaptive process of the fascial system from the time of conception

Introduction ° e aim of this book is to ÿ nd the patterns that enable the components of the body to be assembled as a complex biological system. To do this it is essential to identify items and processes of structural and functional communication at di˛ erent stages of the body’s development and also at di˛ erent levels of the body’s architecture. Embryology is a key process that allows us to achieve this aim. ° e life of a human being is initiated by fertilization of an ovum. From the time of this rendezvous, through birth and up to the end of puberty a complex process of assembly takes place. Most body organs are formed at between ÿ ve and eight weeks of intrauterine life. After that, there is continued growth and development up to the time of delivery, which occurs following 38 to 42 weeks of gestation in the uterus. ° roughout its progression, the single fertilized egg develops into 1,000,000,000 (a billion) cells comprising almost 200 kinds of tissue. During this time, and to varying degrees, the process is always related to the integration of genetic, morphological, chemical, and mechanical factors.

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° is process involves cellular dynamics such as differentiation and reorganization:

•

Cellular di˛ erentiation is a process by which the newly formed cells become more specialized and di˛ er from each other as they mature. Despite the fact that all the cells that make up the body have the same genome (entire set of genetic instructions), the activation (gene expression) of the precise instructions (genes) in certain cells, through chemical and mechanical signaling, induces di˛ erentiation between them. In this way they can fulÿ ll di˛ erent functions through the repression or stimulation of certain genes.

•

Cellular reorganization means cells are organizational units and could activate themselves through their own (intrinsic) functional structures for the fulÿ llment of their purposes. ° rough the reorganization, cells are labeled depending on their location and future function, then assembled into distinct combinations, diverse tissues, organs, systems, and ÿ nally the human being. ° e development of the tissue and also its growth and maturation do not end at birth but rather continue until puberty (Fig. 4.1). ° e main di˛ erences between the two processes,

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A

B

C

F

E

D

Figure 4.1 The process of embryology. A Fertilized ovum. B Cellular division. C Cellular differentiation. D Cellular growth. E Fetus. F Infant

inside the uterus and a˙ er birth, are external factors, the environment that surrounds the subject, and the manner in which the body is related to it. ° e basic embryonic structure can be split into three zones: ectoderm, endoderm, and mesoderm. Connective tissues arise from specialized cells within the area of the mesoderm. In the cephalic region, mesenchymal cells can also develop from the neural crest or surface ectoderm. Despite these marked di˛ erences in origin, all connective tissue cells act in conjunction with each other. ° roughout embryological development cells need to interact in the process known as embryonic induction. During this process, a group of cells (the inducting tissue) conditions the development of another group of

cells (the responding tissue). ° e responding tissue has the intrinsic capacity to develop and to express this capacity. To achieve this, it needs the appropriate environmental conditions. (It is hypothesized that this could be the ÿ rst indication of the integrity of fascial dynamics in a developed body.) During this process cells migrate, specialize, merge, separate, elongate, and form folds and layers to ÿ nally sculpt the human body shape. In this context, the mechanical conditions of the cell, the embryo, and ultimately the child’s body represent an important part of the development of the human being. ° e relevance of the mechanical behavior of the ECM and glial cells during neurodevelopment is discussed below.

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Mechanobiology and embryonic development (embryogenesis)

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environment that can be dissolved) are separated from the producer cells to generate concentration gradients of chemoattractants (a chemical agent that induces a cell to migrate toward it) which conduct tissue formation patterns (Mammoto & Ingber 2010, Mammoto et al. 2012) (Fig. 4.3A).

Embryology and morphology cannot proceed independently of any reference to the general laws of matter, to the laws of physics and mechanics. Sir William Turner (Davidson 2017)

Arrangement – distribution – activity Embryonic development is widely described in the literature and usually well-known to the reader (Fig. 4.2). ° is chapter focuses only on the main stages of embryogenesis and the in˝ uence of kinetics on the development of the embryo. ° e embryo is formed through a complex process of self-assembly where its cells are organized into tissues and organs with highly specialized design and functions. ° e cell can modify its pattern of expression depending on the signals it receives. ° ere is a long-standing dogma that there are chemical substances (soluble morphogens) which control the changes related to cell growth, migration, di˛ erentiation, and change of cell fate, thereby mediating the morphogenetic control of embryonic development (Mammoto & Ingber 2010, Mammoto et al. 2012). ° is paradigm assumes that soluble factors (molecules released to the cellular environment or extracellular

One example of the this process can be observed during morphogenesis of the nervous system. During the neurodevelopment process, axons grow and extend along speciÿ c pathways signaled by chemotaxis, meaning that neurites (axon ends) are directed toward the highest concentrations of the speciÿ c chemical agent, secreted by growth-inducing cells. ° is mechanism establishes the primitive routes of provisional neuronal connections that are subsequently improved by electrical signaling (Alberts et al. 2002) (Fig. 4.3B). ° e soluble factors are essential in the development of the process of embryonic polarization. ° is process determines the establishment of the polarity of the embryo, di˛ erentiating its opposite poles. In this way the anteroposterior axis (A–P), the dorsal–ventral (D–V) axis and the bilateral symmetry (from le˙ to right: L–R) are deÿ ned. ° ey will be points of reference to di˛ erentiate the fate of the cells, relating it to the position they occupy in relation to other cells (Fig. 4.4). Although soluble factors are clearly signiÿ cant contributors to the control of embryonic development and polarization, recent studies have revealed that

Caudal

A

B

C

D

E

Figure 4.2 The first step – on the way to the uterine body. A Fertilized egg – day 1. B Zygote – day 2. C Morula – days 2–3. D Early blastocyst – day 4. E Late blastocyst – days 4–5

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4 1

2

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Figure 4.3 Cell migration A The four steps of cell migration 1 Prior to migration, cells exhibit a simple morphology and lack protrusions 2 In the first step of migration cells extend protrusions in all directions but are still immotile 3 Cellular extensions are polarized in the direction of migration in response to a gradient of chemoattractant. Cells may also be oriented by repulsive cues 4 Cells reach a region of uniform attractant B Axonal growth cone targeting i Attractive guidance ii Axon iii Growth cone

A

After Prokop A., Beaven R., Qu Y., SánchezSoriano N. (2013) Using fly genetics to dissect the cytoskeletal machinery of neurons during axonal growth and maintenance. Journal of Cell Science 126(Pt. 11):2331–2341

i

B

ii

iii

the mechanical forces generated within the cells (cytoskeleton) and tissues of the embryo can provide regulatory signals of embryonic development that are as important as those transmitted by chemicals and genes (Alarcón & Marikawa 2003, Honda et al. 2008, Kurotaki et al. 2007, Motosugi et al. 2005, Mammoto & Ingber 2010, Mammoto et al. 2012). In conclusion, morphogenesis is mediated by a well-coordinated mechanochemical process in which the cytoskeleton tension of the cells (that make up the developing embryo) depend, at least partially, on the forces generated by neighboring cells and the underlying ECM (Mammoto & Ingber 2010, Mammoto et al. 2012).

Cellular migration and mechanical guidance As mentioned earlier in this chapter, cell migration can be triggered by chemoattractants (substances which attract motile cells of a particular type) acting as decoys that direct the polarization and direction of cell movement. However, cell migration, and therefore embryonic development, can also happen through the mechanical behavior of the ECM.

ECM-mediated contact guidance In early studies, Paul Weiss (Weiss & Taylor 1956) observed “that cells and axons, seeded on 2D culture

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mechanism can even be part of chemotaxis, since the chemoattractants can act by modifying the sti˛ ness of the ECM to direct cell migration. In conclusion, durotaxis and chemotaxis can act together and/or be interdependent in guiding cell migration (Das 2014).

Anteroposterior axis

Abembryonic (dorsal) end

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Embryonic (ventral) end

Embryonic (ventral)–abembryonic (dorsal) axis

Figure 4.4 Embryonic polarization of a blastocyst. Modified with permission from Álvarez-Miguel I.S., Miguel-Lasobras E.M., Martín-Romero F.J., Domínguez-Arroyo J.A., González-Carrera E. (2006) Polarity during early embryo development. ASEBIR 2(2):35

dishes, elongate and migrate along topographical features of the substrate, such as engraved parallel microgrooves and oriented ÿ brillary structures.” ° is mechanism was studied in embryological development, and it was noted that cell migration during embryo development can occur through mechanical contact. ° e cells have the ability to use the lack of homogeneity of the ECM to adhere, polarize, and guide their migration. In studies of cells it has been observed that the growing neurons use the “slots” of the culture plate to direct their path, that is, they use physical references to direct their destiny. It means that a speciÿ c alignment in the embryo’s ECM ÿ brils can provide physical signals that represent the “contact path” for neuronal growth and migration (Weiss 1945, 1959, Weiss & Taylor 1956, Reig et al. 2014).

The durotaxis migration process Durotaxis is a mechanism similar to the chemotaxis process explained above. ° e di˛ erence between them lies in the kind of impulse used in durotaxis. ° is process occurs through physical (mechanical) signals to the cells in order to direct their migration and growth. ° e changes in the sti˛ ness of the ECM of the embryo are detected by the migrating cells, which subsequently are directed toward its more rigid ECM area. ° is

The blastocyst and trilaminar embryonic disc ° e blastocyst is the stage of the embryo a˙ er ÿ ve or six days of ontogenesis (cell division process). It arises from the preceding morula stage, forming the blastocoele by cavitation of morula masses composed of 30 to 32 cells (see Fig. 4.2). In this stage, during which a ˝ uid-ÿ lled cavity begins to form, the two layers of cells formed in the morula become more deÿ ned as the outer cells. ° e outer layer becomes committed to the trophoblast (trophectoderm) lineage and surrounds the cavity, and the inner layer, which forms the inner cell mass, forms a compact mass on one side of the cavity (deÿ ned as the embryonic pole versus the opposing side which is known as the mural or abembryonic pole). During the next two weeks, the blastocyst invaginates and undergoes gastrulation. At the end of the invagination process three layers of germinative discs are developed, consisting of ectoderm, mesoderm, and endoderm (Fig. 4.5).

•

° e ectoderm will form the nervous system, neural networks, and skin.

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° e mesoderm, located in the middle of the ectoderm and the endoderm, will form the muscles, connective tissues, blood, lymph, kidneys, part of the genital organs, and the adrenal glands of the cortex. ° e concept of the mesoderm being the precursor of the ÿ brous network and the fascial tissue will be expanded on later.

•

° e endoderm will form the tracts of the blood vessels, the organs of the digestive system, and the glands.

The ECM and organogenesis According to Mammoto and Ingber (2010) almost all organs are sensitive to mechanical signals in the course of their formation in the ÿ nal stages of embryological development. ° ey cite several authors who argue that

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4 Zygote Trophoblast Inner cell mass Hypoblast Epiblast

Primitive streak Extraembryonic mesoderm

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Surface ectoderm

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Endoderm

Sensory organs

Neural tube

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Spinal cord Brain

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Lateral plate mesoderm

Gut tube

Kidney

Spleen

Thyroid

Head mesenchyme

Dermis

Lower urinary tract

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Liver

Peripheral nervous system

Fascia

Reproductive system

Heart

GI tract

Smooth muscle

Prostate

Lymph

Pancreas

Skeletal muscle

Endothelium

Lung

Cartilage

Blood

Thymus

Bone

Adipose tissue

Tendon, aponeurosis, and ligament

Figure 4.5 Embryonic development: the ontology tree

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mechanical forces are crucial for the formation of organs like blood vessels (Lucitti et al. 2007, Mammoto et al. 2009), lungs (Cohen & Larson 2006, Gutierrez et al. 2003, Inanlou & Kablar 2003, Moore et al. 2005), kidneys (Serluca et al. 2002, Vasilyev et al. 2009), muscle (Kahn et al. 2009), mammary glands (Alcaraz et al. 2008), brain (Anava et al. 2009, Moore et al. 2005, Wilson et al. 2007), cartilage and bone (Ohashi et al. 2002, Stokes et al. 2002), as well as of the hematopoietic system (Adamo et al. 2009, North et al. 2009) and the heart (Forouhar et al. 2006, Hove et al. 2003, Voronov et al. 2004). Mammoto and Ingber (2010) state that: embryonic organs appear to adapt their material properties in response to the changes in the physical demands on their function that occur during each developmental stage, and cytoskeletal prestress and mechanotransducer molecules play central roles in these responses, much as they do in adult tissues …

Mammoto & Ingber (2010) and Mammoto et al. (2013) quote a series of studies that show that organogenesis and morphogenetic movements imply the dynamic remodeling of ECM in the embryo. However, it should be noted that these mechanical signals must be integrated

4

with chemical signals, such as growth factors, to address the speciÿ c cell destination, the tissue remodeling, and several of the development processes. It can be concluded that the mechanical properties of the ECM are important in the modulation of cellular processes relating to cell migration, morphogenesis, and organogenesis during the embryonic stage.

Embryological development of fascial tissue As mentioned above, the formation of the fascial network derives from the mesoderm or intermediate layer. During the second week of embryological development, there is hardly any cellular di˛ erentiation in the mesoderm and almost all cells are exact copies of each other. However, as the embryo develops a greater specialization emerges. In the center of the mesoderm there will be a thickening called the notochord, which will give rise to the vertebral column, vertebral bodies, and intervertebral discs, and ˝ anking these, in the paraxial mesoderm, a special section known as mesenchyme (Snyder 1975 cited by Marchuk & Stecco 2015) (Fig. 4.6).

Figure 4.6 Formation and location of the notochord and paraxial mesoderm

Amniotic cavity Ectoderm Paraxial mesoderm

Intraembryonic mesoderm

Extraembryonic mesoderm

Notochord

Endoderm

Yolk sac

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4 ° e mesenchyme is the tissue in the embryonic phase and is composed of the abundant extracellular matrix that contains a small number of cells and also thin ÿ bers. Due to these characteristics the cells can migrate freely and play a crucial role in morphogenesis during the embryonic and fetal stages, giving rise to most of the connective tissue of the body (mainly the loose connective tissue), from the bones and cartilage to the lymphatic and circulatory systems. ° e mesenchyme is a transition tissue; although it is crucial for morphogenesis during development, little can be found in adult organisms (MacCord 2012). In light of the adaptive features of mature fascial tissue (see Chapter 5 for more information), it can be deduced that it has functional similarities with tissue that has given origin. It seems that the mature fascial system, in a dysfunctional state (e.g., as a result of trauma), retains some ontogenetic properties of mesenchymal tissue and it adapts to the mechanical properties of the environment. In this way, perhaps, it retains one of its main attributes: plasticity. It can be hypothesized that the mature organism still conserves cellular focal points with the potential of di˛ erentiation, similar to embryonic stage tissues. According to Prósper et al. (2006) this exception is composed of mesenchymal stem cells, which are found in the bone marrow (hematopoietic tissue), skeletal muscle, epidermis, intestine, testicles, liver, and more recently in tissues such as the central nervous system or the heart. According to this author, “the adult stem cells are considered multipotential, that is, capable of di˛ erentiating a limited number of tissues, mainly based on their embryonic origin.” ° is potentiality is represented in the use of hematopoietic stem cells as “cell therapy,” which, as the author continues, “are capable of di˛ erentiating hepatocytes, cardiac muscle, endothelium or even tissues derived from the three embryonic layers” (Prósper at al. 2006). In this context, it is appropriate to comment on the dynamics of the newly discovered cells, the telocytes (Popescu et al. 2011). ° e telocytes coexist with numerous types of cells, creating together with the ÿ broblasts an extensive network of cellular interconnection. ° is interconnected network is located mainly in the cellular interstices of the mature skeletal muscle system and is also found in other organs such as the uterus. Telocytes are characterized by the presence of protoplasmic

expansions called telepods, which can create connections over a very long distance. ° ey can play an essential role in the integration of signals for the regulation and regeneration of skeletal muscle ÿ bers. Telocytes support paracrine signaling that stimulates the migration and di˛ erentiation of stem cells from the muscular “niches” to the zones of the regenerating tissue. Embryonic mesenchymal stem cells are progenitors of ÿ broblasts and secrete reticular ÿ bers (a primitive form of collagen) in interstitial spaces. ° e mesenchymal cells gradually replace the reticular ÿ bers with collagen ÿ bers which form a unique and uninterrupted three-dimensional ÿ brous network throughout the body (Schultz & Freitis 1996). Langevin et al. (2004) observe that “the connective tissue collagen ÿ bers remain connected and are continuous, as are mature ÿ broblasts.” As outlined above in the section on ECM and organogenesis, these reticular ÿ bers seem to control, through their own orientation, the muscle formation patterns guiding the migration of myoblasts through the mesoderm (Brand-Seberi & Christ 1999). ° e connective tissue develops compartments to accommodate di˛ erent muscle structures. ° ese compartments consist of two parts: a small portion called the epimere, which is made up of myotomes and where the extensor muscles of the spine will develop, and a hypomeric portion (hypomere), which is bigger and is located in the ventral region where the muscles of the extremities and the ventral area will develop (Marchuk & Stecco 2015). Marchuk and Stecco (2015) also cite Langman’s Medical Embryology (Sadler 2001), which states that: the nerves (axons and growth cones) that pass through the segmental muscles during their development will be divided into a primary dorsal branch for the epimere and a ventral branch for the hypomere. They will accompany the muscles throughout their migratory trajectory. ... The nerves play an important role in the differentiation and motor innervation of the muscles of the limb as well as providing the sensory innervation of the dermatomes.

° is link between the growing axons and the muscle cells will establish an inseparable morphofunctional relationship, which even continues in the postembryonic stage (see Chapter 7).

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Integration of the neurocranium and brain ° e evolution of mammals provides strong evidence that the structures of the skull and the brain are modiÿ ed in sync. ° e development of the embryonic skull is closely dependent on adequate coordination between neural structures, precursors of bone tissue, and the meninges. Richtsmeier et al. (2006) point out the dynamics of the skull sutures jointly with the meninges and neurocranium in developing the shape of the brain. ° e morphological interdependence between the brain and the skull is shown in pathologies such as craniosynostosis (premature closure of cranial sutures) and microcephaly (lack of brain growth) (Morriss-Kay et al. 2001, Wilkie and Morriss-Kay 2001 cited in Richtsmeier et al. 2006). Richtsmeier et al. (2006) highlight the relevance of the dura mater as an intermediary between brain growth and skull development. ° e union of the falx cerebri and the tentorium cerebelli in a speciÿ c location of the skull base and inside the sutures suggests that cerebral expansion exerts a pressure that is transmitted by the meninges toward the intersutural osteogenic cells, which determine both the permeability of the suture as well as the shape of the skull.

Intersutural permeability

° e cells, which are the lineage of osteoblasts and located in the bone perimeters, also produce collagen and lead to the formation of bone at the edges of the suture. ° ese mechanisms are linked to the processes of mechanotransduction due to the loads received from the dura mater. As a result of this process the cells can control the tension within the suture related to cranial expansion and the growth of the brain. Scarr (2008) considers that the above process complies with the principles of tensegrity (Fig. 4.7) (see Chapter 6). We can assume that maintenance of the optimal mechanical conditions in the suture environment in the developing period will contribute to preserving sutural permeability and therefore to normal expansion in the growth of the brain.

Mechanical control of development of the nervous system ° e development of the nervous system has been considered in the context of biochemistry, molecular biology, and genetics. However, there is growing evidence that many biological systems are part of the mechanical information that participates in the cellular behavior and morphogenesis of the nervous system.

In the development of the neurocranium, the mesenchyme manifests as a capsular membrane that surrounds the brain. Its structure is divided into two layers: the internal endomeninx and the external ectomeninx. ° e former is of neural crest origin and the latter is of mixed paraxial mesodermal crest origin.

° ese ÿ ndings seem to reinforce the belief that the development of the nervous system, which, as mentioned above, depends on processes such as the di˛ erentiation of neural progenitor cells, neuronal migration, axon extension and brain folding, is driven by mechanical signals (forces) (Franze 2013).

Scarr (2008), analyzing the development process of cranial sutures, determined that “a complex coupling between ÿ broblast, osteoblast and osteoclast populations determines the actual position and rate of sutural development.”

Axons grow oriented by chemoattractants and by the mechanical conditions of their environment. ° is “mechanodependent” axonal growth occurs in two phases, which can be distinguished by the nature of the forces that control the growth. Franze (2013), based on the work of Betz et al. (2011) and Lamoureux et al. (1989), considers that in the ÿ rst phase the growth cones operate actively on their environment (ECM of the CNS). Kandel et al. (2001) state that the growth cones present expansions called ÿ lopodia. ° ese extensions are in charge of testing the area, advancing with rapid movements and performing a detailed inventory of the environment and its ˝ exibility. In this

° e cells of the ectomeninx, which are located in the intersutural space, undergo epithelial–mesenchymal transitions (a phenotypic mechanism to diversify the di˛ erent cell populations) during the development of the sutures. In addition, the ÿ broblast-like cells, present in the intersutural space, are collagen-producing and contribute to maintaining suture permeability.

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4 Bone condensation

Ectomeninx

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Growing brain Bone

Periosteum Peririosteum m Osteogenic front of the bone

Ectomeninx

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Figure 4.7 A model of the cranial vault as a tensegrity structure. A Superior view of the cranium showing bone growth 1 Bone condensation within the ectomeninx (embryo +/−8 weeks) 2 Sutures and fontanelles (full-term fetus) 3 Patent sutures allow the bones to grow around their edges and the cranium to enlarge B Diagram illustrating suture growth From Scarr G. (2018) Biotensegrity: The Structural Basis of Life. 2nd ed. Edinburgh: Handspring Publishing

way they are able to navigate through cells and other obstacles. Several molecular motors, such as actin and myosin, drive the axon to grow. In a second phase, a˙ er connecting with their target tissue, the axons can be passively stretched by the increasing distance between the target and the nervous tissue, which results in a considerable growth in length. Once the ÿ nal connectivity is established, the emergent tension can develop along the neuronal axons, participating in the formation of the neural network, the synaptic conformation, and the folding of the brain (gyriÿ cation) (Franze 2013).

Folding of the brain (gyrification) ° e folding of the mammalian cortex is the ÿ nal mechanical event in the development of the central nervous system (CNS). ° e degree of cortical folding increases with the size of the brain; the brains of larger animals tend to be more complex. ° e cortical folding is a succession of grooves and ÿ ssures, which only form

a˙ er all cortical neurons have been generated and the neuronal migration has been completed. It is currently accepted that gyriÿ cation depends on the tangential expansion (from the center to the periphery) of the cortical regions (corresponding to the second phase of axonal growth discussed above), driven by the increased local proliferation of cells, changes in size and shape of the neurons, and by the resulting tension along the axons in the white matter. ° ese events would explain the way in which the cortex bends to form the circumvolution (Fig. 4.8). During the ÿ rst 25 weeks of fetal development the cortex remains relatively smooth while the emerging neurons send out ÿ bers to connect with neurons in other regions of the brain, where they become tethered. As the cortex continues to grow mounting tension between regions connected via numerous ÿ bers begins to draw them together, producing a gyrus (bulge) between them. Weakly connected regions dri˙ apart, creating a

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Figure 4.8

Gyrus

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The gyrification process A Axon tension B Skull constraint C Cortical growth D Radial unit E Cortical folds 1 Crumpling 2 Pulling 3 Buckling 4 Patterning Yellow area – cortex Gray area – subcortical layer After Garcia K.E., Kroenke C.D., Bayly P.V. (2018) Mechanics of cortical folding: Stress, growth and stability. Philosophical Transactions of the Royal Society B 373:20170321.

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sulcus (valley). ° e folding is mostly complete by the time of birth. ° ere are di˛ erent approaches to the shape of the mechanical forces that lead to cortical folding. Leading hypotheses have focused on the roles of tangential growth of the outer cortex, spatiotemporal patterns in the birth and migration of neurons, and internal tension in axons. Recent research focuses on the stress state, mechanical properties, and spatiotemporal patterns of growth in the developing brain.

The ECM and mechanobiology of the nervous system ° e ECM provides a microenvironment that regulates the development and activity of neural cells. It occupies the space between neurons and glial cells, where these cells secrete diverse molecules that contribute to the composition of the ECM. During the development of the CNS the ECM undergoes signiÿ cant changes and acts together with the cells in neurogenesis, glycogenesis, synaptogenesis, cell migration, and also axonal development and orientation. In adulthood, the ECM participates in cell survival, plasticity, and also in tissue regeneration (Soleman 2013). Unlike the ECM of other organs, the ECM of the brain has a low component of collagen ÿ bers. ° e major components of the ECM in the nervous system are

proteoglycans. ° ese high molecular weight proteins are responsible for cell mobility and regeneration. ° ey are also involved in cell migration during development and reconnection between two neurons a˙ er axonal injury (Soleman 2013).

Relevance of the ECM in the mature and developing nervous system As emphasized already, the ECM of the nervous system plays an important role in neuronal migration during neurodevelopment. ° is cell journey also depends on changes in the physical permeability of the ECM. One example of the process is the diˆ culty of the migration of multipotential cells from the neural crest of the embryo which aim to colonize the enteric nervous system. ° e excessive deposit of collagen increases the rigidity of the ECM, a˛ ects the colonization of the cells at their ÿ nal destination, and can initiate the development of congenital diseases or cancer (Chevalier et al. 2016).

Glial cells and neurodevelopment In recent years, the importance of the role of glial cells in the various activities of the nervous system has become clearer. It is important to highlight their crucial role in neurodevelopment as they participate, for example, in cell migration.

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4 ° e link between neurons and glial cells is established very early in the development of the embryo. In corticogenesis (formation of the cerebral cortex) Cajal–Retzius cells (located in the ECM) secrete a chemoattractant called reelin. Migrating cells use these signals to target the corresponding cortex layer. ° is tangential migration starts when the neurons “climb” radial glia oriented tangentially in the cerebral cortex. ° is morphofunctional relationship does not seem to be exclusive to the embryonic stage. It has recently been demonstrated, that “niches” of immature neuronal cells (neuroblasts) exist in the mature brain. ° ese cells, using similar mechanisms to those discussed above, use a “migration path” provided by tubes or channels composed of glial cells and ECM. ° ese mechanisms present in the neurogenesis of the mature brain have been called “migratory currents” and represent an integral part of the phenomena of cerebral plasticity (Troy 2007).

Conclusion In this chapter the mechanobiological aspects of embryonic development have been analyzed. In this context,

and according to the literature, the viscoelastic properties of the ECM modulate the cellular processes involved in the morphogenesis of the embryo (migration, proliferation, etc.). We can consider the mature fascial system as a system anchored in its behavior (plasticity and adaptability) to the mesenchymal origins of the primitive ECM, which derives from the mesoderm and which through its constitution is an integral part of the embryo, both from a structural and functional point of view. It is also important to highlight the interaction between the di˛ erent embryological origins of body tissues. In the example used we have seen that the brain and the skull come from layers associated with the embryonic stage and that they evolve interdependently. In this example the ECM, which occupies the intersutural space and is continuous with the future meninges of the nervous system, is in charge from the early stages of development of unifying the provenances of the mature tissues that constitute the integrated body model that we conceive from the myofascial perspective.

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REFERENCES

Adamo L, Naveiras O, Wenzel PL, McKinneyFreeman S, Mack PJ, Gracia-Sancho J, Suchy-Dicey A, Yoshimoto, M, Lensch MW, Yoder MC, García-Cardeña G, Daley GQ (2009) Biomechanical forces promote embryonic haematopoiesis. Nature 459:1131–1135. Alarcón VB, Marikawa Y (2003) Deviation of the blastocyst axis from the ÿ rst cleavage plane does not a˛ ect the quality of mouse postimplantation development. Biol Reprod 69(4):1208–1212. Alberts B, Johnson A, Lewis J, Ra˛ M, Roberts K, Walter P (2002) Molecular Biology of the Cell. 4th ed. New York: Garland Science. Alcaraz J, Xu R, Mori H, Nelson CM, Mroue R, Spencer VA, Brownÿ eld D, Radisky DC, Bustamante C, Bissell MJ (2008) Laminin and biomimetic extracellular elasticity enhance functional di˛ erentiation in mammary epithelia. EMBO J 27(21):2829–2838. Álvarez-Miguel IS, Miguel-Lasobras EM, Martín-Romero FJ, Domínguez-Arroyo JA, González-Carrera E (2006) Polaridad durante el desarrollo embrionario inicial [Polarity during early embryo development]. ASEBIR 2(2):35. Anava S, Greenbaum A, Ben Jacob E, Hanein Y, Ayali A (2009) ° e regulative role of neurite mechanical tension in network development. Biophys J 96(4):1661–1670. Betz T, Koch D, Lu YB, Franze K, Käs JA (2011) Growth cones as so˙ and weak force generators. Proc Natl Acad Sci USA 108(33):13420–13425. Brand-Seberi B, Christ B (1999) Genetic and epigenetic control of muscle development in vertebrates. Cell Tiss Res 296(1):199–212. Chevalier NR, Gazquez E, Bidault L, Guilbert T, Vias C, Vian E, Watanabe Y, Muller L, Germain S, Bondurand N, Dufour S, Fleury V (2016) How tissue mechanical properties a˛ ect enteric neural crest cell migration. Sci Rep 6:20927. Cohen JC, Larson JE (2006) Cystic ÿ brosis transmembrane conductance regulator (CFTR) dependent cytoskeletal tension during lung organogenesis. Dev Dyn 235(10):2736–2748. Das A (2014) A critical pull to polarize the cell. Biophys J 107(2):285–286.

Davidson LA (2017) Mechanical design in embryos: Mechanical signalling, robustness and developmental defects. Philos Trans R Soc Lond B Biol Sci 372(1720).

Kurotaki Y, Hatta K, Nakao K, Nabeshima Y, Fujimori T (2007) Blastocyst axis is speciÿ ed independently of early cell lineage but aligns with the ZP shape. Science 316(5825):719–723.

Forouhar AS, Liebling M, Hickerson A, Nasiraei-Moghaddam A, Tsai HJ, Hove JR, Fraser SE, Dickinson ME, Gharib M (2006) ° e embryonic vertebrate heart tube is a dynamic suction pump. Science 312(5774):751–753.

Lamoureux P, Buxbaum RE, Heidemann SR (1989) Direct evidence that growth cones pull. Nature 340:159–162.

Franze K (2013) ° e mechanical control of nervous system development. Development 140(15):3069–3077. Garcia KE, Kroenke CD, Bayly PV (2018) Mechanics of cortical folding: Stress, growth and stability. Phil Trans R Soc B 373:20170321. Available: ht t p://d x .doi .org /10.10 98/rs tb. 2 017.0321 [accessed October 13, 2021]. Gutierrez JA, Suzara VV, Dobbs LG (2003) Continuous mechanical contraction modulates expression of alveolar epithelial cell phenotype. Am J Respir Cell Mol Biol 29(1):81–87. Honda H, Motosugi N, Nagai T, Tanemura M, Hiiragi T (2008) Computer simulation of emerging asymmetry in the mouse blastocyst. Development 135:1407–1414. Hove JR, Koster RW, Forouhar AS, AcevedoBolton G, Fraser SE, Gharib M (2003) Intracardiac ˝ uid forces are an essential epigenetic factor for embryonic cardiogenesis. Nature 421(6919):172–177. Inanlou MR, Kablar B (2003) Abnormal development of the diaphragm in mdx:MyoD–/– (9th) embryos leads to pulmonary hypoplasia. Int J Dev Biol 47:363–371. Ingber DE (2006) Cellular mechanotransduction: Putting all the pieces together again. FASEB J. 20(7):811–827. Kahn J, Shwartz Y, Blitz E, Krief S, Sharir A, Breitel DA, Rattenbach R, Relaix F, Maire P, Rountree RB, Kingsley DM, Zelzer E (2009) Muscle contraction is necessary to maintain joint progenitor cell fate. Dev Cell 16(5):734–743. Kandel ER, Schwartz JH, Jessell TM et al. (Eds.) (2001) Principios de Neurociencia. 4th ed. Madrid: McGraw Hill Interamericana, p. 1072.

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Langevin HM, Cornbrooks CJ, Taatjes DJ (2004) Fibroblasts form a body-wide cellular network. Histochem Cell Biol 122(1):7–15. Lucitti JL, Jones EA, Huang C, Chen J, Fraser SE, Dickinson ME (2007) Vascular remodeling of the mouse yolk sac requires hemodynamic force. Development 134(18):3317–3326. MacCord K (2012) Mesenchyme. ° e Embryo Project Encyclopedia, p. 1. http://embryo.asu. edu/handle/10776/3941 [accessed August 8, 2021]. Mammoto T, Ingber DE (2010) Mechanical control of tissue and organ development. Development 137(9):1407–1420. Mammoto A, Connor KM, Mammoto T, Yung CW, Huh D, Aderman CM, Mostoslavsky G, Smith LE, Ingber DE (2009) A mechanosensitive transcriptional mechanism that controls angiogenesis. Nature 457:1103–1108. Mammoto A, Mammoto T, Ingber DE (2012) Mechanosensitive mechanisms in transcriptional regulation. J Cell Sci 125:3061–3073. Mammoto T, Mammoto A, Ingber D (2013) Mechanobiology and developmental control. Annu Rev Cell Dev Bio 29:27–61. Marchuk C, Stecco C (2015) ° e role of connective tissue in the embryology of the musculoskeletal system: Towards a paradigm shi˙ [version 1; referees: 2 approved with reservations]. F1000 Research 4: 635. Moore KA, Polte T, Huang S, Shi B, Alsberg E, Sunday ME, Ingber DE (2005) Control of basement membrane remodeling and epithelial branching morphogenesis in embryonic lung by Rho and cytoskeletal tension. Dev Dyn 232(2): 268–281.

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4

REFERENCES

Morriss-Kay GM, Iseki S, Johnson D (2001) Genetic control of the cell proliferation-di˛ erentiation balance in the developing skull vault: Roles of ÿ broblast growth factor receptor signalling pathways. Novartis Found Symp 232: 102–116. Motosugi N, Bauer T, Polanski Z, Solter D, Hiiragi T (2005) Polarity of the mouse embryo is established at blastocyst and is not prepatterned. Genes Dev 19(9):1081–1092. North TE, Goessling W, Peeters M, Li P, Ceol C, Lord AM, Weber GJ, Harris J, Cutting CC, Huang P, Dzierzak E, Zon LI (2009) Hematopoietic stem cell development is dependent on blood ˝ ow. Cell 137(4):736–748. Ohashi N, Robling AG, Burr DB, Turner CH (2002) ° e e˛ ects of dynamic axial loading on the rat growth plate. J Bone Miner Res 17(2):284–292. Popescu LM, Manole E, Serboiu CS, Manole CG, Suciu LC, Gherghiceanu M, Popescu BO (2011) Identiÿ cation of telocytes in skeletal muscle interstitium: Implication for muscle regeneration. J Cell Mol Med 15(6):1379–1392. Prósper F, Gavira JJ, Herreros J, Rábago G, Luquin R, Moreno J, Robles JE, Redondo P (2006) Cell transplant and regenerative therapy with stem cells [Article in Spanish]. An Sist Sanit Navar 29(Suppl. 2):219–234. Reig G, Pulgar E, Concha ML (2014) Cell migration: From tissue culture to embryos. Development 141(10):1999–2013.

Richtsmeier JT, Aldridge K, DeLeon VB, Panchal J, Kane AA, Marsh JL, Yan P, Cole TM 3rd (2006) Phenotypic integration of neurocranium and brain. J Exp Zool B Mol Dev Evol 306(4):360–378. Sadler TW (2001) Embriología médica con orientación clínica Langman, 8th ed. [Langman’s Medical Embryology; trans. José Luis E. Ferrán and Liliana G. Vauthay]. Madrid: Médica Panamericana. Scarr G (2008) A model of the cranial vault as a tensegrity structure, and its signiÿ cance to normal and abnormal cranial development. International Journal of Osteopathic Medicine 11(3):80–89. Schultz L, Freitis R (1996) ° e Endless Web. Berkeley: North Atlantic Books, pp. 8–10. Serluca FC, Drummond IA, Fishman MC (2002) Endothelial signaling in kidney morphogenesis: A role for hemodynamic forces. Curr Biol 12(6):492–497. Snyder G (1975) Fasciae: Applied Anatomy and Physiology. Kirksville College of Osteopathy. Soleman S (2013) Targeting the neural extracellular matrix in neurological disorders. Neuroscience 253:194–213.

Vasilyev A, Liu Y, Mudumana S, Mangos S, Lam P, Majumdar A, Zhao J, Poon K-L, Kondrychyn I, Korzh V, Drummond IA (2009) Collective cell migration drives morphogenesis of the kidney nephron. PLOS Biol 7:e9. Voronov DA, Alford PW, Xu G, Taber LA (2004) ° e role of mechanical forces in dextral rotation during cardiac looping in the chick embryo. Dev Biol 272(2) 339–350. Weiss P (1945) Experiments on cell and axon orientation in vitro: ° e role of colloidal exudates in tissue organization. J Exp Zool 100:353–386. Weiss P (1959) Cellular dynamics. Rev Mod Phys 31:11–20. Weiss P, Taylor AC (1956) Fish scales as a substratum for uniform orientation of cells in vitro. Anat Rec 124:381. Wilkie AO, Morriss-Kay G (2001) Genetics of craniofacial development and malformation. Nat Rev Genet 2(6):458–468. Wilson NR, Ty MT, Ingber DE, Sur M, Liu G (2007) Synaptic reorganization in scaled networks of controlled size. J Neurosci 27(50): 13581–13589.

Stokes IA, Mente PL, Iatridis JC, Farnum CE, Aronsson DD (2002) Growth plate chondrocyte enlargement modulated by mechanical loading. Stud Health Technol Inform 88:378–381. Troy H (2007) Neuronal migration in the adult brain: Are we there yet? Nat Rev Neurosci 8(2):141–151.

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Histological aspects of the fascial system With a contribution from Germán Digerolamo

5

KEY POINTS •

The histological characteristics of fascia

•

The extracellular matrix as an integrating structure of bodily communication

•

The dynamics of collagen in the connective tissue configuration and its mechanical behavior

•

Fascia as a dynamic component of muscular contraction

•

Mechanochemical coupling in cellular communication

•

The relevance of interstitial fluid to movement

•

The dynamics of the extracellular matrix of the nervous system

Introduction Contemporary body movement analysis focuses mainly on complex processes and mechanisms that take place in the extracellular matrix (ECM). ° e study of the ECM, its construction and dynamics, and also its interactions with other structures has allowed us to better understand di˛ erent body processes. ° e possibility of studying the movements of living organisms at a very small construction scale, through sophisticated electronic microscopes, as well as the con˝ uence of several scientiÿ c disciplines have accelerated the progress of research and forced us to review former interpretations. ° e movement model we are used to using has frequently been revealed to be weak and oversimpliÿ ed. ° e development of neuroscientiÿ c and molecular biology, together with research in the ÿ eld of mechanotransduction processes that act on organic compounds that are the basis of proteins, allows us to glimpse a surprising and increasingly informed future. ° erefore, the common concepts relating to the formation and treatment of movement dysfunctions require intense revision. In the overlapping area between biology and physics recent research on nanomaterials and nanoengineering has enabled us to answer questions on the capacity

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of self-organization and self-assembly that invariably characterizes life processes at various levels, from proteins to planetary ecosystems (exchanges between living organisms and their environment). ° e histological characteristics of the fascial system are the biological determinants of its mechanical and mechanobiological behavior, its mechanosensitivity, and chemosensitivity (see Chapter 8), its immunological role, its participation in the di˛ usion of ˝ uids (e.g., interstitial ˝ uid), and the ability to mediate the body’s communication systems. In any system, structure and function are interdependent (see Chapter 2). Each component of the system is the means and at the same time the purpose in that it acts according to the skills of the whole and at the same time has its place and function determined for the beneÿ t of the entire system. ° e size, shape, and structure of the cells that make up the system vary greatly in relation to the special tasks they have to perform for their own beneÿ t and for the service of the whole (von Bertalan˛ y 1968, Gassó 2009). Note: ° is chapter analyzes the features of fascia, from macroscopic to microscopic scales, and relates only to various aspects of body movement. For a

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5 complete histological analysis of connective tissue the reader is referred to the many specialized publications that are available on the subject. ° e classiÿ cation, composition, functions, and activities of connective tissue (CT) are summarized in the following ÿ gures and tables:

• • •

Figure 5.1 Classiÿ cation of connective tissue.

•

Figures 5.2–5.12 illustrate the macrostructure of di˛ erent types of CT (loose CT, dense CT, collagenous CT, elastic CT, ligaments, tendons, aponeurosis, epimysium, fat, cartilage).

Table 5.1 Composition of connective tissue. Table 5.2 Basic functions and activities of connective tissue.

Fascia is composed histologically of speciÿ c cells, ground substance, and ÿ bers (mainly collagen). ° ese components are combined in di˛ erent ways depending on the region of the body, the phase of growth, the homeostatic condition, etc. ° e histology of fascial tissue is changeable, that is, it has a great plasticity (ability to accommodate) which depends on the mechanical and chemical stimuli that “accommodate” its composition in a systematic way, based on cellular dynamics and the components produced by them.

Fascia: The connective, supporting, sustaining tissue? ° is chapter covers not only those tissue structures that are at the service of mechanical functions, especially static ones, but also tissues with multiple functions such as regulation of heat, metabolism, defense, and regeneration. ° e grouping together of connective tissues with such a variety of functions is based on the fact that some of the tissues simultaneously fulÿ ll mechanical and physicochemical functions, for example adipose tissue. In addition, they have a common origin in the middle layer of the embryo – the mesoderm (see Chapter 4). ° is can be of vital signiÿ cance when the cells of one type of tissue change to another under certain pathological circumstances. At the cephalic pole of the embryo, the ectodermal neural crest takes part in the constitution of the mesoderm and ectoderm. Sources of connective tissues are,

ÿ rstly, the medial (internal) parts of the primitive segments and, secondly, parts of the pedicle of the same segments and the part of the mesoderm that is not segmented (lateral blades). At the expense of the mesoderm, the embryonic connective tissue, the mesenchyma, is formed as the ÿ rst support tissue, which at the same time is the matrix of all the support tissues that will be formed later on (see Chapter 4). A special place is occupied by the ÿ rst supporting organ of the body, the dorsal cord or notochord, common to all chordates. ° e mesoderm-prechordal plate is the starting material for the formation of the mesoderm and the notochord. It is compact and does not form through the mesenchyma, as is the case with all other tissues and supporting organs. With it, a guide structure is created early on for the development of more di˛ erentiated forms of the supporting tissues that surround the notochord itself (cartilage, bone) (° ews et al. 1983). From this brief embryological overview, it can be concluded that connective tissue has suˆ cient resources to deÿ ne, connect, organize, control, and protect the body. In view of the complexity of the interactions between connective tissue components the basic concepts are expanded on separately below.

The living matrix The three matrices: Intercommunication To comply with the functions outlined above, an eˆ cient system of communications is essential. ° e information must ˝ ow eˆ ciently between the extracellular, intracellular, and intranuclear domains. In a way we are talking about three matrices – the extracellular, the cytoskeleton (the intracellular), and the intranuclear – which are intimately integrated into systemic dynamics. ° ese three matrices house an omnidirectional communication system that involves all the tissues of the human organism. Each matrix forms a coherent interactive system. ° e entire matrix is hydrophilic. ° e intrinsic and extrinsic mechanical impulses are capable of altering the dynamics of the network of matrices. Recent studies support this possibility. Langevin et al. (2010) state that the stretching of the tissue remodels the cell nucleus of the ÿ broblasts and that under normal physiological conditions the ÿ broblasts actively regulate the tension of the connective tissue.

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5

Histological aspects of the fascial system

Areolar

Loose CT

Reticular

Proper CT

Irregular

Dense CT

Regular

Ligaments

Collagenous

Adipose Organized

Connective tissue (CT) Specialized CT

Tendons

Cartilaginous Aponeurosis Osseous

Elastic Epimysial fasciae

Mesenchymal Multilayered Embryonic CT

? Mucous

Aponeurotic fasciae

Figure 5.1 Classification of connective tissue

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Collagen

Glycosaminoglycans

Elastin

Reticulin

Water

Ions

Polar molecules attract water which forms a gel giving glycosaminoglycans their elastic properties

Fibers

Composition of connective tissue

ECM is the noncellular matrix that surrounds cells and provides them with structural and biochemical support

Table 5.1

Short, fine collagenous fibers that can branch extensively to form a delicate network

Long, thin fibers that form branching networks in the extracellular matrix. The fibers help connective tissue to stretch and recoil

Fibrous proteins which are secreted in the extracellular space and provide high tensile strength to the matrix

A type of animal tissue comprised of loose cells. Its loose and fluid nature allows it to migrate easily and play a crucial role in the origin and development of morphological structures during the embryonic and fetal stages of life. Mesenchyme directly gives rise to most of the body’s connective tissues, from bones and cartilage to the lymphatic and circulatory systems Cells that secrete the major components of cartilage Cells that maintain cartilage Cells that produce bone ECM and are responsible for its mineralization Osteoblasts that have been incorporated into bone matrix A type of interstitial cell characterized by a triangular body with three or four long and thin prolongations – telopods – through which they communicate with each other and with other cells, creating a threedimensional network, special types of synapses, and a true mechanical support that enables homeostasis of the organism to be maintained Fibroblast-like cells with the specialized functions of hyaluronic acid synthesis and secretion

Mesenchyme

Chondroblasts Chondrocytes Osteoblasts

Fasciacytes

Telocytes

Osteocytes

Large, specialized cells that recognize, engulf, and destroy target cells

Cells that specialize in storing energy as fat, mainly triglycerides, in lipid droplets which are organelles

Cells that synthesize the extracellular matrix and collagen

Macrophages

Adipocytes

Fibroblasts

Cells

5

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Table 5.2

5

Purposes and functions of connective tissue

Purposes

Functions

Structural support

Provides a framework for the body Is found in all organs Provides structure and support Is a “space filler” for areas not occupied by other tissue Forms a supporting scaffold for the cells or blood vessels within the tissue Note that the types of connective tissue fall into two main groups: connective tissue consisting of cells within an extracellular, collagen-rich matrix (bone, cartilage, fibrous tissue) connective tissue with an internalized, specialized organic matrix (smooth, cardiac, and skeletal muscle, and fat)

Connection

There are tissues that are composed exclusively of connective tissue, such as ligamentous tissue or blood Connects muscles, ligaments, tendons, etc. Is responsible for maintaining structural interrelationships between tissues and cells Transport of fluid, nutrients, waste, and chemical messengers is ensured by specialized fluid connective tissues, such as blood and lymph

Protection

Protects against excessive compression or traction Prevents friction Assures motility between organs Specialized cells in connective tissue defend the body from microorganisms that enter the body

Energy storage

Adipose cells store surplus energy in the form of fat and contribute to the thermal insulation of the body

Scar formation

Fibroblast activity, collagen secretion

Place for exchange

Regulates exchange of metabolic waste, nutrients and oxygen between the blood and cells

Insulation

Fat contributes to thermal insulation of the body

TFL

Cranial

Caudal

Figure 5.2

Figure 5.3

Lateral view of the thigh in a cadaver dissection of an obese person. Note the definition of the fat lobules and encrusted vessels. TFL = tensor fasciae latae muscle

Deep fascia: lateral view of the leg. Note the multidirectional orientation of the fiber bundles

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5 Figure 5.4

A

Cross-section of the knee joint. Note the cartilaginous structure of the patellofemoral joint A Patella B Femur C Cartilage in the patella D Cartilage in the femoral condyle Circle – effects of osteoporosis in the patellar body

A B C D

1 A B

A

2

B Figure 5.6 1

Figure 5.5

Posterior view of the leg A Gastrocnemius muscles have been dissected from their origin and lifted B Soleus muscle 2 Close-up. Note the deep fascia on the inside of the gastrocnemius and soleus muscles and the multilevel and multidirectional construction of the path of the collagen fibers. In the red circle an adherence between the gastrocnemius and the soleus can be seen. This type of anomaly can obstruct the natural process of sliding between the epimysia of both muscles. Note also the infiltration of fat lobes between the collagenous fibers and the abundant hydration (white circle) that facilitates the gliding between muscles

The patellofemoral joint. The rectus femoris muscle has been dissected from the patella. The patella has been lifted A Patella (inner view) B Patellar ligament (inner view). Note the parallel organization of the collagen fibers

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A

B

5

A

B C D B E Figure 5.7

Figure 5.9

Superficial fascia with fat lobules in the cervicopectoral and arm regions. Note the following: A Continuity of the fascial structures between the parts of the body (neck, arm, and thorax) B Attachment of the skin to the superficial fascia

The elbow area. Note that the cutaneous nerves and veins are embedded in the superficial fascia A Skin on the arm and forearm B Superficial fascia with adipose lobes: outer surface and inner surface. Note the high hydration of the superficial fascia C Deep fascia D Cutaneous nerve E Cutaneous vein

A A

B

B

C D E

C D

F

E F Figure 5.8

Figure 5.10

Deep fascia: anterolateral view of the pectoral region A Pectoralis major muscle fascia B Groove between the pectoralis major and serratus muscles C Deltoid muscle fascia D Serratus muscle E Loose connective tissue between the superficial and deep fascia F Fat lobes embedded in the superficial fascial net

Lateral view of the right sacroiliac joint A Posterior view of the sacrum B Sacroiliac joint line C Thoracolumbar fascia D Iliac crest E Gluteus medius aponeurotic fascia F Gluteus maximus epimysial fascia

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5 A

A B

B

C

C

D

D E F

E F

G

G

H Figure 5.11

Figure 5.12

Dorsal view of the forearm showing the various connective tissue structures A Skin B Fibrous septa C Epimysial fascia D Fat lobes E Deep fascia F Muscle fibers G Skin (underside)

Scapular area with the trapezius muscle dissected and lifted A Aponeurosis of the trapezius B Veins embedded in loose connective tissue C Rhomboid muscle D Trapezius insertion in the spine of the scapula E Scapular spine F Skin (underside) G Infraspinatus fascia H Latissimus dorsi muscle

Figure 5.13 Extracellular matrix and its components

Adipocyte Fibroblast Hyaluronic acid Collagen Elastin Fibronectin

Extracellular matrix As mentioned above, the components of the CT are submerged within the ECM (Fig. 5.13), which represents a set of macromolecules that are located between the

cells of a particular tissue and forms their ecosystem. ° is three-dimensional biophysical ÿ lter controls the transmission of nutrients, cellular waste products, mediators, and any other substance to and from the cell surroundings. Even the release of neurotransmitters by

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a nerve cell can reach the next cell only through the matrix. Each of the macromolecules that make up the matrix performs functions in an integrated manner with the others; this means the matrix is a true complex functional system. Among the macromolecules the following stand out (Comper & Laurent 1978, Silvera & Barios de Zurbarán 2002):

•

•

Glycosaminoglycans and proteoglycans have a fundamental role in the electrolyte and acid-base balance of the body. Proteoglycans are groups of macromolecules formed by the covalent bonding between polypeptide chains and glycosaminoglycans. Hyaluronan is the only glycosaminoglycan that does not bind to the peptide chain. It plays a major role in cell migration. It facilitates the hydration of tissues, due to the large number of free radicals that bind to water molecules. ° erefore, the hydration of tissues depends on the concentration and the physiological state of hyaluronan. Multifunctional glycoproteins (laminins, ÿ bronectin, tenascin, and others) act as adhesion molecules of the intercellular substrate and are of major importance in cell–cell and cell–matrix interactions. To fulÿ ll their functions these molecules need other molecules to serve as a link between the extracellular matrix and the cellular cytoskeleton, for example, integrins, cadherins, immunoglobulins, and selectins. Adhesion molecules are a group of glycoproteins that regulate the relationships between cells and the extracellular matrix.

Another function of the extracellular matrix is to act as a reservoir for other molecules, including growth factors, cytokines, and proteases. ° e equilibrium of the extracellular matrix is maintained by a balance between:

• • • •

synthesis assembly wasting remodeling.

° is process is regulated by molecules that stimulate its elaboration, such as growth factors and other factors that regulate its catabolism and its regeneration.

5

Intracellular matrix (cytoskeleton) Mechanotransduction is the process by which cells respond to mechanical changes by converting the mechanical signals that go through the cell membrane into biochemical signals that elicit speciÿ c cellular responses. ° e ÿ laments of the cytoskeleton are composed of ultramicroscopic beams of molecules. ° e main ÿ laments of the cytoskeleton are microtubules, actin microÿ laments, and intermediate ÿ laments (Fig. 5.14). ° e three-dimensional structure of the cytoskeleton is, in essence, the same as the structure of the ECM. Both structures have the same capacity for adaptation and the same characteristic of nonimmutability/variability. ° e connections cell–matrix–cell–... determine the globality of the body and the interaction and interdependence between di˛ erent body segments of the extracellular matrix. ° e viscoelastic mechanical properties of the cells are also found in the extracellular matrix of the CT. We could say that the human body is a great mass of ˝ uids (water) organized around a matrix of proteins. ° ese proteins retain water and prevent it (and the great weight it represents) from falling toward the lower part of the body due to the action of gravitational force. ° e lipid bilayers (a species of dynamic separating membranes) organize the matrix proteins. In this way, each group of proteins can fulÿ ll speciÿ c functions for its own beneÿ t and simultaneously for beneÿ t of the matrix as a whole (Gassó 2009). Again, the concept of the systemic pattern stands up.

Intranuclear matrix ° e nucleus is the main organelle of the cell. Within the nucleus, the genetic material of the cell is encoded by a complex code of genes that are binary activated or inactivated (expression or nonexpression of genes). Each gene governs a speciÿ c task of the cell; when it is activated the functions of the cell react accordingly. ° e core content is well protected by an endoplasmic reticulum layer, a nuclear sheath, and an intranuclear matrix that functions as a biophysical ÿ lter. In conclusion, the nucleus:

•

is an entity surrounded by a double-layered membrane perforated by stomata;

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5 Fibroblast embedded in the collagenous network

Figure 5.14 The structure of the cytoskeleton and its components

Microtubule

Intermediate filaments

Actin filaments Close-up of the internal structure of fibroblasts

• •

contains genetic material;

Fibers

is organized by chromosomes (highly organized forms of DNA and proteins);

• •

Collagenous and elastic systems represent ÿ brous structures that constitute the architecture of the ECM.

contain genes; and

Elastin and its characteristics

contains fragments of DNA that codify proteins.

We are the result of an interaction between our genes and the environment in which we live. ° e cell is governed by gene expression. Genes can be expressed or not. ° e decision depends on three essential factors: genetics, epigenetics, and chance (stochastic process). Epigenetic phenomena do not a˛ ect the DNA sequence of the genes but do vary their expression. ° e genetic sequences of individuals are not determined by the heritage or history of gene expression patterns. A stochastic process characterizes a succession of random variables that evolve according to another variable, usually time. Each of the random variables of the process has its own function of distribution probability and among them they can be correlated or not (Burga et al. 2011).

Elastic ÿ bers are homogeneous. In contrast with the behavior of collagen ÿ bers, elastic ÿ bers branch out abundantly and anastomose. ° ey form irregular networks in which nodal points widening as thin membranes can be observed (Fig. 5.15). Elastic ÿ bers are capable of increasing their length by 100–140ˇpercent, their extensibility being compared to that of rubber; their resistance to stretching is very small, being governed by Young’s modulus (modulus of elasticity). Isolated ÿ brils stretching up to 50ˇpercent recover their original length; if stretching reaches 100ˇpercent, the elasticity decreases only by a small extent. As stretching progresses the resistance of the tensile elastic ÿ bers increases, so that they can then act as transmitters of the muscle contraction (acting as elastic tendons). Stretching generates kinetic energy in the ÿ bers, which

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5

A

B

Figure 5.15 Elastin and its characteristics. A Elastin at rest. B Elastin in stretch

once stored allows the ÿ ber to return to its previous condition, acting as a spring when the stretching force is eliminated.

Collagen and its characteristics Collagen is a triple-helical glycoprotein, organized in bundles or ÿ brillar chains, which is a key component in the mechanical behavior of fascial tissue. It is a complex structure whose mechanical properties are due both to its biomechanical composition and to the disposition of its molecules. In the same way that a collagenous ÿ ber is made up of ÿ brils, a ÿ bril is made up of linear molecules (Fig. 5.16). Each ÿ ber has a generally elliptical cross-section and resembles a lock of curly hair. Collagen ÿ brils have an imbricate structure and are characterized by their great ˝ exibility and a remarkable resistance to traction. ° ey have a high modulus of elasticity (Young’s modulus). Subjected to maximum traction, collagen ÿ brils do not lengthen more than approximately 5ˇpercent of their own length. ° is limited extensibility is due to the chains of polypeptides of the collagen ÿ ber being stretched chains (like those of a bicycle). ° e resistance of ÿ brils is attributable in part to molecular winding, but mainly to the stability of the main bonds of the polypeptide chains. In any case, the resistance to tearing o˛ ered by tissue crossed by collagen ÿ bers is not only due to the qualities of its ultrastructure,

A

B

C

Figure 5.16 Composition of a collagen fiber. A Triple helix. B Collagen fibril. C Collagen fiber

but also to the way the ÿ bers are interlaced (architecture) (Fig.˜5.17). ° e systems of collagen ÿ bers return to their original positions through the action of elastic ÿ bers once the displacement that they have experienced has ceased. Before reaching the extent at which they tear, the viscoelastic process of collagen ÿ bers initiates a progressive and nonreversible increase in the length of the ÿ ber. Usually, the ÿ bers do not follow the traction lines exactly; conversely, the longitudinal axis of the plexuses or networks tend to align in the direction of the tension (Benningho˛ 1925, van Turnhout et al. 2008). ° e sets of collagenous ÿ bers in dense connective tissue (cartilage, bone, dentin) are also oriented according to the directions of movements and frictions relevant to the function they perform (van Turnhout et al. 2008). ° ere are many types of collagen – there are up to 28 described – although Type I represents 90ˇpercent of

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5 Figure 5.17 Collagen triple helix. A Type I collagen. B Type II collagen. C Type III collagen. 1 Collagen in a tendon structure. 2 Collagen in cartilage

1

2

A

95%

0%

B

1%

99%

C

5%

1%

the collagen in the human body. Collagen is produced by the stable cells of the fascial tissue – the ÿ broblasts. Mediated by the dynamics of ÿ broblasts and by changes in their gene expression when subjected to di˛ erent mechanical stimuli, the transcription of procollagen (precursor of collagen) will modify the type of collagen produced. For example, in situations where the ÿ broblast has an increased load, type I collagen can be produced to synthesize type III collagen. ° is shows, as previously anticipated, the interdependence of the analyzed components. It has been observed that the predominance of type III collagen in tissues where the natural predominance is type I could mean a loss of resistance in abdominal fascial structures, which could, for example, predispose to inguinal hernias. ° erefore, the type of collagen appears to be an important element in fascial mechanics. No less important is the fact that the ÿ bers are properly oriented. ° e direction of forces to which the tissue is subjected will determine the organization of the collagen and the mechanical properties of the transmission of tissue forces (see lateral force transmission in Chapters 6 and 7). In this process, the cross-linking of collagen is relevant. ° is mechanism consists of the formation of crossed links arranged between the ÿ bers of collagen, forming

Figure 5.18 Collagen cross-links

bundles of ÿ bers with the aim of stabilizing them and making their mechanical behavior more e˛ ective (Fig.˜5.18).

Reticulin (type III collagen, immature) Reticulin is found mainly in the limiting surfaces that separate the epithelial tissue from muscle tissue or from the endothelium of the capillaries. ° ey are very delicate, meandering ÿ brils and, in opposition to the ÿ bers of mature collagen, form true networks and extraordinarily compact lattices. ° ey also exist within the epithelium of solid organs, in which they surround each cell or group of cells with a common function. ° ey are also present on the surface of inert encapsulated agglomerations. In the presence of tissue necrosis they prove to be extraordinarily resistant. Despite the continuity between collagen and reticulin ÿ brils, there are physical di˛ erences between the two. ° e collagen ÿ bril resists traction, whereas the

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5

reticulin ÿ brils are elastic and ˝ exible, and they yield to traction and ˝ exion. ° e reticulin membranes, like those of the blood capillaries or the sarcolemma of the muscle ÿ bers, can be distended, recovering their initial form when the distending action ceases (Gassó 2009). With age, reticulin can manifest itself as mature collagen, with the corresponding dynamic changes. Due to its elastic stability the reticular ÿ bers are the most suitable support for delicate cellular nets. ° anks to these ÿ bers, cavitated structures such as ÿ lled glandular tubes or capillaries ÿ lled with blood can pass into a state of elastic tension (Gassó 2009).

The microvacuolar system

Figure 5.19

° e structures which specialize in the transmission of force have a predominant organization of type I collagen ÿ bers, aligned in the form of parallel bundles. For Guimberteau et al. (2010), there is another type of fascia, microvacuolar fascia, which, unlike that which is organized to resist traction, provides lubrication to the sliding movements between aponeurotic planes, tendons, and nerves with their pulleys, etc., thus avoiding possible friction between anatomical elements. ° e microvacuolar system (see Chapter 6) is composed of 70ˇpercent proteoglycans (this will be discussed later) and 23ˇpercent collagen types I and III.

The microvacuolar system inside the superficial fascia of the thigh

° e microvacuolar dynamic absorption system acts as a damping system while allowing frictionless sliding of the aponeurotic planes and tendons, also providing a protective compartment for blood vessels, nerves, and lymphatic tissue. ° is sliding system is a space ÿ lled with a collagenous network which is vascularized and transparent and organized according to the principles of tensegrity (see Chapter 6) (Fig. 5.19). In addition, as mentioned above, it has a high content of proteoglycans, the viscoelastic properties of which allow it to behave like a gel, which explains its ability to facilitate sliding and allow the adaptation of fascial tissue.

Fibroblast dynamics and body movement ° e mechanical behavior of the fascial system depends to a large extent on its anatomical characteristics (broadly deÿ ned in this publication) and also, as already stated, on its histological composition.

° ere is a continuous replacement of the constituent components of the ECM, the ÿ broblast being one of the main components responsible for the production and degradation of the same. ° is dynamic is associated with how tissues process mechanical stimuli, as well as the presence of growth factors and interleukins (low molecular weight proteins that facilitate intercellular communication). (° is phenomenon is explained in detail below in the paragraph on remodeling of the matrix, page 128). It should be noted that these cellular processes are not only part of the physiological maintenance of the tissues, but also of the dynamics of body movement. ° e individual and/or collective alteration of the cell’s behavior induces movement dysfunction. As described later (see Chapter 9), excess collagen production facilitates the formation of ÿ brosis. Fibrotic changes represent one of the most signiÿ cant disturbances in the mechanics of CT. We generally associate them with post-traumatic (wound) events and the consequent formation of scars. However, chronic in˝ ammation can also lead to the development of a scar and consequent ÿ brosis formation (Klingler et al. 2014), for example, as in ÿ broproliferative diseases such as Dupuytren’s contracture (Wynn 2007). Fibrosis can develop due to excessive collagen secretion by the myoÿ broblasts (Hinz et al. 2001). ° e ÿ broblast can modify its phenotype (see below) and become

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5 a myoÿ broblast due to mechanical stress, the release of transforming growth factor beta 1 (TGFβ1) (Wip˛ et al. 2007), and events related to communication between ÿ broblasts which increase the frequency of calcium oscillation (as will be seen below) depending on the mechanical stimulus (Godbout et al. 2013).

Fibroblast remodeling and changes in tissue viscoelasticity In contrast to muscle, which is capable of actively contracting and relaxing to generate di˛ erent stages of tension, connective tissue (fascial tissue) is considered a passive viscoelastic material whose biomechanical behavior is determined by the properties of the elements that make up its extracellular matrix. However, as we will see below, fascial tissue plays an active role in movement. ° e viscoelastic behavior of fascial tissue depends on the properties of the extracellular matrix and the dynamic (active) remodeling of the cytoskeleton by ÿ broblasts. Studies by Langevin et al. (2011), both in vivo and ex vivo, have shown that a˙ er several minutes of stretching ÿ broblasts actively remodel the viscoelastic characteristics of the tissue being tested. Similarly, other authors, amongst them Prajapati et al. (2001) and Schleip et al. (2019), have established that connective tissue ÿ broblasts can indirectly in˝ uence matrix sti˛ ness (passive remodeling, mediated by their phenotype) through the production and degradation of matrix proteins. Unlike the previous mechanism (active remodeling), which is instantaneous, this process is longer and may even take hours. ° is phenomenon means that fascia, based on the dynamics of ÿ broblasts (which it should be noted connect and communicate as a network throughout the body), has the ability to increase the tension of tissue and contributes to the viscoelastic changes involved in the development of movement. ° us, fascia is not merely a transmitter of forces that arise from muscular contraction, as had been commonly thought, but an essential and active component of the movement. On the same subject, the research group formed by Schleip et al. (2016) highlights that: The fascial tissue contains contractile elements that actively generate and modulate force within the tissue and are

involved in mechano-sensory fine-tuning. Imbalance of this regulatory mechanism causes increased or decreased myofascial tonus, or diminished neuromuscular coordination, which contributes to several musculoskeletal pathologies and pain syndromes.

Similarly, Langevin et al. (2011) describe the intimate anatomical bond of muscles and connective tissue, suggesting that active remodeling of ÿ broblasts is relevant to basic musculoskeletal physiology: Exploration of a possible dynamic interplay between muscle and connective tissue tension/relaxation therefore could further illuminate the role of connective tissue in muscle function.

Also relevant to this chapter, Langevin et al. (2011) suggest: Thus, in vivo, connective tissue tension may impact not just connective tissue itself, but also the vascular, nervous and immune cell populations that reside within the connective tissue network, as well as adjacent organ-specific cell populations.

Tensional homeostasis and extracellular matrix remodeling Fibroblasts synthesize, organize, and maintain connective tissue during development as well as in response to trauma (see Chapter 8) or in the presence of a ÿ brotic disease (e.g., scleroderma). Carrying out these activities depends on the ability of these cells to exert mechanical force and remodel (structurally replace) the extracellular component of the tissue. According to the biologist Frederick Grinnell, one of the most important reference sources in this ÿ eld, there is a complementary, dynamic, and adaptive reciprocity between ÿ broblasts and their matrix environment based on mechanical interaction and chemical signaling. According to Grinnell (2003), the physicochemical variation of the cellular environment stimulates the remodeling of the matrix through the activity of theˇÿ broblasts. ° e result of this process determines the condition of homeostasis and the ability of the tissue to repair. Fibroblasts modify the mechanisms they use to remodel the matrix as the mechanical load of their

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environment increases (durotaxis or tensotaxis), it being possible to identify two phases. ° e process is reciprocal. ° e characteristics of the matrix stimulate the behavior of the ÿ broblasts and the dynamics of the ÿ broblasts participate in the remodeling of the matrix. In a ÿ rst phase, as a response to the increased rigidity of the environment, the remodeling depends on the cellular migratory activity, that is to say, the ÿ broblasts migrate toward the area of greatest stress (durotaxis or tensotaxis). An increase in isometric stress is then triggered resulting in the contraction of ÿ broblasts followed by the biosynthesis of products from the extracellular matrix (collagen production). In a second stage, the even greater increase in cell contraction (matrix contracture) depends on the in˝ uence of TGFβ1 and the cell di˝ erentiation of the ÿ broblast to protomyoÿ broblast and ÿ nally to myoÿ broblast (Fig. 5.20). It is important to clarify that the use of the term contracture refers to the involvement of ÿ broblasts that trigger a retraction in the extracellular matrix and does not mean contracture as a result of sustained activation of muscle ÿ ber activity (Tomasek et al. 2002). One of the main functions of ÿ broblasts is their role in wound healing. ° eir phenotypic capabilities allow them to di˝ erentiate into myoÿ broblasts which acquire contractile properties and are capable of generating signiÿ cant increases in connective tissue tension over long periods of time (hours to weeks) (Gabbiani et al. 1978, Hinz et al. 2001, Majno et al. 1971, Tomasek et al. 2002, Schleip et al. 2005). It should be noted that there is an intermediate cell form known as a protomyoÿ broblast (Hinz 2007), characterized by a high

A

5

production of ÿ bronectin, similar to how ÿ broblasts behave in the embryonic stages.

Cellular communication For a cell the most important task for proper functioning and survival is the ability to exchange mechanochemical information with the environment and with other cells, so it can adapt to changes in the surrounding environment in order to survive. Each cell type has its own proÿ le of receptors, which are the communication interface with the surrounding microenvironment. ° e cells are perfectly prepared to detect signals of chemical and/or mechanical origin, respond mechanically, and coordinate a complex biomechanical and mechanochemical process at the molecular level. All cell communication requires the transmission of information through the cell membrane (Fig. 5.21). ° e di˛ erent components of the cell membrane have the ability to move and perform di˛ erent types of molecular movements, such as rotating, tilting between the external and internal surfaces, and moving tangentially across the length and width of the membrane.

Types of cellular communication ° e most important requirement for the correct functioning and survival of a system (cells embedded in the ECM) is the ability to exchange mechanochemical information with the environment and with other cells. By communicating, the cell adapts to the changes that take place in the adjacent environment and survives. Each cell type shows its own proÿ le of receptors which constitute the communication interface with the microenvironment that surrounds it.

B

C

Figure 5.20 The fibroblast morphogenesis process relating to the secretion of TGF° 1 and mechanical matrix modifications A Fibroblast. B Protomyofibroblast. C Myofibroblast

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5 Figure 5.21

A

Integrins and mechanical force transmission A Collagen fiber B Integrin C Cell membrane D Nuclear membrane E Intracellular proteins

B

C

D

E

Various message-transmitting molecules travel through the cells, enabling them to respond to changes in the environment in a coordinated manner. ° ese molecules can trigger a number of reactions, including changes in metabolism and gene expression. Depending on the cells that emit these transmitting molecules, and in which tissue and at what distance from the origin are the cells targeted by them, we can distinguish four types of cell communication:

•

Paracrine communication. ° e messengers of a sending cell a˛ ect adjacent or relatively close target cells.

•

Juxtacrine communication. ° is is contact with other cells or with the extracellular matrix through cell adhesion molecules (for example, gap junctions). Adhesion between homologous cells is fundamental for the control of cell growth and tissue formation; adhesion between heterologous cells is important for immune response.

•

Autocrine communication. ° e products secreted by the cell in˝ uence the cell itself (it is actually a kind of self-communication).

•

Endocrine communication. A gland releases hormones that can act on cells or organs anywhere in the body (target cells or organs). Endocrine glands

release hormones into the bloodstream. ° e hormone recognizes its speciÿ c receptor in the cell membrane. ° e most important part of cell communication between the intracellular and extracellular environment is carried out by mechanical receptors known as integrins which are embedded within the cell membrane. Integrins are true molecular bridges and through them a complex process of communication and interaction between the extracellular matrix and the cytoskeleton takes place. ° rough integrins, each cell senses its environment and responds to it according to its own needs. Integrins are a set of glycoproteins formed by the association of two subunits, α and β, joined together by noncovalent bonds. ° e β subunits have eight di˛ erent variants, classiÿ ed from β1 to β8. ° e α chain has 15 di˛ erent subunits. Each subunit has three domains: a long extracellular domain, a transmembranous domain, and a short intracytoplasmic domain. ° e latter interacts with cytoskeleton components (talin, vinculin, actin, ÿ brillin) and serves as a messenger when emitting transduction signals. Integrins activate complex intracellular signaling, informing the cell about the mechanical characteristics of the extracellular matrix.

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° e degree of matrix sti˛ ness determines the phenotypic di˛ erentiation in the mesenchymal stem cells. According to the degree of matrix tension, neurogenic, muscular, or osteogenic di˛ erentiation can be created from the same mesenchymal cell. ° e β1 integrins have receptors for various matrix components, including ÿ bronectin and collagen types II and VI, which interact in the adhesion of the cells to the matrix. ° ey can stimulate the secretion of collagenase and consequently contribute to the reconstruction of the matrix. Collagen ÿ laments transmit mechanical signals to the intracellular environment. ° e mechanical forces applied to a living organ go through di˛ erent scales of size, until they become a cellular biochemical stimulus through a speciÿ c process of molecular transduction. ° e cells essential for matrix dynamics are ÿ broblasts and their morphological transformations are protomyoÿ broblasts and myoÿ broblasts (Alberts et al. 1989, Alenghat & Ingber 2002, Ingber 2003, Shoham & Gefen 2012).

Structural and functional communication of fibroblasts Based on research into connections and communication between ÿ broblasts, Langevin et al. (2004) propose that these cells are organized in a reticular network that runs through all areolar connective tissue and these connections may have a signiÿ cant and hitherto unsuspected role in communication and integration in the body. To communicate with each other the cells of multicellular organisms have developed various mechanisms, the

5

most rapid being channels that directly connect the cytoplasms of adjacent cells. ° ese channels or gap junctions (Fig. 5.22) are passive channels that allow the passage of ions, for example calcium ions. ° ey are sensitive to mechanical stimuli; i.e., cells such as ÿ broblasts trigger the passage of ions through the “gap pathway” when they receive a mechanical stimulus (Hervé & Derangeon 2013). Electron microscopy research has revealed contact points between ÿ broblasts in mouse areolar connective tissue samples that present a type of protein complex known as connexin 43 which communicates via gap junctions. Langevin et al. (2004) propose that ÿ broblasts are organized in a reticular network that crosses all areolar connective tissue and suggest these connections may play a signiÿ cant and hitherto unsuspected role in communication and integration in the body. ° ese connections may play an important role in the mechanochemical coupling of myoÿ broblasts, an event that seems to precede groups of these cells responding to an environment of increased rigidity. In addition, gap connections between ÿ broblasts appear to be related to the innate immune response of the tissues. Sirén et al. (2006) suggest that ÿ broblasts act as sentries for tissue damage. ° ey conclude that direct cell-to-cell contact (gap junctions) is part of the communication needed between ÿ broblasts to trigger the in˝ ammatory response, the recruitment of mesenchymal cells for regeneration, and the activation of Figure 5.22 Gap junction between two fibroblasts A Gap junction B Connexon C Connexin D Molecules of calcium assemble in a “calcium wave” after the mechanical stimulation of the fibroblast

A

Ca+

Ca+ Ca+

Ca+

D

B

C

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5 metalloproteinases – enzymes responsible for the excision (degradation) of collagen during the remodeling of connective tissue.

Telocytes, interstitial cells, and gap communication It should be noted that histologically ÿ broblasts and other cells, for instance mast cells, macrophages, and blood-derived immune cells (plasma cells, neutrophils, eosinophils, and lymphocytes), have been classiÿ ed as interstitial cells. In this context, it is worth noting the importance the subject of interstitium has assumed. ° is classiÿ cation also includes telocytes (TCs), which are cells similar to ÿ broblasts arranged in a threedimensional network by homocellular contacts from protoplasmic expansions known as telopods. In addition to contacting each other, TCs have heterocellular contacts with immune cells (mast cells, macrophages, basophil, eosinophils, neutrophils, T cells, B cells) and tissue cells (ÿ broblasts, neurons, epithelial cells, endothelial cells, neurons) (Shi et al. 2016). It is interesting to re˝ ect on the connection between TCs and ÿ broblasts. Could it be that they have a joint function, since both are attributed roles linked to mechanosensitive and regenerative functions? TCs are cells located in the anatomical structures of mammals in the cardiovascular, respiratory, digestive, reproductive, urinary, musculoskeletal, visual, nervous, and hematopoietic systems. For example, TCs are considered to be mechanical sensors in the human uterus. ° e systematic review by Radu et al. (2017) concludes that, due to the presence of gap junctions between the TCs present in the human uterus and their link with the detection of mechanical stimuli, these cells may be involved in the growth and contraction of the uterine wall. ° is signaling mechanism appears to be involved in ensuring the uniform thickness of the walls of the uterus during its growth in pregnancy. It is believed that therapeutic modulation of TC gap junctions may prevent uterine ruptures secondary to hypertrophy (alteration in thickness). Promising therapeutic alternatives currently available include the prevention of uterine ruptures secondary to hypotrophy using gap linkage modulators between TCs.

Mechanochemical coupling of myofibroblasts We have previously commented that ÿ broblasts communicate through gap junctions. ° is communication is mediated by the emission of waves of calcium ions (Ca2+) which act as an intercellular messenger. A study by Godbout et al. (2013) suggests that this form of communication used by myoÿ broblasts, when grown in artiÿ cial matrices at di˛ erent (increasing) stages of sti˛ ness, may be related to the contractile activity of these cells in response to changes in environmental stress. When myoÿ broblasts sense the increasingly sti˛ environment they increase the frequency of Ca2+ wave oscillations, and when grown in more “so˙ ” environments Ca2+ waves are less frequent. ° e authors suggest that the level of extracellular mechanical challenge modulates the oscillatory dynamics of Ca2+ to control the contractile activity of the myoÿ broblasts. In this way, myoÿ broblasts use chemical signaling to respond by mechanical action, hence the process we call mechanochemical coupling. ° is process seems to suggest that the collective remodeling of the myoÿ broblasts is due to intercellular communication, and not only to the perception of each of these cells in their immediate surroundings. Does this mean that myoÿ broblasts located outside the range of rigidity could react when receiving information through gap junctions? If this could be proven it might explain the changes in distant tension that are usually observed clinically.

Gap junctions and collagen synthesis ° e coupling of connective tissue cells (gap junctions) appears to play an important role in the production and maintenance of matrix components, as in the case of collagen. In an interesting study by Waggett et al. (2006), the authors analyzed the dynamics of two di˛ erent types of gap junctions that are present in tenocytes (tendon ÿ broblasts). Tenocytes express two types of gap junctions in vivo: connexin 32 and the aforementioned connexin 43. ° ere is a signiÿ cant di˛ erence between the two, namely that the junctions through connexin 32 are arranged along the main load line in the tendon (longitudinal to

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the collagen ÿ bers), while connexin 43 links the cells in all directions. ° ese bonds have di˛ erent functions related to collagen synthesis. ° e authors have shown that these unions act in a complementary manner; whereas connexin 43 is inhibitory, connexin 32 increases collagen secretion in response to loading (Fig. 5.23).

Fibroblasts, mechanotransduction, and gene expression Fibroblasts have at least two ways to respond to the mechanical environment by changing their gene expression. Direct mechanotransduction is mediated by integrins, which act as mechanical sensors capable of sensing the rigidity of the cellular environment. Fibroblasts can also respond to the mechanical conditions of their environment indirectly through mechanosensitive ion channels. Genetic studies conducted by Wang et al. (2007) have highlighted that the presence of growth factors (TGFβ) or cytokines (IL1β) in the cellular environment can condition the gene expression of ÿ broblasts and therefore the production of collagen.

It should be noted that the orientation of the connections depends on the orientation of the tenocytes, since these channels are integrated into the cellular cytoskeleton; therefore, the remodeling of the tenocytes from a speciÿ c matrix environment may cause the gap channels to change their orientation. It is speculated that in a situation of matrix disorganization (fascial restriction), the complementary activity of these channels could be a˛ ected and could therefore alter the production or inhibition of collagen production. A

5

B D C

E

F

G

Figure 5.23 Tenocyte dynamics A Tenocyte network B Collagen fibers C Connexin 32 (along the tendon load line) D Connexin 43 (multidirectional orientation) E Tendon at rest F Tendon with axial load (connexin 32 stimulation) G Tendon with increased axial load (connexin 43 stimulation)

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5 The fibroblasts that receive mechanical load in the presence of TGFβ increase the synthesis of collagen (anabolic response); however, in the presence of proinf lammatory cytokines (IL1β) these cells increase the production of metalloproteinases (catabolic enzymes) which act by degrading collagen and other components of the matrix. It is interesting from a clinical point of view to recall the work of Mense and Hoheisel (2016) in which it has been seen that by causing neurogenic in˝ ammation (see Chapter 8) in the thoracolumbar fascia in experimental animals, an increase in the density of nociceptors was caused. Neurogenic in˝ ammation may be mediated by IL1β; therefore, in view of what we have described above, the thoracolumbar fascia could be involved in catabolic processes in the presence of this substance and in parallel have to respond to mechanical stimuli.

Do astrocytes have behavior analogous to fibroblasts? Astrocytes are the predominant glial cells of the central nervous system. In recent years, their participation in the metabolic processes (neuronal nutrition, ion balance, etc.) and functional processes linked to the neurons (regulation of circuits) of the mature nervous system has been highlighted, both in normal and pathological conditions. ° ese cells are mechanosensitive meaning they are sensitive to tension changes and particularly to an increase in the rigidity of their environment. Under conditions of mechanical injury (brain trauma, constrictive nerve damage, for example) astrocytes are capable of triggering a response known as reactive gliosis, apparently with the aim of preserving the integrity of neurons. In this state, these cells adopt hypertrophic characteristics (larger size) and become more rigid to deformation. In an in vitro study conducted by Cullen et al. (2007) these cells were observed to respond to mechanical stress at di˛ erent speeds and in the presence of TGFβ. ° e authors conclude that astrocytes react to these stimuli by increasing the protein expression of their cytoskeleton, which conÿ gures their characteristic robust morphology.

Since these cells are responsible for the scar processes of the nervous system in the face of lesions of various etiologies (hemorrhagic, ischemic, traumatic, etc.) and considering that nerve tissue has a low presence of connective tissue itself, it is at the very least a tempting idea that astrocytes could be cells that are analogous to ÿ broblasts in terms of their participation in the processes of protection, repair, and regeneration of the nervous system.

Ground substance Composition of the matrix and the importance of water According to studies by Stecco et al. (2013), hyaluronan (HA) is a high molecular weight proteoglycan that is omnipresent in fascial tissue. It is located particularly in the endomysium (which surrounds the muscle ÿ bers), perivascular connective tissue, and neuroconnective tissue. ° e authors stress the importance of the presence of HA which acts as a lubricant in the gliding of fascial planes and assert: We have confirmed that HA is found in considerable amounts at the interface between the deep and superficial fascia of the muscle. A layer of HA-secreting cells has been identified in the inner layer of deep fascia. These fibroblast-like cells are called fasciacites.

° ese authors emphasize that because HA has a neutral charge (isoelectric pH) it attracts a large volume of water which acts as an essential lubricant. ° e presence of water in fascial tissue contributes signiÿ cantly to its viscoelastic properties. ° e increase in viscosity is linked to the irritability of the mechanoreceptors, which in a viscous environment lower the trigger threshold and increase their mechanosensitivity.

Metalloproteinases and collagen degradation Metalloproteinases (MMPs) are proteolytic enzymes responsible for the degradation and remodeling of the extracellular matrix (mainly collagen). In healthy tissue, some MMPs are expressed at low levels. However, during tissue remodeling, disease, or in˝ ammation MMP levels are o˙ en high. ° eir regulation is controlled, as mentioned in the case of tendons, by growth factors (TGFβ) and by cytokines (TNFα and IL1).

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° ere are di˛ erent subtypes of MMPs. According to the review by van Marion (2006), MMP1 and MMP2 are the main subtypes responsible for collagen degradation (type I, for example). It is suggested that a change in the mechanical environment of interstitial cells causes an activation of MMPs, resulting in positive regulation (increased production) of the enzymes related to matrix remodeling. ° ese enzymes are an essential part of the connective tissue remodeling process.

Mechanical induction of collagen remodeling ° e quality of connective tissue (fascial tissue) can be improved in its morphological organization both in structure (more organized collagen ÿ bers) and mechanical properties. It has been established that tension applied to a tissue improves the production and organization of the matrix, while the interstitial cells are favored in terms of their viability. ° e activity of MMPs underlies these mechanisms. Seliktar et al. (2001) suggest that mechanical stretching and shearing of tissues in˝ uence the expression, production, and activity of MMPs, resulting in a change in the remodeling of the tissue and its mechanical properties. ° ese studies establish that the quantity and type of load have a significant e˛ ect on the enzymatic degradation of collagen.

The extracellular matrix and cancer progression ° e local microenvironment or niche of a cancer cell plays an important role in the development of cancer. A main component of the niche is the extracellular matrix (ECM), which participates in the genesis and progression of the disease through its composition and biochemical and biomechanical properties.

Biomechanical carcinogenic properties ° e physical or biomechanical properties of the ECM refer to its rigidity, porosity, insolubility, spatial arrangement, and orientation (or topography), as well as other physical characteristics that together (combined) determine its role in the architecture and integrity of the tissue. According to research by Levental et al. (2009), the tumor environment is typically more rigid than normal. In the case of breast cancer, for example, cancerous tissue can be up to 10 times sti˛ er than normal breast tissue. It should be noted that ECM rigidity

5

is not only a secondary outcome of cancer, but rather plays a causal role in the pathogenesis of cancer. Biomechanical characteristics are also implicated in the phenomena of tumor cell migration (metastasis). It appears that the linear arrangement of the collagen packages (in addition to their rigidity) arranged perpendicularly to the tumor niche favors the migratory access of metastasizing cells to the vascular networks. Conversely, the reticular (net-like) organization of collagen ÿ bers hinders or prevents cell migration unless MMPs are activated simultaneously, causing physical permeability conditions (Egeblad et al. 2010). Changes in the quantity and composition of the ECM can alter the biochemical properties of the ECM and enhance the oncogenic e˛ ects of various signaling pathways linked to growth factors involved in malignant cell transformation (Nasser 2008).

Interstitium and diffusion of liquids Recently in an article in the prestigious journal Nature a group led by Benias et al. (2018) published high-precision images obtained with state-of-the-art imaging technology of interstitium in various body structures. ° e authors refer to interstitium as the main source of lymph and as a major ˝ uid compartment in the body. ° e authors conclude that the collagen network that occupies this space is bathed in interstitial ˝ uid and organizes together with the ÿ broblasts the compartments that the immune cells and other cells must cross during their journey to the site of demand (focus of attack). In another article, Langevin et al. (2013) highlight the work of the ÿ broblast network in relation to interstitial ˝ uid dynamics, which acts through a sort of sponge effect. ° e increase or decrease in tension of the collagen network from ÿ broblast contraction adjusts the size of the “pore” through which water molecules are able to ˝ ow attracted by glycosaminoglycans. A subtype of glycosaminoglycan, the salt state of hyaluronan (hyaluronate), has been linked to the mechanical behavior of connective tissue, more precisely to its viscoelasticity, and the facilitation of sliding between fascial planes.

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5 It can be concluded that the extensive network of ÿ broblasts and their tension state are capable of altering the hydration of tissues. ° ey therefore can a˛ ect the capture and retention of water by the heavy proteins that contribute signiÿ cantly to the mechanical behavior of tissues.

Astrocytes and diffusion of brain fluids ° e di˛ usion of liquids in the nervous system by astrocytes has great similarities with the mechanisms described above in terms of interstitial ˝ uid dynamics. ° e di˛ usion of brain ˝ uids (interstitial ˝ uid and cerebral spinal ˝ uid) is roughly determined by an intercellular (between cells) and a transcellular (through cells) mechanism. In the ÿ rst of these, intercellular di˛ usion, liquids ˝ ow through cellular spaces, which can be more or less permeable depending on the tension of the extracellular matrix, which in turn is conditioned by the proliferative dynamics of the astrocytes. ° ese can increase or decrease their morphology, and because they are anchored to the mechanical environment of the nervous system they can trigger an increase in their stress state. ° us, increased stress caused by astrocytes can modify the ˝ ow of ˝ uids through the intercellular spaces. In the case of transcellular di˛ usion, speciÿ c proteins called aquaporins are involved. Astrocytes have aquaporins located at the ends of their “feet” (sucking feet). ° ese proteins act as true water channels, which are responsible for the di˛ usion of liquids in the cerebral

microcirculation, as well as through the intercellular spaces described above. It has been shown that in the event of reactive gliosis the acquaporin channels change their position (they withdraw or migrate towards the bodies of the astrocytes), altering the circulation given by convection ˝ ow from the arterial perivascular space to the venous one, which generates a stagnation of the interstitial ˝ uids (interstitial ˝ uid and spinal brain ˝ uid) (Fig. 5.24). An analysis of the phenomena described above could facilitate the development of contemporary models of therapeutic processes applied to cranial structures.

Conclusion ° e ECM is an essential component of the structure and function of the fascial system. It acts as a complex network of molecules that are assembled into di˛ erent structures. ° e ECM, through the regulation of growth factors and the availability of chemokines (chemotaxis control), constantly remodels and reorganizes the tissue. ° rough biochemical and biomechanical signals, which are required for optimal functioning, the ECM contributes to maintaining tissue morphogenesis, differentiation, and homeostasis. Changes in the composition of the ECM may be related to pathological conditions such as ÿ brosis or cancer. ° erapeutic procedures should focus on the architecture of the ECM and the interactions with its cellular components.

Figure 5.24

A Dura mater

B

Subarachnoid space Para-arterial influx Connective flux Paravenous efflux

C D E

Astrocyte Reactive astrocyte

The dynamics of aquaporins A Perivascular arterial space B Perivascular venous space C Convection flow in a physiological situation. Note the accumulation of aquaporins located at the feet of the astrocytes D Reactive gliosis and convection flow loss. Note the disorganization at the site of the aquaporins E Accumulation of waste products

Neuron Interstitial solute Aquaporin-4 Aggregates

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REFERENCES

Alberts B, Bray D, Lewis J, Ra˛ M, Roberts K, Watson JD (Eds.) (1989) Molecular Biology of the Cell. 2nd ed. New York: Garland Publishing, pp. 791–836. Alenghat FJ, Ingber DE (2002) Mechanotransduction: All signals point to cytoskeleton, matrix, and integrins. Sci STKE 2002(119):pe6. Benias PC, Wells RG, Sackey-Aboagye B, Klavan H, Reidy J, Buonocore D, Miranda M, Kornacki S, Wayne M, Carr-Locke DL, ° eise ND (2018) Structure and distribution of an unrecognized interstitium in human tissues. Nature Sci Rep 8(1):4947. Benningho˛ , A (1925 [2013]) Form und Bau der Gelenkknorpel in ihren Beziehungen zur Funktion. Zweiter Teil: Der Aufbau des Gelenkknorpels in seinen Beziehungen zur Funktion. Z Zellforsch 2(5):783–862.

Grinnell F (2003) Fibroblast biology in threedimensional collagen matrices. Trends Cell Biol 13(5):264–269. Guimberteau JC, Delage JP, McGrouther DA, Wong JK (2010) ° e microvacuolar system: How connective tissue sliding works. J Hand Surg Eur Vol 35(8):614–622. Hervé JC, Derangeon M (2013) Gap-junctionmediated cell-to-cell communication. Cell Tissue Res 352(1):21–31. Hinz B (2007) Formation and function of the myoÿ broblast during tissue repair. J Invest Dermatol 7(3):526–537. Hinz B, Celetta G, Tomasek JJ, Gabbiani G, Chaponnier C (2001) Alpha-smooth muscle actin expression upregulates ÿ broblast contractile activity. Mol Biol Cell 12(9):2730–2741.

Burga A, Casanueva MO, Lehner B (2011) Predicting mutation outcome from early stochastic variation in genetic interaction partner. Nature 480(7376):250–253.

Ingber DE (2003) Tensegrity II. How structural networks in˝ uence cellular information processing networks. J Cell Sci 116(Pt. 8):1397–1408.

Comper WD, Laurent TC (1978) Physiological function of connective tissue polysacharides. Physiol Rev 58(1):255–315.

Klingler W, Velders M, Hoppe K, Pedro M, Schleip R (2014) Clinical relevance of fascial tissue and dysfunctions. Curr Pain Headache Rep 18(8):439.

Cullen DK, Simon CM, LaPlaca MC (2007) Strain rate-dependent induction of reactive astrogliosis and cell death in three-dimensional neuronalastrocytic co-cultures. Brain Res 1158:103–115.

Langevin HM, Cornbrooks CJ, Taatjes DJ (2004) Fibroblasts form a body-wide cellular network. Histochem Cell Biol 122(1):7–15.

Egeblad M, Rasch MG, Weaver VM (2010) Dynamic interplay between the collagen sca˛ old and tumor evolution. Curr Opin Cell Biol 22(5):697–706. Gabbiani G, Chaponnier C, Hüttner I (1978) Cytoplasmic ÿ laments and gap junctions in epithelial cells and myoÿ broblasts during wound healing. J Cell Biol 76(3):561–568. Gassó, R (2009) Personal communication with R Gassó MD, PT, Associate of the Research Group of Dr. Alfonso Rodriguez Baeza, Professor of Anatomy, Department of Morphological Sciences, Faculty of Medicine, Universitat Autònoma de Barcelona. Godbout C, Follonier Castella L, Smith EA, Talele N, Chow ML, Garonna A, Hinz B (2013) ° e mechanical environment modulates intracellular calcium oscillation activities of myoÿ broblasts. PLOS ONE 8(5):e64560.

Langevin HM, Storch KN, Snapp RR, Bou˛ ard NA, Badger GJ, Howe AK, Taatjes DJ (2010) Tissue stretch induces nuclear remodeling in connective tissue ÿ broblasts. Histochem Cell Biol 133(4):405–415. Langevin HM, Bou˛ ard NA, Fox JR, Palmer BM, Wu J, Iatridis JC, Barnes WD, Badger GJ, Howe AK (2011) Fibroblast cytoskeletal remodeling contributes to connective tissue tension. J Cell Physiol 226(5):1166–1175. Langevin HM, Nedergaard M, Howe AK (2013) Cellular control of connective tissue matrix tension. J Cell Biochem 114(8):1714–1719. Levental K, Yu H, Kass L, Lakins JN, Egeblad M, Erler JT, Fong SFT, Csiszar K, Giaccia A, Weninger W, Yamauchi M, Gasser DL, Weaver VM (2009) Matrix crosslinking forces tumor progression by enhancing integrin signaling. Cell 139(5):891–906.

5

Majno G, Gabbiani G, Hirschel BJ, Ryan GB, Statkov PR (1971) Contraction of granulation tissue in vitro: Similarity to smooth muscle. Science 173(3996):548–550. Mense S, Hoheisel U (2016) Evidence for the existence of nociceptors in rat thoracolumbar fascia. J Bodyw Mov ° er 20(3):623–628. Nasser NJ (2008) Heparanase involvement in physiology and disease. Cell Mol Life Sci 65(11):1706–1715 Prajapati RT, Eastwood M, Brown RA (2001) Duration and orientation of mechanical loads determine ÿ broblast cyto-mechanical activation: Monitored by protease release. Wound Repair Regen 8(3):238–246. Radu BM, Banciu A, Dumitru Banciu D, Banciu DD, Radu M, Cretoiu D, Cretoiu SM (2017) Calcium signaling in interstitial cells: Focus on telocytes. Int J Mol Sci 18(2):397. Schleip R, Klingler W, Lehmann-Horn F (2005) Active fascial contractility: Fascia may be able to contract in a smooth muscle-like manner and thereby in˝ uence musculoskeletal dynamics. Med Hypotheses 65(2):273–277. Schleip R, Klingler W, Wearing S, Naylor I, Zuegel M, Hoppe K (2016) Functional in vitro tension measurements of fascial tissue – a novel modiÿ ed superfusion approach. J Musculoskelet Neuronal Interact 16(3):256–260. Schleip R, Gabbiani G, Wilke J, Naylor I, Hinz B, Zorn A, Jäger H, Breul R, Schreiner S, Klingler W (2019) Fascia is able to actively contract and may thereby in˝ uence musculoskeletal dynamics: A histochemical and mechanographic investigation.ˇFront Physiolˇ10:336. Seliktar D, Nerem RM, Galis ZS (2001) ° e role of matrix metalloproteinase-2 in the remodeling of cell-seeded vascular constructs subjected to cyclic strain. Ann Biomed Eng 29(11):923–934. Shi L, Dong N, Chen C, Wang X (2016) Potential roles of telocytes in lung diseases. Semin Cell Dev Biol 55:31–39. Shoham N, Gefen A (2012) Mechanotransduction in adipocytes. J Biomech 45(1):1–8.

137

Pilat_Myofascial Induction.indb 137

03/12/21 4:01 PM

5

REFERENCES

Silvera L, Barrios de Zurbarán C (2002) La matriz extracelular: el ecosistema de la célula. Salud Uninorte 16:9–18. Sirén V, Salmenperä P, Kankuri E, Bizik J, Sorsa T, Tervahartiala T, Vaheri A (2006) Cellcell contact activation of ÿ broblasts increases the expression of matrix metalloproteinases. Ann Med 38(3):212–220. Stecco A, Gesi M, Stecco C, Stern R (2013) Fascial components of the myofascial pain syndrome. Curr Pain Headache Rep 17(8):352. ° ews G Mutschler E, Vaupel P (1983) Anatomía, ÿ siología y patoÿ siología del hombre: manual para farmacéuticos y biólogos. Editorial Reverté pp. 27–45.

Tomasek JJ, Gabbiani G, Hinz B, Chaponnier C, Brown RA (2002) Myoÿ broblasts and mechano-regulation of connective tissue remodelling. Nat Rev Mol Cell Biol 3(5):349–363. van Marion MMH (2006) Matrix metalloproteinases and collagen remodeling: A literature review. BMTE 06:55. van Turnhout MC, Haazelager MB, Gijsen MAL, Schipper H, Kranenbarg S, Van Leeuwen JL (2008) Quantitative description of collagen structure in the articular cartilage of the young and adult equine distal metacarpus. Anim Biol 58:353–370. von Bertalan˛ y L (1968) General System ° eory: Foundations, Developments, Applications. New York: Braziller.

Waggett AD, Benjamin M, Ralphs JR (2006) Connexin 32 and 43 gap junctions di˛ erentially modulate tenocyte response to cyclic mechanical load. Eur J Cell Biol 85(11):1145– 1154. Wang JH ° ampatty BP, Lin JS, Im HJ (2007) Mechanoregulation of gene expression in ÿ broblasts. Gene 391(1–2):1–15. Wip˛ PJ, Rifk in DB, Meister JJ, Hinz B (2007) Myoÿ broblast contraction activates latent TGF-beta1 from the extracellular matrix. J Cell Biol 179(6):1311–1323. Wynn TA (2007) Common and unique mechanisms regulate ÿ brosis in various ÿ broproliferative diseases. J Clin Invest 117(3):524–529.

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The concept of tensegrity: Fascia as a tensegrity structure

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The molecules that make up cells and the cells that comprise tissues continually turn over; it is maintenance of pattern integrity that we call “life.” Donald Ingber (1993)

KEY POINTS •

Discovery and development of the theory of tensegrity

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Analysis of multidisciplinary investigations into tensegrity

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Advantages of the tensegrity model

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How the tensegrity model relates to the dynamics of biological structures

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Analysis of the hierarchy of tensegrity structures in the construction of the body

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Fascia as a tensegrity structure

Origin of the tensegrity concept

Compression-based structures

° e only exceptions were seen a˙ er the adoption of iron as a construction material. Suspension bridges, for example, had wires subjected to traction to support carriageways. ° e capacity of iron to absorb the forces of traction also led to the reinforced concrete technique, which at the same time led to bigger and more ˝ exible constructions, the static behavior of which could be reliably predicted at the design stage (Gordon 1978).

For thousands of years architectonic elements were designed to respond to the forces of pure compression. ° e mass of a construction was distributed and pushed downward to the ground through components whose orientation toward verticality was essential. Walls, columns, beams, and arches were assembled as a set that remained stable because it adhered to the ground by virtue of gravitational attraction (Fig. 6.1). ° is condition of stability obeyed a few simple rules imposed by the barycenter (the set’s virtual point on which weight and additional charges were concentrated when located inside the perimeter of the base). ° e forces to which structures were subjected were almost exclusively those of compression.

° e main di˛ erence when building or trying to elevate a large structure by means of one of these two strategies, compression or traction, is that in compression the elements are subject to buckling and liable to collapse. By contrast, in traction the elements are not a˛ ected by buckling, meaning it is possible to use as much as 60ˇpercent less construction material. It helps if we visualize the di˛ erence between how a stool and a swing support the weight of the person sitting on it. ° e stool requires four or a minimum of three support points and a material of a high enough density to support the load. ° e swing meets the demands with a much lower density of material and just two support points.

Halfway through the twentieth century among artistic communities and architectural and engineering circles began the di˛ usion of a completely new structural concept, the implications of which came to be extended and interpreted as a universal principle of organization.

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A

B

C

Figure 6.1 Architectural models of compression. The participation of gravitational force is essential for the stability of these structures. A Beam and column. B Pyramid. C Arc

Geodesic structures In the 1920s the ÿ rst domes based on rigid triangular modules assembled in an almost spherical structure appeared (Fig. 6.2). ° ese domes, later called geodesic domes, allowed for great savings in materials, increased rigidity and above all manifested an integral reaction when submitted to stress. A force applied to one point was evenly distributed throughout the entire structure, including the foundations, and in the same way the resulting deformation was spread.

Tensional tensegrity–integrity Real revolution came around 1948 with surprising simultaneity, as if to highlight the fact that the times were advanced enough for new paradigms. US architect, mathematician, philosopher, and philanthropist Richard Buckminster Fuller had organized in a coherent synthesis, over nearly two decades, his research on structures (including geodesic domes) to respond to tensile stresses as well as compression. ° e objective was to identify a stable structural set whose constituent elements were equally disposed in a geometric conformation – some stretching (responding to traction) and others contracting (responding to compression). For clarity, the author will refer to the traction-resistant extensible elements as “wires” and the rigid elements that resist compression as “bars.” Buckminster Fuller noticed that it was possible to integrate bars and wires

into a new type of structure with unusual features, for example, that the stability remained in spite of the space orientation and that it was also extremely eˆ cient. ° is meant that the amount of material needed to ensure dynamic stability was very small compared to conventional construction. Fuller at that time taught classes on geometric models in the Black Mountain College in North Carolina. In the summer of 1948 Kenneth Snelson, a plastic arts student at the University of Oregon, attended some of these classes. Snelson got excited by Fuller’s ideas and started to apply them by experimenting with 3D models inspired by the work of the sculptor Alexander Calder and the painter Josef Albers. Finally, Snelson built a very stable and ˝ exible wires and bars artifact which he showed to Fuller the following summer. ° e architect noticed the artifact’s huge potential and put it in the frame of his advanced geometry research, conferring a high degree of theoretical justiÿ cation. It was he who coined the term “tensegrity” for these new kinds of structures by combining two words – “tensional” and “integrity.” As if to make things more diˆ cult (regarding the invention of tensegrity), almost at the same time in Europe the Hungarian architect David-Georges Emmerich was elaborating a “proto-form” of wires and bars, inspired by a 1920s prototype created by the Russian artist Karl Ioganson (1990). ° e Emmerich structure had nine tensed wires and three bars and di˛ ered from

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The concept of tensegrity: Fascia as a tensegrity structure

B

C

6

D

A Figure 6.2 A geodesic dome. Only tension and compression are present and it is a structure of low energy consumption. A The beam and column, pyramid, and arch are structures based on compression force. B Stressing a structure which has its assembly based on the behavior of right angles requires a great use of energy. C In a structure based on a triangle, an integral reaction occurs when it is subjected to stress: Force applied at one point is evenly distributed throughout the whole structure. D A dome based on rigid triangular modules allows for a great saving in materials

the Ioganson structure which had eight wires (one was not tensed) and three bars. It was immediately clear that the separate vindications of Fuller, Snelson, and Emmerich, registered as three di˛ erent patents, referred to the same structure. Soon a controversy arose over the authorship of the discovery, which lasts to this day. What seems undeniable is that Buckminster Fuller integrated the concept of tensegrity into the corpus of his theoretical investigations, considering it a fundamental principle of nature, while Emmerich devoted himself to the search for structural variants related to tensegrity principles. Meanwhile, Snelson gained wide notoriety for the development of intriguing, apparently weightless sculptures and for using these new concepts in other interesting areas away from engineering (Gómez-Jáuregui 2007, Motro 2003, Snelson 2014).

reaching the limit of the metaphor when he deciphers tensegrity phenomena in the planetary system, the formation of atoms, man–woman relationships, and teacher– student relationships, etc. (Buckminster Fuller 1975). Fuller’s idea of interpreting tensegrity as synergy between a basic physical bipolarism (traction–compression, pull– push, attraction–repulsion, etc.) turns out to be fascinating, but, as Snelson pointed out on several occasions, this exercise can weaken the concept. ° e greater the number of phenomena interpreted as tensegrity structures, the less univocity we will be able to ÿ nd in the analysis of the balancing mechanisms involved. Beyond the analogical and poetic suggestions in this context it is convenient to try to elaborate a ˝ exible deÿ nition of tensegrity and ÿ nd out how much of it can be useful to explain the biological phenomena that interest us.

A˙ er the 1950s, the focus on tensegrity structures spread rapidly in ÿ elds as diverse as architecture, engineering, biology, anatomy, organic chemistry, and even vitalism and self-healing. Buckminster Fuller himself, in his book Synergetics (1975), identiÿ es tensegrity as the spontaneous tendency of any organism to ÿ nd structure,

Tensegrity in engineering From a basic engineering point of view, a tensegrity structure is made up of isolated rigid bars, whose ends are connected by pre-tensed wires (we can equate the wires with rubber bands) (Fig. 6.3). It is precisely

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6 we refer to “canonic tensegrity” when internal discontinuous compression and external continuous traction exist. Because of these restrictions the expression (adopted by Buckminster Fuller) “˝ oating compression” as a synonym for tensegrity is used, i.e., compression isles in an ocean of traction.

Figure 6.3 A tensegrity model. A tensegrity system is a system that is in equilibrium, is stable on its own, and comprises a discontinuous set of compressed components within a continuous set of cable-stayed components. Reproduced with permission from ArtefactPro

pre-tension (that is, the ability to stretch the wires during assembly) that confers its main characteristic to the structure – ˝ exibility. ° e forces applied at any point are transmitted to every other constituent, the deformations are spread throughout all the elements, and the whole reacts unitarily. A tensegrity structure can roll in any direction while maintaining structural integrity as a result of the weight distribution of its elements. It is practically una˛ ected by gravity. In addition, as its complexity grows its resistance to deformation increases. Its balance is remarkable not only in static conditions (constant applied forces), but also in a dynamic regime (vibrations and displacements are transmitted and neutralized uniformly at all points). Its global behavior is very similar to that of an ideally elastic substance. When an external force is applied it deforms symmetrically, and when the force disappears it returns to its original shape. ° e members are automatically placed in a state of minimum energy, as their conditions vary with the variation of the load and the initial pre-tension (Scarr 2014, pp. 7–8). In the ÿ eld of engineering some restrictions must be considered. A true tensegrity structure has bars as internal parts, the bars do not touch each other, and the wires are placed at the external surface. Consequently,

° is restricted deÿ nition is almost exclusively used in the ÿ eld of architecture. A lot of work has been carried out in past decades to classify the geometric, mathematical, topological, and functional properties of tensegrity structures, including the creation of generalized instruments relating to its dynamic and static calculations, notably by René Motro (2003) in France, R.ˇW.ˇBurkhardt in the United States, and Valentín Gómez-Jáuregui (2007) in Spain. However, as regards pure tensegrity structures (functional architectonic constructions designed to cover environments with large dimensions) there are not more than four or ÿ ve in existence in the world. In spite of this, the excellent potential of tensegrity structures can be seen in space exploration and colonization, where lightness, ˝ exibility, unfolding, independence from gravitational bonds, and impact tolerance play a decisive part. In this context, another singular feature is relevant – these structures are self-sustainable and allow quick sca˛ oldless settings since they work as sca˛ olds themselves. A more ˝ exible deÿ nition of tensegrity allows for a completely di˛ erent panorama because then the tensegrity concept can be combined with geodesic domes, pneumatic structures, suspension roofs, tensile structures (Frei Otto), spoked wheels, ruled surfaces, ˝ ying buttresses (Antoni Gaudí), radial roofs, and roof designs based on a spider’s web, etc. ° ere are many examples, and in academic research they are of growing interest. Apparently, Kenneth Snelson was right when he expressed doubt about the possibility of using canonic tensegrity for architectural purposes. ° e extreme ˝ exibility of pure tensegrity structures makes them diˆ cult to control and if automatized systems to correct tension in the wires to dynamically ÿ x the ˝ exibility were adopted – as has been proposed by René Motro (2003) and others – the expense would be prohibitive compared to the possible advantages. Another diˆ culty relates to the physical dimensions of the components in extensive structures such as those designed to cover very large spaces. Although it is relatively easy to design a

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self-stable tensegrity geometric model, when it comes to deÿ ning the materials and the actual dimensions the elements frequently interfere with each other. By contrast, striking examples of pure tensegrity (“symbolic,” nonarchitectural) are found everywhere, for example, sculptures, masts, arches, nonfunctional bridges, furniture, jewelry, assembly toys and games, and “tensegrobots.” Most researchers agree that the full implications of the phenomenon of tensegrity are not yet fully understood and that its elusive deÿ nition must be channeled in such a way as to allow greater interpretative ˝ exibility. It is as if we were just glimpsing the enormous potentialities of a dynamic “hyperequilibrium,” extremely simple and eˆ cient, as the basis of any structural organization that is physically realizable, and also repeatable and independent of the scale of construction. Proof of this is the extraordinary complexity of the mathematical models that try to describe the compound tensegrities, those that derive from the intersection of several simple tensegrities that share knots or faces between them, or that are contained among others. ° e reason is evident. Although it is easy to build up equations that represent the equilibrium of a vertex in which several wires and bars converge, the complexity grows exponentially when other compatible structures are assembled, then another, and so on. ° e calculation instruments currently available are well below the capacity needed to deal with these complex models (Connelly 2013, Motro 2003). ° e novel characteristics of structures that correspond to the tensegrity concept soon motivated dozens of investigations in areas surprisingly distant from engineering, ranging from organic chemistry and biology to shamanism and self-healing. Predictably, these came under the noncanonic deÿ nition of tensegrity (discontinuous compression and continuous traction, but without the limitation of internal compressed elements and external tensioning). Many authors even extended the concept further, so that it included nontriangular based structures (spider’s web, in˝ atable membranes), and structures with movable knots and springs instead of wires.

Tensegrity in organic chemistry ° e 1996 Nobel Prize in Chemistry was awarded to a group of scientists (Robert F. Curl Jr., Sir Harold W. Kroto, and Richard E. Smalley) on the discovery, in 1985, of a new carbon form composed of 60 atoms organized

Figure 6.4 The new form of carbon made up of 60 atoms organized in spheroidal form, which appropriately was given the name of “buckminsterfullerene,” or colloquially “buckyball,” in honor of Buckminster Fuller

in a spheroidal fashion to which the signiÿ cant name of “buckminsterfullerene” (or colloquially “buckyball,” in honor of Buckminster Fuller) was given. Buckyballs are molecules whose atoms are disposed in the vertices of a truncated icosahedron with 12 pentagonal faces and 20 hexagonal faces meaning they constitute a perfect geodesic structure (the sides have the minimum length that the coupling bonds allow) (Fig. 6.4). ° ey can also perform outstanding feats. ° ey are highly resilient (capable of recovering from deformation caused by external force); they can be compressed by up to 60ˇpercent of their original volume, and once compressed turn out to be twice as rigid as diamonds; they can act as conductors, isolators, semiconductors, or superconductors depending on the environmental conditions; they have variable ferromagnetic properties; and in their hollow interiors they can hold molecules of other elements. ° e potential applications seem inÿ nite, ranging from oncological medicine to the production of plastic materials with revolutionary properties, and even the creation of mechanical and electronic parts at the nanotechnological level. ° eir relatives the “buckytubes,” which were discovered later and consist of stretched and empty buckyballs that are more resistant than carbon ÿ bers, without doubt presage an impressive series of technological applications.

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6 Tensegrity in biology (biotensegrity) Living organisms are hierarchical structures that integrate their smallest constitutive parts (DNA molecules, proteins, carbohydrates, lipids) through multiple organizational levels: from organelles to cells, tissues, organs, and the organism. ° erefore, one of the challenges of biomedicine is to comprehend how so many and such di˛ erent molecules interact, assemble, and self-organize as a ÿ nal body, exhibiting properties that cannot be explained exclusively in terms of the individual properties of each of the components. At the same time, the constructive elements of the body can be structurally independent and interdependent. In the 1970s, Stephen Levin (1981), an orthopedic surgeon, suggested the use of the expression “biotensegrity,” with the preÿ x “bio” referring to biological structures and their physiology, with particular focus on the construction of the human body. According to Levin, in the biotensegrity model the extremities are semirigid, nonlinear, viscoelastic bone segments. ° ey are interconnected by nonlinear, viscoelastic connectors that include cartilage, joint capsules, and ligaments with an integrated nonlinear, viscoelastic active motor system. Muscles, tendons, and structures of biotensegrity are integrated into continuous prestressed myofascial networks with ˝ oating discontinuous compression struts (skeleton) contained within them (as networks). In addition, the molecules (Liedl et al. 2010, Zanotti & Guerra 2003), tissues (Mammoto & Ingber 2010, Ghosh & Ingber 2007), organs, bone (Chen & Ingber 1999, Huang & Ogawa 2010), heart (Parker & Ingber 2007), lungs (Maina 2007), and even entire organisms (Masi et al. 2007) can be considered tensegrity structures. Perhaps the most resonant tensegrity interpretation (applied to biology) is due to cell biologist and bioengineer Donald Ingber, who published the original ideas he had been developing since the 1980s in the famous article “° e architecture of life” (Ingber 1998).

Cellular biotensegrity According to Ingber (1998), cell structure obeys the principles of tensegrity (Kumar et al. 2006, Alberts et al. 2002) (for details see Chapter 5) (Fig. 6.5):

Microtubule Intermediate filaments

Actin filaments

Figure 6.5 The cellular tensegrity model

•

° e role of the bars is assumed by the microtubules. ° ey are rigid, thin ÿ laments in the form of 25 nm diameter tubes. ° ey are very dynamic and stable.

•

° e “cables” are extendable actin microÿ laments (possibly acting as springs). ° ey are extremely dynamic ÿ laments which are thin and ˝ exible and 7 nm in diameter. ° ey control the shape and surface of the cell. ° ey are mainly concentrated on structures such as tension ÿ bers and the cortex of the cytoskeleton.

•

° e cytoskeleton’s intermediate protein microÿ laments are 10 nm in diameter semi˝ exible ÿ laments and they are very stable proteins. ° ey form a kind of three-dimensional gelatin inside the cytoplasm and protect the cell from overloads.

° e proposed conÿ guration allows the cell to assume di˛ erent forms according its position, function, and adaptation to the environment; moreover, it allows it to be anchored to the extracellular matrix and facilitates the transmission of nutrients and signals through the membrane, even to the nucleus through the dynamics of the integrins (Ingber 1998). Integrins are transmembrane proteins that, with their extracellular ligands and intracellular multiprotein assemblies, connect to the actin cytoskeleton (Fig. 6.6). Mechanochemical communication takes place between the intracellular and extracellular environments and it is carried out by the integrins. ° ere are authentic molecular bridges between the extracellular matrix and cytoskeleton.

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The concept of tensegrity: Fascia as a tensegrity structure

° rough them a complex process of communication and interaction between the extracellular matrix and cytoskeleton takes place. By means of the integrins each cell feels its surroundings and responds to them according to its requirements. Integrins are a set of glycoproteins formed by the combined form of two subunits, α and β, linked together by noncovalent unions. β subunits have eight di˛ erent variants, classiÿ ed as β1 to β8. ° e α chain has 15 di˛ erent subunits. Each subunit displays three Fibroblasts ECM

Integrin

Collagen fiber

Cytoskeleton

Figure 6.6 Fibroblasts anchored to the extracellular matrix by integrins

A

B

6

domains: a large extracellular domain, a transmembrane domain, and a short intracytoplasmic domain that interacts with the components of the cytoskeleton (e.g., talin, vinculin, actin, and ÿ brillin) and serves as a messenger by emitting transduction signals. Integrins activate complex intracellular signaling, informing the cells of the mechanical characteristics of the extracellular matrix. ° e communication process is carried out through focal adhesion, which is the adhesive contact between the cell and extracellular matrix through the integrins (Figs. 6.7 and 6.8). Focal adhesion anchors the cell to the substratum (an underlying layer or substance) and can mediate both mechanical and biochemical signaling. ° e degree of rigidity in the matrix determines the phenotypic di˛ erentiation in the same mesenchymal stem cells. ° us, according to the degree of tension in the matrix, a neurogenic, osteogenic, or muscular differentiation can be created from the same mesenchymal cell. β1 integrins have receptors for several matrix components, including ÿ bronectin, collagen II, and collagen VI, which interact in the adhesion of cells to the matrix. ° ey can stimulate the secretion of collagenase and consequently contribute to the reconstruction of the matrix. Collagen ÿ laments transmit mechanical signals to the intracellular environment. Mechanical forces applied to a living organism increase in size until

C

Figure 6.7 Deformation of a tensegrity structure. A Without the action of compression force. B With a small amount of force. C With large amount of force. Reproduced with permission from ArtefactPro

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6 A C

1

D ECM

Cytoskeleton

E

B

A C 2 D Figure 6.8 The focal adhesion process. When tension is applied to the ECM microtubules become decompressed (after Ingber 2003) 1 The cell membrane in a relaxed position 2 The cell membrane in tension A Microtubule B Assembly of focal adhesions C Microfilaments D Intermediate filaments E Cell membrane

they become a cellular biochemical stimulus through a speciÿ c process of molecular transduction. ° e cells that are essential to the dynamics of the matrix are ÿ broblasts and their morphological transformations, known as protomyoÿ broblasts and myoÿ broblasts (see Chapter 5).

to a molecular level (mechanotransduction). One process that is relevant to the mechanical activation of primary nociceptors is the mechanical process related to the charge transfer from the extracellular matrix to the cell membrane plasma. In this way fascial dynamics are involved in the perception of pain (see Chapter 9).

° e dynamic response of ÿ broblasts to the application of stretching force has been observed (Langevin 2011). Mechanical pressure (also manual pressure) is converted into chemical signaling in the body. Cells are perfectly well prepared to detect signals of physical origin, to respond mechanically, and coordinate a complex biomechanical and mechanochemical process

Another outstanding feature, strictly related to the typical ˝ exibility of tensegrity structures, is that when altering the external form of the cell, di˛ erent genetic programs can be activated. A ˝ attened cell free of external stimuli tends to divide and a compressed spherical cell tends to become extinct (apoptosis). Meanwhile the intermediate conditions prioritize tissue speciÿ city,

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The concept of tensegrity: Fascia as a tensegrity structure

meaning that the cell divides and develops according to the guidelines provided in the RNA for the organ to which it belongs. ° e close interrelation between the cells and extracellular matrix, which is formed through ÿ laments and globular proteins with an exchange of chemical and mechanical messages (chemoreceptors and mechanoreceptors), authorizes the hypothesis of a supracellular ensemble (intimately synergistic) that extends throughout the whole body (Ingber 2008, Yoon et al. 2002, Coughlin & Stamenovich 2003). ° is is a further example of hierarchical distribution. ° e principles of tensegrity can extend to any manifestation of nature, from the atom to the human, to society or to galaxies (this brings us back to the visionary approach of Buckminster Fuller, who was in turn indebted to the systemic paradigm, one of the most signiÿ cant developments of the second half of the twentieth century). Numerous manual therapies are based on this new paradigm, o˙ en supported by overwhelming evidence.

Under-skin synergy With 25x magniÿ cation and through an endoscopy camera, Jean-Claude Guimberteau (2015) shows the elements of fascia in vivo; the complexity of forms,

6

processes, and joints is just dazzling. First and foremost, it can be appreciated that fascia is constituted of many layers di˛ erentiated by density and consistency, all connected through a network of “microvacuolar” ÿ bers (the ÿ laments surrounding cavities), constructed in the form of fractals. For example, the layers surrounding a tendon can be seen opposing increasing resistance, from the most external layer to the most internal, in response to the telescopic movement of the tendon. ° e layers slide over one another like concentric tubes ÿ lled with viscous liquid. In even greater detail, a surprising variability and some metamorphism in the collagen ÿ bers that constitute the layers can be observed. In response to the applied forces, ÿ laments vary in thickness and consistency. ° ey combine to form thicker ÿ bers or split into delicate ÿ bers. ° ey can also expand into membranes or be generated by the fraying of tissue (Fig. 6.9). ° e articulation points are not ÿ xed but they move across a continuously mutating three-dimensional lattice whose faces are not always triangular as expected in the analogy of a geodesic model. On some occasions, hinges and knots are formed and dissolved, as if obeying a ÿ nely articulated structural choreography,

Figure 6.9 An uninterrupted continuum of fibers forms the three-dimensional fascial network

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6 simultaneously inspired by an exquisite sense of improvisation.

The concept of tensegrity and the dynamics of the locomotor system ° e body model based on Newtonian mechanics which focuses on the properties of linear mechanics and compression principles is not suˆ cient for analyzing the static state and locomotion of humans (Levin 1981) (Fig. 6.10). In the human body, tension and compression, synergy and energy, gravity and radiation, syntropy and entropy, growth and decay all complement each other perfectly. ° ese parameters, which may seem antithetical, are in reality two extremes of a single system and remain interrelated. ° e locomotor system is an unstable structure, which is locked in a constant search for stability, or rather multistability, under the control of the central nervous system (CNS). Initiated in the 1970s, the studies of Gracovetsky et al. (1977, 1985) point out that models used in biomechanical research are useful for analyzing homogeneous structures that over time do not deform in a signiÿ cant way. However, the human body is constantly deforming

A

with some ease, given that is made up of materials with signiÿ cant viscoelastic properties. ° is deformation does not destabilize the body in a permanent way. In its dynamic behavior, the body constantly performs a complex process of dynamic adaptations, allowing it to always act on the principle of maximum eˆ ciency with minimum energy expenditure. It should also be noted that in the body the process of continuous loading and unloading usually occurs in a fast way, which requires a prompt and precise redirection of forces. It can be concluded that the musculoskeletal system is inherently unstable and its optimal functional stabilization depends on several factors adapting actively and constantly. Biological tissues, including muscles and fascia, have nonlinear stress–strain curves. A model inspired by tensegrity can perfectly simulate an anatomical joint, reproducing the conditions that allow the bones to “˝ oat,” with respect to each other and without touching, while the surrounding tissues are integrated into the fascia as a functional unity that involves other body systems (Fig. 6.9) (Scarr 2014, pp. 29–32, Levin 2006). ° e tensegrity model deepens our knowledge of the structure, its mechanical properties (hardware), and its

B

Figure 6.10 The spine as a tensegrity structure. According to the theory of biotensegrity, the bones are the discontinuous compression-resistant struts, while the muscles, tendons, and ligaments are the tension elements. A A skeleton model of the spine. B A model of the spine based on tensegrity. B is reproduced with permission from ArtefactPro

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information processing capabilities (so˙ ware), as well as the interrelation of cellular form and function. ° e constructive elements of our body (bones, cartilages, capsules, and ligaments) would not contribute much to the vertical dynamics of our body if it were not for the collective activity of the integrated myofascial system.

Fascia as a tensegrity system In recent years, maintaining the structural integrity of the body has been hailed as the main function of fascia. ° ere are good reasons to propose the tensegrity model as a conceptual model for the human body; the bones assume the role of the bars (discontinuous elements), while the fasciae correspond to the continuous cables. We can even talk of canonic tensegrity given that the tension elements are external and the compression elements are internal. In this representation, the muscles and tendons could be interpreted as artifacts that dynamically modify the local tension of the fascia (variable pre-tensioning) to counteract an external stimulus or to modify the balance where it is needed (Huijing & Baan 2003). ° e fascial system has to act as a factor (system) of force transmission (Huijing 2009). It is important to emphasize that the fascial system is an uninterrupted continuum of ÿ bers submerged in the matrix that covers the entire body, as a kind of three-dimensional, continuous network, from the brain to the feet. ° e density, distribution, and organoleptic characteristics of the system di˛ er substantially throughout the organism but its continuity is fundamental. ° is allows fascia to act as a synergistic whole, absorbing a local stimulus and distributing it to all parts of the system. In some cases of excessive and sudden e˛ orts, the fascia can instantly regulate the degree of its tension making possible otherwise unexplained feats (for example, a dancer’s jumps or extreme sports activities). It is the intrinsic structural synergy of the fascial system that allows the human body to be relatively independent from gravitational forces, which would be impossible with a purely biomechanical model, and that privileges the functioning of the arthrokinematics of the skeleton and muscles and allows them to act as a set of levers (Fig. 6.11).

stretches and retracts according to demands from inside or outside the body, for example, during gestation or according to the nutrients and energy available in the environment.

Another key feature of fascia is its extreme ˝ exibility and ability to adapt. By virtue of its elasticity, it

In addition to its structural function, fascia assumes and distributes the stimuli that the body receives. Its

Figure 6.11 The upper extremity as a tensegrity structure

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6 sensory network registers thermal, chemical, pain, pressure, vibration, and movement impulses, classiÿ es them, and sends them to the CNS. Consequently, it redirects the instructions produced by the CNS to the organs in the form of corrective actions. ° e deep fascia, the system’s innermost layer, is even capable of regulating its consistency in response to prolonged mechanical stress. ° rough the secretion of collagen and other proteins in the extracellular matrix, the deep fascia “orders” the creation of new ÿ brous material, reducing its own ˝ exibility and increasing its rigidity. When the critical conditions disappear, the remaining material is eliminated by the macrophages and the fascia recovers its original elasticity. ° e concept of the myofascial system (muscles + fascia) suggests a viscoelastic organism, meaning it has the characteristics of viscosity (an alteration due to an applied force lasts even when its application ceases) and elasticity (when the action stops the initial form is recovered). In other words, sometimes fascia shows a tendency to recover its original conÿ guration (especially in young tissue), while in other cases it distorts into prolonged and even permanent deformations. ° e most obvious cause of this double behavior is the application of external or internal mechanical stimuli (stretches, compressions, or varying degrees of trauma-induced stress). However, other factors may also be involved, such as thermal variations, pathological dysfunctions, or postural malformations. In general, the behavior of fascia can be compared to that of a rubber brick, which combines a certain degree of hysteresis with the elastic properties of fascia. When an external force is applied, part of the energy is released with recovery of the original form, but another part of the energy induces a deformation of signiÿ cant duration. ° e ability of fascia to tone up (and even regenerate) in response to adequate mechanical treatments should be emphasized. By virtue of its biomechanical complexity the fascial system can behave like an extremely reactive and malleable organ. As we have seen, fascia is a highly integrated and reactive system, which maximizes eˆ ciency in terms of energy expenditure and in maintaining the equilibrium of the body (exteroception–proprioception– interoception). ° e characteristics of ˝ exibility, self-regulation, and adaptation are certainly compatible with the concept of tensegrity, but, if we change the

analysis to the microscopic level of body construction, the conventional tensegrity explanation begins to become insuˆ cient. In summary, if when deÿ ning fascia as a tensegrity system we want to re˝ ect the multitude of processes, forms, and functions observed in fascia, it seems necessary to adopt less strict deÿ nitions for structural elements based on tensegrity principles. For example, it must be accepted that bars occasionally act as tie rods and assume curved or plate conÿ gurations, and also that cables can vary their length and modulate internal stresses, thus modifying the minimal-energy state continuously (Scarr 2014, pp. 109–116).

Conclusion Having examined the potential applications of the tensegrity concept in ÿ elds as varied as structural design, organic chemistry, biology, and modeling of complex organisms, it seems necessary – in the light of current knowledge – to overcome the limitations of current deÿ nitions. At present tensegrity represents just a skeletal metaphor for the complex phenomena it tries to explain. For it to be useful it would be necessary to transfer the biomechanical descriptive model to a new tensegrity paradigm, adopting a generalized design that describes the principles of spatial organization and movement present in the systems of nature. Perhaps this model could incorporate the mathematical theory of ÿ nite elements, allowing for a viscoelastic description of the represented ensemble in several hierarchical scales. All this would be possible without abandoning the admirable simplicity of the original principles (economy of materials, minimization of energy and space, balance between elements without the need to involve torsion and cutting maneuvers, integration at all levels, etc.). Of course, it would require enormous ˝ exibility to include detailed descriptions of the processes and transformations occurring in the basic elements (physical changes in the constituent materials, instant reconÿ gurations to control localized stimuli, displacements in force application points, signal transmission to contiguous and distant points, etc.). But certainly, the challenge merits it. Further investigation along these lines could lead to a more reÿ ned level of understanding of the mysterious adaptive eˆ ciency and amazing organizational synergy that underlies all nature.

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REFERENCES

Alberts B, Johnson A, Lewis J, Ra˛ M, Roberts K, Walter P (2002) Molecular biology of the cell. 4th ed. NewYork: Garland Science, pp. 351–352. Buckminster Fuller R (1975) Synergetics: Explorations in the Geometry of ° inking. New York: Macmillan. [Online] Available: http://www. rwgrayprojects.com/synergetics/synergetics. html [accessed July 5, 2021]. Chen CS, Ingber DE (1999) Tensegrity and mechanoregulation: From skeleton to cytoskeleton. Osteoarthritis Cartilage. 7(1):81–94.

Huijing PA (2009) Epimuscular myofascial force transmission: A historical review and implications for new research. International Society of Biomechanics Muybridge Award Lecture, Taipei, 2007 J Biomech 42(1):9–21. Huijing PA, Baan GC (2003) Myofascial force transmission: Muscle relative position and length determine agonist and synergist muscle force. J Appl Physiol 94(3):1092–1107. Ingber DE (1993) Cellular tensegrity: Deÿ ning new rules of biological design that govern the cytoskeleton. J Cell Sci 104(Pt. 3):613–627.

Connelly R (2013) What is ... a tensegrity? Notices of the American Mathematical Society. 60(1). doi:10.1090/noti933.

Ingber DE (1998) ° e architecture of life. Sci Am 278(1):48–57.

Coughlin MF, Stamenovich D (2003) A prestressed cable network model of the adherent cell cytoskeleton. Biophys J 84(2):1328–1336.

Ingber DE (2003) Tensegrity I. Cell structure and hierarchical systems biology. J Cell Sci 116:1157–1173.

Ghosh K, Ingber DE (2007) Micromechanical control of cell and tissue development: Implications for tissue engineering. Adv Drug Deliv Rev 59(13):1306–1318. Gómez-Jáuregui V (2007) Tensegrity: Tensegritic structures in science and art. Santander: Publications Service of the University of Cantabria. Gordon JE (1978) Structures, or Why ° ings Don’t Fall Down. UK: Penguin Books Ltd, pp. 195–215. Gracovetsky S, Farfan HF, Lamy C (1977) A mathematical model of the lumbar spine using an optimized system to control muscles and ligaments. Orthop Clin North Am 8(1):135–153. Gracovetsky S, Farfan H, Helleur C (1985) ° e abdominal mechanism. Spine 10(4):317–324. Guimberteau J-C (2015) Architecture of Human Living Fascia. Edinburgh: Handspring Publishing, p. 9. Huang C, Ogawa R (2010) Mechanotransduction in bone repair and regeneration. FASEB J 24(10):3625–3632.

Ingber DE (2008) Tensegrity-based mechanosensing from macro to micro. Prog Biophys Mol Biol 97(2–3):163–179. Ioganson K (1990) From construction to technology and invention. In: Andrews R, Kalinovska M (Eds.) Art into Life: Russian Constructivism 1914–1932. Henry Art Gallery / Rizzoli, p. 70.

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Liedl T, Högberg B, Tytell J, Ingber DE, Shih WM (2010) Self-assembly of three-dimensional prestressed tensegrity structures from DNA. Nat Nanotechnol 5(7):520–524. Maina JN (2007) Spectacularly robust! Tensegrity principle explains the mechanical strength of the avian lung. Respir Physiol Neurobiol 155(1):1–10. Mammoto T, Ingber DE (2010) Mechanical control of tissue and organ development. Development 137(9):1407–1420. Masi AT, Benjamin M, Vleeming A (2007) Anatomical, biomechanical, and clinical perspectives on sacroiliac joints: An integrative synthesis of biodynamic mechanisms related to ankylosing spondylitis. In: Vleeming A, Mooney V, Stoeckart R (Eds.) Movement, Stability & Lumbopelvic Pain, 2nd ed. Edinburgh: Churchill Livingstone Elsevier, pp. 205–227. Motro R (2003) Tensegrity: Structural Systems for the Future. London: Kogan Page Limited. Parker KK, Ingber DE (2007) Extracellular matrix, mechanotransduction and structural hierarchies in heart tissue engineering. Philos Trans R Soc Lond B Biol Sci 362(1484):1267–1279.

Kumar S, Maxwell IZ, Heisterkamp A, Polte TR, Lele TP, Salanga M, Eric Mazur E, Ingber DE (2006) Viscoelastic retraction of single living stress ÿ bers and its impact on cell shape, cytoskeletal organization, and extracellular matrix mechanics. Biophys J 90(10):3762–3773.

Scarr G (2014) Biotensegrity: ° e Structural Basis of Life. Edinburgh: Handspring Publishing.

Langevin HM (2011) Fibroblast cytoskeletal remodeling contributes to connective tissue tension. J Cell Physiol 226(5):1166–1175.

Yoon Y, Pitts K, McNiven M (2002) Studying cytoskeletal dynamics in living cells using green ˝ uorescent protein. Mol Biotechnol 21(3):241–250.

Levin SM (1981) ° e icosahedron as a biologic support system. Houston: Alliance for Engineering in Medicine and Biology, p. 404.

Zanotti G, Guerra C (2003) Is tensegrity a unifying concept of protein folds? FEBS Lett 534 (1–3):7–10.

Snelson K (2014) Weaving: Mother of Tensegrity. [Online] Available: http://www.kennethsnelson. net/icons/struc.htm [accessed July 5, 2021].

Levin SM (2006) Tensegrity: ° e new biomechanics. In: Hutson M, Ellis R (Eds.) Textbook of Musculoskeletal Medicine. Oxford University Press.

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Movement and force transmission in the fascial system With a contribution from Eduardo Castro-Martín

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KEY POINTS •

Aspects of the fascial system related to movement

•

How the fascial structure influences the contractile dynamics of muscle fibers

•

The role of fascia in the stabilization of movement

•

How the fascial system fulfills the role of modulating and amplifying muscle strength

•

The role of fascia in the facilitation of the dynamics of sliding and gliding

The fascial system provides an environment that ensures the integrated functioning of all body systems thus facilitating body movement.

1. Motor control is the ÿ rst level of interaction and is related to:

Introduction: Movement Movement is life and without movement life is unthinkable. Moshe Feldenkrais A living organism is always in motion and never stops moving. It requires dynamics and movement, and without these it would disappear (Acuña 2001). ° e body experiences movement through constant accommodation, continuous change and progress, and adapting to environmental requirements (macroscopic adjustments) and molecular demands (microscopic adjustments). ° is does not refer exclusively to positional modiÿ cation with respect to time and space, but to a strategy of integration of communication between the di˛ erent levels of the body’s architecture and the world that surrounds us. In relation to movement, fascia is deÿ ned as a system (see Chapter 2) and similarly the analysis of movement requires a systemic approach. ° e focus is on a complex biological suprasystem that obeys self-structuring in relation to systems, subsystems, and components that in turn establish multiple relationships with di˛ erent

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degrees of complexity (Triana et al. 2000). ° e three levels outlined below determine the degree of relationship and interaction with and delimitation of the environment and functional achievement:

▶ an individual’s motor ability ▶ integration of biological, psychological, and social components ▶ reorganization of motor activity and determination of its characteristics. 2. Motor learning refers to: ▶ integration of permanent transformations of movement patterns from a particular and individual perspective ▶ use of motor skills (the individual’s potential) ▶ improvement of motor control. 3. Context refers to: ▶ an individual’s motor capacity in a temporal and spatial scenario based on social rules and regulations. ° e approach proposed here is consistent with the complexity paradigm and the concept that it is not possible to understand and explain a particular reality without understanding the multiple relationships that determine the totality. It is the di˛ erence between complex and

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7 complicated systems. A complex system cannot be disassembled and reassembled, whereas a complicated system can. A complex system has to adapt to interactions with and within the subsystems and simultaneously have the ability to adapt to environmental stimuli. It is in this complexity, and in its role as communicator, that the fascial system participates, providing an environment that allows the integrated functioning of all body systems and thereby facilitating the ÿ nal movement (see Chapter 2).

or myoaponeurotic junctions, thus triggering movement (Fig. 7.1). ° is perspective has led to two instances of conceptual confusion. ° e ÿ rst assumes that the myotendinous union is the place and the exclusive route for transmission of the force generated within the sarcomeres (Tidball 1991) and the second considers the muscle to be an independent functional unit (Herbert et al. 2008). ° ese instances of confusion are due to analysis being focused on intramuscular dynamics, in which

Fascia participates directly in the transmission, stabilization, modulation, and ampliÿ cation of muscle strength. Ultimately, it will respond, adapting and facilitating the sliding process during adjustment of the body. ° is capability makes movement occurring in the myofascial, ligamentous, viscerofascial, and neurovascular fascial units a more eˆ cient action (low energy expenditure). Body movement manifests itself in three speciÿ c correlations (Richardson et al. 2004):

• •

movement of the body in space (when walking)

•

movement in the speciÿ c region (of the leg when walking).

movement between speciÿ c body regions (between the hip and knee when walking)

° ese three correlations act reciprocally and should be controlled in order to obtain dynamic stability; the fascial system also participates in this demand. A common example is the stabilizing role of the thoracolumbar fascia (TLF) on the lumbar spine which in˝ uences the activity of the paravertebral and abdominal muscles (Choi & Kim 2017, Fan et al. 2018). ° e biomechanical processes of the fascial system as a facilitator of movement are analyzed below.

Force transmission in the myofascial unit ° e universal muscle contraction model based on the sliding of actin and myosin ÿ laments, described more than 40 years ago by Huxley and Simmons (1971), has supported the Newtonian analysis of body movement which is characterized by the action of levers. In this model, the myoÿ brils, arranged in series, act as independent motors that approximate the myotendinous

Figure 7.1 Myofascial force transmission (bidimensional model). In this model the myofibrils, arranged in series, act as independent motors that approximate the myotendinous or myoaponeurotic junctions thus triggering movement. Note the similarity of structure from microlevel to macrolevel

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Movement and force transmission in the fascial system

the connections between the muscle ÿ bers and the extracellular matrix (ECM) only exist at both ends of the musculoskeletal ÿ ber at the musculotendinous or musculoaponeurotic junctions, and being conducted in isolation from all external (epimuscular) relationships. However, the discovery of the ultrastructure and mechanobiology of the sarcomere unit has given shape to a new model of myoÿ brils embedded within the ECM, which at the same time participates (through its own dynamics) in the contractile phenomenon. ° e shortening of the myoÿ bril generates force within the fascial structure (endomysium, perimysium, and epimysium) and its development is more in line with the principles of tensegrity (see Chapter 6) rather than an isolated linear analysis (movements arranged in series). By contrast, anatomical studies of unembalmed cadavers have allowed for a di˛ erent view and a deeper analysis of the anatomical connections. ° ese studies have revealed bonds of a more dynamic nature (° iel

7

2000, Pilat 2014, 2017) thus creating a new vision of fascia that is di˛ erent from the traditional view of the structure that envelops the muscle. Consequently, the muscle is not considered as the exclusive protagonist of the movement, and it is suggested that this role be extended to the myofascial unit. ° is term refers to the group of highly specialized collagenous structures in a crossed-helical arrangement that are intimately linked to muscle ÿ bers (Scarr 2016). ° is unit incorporates the macrostructure of the muscle – the tendon and aponeurosis, the musculotendinous junction (Fig. 7.2), and the tendon-to-periosteum attachment (Fig. 7.3) – as well as the intramuscular connective tissue (endomysium, perimysium, epimysium) (Fig. 7.4). ° e concept of transmission of myofascial force implies any type of transmission between these structures, from the myoÿ brils to the ECM, to the adjacent myoÿ brils, and ÿ nally to the tendon and aponeurosis. ° e concept expands to the nearby structures of a

Figure 7.2 The structure of a musculotendinous unit. The circled areas indicate the direction of the muscle fibers. Note that not all muscle fibers reach the tendinous body. The endomysium that surrounds each of the muscle fibers is continuous with the endotendon thus ensuring the uninterrupted transmission of the contractile force of each muscle fiber

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7 A B

C

D F

Figure 7.3 The insertion site of aponeurosis attached to the bone. Note the continuity of the two structures and the complete integration of the collagenous fibers with the periosteum

E

given muscle such as muscle bellies and adjacent tendons, neurovascular tracts, and other connective tissue structures (Figs. 7.5 and 7.6). Huijing (2003) deÿ nes this phenomenon as “lateral transmission of muscle strength.” ° e di˛ erent routes of force transmission (Fig. 7.7) are:

• •

intramuscular epimuscular ▶ intermuscular ▶ extramuscular.

° ese lateral connections between the above structures deÿ ne the e˛ ectiveness of the movement when myoÿ brillar contraction is performed. ° ese connections and mechanisms, from microstructure (molecules and cells) to macrostructure, are examined below.

Figure 7.4 The continuity of myofascial architecture. The endomysia are continuous with the endotendons. A similar collagenous network surrounds the groups of tendinous collagen fibers A Muscle fiber B Endomysium C Primary muscle fascicle D Perimysium E Tendon F Epimysium

The architecture of the myofascial unit is composed of the muscle belly, musculotendinous junction, the tendon, and the integration of the tendon into the periosteum. This system incorporates the intramuscular connective tissue (endomysium, perimysium, and epimysium).

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Movement and force transmission in the fascial system

A

Caudal

B

7

Cranial

Figure 7.6 Ventral aspect of the forearm. Note the presence of the myofascial unit. In this dissection the extramuscular fascial structure has been preserved. Note the lateral connections between the tendons and also between the tendon and the muscle belly (circled areas)

Figure 7.5 Ventral aspect of the forearm. The tendons of the flexor muscles of the wrist and fingers are circled. This is a “clean” anatomical dissection. The extramuscular fascial structures have been removed. Note the clearly defined tendons and muscle bellies. The image suggests the transmission of force through the muscles and their tendons in a linear manner, as in a cable and pulley system. A Carpal tunnel (carpal transverse ligament) B Thenar eminence

Figure 7.7

Epimuscular pathways

Myotendinous pathway

Muscle fiber

Muscle–tendon junction

Tendon

Intramuscular

Intermuscular

Bone

Pathways of myofascial force transmission to the skeleton. The flowchart illustrates the different routes via which the force generated inside the muscle fibers can leave the muscle to be transmitted to the skeleton. The myotendinous pathway involves the transmission of contraction through all the connective structures of the myofascial unit. There are two epimuscular pathways: intermuscular and extramuscular Intermuscular refers to transmission of force between two neighboring muscles through the continuous connective tissue at their muscle belly interface. Extramuscular refers to transmission of force between one muscle and the adjacent nonmuscular structures (such as the neurovascular tracts)

Extramuscular

Intramuscular force transmission At the deepest level of myofascial organization an endomysial and myoÿ brillar relationship can be found. ° e muscle ÿ bers are immersed in the collagenous matrix creating an intimate bidirectional relationship. As already referred to in Chapter 5, each muscle ÿ ber

operates within the envelope of its endomysium and together they in turn communicate laterally with other ÿ bers to form a fascicle. Finally, the endomysia are continuous with the endotendons (a similar collagenous network that surrounds groups of tendinous collagen ÿ bers) (see Fig. 7.2).

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7 Figure 7.8 A In this model the myofibrils, arranged in series, act as independent motors that approximate the myotendinous or myoaponeurotic junctions thus triggering movement. There is a conceptual confusion in this model as the connections between the muscle fibers and the extracellular matrix do not only exist at the ends of the musculoskeletal fiber. B This model includes the phenomenon of lateral force through the fascial structures. Intramuscular dynamics are present throughout the myofascial unit

A

B

In this way, the force generated by the muscle ÿ bers is transmitted by means of a three-way orientation and relationship (Figs. 7.8 and 7.9), speciÿ cally:

•

transmission between active or passive sarcomeres within the muscle ÿ bers (between their basal lamina and endomysia);

•

transmission between the adjacent endomysia, within the fascicle, transverse to the entire muscle belly;

•

transmission in a longitudinal direction with the tendon, since the endomysium is continuous with the endotendon (fascial tendinous transmission).

Chi Zhang (Zhang & Gao 2012), following on from Huijing’s concept of “transmission of lateral force in the skeletal muscles” (Huijing 2003), proved that the force generated in the myoÿ brils has to be transmitted laterally through the ECM to the adjacent ÿ bers. Purslow (2010) showed that the endomysium seems to provide an eˆ cient mechanism for the transmission of contractile forces from adjacent muscle ÿ bers within the fascicles. In addition, he demonstrated that, in certain

Figure 7.9 The gluteus maximus muscle. Note the connections between muscle perimysia A Lateral aspect of the sacrum

circumstances, the perimysium and the epimysium are able to act as transmission routes for myofascial force. Recently, using ultrasound imaging on live subjects, Randhawa and Wakeling (2018) found that the transverse deformation of muscle fascicles during contraction depends on the rigidity of the connective tissue surrounding the myoÿ bril and the muscle in general.

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° us, this fascial system can modify the physiological change of form and in˝ uence muscular mechanics. We can aˆ rm that the stroma of the intramuscular connective tissues, including the epimysium, participates in the transmission of the active and passive forces exerted by the myoÿ brils. ° is property allows for a more e˛ ective use of contraction in all muscle ÿ bers (although not directly connected to the tendon), improving the range of active e˛ ort with the consequent increase in the range of joint movement (ROM) (Huijing et al. 1998).

The state of the collagenous matrix within the myofascial unit will condition the effectiveness of the contraction.

It seems logical that the state of the collagenous matrix within the myofascial unit will condition the effectiveness of contraction, as happens for example in overuse injuries during exercise or in the aging process when in˝ ammatory reactions may occur. ° e presence of some ÿ brogenic cytokines, for example interleukin 1 beta (IL1β), tumor necrosis factor (TNF), and transforming growth factor beta 1 (TGFβ1), can promote ÿ brosis through excessive proliferation of ÿ broblasts and deposition of collagen in the matrix (Barbe et al. 2013, Zügel et al. 2018) (see Chapter 5) (Fig. 7.10).

A

B

Figure 7.10 The restrictions of the fascial system limit the elasticity of the tendons for the performance of lateral movements and decrease their capacity for stretching. Note the distance between muscle fiber and bone in the presence of myofascial restriction (A) and after the release of the restriction (B). Modified from Pilat A. (2003) Terapias miofasciales: Inducción miofascial. Madrid: McGraw Hill Interamericana de España

7

Of relevance to this review is the fascial relationship between myotendinous transmission and fascial tendinous transmission. It is clear that the tendon is internally related to the muscle belly via the endomysium–endotendon pathway. However, it should be pointed out that externally the epimysium (which covers the entire surface of the muscle) is also related to the myotendinous structure. In this way fascia participates in the performance and tasks of the tendon. Its elastic characteristics are important in maximizing muscle eˆ ciency during walking, running, and jumping and storing, releasing, and attenuating the absorption of energy (Roberts & Marsh 2003, Lichtwark & Wilson 2007, Roberts & Konow 2013). For example, this tendinous e˛ ort (including the related fascial system) allows the muscle fascicles of the lower extremities to operate relatively isometrically during locomotion, reducing muscle energy expenditure (Raiteri et al. 2018). In this context, it has been identiÿ ed that rigidity of the tendon-related epimysium can be modulated during active muscle contractions compared to moments of passive loading (lengthening of the tendon), not only due to longitudinal force but also transversal transmission (through the endomysia, perimysia, and epimysia) (Azizi & Roberts 2009, Arellano et al. 2016). ° is mechanism provides for the possibility of rapid and dynamic changes in the e˛ ective sti˛ ness of the tendons during muscle contractions (Roberts & Azizi 2011). ° e elasticity of muscular connective tissues is part of the elasticity of muscles and therefore part of the active and passive behavior of the myotendinous structures. In an in vivo study conducted with humans using ultrasound and elastography techniques, Raiteri et al. (2018) showed that the rigidity of the aponeurosis of the tibialis anterior muscle increased with muscle contraction and also with an increase in the length of the tendon. It is likely that such a mechanism is beneÿ cial for di˛ erent movement scenarios and in˝ uences force transmission as well as energy expenditure. ° ere are still many questions to be answered with regard to fascial dynamics. Finally, a further study conducted with sonoelastography tested, in vivo, the association between tissue elasticity and passive sti˛ ness of the ankle joint (Chino & Takahashi 2015). ° e researchers concluded that the joint sti˛ ness was due to the aponeurotic structures of the medial gastrocnemius (MG) muscle, the ligaments, and the joint capsule, rather than the elasticity or tension

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7 of the muscle belly of the MG or of the Achilles tendon. Perhaps the present paradigms for joint ROM limitations should be revised.

A1

Epimuscular force transmission

A2

Two decades have passed since Professor Peter Huijing, in his laboratory in the Neuromechanics department of the Faculty of Behavioural and Movement Sciences at the Vrije Universiteit Amsterdam, began to propose alternative routes to the myotendinous pathway in the transmission of muscle strength. For this reason the term epimuscular was coined to refer to a path between the epimysia of neighboring muscles (intermuscular communication) and also between the epimysium and other neighboring collagenous structures (extramuscular communication). It is true that most of the contractile forces are destined for myotendinous units, however, it is estimated that approximately 30ˇpercent of them use epimysial transmission paths (through the epimysia), that is, parallel to the tendinous paths (Huijing 2007). In general, most research designs related to body movement do not consider these lateral connections and the consequences of their presence. Fascial tissue makes possible mechanical interactions that cannot be explained by conventional biomechanical analysis (van der Wal 2009, Turvey & Fonseca 2009, 2014).

The intermuscular pathway In recent years, several studies (clinical research and analysis models) have shown mechanical interactions between adjacent muscles (intermuscular pathway) (Figs. 7.11 and 7.12). ° ere are two main areas of research. ° ese concern: 1. Alterations in movement patterns due to the existence of pathological conditions, that is, spasticity or the presence of post-traumatic and postsurgical scars. ▶ A˙ er performing a ˝ exor carpi ulnaris muscle tenotomy Smeulders and Kreulen (2007) mobilized the wrist passively from maximum ˝ exion to maximum extension. As a result, the ˝ exor carpi ulnaris muscle lengthened at its distal end despite the fact that this muscle (a˙ er the tenotomy) no longer crossed the wrist joint line. ° is phenomenon, exposed by the tendon transmissions, is of clinical signiÿ cance as it shows that

B1

B2

C1

C2 Figure 7.11 Muscular lateral force transmission. After Maas & Sandercock (2008). The schematic drawings illustrate the changes in length of intermuscular links in different positions. Note that in the resting position the extramuscular connective tissue joins the bellies of two adjacent muscles. As the contraction of one of the muscles increases, that transverse union becomes tense and finally stimulates the adjacent muscle for contraction. This can also happen in situations of muscle elongation A Relationship between two muscles at rest: A1 and A2 are two muscles in repose B With elongation of a muscle: B1 Elongated muscle B2 Muscle in repose C With shortening of a muscle: C1 Muscle in repose C2 Contracted muscle

intermuscular extratendinous connections participate in the transmission of muscular strength. ▶ A˙ er performing a ˝ exor carpi ulnaris muscle tenotomy in ten patients with cerebral palsy and spastic palsy Kreulen and Smeulders (2008) noticed a permanence in the ˝ exed position of the hand. ° is demonstrated that this position is maintained through the epimuscular connections of the ˝ exor carpi ulnaris muscle tendon, together with the ˝ exor muscle units of the wrist and ÿ ngers. ▶ De Bruin et al. (2011) conclude that, despite the tenotomy of the distal tendon, the ˝ exor carpi ulnaris muscle still contributes to the ˝ exion torque

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of the extensor muscles of the knee in 40 patients with hemiparesis. As a result, they observed the negative correlation between spasticity and muscular strength, concluding that spastic muscles are weaker and, therefore, that it is the tension of the fascial system that is in charge of maintaining the position of the knee and the gait pattern. ▶ In research conducted with cerebral palsy patients Kaya et al. (2018) concluded that the transmission of intersynergistic myofascial epimysial force between the coactivated muscles (additional activation of the semimembranous and gracilis muscles) substantially increases (by 33ˇpercent) the force of the activated spastic semitendinosus muscle. ° e researchers deduce that this form of force transmission can cause spastic sarcomeres to reach favorable lengths closer to their full superposition of myoÿ laments.

A

2. Analysis of muscle dynamics in healthy subjects, centered on local and distant muscle synergies.

B

▶ Yu et al. (2007) observed changes in the dynamics of the motor units of the index ÿ nger when activating the motor units of the ˝ exor pollicis longus muscle, although there is no histological connection between the ˝ exor muscles of the thumb and the index ÿ nger.

C Figure 7.12 The ventral aspect of the forearm. Note the lateral attachments of loose (extramuscular) connective tissue between the tendon and the epimysia of muscles in different positions of the tendon. The movement of the tendon during muscular contraction drags the extramuscular connective tissue and influences the movement of the adjacent muscles and tendons. The yellow arrows indicate the direction and orientation of the loose connective tissue fibers between the tendons and the muscles. The red dot indicates the resting tendon. The red arrows show the direction of the deforming force. A Resting position. B Downward traction. C Upward traction

in the wrist through the transmission of myofascial force. ▶ Abdollahi et al. (2015) investigated the relationship between the degree of spasticity and the strength

▶ When examining in vivo the dynamics of the muscles of the leg Yaman et al. (2013) observed (through 3D MRI) that the contraction of the gastrocnemius muscles generates changes in the length of the synergistic muscles (soleus and long ˝ exor muscles) and also of the antagonists (tibialis anterior and peroneal group muscles). ° ey concluded that, in principle, the muscles of the leg are not mechanically independent and that the contractile forces are also transmitted through the “epimysial pathways.” ▶ Research by Ateş et al. (2018) using elastography suggests strong intermuscular mechanical interactions (epimuscular/epimysial) in the muscles of the lower leg. ° ese interactions can occur both between adjacent synergistic muscles and between antagonistic muscles, suggesting that various communication paths may be involved. ° ese results provide evidence of a non-negligible intermuscular mechanical interaction between the leg muscles during ankle rotations.

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7 ▶ A˙ er examining the behavior of the soleus, the lateral gastrocnemius muscles, and its fascial system during joint mobilizations Finni et al. (2017) concluded that the transmission of force between these muscles can serve to decrease nonuniform loads in the Achilles tendon, thus reducing a possible injury mechanism. ▶ Using electromyography (EMG) in a study of 37 participants Carvalhais et al. (2013) observed the interaction between the latissimus dorsi muscle and the opposite gluteus maximus muscle through the tensor fasciae latae. ▶ Cruz-Montecinos et al. (2015) evaluated the relationship between pelvic movement and displacement of the deep fascia in the medial gastrocnemius muscle. ° e displacement of the deep fascia was assessed through automatic tracking with ultrasound. ° e angular variation of the pelvis was determined by 2D kinematic analysis. ° e results supported the concept of remote myofascial tissue connectivity in an in vivo model, reinforcing the functional concept of force transmission through synergistic muscle groups and providing new perspectives on the role of fasciae in restricting movement in remote areas. ▶ In an in vivo EMG study of 37 participants Marinho et al. (2017) demonstrated the existence of myofascial force transmission between the joints of the lower limb. ° e mechanical behavior of the ankle during the positional changes of the knee and hip demonstrated the existence of tissue continuity between these joints under physiological conditions.

connections between the iliotibial tract and the femur, patella, and tibia.

The extramuscular pathway ° is section refers to the analysis of epimysium as it relates to other collagenous structures that do not belong directly to the muscle, although they are indirectly related to it. Huijing and Jaspers (2005) observed that the transmission of forces did not occur exclusively between muscles but also among other nonmuscular structures of the connective tissue, such as neurovascular tracts (Figs. 7.13 and 7.14). Huijing conÿ rmed this years later (Huijing et al. 2011) through an evaluation with MRI in healthy human volunteers, stating that the neurovascular tracts (which envelop and reinforce blood vessels, lymphatics, and peripheral nerves) are strong candidates for being a major route in force transmission. In an in vivo study of 39 asymptomatic healthy subjects using shear wave elastography researchers performed manual stretching of the ulnar nerve and observed tensional changes in the tendon and belly of the ˝ exor carpi ulnaris muscle. ° e authors suggest the presence of a route of lateral force transmission through the fascial structures between the neurovascular tract and the epimysia (Fig. 7.15, Video 7.1), from the nerve to the muscle (Álvarez González et al. 2019).

1

Others have demonstrated a distinct structural continuity between the fascial system components:

• •

•

In their research on cadavers, Vleeming et al. (1995) pointed out the connections between the gluteus maximus and the thoracolumbar fascia. Stecco et al. (2013) demonstrated the continuity of the gluteus maximus muscle and the fascia lata, suggesting a possible path for transmission of force between the lumbopelvic region and the lower limb. Another route for the transmission of myofascial force within the lower extremity was demonstrated by Vieira et al. (2007), who found signiÿ cant

A B C

2 Figure 7.13 1 Anterior aspect of the upper limb. Note the continuity of the deep fascia. 2 Close-up of the ventral aspect of the forearm (photomontage of dissections) A Extramuscular connective tissue B Neurovascular tract C Flexor carpi ulnaris muscle

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Movement and force transmission in the fascial system

A

B

Figure 7.14 Cross-section of the thigh. Note the continuity of the intimate relationship of the artery with the adjacent muscles

Cubital nerve

Finally, when carrying out research on anatomical dissection in unembalmed cadavers (Pilat 2003, 2009, 2014, 2015, 2017, Fernández de las Peñas & Pilat 2012) in which the fascial structures were preserved, it was possible to demonstrate that:

•

° ere is fascial continuity in the extrinsic and intrinsic layers of the body’s construction.

•

Parallel “epimysial” paths for the transmission of contractile force are present. Examples of this phenomenon are the aponeurotic expansion (lacertus ÿ brosus) of the biceps brachii muscle in the forearm and also the continuity between the pectoral and brachial fasciae.

•

° e epimysium and the perimysium act as transmission routes for muscular strength.

•

Numerous ÿ bers in the long muscles ÿ nish their trajectory without reaching the ends of the tendon or aponeurosis.

•

° e muscles are connected laterally to adjacent structures, such as blood vessels or peripheral nerves.

•

° e neurovascular connective tracts envelop and reinforce blood and lymph vessels, as well as the peripheral nerves, and are strong candidates for being a major route in force transmission.

•

° e intramuscular and perimuscular connective tissue acts as a protective network against a traumatic event related to the tendon or the muscle belly.

Flexor carpi ulnaris

Flexor digitorum profundus

Figure 7.15 Dynamic ultrasound imaging of the ventral aspect of the forearm of a living subject. The subject performs active flexion–extension of the fingers. Note that the three structures (flexor carpi ulnaris muscle, flexor digitorum profundus muscle, and the cubital nerve) move together. Image courtesy of Javier Álvarez González

Video 7.1 Dynamic ultrasound imaging of the ventral aspect of the forearm in a living subject

The transmission path of epimuscular force is related to the muscle and how it is relates to other muscles and the neurovascular tracts.

7

° ese scientiÿ c and clinical ÿ ndings o˛ er a genuinely di˛ erent and broader perspective on which to base our understanding and analysis of the body’s mechanics and pathomechanics.

Stabilization, modulation, and amplification of force As mentioned above, the eˆ ciency of the body’s movement depends in part on its dynamic stabilization. ° e fascial system can participate in this task without direct energy expenditure, by taking advantage of muscle strength and the kinetics of the body. Studies by Willard and Vleeming (Willard et al. 2012, Vleeming et al. 2014) indicate the importance of the stabilizing role of the thoracolumbar fascia during the activity of the paraspinal and abdominal muscles.

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7 Recently, Choi and Kim (2017), using a validated model of ÿ nite elements of the lumbosacral spine, demonstrated that involvement of the lumbar fascia in the stability of the spine is signiÿ cant during lumbosacral movements (L4–S1). An important fact is that during ˝ exion movement, an increase in tension occurs on the vertebral segment creating an almost linear increase in fascial tension with a consequent improvement of spine stability. ° is observation is of great interest to practitioners in relation to the dysfunctional processes that are established during lumbar ˝ exion. Beyond the muscles, the condition of the lumbar fascia should be analyzed. More recently, using computed tomography on cadavers and living subjects, Fan et al. (2018) veriÿ ed the fascial continuity of the external oblique muscle and the TLF. ° us, they conÿ rmed the importance of maintaining the stability of the lumbar spine through a hydraulic e˛ ect. ° ey also stated that the myofascial continuity between the TLF and the abdominal muscles ensures synchronization between the erector spinae and rectus abdominis muscles, which relates to the epimuscular transmission routes explained above. In studies on acromioclavicular joint dynamics in relation to the stabilizing role of the deltotrapezial fascia (DTF), Pastor (2016) concludes that a combined lesion of the acromioclavicular ligament (ACL) and DTF would cause a signiÿ cant increase in the anterior rotation and a tendency to lateral translation of the clavicle in relation to the acromion. ° is increment was not signiÿ cant with the mere injury of the ACL. ° e researcher concluded that the DTF could fulÿ ll the stabilizing role of the acromioclavicular joint although more studies are needed to conÿ rm it (Pastor 2016).

The fascial system participates in dynamic stability without using (wearing down) contractile energy.

Ligaments are also structures that belong to the fascial system. ° eir importance in the joint stabilization process is well-known (Standring 2008). However, more than just passive elements, ligaments can be considered to be dynamic structures belonging to a system of joint stability and force transmission, which is composed of myofascial units, joint capsules, and ligaments. Ligaments interlock and function in series,

loading and stretching, through both the movement of related skeletal parts and the tension of the muscle tissue that is inserted into this connective tissue (van der Wal 2009). Takeshita et al. (2004) proposed a biomechanical study to deÿ ne the function of the nuchal ligament (NL) in ˝ exion retention of the cervical spine. ° e authors split di˛ erent ligaments. When sectioning only the NL they observed an increase in cervical ˝ exion of 28ˇpercent and a decrease in sti˛ ness of the spine of 27ˇpercent. After sectioning the three major ligaments (the yellow, interspinous, and supraspinous ligaments) they obtained a 24ˇpercent increase in ˝ exion and only an 8ˇpercent decrease in sti˛ ness. ° e conclusion was that the damage of the nuchal ligament increased the range of cervical ˝ exion and decreased the ˝ exion sti˛ ness, which could increase the risk of cervical spine instability and misalignment (maintenance of physiological curves). It must be remembered that the NL is not an independent structure but rather an integration of the aponeurotic ÿ bers of the trapezius, splenius capitis, rhomboid minor, and serratus posterior superior muscles (Johnson et al. 2000). ° ese conclusions demonstrate again the need to monitor fascial tissue when analyzing mechanical dysfunctions of the spine. Another example of the stabilizing behavior of ligaments is the discovery of the “oblique popliteal ligament” (Morgan 2010). ° is structure is a product of the collagenous densiÿ cation located in the posterior patellofemoral region, whose function turns out to be the main ligamentous restriction to hyperextension of the knee. Recent studies (Chahla et al. 2018, Za˛ agnini et al. 2018) have identiÿ ed another new ligament in the knee, the “anterolateral ligament.” ° is ligament looks like a type of a ÿ brous expansion between the lateral femoral epicondyle and the tibia, with an important stabilizing role during internal rotation of the tibia. Some authors even mention the “anterolateral knee complex” (Herbst et al. 2017, Kowalczuk et al. 2018, Kittl et al. 2018) which is composed of the anterolateral ligament, the superÿ cial and deep iliotibial band, the capsular bony layer of the iliotibial band (Kaplan ÿ bers), and the anterolateral capsule. ° is complex is thought to control internal tibial rotation and function synergistically with adjacent meniscal tissue and meniscal roots.

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Far from being ultraspecialized structures ligaments are part of the fascial system endowed with collagenous features in order to participate in force transmission, control of movement, and maintenance of stability without causing energy to be expended. ° ey are not just “inert” elements (van der Wal 2009). Fascia also participates in the modulation of muscular e˛ ort, creating a relationship between fascial tension and decreased muscle contraction. ° e “˝ exion re˝ ex,” evidenced in cervical and lumbar ˝ exion movements, highlights the contribution of fascial tissue tension to the phenomenon of eccentric muscle contraction. ° e results of electromyography tests conducted by Colloca and Hinrichs (2005) on eccentric contractions of the paravertebral lumbar muscles showed an inhibition of the contraction despite the fact that the moment of lever force increased. ° is phenomenon is indicative of a modulation of the load shared with the connective tissue structures (ligaments and fascial systems).

Fascia also intervenes to modulate muscular effort.

Finally, it should be noted that the compartmental organization of fascial tissue triggers a phenomenon of hydraulic ampliÿ cation in relation to the dynamics of muscle contraction (Gracovetsky et al. 1977). During contraction, the muscle ÿ bers (arranged in parallel) are widened. ° is phenomenon, at the tissue level (muscle belly), can be observed as an expansion in all dimensions of muscle volume, creating pressure on its epimysium or on the fascial compartment. As previously mentioned (see Chapters 3 and 5), myofascia is characterized by a complex hierarchy of helically reinforced “tubes” contained within larger tubes (cylinders), which surround groups of muscles. ° is architectural design extends to the highest level of the body’s construction, surrounds the extremities and ultimately the entire body. ° e bundles of collagen ÿ bers in the perimysium and epimysium build crossed-helical conÿ gurations that balance longitudinal and circumferential loads and coordinate changes in muscle shape during contraction and extension (Scarr 2016). By this “hydraulic” phenomenon, the tension of the fascia strengthens muscle contraction and ampliÿ es muscle strength (Willard et al. 2012).

7

Adaptation and facilitation of gliding At a macroscopic level the fascial system applies its deformability to adapt itself to movement in the same way as other body structures adapt to movement. For example, the change in the shape (and volume) of the extensor muscles appears during the knee ˝ exion movement. ° e same phenomenon manifests itself in the ligaments, tendons, and other connective tissue structures linked to the movement of the knee. Fascia facilitates movement by allowing gliding between the structures it surrounds (Pilat 2015, 2017). From an analysis of the relationship of the skin with superÿ cial fascia and of superÿ cial fascia with deep fascia up to the level of the endomysium, perimysium and epimysium, Yoshitake et al. (2016) demonstrated that connective tissue (with a high level of hydration) allows gliding between myoÿ brils, muscle fascicles, and muscle bellies. In a body compartment, a large number of neurovascular, visceral, and muscular structures can be found, and all of them realize free dynamic behavior to allow deformation during movement (Chaitow 2014). ° e loose connective tissue (areolar fascia) is relatively less organized and seems to facilitate easy mobility between planes. The fascial system facilitates movement by allowing gliding between adjacent structures.

In reference to tendinous mobility, Guimberteau and Delage (2012) state that the current notion of tendon slippage is erroneous and suggests the existence of a mechanically adaptable “multimicrovacuolar” ÿ brous system that allows full gliding movement without dynamic in˝ uence in the surrounding tissues. Another example of adaptation and gliding is in the neurobiomechanics of the nervous system. During spinal ˝ exion movement the neuraxis changes its length from 8 to 9 cm and increases its tension by 30ˇpercent (in the dura matter) and 16ˇpercent in the sacral roots (Adams & Logue 1971, Louis 1981, Yuan et al. 1998). ° ese changes will allow gliding, for example, between the dura mater and the yellow ligaments (Butler 2000) or between the lumbosacral roots and the intervertebral foramina (Breig 1978).

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7 An example of this process in the peripheral nervous system is the behavior of the epineurium. It facilitates intraneural gliding between the perineuria of the fascicles during movement of the lower extremities (Millesi et al. 1986) and it also allows the external movement of the nervous trunk in relation to its neural bed (Sunderland 1978, Coppieters et al. 2015). ° e arguments above also suggest dynamic behavior of the autonomic nervous system in relation to movement of the body. Especially perceptible is the adaptation and movement of the sympathetic chain with its connective sheaths during inclination, extension, and ˝ exion of the trunk (Butler 2000). ° e adaptation and mobility of the nervous system outlined above also corresponds to the concept of continuity of the fascial system transmitting changes at a distance:

•

•

Gilbert et al. (2007) in a study with unembalmed cadavers using ˝ uoroscopic images showed that performing dorsi˝ exion of the ankle during straight leg elevation causes an increase in tension and in the distal gliding of the lumbosacral nerve roots (L5 and S1). Shacklock et al. (2016) conducted an investigation with asymptomatic subjects and with cadavers

during the slump test. ° ey evidenced that the application of neurodynamic movement in the contralateral limb can reduce tension in the lumbar neural tissues thus improving the symptomatology of the symptomatic limb.

•

Another recent study with high resolution ultrasound in vivo (Sierra-Silvestre et al. 2018) showed the glide of the femoral nerve in the groin during ˝ exion of the neck when performing the femoral slump test.

It is logical to conclude that an intraneural ÿ brosis or an adherence of the nerve in relation to its bed can cause a gliding deÿ cit and consequently a neuroconnective dysfunction that will a˛ ect movement (Shacklock 2005, Pilat 2003).

Conclusion Gliding between fascial structures that surround muscles, nerves, neurovascular tracts, and other body structures is fundamental to optimal body dynamics. We can conclude that fascia transmits, orients, adapts, responds, and facilitates movement, generating greater eˆ ciency in muscular dynamics and allowing a better fulÿ llment of function and human adaptability.

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REFERENCES

Abdollahi I, Taghizadeh A, Shakeri H, Eivazi M, Jaberzadeh S (2015) ° e relationship between isokinetic muscle strength and spasticity in the lower limbs of stroke patients. J Bodyw Mov ° er 19(2):284–290. Acuña DA (2001) El cuerpo en la interpretación de las culturas. Boletín Antropológico 1(51): 31–52. Adams CB, Logue V (1971) Studies in cervical spondylotic myelopathy. I. Movement of the cervical roots, dura and cord, and their relation to the course of the extrathecal roots. Brain 94(3):557–568. Álvarez González MJ, Digerolamo G, Cuenca Zaldivar JN, Campos Vicente D, Sánchez Jorge S, Pilat A, Arroyo M (2019) Changes in the tension of the ˝ exor carpi ulnaris muscle by the tensioning of the ulnar nerve by shear-wave elastography [Unpublished manuscript]. Arellano CJ, Gidmark NJ, Konow N, Azizi E, Roberts TJ (2016) Determinants of aponeurosis shape change during muscle contraction. J Biomech 49(9):1812–1817. Ateş F, Andrade RJ, Freitas SR, Hug F, Lacourpaille L, Gross R, Yucesoy CA, Nordez A (2018) Passive sti˛ ness of monoarticular lower leg muscles is in˝ uenced by knee joint angle. Eur J Appl Physiol 118(3):585–593. Azizi E and Roberts TJ (2009) Biaxial strain and variable sti˛ ness in aponeuroses. J Physiol 587(Pt. 17):4309–4318. Barbe MF, Gallagher S, Popo˛ SN (2013) Serum biomarkers as predictors of stage of workrelated musculoskeletal disorders. J Am Acad Orthop Surg 21(10):644–646. Breig A (1978) Adverse Mechanical Tension in the Central Nervous System. Stockholm: Almquist and Wiksell. Butler DS (2000) ° e Sensitive Nervous System. Adelaide: Noigroup Publications. Carvalhais VO, Ocarino Jde M, Araújo VL, Souza TR, Silva PL, Fonseca ST (2013) Myofascial force transmission between the latissimus dorsi and gluteus maximus muscles: An in vivo experiment. J Biomech 46(5):1003–1007.

Chahla J, Geeslin AG, Cinque ME, LaPrade RF (2018) Biomechanical proof for the existence of the anterolateral ligament. Clin Sports Med 37(1):33–40. Chaitow L (2014) Somatic dysfunction and fascia’s gliding-potential. J Bodyw Mov ° er 18(1):1–3. Chino K, Takahashi H (2015) ° e association of muscle and tendon elasticity with passive joint sti˛ ness: In vivo measurements using ultrasound shear wave elastography. Clin Biomech (Bristol, Avon) 30(10):1230–1235. Choi HW, Kim YE (2017) E˛ ect of lumbar fasciae on the stability of the lower lumbar spine. Comput Methods Biomech Biomed Engin 20(13):1431–1437. Colloca CJ, Hinrichs RN (2005) ° e biomechanical and clinical signiÿ cance of the lumbar erector spinae ˝ exion-relaxation phenomenon: A review of literature. J Manipulative Physiol ° er 28(8):623–631. Coppieters MW, Andersen LS, Johansen R, Giskegjerde PK, Høivik M, Vestre S, Nee RJ (2015) Excursion of the sciatic nerve during nerve mobilization exercises: An in vivo cross-sectional study using dynamic ultrasound imaging. J Orthop Sports Phys ° er 45(10):731–737. Cruz-Montecinos C, González Blanche A, López Sánchez D, Cerda M, Sanzana-Cuche R, CuestaVargas A (2015) In vivo relationship between pelvis motion and deep fascia displacement of the medial gastrocnemius: Anatomical and functional implications. J Anat 227(5):665672. de Bruin M, Smeulders MJ, Kreulen M (2011) Flexor carpi ulnaris tenotomy alone does not eliminate its contribution to wrist torque. Clin Biomech (Bristol, Avon) 26(7):725–728. Fan C, Fede C, Gaudreault N, Porzionato A, Macchi V, De Caro R, Stecco C (2018) Anatomical and functional relationships between the external abdominal oblique muscle and the posterior layer of the thoracolumbar fascia. Clin Anat 31(7):1092–1098. Fernández-de-las-Peñas C, Pilat A (2012) 11.1 So˙ tissue manipulation approaches to pelvic pain (external). In: Chaitow L, Jones RL (Eds.)

7

Chronic Pelvic Pain and Dysfunction: Practical Physical Medicine. Edinburgh: Elsevier. Finni T, Cronin NJ, Mayÿ eld D, Lichtwark GA, Cresswell AG (2017) E˛ ects of muscle activation on shear between human soleus and gastrocnemius muscles. Scand J Med Sci Sports 27(1): 26–34. Gilbert KK, Brismée JM, Collins DL, James CR, Shah RV, Sawyer SF, Sizer PS Jr. (2007) 2006 Young Investigator Award Winner: Lumbosacral nerve root displacement and strain: Part 2. A comparison of 2 straight leg raise conditions in unembalmed cadavers. Spine (Phila Pa 1976) 32(14):1521–1525. Gracovetsky S, Farfan HF, Lamy C (1977) A mathematical model of the lumbar spine using an optimized system to control muscles and ligaments. Orthop Clin North Am 8(1): 135–153. Guimberteau JC, Delage JP (2012) ° e multiÿ brillar network of the tendon sliding system. Ann Chir Plast Esthet 57(5):467–481. Herbert RD, Hoang PD, Gandevia SC (2008) Are muscles mechanically independent? J Appl Physiol 104(6):1549–1550. Herbst E, Albers M, Burnham JM, Fu FH, Musahl V (2017) ° e anterolateral complex of the knee. Orthop J Sports Med 5(10):2325967117730805. Huijing PA (2003) Muscular force transmission necessitates a multilevel integrative approach to the analysis of function of skeletal muscle. Exerc Sport Sci Rev 31(4):167–175. Huijing PA (2007) Epimuscular myofascial force transmission between antagonistic and synergistic muscles can explain movement limitation in spastic paresis. J Electromyogr Kinesiol 17(6):708–724. Huijing PA, Jaspers RT (2005) Adaptation of muscle size and myofascial force transmission: A review and some new experimental results. Scand J Med Sci Sports 15(6):349–380. Huijing PA, Baan GC, Rebel G (1998) Nonmyotendinous force transmission in rat extensor digitorum longus muscle. J Exp Biol 201(Pt. 5):682–691.

167

Pilat_Myofascial Induction.indb 167

03/12/21 4:06 PM

7

REFERENCES

Huijing PA, Yaman A, Ozturk C, Yucesoy CA (2011) E˛ ects of knee joint angle on global and local strains within human triceps surae muscle: MRI analysis indicating in vivo myofascial force transmission between synergistic muscles. Surg Radiol Anat 33(10):869–879.

popliteal ligament and other structures in preventing knee hyperextension. Am J Sports Med 38(3):550–557.

Roberts TJ, Azizi E (2011) Flexible mechanisms: ° e diverse roles of biological springs in vertebrate movement. J Exp Biol 214(Pt 3):353–361. Roberts TJ, Konow N (2013) How tendons buffer energy dissipation by muscle. Exerc Sport Sci Rev 41(4):186–193.

Huxley AF, Simmons RM (1971) Proposed mechanism of force generation in striated muscle. Nature 233:533–538.

Pastor MF, Averbeck AK, Welke B, Smith T, Claassen L, Wellmann M (2016) ° e biomechanical in˝ uence of the deltotrapezoid fascia on horizontal and vertical acromioclavicular joint stability. Arch Orthop Trauma Surg 136(4):513519.

Johnson GM, Zhang M, Jones DG (2000) ° e ÿ ne connective tissue architecture of the human ligamentum nuchae. Spine (Phila Pa 1976) 25(1):5–9.

Pilat A (2003) Terapias miofasciales: Inducción miofascial. Madrid: McGraw Hill Interamericana de España.

Kaya CS, Temelli Y, Ates F, Yucesoy CA (2018) E˛ ects of inter-synergistic mechanical interactions on the mechanical behaviour of activated spastic semitendinosus muscle of patients with cerebral palsy. J Mech Behav Biomed Mater 77:78–84.

Pilat A (2009) Myofascial induction approaches for headache. In: Fernández-de-las-Peñas C, Arendt-Nielsen L, Gerwin RD (Eds.) Tension Type and Cervicogenic Headache: Pathophysiology, Diagnosis, and Management. Boston: Jones & Bartlett Publishers.

Kittl C, Inderhaug E, Williams A, Amis AA (2018) Biomechanics of the anterolateral structures of the knee. Clin Sports Med 37(1):21–31. Kowalczuk M, Herbst E, Burnham JM, Albers M, Musahl V, Fu FH (2018) Clin Sports Med 37(1):1–8. Kreulen M, Smeulders MJ (2008) Assessment of ˝ exor carpi ulnaris function for tendon transfer surgery. J Biomech 41(10):2130–2135.

Pilat A (2014) Myofascial induction approach. In: Chaitow L (Ed.) Fascial Dysfunction: Manual ° erapy Approaches. Edinburgh: Handspring Publishing. Pilat A (2015) Myofascial induction approaches. In: Fernández-de-las-Peñas C, Cleland JA, Dommerholt J (Eds.) Manual ° erapy for Musculoskeletal Pain Syndromes: An Evidence- and Clinical-Informed Approach. London: Elsevier.

Lichtwark GA, Wilson AM (2007) Is Achilles tendon compliance optimised for maximum muscle eˆ ciency during locomotion? J Biomech 40(8):1768–1775.

Pilat A (2017) Myofascial induction therapy. In: Liem T, Tozzi P, Chila A (Eds.) Fascia in the Osteopathic Field. Edinburgh: Handspring Publishing.

Louis R (1981) Vertebroradicular and vertebromedullar dynamics. Anatomia Clinica 3:3–11.

Purslow P (2010) Muscle fascia and force transmission. J Bodyw Mov ° er 14(4):411–417.

Maas H, Sandercock T (2008) Are skeletal muscles independent actuators? Force transmission from soleus muscle in the cat. J Appl Physiol (1985) 104(6):1557–1567.

Raiteri BJ, Cresswell AG, Lichtwark GA (2018) Muscle-tendon length and force a˛ ect human tibialis anterior central aponeurosis sti˛ ness in vivo. Proc Natl Acad Sci USA 115(14):E3097– E3105.

Marinho HVR, Amaral GM, Moreira BS, Santos TRT, Magalhães FA, Souza TR, Fonseca ST (2017) Myofascial force transmission in the lower limb: An in vivo experiment. J Biomech 63:55–60. Millesi H (1986) ° e nerve gap. ° eory and clinical practice. Hand Clin 2(4):651–663. Morgan PM, LaPrade RF, Wentorf FA, Cook JW, Bianco A (2010) ° e role of the oblique

Randhawa A, Wakeling JM (2018) Transverse anisotropy in the deformation of the muscle during dynamic contractions. J Exp Biol 221:jeb175794. doi:ˇ10.1242/jeb.175794. Richardson C, Hodges P, Hides J (2004) ° erapeutic Exercise for Lumbopelvic Stabilization: A Motor Control Approach for the Treatment and Prevention of Low Back Pain. 2nd ed. London: Churchill Livingstone.

Roberts TJ, Marsh RL (2003) Probing the limits to muscle-powered accelerations: lessons from jumping bullfrogs. J Exp Biol 206(Pt. 15):2567–2580. Scarr G (2016) Fascial hierarchies and the relevance of crossed-helical arrangements of collagen to changes in the shape of muscles. J Bodyw Mov ° er 20(2):377–387. Shacklock M (2005) Clinical Neurodynamics: A New System of Neuromusculoskeletal Treatment. Butterworth-Heinemann Elsevier. Shacklock M, Yee B, Van Hoof T, Foley R, Boddie K, Lacey E, Poley JB, Rade M, Kankaanpää M, Kröger H, Airaksinen O (2016) Slump Test: E˛ ect of contralateral knee extension on response sensations in asymptomatic subjects and cadaver study. Spine (Phila Pa 1976) 41(4):E205–E210. Sierra-Silvestre E, Bosello F, Fernández-Carnero J, Hoozemans MJM, Coppieters MW (2018) Femoral nerve excursion with knee and neck movements in supine, sitting and side-lying slump: An in vivo study using ultrasound imaging. Musculoskelet Sci Pract 37:58–63. Smeulders MJ, Kreulen M (2007) Myofascial force transmission and tendon transfer for patients su˛ ering from spastic paresis: A review and some new observations. J Electromyogr Kinesiol 17(6):644–656. Standring S (Ed.) (2008) Gray’s Anatomy: ° e Anatomical Basis of Clinical Practice. 40th ed. London: Churchill Livingstone. Stecco A, Antonio S, Gilliar W, Wolfgang G, Hill R, Robert H, Fullerton B, Stecco C (2013) ° e anatomical and functional relation between gluteus maximus and fascia lata. J Bodyw Mov ° er 17(4):512–517. Sunderland S (1978) Nerves and nerve injuries. Edinburgh: Churchill Livingstone. Takeshita K, Peterson ET, Bylski-Austrow D, Crawford AH, Nakamura K (2004) ° e nuchal

168

Pilat_Myofascial Induction.indb 168

03/12/21 4:06 PM

REFERENCES

ligament restrains cervical spine ˝ exion. Spine (Phila Pa 1976) 29(18):E388–393. ° iel W (2000) Atlas fotográÿ co de anatomía práctica. Volumen I, abdomen y extremidad inferior. Barcelona: Springer-Verlag Ibérica. Tidball JG (1991) Myotendinous junction injury in relation to junction structure and molecular composition. Exerc Sport Sci Rev 19:419–445. Triana JA, Arenas QB, Restrepo BH, Toro DJ, Rodríguez GJ, Hoover VJ. (2000) El movimiento como sistema complejo. Revista Digital – Buenos Aires 5(26). Turvey MT, Fonseca S (2009) Nature of motor control: Perspectives and issues. Adv Exp Med Biol 629:93–123.

Vieira ELC, Vieira EÁ, da Silva RT, dos Santos Berlfein PA, Abdalla RJ, Cohen M (2007) An anatomic study of the iliotibial tract. Arthroscopy 23(3):269–274. Vleeming A, Pool-Goudzwaard AL, Stoeckart R, van Wingerden JP, Snijders CJ (1995) ° e posterior layer of the thoracolumbar fascia. Its function in load transfer from spine to legs. Spine (Phila Pa 1976) 20(7):753–758. Vleeming A, Schuenke MD, Danneels L, Willard FH (2014) ° e functional coupling of the deep abdominal and paraspinal muscles: ° e e˛ ects of simulated paraspinal muscle contraction on force transfer to the middle and posterior layer of the thoracolumbar fascia. J Anat 225(4):447–462.

Turvey MT, Fonseca S (2014) ° e medium of haptic perception: A tensegrity hypothesis. J Mot Behav 46(3):143–187.

Willard FH, Vleeming A, Schuenke MD, Danneels L, Schleip R (2012) ° e thoracolumbar fascia: Anatomy, function and clinical considerations. J Anat 221(6):507–536.

van der Wal J (2009) ° e architecture of the connective tissue in the musculoskeletal system— an o˙ en overlooked functional parameter as to proprioception in the locomotor apparatus. Int J ° er Massage Bodywork 2(4):9–23.

Yaman A, Ozturk C, Huijing PA, Yucesoy CA (2013) Magnetic resonance imaging assessment of mechanical interactions between human lower leg muscles in vivo. J Biomech Eng 135(9):91003.

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Yoshitake Y, Miyamoto N, Taniguchi K, Katayose M, Kanehisa H (2016) ° e skin acts to maintain muscle shear modulus. Ultrasound Med Biol 42(3):674–682. Yu WS, Kilbreath SL, Fitzpatrick RC (2007) ° umb and ÿ nger forces produced by motor units in the long ˝ exor of the human thumb. J Physiol 583(Pt. 3):1145–1154. Yuan Q, Dougherty L, Margulies SS (1998) In vivo human cervical spinal cord deformation and displacement in ˝ exion. Spine (Phila Pa 1976) 23(15):1677–1683. Za˛ agnini S, Grassi A, Marcheggiani Muccioli GM, Raggi F, Romagnoli M, Bondi A, Calderone S, Signorelli C (2008) ° e anterolateral ligament does exist: An anatomic description. Clin Sports Med 37(1):9–19. Zhang C, Gao Y (2012) Finite element analysis of mechanics of lateral transmission of force in single muscle ÿ ber. J Biomech 45(11):2001–2006. Zügel M, Maganaris CN, Wilke J, Jurkat-Rott K, Klingler W, Wearing SC, Findley T, Barbe MF, Steinacker JM, Vleeming A, Bloch W, Schleip R, Hodges PW (2018) Fascial tissue research in sports medicine: from molecules to tissue adaptation, injury and diagnostics. Br J Sports Med 52(23):1497.

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The neurodynamics of fascia With a contribution from Germán Digerolamo

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KEY POINTS •

Description of neurofascial architecture

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How peripheral and central pain sensitization are linked

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Correlation of chronic (nonspecific) pain with fascial dysfunction

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Analysis of advances in the study of fascial innervation

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The role of the neurovascular tract in force transmission

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Analysis of the involvement of glial cells in the dynamics of the nervous system

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The concept of allostasis and how it relates to the fascial system

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Correlation of interoception and the afferent homeostatic pathway

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How interoception and the central sensitization process are linked

Introduction Neural structures are anatomically integrated into the fascia in its extrinsic and intrinsic architecture (Figs. 8.1 and 8.2). ° e peripheral nerves require extensive mobility in relation to the surrounding tissues. ° e dynamics of the interface between both structures is essential to their functionality. Fast adaptation to mechanical impulses (external and internal stresses due to muscular contraction), movement of ˝ uids, changes in pressure, resistance, elastic recoil, and the eˆ ciency of sliding and gliding will determine the quality of the nerve signal transmissions (Butler 2000, Shacklock 2005). Pathological processes, including pain, do not have to always involve damage to nerve cells (axonopathy); they can primarily be related to in˝ ammatory mechanisms coming from the nerve’s connective tissue that act as potential mediators for peripheral sensitization and cause the release of multiple chemicals from mast cells, immune cells, and macrophages, among others.

Neurofascial architecture Correct functioning of the peripheral nervous system (PNS) is related to the dynamics of four fascial sheaths

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that not only envelop and protect the nerves, but also actively participate in the mechanical behavior of neural tissue. In ascending order they are (see Fig. 8.2):

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° e endoneurium, which extends along the nerve ÿ ber between the basal lamina of the Schwann cells and the perineurium. ° e endoneurium is constituted of collagen ÿ bers (type IV, type II, and type I with longitudinal orientation of ÿ bers), ÿ broblasts, ÿ xed macrophages, perivascular mast cells, capillaries, and extracellular ˝ uid. ° e extracellular ˝ uid of the endoneurium is isolated from the extracellular environment protecting the axon. ° e arterioles are tightly wrapped by the endoneurial cells to create an additional barrier to the blood. ° e venules carry the blood back to the venous system. ° e lymphatic system, however, is present only in the epineurium; there is already a lack of lymphatic vessels inside the nerves (Gao et al. 2013).

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° e perineurium, which is wrapped around a nerve fascicle. It is denser than the endoneurium and is composed of various layers of ÿ broblasts. Longitudinal, circular, and oblique collagen ÿ bers and also elastic ÿ bers are abundant. ° e perineurium acts as a blood–nerve barrier (it does not allow all ÿ ltered

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8 AA

BB

BB CC

DD . Pencaitland, . Pencaitland,

Figure 8.1 Figure 8.1 Figure 8.1 Ventral aspect of the forearm

Ventral aspect of the forearm AVentral Deepaspect fascia of the forearm A Deep fascia BA Peripheral Deep fascianerve embedded in the fascia B Peripheral nerve embedded in the fascia CB Superfi cial nerve fascia embedded with fatty nodes Peripheral in the fascia C Superficial fascia with fatty nodes DC Subcutaneous veinwith fatty nodes Superficial fascia D Subcutaneous vein D Subcutaneous vein

Blood vessels Blood vessels

Figure 8.2 Figure 8.2

Epineurium Epineurium

A cross-section of a peripheral nerve. Structurally, the hierarchy of peripheral A cross-section of a peripheral nerve. Structurally, the hierarchy of peripheral nerve assembly is similar to that of skeletal muscle. nerve assembly is similar to that of skeletal muscle. Reproduced with permission from Lesondak D. (2017) Fascia: Reproduced with permission from Lesondak D. (2017) Fascia: What It Is And Why It Matters. Edinburgh: Handspring Publishing. What It Is And Why It Matters. Edinburgh: Handspring Publishing. Fascicle Fascicle

Perineurium Perineurium

Endoneurium Endoneurium

Myelin Myelin

Axon (Schwann cell) Axon (Schwann cell)

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The neurodynamics of fascia

substances to reach the endoneurium). It also participates in maintaining a constant pressure inside the nerve. In this way a favorable internal environment is created for the nerve ÿ bers and the Schwann cells present inside the endoneurium. Without the presence of the perineurium, and the consequent absence of intrafascicular nerve pressure, an eˆ cient and selective transit of nutrients to axons and Schwann cells could not be guaranteed (Mizisin & Weerasuriya 2011). During the body’s daily movements the nervous system is subject to a multitude of mechanical loads. ° erefore, it is exposed to compression and stretching and sliding phenomena in relation to the structures that surround it. ° e neural structures, when undergoing compression, alter their size and even their position (e.g., the median nerve in the carpal tunnel when the extension movement of the wrist and ÿ ngers is performed) (Wang et al. 2014). ° e main layer of protection is the perineurium. It allows peripheral nerves to withstand up to 15–22ˇpercent of excessive tensile force–strain before the system fails (Butler 2002). It can be concluded that the perineurium performs important functions in the protection and repair of nervous tissue (Tos et al. 2015).

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° e epineurium, which is the external sheath of a peripheral nerve. It surrounds multiple nerve fascicles and joins them together in a single bundle. It is a thick, mechanically resistant envelope of dense Vasa nervorum

Epineurium

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connective tissue (mainly formed of longitudinal collagen ÿ bers). ° e collagen ÿ bers prevent the nerves from stretching and protect them from damage when the body is moving or when strong external force is applied (particularly compressive force). ° e presence of vasa nervorum (the blood vessels of the nerve) allows the epineurium to maintain its constant microvascularization. ° is activity is facilitated by the orientation of the vessels in a rolled-up form which allows them to adapt better to strain if the nerve is elongated (Fig. 8.3) (Barral & Croibier 2009). ° ese three layers develop continuity with the meninges (Fig. 8.4) (Bove 2008, Mizisin & Weerasuriya 2011, Kimmell et al. 2011).

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° e mesoneurium (also known as adventitia or paraneurium) is the key connective tissue (the fourth sheath) that facilitates the movement of the nerve in its environment. It is the outermost covering layer. ° e nerve is able to glide into this sheath during movement as well shi˙ laterally in the process of accommodation. In the structure of the mesoneurium loose connective tissue predominates. It is characterized by the presence of anchors that link to adjacent structures. In˝ ammation or scarring of the mesoneurium can lead to neuroimmune irritation and potential midaxon discharge (Butler 2000). In the therapeutic process the mesoneurium cannot be ignored, and it is becoming the target tissue for assessment and treatment.

Nervi nervorum

Figure 8.3 A cross-section of a peripheral nerve showing the intrinsic nerve structures, vasa nervorum, and nervi nervorum

Blood vessels

Axon (Schwann cell)

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8 Endoneurium

Subarachnoid space

Figure 8.4 The relationship of peripheral nerve and spinal root connective tissue ensheathments to the meningeal coverings of the spinal cord. The dura is continuous with the epineurium, while the arachnoid layer fuses with the external perineurial lamellae

Perineurium

Epineurium

Arachnoid

Dura mater

Nervous tissue as a source of pain A nociceptive neuron (nociceptor):

is an ending that by its discharge behavior is capable of distinguishing between an innocuous and a noxious stimulus. An important point for the understanding of the function of nociceptors is that their stimulation threshold is just below tissue-damaging intensity. The function of nociceptors is not to signal existing tissue damage, but to inform the central nervous system (CNS) when stimuli approach tissue-threatening intensities. (Mense 2020) Nociceptors protect the body from threat and from harmful actions (danger of necrosis). However, the nerves also have their own protection system. Some nociceptive neurons are involved with detecting any threat that a˛ ects the neurons. ° ese are known as nervi nervorum (see Fig. 8.3). ° e nervi nervorum, present in all the neuroconnective layers, are primarily made up of unmyelinated or poorly myelinated ÿ bers

located in peripheral nerve sheaths. ° ey contribute to the sensitivity of the nerve in relation to excessive (traumatic) mechanical impulses of compression and/ or stretching and chemical and thermal changes in the environment (Treede 2016). ° e nervi nervorum adapt to regular movement without being damaged. However, the presence of sustained or repetitive, but low-frequency/intensity stimulus can activate the nociceptors and the nociceptive process (that has already been sensitized). ° is brief anatomical analysis might lead us to conclude that neuropathic pain is related to the in˝ ammatory mechanism originating from the connective tissue of the nerve mediated by the nervi nervorum. ° e nociceptors of the nervi nervorum are described as peptidergic. ° is means that they can release neuropeptides into the neuroconnective tissues and regulate tissue functions, as in neurogenic in˝ ammatory response (peripheral sensitization) which gives rise to truncal pain. ° e clinical characteristics of this type of pain are that it is nociceptive and proportional

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to the magnitude of the stimulus applied. It should be noted that if the process of neurological in˝ ammation does not subside over an appropriate period of time or worsens it may trigger pain with neuropathic characteristics (central sensitization) or both central and peripheral modalities. ° is means that this process does not involve a change in nerve behavior; however it does a˛ ect neural mechanosensitivity. ° is issue will be discussed extensively later in this chapter in relation to the sensitization process of the thoracolumbar fascia.

Pain and peripheral sensitization “Peripheral sensitization is described as a reduction in pain threshold and increased responsiveness of peripheral nociceptors” (Fernández-de-las-Peñas & Dommerholt 2014). Tissue and/or peripheral nerve injury includes in˝ ammation and subsequent release of proin˝ ammatory and pronociceptive mediators such as bradykinin, histamine, serotonin, SP (substance P), extracellular ATP (adenosine triphosphate), protons, cytokines, chemokines, growth factors, peptides, and prostaglandins that will act on the corresponding receptors and ion channels, altering their sensitivity to stimuli and facilitating the presence of neurogenic in˝ ammation (Si-Qi et al. 2019). Usually pain starts as nociceptive, and the internal mechanism of nerve signal transduction remains largely intact. However, as a result of a persistent and/or high-intensity process, it could evolve toward neuropathic or even nociplastic pain (Ochoa et al. 2005).

Nociplastic pain is the semantic term suggested by the international community of pain researchers to describe a third category of pain that is mechanistically distinct from nociceptive pain, which is caused by ongoing inflammation and damage of tissues, and neuropathic pain, which is caused by nerve damage. (Fitzcharles et al. 2021) The experience of pain is always influenced by biopsychosocial aspects. The peripheral nerves can produce: a) pain without any stimulus; b) allodynia (pain in response to a harmless stimulus); c) hyperalgesia (pain in response to a harmful stimulus) that could

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be primary or secondary. Primary hyperalgesia increases pain sensitivity at a site of tissue damage and occurs to both thermal and mechanical stimuli. In the case of inflammatory pain, primary hyperalgesia is usually due to sensitization of primary afferent nociceptors. Secondary hyperalgesia involves only mechanical stimuli, i.e., allodynia and increased pain sensitivity when a noxious stimulus is administered to a region surrounding, but not including, the area of direct injury. “Secondary hyperalgesia is due to sensitization of central neurons and requires a continuous input of nociceptors from the area of primary hyperalgesia for its maintenance” (Schmidt & Willis 2007). It should be recalled that the fibers frequently involved in peripheral sensitization are the A˘ and C fibers. Fascial tissue contains a high concentration of these fibers.

Pain and central sensitization Central sensitization is subject to changes in information processing by the central nervous system (CNS). ° ere is a responsible neuronal substrate which, through a varied cellular and molecular response at di˛ erent levels of the nervous system (spinal cord, subcortical, and cortical centers), orchestrates a rupture between the magnitude of the nociceptive stimulus and the painful experience. A person may perceive pain in the presence of central sensitization, even in the absence of nociceptive input or from simple mechanosensitive stimuli (rubbing the skin, for example). In such cases there is poor adaptation of the somatosensory system involving deregulation of the stress response system and cognitive-behavioral factors in response to a perception of threat. Recent signiÿ cant advances in neuroscience have changed the pain models used by clinicians, particularly in relation to chronic processes with signiÿ cant psychosocial components (Boyling & Jull 2005). Traditional understanding of osteoarthritis-related pain has recently been challenged. In light of evidence it is believed that central sensitization (which underlies these repeated clinical ÿ ndings) plays a key role in a subgroup of this population. ° is subgroup of patients presented an overwhelming symptomatology regarding the degree of tissue injury, even in the absence of

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8 injury (Lluch Girbés et al. 2015). Neuropathic features are a dominant characteristic of these painful processes. ° e lack of correlation between the magnitude of the damage and the pain characteristics (intensity and extent) presented in this patient population have led musculoskeletal therapists to conclude that manual interventions (“hands-on” procedures) are not appropriate for pain management in cases where the characteristics of central sensitization are dominant (neuropathic pain). In light of this, it is suggested in the treatment protocols that interventions for patients with central sensitization that do not “present a diagnosis of peripheral tissue injury” should be “hands-o˛ ,” and that neuroscience education (NE) should be the exclusive therapy (Lluch Girbés et al. 2015). However, before the initiation of clinical reasoning and the subsequent decisions on the clinical process, at least three points should be carefully considered:

•

•

° e ÿ rst point relates to the sensitivity of conventional diagnostic tools (X-ray, MRI, etc.) for identifying tissue damage. ° e usefulness of these tools is well documented, for example, in diagnosing osteoarthritis (OA) of the spine because of their sensitivity to the physiopathological changes in facet joints and the surrounding tissue (joint capsule, subchondral bone) (Gellhorn et al. 2013). However, the aforementioned tools do not have the same sensitivity (e˛ ectiveness) for identifying damage to so˙ tissue. Questions arise when the ÿ ndings of these tests do not correspond with the clinical reality of the patient. For example, does the detection of a facet joint pathology (clearly observable in an X-ray image) assure us that these changes are the source of the patient’s pain (Chou et al. 2011)? In addition, does the fact that these tools are not sensitive enough to detect alterations in so˙ tissue mean that the patient is free from pathological processes in those structures that could be a source of symptoms? In this context, ultrasound techniques (e.g., sonoelastography) have been proposed as tools capable of detecting dynamic changes in unspecialized connective tissue (fascial tissue) (Langevin etˇal. 2009), which may be involved in the expression of painful symptoms. ° e second point to consider relates to NE and the new protocols for understanding pain and the

application of therapies to promote patient education in order to minimize negative behavioral aspects (anxiety, stress, etc.) regarding their illness (Louw et al. 2011). However, some researchers suggest not separating the clinical reasoning relating to pain associated with central and peripheral sensitization. For example, Baron et al. (2013) suggest that many of the painful processes are related to so˙ tissue and/or peripheral nerve damage, which consequently maximizes secretion of neurotransmitters (with the potential to generate pain) within the spinal cord, thus triggering central sensitization. ° ey state that: “Central sensitization is maintained by continuing input from the periphery, but also modulated by descending controls, both inhibitory and facilitatory, from the midbrain and brainstem. ° e projections of sensitized spinal neurons to the brain, in turn, alter the processing of painful messages by higher centers.”

•

Lastly, tissue injury is not required to have peripheral or central sensitization. As an example, the altered chemical environment of active TrPs can lead to peripheral and central sensitization without any tissue injury. We can conclude that diagnosing central sensitization is not an easy task, especially if only conventional procedures are used as determinants of interpretation. Growing evidence suggests that treatment strategies that desensitize the peripheral and central nervous systems are required. Baron et al. (2013) state that the treatments “should generally involve a multimodal approach, so that therapies may target the peripheral drivers of central sensitization and/or the central consequences.” Perhaps an extreme “brain-centered” vision (placing the brain as the epicenter of the problem) could be subject to an “extremely cognitivist” focused analysis. ° is clinical contingency could be a re˝ ection of a tendentious interpretation of the complex functioning of the brain and an underestimation of the participation of the peripheral component of the central sensitization processes. We should be vigilant of the epistemological perspective that is the basis for educating clinicians and their trainers in interpreting the functioning of the nervous system and consequently the phenomenon

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of pain. Clinicians and trainers might overlook the neuroethical warning signs and potentially lose sight of the complexity of the nervous system, interpreting it in a reductionist manner and, in particular, underestimating its particular and unique individuality (Ramos-Zúñiga 2014).

Innervation and vascularization of the fascial system Fascia is a neurosensitive structure in which a complex functional network of interconnected and integrated body dynamics is assembled (Stecco et al. 2007). ° e CNS and the autonomic nervous system (ANS) receive most of their mechanosensitive information from the body’s connective tissues (the neurofascial system or NFS). Di˛ erent fascial structures thus play a major role A

B

C

D

8

in the processing of mechanoreception. Mechanoreceptors are distributed all over the body rather than concentrated in speciÿ c areas. Each receptor is specialized to convey a speciÿ c kind of mechanical stimuli, such as pressure, stretching, or vibration. ° e receptors detect harmless and harmful mechanical stimuli that determine our senses of touch and pain. If the deformation of the fascia that covers the nerve endings is great enough, and when the signal is passed through to the dorsal horn, the fascia transmits the impulse to the central nervous system. ° e receptors, along with the peripheral nerves and the brain, thus constitute the somatosensory system, which interacts with the autonomous nervous system. ° e mechanoreceptors di˛ er depending on their location, the type of mechanical stimuli, the speed of adaptation to each stimulus, and the receptivity area (Kandel et al. 2001) (Fig. 8.5) (see also Table 3.2). E

F

G

Figure 8.5 Cutaneous somatosensory receptors A Hair follicles B C fibers C Polymodal receptors: C fibers and Aδ fibers D Merkel receptor E Ruffini corpuscle F Meissner corpuscle G Pacinian corpuscle

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8 Only approximately 20ˇpercent of these sensory ÿ bers are well known. ° ere are type I and type II ÿ bers (myelinated, fast conductors) that originate in the Golgi tendon organs, the muscle spindles, and the Ruˆ ni and Pacini corpuscles. ° e remaining 80ˇpercent of the fascial sensory substrate comes from the interstitial receptors (free nerve endings). ° ese are type III (10ˇpercent) and type IV (90ˇpercent) ÿ bers, barely myelinated or unmyelinated with slow conductivity, which are found in all fascial tissues, but mainly in the superÿ cial fascia (subdermal layer), outer layer of the deep fascia, periosteum, endomysium, perimysium, and visceral connective tissues (Schleip 2003, Tesarz et al. 2011). ° e spine, for example, is richly innervated with sensory and sympathetic ÿ bers, both of which can be the source of nociceptive a˛ erents (Youssef et al. 2016). Similarly, the presence of free nerve endings in muscle has been histologically proven. Curiously, these endings are not located in muscular ÿ bers per se, but primarily in the adventitia of the muscular arteries and veins (Mense & Gerwin 2010). However, in general muscular pain study models have underestimated the in˝ uence of fascial tissue in low back pain (Langevin et al. 2011). Innervation of the fascial system has been a topic of interest and signiÿ cant research in recent years (Mense & Hoheisel 2016, Mense 2019, Abdo et al. 2019, Fede et al. 2020, Magerl et al. 2021, Fede et al. 2021). ° e results have made physicians hopeful of shedding light on nonspeciÿ c musculoskeletal pain as, for example, in the case of idiopathic low back pain (Corey et al. 2011). Somatic protopathic sensitivity (e.g., pain, temperature) and epicritic sensitivity (e.g., topognosia, proprioception) are mediated respectively by free receptors (slow-conduction unmyelinated ÿ bers) and specialized receptors (fast-conduction myelinated ÿ bers) (Kandel et al. 2001). ° e topographic distribution and electrophysiological characteristics of these receptors have been thoroughly studied in skin and deep somatic tissues (viscera, muscles, joints, etc.). Pain (whether nociceptive or neuropathic), the sensation of movement (kinesthesia), and temperature depend in part on the electric signals created by the transduction signal

processes originating from these receptors (Kandel et al. 2001). However, the sensory characteristics of the majority of nonspecialized connective tissues have not yet been clearly established. Electrophysiological and immunohistochemical studies on animals have shown the existence of sensory nerves and free nerve endings within the collagen matrix of the nonspecialized connective tissues in the low back of test rats (Corey et al. 2011). It is interesting to consider the conclusions of some studies on cell cultures that refer to the existence of a functional and structural connection between the nerve endings and the extracellular matrix. Hu et al. (2010) provide direct evidence that mechanosensitive channels located in the membrane of sensory receptors, that underlie the tactile sensation of vertebrates, require an extracellular anchoring protein to function. ° ese authors propose, as a hypothesis, that the mechanosensitive ion channels of the nociceptors are controlled by a link to the matrix surrounding the ÿ broblast. ° is means that the mechanical displacement of the ÿ broblast adjacent to the neurite (branched end of the free nerve ending) can evoke rapid mechanosensitive currents in sensory neurons. Human studies have shown that, as in rats, the thoracolumbar fascia (TLF) is substantially populated with free nerve endings corresponding predominantly to sympathetic ÿ bers (as with muscular innervation) and primarily located in the outer layer of the TLF and in the superÿ cial fascia. ° ese sensory ÿ bers are reactive to substance P antibodies (meaning that they use substance P as a mediator for nociceptive transmission) and appear to play an important role in the activation of the nociceptive neurons located in the dorsal horn of the medulla. ° is activation means these mediators have the potential to participate in the pain process (Mense & Hoheisel 2016, Corey et al. 2011). It has been shown that these free nerve endings, which correspond to unmyelinated C ÿ bers, are involved in neurogenic in˝ ammation, meaning that they can trigger in˝ ammation in the tissue they innervate (for example, in the synovium of the joints) when nerve damage is present (Wieland et al. 2005). In physiological conditions, the activity of these ÿ bers is orthodromic in nature meaning they mediate the stimuli that “travel” from the periphery to the medulla; but in situations when

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the nerve is a˛ ected (neural edema), these ÿ bers can act in an antidromic manner (toward the periphery) and cause local in˝ ammation in the innervated tissues, meaning in˝ ammation of neurogenic origin (Kandel et al. 2001, Wieland et al. 2005). It has been shown that this situation increases the density of the nociceptors in the TLF (Mense & Hoheisel 2016). ° is means that nerve tissue damage can generate a neuroplastic change in the free receptors located in the fascial tissue and generate mechanosensitivity (hypersensitivity to mechanical stimuli) to movement. A patient’s pain could thus begin with peripheral sensitization which could cause changes in higher centers leading to central sensitization with modiÿ cation of the cortical representation of the body. ° e contribution of these studies allows us to understand the pathophysiology of nonspeciÿ c low back pain and possibly clarify, at least in part, the clinical characteristics linked to low back pathomechanics. ° e close connection between free and speciÿ c receptors and the extracellular matrix also conÿ gures an unconventional model for interpreting the behavior of the receptors, which could serve as an argument for the surprising beneÿ ts of myofascial induction in the treatment of patients with nociceptive and neuropathic pain and signs of myofascial dysfunction. It remains to be clariÿ ed whether the clinical beneÿ ts are due, at least in part, to the fact that the remodeling of connective tissue, through the application of a systemic procedure, releases free receptors (nociceptors) trapped in the collagenous network. Alternatively, perhaps this remodeling is due to changes in the mechanical behavior of the ÿ broblast during the application and, as a consequence of this, modiÿ cation of the extracellular matrix causing changes in the opening of the mechanosensitive channels of the nociceptors. ° is paradigm could provide important data for understanding the pathophysiology of pain (particularly pain linked to myofascial dysfunction) and could support the biological argument for the beneÿ ts of Myofascial Induction ° erapy (MIT).

Aδ and C fibers ° e ÿ bers that conduct the stimuli coming from the free nerve endings anchored in the fascial network are thin and have slow conduction velocity. ° ere are two

8

groups: group III or A˘ ÿ bers (2.5–30 m/s) and group IV or C ÿ bers (0.5–2.5 m/s). ° ese ÿ bers are responsible for transmitting nociceptive a˛ erents caused by harmful neurogenic mechanical stimuli through nociceptor sensitivity (Mense & Gerwin 2010, Mense & Hoheisel 2016). In addition, these ÿ bers conduct thermal and chemical stimuli (for example, changes in pH of the tissues) and other parameters that determine or “provide information” about the condition of tissue homeostasis (Craig 2002). ° e “allostatic condition of the tissues” will be used to mean “the homeostatic changes in the tissues.” ° e nociceptive nature of the nerves, determined by the rich innervation provided by the nervi nervorum, has been seen in certain disorders that present with truncal pain characteristics, as mentioned earlier in this chapter (Bove 2008). ° is type of pain has similarities with nociceptive pain originating in the myofascial structures. Clinicians consider this data to be useful and state the importance of the structural di˛ erentiation tests when applying neural tension assessment (Davis et al. 2008).

Continuity and transition of the nervous system From the classic neuroanatomy point of view, the nervous system is divided into the central nervous system and the peripheral nervous system (Johnson et al. 2006). Nevertheless, it is diˆ cult to ÿ nd a consensus in the literature that establishes a clear anatomical reference for this division. Histologically, it seems even more diˆ cult to establish this division since studies show a clear continuity between the connective sheaths of the central nervous system, or meninges, and the sheaths of the peripheral nervous system. ° e nerve roots emerge from the spinal cord and go toward the oriÿ ce (cranial nerves) or intervertebral foramen (peripheral plexus). ° ey are wrapped in pia mater and immersed in cerebrospinal ˝ uid to connect with the arachnoid mater and dura mater and to continue uninterrupted with the connective sheaths of the nerve trunks, mainly the epineurium. ° us, in addition, there is continuity among the cells that are covered by the endoneurium that make up the nerve ÿ bers. ° e transition between the continuity of the ÿ rst (peripheral) neuron and the

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8 second (central) neuron is represented by the glia limitans cells (astrocytes forming a border). ° ese cells serve as functional barriers at interfaces between nonneural tissue and CNS neural parenchyma along blood vessels, meninges, and tissue lesions (Johnson et al. 2006). ° e glial cells, of which astrocytes are the most abundant subtype, have recently been shown to be involved in many nervous system functions (Katiyar et al. 2017). ° ese cells have been shown to participate in neuroregeneration processes. Astrocytes develop a sca˛ old for neurite growth, both during neurodevelopment and regeneration of the nervous system. It has been shown that axonal stretching stimulates the astrocytes located in the transition zones to form channels where they circulate during growth (regeneration) (Katiyar et al. 2017). Nerves create an intricate, interconnected, threelayered fascial structure (see Fig. 8.2). Axons are covered by the endoneurium, which is then bundled by the perineurium, which is the most mechanically resistant layer and is responsible for maintaining positive intraneural pressure (blood-nerve barrier). Connected to the outside of the perineurium is the most vascularized layer – the epineurium (Bove 2008). All of these layers join with the nerve to become part of the capsules of the sensory receptors, as in the case of Meissner corpuscles, or they cover the motor plate when reaching the muscle ÿ ber (Mizisin & Weerasuriya 2011). ° e continuity of the nervous system is established by the uninterrupted network of connective tissue that forms it. To represent this fact the term neurofascial system is used. ° is continuity at the cellular and tissue levels shows that the neurofascial system has many structural and functional similarities with the fascial system and, as will be seen later, both functions seem to overlap in bodily movement. ° e presence of anatomical continuity between all of the structures mentioned above should also be noted; this is discussed in detail in Chapter 3.

The neurovascular tract and lateral transmission of forces ° e neurovascular tract is the connective tissue structure that covers, joins and protects the nerves and blood vessels that penetrate the muscle (Maas 2009).

° is structure is continuous with the extensive intramuscular connective tissue network, i.e., the endomysium and the perimysium, and it participates in the transmission of lateral force (Maas et al. 2005, 2003). ° is means it is diˆ cult to think of body movement as an action that is separate from the fascial–neurofascial system as they are both continuous. Clinically, this has been shown in cases where tenotomy has been performed on the ˝ exor carpi ulnaris muscle in patients with cerebral palsy to reverse the ˝ exion limitation and ulnar deviation of the wrist. ° e isolated tenotomy of this muscle does not reverse the “spastic” position of the wrist since, as suggested by Huijing’s studies (de Bruin et al. 2011), the neurovascular tract or the tertiary perimysium is particularly dense in these patients and would be responsible for lateral force transmission causing the ˝ exion position of the wrist to not be reversed despite the tenotomy. It is necessary, during the surgical process, for the neurosurgeon to perform a “surgical cleaning” (dissection) of the tertiary perimysium to restore the functionality of the wrist in these patients (de Bruin et al. 2014).

Physiopathology of the nerve and glial response ° e nerves and neurons are a functional unit. ° ey are both subjected to tensile or stretching load in many scenarios, including growth and development, normal movement of the joints in the mature nervous system, nerve damage, orthopedic surgery, etc. Excessive loads (compression and shearing) or repetitive strain injury (RSI) can trigger entrapment neuropathies such as carpal tunnel syndrome, radiculopathy, and myelopathy (Bueno & Shah 2008). Traumatic nerve damage can stimulate production of proin˝ ammatory mediators (interleukins) by the Schwann cells (cells that carry out myelination and covering of nerve ÿ bers). ° is is caused by an increase in the permeability of the blood-brain barrier (bloodnerve interface) and in˝ ammation of the endoneurium (within the nerve) due to inÿ ltration of immunological cells (Calvo et al. 2011, Lim et al. 2014). In turn, the overloading of the richly innervated connective structures can activate nociceptors (nociceptive a˛ erents)

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and endoneurium ÿ broblasts causing ÿ brotic processes and neurogenic in˝ ammation that limit nerve elasticity (Topp & Boyd 2006). A˙ er injury of the peripheral nerve microgliosis develops in the ganglia at the dorsal root and in the spinal cord. ° ere is great functional diversity in this microglial response, ranging from migration and cellular proliferation to release of cytokines and immune recruitment (Tˇlymphocytes). ° ese events can trigger or contribute to neuropathic pain and central sensitization by increasing excitatory synaptic transmissions, which are mediated by the participation of the glutamate neurotransmitter and other mechanisms that increase the e˛ ectiveness of nociceptive information input(Calvo et al. 2012).

Allostasis and the fascial system Allostasis refers to the stability organisms acquire through change (Sterling 2004). ° e concept of allostasis has recently gained ground to the extent that the scientiÿ c community has begun to review whether the traditional principle of homeostasis is so completely representative of general biological behavior for it to be used axiomatically as it has been until now, for example, in biomedicine. ° e concept of homeostasis proposes that organisms maintain a constant internal condition based on compensations related to changes in the environment (Schulkin 2003). It suggests that in physiological terms biometric parameters are the reference for balance or stability in organic functioning. Homeostasis allows the values of body constants (temperature, concentration of salt, glucose, oxygen levels) to be maintained within their proper limits. ° e process is reciprocal and generally occurs through microresponses that are not consciously registered. However, physiology clearly shows that constants are only one component of transition and that organisms need to occupy distinct states to the point of sometimes reaching polarity and moving with the greatest ˝ exibility and eˆ ciency among themselves. ° e concept of allostasis proposes viability through change and therefore reformulates one of the basic ideas of the current paradigm regarding biological behavior (Sterling 2004). ° rough the alteration (variation) of normal, optimal conditions the organism returns to

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normality. ° erefore, it can be said that the fascial system, like an organic system, meets the conceptual allostatic criteria and acts according to these principles. ° ere are two fundamental principles within the concept of allostasis on which the behavior of the fascial system rests, and these relate speciÿ cally to body movement. ° ese principles are the prediction and conservation of energy. To this end, the allostatic and interoceptive properties present in fascia combine to interact with the nervous system and create predictive, “cost-e˛ ective” action. In recent years, it has been suggested that the brain “does not react to the world,” but rather that it predicts and formulates hypotheses of body models based on previous interoceptive experiences to later make a probable statistical inference (interpretation), which is evidenced at the moment the incoming sensory information is received. ° ese predictions, also known as e˛ erent copy (Tsay et al. 2015), fulÿ ll the allostatic principle of energy eˆ ciency. In this way, the brain anticipates needs to satisfy demands before they occur. Predictions of movement are based on the available interoceptive information created by global changes that involve the immunological, endocrine, and autonomous systems, which in turn modify the interoceptive sensations that, as mentioned previously, generate new predictive hypotheses. It should be noted that interoceptive information also includes permanent mechanical stimuli coming from the mechanoreceptors that capture the pre-tension state of the fascial system (tensegrity system) (Barrett et al. 2016). Recently Ekman, Kok, and de Lange (2017) have conÿ rmed that the brain uses past experiences to anticipate the future, allowing us to address dangerous situations and make intelligent predictions about what will happen in the immediate future. For example, the visual system can anticipate the trajectory of an object at least twice as fast as the actual trajectory, which gives us the time to anticipate the trajectory and act accordingly. However, it should be noted that the brain does not see the future, but rather uses past experiences to construct future perceptions. ° e visual cortex predicts these events, including when attention is focused elsewhere. ° e fact that the prediction of events is independent of the level of attention suggests that it is an automatic process. In addition to the visual cortex, this

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8 process of anticipating the immediate future involves the hippocampus – a brain area connected to memory and also involved in the anticipation of the future. ° us, it can be surmised that through its own innervation and state of tension the fascial system contributes to the emerging interoceptive information for the formulation of predictive inferences prior to movement and therefore activates bodily movement in advance.

Interoception and the afferent homeostatic pathway Nowadays there is converging scientiÿ c information suggesting a critical review of the neuronal substrate to which the transmission of pain, the representation of the body in the brain, and the phenomena connected to body awareness has classically been assigned. ° ese ÿ ndings propose focusing on a neuronal conduction pathway called the a˛ erent homeostatic pathway, which may be responsible for informing the brain about the physiological condition of the body tissues and creating a subjective image of body sensations (emotional interpretation of body perception) (Craig 2002). ° ese events are represented in an area of the cerebral cortex known as the insular cortex (IC), located deep in the Sylvian ÿ ssure of the brain. Neuroimaging studies show that the IC is greatly involved in processing nociceptive information, (temperature, hypoxia, hyperglycemia, hypo-osmolality, the presence of metabolic waste, and even a˛ ective touch) (Craig 2002). ° is a˛ erent pathway, also known as the interoceptive pathway (Fig. 8.6), is functionally “linked” with the primary centers of autonomic regulation of the nervous system, which are located in the homeostatic region of the brainstem. ° is region is responsible for managing the autonomic regulation of changes in the physiological condition of tissues (Craig 2003). ° e interoceptive information is able to create a subjective image of the state in which the body tissues are found, which, as previously stated, is represented in the IC (Damasio & Carvalho 2013, Craig 2002). Various studies using positron emission tomography (PET) have shown an increase in the activity registers of the IC during isometric muscular contraction, dynamic

exercise, chronic pain, and respiration (Williamson et al. 1999, Banzett et al. 2000). ° is area is separate from those that register exteroceptive phenomena related to touch, which are primarily associated with sensory areas of the cerebral parietal lobe (Craig 2002). ° is means that interoceptive phenomena are not only linked to the processing of visceral information (the role that was classically assigned to them), but they also participate in the multidimensional aspects of body states (feelings) (Kandel et al. 2001, Damasio & Carvalho 2013). ° e IC has a fundamental role in the integration of the representation of the internal state of the body (interoception) and along with the anterior cingulate cortex (ACC) participates in the regulation responses to allostatic tissue loading. ° e ACC is located in the frontal part of the cingulate gyrus and manages the e˛ erent responses depending on the interoceptive load. ° ese two brain areas act analogously to the sensory and motor areas of the parietal cortex in managing perception and movement (sensorimotor integration), but do so in relation to the management of emotions (Craig 2003). Current data indicates that interoception, in addition to participating in the aspects mentioned earlier in this chapter, is linked to mental phenomena like motivation, emotion, and social cognition. Recently, interoception has been associated with psychiatric disorders like depression, addiction, and anorexia (Tsakiris & Critchley 2016).

Interoception, emotion, and behavior Interoceptive information is omnipresent. In addition to in˝ uencing the biological aspects mentioned earlier in this chapter, current studies show that it has the capacity to participate in emotional processing (bodily feelings), conÿ guration of memory, and higher order processes such as cognition, attention, and decisionmaking (Barrett et al. 2016). In other words, interoception can be deÿ ned as the capacity to perceive and integrate body signals in order to generate a˛ ective states that serve as the abstract representation of body awareness (Tsay et al. 2015). ° is means that the emotional experience is signiÿ cantly “fed” by the physiological condition of the tissues. As with movement, the brain creates emotional predictions based on past

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Insular cortex Amygdala Hypothalamus Cingulate and orbitofrontal cortices

Posterior ventromedial thalamus

D

Parabrachial nucleus (PBN) Periaqueductal gray (PAG) Nucleus of the solitary tract (NST)

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Figure 8.6 The parallel ascending pathways for small-diameter afferent activity that originate in lamina I and the nucleus of the solitary tract. A Small-diameter (Aδ and C) primary afferent fibers (which include nociceptors, thermoreceptors, osmoreceptors and metaboreceptors) report the physiological status of the various tissues of the body. B Lateral spinothalamic tract. These fibers terminate monosynaptically on projection neurons in the most superficial layer of the dorsal horn (lamina I). C Brain stem homeostatic control centers. In the brain stem, the neurons in lamina I and those from the viscera (vagus nerve), are projected exclusively in recognized homeostatic integration sites – the parabrachial nucleus (PBN), the periaqueductal gray (PAG), and the nucleus of the solitary tract (NST). D Posterior ventromedial thalamus. Spinothalamic projection to a specific thalamocortical relay nucleus in turn projects to a discrete portion of dorsal posterior insular cortex or interoceptive cortex. The insula is a cortical “island” buried within the lateral sulcus that has intimate connections with amygdala, hypothalamus, cingulate, and orbitofrontal cortices. Together, these pathways through spinothalamic projection provide a direct cortical image of all homeostatic afferent activity. Interoceptive representation, subjective sensation, emotional awareness, social interactions, intuition, emotional processing, emotional affect, and movement awareness are all expressions of the interoceptive role

Brainstem homeostatic centers

C

Monosynaptic connection in the superficial layer of the dorsal horn

B Lateral spinothalamic tract Lamina I

Nociceptors Thermoreceptors Osmoreceptors Metaboreceptors

A C fiber

Aδ fiber

Small diameter (Aδ and C) primary afferent fibers

experiences and selects “the closest one” to those that are “known.” Once an event is selected, the allostatic response is adapted to ÿ t the emotional situation that must be handled. In the event that the prediction is far from the level of demand of the incoming

sensory-emotional event, the allostatic “costs” will be greater (Barrett et al. 2016). ° e systemic responses (endocrine, immunological, etc.) resulting from these “costs,” and also from

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8 triggering changes in the interoceptive body condition (state of being), create predictive guidelines for the body that serve as a reference for the conÿ guration of actions such as movement. ° us, the consequences of incoherence between the predictive emotional state of the body (high allostatic load) and a sensory input corresponding to a movement that is, in theory, low demand will create an unnecessary or exaggerated pain process (meaning that movement could cause tissue damage) (Fig. 8.7).

Interoception and central sensitization ° ere is increasing evidence that chronic pain conditions may be related to an associated central pathology, which involves both cortical reorganization and also incongruity between expected and real sensorimotor feedback (inference). ° e representation of the body in the brain is a multidimensional and multimodal process that at a minimum involves integration of the processing of interoceptive and exteroceptive information. In chronic or persistent pain disorders like complex regional pain syndrome (CRPS), phantom limb pain, chronic low back pain (CLBP), and ÿ bromyalgia there is evidence of distortion of the construction of the physical self (Tsay et al. 2015). In this construction the representation of the body in the brain seems to be substantial. Environmental stressors (work, home, neighborhood)

In terms of the processing of interoceptive information, recent studies have begun to explore the value of interoceptive awareness in neuropathic-type persistent pain disorders. It has been shown that interoceptive awareness (discrimination of perceptible changes in physiological sensations) can modify exteroceptive representation; likewise, it is known that telereceptive perception, more speciÿ cally vision, can a˛ ect body autoperception phenomena (rubber hand illusion) (Ehrsson et al. 2004). Patients with chronic pain usually have low interoceptive awareness (body awareness), which seems to coincide with autonomic deregulation (Tsay et al. 2015). ° e neurobiological mechanisms that underlie central sensitivity can be varied and occupy a large spectrum of possibilities ranging from changes in neuronal excitability in second-order neurons in the posterior horn of the spinal cord to a decrease in the activity of descending pain modulation processes. It has been shown that postinjury patients present autonomic dysregulation of the centers that manage the mechanisms of descending pain modulation (homeostatic region). ° is seems to be related to negative post-traumatic emotional states (Cui et al. 2012). In one study where positron emission tomography (PET) was used in patients with ÿ bromyalgia, it was found that the ACC, which appears to have a strong in˝ uence on descending pain modulation activity, showed decreased Trauma, abuse

Major life events

Figure 8.7 The allostatic load process

Perceived stress (threat or no threat, helplessness, vigilance)

Individual differences (genes, development, experience)

Environmental stressors (work, home, neighborhood)

Physiological responses Adaptation

Allostasis

Allostatic load

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activity, leading to the conclusion that the central sensitization features that characterize these patients do, at least in part, inhibit this cerebral area (Jensen et al. 2009). Epidemiological, transverse, and prospective studies suggest that insomnia, chronic pain, and depression frequently occur concomitantly, and their conditions mutually interact (Finan & Smith 2013). Depression can be deÿ ned as a manifestation of a negative view of the relationship between the self and the world. Similarly, an important aspect of the construction of the self is body awareness. Body awareness has been deÿ ned as the perception, knowledge, and evaluation of one’s own body, as well as other organisms. ° e act of thinking about oneself, i.e., creating metacognitive processes about the self, appears to a˛ ect an individual’s selfesteem and also appears to play a crucial role in maintaining emotional and physical balance. Awareness of the inner state contributes to managing allostatic changes and is helpful in the treatment of depressive and chronic pain disorders (Paulus & Murray 2010).

Conclusion From a structural and functional point of view, the integration of the fascial and the neuroconnective systems forces us to analyze them as interdependent entities. ° e transmission of lateral force through the

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neurovascular tract during body movement or in a sustained posture suggests that tensional overload of the myofascial system is found in conditions that generate traumatic overload (by transmission of force or compartmental entrapment) in nerve structures and trigger physiopathological processes in these structures. ° is bodily state may simultaneously create mechanosensitivity, neurogenic in˝ ammation and neuropathic pain, neuroprotective responses (increase in muscle activity to protect the nerve from stress and neuromodulatory responses in the nerve tissue itself), and impaired connective matrix quality through the response of the ÿ broblasts carrying the load which contributes to the alteration of their mechanical behavior. Fascial tissue, as a primordial source of interoceptive information, has the physiological relevance to condition aspects linked to the body’s perceptive subjectivity (emotion or pain). ° e allostatic load established in the fascial system can contribute to the development of central sensitivity and persistent pain, giving rise to signiÿ cant impairment of motor control, both in its arrangement and execution. Taking into account the importance of the allostatic load from a therapeutic perspective could signiÿ cantly reshape the approach to patients who present with these clinical features.

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REFERENCES

Abdo H, Calvo-Enrique L, Lopez JM, Song J, Zhang MD, Usoskin D, El Manira A, Adameyko I, Hjerling-Leffler J, Ernfors P (2019) Specialized cutaneous Schwann cells initiate pain sensation. Science 365(6454):695–699. Banzett RB, Mulnier HE, Murphy K, Rosen SD, Wise RJ, Adams L (2000) Breathlessness in humans activates insular cortex. Brain Imaging 11(10):2117–2120. Baron R, Hans G, Dickenson AH (2013) Peripheral input and its importance for central sensitization. Ann Neurol 74(5):630–636. Barral JP, Croibier A (2009) Manipulaciones de los nervios periféricos. Barcelona: Elsevier Masson. Barrett LF, Quigley KS, Hamilton P (2016) An active inference theory of allostasis and interoception in depression. Phil Trans R Soc B 371:20160011; https://doi.org/10.1098/ rstb.2016.0011. Bove G (2008) Epi-perineurial anatomy, innervation, and axonal nociceptive mechanisms. JˇBodyw Mov ° er 12(3):185–190. Boyling JD, Jull GA (Eds.) (2005) Grieve’s Modern Manual ° erapy: ° e Vertebral Column. 3rd ed. Churchill Livingstone, pp. 3–5. Bueno FR, Shah SB (2008) Implications of tensile loading for the tissue engineering of nerves. Tissue Eng Part B Rev 14(3):219–233. Butler D (2002) Movilización del sistema nervioso. Barcelona: Paidotribo. Butler DS (2000) ° e Sensitive Nervous System. Adelaide Noigroup Publications, pp. 103–104; 380; 405–410. Calvo M, Dawes JM, Bennett DL (2012) ° e role of the immune system in the generation of neuropathic pain. Lancet Neurol 11(7):629–642. Chou R, Qaseem A, Owens DK, Shekelle P, Clinical Guidelines Committee of the American College of Physicians (2011) Diagnostic imaging for low back pain: Advice for high-value health care from the American College of Physicians. Ann Intern Med 154(3):181–189.ˇ

Corey S, Vizzard MA, Badger GJ, Langevin HM (2011) Sensory innervation of the nonspecialized connective tissues in the low back of the rat. Cells Tissues Organs 194(6):521–530.

Fernández-de-las-Peñas C, Dommerholt J (2014) Myofascial trigger points: peripheral or central phenomenon? Curr Rheumatol Rep 16(1):395.

Craig A (2002) How do you feel? Interoception: ° e sense of the physiological condition of the body. Nat Rev Neurosci 3(8):655–666.

Finan PH, Smith MT (2003) ° e comorbidity of insomnia, chronic pain, and depression: Dopamine as a putative mechanism. Sleep Med Rev 17(3):173–183.

Craig AD (2003) Interoception: ° e sense of the physiological condition of the body. Curr Opin Neurobiol 13:500–505. Cui Y, Xu J, Ruping Dai R, He L (2012) ° e interface between inhibition of descending noradrenergic pain control pathways and negative a˛ ects in post-traumatic pain patients. Ups J Med Sci 117(3):293–299. Damasio A, Carvalho GB (2013) ° e nature of feelings: Evolutionary and neurobiological origins. Nat Rev Neurosci 14(2):143–152. Davis DS, Anderson IB, Carson MG, Elkins CL, Stuckey LB (2008) Upper limb neural tension and seated slump tests: ° e false positive rate among healthy young adults without cervical or lumbar symptoms. J Man Manip ° er 16(3):136–141. de Bruin M, Smeulders MJ, Kreulen M, Huijing PA, Jaspers RT (2014) Intramuscular connective tissue di˛ erences in spastic and control muscle: A mechanical and histological study. PLOS ONE 9(6):e101038.

Fitzcharles MA, Cohen SP, Clauw DJ, Littlejohn G, Usui C, Häuser W (2021) Nociplastic pain: Towards an understanding of prevalent pain conditions. Lancet 397(10289):2098–2110. Gao Y, Weng C, Wang X (2013) Changes in nerve microcirculation following peripheral nerve compression. Neural Regen Res 8(11): 1041–1047. Gellhorn AC, Katz JN, Suri P (2013) Osteoarthritis of the spine: ° e facet joints. Nat Rev Rheumatol 9(4):216–224. Hu J, Chiang LY, Koch M, Lewin GR (2010) Evidence for a protein tether involved in somatic touch. Gr Embo J 29(4):855–867. Jensen KB, Kosek E, Petzke F, Carville S, Fransson P, Marcus H, Williams SCR, Choy E, Giesecke T, Mainguy Y, Gracely G, Ingvar M (2009) Evidence of dysfunctional pain inhibition in ÿ bromyalgia re˝ ected in rACC during provoked pain. Pain 144(1–2):95–100.

Ehrsson HH, Spence C, Passingham RE (2004) ° at’s my hand! Activity in premotor cortex re˝ ects feeling of ownership of a limb. Science 305(5685):875–877.

Johnson EO, Vekris MD, Zoubos AB, Soucacos PN (2006) Neuroanatomy of the brachial plexus: ° e missing link in the continuity between the central and peripheral nervous systems. Microsurgery 26(4):218–229.

Ekman M, Kok P, de Lange F (2017) Timecompressed preplay of anticipated events in human primary visual cortex. Nat Commun 8:15276.

Kandel ER, Schwartz JH, Jessell TM (2001) Principios de Neurociencia. 4th ed. Madrid: McGraw Hill Interamericana de España, pp. 412–417; 430–431.

Fede C, Porzionato A, Petrelli L, Fan CH, Pirri C, Biz C, De Caro R, Stecco C (2020) Fascia and so˙ tissues innervation in the human hip and their possible role in post-surgical pain. J Orthop Res 38(7):1646–1654.

Katiyar KS, Winter CC, Struzyna LA, Harris JP, Cullen DK (2017) Mechanical elongation of astrocyte processes to create living sca˛ olds for nervous system regeneration. J Tissue Eng Regen Med. 11(10):2737–2751.

Fede C, Petrelli L, Guidolin D, Porzionato A, Pirri C, Fan C, De Caro R, Stecco C (2021) Evidence of a new hidden neural network into deep fasciae. Sci Rep 11:12623.

Kimmell KT, Dayoub H, Shakir H, Sinco˛ EH (2011) Spinal dural attachments to the vertebral column: An anatomic report and review of the literature. Surg Neurol Int 2:97.

186

Pilat_Myofascial Induction.indb 186

03/12/21 4:08 PM

REFERENCES

Langevin HM, Stevens-Tuttle D, Fox JR, Badger GJ, Bou˛ ard NA, Krag MH, Wu J, Henry SM (2009) Ultrasound evidence of altered lumbar connective tissue structure in human subjects with chronic low back pain. BMC Musculoskelet Disord 10:151. Langevin HM, Fox JR, Koptiuch C, Badger GJ, Greenan-Naumann AC, Bou˛ ard NA, Konofagou EE, Lee W-N, Triano JL, Henry SM (2011) Reduced thoracolumbar fascia shear strain in human chronic low back pain. BMC Musculoskelet Disord 12:203. Lim TK, Shi XQ, Martin HC, Huang H, Luheshi G, Rivest S, Zhang J (2014) Blood-nerve barrier dysfunction contributes to the generation of neuropathic pain and allows targeting of injured nerves for pain relief. Pain 155(5):954–967. Lluch Girbés E, Meeus M, Baert I, Nijs J (2015) Balancing “hands-on” with “hands-o˛ ” physical therapy interventions for the treatment of central sensitization pain in osteoarthritis. Man ° er 20(2):349–352. Louw A, Diener I, Butler DS, Puentedura EJ (2011) ° e e˛ ect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil 92(12):2041–2056. Maas H (2009) Mechanical interactions between skeletal muscles. In: Shinohara M (Ed.) Advances in Neuromuscular Physiology of Motor Skills and Muscle Fatigue. Kerala, India: Research Signpost, pp. 285–302. Maas H, Jaspers RT, Baan GC, Huijing PA (2003) Myofascial force transmission between a single muscle head and adjacent tissues: Length e˛ ects of head III of rat EDL. J Appl Physiol 95(5):2004–2013. Maas H, Lehti TM, Tiihonen V, Komulainen J, Huijing PA (2005) Controlled intermittent shortening contractions of a muscle–tendon complex: Muscle ÿ bre damage and e˛ ects on force transmission from a single head of rat EDL. J Muscle Res Cell Motil 26(4–5):259–273. Magerl W, ° alacker E, Vogel S, Schleip R, Klein T, Treede RD, Schilder A (2021) Tenderness of the skin a˙ er chemical stimulation of underlying temporal and thoracolumbar fasciae reveals

somatosensory crosstalk between superÿ cial and deep tissues. Life (Basel) 11(5):370.

and treatments: A message to researchers and clinicians. Manual ° erapy 10(3):175–179.

Mense S (2019) Innervation of the thoracolumbar fascia. Eur J Transl Myol 29(3):8297.

Si-Qi W, Zhuo-Ying T, Yang X, Dong-Yuan C (2019) Peripheral sensitization. In: Turker H, Benavides LG, Gallardo GR, del Villar MM (Eds.) Peripheral Nerve Disorders and Treatment. London, UK: IntechOpen. Available: https://www.intechopen.com/books/peripheral-nerve-disorders-and-treatment/peripheral-sensitization [accessed December 2, 2020].

Mense S (2020) 5.03 – Anatomy of nociceptors. In: Fritzsch B (Editor-in-Chief) ° e Senses: A Comprehensive Reference. 2nd ed. Volume 5, pp. 11–32. Elsevier. Available: https://www.science direct.com/science/article/pii/B978012809324 5242077 [accessed August 18, 2021]. Mense S, Gerwin RD (Eds.) (2010) Muscle pain: Understanding the Mechanisms. SpringerVerlag Berlin Heidelberg. Mense S, Hoheisel U (2016) Evidence for the existence of nociceptors in rat thoracolumbar fascia. J Bodyw Mov ° er 20(3):623–628. Mizisin AP, Weerasuriya A (2011) Homeostatic regulation of the endoneurial microenvironment during development, aging and in response to trauma, disease and toxic insult.ˇActa Neuropathol 121(3):291–312. Ochoa JL, Campero M, Serra J, Bostock H (2005) Hyperexcitable polymodal and insensitive nociceptors in painful human neuropathy. Muscle Nerve 32(4):459–472. Paulus M, Murray B (2010) Interoception in anxiety and depression. Brain Struct Funct 214(5–6):451–463. Ramos-Zúñiga R (2014) La neuroética como una nueva perspectiva epistemológica en neurociencias. Rev Neurol 58(4):145–146. Schleip R (2003) Fascial plasticity – a new neurobiological explanation: Part 1. J Bodyw Mov ° er 7:11–19. Schmidt R, Willis W (Eds.) (2007) Secondary hyperalgesia. In: Encyclopedia of Pain. Berlin, Heidelberg: Springer. Available: https://doi. org/10.1007/978-3-540-29805-2_3903 [accessed August 18, 2021]. Schulkin J (2003) Allostasis: A neural behavioral perspective. Horm Behav 43(1):21–27; discussion 28–30. Shacklock M (2005) Editorial: Improving application of neurodynamic (neural tension) testing

8

Stecco C, Gagey O, Belloni A, Pozzuoli A, Porzionato A, Macchi V, Aldegheri R, De Caro R, Delmas V (2007) Anatomy of the deep fascia of the upper limb. Second part: Study of innervation. Morphologie 91(292):38–43. Sterling P (2004) Principles of allostasis: Optimal design, predictive regulation, pathophysiology and rational therapeutics. In: Schulkin J (Ed.) Allostasis, Homeostasis, and the Costs of Adaptation. Cambridge: Cambridge University Press, p. 17. Tesarz J, Hoheisel U, Wiedenhofer B, Mense S (2011) Sensory innervation of the thoraco-lumbar fascia in rats and humans Neuroscience 194:302–308. Topp KS, Boyd BS (2006) Structure and biomechanics of peripheral nerves: Nerve responses to physical stresses and implications for physical therapist practice. Phys ° er 86(1):92–109. Tos P, Crosio A, Pugliese P, Adani R, Toia F, Artiaco S (2015) Painful scar neuropathy: Principles of diagnosis and treatment. Plast Aesthet Res 2:156–164. Treede RD (2016) Gain control mechanisms in the nociceptive system. Pain 157(6):1199–1204. Tsakiris M, Critchley H (2016) Interoception beyond homeostasis: A˛ ect, cognition and mental health. Phil Trans R Soc Lond B Biol Sci 371(1708). Tsay A Allen TJ, Proske U, Giummarra MJ (2015) Sensing the body in chronic pain: A review of psychophysical studies implicating altered body representation. Neurosci Biobehav Rev 52:221–232. Wang Y, Filius A, Zhao C, Passe SM, ° oreson AR, Kai-Nan An MS, Amadio PC (2014) Altered median nerve deformation and transverse displacement during wrist movement in patients

187

Pilat_Myofascial Induction.indb 187

03/12/21 4:08 PM

8

REFERENCES

with carpal tunnel syndrome. Acad Radiol 21(4):472–480. Wieland HA, Michaelis M, Kirschbaum BJ, Rudolphi KA (2005) Osteoarthritis an Untreatable disease? Nat Rev Drug Discov 4(7): 543.

Williamson W, McColl R, Mathews D, Ginsburg M, Mitchell JH (1999) Activation of the insular cortex is a˛ ected by the intensity of exercise. JˇAppl Physiol (1985) 87(3):12131219.

cal and immunohistochemical review of the innervation of the human spine and joints with application to an improved understanding of back pain. Childs Nerv Syst 32(2):243–251.

Youssef P, Loukas M, Chapman JR, Oskouian RJ, Tubbs RS (2016) Comprehensive anatomi-

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Fascial trauma and dysfunction With a contribution from Germán Digerolamo

9

KEY POINTS •

Trauma to the fascial system and the adaptive systemic response

•

Combined response of the fascial system in repairing, remodeling, and fibrosis

•

Mechanochemical coupling in the pathophysiology of ECM

•

The fascial system and immunomodulation

Introduction ° e challenge in the study of living matter is the deÿ nition of a theoretical framework that allows for the understanding of highly organized biological organisms and of those complex structures that are linked to the acquisition and conversion not only of metabolic energy but also of information (see Chapters 4, 5, and 6). We generally separate the social sciences from the natural sciences, chemistry from physics, and biology from psychology. However, it is precisely the con˝ uence of the di˛ erent disciplines that marks contemporary scientiÿ c development. ° e new tools available to physics and engineering (e.g., nanoscale measurement and analysis of motion) have allowed us to perfect tasks that formerly belonged exclusively to biology. ° e discovery of the double helix of DNA, the structural coherence of which encodes the morphogenetic and informational potential of the living organism, opened the way to modern biology. It also marked the beginning of the close collaboration between biology and physics. ° e relatively simple interactions between di˛ erent nucleotide pairs reveal an almost inÿ nite ability to store information in the DNA heteropolymer. It is the intimate connection between interaction and information that constitutes the tissue of living matter. Biological complexity is based on the speciÿ c interactions between molecules. ° ese interactions create complex networks that are kept in balance because of their interconnection. ° ese networks control and regulate the

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exchange of signals governing intracellular functions and multicellular behavior throughout the development of the organism (see Chapter 4). Alterations in the transmission and interpretation of information create diˆ culties in decision making. ° ey can go wrong or be slowed down, creating, in either situation or in a combination of the two, inappropriate decision making. Here this refers to the processing of information by the nervous system and the guidelines it issues. ° e usual imaging tests (X-ray, MRI, CT, or US imaging) do not always provide the complete information needed to determine the diagnosis in the most common musculoskeletal disorders. Tissue changes may be hidden for these tests; however, they may be detected by histological analysis of the tissues involved. For example, the results could provide valuable information on the density of the nociceptors involved in persistent pain. ° is process can complement the functional assessment and open new treatment perspectives. Analyses of the consequences of locomotor system trauma focused on the macroscale of body construction are well-known and supported by extensive research. ° is chapter aims to analyze the processes that are present mainly at the microscale and to associate them with the most common fascial dysfunctions. Trauma to the fascial system is common. We o˙ en injure ourselves without realizing it. With the exception of direct trauma (injury, surgical procedures) and its outcome, the establishing of dysfunction or disease

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9 2

1

Hypomobility Immobilization

Scarring

Immunodepression

Acidification process

3

Fascial trauma Matrix dysfunction

Aging

Kinesiophobia

Figure 9.1 Causes of the dysfunctional process 1 Fascial trauma triggers the dysfunction of the extracellular matrix (ECM). 2 ECM dysfunction diminishes essential immune functions such as migration of T lymphocytes within the inflamed tissues as well as their proliferation, differentiation, and polarization. This situation can affect the pH of the tissue and its healing (pathological scarring). 3 Fascial trauma triggers tissue rigidity (hypomobility), which within the framework of a maladaptive response leads to kinesiophobia. This installed dysfunctional circuitry affects the quality of the matrix and accelerates the aging process.

is a process – a slow, progressive, and cumulative process. Alterations of the usual movement patterns can be established because of various factors, the most signiÿ cant of which are illustrated in Figure 9.1. Contemporary body movement analysis focuses primarily on complex processes and mechanisms that converge within the connective tissue matrix. Qualitative changes in the matrix form a barrier that distorts the initial mechanical impulse (contraction of the musculoskeletal ÿ bers) and contaminates its transmission. ° e ˝ ow of information is distorted (decreased or interrupted) by changes in the quality of its components (Fig. 9.2). ° e process also creates erroneous

information (feedback) that is directed to the nervous system (Oschmann 1997). Body awareness can be adaptive or maladaptive. ° e objective of assessment is to identify maladaptive dysfunctions caused by di˛ erent types of trauma that are in˝ uencing the fascial system. ° e processes involved in the thickening and “densiÿ cation” of the loose connective tissues, and their extracellular matrix, appear to correspond to the loss (or reduction) of sliding and gliding potential between dense fascial layers and adjacent structures (Fernández-de-las-Peñas & Pilat 2012, Pilat 2014). ° e function of many so˙ tissues involves their ability to slide, glide, and generally to be able to accommodate to the movements of adjacent structures (Chaitow 2014). ° e signiÿ cance of the ability of the tissue to slide and/or glide has not been studied in depth, but some researchers have reported interesting conclusions. Stecco et al. (2013b) state: Ultrasound indicates that the main alteration in the deep fasciae is increased loose connective tissue between the fibrous sub-layers. It is for this reason that, in indicating fascial alteration, we do not use the term “fibrosis”, which indicates an increase in collagen fiber bundles. We prefer the term “densification”, which suggests a variation in the viscosity of the fascia. Before we focus on the main subject of this chapter – fascial trauma and dysfunction – we must ÿ rst understand how the fascial system acts against pathomechanical processes. We will see that fascia has many ways of adapting to adverse situations. ° ese adaptations are not necessarily biomechanical or neurological responses, which o˙ en prevail as the rationale of existing schools of thought, but may also be immunological in nature. It should be noted that the immune response underlies any adaptive biological process since it is the defensive system par excellence of the human organism. To be more precise, the fascial system responds systemically and, although dysfunction and pain are the most visible manifestations of pathomechanics, new advances in the study of cellular mechanobiology and the great interest in ECM in recent years have revealed that the consequences can be much more profound and surprisingly extensive.

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Fascial trauma and dysfunction

Adaptive response and injury Allostasis (see Chapter 8) of the fascial system is determined by the eˆ cient administration of mechanical forces (mechanotransduction), an adequate neuroimmunological response (in˝ ammation), and the appropriate activity of the nervous system (perception and/or movement). ° e integrated operation of these mechanisms determines the functional remodeling of the connective tissue and its capacity to adapt to the di˛ erent ranges of mechanochemical demand. ° e demand on the fascial system can be variable and can be placed in extreme ranges (e.g., sustained posture over time), which can pose a signiÿ cant risk of injury. It may also happen that the adaptive responses of the system may be insuˆ cient (functional instability), triggering the same pathological situation. With either of the above options, the fascial system will activate adaptive mechanisms (allostatic loading) in the short term (dynamic remodeling of the ÿ broblasts) or long term (changes of the ECM). If this response is temporary (as in an emerging attitude, for example), there will be no permanent changes; on the other hand, if the system needs to adapt to an excessive or prolonged stimulus, there is the potential for an allostatic load to be established and permanent (see Chapter 8). ° e allostatic response will be organized in a systemic way (see Chapters 2 and 6), i.e., any of the actions mentioned above (mechanotransduction, immune or neurological responses) or their interactions will be activated to respond to the request. ° e viability (positive adaptability) of the fascial system will depend on developed or preserved plasticity (wide range of adaptive responses). It refers to individuals who possess or acquire sustained body behavior based on consciousness, balanced kinetic energy, and maintenance of a healthy diet and lifestyle. However, the response of some of the components (of the allostatic response) may be inappropriate or excessive (negative adaptability), undermining the viability and functionality of the fascial system. ° is may happen in cases where an incorrect self-perception of the problem is established in patients (catastrophizing) or where medication ends up being a paradoxical palliative, i.e., relief of the symptoms triggers an allostatic load and, a˙ er

9

the bioavailability of the medication has concluded, the problem is worse or a new problem arises. (° is conclusion does not mean that the use of drugs should be denied, but rather their indiscriminate use to alleviate or eliminate the symptoms without searching for the cause). ° e main objective of induction of the fascial system is to restore coherence and e˛ ectiveness to its systemic response, using movement as a meeting point.

Trauma to the fascial system Mechanical loading is one of the fundamental stimuli in the development and viability of tissues (Fig. 9.3). ° e structural conformation and functional characteristics of connective tissue are established to a great extent by the load patterns it receives. ° e cells of multicellular organisms are exposed to mechanical forces that contribute to embryonic development, tissue homeostasis, and pathogenesis. ° e concept that mechanical forces drive embryonic development has been discussed in previous chapters (see Chapter 4), where the role of forces in movement, cell di˝ erentiation, and cell migration associated with embryogenesis has been described. Similarly, Chapter 6 contains an analysis of the effects of mechanical forces on mature tissue cells and how they a˛ ect the behavior of the cells. It is important to note that the cellular processes that occur in the embryonic stage, for example cell migration, underlie the dynamics of mature tissues and are of vital importance to their allostatic condition and functioning. According to Carver et al. (2017), understanding the mechanisms of mechanical signal transmission from the microenvironment will identify new therapeutic targets in relation to ÿ brosis (a process linked to fascial tissue dysfunction) and other pathological conditions (autoimmune diseases). Mechanical forces play particularly important roles in the morphological regulation of di˛ erent forms of connective tissue, including not only bone and cartilage but also the interstitial tissues of most organs (including viscera). In vivo studies conducted by Carver and Goldsmith (2013) have correlated changes in mechanical stress with modulation in extracellular matrix

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9 Modified collagen and elastin fibers Adipocyte

Fibroblast Hyaluronic acid

Type I collagen

Epithelial cell (apical–basal polarity)

Fibronectin

Myoepithelial cell (in contact with basement membrane)

A

TENSIONAL HOMEOSTASIS

Nonenzymatic cross-linking

Collagen cross-linking enzymes

Inflammatory cell

MMP Contracting myofibroblast

Contracting myofibroblast

Cell proliferation

Proteoglycan and glucosaminoglycan chains

Stiff cross-linked collagen fibers

Senescent fibroblast

Growth factors

Fibrin blood clot Protomyofibroblast Myofibroblast

Solid stress

Activated inflammatory cell

D

RECIPROCAL ECM RESISTANCE

Epithelial to mesenchymal transition

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Fascial trauma and dysfunction

Weak basement membrane

Stiff cross-linked collagen fibers

Exer

B

Migrating and dividing cells

ted f orce

9

Figure 9.2 The matrix and the application of mechanical forces. A In tensional homeostasis mechanotransduction processes (the immune and neurological responses) are in accordance with the mechanical request. B The proper alignment and quality of the collagen optimizes the effectiveness of ECM resistance. C In dynamic resistance of the ECM dynamic remodeling of fibroblasts (contraction and proliferation) is the first adaptive response followed by phenotypic changes (protomyofibroblasts). D Allostatic load results in permanent contractile activity of the myofibroblasts and excess production of matrix components (densification)

ECM RESISTANCE

Contracting myofibroblast

Stiff cross-linked collagen fibers

Solid stress

C

RECIPROCAL ECM RESISTANCE

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9 Adipocyte

Fibroblast Hyaluronic acid

Type I collagen

Epithelial cell (apical–basal polarity)

Fibronectin

Myoepithelial cell (in contact with basement membrane)

Nonenzymatic cross-linking

Collagen cross-linking enzymes

A

NORMAL

Inflammatory cell Loss of apical–basal polarity

Cell proliferation

MMP Proteoglycan and glucosaminoglycan chains Senescent fibroblast

Growth factors

Fibrin blood clot

Myofibroblast

Activated inflammatory cell Epithelial to mesenchymal transition

D

TUMOR

Metastatic cell migration

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Fascial trauma and dysfunction

Loss of cell–cell adhesion

Thinner basement membrane

9

Figure 9.3 The normal structure and function of the ECM and changes in its behavior. A In its normal state the ECM has a wide margin of mechanochemical adaptability (viability). B Aging: This shows the ECM with impaired immune response, dehydrated, and with a deficient mechanochemical adaptability. C In the wound or fibrosis process there is an exaggerated cicatricial response due to the presence of a neuroinflammatory substance (substance P), proteolytic enzymes (matrix metalloproteinases, MMPs), and growth factors (TGF° 1). D The matrix environment of a metastatic tumor. The ECM is organized to create a pore through which cancer cells can migrate

B

AGING

Loss of apical–basal polarity

Cell migration

C

WOUNDED OR FIBROTIC

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9 production and have indicated that increased mechanical strength contributes to improved expression and deposition of extracellular matrix components, which are the mechanisms responsible for ÿ brosis.

Remodeling versus fibrosis The magnitude of mechanical stress is in a delicate state between functional tissue remodeling and the development of chronic tendon disease. (Snedeker & Foolen 2017) Fascia, when subjected to deformation, has the extraordinary ability to drastically change from smooth and elastic movement to maximum resistance according to the intensity of the impulse received. ° is ability is crucial for biological function: When tissue is elastic, cells can move and properly perform their duties. At the same time, the tissue protecting the cells must not break and therefore becomes more rigid when the deformation is excessive (Burla et al. 2019). ° e balance point between both behaviors is very fragile and can deÿ ne the tendency toward health or disease. One of the most studied connective tissue structures in relation to its morphology and function is the tendon. Although there are signiÿ cant di˛ erences between connective tissues (see Chapters 3 and 5), the mechanisms of remodeling and repair are similar. ° is means that a thorough knowledge of the cellular and/or subcellular mechanisms that make up the physiology and pathophysiology of the tendon helps to understand the functioning of fascial tissue. Tendons play a central role in body movement (transfer of myotendinous forces) and allow e˛ ective transmission of musculoskeletal force, for example in locomotion. During the most extreme mechanical demands on or for human beings, eˆ cient tendons are able to support up to eight times the body weight and store up to 40 percent of the deformation energy during walking (Snedeker & Foolen 2017). ° e capacity of the tendon to support these loads originates in its organization and structural composition. Tendon cells (tenocytes) can strengthen tissue when the load demand increases. However, sudden and/or repeated exposure to high mechanical stresses

can lead to risk of damage. ° is tissue overload can be understood in terms of repetitive strain injury (RSI). An RSI is deÿ ned as an injury to the neuromusculoskeletal system (fascial system) resulting from the effects of tissue fatigue over a period of time greater than the adaptive capacities that a speciÿ c structure can withstand (Roos & Marshall 2014). RSI occurs when several repetitive forces are applied in a concentrated manner to a given tissue (referred to as overuse), each of which is less than the acute lesion threshold of the structure. ° e onset is gradual over time, and RSIs do not have a speciÿ c triggering incident but progress with continued activity, particularly if between loading episodes there is not enough time for adaptation or recovery. In a “destabilized” fascial system and/or with an allostatic load, the loads transferred during movement may be concentrated on a given area or tissue, resulting in excessive tissue demand and predisposing to an RSI. Permanent tissue damage (microruptures) can directly activate the adaptive immune response (see below). In˝ ammatory and immunological mediators (cytokines, chemokines, and free radicals) are activated in an attempt to remove the inciting factor or “strengthen” the tissue to increase its resilience. ° is activates inactive resident ÿ broblasts to become myoÿ broblasts (see Chapter 5) which orchestrate angiogenesis and excessive production of ECM components, such as collagen, causing tissue densiÿ cation (increased collagen deposition) or ÿ brosis. ° e mechanism described above represents a common form of fascial trauma. As outlined in Chapter 6, lateral force transmission mediated by the fascia and in particular the neurofascial tissue can play an important part, as do the tendons, in the transmission of the forces that shape body movement through the epimysium and the neurovascular tract respectively. ° is means that these structures can receive an excessive accumulation of forces when the system is in dysfunction leading to an RSI and the development of cumulative ÿ brotic processes. Permanent injury to fascial tissue has been demonstrated in ultrasound imaging by Langevin et al. (2011). Using ultrasound imaging in human subjects with

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chronic low back pain of more than 12 months’ duration Langevin et al. (2011) found an increase in the thickness and echogenicity of the perimuscular connective tissues that form the thoracolumbar fascia in the lower back. ° e potentially signiÿ cant consequences of the injury may be ÿ brosis and adhesions (see below) causing the loss of independence and movement of adjacent layers of connective tissue that could further restrict body movements. On the other hand, and from a clinical point of view, these authors suggest that altered connective tissue (with the above characteristics) may be a predisposing factor for low back pain or a consequence of injury and/or changes in movement patterns that occur as a result of painful chronic diseases. ° ese data may be related to studies by Stecco et al. (2013a) regarding the importance of the presence of hyaluronic acid (HA) between the fascial layers to the facilitation of nontraumatic gliding between them. As highlighted in the histology chapter (see Chapter 5), the proper balance of hyaluronan (HA) contributes to the homeostasis of connective tissue, suppressing cell proliferation, migration, angiogenesis, in˝ ammation, and immunogenicity. HA is ubiquitous in ECM, particularly in the loose connective tissue surrounding the muscle bundles. It is also present in the endomysium that individually surrounds the muscle ÿ bers and in the perivascular and perineural (neurofascial) connective tissue. As it is the reservoir of water and lubricant at sites with the need for gliding, such as joints (synovial ˝ uid), tendons, pleura, and pericardium, HA is important to healing, ovulation, fertilization, signal transduction, and tumor physiology (Pratt 2021). Stecco et al. (2013a) suggest that HA is found in considerable amounts at the interface between the deep fascia and the surface of the muscle. ° e presence of HA provides a lubricant for the sliding of the surface fascia over the muscular epimysium and tendons, as well as favoring the response to compressive forces due to the hydraulic phenomenon (Willard et al. 2012). In fascial dysfunction situations HA becomes an adhesive rather than a lubricant which predisposes the distribution of force lines within the fascia to be altered resulting in tissue stress and favoring microrupture.

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Remodeling and repair: A combined fascial process The intrinsic compartment gives the tissue its mechanical strength, and the extrinsic system provides maintenance and repair. (Snedeker & Foolen 2017) ° e remodeling and repair of the fascial tissue (in the tendon) is a complex process. Quality and e˛ ectiveness are subject to the coordinated interaction of the intrinsic compartment (ÿ broblasts and organized collagen) and the extrinsic compartment (microvacuolar system, including vascular and immunological elements). ° e coordination between the intrinsic and extrinsic compartments in the repair function and its “discord” during degenerative processes is not yet fully understood. Collagen structures in the healthy tendon tend to be highly aligned compared to collagen in the superÿ cial fascia (the skin and subdermal level), joint capsules, and other tissues that support more heterogeneous mechanical loads. However, there is a wide range of structural conÿ gurations that a tendon can adopt, in direct conformity to the diverse functional range of the muscle it binds to (Snedeker & Foolen 2017). Tendons that function in large ranges of motion and around multiple axes have anatomical subdivisions that adapt to the state of joint positioning and muscle activation (e.g., deltoid or gastrocnemius). In these structures, there are signiÿ cant lateral slides to allow the joint to “explore” its movements (Snedeker & Foolen 2017) (see Chapter 7). ° e pathophysiology of fascial tissue, as with tendons, results from a con˝ ict of complex interactions between the intrinsic compartment (ÿ broblasts and extracellular matrix production) and the extrinsic compartment (neuroimmunological response and vascularization). Fibroblasts of the intrinsic fascial compartment cope with mechanical disturbances through their structural adaptation (cytoskeleton and nucleus remodeling) (see Chapter 5) and extracellular matrix adaptation until their mechanical environment reaches homeostasis. ° e altered intrinsic regeneration of fascial tissue will predispose to reticulation (pathological bonds)

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9 of collagen resulting in altered viscoelastic properties and increased risk of microtearing. If the extrinsic compartment has an altered e˛ ector nerve response (neuroin˝ ammation) and impaired circulation (blood supply and lymphatic activity) repair or remodeling will not be adequate. As long as there is eˆ cient dynamic integration between the compartments the fascial tissue can be adapted to the demand without modifying its essential properties. If the intrinsic regenerative capacity is limited or if the interactions with the extrinsic components (vascular, nervous, and immune) come into con˝ ict, the processes of deterioration of the quality of the tissue (changes in the type of collagen, e.g., in a tendinosis) will take place and/or a prolonged in˝ ammatory process will be established leading to the development of processes of vascular neoformation (malformation of existing vessels in the tissue that do not improve irrigation) and nervous processes (activation of silent nociceptors). In this way tissue mechanosensitivity and/or pain increase. An example of this is alteration of the tissue properties of the TLF as a source of low back pain.

Collagen remodeling and repair ° e breakdown of collagen from damaged fascial tissue and the initiation of various repair events involve matrix metalloproteinases (MMPs). ° e activity or inhibition of this enzyme (see Chapter 5) can be mechanically mediated. MMP-regulated signaling can govern the modeling and remodeling of the collagen matrix, so these enzymes may be the key to understanding the pathological processes of connective tissue. It should be noted that the mechanical demand may in˝ uence their release. In the tendon, for example, MMP activity is driven both by increased mechanical stimulation (action – overloaded tissue) and by the elimination of MMP (inhibition – unloaded tissue) (Snedeker & Foolen 2017). In addition, it is known that the activity of MMPs is regulated by various cytokines and signaling molecules (the most important are TGF˙ , IL1˙ , and TNF). ° is infers that the neuroimmune system is involved in the remodeling of fascial tissue. It is important to remember that these molecules are part of the neurogenic in˝ ammatory response (see Chapters 5 and 8). ° is

implies an understanding that there is a link between mechanical stimulation and the immune response in the regulation of MMPs; therefore, from a therapeutic point of view, both actions should be considered. Myofascial induction therapy (MIT) can act in parallel on both the mechanical and the immunological components, as we will see below.

The fascial system and immunomodulation ° e fascial system participates in the immune response by signiÿ cantly modulating its behavior based on the biophysical and biochemical properties of the ECM. ° e ECM plays an important role in the behavior of immune cells in in˝ amed tissues. ° e individual components of the ECM and its three-dimensional ultrastructure can signal speciÿ c information to immune cells (T lymphocytes) and modulate essential immune functions, such as migration within in˝ amed tissues and activation, proliferation, di˛ erentiation and polarization of T lymphocytes. Remember that T lymphocytes are part of the immune system and are formed from stem cells in the bone marrow. ° ey are cells that are programmed to recognize, respond to, and remember antigens and contribute to immune defenses. ° e ECM acts as a secondary lymphoid organ. ° rough the basement membrane (thin, highly crisscrossed networks) surrounding the blood vessels and the interstitial matrix (see Chapter 5) that weakly interconnects mesenchymal cells or ÿ broblasts it acts as a barrier to lymphocyte inÿ ltration into in˝ amed tissue. ° is would mean that dysfunction of the fascial system where there is an altered organization of the components of the ECM (intercrossing of collagen ÿ bers), in addition to the deterioration of their molecular properties (alteration of HA), makes it impossible for lymphocytes to e˛ ectively access the harmful foci. ° e ECM in dysfunction forms an impenetrable physical barrier to these cells. Likewise, and inversely, chronically in˝ amed tissues (presence of cytokines) can modify the properties of the ECM, modulating the expression of a wide range of its molecules (see below). ° is can trigger a ÿ brotic

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response (collagen buildup) and modify its mechanical behavior.

immune cell mobility results in a deterioration of immune responses.

° us it is feasible that mechanical impulses may affect the immune or visceral response.

T cell survival (T lymphocytes) deteriorates in very restricted environments, as the forced passage of cells under such conditions results in multiple damage to the plasmatic membrane and nucleus which can culminate in cell death (Moreau et al. 2017).

Immunosenescence Other data that seem to conÿ rm the immunomodulatory e˛ ects of the fascial system relate to research on immunoscenescence. Increased sti˛ ness and cross-linking of the senescent ECM leads to progressive immunodeÿ ciency due to an age-related decrease in Tˇcell mobility and eventually Tˇcell death. A key element of this mechanism is the mechanical stress to which the cytoplasm and the cell nucleus are subjected during their passage through the ECM. ° ere are lines of research (Moreau et al. 2017) that highlight the importance of ECM in the immune response. According these authors, age-related changes in the three-dimensional microenvironment in which most immune cells are mobile and operate (act) can affect the immune response. Citing Carbone (2015), they make the following observation: Immunologists have neglected the implications of such changes, partly because most of the studies carried out on immunosenescence, at least until very recently, focused on blood because it is the most accessible source of cells and biological fluid in humans. Although of value, these data, lead to an overestimated qualitative and quantitative importance of this compartment in the understanding of the immune system physiology. The recent discovery of resident memory T cells, or TRM, showed immune surveillance to be largely local and, therefore, not readily accessible through studies on blood. Progressive and irreversible age-related changes can actually provide a unifying framework in the extracellular matrix that explains all the molecular and cellular characteristics of immunosenescence. ° e key point is that for immune cells to be functional they must be free to recirculate, navigate, and rest within the extracellular matrix in tissues and organs. Mobility of immune cells in nonlymphoid tissues (the fascial system) is a necessary element for e˛ ective immunity. A lack of

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It is important to note that the quality of fascial tissue aging will not only be due to the passage of time. As outlined in the introduction, sustained body behavior based on consciousness, balanced kinetic energy, and maintenance of a healthy diet and lifestyle may condition the quality of ECM over the years. ° erefore, immunosenescence should be analyzed in relation to the variables that condition the quality of fascial tissue in the early years.

Neuroimmune response, neurogenic inflammation, and remodeling As outlined in Chapter 8, the in˝ ammatory processes of the peripheral nerves (chronic constrictive lesion) and the states of central sensitization (neuroin˝ ammation) can develop antidromic activity (neuroe˝ ector) of the nociceptors that innervate the fascial tissue (e.g., the TLF) which generates neurogenic in˝ ammation and peripheral sensitization (nociceptive pain). ° is situation, caused by the irritation of nerve tissue, can cause the release of proin˝ ammatory cytokines into the connective tissue, which in turn can activate the MMPs of the matrix and trigger their remodeling (Snedeker & Foolen 2017).

Injuries and scarring ° e cicatricial processes and their resolution depend on various mechanical and/or biochemical factors which, as mentioned in this chapter in relation to fascial trauma, deÿ ne the physiopathological and clinical characteristics of the scars. Scars are extremely common. According to Taberner Ferrera et al. (2005), in a study conducted in Spain, 66ˇpercent of the population reported having a scar or mark somewhere on the body. Surgical scars are

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9 the most frequently reported (45ˇpercent), followed by mechanical scars (44ˇpercent). Only 3ˇpercent of the patients surveyed in this study state that they were recommended some type of treatment for the scar. According to Herranz & Santos Heredero (2012), there are variables that can in˝ uence the scarring process of the patient, such as:

• • • •

Anatomical location. ° ere are areas of the body that completely regenerate (gingivae) and areas of “bad quality” scarring (back and thorax, for example).

biomechanical properties of the superÿ cial fascial system and the e˛ ects are not as superÿ cial as you might think. For example, Wilke and Tenberg (2020) suggest the existence of a direct mechanical relationship between the superÿ cial fascia and the skeletal muscle and add that: “Deep pathologies or altered muscle sti˛ ness could thus have long-term consequences for rather superÿ cial structures and vice versa.”

Scarring: The healing process

Racial di˛ erences. ° ese may condition the quality of ECM over the years. Scarring in black and Asian skin is worse than in Caucasian skin.

Four main stages can be di˛ erentiated in skin healing: hemostasis, in˝ ammation, proliferation, and remodeling (Fig. 9.4).

Age. Scarring is worse in young individuals.

° e healing process of the surface of the skin begins with the lesion, when the bleeding transmits the blood elements to the area of injury (platelets, ÿ brin, ÿ bronectin, glycoprotein), aiming to produce a parallel vasoconstriction. ° e blood platelets come in contact with exposed collagen and other elements of the extracellular matrix. ° is contact induces the release of important growth factors, transforming growth factor beta (TGFβ) and platelet-derived growth factor (PDGF), while the coagulants begin the reconstitution process. Coagulation belongs to the ÿ rst reconstitution stage of the injured tissue: hemostasis. ° is process results in a deposit of ÿ brin and other similar substances, which represents a provisional matrix of successive healing events.

Wound size and local contamination. ° e ÿ nal size of the lesion is dependent on these factors.

Furthermore, the orientation of the scar in regard to the axis of the body or of the limb and the tension lines of the skin (see the description of Langer’s Lines in Chapter 3) represent an important factor in the quality of the scarring and healing process (see below). When an injury (with wound formation) occurs the processes of cutaneous repair are triggered to maintain internal homeostasis through the formation of a local scar, which is inevitable when the initial damage reaches a third of the thickness of the skin. Its appearance often leads to a series of undesirable side e˛ ects, which are both symptomatic (itching, fragility and pain, or a burning sensation) and have esthetic repercussions, which can be associated with sleep disturbance, anxiety, and depression and which can interfere with the performance of daily activities. In this context, the skin is the organ most frequently involved in scar formation and is the organ in which the mechanisms of healing have been studied more exhaustively. Skin scarring is deÿ ned as the macroscopic alteration of the structure and appropriate functions of the skin, caused by the appearance of replacement ÿ brous dermal tissue which develops a˙ er the healing of a wound, which could be traumatic, surgical, or due to a burn. ° e skin’s relevance to body movement was discussed extensively in Chapter 3. Scarring a˛ ects the

ECM is a vital participant in tissue activity and wound healing. Growth factors such as TGFβ and PDGF are the most important cytokines that initiate the second stage of the skin healing process; namely, in˝ ammation. ° is stage can be conditioned to the presence of other neuropeptides (substance P and growth factors of cutaneous nerves, among others.), which can be released by free nerve endings. During the third stage the ÿ broblasts, which are stimulated by the di˛ erent growth factors, divide and transform into myoÿ broblasts which behave similarly to smooth muscle cells. ° ese cells can contract and therefore reduce the open area of the wound. A˙ er their contraction, they begin their apoptosis and gradually disappear. ° e last stage of remodeling can last for years and depends on the size and nature of the wound. In this phase, type III collagen is replaced by a stronger ÿ ber,

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A

D

B

E

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C

Growth factor

Degraded protein

Elastin

Fibroblast

Type I collagen

Protomyofibroblast

Type III collagen

Myofibroblast

Fibrin

Apoptotic fibroblast

Vitronectin

Blood

Fibronectin

Proteoglycan

Figure 9.4 The appearance of ECM proteins correlates with phases of wound healing. The ECM composition of a wound changes as it progresses through the hemostatic, inflammatory, proliferative, and remodeling phases of healing. Fibrin, fibronectin, and other clotting proteins dominate in the hemostatic acute wound, but as fibroblasts migrate into the wound they produce proteoglycans and collagen that are associated with mature healing wounds. A Homeostasis is the phase of coagulation and vasoconstriction. The blood elements (platelets, fibrin, etc.) together with the components of the ECM organize the reconstruction through an interim ECM (type III collagen). B In the inflammatory phase, there is activation of proinflammatory cells (fibroblasts, mast cells, etc.) and release of neuropeptides by nociceptors (neuroinflammation). C In the proliferative phase, fibroblasts transform into myofibroblasts, which participate in the “sealing” of the wound. D In the remodeling phase remodeling and maturation of the provisional matrix (collagen type I) takes place. E Apoptosis is the programmed death of myofibroblasts (nonpathological scarring)

such as type I collagen, but it is aligned without a speciÿ c order (but has forces that indicate the orientation) and is smaller than the collagen of the surface of intact skin. ° is results in the gaining of more strength but also a loss of elasticity.

What happens if these processes have been altered? As mentioned above, the processes involved in the healing of wounds are diverse; the mechanical and chemical factors and their interrelation can determine the time of healing, as well as the quality and clinical manifestation. ° e healing process can trigger a nonphysiological scar, resulting in a hypertrophic scar (HS), a keloid scar (KS), or an atrophic scar (AS), each with a di˛ erent etiology.

° e HS, by deÿ nition, is a healing process that increases in height, but is always limited to the area of the original wound. ° e KS not only increases in height, but also proliferates beyond the limits of the original lesion. ° e KS and HS can represent two di˛ erent stages of the same pathological process. ° e AS appears as a cutaneous depression. When the dermis and fascia are a˛ ected by scars, these structures are altered and their functioning and ability to interact with the external and internal environment are insuˆ cient. ° ere are many reasons for such events, however, the scientiÿ c panorama o˛ ers convincing hypotheses suggesting that neuroin˝ ammatory phenomena and mechanisms related to mechanotransduction are decisive in the quality of the scar (Bordoni & Zanier 2014).

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9 Pathological scarring: A neuroinflammatory phenomenon? ° e neuroin˝ ammatory response can be caused by anomalous stress stimuli that originate in the lesion. ° is process causes the release of neuropeptides from native cells of the extracellular matrix, stimulating an in˝ ammatory re˝ ex arc (Bordoni & Zanier 2014). ° e neuroin˝ ammatory mechanisms can be derived from poor management of stress by the central nervous system, which establishes an allostatic load (see Chapter 8). ° e central nervous system perception of stress translates into peripheral tissues such as skin, not only through the endocrine system but also through neurotrophins and neuropeptides. ° is can result in neurogenic in˝ ammation, which is likely to contribute to the triggering and/or aggravation of immunodermatosis.

The brain–skin connection ° e maladaptive response (negative adaptation), central and/or peripheral by the nervous system occurs through the neuroin˝ ammatory mediators (neuropeptides), which challenge cellular homeostasis and neuro–endocrine–immune balance. ° e expression and increased release of substance P (SP) induced by stress from the nerve ÿ bers that innervate the skin, and of the cutaneous nerve growth factor (NGF) lead to the development of neurogenic in˝ ammation of the skin, recognized for its classic and characteristic degranulation of mast cells, vasodilation, and extravasation of plasma. Peptidergic cutaneous innervation (capable of synthesizing peptides), which is subject to plasticity, is modiÿ ed in response to stress, which is re˝ ected in an increase in nerve ÿ bers that synthesize SP and a greater expression of NGF.

lumbar surgery) in the presence of neuroin˝ ammatory activity. As analyzed, in an unfavorable neurochemical context (with the presence of SP and NGF), scar tissue processes in the fascial tissue may not be adequate, developing a hypertrophic or keloid scar in the TLF. We can conclude from this hypothesis that these phenomena could be present in postsurgical lumbar pain.

Mechanotransduction and the scarring process Alteration of the scarring processes can be related to an incorrect administration of loads (mechanotransduction). Miyamoto et al. (2009) considered that “pathological” scars may be due to the altered tension they receive during the scarring process. ° e tension placed on the healing wound causes misalignment of the orientation of collagen ÿ bers and proliferation of ÿ broblasts, as well as delayed maturation of the scar. If the wound is subjected to continuous severe stress, or a mobility deÿ cit, hypertrophic scar formation can occur (Miyamoto et al. 2009). According to these authors, mechanical stress is the main cause of hypertrophic scarring. ° ere are a number of biomechanical factors that can in˝ uence these tensions, such as the area of the body a˛ ected, individual di˛ erences in elastic properties, skin tension lines, the amount of physical exertion, the wound healing phase, and other factors (Miyamoto et al. 2009). Having this in mind and from a therapeutic point of view, it has been seen that compression therapy is able to improve the pathological characteristics of the scar. ° e justiÿ cation of this mechanism is also based on mechanotransduction.

As discussed in Chapter 8, there is a rich sympathetic innervation in the superÿ cial layer of the TLF and inside the superÿ cial fascia, meaning there is a “brain– fascia” connection. ° erefore, it can be hypothesized that as a result of an excessive response to stress (allostatic load), or due to the irritation of the peripheral nerves, neuroin˝ ammatory processes could be triggered in these fascial layers (Joachim et al. 2007).

° e use of mechanical stimuli on the scar has beneÿ cial e˛ ects. ° e reorganization of the extracellular matrix, which also involves the degradation of collagen, together with the disappearance of myoÿ broblasts (apoptosis) may explain the improvements obtained by using mechanical pressure as a scar treatment. ° e authors suggest that the pressure induces a decrease in the number of cells, similar to that observed in the ÿ nal stages of the normal healing process where apoptosis is the mechanism through which vascular cells and ÿ broblasts are gradually eliminated.

It is appropriate to consider, in this context, what would happen in the case of a lesion (surgical) and subsequent healing of the fascial tissue (in the case of

° ese mechanisms allow a reorganization of the extracellular matrix of the scar, inducing a change in appearance and clinical expression.

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In a study conducted by Chamorro Comesaña et al. (2017) of a group of women who had had cesarean sections a minimum of 18 months ago (the average being 7.3 years ago) it was determined through ultrasound assessment that MIT modiÿ es the thickness of the scar fold a˙ er eight interventions. ° e authors conclude that the structure of a scar can be modiÿ ed by MIT, even a˙ er it has completed its natural remodeling process.

Centripetal microdeformation involves suction through a coil that pulls from the center of the wound toward its margins. ° e stretching of the tissues directly stimulates the cells and increases the interstitial pressure. In addition, microdeformation reduces edema by increasing the di˛ erential pressure from the interstitial space through the interface material (polyurethane foam); it also temporarily reduces blood ˝ ow at the edges of the wound, stimulating cell proliferation and angiogenesis (Lancerotto et al. 2012).

° e use of mechanotransduction to improve the scarring processes allows us to observe amazing clinical results, which were previously unthinkable, and to modify the paradigm of wound intervention. In the case of open wounds, the use of centripetal microdeformation devices has shown encouraging results in wound healing treatments. 3

4

Conclusion ° e optimal behavior of the fascial system depends on complex and interactive processes (Fig. 9.5). ° e Widening range of response

Positive adaptation

Supercompensation of the fascial system

Negative adaptation

Myofascial Induction Therapy

Functional remodeling

2

9

Allostatic load

Fascial dysfunction

Mechanotransduction Immune response Nervous system

Mechanochemical request

1

Fascial system

5

Tissue injury

Figure 9.5 MIT and physiopathology of the fascial system 1 The integrated functioning mechanisms (mechanotransduction–immune response–nervous system) determine the (functional) remodeling of the connective tissue and its ability to adapt to the different ranges of mechanochemical demands. 2 The connective tissue is remodeled to adapt its cellular and subcellular properties (fibroblast dynamics and collagenous matrix synthesis) to the stimuli it receives. 3 The fascial system adapts by expanding its response range and becoming more resilient (supercompensation). 4 The fascial system responds disproportionately or wrongly to a stimulus, establishing an allostatic load (proinflammatory state) and increasing its state of pre-tension, which leads to dysfunction (kinesiophobia). 5 The mechanical requests of the fascial system exceed the adaptive capacity and the threshold of tissue injury

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9 physiopathology of the fascial system cannot be understood if it is viewed from a single viewpoint or from several viewpoints at di˛ erent times. Orthodox clinical reasoning generally adopts a linear perspective, suggesting that systemic reasoning is more appropriate since it involves the analysis of clinical phenomena that manifest themselves in parallel and can overlap. It is encouraging to think that fascial tissue is not only involved in mechanical behavior, but is also an important determinant of the immune response and thus transmission of the “painful” impulse. Undoubtedly, these mechanisms are fundamental to the understanding of pathologies such as ÿ bromyalgia, for example, which seems to bring together conceptually the points discussed in this chapter. Recently, Goebel et al. (2021) injected healthy mice with immunoglobulin antibodies (IgG) from people with ÿ bromyalgia

syndrome (FMS) and found that the mice rapidly developed greater sensitivity to pressure and cold and also reduced grip strength. In contrast, mice injected with antibodies from healthy people were una˛ ected. ° e authors concluded that: “Our results demonstrate that IgG from FMS patients produces painful sensory hypersensitivities by sensitizing peripheral nociceptive a˛ erents.” ° e authors suggest that this is a disease of the immune system, rather than the current view that it originates in the brain. However, these results should be treated cautiously as they are preliminary ÿ ndings. Scarring processes are closely related to the systemic response of the fascial system. ° e forces of the cicatricial environment (mechanotransduction and tensegrity), the neuroimmunological activity conditioned by the threat perception of the injury (allostatic load), and genetic conditions act for or against a functional, asymptomatic, and esthetic scar.

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REFERENCES

Bordoni B, Zanier E (2014) Skin, fascias, and scars: Symptoms and systemic connections. JˇMultidiscip Health 7:11–24. Burla F, Tauber J, Dussi S, van der Gucht J, Koenderink JH (2019) Stress management in composite biopolymer networks. Nat Phys 15(6):549–553. Carbone FR (2015) Tissue-resident memory T cells and ÿ xed immune surveillance in nonlymphoid organs. J Immunol 195(1):17–22. Carver W, Goldsmith EC (2013) Regulation of tissue ÿ brosis by the biomechanical environment. Biomed Res Int 2013:101979. Carver W, Esch AM, Fowlkes V, Goldsmith EC (2017) ° e biomechanical environment and impact on tissue ÿ brosis. In: Corradetti B (Ed.) ° e Immune Response to Implanted Materials and Devices: ° e Impact of the Immune System on the Success of an Implant. Cham: Switzerland: Springer International Publishing. Cenaj O, Allison DHR, Imam R, Zeck B, Drohan LM, Chiriboga L, Llewellyn J, Liu CZ, Park YN, Wells RG, ° eise ND (2021) Evidence for continuity of interstitial spaces across tissue and organ boundaries in humans. Commun Biol 4(1):436. Chaitow L (2014) Somatic dysfunction and fascia’s gliding-potential. J Bodyw Mov ° er 18(1):1–3. Chamorro Comesaña A, Suárez Vicente M, Docampo Ferreira T, Pérez-La Fuente Varela M, Porto Quintáns MM, Pilat A (2017) E˛ ect of myofascial induction therapy on post-c-section scars, more than one and a half years old. Pilot study. J Bodyw Mov ° er 21(1):197–204. Fernández-de-las-Peñas C, Pilat A (2012) So˙ tissue manipulation approaches to pelvic pain (external). In: Chaitow L, Jones RL (Eds.)

Chronic Pelvic Pain and Dysfunction: Practical Physical Medicine. Edinburgh: Elsevier.

therapies. Dover, New Hampshire: Nature’s Own Research Association.

Goebel A, Krock E, Gentry C, Israel MR, Jurczak A, Urbina CM, Sandor K, Vastani N, Maurer M, Cuhadar U, Sensi S, Nomura Y, Menezes J, Baharpoor A, Brieskorn L, Sandström A, Tour J, Kadeto˛ D, Haglund L, Kosek E, Bevan S, Svensson CI, Andersson DA (2021) Passive transfer of ÿ bromyalgia symptoms from patients to mice. J Clin Invest 131(13):e144201.

Pilat A (2014) Myofascial induction approach. In: Chaitow L (Ed.) Fascial Dysfunction: Manual ° erapy Approaches. Edinburgh: Handspring Publishing.

Herranz P, Santos Heredero X (2012) Cicatrices, guía de valoración y tratamiento. Publicidad Just in Time S.L. Joachim RA, Kuhlmei A, Dinh T (2007) Neuronal plasticity of the “brain–skin connection”: Stress-triggered up-regulation of neuropeptides in dorsal root ganglia and skin via nerve growth factor-dependent pathways. J Mol Med 85(12):1369–1378. Lancerotto L, Bayer LR, Orgill DP (2012) Mechanisms of action of microdeformational wound therapy. Semin Cell Dev Biol 23(9):987–992. Langevin HM, Fox JR, Koptiuch C, Badger GJ, Greenan-Naumann AC, Bou˛ ard NA, Konofagou EE, Lee W-N, Triano JJ, Henry SM (2011) Reduced thoracolumbar fascia shear strain in human chronic low back pain. BMC Musculoskelet Disord 12:203.

Pratt R (2021) Hyaluronan and the fascial frontier. Int J Mol Sci 22(13):6845. Roos KG, Marshall SW (2014) Deÿ nition and usage of the term “overuse injury” in the US high school and collegiate sport epidemiology literature: A systematic review. Sports Med 44(3):405–421. Snedeker JG, Foolen J (2017) Tendon injury and repair – a perspective on the basic mechanisms of tendon disease and future clinical therapy. Acta Biomater 63:18–36. Stecco A, Gesi M, Stecco C, Stern R, (2013a) Fascial components of the myofascial pain syndrome. Curr Pain Headache Rep 17(8):352. Stecco A, Meneghini A, Stern R, Stecco C, Imamura M (2013b) Ultrasonography in myofascial neck pain: Randomized clinical trial for diagnosis and follow-up. Surg Radiol Anat 36(3):243–253.

Miyamoto J, Nagasao T, Miyamoto S, Nakajima T (2009) Biomechanical analysis of stresses occurring in vertical and transverse scars on the lower leg. Plast Reconstr Surg 124(6):1974–1979.

Taberner Ferrer R, Vila Mas AT, Puig Sanz L, Artés Ferragud M, Martínez Álvarez JJ (2005) Prevalencia de cicatrices en la población española y su abordaje terapéutico. Piel 20(2):63–67.

Moreau JF, Pradeu T, Grignolio A, Nardini C, Castiglione F, Tieri P, Capri M, Salvioli S, Taupin JL, Garagnani P, Franceschi C (2017) ° e emerging role of ECM crosslinking in T cell mobility as a hallmark of immunosenescence in humans. Ageing Res Rev 35:322–335.

Willard FH, Vleeming A, Schuenke MD, Danneels L, Schleip R (2012) ° e thoracolumbar fascia: Anatomy, function and clinical considerations. J Anat 221(6):507–536.

Oschman JL (1997) Readings on the scientiÿ c basis of bodywork, energetic, and movement

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Wilke J, Tenberg S (2020) Semimembranosus muscle displacement is associated with movement of the superÿ cial fascia: An in vivo ultrasound investigation. J Anat 237:1026–1031.

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The assessment process

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KEY POINTS •

Definition of the proper performance of the body

•

Definition of dysfunction of the body’s systems

•

Establishing reliable rating criteria for the clinical assessment of myofascial dysfunctions

•

Principles of clinical reasoning

•

Importance of the history taking process

•

Local versus global assessment

•

Outline of functional global assessment (myofascial components)

•

Stability and mobility

•

Dynamic balance and muscle synergy

•

The importance of assessing all systems linked to fascia

Introduction ° e proper performance of the body in daily activities can be deÿ ned as the ability of the person to attain and then maintain optimal alignment of the segments of the body (the head, spine, thorax, upper extremities, pelvis girdle, and lower extremities). ° e term “optimal” means the capacity to reach maximum eˆ ciency with minimum energy expenditure. ° e generation of force and energy by muscles contributes to the energy ˝ ow between the individual segments during execution of a task. Each additional activity (compensatory action) will generate further energy expenditure which is expressed as ineˆ ciency of the system (dysfunction). ° e assessment of dysfunctions focuses mainly on the analysis of global stability and mobility, rather than the stability of individual segments or within individual segments:

•

Stability is the ability to maintain optimal posture and control movements. Stability can be either static (postural control) or dynamic (motor control).

•

Mobility is deÿ ned as a combination of muscle ˝ exibility, the range of motion of joints, and the

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synergistic redistribution of energy generated by muscles, closely associated with the neuromechanics of neuroconnective tissue. ° erefore, dysfunction can be deÿ ned as a failure of stability and/or mobility with the resulting alteration in the freedom or quality of body movement. ° e establishment of reliable rating criteria that could be used to clinically assess myofascial dysfunctions is still an ongoing challenge. Research related to the reliability of local (speciÿ c) tests that are frequently used in orthopedic assessment is inconclusive. Some of the tests are supported by strong scientiÿ c evidence and others are not (Cook 2007). Diagnostic accuracy varies considerably. For example, the evidence for the validity and reliability of the Faber test (used to assess if the hip joint is the source of the patient’s pain and also to assess sacroiliac joint dysfunction) is contradictory. Some researchers say it is an invalid and unreliable test (Ross et al. 2003), whereas others have reported a reasonable level of reliability and a 95ˇpercent conÿ dence level (Martin & Sekiya 2008). Age and gender should also be taken into consideration as they can a˛ ect the outcome. However, other research suggests

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10 that practitioners should use clinical assessment ÿ ndings as the basis for treatment selection (Vincenzino & Twomey 1993). In clinical practice certain tests might be interpreted di˛ erently to the original design, depending on the paradigm of clinical reasoning used in their analysis. For example, the ° omas test is a maneuver commonly used to assess shortening of the psoas muscle. However, it can also be used to assess the neuromechanics of the femoral nerve, which if altered leads to increased tension in the psoas muscle with the resulting loss of hip extension in the neuroprotective response. As stated above, the purpose of the assessment is to explore the stability and mobility of the whole system (body), rather than just the stability of individual segments or within individual body segments. ° is process involves multiple coordinated body systems starting with the nervous and myofascial systems, and then moving on to the visceral and circulatory systems and breathing activity. Fascia creates functional and structural links between all these systems and participates in the coordination process which is closely linked to the nervous system.

In conclusion, it is recommended that the primary focus of the assessment is the whole (big) picture. It is important to analyze patterns rather than specific parts of the body. Specific components can be assessed later using local (specific) tests. The tests should be simple, so that they can be easily administered.

Global assessment Listen – Observe – Assess

The clinical reasoning process ° e assessment of myofascial dysfunction syndrome (MDS) should take place within the ordinary clinical process and particularly within the usual assessment performed in manual therapy. ° e practitioner should perform his usual task of focusing on the integrity and autonomy of the three basic aspects of the body (Viel 1999, Meadows 2000, Pilat 2001):

• Rather than focusing attention on a particular body segment, global movement should be analyzed first.

It is feasible that the presence of a speciÿ c (local) dysfunction in the myofascial system may not be due to a local disorder (i.e., a given structure that is tight or weak), but is more likely to be due to disturbances resulting from neurological, circulatory, visceral, or breathing disorders. If a dysfunction is found while performing the global test it is recommended that the practitioner continues testing the related structures in order to obtain global information and then performs local testing and links both to the clinical performance of the patient. As with any dysfunction it is not usually one location that is a˛ ected but many. ° ese entrapment zones may be inactive, or demonstrate limited activity, but they are still signiÿ cant. ° erefore, it is essential to identify the a˛ ected network that may involve several systems and to determine how the systems behave collectively. ° e goal is to restore synergy.

Physical autonomy: ▶ range of motion (ROM) ▶ muscular strength ▶ integrity of inert and contractile structures.

•

Organic autonomy: ▶ cardiovascular capacity ▶ breathing activity ▶ static and dynamic balance capacity.

•

Sensory autonomy: ▶ presence of pain ▶ visual integrity ▶ auditory integrity ▶ touch perception ▶ compression of language and phonation ▶ memory ▶ judgment capacity.

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The assessment process

Stage or phase

Irritability

Severity

Stability

ASSESSMENT Signs and symptoms

Subjective experience

Exteroception

Interoception

Proprioception

Biomechanics Neurophysiology Neuroscience

Background

Misuse

Disuse

Autonomic response

TPs in taut bands

Restriction at deep levels

History taking

Abuse

Skin quality (Skin mobility)

Functional assessment

Global functional assessment

Neural tests

Complementary assessment

Circulatory tests

Specific functional tests

Static stability

Postural control Gravitational load Postural neuroprotection pattern

Dynamic stability

Motor control Force Resistance

ROM

Internal: local ROM related to each of the segments External: entire ROM related to the external environment

Movement synergy

Synergistic redistribution of energy generated by the muscles

Stability

Palpatory assessment Global functional assessment

MRI, EMG, US imaging, etc.

Visceral tests

Mobility

Patient and practitioner interpretation

Figure 10.1 The assessment process algorithm. EEG – electroencephalogram. MRI – magnetic resonance imaging. ROM – range of motion. TP – trigger point. US – ultrasound

° e algorithm in Figure 10.1 outlines the assessment process proposed in this book that is discussed below. ° is chapter covers the general assessment process. ° e clinical reasoning process follows the principles that are widely accepted among practitioners (Fig. 10.2). ° e detailed assessment of speciÿ c areas of the body is covered in the second (clinical) part of each volume of this book. ° e proposed algorithm does not preclude

the addition of other forms of assessment familiar to the practitioner and part of their routine. However, it is recommended that the practitioner follows the order shown in the assessment algorithm.

History taking In the history taking process the use of functional scales is helpful. In the past few decades several

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10 Clinical reasoning Practitioner/patient perspective

Practitioner

Figure 10.2

Patient

Information Perception Interpretation

Multiple hypotheses

Data History taking Assessment Complementary tests

Clinical reasoning flowchart – practitioner and patient/client perspective. After Jones M., Edwards I., Jenson G.M. (2019) Clinical reasoning in physiotherapy. In: Higgs J., Jensen G.M., Loftus S., Christensen N. (Eds.) Clinical Reasoning in the Health Professions. 4th ed. Elsevier, pp. 247–260.

Patient’s own hypotheses

Evolving concept of the person and problem Hypotheses modified

Evolving concept of the problem

Diagnostic management

Understanding of diagnosis and treatment proposal

Therapeutic procedure

Education Exercises Motor imagery

Reassessment

Self-management Self-efficacy

Knowledge Cognition Metacognition

functional scales have been developed to assess the functional status of patients with movement dysfunctions. Functional scales are questionnaires containing questions relating to a person’s ability to perform daily tasks. ° ey can be used by practitioners to measure the patient’s initial function, ongoing progress, and outcome, as well as to set functional goals. ° ey can even be used to assess the patient’s self-perception of their disability and its relevance to the dysfunction. ° ey have been used, for example, to evaluate the functional impairment of a patient with dysfunctions of the lower back (Stuge et al. 2011, Vleeming et al. 2008, Stratford

& Binkley 2000, Longo et al. 2010) or lower extremities (Binkley et al. 1999). A functional scale is a useful tool for monitoring the patient over time and for evaluating the e˛ ectiveness of an intervention.

Analyzing myofascial dysfunction syndrome: The past and the present (see Fig. 10.1) (Pilat 2011) The past An analysis of the patient’s previous experience (the past), in relation to the present signs and symptoms, allows the practitioner to determine the extent of the

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in˝ uence of earlier experiences on present behavior. Previous lesions can not only reduce the biomechanical integrity of the tissue but can also increase neurophysiological sensitivity (see Chapter 7). Previous experience of injury and pain can also determine the behavior of the patient in relation to activity (movement or rest) and, depending on their experience, may lead them to dismiss the symptoms a˛ ecting them (e.g., pain). Frequently, in cases of recurrent lesions or long-term pathologies, the presence of central sensitization is a possibility. ° is can lead to avoidance behavior (kinesiophobia) which traps the patient in a process of fear and progressive hypomobility. ° us, the evaluation parameters should include frequency and training mechanisms, as well as the type or form of pain (duration, quality, intensity). In general, the history of a patient’s pathology can be summarized as three types of behavior:

• • •

misuse: reduced coordination and/or stability; overuse: movements and/or repetitive overload; abuse: trauma.

If not treated early, or if treated incorrectly, these behaviors can lead to:

•

disuse: atrophy or reduced load capacity.

The present An analysis of the current signs and symptoms (the present) should include the mechanisms of formation, the state of pathology, and the severity of the symptoms.

Note: Dysfunctions of the fascial system can alter the tensional homeostasis of the body temporarily or permanently, thus conditioning the postural attitude (antigravitational behavior) and locomotion.

Global functional assessment (myofascial components) Human beings move in patterns (Sahrmann 2002).

An outline for the exploration of body movement is presented in Figure 10.3 which is part of the assessment process algorithm (Fig. 10.1). ° ese are validated tests used to explore deÿ ciencies in the functionality of the musculoskeletal system. ° ere is no clear scientiÿ c consensus on which speciÿ c test to choose or on the manner of its application; there are many versions of each test. According to their training and the clinical demands they face (category of patient and their age, gender, beliefs, etc.) the practitioner is at liberty to select other tests that are commonly used and considered necessary. Consequently, a basic exploration of other systems linked to fascia is recommended, primarily to rule out

Clinical decisions regarding pain will vary depending on the development of:

•

severity (in˝ uence of pain on the quality of daily life; 24-hour schedule);

•

impairment of stability neurophysiological);

• •

(mechanical

and

Static stability

Postural control Gravitational load Postural neuroprotection pattern

Dynamic stability

Motor control Force Resistance

ROM

Internal: local ROM related to each of the segments External: entire ROM related to the external environment

Movement synergy

Synergistic redistribution of energy generated by the muscles

Stability

Global functional assessment

irritability (how quickly the worsening of pain or improvement occurs);

Mobility

stage or phase of the disease (pain has a tendency to decrease, increase, or be stable).

Both analyses (of the antecedents as well as of the present signs and symptoms) should always be conducted within a framework of biomechanics and neurophysiology.

10

Figure 10.3 Global functional assessment flowchart

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10 associated pathologies and to determine which pathologies are relevant, for example, to the presence of pain.

Static stability assessment ° is assesses:

• • •

postural control gravitational load distribution postural neuroprotection pattern.

What does static posture assessment really tell us and how does it relate to our patient’s symptoms? ° e recent literature is very critical and concludes that there is no clear evidence of a relationship between postural alterations and the patient’s symptoms:

•

“° ere is strong evidence to support there is no relationship between prolonged static posturing and the development of low back pain” (Fedorak et al. 2003).

•

“We urge physical therapists to avoid prescribing therapeutic exercise programs of muscle strengthening of abdominal muscles in patients with CLBP based solely on assessment of relaxed standing posture” (Ro˛ ey et al. 2010).

•

“No association between self-reported symptoms and performance measures of postural instability was found” (Cobb & Nichols 1998).

•

° e intrarater reliability is fair and an interater reliability in determining lordosis from a pure visual assessment is poor (Fedorak et al. 2003).

What are we looking for in the static posture assessment?

• •

Are we looking for abnormalities?

•

What is the correlation between mechanical stress (“bad” posture) and pain?

• •

What is the “correct” posture for any individual?

Can we draw conclusions (diagnose) by observing static posture?

Can we completely ignore the static posture assessment?

It is noteworthy that static posture “is always a movement or adjustment, albeit slight, in order to maintain antigravity equilibrium” (Key et al. 2008, Pavlu & Novosadova 2001). Shumway-Cook & Woollacott

(2007) deÿ ne postural control as “the ability to control the body’s position in space for the combined purposes of stability and orientation.” ° e postural orientation for most functional tasks requires a vertical point of reference between the body and the environment. Janda (1996) states that: the static posture assessment, particularly from the muscular standpoint, gives you a baseline of info that could save you time in your total assessment but overall will guide you to the regions where you could focus your attention on. It may be your wakeup call that something is not right in a specific region of the body. What is described in morphology as organic forms and structures is actually a momentary cross-section through a space–time pattern. What is called a structure is a long, slow process, and a function is a rapid process of short duration (Ludwig von Bertalanffy 1951).

Analysis of static posture is a useful starting point in the assessment process. It allows the practitioner to verify how a person distributes gravitational load and to identify signiÿ cant asymmetry (but not pathologies). It also helps them to select the subsequent assessment strategies, guiding them to the regions on which they need to focus. It is also a simple tool for reassessment, to quickly identify alterations in the appearance of the body, and is useful for both the practitioner and patient. For the patient it can be an educational tool. ° ere is a strong belief that there is a causative relationship between posture and pain. Neuroscience research, however, does not conÿ rm that reasoning (Fedorak et al. 2003). Should we therefore associate posture with the presence of pain? It is suggested that the way in which we hold our posture does correspond with what our brain feels as discomfort or pain. ° e interpretation of pain is essential in the process of assessment; however, pain does not tell the whole story of our health (see Chapter 8). Exaggerated asymmetry of static posture is related to loss of balance between feedback and feedforward control actions. ° is also a˛ ects the cellular level. Each and every individual molecule in the body experiences a force due to gravity that is distributed all over

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the body (see Chapter 8). ° ese postural changes manifest how the body, through its systems, copes with its weight and has adapted over time. Static posture assessment, as a neuroscientific analysis, is only one part of the entire picture.

In conclusion, it is recommended that the static posture assessment is not discarded, but it should be complemented by global and local functional tests to analyze the presence of pain and its behavior. Table 10.1 summarizes the assessment of static stability. There is no such thing as an average correct posture. Our posture is our fingerprint. It is unique for each of us. Every patient needs to be assessed and treated individually with particular attention paid to his or her dysfunction and related psychosocial factors.

Dynamic stability assessment – motor control Instead of focusing the assessment on a particular part of the body, it is recommended that global movement be analyzed first.

10

produces purposeful, coordinated movements in its interaction with the rest of the body and with the environment” (Latash 2010). However, as there are no universally accepted criteria, it is useful to give a brief historical overview of different theories on motor control. 1. Re˝ ex theory (Charles Sherrington 1906, Eccles 1957) ▶ Movement is controlled by a series of chained re˝ exes. ▶ Re˝ exes are the fundamental building block of movements. ▶ Complex movements are a sequence of re˝ exes elicited together. ▶ Sensory stimulus is essential to produce a movement. ▶ Limitations:

° Movement can occur without a sensory stimulus.

° Sequences of movements occur too fast to allow for sensory stimuli.

° Re˝ exes can be modulated according to the context.

What is motor control and why do we move the way we do? It is not easy to answer this question or to explain the process and accuracy of volitional movement. Mark Latash (2010) in his paper “Motor synergies and the equilibrium-point hypothesis” states: Movement of a human effector, from a single joint to the whole body, is a transition between its equilibrium states (equilibrium points, EPs). To perform a movement requires that the original EP disappears and a new one (or a time series of new EPs) is established. ... stability may not be always desirable since it implies a trade-off with maneuverability ... [related to the] notion of synergies as neural organizations that simultaneously ensure stability and flexibility of movements. ° erefore, the question as to why we move in a speciÿ c manner is related to “how the central nervous system

° Novel movements can be carried out by combing stimuli and response previously learned.

▶ Clinical relevance:

° Sensory input is used to control motor output. ° Good re˝ exes are stimulated. ° Undesirable (primitive) re˝ exes are inhibited. 2. Hierarchical theory (top-down organization) (Hughlings Jackson, 1930, Foerster 1936) ▶ Movement is controlled by an evolutionary hierarchy consisting of four levels:

° motor areas in the cerebral cortex ° midbrain ° brainstem ° spinal cord. ▶ Higher levels control lower levels.

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10 Table 10.1 Static stability assessment. Postural control – gravitational load distribution – postural neuroprotection pattern Test

Aim

Assessment of postural control (that maintains the body in an upright position) in relation to stability and orientation (Shumway-Cook & Woollacott 2007)

Postural control Front and rear views

A

B C

D

Description

Interpretation (positive sign)

Clinical analysis

References

The patient stands barefoot in a relaxed position

Asymmetry between A and B suggests a tendency to lateral flexion (on the side of the triangle with the larger volume)

Presence of alteration of automatic reflexes and responses. Functional asymmetry between the right and left sides of the body represents a much higher risk factor for injury (Kartal 2014)

Bullock-Saxton 1993

Observe the patient from the ground upwards from the front, rear and sagittal views Front and rear views Detect asymmetries in the distribution of gravitational loading. Reference points: the volume of the waist triangles (A and B) and the position of the hands in relation to the lateral thigh (C and D)

The asymmetry ratio of the hand position related to the lateral thigh (C and D) suggests a tendency to rotation; e.g., the right hand over the right anterior thigh indicates a leftward rotary trend Tendency to lateral bending and rotation

Preece et al. 2008 Kartal 2014 Shumway-Cook & Woollacott 2007

A consistent postural alignment is assumed (in terms of spinal curvature and pelvic inclination) when an individual is asked to stand comfortably erect (Bullock-Saxton 1993)

Lateral view Lateral view Assess for the following: A Feet. Achilles tendon verticality B Tendency to genu flexum or genu recurvatum C Pelvic tilt D Forward abdominal muscles E Dorsal kyphosis F Flat chest G Forward head posture

G F

E

D

C

B

A

Gravitational load distribution E D

H

C B

G

A

F

Assessment of gravitational load distribution in standing. All muscles must be activated to work in complete synergy Postural control requires the production of movements or muscular contractions that help keep the body upright in space

The patient stands in a relaxed position Observe the patient from the ground upwards

Anterior pelvic tilt is associated with a loss of core stability, and therefore the degree of pelvic tilt is used to assess core strength (Preece et al. 2008)

Front view A Position of the feet (excessive eversion) B Position of the knees: Up or down? Right or left displacement? C Thigh fold symmetry D Superior pubic position E ASIS position Rear view F Achilles tendon verticality G Popliteal fossa position H Gluteal fold symmetry

Loss of balance between feedback and feedforward actions. This also affects the cellular level. Each and every individual molecule in the body experiences gravitational force that is distributed throughout the body (see Chapter 9). The changes show how the body copes with its weight and has adapted over time

Winter 1995 Latash 2008 Aruin et al. 2001

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▶ Higher cerebral centers control lower centers via inhibition.

▶ Limitations of ecological theory:

° It places less emphasis on the nervous system.

▶ Re˝ exes controlled by lower centers are present only when higher centers are damaged.

▶ Clinical relevance:

° It helps to explore multiple forms of the thera-

▶ Limitations:

° Environmental and other non-CNS factors can a˛ ect movement.

° Lower level re˝ exes are present in adults. ▶ Clinical relevance:

° ° e tone is normalized. ° ° e hyperactive stretch is reduced. ° ° e identiÿ cation and prevention of primitive re˝ exes is facilitated.

° ° e developmental sequence is organized. 3. System theory (Bernstein 1967, Bongaardt & Mejijer 2000) ▶ Movement emerges spontaneously from the interaction of the individual, the task, and the performance environment. ▶ ° e same central command can result in di˛ erent movements. ▶ Di˛ erent commands can produce the same movement. ▶ Limitations:

° ° e body is viewed as a mechanical system. ▶ Clinical relevance:

° Practice under a variety of conditions is facilitated. ° ° e use of functional tasks is developed. ° ° e modiÿ cation of environmental contexts is extended.

4. Ecological theory (Gibson & Gibson 1955) ▶ Movement regulation is viewed as distributed processing. ▶ Motor development is treated as a perception– action system. ▶ ° ere is interaction of multiple factors working together to generate and control movement.

10

peutic process to achieve healing.

Although none of the above models are wholly acceptable, they cannot be dismissed completely. In fact, the concepts expressed in each of the models are widely used in therapeutic processes. Motor control dysfunctions are manifested through mechanical deÿ cit and/or the sensation of instability (Goldenberg 2014). However, mechanical input is not necessary for dysfunction to occur (see Chapter 7). Motor impairments may be expressed in three areas:

• •

action (muscle tone and muscle strength);

•

cognition (attention, emotions, motivation).

perception (registration or integration of sensory information);

Faced with a deÿ ciency or deÿ ciencies, the central nervous system optimizes itself, using a set of elemental variables to perform several tasks simultaneously without sacriÿ cing accuracy (stability) in the performance of any of them (Latash et al. 2010). ° e process is guided by intentions (emotion, motivation, ideas) related to environmental resources used in the search for the intrinsic homeostatic mechanism. ° e ÿ nal process will manifest the system’s capacity in managing synergies to achieve optimal stable dynamic balance. Latash et al. (2010) claim that: “Most existing models of motor synergies have a common drawback, they use a language of performance variables instead of trying to link performance to changes in control variables.” In the assessment process the practitioner searches for resources by analyzing motor behavior. Table 10.2 summarizes the assessment of motor control. The assessment of function should not be based on a single static test. An assortment of tests is required. The findings of the different tests should be analyzed together, and not separately. Every piece of information must be considered in relation to the whole.

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10 Table 10.2 Dynamic stability assessment – motor control Test

Aim

One-leg standing test

To evaluate dynamic trunk control over the weight-bearing leg in all planes of motion: sagittal, frontal, and transverse planes

Description

Interpretation (positive sign)

Clinical analysis

References

The patient is required to stand on one leg while flexing the contralateral hip up to 90 degrees (Sahrmann 2002)

Check for lumbar or pelvic rotation, hip adduction (hip drop) or lumbar inclination toward the support limb (Sahrmann 2002)

Impairment syndrome (extension–rotation)

Harris-Hayes et al. 2005

One-leg stance: reliable tests for rotational dysfunction

Sahrmann 2002 Kibler et al. 2006 Luomajoki et al. 2007 Shamsi et al. 2017

One-leg standing test (muscle activation order)

Single-leg squat

To check for muscle activation dysfunction and load transfer downward by the thoracolumbar fascia

Check the order of muscle activation:

To identify clinically abnormal movement patterns. To assess the patient’s ability to attain and then maintain optimal lower quadrant segment alignment when performing a single-leg squat

The patient stands on one leg with the other leg bent at the knee and lifted, so that the hip is slightly flexed and the knee of the non-stance leg is also slightly flexed. The arms are crossed over the chest. From this position, the patient squats down at not more than 75 percent of knee flexion and then returns to the starting position. The test takes approximately 4 seconds (descent phase – 2 seconds; ascent phase – 2 seconds)

1 Gluteus maximus 2 Hamstrings (simultaneous activation of the gluteus maximus and hamstrings is possible) 3 Contralateral erector spinae 4 Ipslateral erector spinae

Activation of the hamstrings before the gluteus maximus or before the ipsilateral erector muscles

Excessive anterior pelvic tilt

Modified from Janda 1996

Overall impression Staggered movement and increased speed

Presence of the weakness of: Quadriceps Hamstrings Gluteus Core muscles

Perrot et al. 2012

Weight transfer The magnitude of deviation from neutral alignment, the degree of movement oscillation, and the extended time taken to transfer are tested using a 4-point rating scale with movement described as having either excessive, moderate or small deviation, or no deviation

Anterior cruciate ligament (ACL) efficiency Motor task synergy alteration Ankle dorsiflexion deficit

Weeks et al. 2012 Kulas et al. 2012 Crossley et al. 2011 Weir et al. 2010 Chmielewski et al. 2007 DiMattia et al. 2005 Conrad & Stanitski 2003

Lumbar spine and pelvic alignment Pelvis tilting up or down, toward or away from the weightbearing leg and in anteroposterior directions. Trunk flexion or increasing lumbar lordosis

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10

Table 10.2 continued Test

Aim

Description

Interpretation (positive sign)

Clinical analysis

References

Leg alignment Appreciable movement

Single-leg squat

Foot alignment Excessive pronation of foot during squat descent. Externally rotated starting position of lower leg or foot

Active straight-leg raise (ASLR) test

To assess for dynamic stability of the pelvic girdle

The patient lies supine on the treatment table with the legs straight and the feet 20 cm apart. The patient tries to raise their legs, one after the other, 20 cm above the table without bending the knees

The patient is asked to score any feeling of impairment (for each side) on a 6-point scale: 0 1 2 3 4 5

not difficult at all minimally difficult somewhat difficult fairly difficult very difficult unable to do

The ASLR provides information about the ability to load transfer and motor control strategies in the lumbopelvic–hip complex

Vleeming et al. 2008 Mens et al. 2001 Beales et al. 2009 Coppieters et al. 2015

The scores for both sides are added together. The total score can range from 0 to 10

Mobility assessment – range of motion It is logical to assume that a patient’s internal resources determine dynamic balance and range of motion (ROM). However, remember that the body does not move in an empty space; its movement is also closely related to the external environment and what is in that environment. ° us, with regard to ROM, we need to evaluate both the intrinsic and extrinsic range. ° e intrinsic ROM is deÿ ned as the range of individual segments and their relationship to others. ° e extrinsic ROM is the movement of the whole body in relation to external factors, such as the type of support base (e.g., rock or sand). ° erefore, alterations in ROM (hypomobility or hypermobility) are not only related to local events (capsular retractions, muscle shortening) but are also associated with external resources. ° e measurement and analysis of ROM should not only be limited to quantiÿ cation. Even if the external

ROM measurements are appropriate, this may be because of an internal compensatory process, meaning that the deÿ ciency in the local range was corrected (compensated) by “borrowing” the range inappropriately from another structure (or other structures). Research shows that when a movement is guided by external factors there are di˛ erent neural pathways involved, compared to movement guided by internal stimuli. ° is means that there are separate pathways that guide the two types of impulses. ° e existence of separate networks of action leads to three considerations:

•

Movement distortion can be linked to the inadequacy or failure of internal (structural) factors and/ or deÿ ciency in the uptake or interpretation of external factors.

•

° e learning process (recovery of range) requires both internal and external stimuli.

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10 •

In the therapeutic process diˆ culty in, or the impossibility of, using one of the reception channels (internal or external) does not invalidate the possibility of action, but rather suggests promotion of external generation of movements, which may be a helpful strategy (Debaere et al. 2003).

Since ROM is part of performance then performance can never remain constant. ° e mobility assessment – range of motion (ROM) tests are summarized in Table 10.3.

Mobility assessment – movement synergy Muscle activity represents the functional outcome of the nervous system. ° e assessment of underlying neural strategies, which result in movement and function, is a complicated task. It cannot be measured directly, particularly in patients with motor disorders. ° us, an exploration of muscle activation may re˝ ect the condition of neural mechanisms (Safavynia et al. 2011). An analysis of muscle synergies (˝ exibility and adaptability) may provide a better understanding of functional deÿ ciency in the nervous system. Research (Overduin et al. 2008) supports the idea that clinical output is related to the neural organization of muscle synergies both at the spinal and cortical levels. ° us, the assessment of abnormalities in di˛ erent muscle coordination patterns can help to identify deÿ ciencies in movement planning and execution. Table 10.4 summarizes the assessment of the synergistic redistribution of energy generated by muscles.

Conclusion ° e assessment process will not reveal the full picture of the patient’s problem. It is only a momentary re˝ ection of the patient’s reality – a snapshot, rather than the whole ÿ lm. For this reason, the patient’s appreciation of the process is essential to the planning of treatment.

Neural tests (Fig. 10.4) An accurate diagnosis of a myofascial dysfunction is diˆ cult due to the complexity of its anatomy and biomechanics. Pain, for example, may be nonspeciÿ c (with considerable overlap of its sensory distribution) and diˆ cult to identify, and there are person-to-person variations. Among the systems involved in myofascial dysfunction, the importance of the nervous system should be emphasized. For example, the diagram in Figure 10.5

illustrates the components of the lumbosacral plexus that can be a˛ ected by myofascial dysfunction. Note that neural entrapment can generate neuroprotective and neuroe˛ ector responses with signiÿ cant consequences for the body’s mechanics.

For a comprehensive analysis of how the fascial and nervous systems are connected see Chapter 7.

Nerve entrapment syndrome A knowledge of the distribution of sensitive areas is very useful in the therapeutic process and it enables the practitioner to identify links between referred symptoms (including multifocal symptomatology). Nerve entrapment syndrome can be one cause of pain and dysfunction. Knowledge of the nerves that may be involved, their anatomy, motor and sensory functions, and the etiology of their dysfunction aids the practitioner to manage these complex problems. For example, nerve entrapments may be responsible for several pain syndromes in the lower limb and lumbopelvic segments, such as in hip, buttock, or groin pain. Figure 10.5 shows the location of the most common entrapments of the lumbosacral plexus and its branches. (More detailed information relating to the upper quadrant can be found in Chapters 16 and 17.)

Performing neural tests In the assessment of myofascial dysfunctions, it is recommended that neural tests be performed as part of the assessment of myofascial dysfunctions in order to analyze the relevance of neural entrapment in the patient’s symptomatology. ° e basic neural tests relating to entrapment of the lumbosacral plexus components are summarized in Figure 10.6. How to perform neural tests is beyond the scope of this book, and the reader should consult the extensive specialized literature available on this subject.

Visceral tests (Fig. 10.7) Continuity of visceral fascia ° e continuity of the fascial system, including visceral fascia as one of its essential components, is discussed

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10

Table 10.3 Mobility assessment – range of motion (ROM) Test

Aim

Standing flexion and extension test

Description

Interpretation (positive sign)

Clinical analysis

References

Flexion Have the patient bend forward as far as possible without bending the knees. Measure the distance between the patient's fingers and the floor

Woolsey et al. (2001) state that the mean motion of lumbar flexion is 56.6 degrees. In optimal conditions the patient should should be able to touch the floor with the tips of their fingers. The extension range is highly variable but is not more than 50 degrees (Youdas et al. 1995)

This is the first step in the assessment of spine mobility

Woolsey et al. 2001

Identification of areas with a dysfunction of the deep trunk stabilizers

Machado et al. 2010

Extension lying prone The patient lies on their stomach with the palms facing down and almost aligned with the shoulders, as if to do a standard push-up. The patient slowly pushes the shoulders up, keeping the hips on the table and letting the back and stomach sag, and then slowly lowers the shoulders

A normal test is the presence of a curve that is consistently free of stiff segments

In the McKenzie Method of Mechanical Diagnostics and Therapy (MDT), the test (with its repeated movements and the application of sustained positions) allows pathological patterns in the lumbar spine to be identified

To assess: Core stability (ability to coordinate and execute movements of the body against gravity)

The patient stands with the feet shoulder width apart and with the arms elevated at approximately 90 degrees

Overall impression What is the ROM? Can the patient reach the bottom of the squat?

Presence of lower cross syndrome

Dynamic flexibility of joints

Instruct the patient to squat as far as possible (without pain) and then return to the starting position

To test the ROM of the spine in flexion and extension To identify areas of stiffness in the thoracic and lumbar spine which do not follow the natural curve

Extension lying prone

Squat test

Muscle strength in the lower quadrant Note: Do not instruct the patient as the movement should be spontaneous. The patient should not be supported by any object while performing the test. However, if they lose their balance they may

Extension The patient stands with the feet shoulder width apart, and the hands placed in the small of the back, and leans backwards

As the patient performs three repetitions, observe the movement from the anterior, lateral, and posterior views Observe the feet, ankles, and knees anteriorly and posteriorly

Anterior view Do the feet turn in or out excessively? Do the knees spread outward or inward? Lateral view Do the arms move up and down too much? Is there an excessive forward tilt in the lumbo-pelvic–hip complex? Is the lower back hyperextended?

Core muscle instability Knee: orthopedic dysfunctions or pathology (ACL, meniscus) Ankle structures: hypomobility and/or instability Other alterations in balance

Youdas et al. 1995

“It is a practical and useful clinical tool to assist diagnosis and help better understand the development and perpetuation of most spinal related disorders.” Key 2010 Key 2013 Ishida & Watanabe 2013

Posterior view Are the heels elevated?

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10 Table 10.3 continued Test

Aim

Squat test

Description

Interpretation (positive sign)

Clinical analysis

References

rest their hands on a chair, table, or wall to continue the action and achieve greater amplitude of joint movement. It is recommended that the patient does not lift the heels (one of the objectives of the test is to evaluate dorsiflexion of the foot). However, if compensatory movements are initiated (see photo), the heels may be lifted, and the patient may continue with the movement

Observe the lumbo-pelvic–hip complex, shoulder, and cervical complex laterally.

Adam’s test

To identify individuals with scoliosis. This is not just an orthopedic test. It can be used to detect scoliotic attitudes of functional or neurological origin

The patient bends forward as far as possible. Check if one side of the rib cage is higher than the other next to the vertebral column

The convex side is the side with the rib hump

It is important to identify individuals at risk of developing severe scoliosis

Simpson & Gemmell 2006

Leg length discrepancy (LLD) test

To assess the effect of LLD on standing posture, standing balance, gait, running, and others pathological conditions

A The patient lies supine with the knees bent. Hold the patient's feet in position and align the internal malleoli

There is still controversy over the magnitude of LLD required to cause musculoskeletal problems

Conflicting information in the literature, combined with differences in the methodology between studies, makes it difficult to generalize. Patients with pulmonary, cardiac, or neuromuscular disease may have difficulty walking with a limb-length discrepancy of as little as 2 cm

Gurney 2002

A

B

C

The flexion of the knees should allow the thighs to become almost parallel with the floor The knees should not extend beyond the toes The angle of trunk tilt should not be greater than that of the tibial slope

B The patient lifts the pelvis as far as they can C When the patient has lowered the pelvis, extend the lower extremities and compare the positions of the internal malleoli

Gurney et al. 2001

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10

Table 10.4 Mobility assessment – movement synergy Test

Aim

Pelvic tilt test

To assess movement coordination during pelvic tilt To assess for back extension dysfunction with and without gravitational loading

Description

Interpretation (positive sign)

Clinical analysis

References

Standing Neutral tilt The patient stands in a relaxed posture. The practitioner assesses the neutral pelvic tilt in relation to the body

Standing A positive sign is if the patient is unable to complete a standing posterior pelvic tilt without rotating the anterior part of the pelvis upward three consecutive times.

Poor or absent synergies

Sahrmann 2002

Posterior tilt movement The patient tightens the abdominal muscles while squeezing the buttocks together Anterior pelvic tilt movement The patient relaxes the abdominal muscles and allows the pelvis to rotate in the anterior direction. The patient should rotate the anterior part of the pelvis downward three consecutive times Supine The patient lies on their back with the knees bent. Instruct the patient to pull the umbilicus in toward the spine and then up without moving the pelvis

Dural tension test

This is a neural tension test that is used to detect altered neurodynamics or neural tissue sensitivity

The patient is side lying with the spine in flexion but without reaching a complete fetal position. Stand or sit behind the patient between the sacrum and skull

Back extension dysfunction Poor or absent gluteal activity

“The most reliable test overall: pelvic tilt for extension dysfunction.” Luomajoki et al. 2007 Preece et al. 2008

Compensatory flexion of the dorsal spine and/or the knees The pelvis does not tilt, or the lower back moves toward extension

Supine You are able to place your hand between the subject's lumbar spine and the surface of the table during three consecutive posterior pelvic tilt maneuvers

Restriction in either direction

Possible extradural entrapment

Liem 2006 Sergueef et al. 2011 Becker 1963

Place one hand on the occiput and the other on the sacrum Move your body weight forward slightly maintaining a smooth and even divergent traction on the occipital bone (in the cranial direction) and sacrum (in the caudal direction)

raction on the occipital bone (in cranial direction) and

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10 Table 10.4 Continued Test

Aim

Slump test

This neural tension test is used to detect altered neurodynamics or neural tissue sensitivity It can be performed in different ways The common factor is that the reproduction of pain as tension is applied to the dura (and neuroconnective components) throughout the test

Description

Interpretation (positive sign)

Clinical analysis

References

Step 1 The patient sits on the treatment table with the lower legs dangling and the hands behind the back

The range of knee extension without pain is limited

Flynn et al. 2008

The practitioner notes the patient’s symptoms in erect posture

The patient may experience tension, pain, or other neurological sensations in the area of adhesions or disc herniation

There is no consensus on what constitutes a “positive” slump test, however, it is the test most frequently used by practitioners in relation to neuropathic pain

Step 2 The patient performs craniocervical and cervical flexion

Step 3 Next, the patient slumps forward into the dorsal and lumbar kyphosis position. Again, the practitioner notes the patient’s symptoms

The patient may not be able to extend the knee because of pain

It is possible to attach structural differentiation or sensitization maneuvers (e.g., dorsiflexion of the feet), which contribute to the richness of the clinical data

Urban & MacNeil 2015

Observe the ROM and the quality of movement of the spine and lower extremities. If pain or other neurological sensations are present a specific neurological assessment is needed

Overpressure can be applied during any of the test positions

Step 4 While maintaining the same position as in step 3, the patient is asked to extend the knee. Objective responses range of knee extension) and subjective responses (pain) are recorded Step 5 While maintaining the same position as in step 3, the patient (with the help of the practitioner) tilts the trunk forward, thus increasing hip flexion and tensing the sciatic nerve on the pulley of the rotating muscles. Again, the symptoms are noted

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Functional assessment

Global functional tests

Neural tests

Visceral tests

Circulatory tests

10

Specific functional tests

Figure 10.4 Neural tests in the algorithm sequence

in Chapter 3. Visceral fascia represents a thin, ÿ brous membrane that envelops organs and glands, binding structures together and also creating divisions between them. ° e viscera of the abdomen linked to fascia include the stomach, intestine, liver and biliary system, pancreas, spleen, kidneys, ureters, and suprarenal glands. ° e positions of the abdominal viscera vary slightly with each person and are also constantly being modiÿ ed depending on gravity, posture, breathing patterns, the amount of abdominal fat, the digestive process, and even the current emotional status of the individual. ° e anatomic continuity between the abdominal wall and intra-abdominal structures occurs via the peritoneum (Fig. 10.8). ° e peritoneum links the intra-abdominal structures to each other and allows their free movement, minimizes friction, resists infection, and stores fat. Although ultimately one sheet, the peritoneum consists of two layers. ° e parietal layer lines the walls of the abdominal cavity, and the visceral layer lines the walls of the abdominal viscera. In some areas, the parietal sheet becomes the visceral layer, forming structures called ligaments, mesentery and omentum which act as a support for the attachment of abdominal viscera. ° e peritoneal cavity contains merely a thin ÿ lm of ˝ uid. ° e peritoneal cavity is completely closed in the male, whereas in the female it communicates with the uterine tubes and hence indirectly with the exterior of the body. ° e parietal peritoneum is supplied by nerves (e.g., phrenic and thoracoabdominal) to the adjacent body wall, and most of it is very sensitive to pain. As an example, painful stimuli to the central part of the diaphragmatic peritoneum are referred to the shoulder. ° e visceral peritoneum is insensitive.

The kidney and the adipose capsule are enclosed in a sheath of fibrous tissue … and named the renal fascia. … The posterior layer extends medialward behind the kidney and blends with the fascia on the Quadratus lumborum and Psoas major, and through this fascia is attached to the vertebral column. … The renal fascia is connected to the fibrous tunic of the kidney by numerous trabeculæ, which traverse the adipose capsule, and are strongest near the lower end of the organ. … The kidney is held in position partly through the attachment of the renal fascia and partly by the apposition of the neighboring viscera. (Standring 2004)

One example of visceral fascia continuity is related to the renal fascia and its anatomical links. Gray’s Anatomy states:

Clinical observation of living people, through modern methods of exploration, conÿ rms the anatomical ÿ ndings from dissections as below:

•

° e continuity of the posterior renal fascia onto the quadratus lumborum muscle fascia was observed in a computed tomography study (Lim et al. 1990).

•

° e relationship between low back pain (LBP) and urinary infections has been reported (Rivera et al. 2008).

•

Changes in breathing patterns in the presence of chronic LBP was observed by Rousselet al. (2009).

•

Cranial–caudal displacement of the kidney during forced respiration in healthy individuals was observed by Suramoet al. (1984).

•

Davies et al. (1994) observed that organ displacement following a deep breath can be three times greater than during quiet breathing.

•

Tozzi et al. (2011) observed a signiÿ cant reduced range of kidney mobility in patients with LBP, compared with that of asymptomatic people.

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10 Figure 10.5 J

A

The most common entrapments of the lumbosacral plexus 1 Anterior view A Iliohypogastric nerve B Lateral femoral cutaneous nerve C Pudendal nerve D Femoral nerve E Obturador nerve F Saphenous nerve G Common peroneal nerve H Superficial peroneal nerve I Dorsal branch of peroneal nerve

C B

K

E

D

2 Posterior view J Lumbar roots K Posterior cutaneous nerve L Sciatic nerve M Common peroneal nerve N Tibial nerve O Sural nerve

L

3 The foot P Plantar nerve Q Calcaneal nerve

F

M

G

H

P

Q N

I

1

3

O

2

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A

Femoral nerve test

B

Obturator nerve test

C

Tibialis posterior nerve test

D

Sural nerve test

E

Superficial peroneal nerve test

F

Deep peroneal nerve test

10

Figure 10.6 Basic neural tests performed on the lower quadrant (Butler 1989, Ellis & Hing 2008, Shacklock 2005, Zamorano 2013)

Functional assessment

Global functional tests

Neural tests

Visceral tests

Circulatory tests

Specific functional tests

Figure 10.7 Visceral tests in the algorithm sequence

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10 Figure 10.8 J

K

L

Cross-section of the visceral, myofascial and aponeurotic girdle at lumbar level Black lines – myofascial structures Red lines – visceral structures Blue lines – aponeurotic structures

M

I H G F E D C B

N O P Q R

A

A B C D E F G H I J K L

Rectus abdominis Gallbladder Pancreas Transversus abdominis Internal oblique External oblique Kidney Serratus posterior inferior Latissimus dorsi Quadratus lumborum Psoas major Erector spinae and transversospinalis musculature

M N O P Q R

Peritoneal cavity Small intestine Large intestine Stomach Parietal peritoneum Visceral peritoneum

Viscerofascial dysfunctions criteria in myofascial induction approaches

of response, adjustment, and feedback (Vaticon 2009) which is:

Fascial entrapments can create disorders in the viscerofascia and can subsequently facilitate the formation of, for example, gastrointestinal dysfunctions. ° is observation not only suggests the presence of speciÿ c pathologies (e.g., visceral), but also disorders in the dynamics of movement between and within the viscera, as well as between the viscerofascial and myofascial structures. ° e sti˛ ness or decreased mobility of viscera may encourage the formation of ÿ brosis. An example of this process is the response of Kup˛ er cells (stellate macrophages) that, through the process of mechanotransduction, recognize an increasing tension in the cellular environment. In˝ ammation of the liver, for example, is commonly associated with the activation of Kup˛ er cells (D’Mello & Swain 2011). ° is process also has been linked to sleep abnormalities, fatigue, and mood disorders (Aouizerat et al. 2009). ° rough the mechanoreceptors the fascial system is in a continuous process

• • • • • •

somatosomatic somatovisceral viscerovisceral viscerosomatic psychovisceral visceropsychic.

Real visceral pain may be minimized or overlooked as it is usually described just as a vague sense of discomfort, malaise, or oppression (Giamberardino 1999). Usually, the intensity of the pain is not consistent with the extent of the internal damage (Vecchiet et al. 1989). It should also be mentioned that symptoms related to visceral dysfunctions could manifest in areas other than the speciÿ c areas linked to the neuroanatomical organization of the metamere (referred pain). ° e

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convergence of visceral and somatic a˛ erent ÿ bers onto the same spinal sensory neurons leads to misinterpretation by the higher brain centers (O’Toole 2003). Referred hyperalgesia from viscera is frequently accompanied by trophic changes, typically a thickening of the subcutaneous tissue and some degree of local muscle atrophy (Fig. 10.9) (Giamberardino et al. 2003, Jänig & Häbler 1995). It can also produce strong autonomic and a˛ ective responses (Sikandar & Dickenson 2012). Visceral dysfunction has the potential to change the body’s overall mechanosensitivity (illness behavior) through neuroimmunologic mechanisms. One example of this is cytokine release in the brain caused by a vagal response related to liver toxicity (Olsen et al. 2011, Bilzer et al. 2006). It is not within the scope of this book to provide a detailed analysis of either viscerofascial anatomy or the clinical approaches for treating viscerofascial

Liver and gallbladder

10

structures. ° is is an extremely complex issue that requires extensive analysis. However, considering that in clinical practice the abdominal region, of all areas of the body, is the most examined and treated, the practitioner should be aware of the need to identify signs and symptoms originating from the viscerofascial system and to recognize red ˝ ags. When carrying out an examination of the abdomen the entire area should be uncovered, from the mammary region to the roots of the extremities, and the whole abdominal area should be examined.

It is recommended that the practitioner performs a basic assessment of the abdominal wall (Ferguson 1990):

•

Visual examination: Note the shape of the abdomen, check for any skin abnormalities or abdominal masses, and note the movement of the abdominal wall with breathing.

Lung and diaphragm

Liver and gallbladder

Heart Stomach Pancreas Small intestine Appendix Urethra

Ovaries Colon Bladder

Kidneys

Figure 10.9 Referred visceral pain

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10 •

Palpation: Examine for crepitus, abdominal tenderness and/or the presence of pain and autonomic responses. ° e position of the hand during palpation of the abdominal area is shown in Figure 10.10.

° e other forms of physical exploration, auscultation and percussion, are used to examine for pathology of the abdominal region and are not covered here. ° e structures most likely to be a˛ ected by visceral dysfunctions are illustrated in Figure 10.11. ° e structures are described in Table 10.5. ° e anterior abdominal wall is topographically divided into nine areas (delineated by the red lines in Fig. 10.11). ° ese areas are divided by two vertical lines corresponding to extensions of the midclavicular lines and continuing down to the midpoint of the inguinal ligament. ° e horizontal upper line is tangential to the costal margin and the lower horizontal line is at the level of the two anterior superior iliac spines. Each of these areas is associated with a particular group of organs. If a visceral dysfunction is present, semiological

Figure 10.10 Abdominal palpation using the two-handed method

A

D

B C

E H

Figure 10.11 The structures most frequently involved in viscerofascial dysfunctions

F G

I

A B C D E F G H I

Cardia Stomach Pylorus Gallbladder Sphincter of Oddi Ileocecal valve McBurney’s point Ureter Sigmoid colon

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10

Table 10.5 The structures most likely to be affected by viscerofascial dysfunctions Visceral structure

Description

Cardia

The area immediately surrounding the opening of the esophagus into the stomach. The sphincter of the cardia helps to reduce the reflux of stomach contents back up into the esophagus. The orientation of the esophagus as it enters the stomach also provides a natural closure for the cardia as the stomach fills and distends

Stomach

A muscular, J-shaped organ in the abdomen. The stomach stores and digests food through gastric juices and a specialized churning action created by folds on its inside

Pylorus

A muscular sphincter (a ring of muscle in a tubular organ) that regulates the movement of digested stomach contents, from the stomach to the duodenum, and prevents backflow of duodenal contents into the stomach

Gallbladder

A pear-shaped, hollow structure located under the liver and on the right side of the abdomen. Its primary function is to store and concentrate bile, a yellow-brown digestive enzyme produced by the liver. The gallbladder is part of the biliary tract

Sphincter of Oddi

A muscular valve that controls the flow of digestive juices (bile and pancreatic juice) through ducts from the liver and pancreas into the first part of the small intestine (duodenum). Sphincter of Oddi dysfunction (SOD) is when the sphincter does not relax at the appropriate time (due to scarring or spasm). The back-up of juices causes episodes of severe abdominal pain

Ileocecal valve

Located between the ileum (final part of the small intestine) and the cecum (first part of the large intestine), its function is to allow digested food material to pass from the small intestine into the large intestine. The ileocecal valve also prevents these waste materials from backing up into the small intestine. It is meant to be a one-way valve that only opens to allow digested food to pass through

McBurney’s point

A point above the anterior superior spine of the ilium located on a straight line joining that process and the umbilicus where pressure of the finger elicits tenderness in acute appendicitis

Ureter

A tube 10 to 12 inches long that carries urine from the kidney to the urinary bladder. The tube has thick, fibrous, muscular walls coated in mucus which are able to contract. There are two ureters, one attached to each kidney. The upper half of the ureter is located in the abdomen and the lower half is located in the pelvic area

Sigmoid colon

A curved, S-shaped region of the large intestine which is the final segment of the colon. It transports fecal matter from the descending colon to the rectum and anus

manifestations relating to certain diseases can appear in the given area during assessment (Ferguson 1990).

Gastrointestinal dysfunctions criteria (Rome IV) (Fig. 10.13)

Figure˜ 10.12 indicates the potential semiological manifestations in each area.

To facilitate clinical decision making, it is recommended that the Rome IV criteria, which refer to gastrointestinal disorders resulting from an alteration in the gut–brain interaction, be used. Previously, in Rome III, the criteria referred only to gastrointestinal functional disorders. In Rome IV a markedly biopsychosocial point of view can be seen, in addition to the inclusion

The relationship of each area with potential abdominal dysfunctions or pathology as outlined in this chapter is for information only and does not, under any circumstances, obviate the need for specialized assessment performed by a physician.

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10 Right hypochondriac

Epigastric

Gallstones Stomach ulcer Pancreatitis

Stomach ulcer Indigestion Pancreatitis Epigastric hernia

Right lumbar

Umbilical

Left lumbar

Right inguinal

Hypogastric

Left inguinal

Kidney stones Urinary infection Constipation Lumbar hernia

Appendicitis Pelvic pain Groin pain

Pancreatitis Early appendicitis Stomach ulcer Inflammatory bowel disease Umbilical hernia

Urinary infection Appendicitis Diverticular disease Inflammatory bowel disease Pelvic pain (gynecological origin)

Left hypochondriac Stomach ulcer Duodenal ulcer Biliary colic Pancreatitis

Kidney stones Diverticular disease Constipation Inflammatory bowel disease

Figure 10.12 Anatomical areas of the anterior abdominal wall and the potential semiological manifestations in each area. Note: the relationship of each area with potential abdominal dysfunctions or pathology is shown here for information only and must not, under any circumstances, replace the need for specialized assessment performed by a physician

Diverticular disease Pelvic pain (gynecological origin) Groin pain (inguinal hernia)

Figure 10.13 Rome IV Criteria for gastrointestinal disorders

Rome A Esophageal disorders

Rome E Gallbladder and sphincter of Oddi disorders

Hepatic disorders? Rome D Centrally mediated disorders of gastrointestinal pain Urogenital disorders?

Rome B Gastroduodenal disorders Rome C Bowel disorders Rome F Anorectal disorders

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of multiple factors that are re˝ ected in the following deÿ nition:

The new definition created by the Board of Directors was shared among the chairs and co-chairs of the Rome IV committees to obtain feedback for modification and, ultimately, approval. The agreed-upon definition is as follows: functional GI disorders are disorders of gut–brain interaction. It is a group of disorders classified by GI symptoms related to any combination of the following: motility disturbance, visceral hypersensitivity, altered mucosal and immune function, altered gut microbiota, and altered central nervous system (CNS) processing. (Drossman 2016) Rome IV Criteria (Drossman & Hasler 2016) ° e criteria have to be fulÿ lled for the last six months with symptom onset at least three months prior to diagnosis. A. Esophageal Disorders A1. Functional chest pain A2. Functional heartburn A3. Re˝ ux hypersensitivity A4. Globus A5. Functional dysphagia B. Gastroduodenal Disorders B1. Functional dyspepsia B1a. Postprandial distress syndrome (PDS) B1b. Epigastric pain syndrome (EPS) B2. Belching disorders B2a. Excessive supragastric belching B2b. Excessive gastric belching B3. Nausea and vomiting disorders B3a. Chronic nausea vomiting syndrome (CNVS) B3b. Cyclic vomiting syndrome (CVS) B3c. Cannabinoid hyperemesis syndrome (CHS) B4. Rumination syndrome C. Bowel Disorders C1. Irritable bowel syndrome (IBS) IBS with predominant constipation (IBS-C)

10

IBS with predominant diarrhea (IBS-D) IBS with mixed bowel habits (IBS-M) IBS unclassiÿ ed (IBS-U) C2. Functional constipation C3. Functional diarrhea C4. Functional abdominal bloating/distension C5. Unspeciÿ ed functional bowel disorder C6. Opioid-induced constipation D. Centrally Mediated Disorders of Gastrointestinal Pain D1. Centrally mediated abdominal pain syndrome (CAPS) D2. Narcotic bowel syndrome (NBS)/opioid-induced GI hyperalgesia E. Gallbladder and Sphincter of Oddi (SO) Disorders E1. Biliary pain E1a. Functional gallbladder disorder E1b. Functional biliary SO disorder E2. Functional pancreatic SO disorder F. Anorectal Disorders F1. Fecal incontinence F2. Functional anorectal pain F2a. Levator ani syndrome F2b. Unspeciÿ ed functional anorectal pain F2c. Proctalgia fugax F3. Functional defecation disorders F3a. Inadequate defecatory propulsion F3b. Dyssynergic defecation G. Childhood Functional GI Disorders: Neonate/ Toddler G1. Infant regurgitation G2. Rumination syndrome G3. Cyclic vomiting syndrome (CVS) G4. Infant colic G5. Functional diarrhea G6. Infant dyschezia G7. Functional constipation

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10 H. Childhood Functional GI Disorders: Child/ Adolescent H1. Functional nausea and vomiting disorders syndrome H1a. Cyclic vomiting syndrome (CVS) H1b. Functional nausea and functional vomiting H1b1. Functional nausea H1b2. Functional vomiting H1c. Rumination syndrome H1d. Aerophagia H2. Functional abdominal pain disorders H2a. Functional dyspepsia H2a1. Postprandial distress H2a2. Epigastric pain syndrome H2b. Irritable bowel syndrome (IBS) H2c. Abdominal migraine H2d. Functional abdominal pain ‒ not otherwise speciÿ ed H3. Functional defecation disorders H3a. Functional constipation H3b. Non-retentive fecal incontinence.

Red flags: Assessment of viscerofascial components (Adapted from Holten & Wetherington 2003)

•

Acute gastrointestinal bleeding (e.g., blood in the stool, vomiting blood).

•

Change in bowel habits (e.g., acute diarrhea, severe constipation).

•

Inability to have a bowel movement or pass gas from the rectum.

•

Inability to swallow (aphagia).

Functional assessment

Global functional tests

Neural tests

•

Jaundice (yellowing of the skin and eyes caused by excess bilirubin [pigment in bile] in the blood).

• • •

Severe abdominal pain or swelling (distention).

•

Presence of autonomic responses during palpation.

Uncontrolled vomiting. Unexplained fever (may be caused by infection of the digestive tract).

Lymphatic and superficial circulatory components: Circulatory tests (Fig.10.14) ° e lymphatic system is a network of tissues and organs that helps the body to drive out toxins, waste and other unwanted materials. ° is extensive system takes care of three major body functions (Cueni & Detmar 2008):

•

Drainage of excess interstitial ˝ uid (regulation of tissue pressure) and proteins back to the systemic circulation.

•

Regulation of immune responses by both cellular and humoral mechanisms.

•

Absorption of lipids from the digestive system.

° e lymphatic system can also contribute to the development of diseases such as lymphedema, cancer metastasis, and various in˝ ammatory disorders (Mallick & Bodenham 2003).

Anatomy of the lymphatic system In the human body the lymphatic system is organized in the form of lymphatic vessels, lymph nodules, and nodes (Fig. 10.15). Humans have approximately

Visceral tests

Circulatory tests

Specific functional tests

Figure 10.14 Superficial circulatory tests in the algorithm sequence

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10

Figure 10.15 Diagram of the lymphatic system. 1 Anterior view. 2 Posterior view A Lymphatic vessels B Lymph nodules C Lymph nodes

B

C A B A

C

A C

A 1

500–600 lymph nodes distributed throughout the body, with bundles found in the underarms, groin, neck, chest, and abdomen. Lymphatic capillaries join to form lymph venules and veins that drain via regional lymph nodes into the thoracic duct on the le˙ side or the right lymphatic duct; from there, the lymph ˝ ows back into the bloodstream (Fig. 10.16) (Mallick & Bodenham 2003, Hematti 2011). ° e arrows on the ÿ gure indicate the directions of lymphatic drainage. Note:

•

° e thoracic duct (le˙ lymphatic duct) is the largest of the body’s lymphatic ducts. It collects almost all of the lymph that circulates throughout the body. It is located in the mediastinum of the pleural cavity which drains lymph ˝ uid from everywhere except the upper right quarter of the body above the diaphragm and down the midline.

•

° e lymphatic duct (right thoracic duct) drains lymphatic ˝ uid from the right thoracic cavity, the right

2

arm, and from the right side of the neck and the head. ° is duct is located near the base of the neck and runs along the medial border of the anterior scalene muscle at the side of the neck.

Lymphatic nodes of the lower quadrant ° e main lymphatic nodes of the lower quadrant are those of the lower extremities and the abdominal area:

•

° e popliteal nodes and the inguinal nodes represent the principal node groups of the lower extremities. As with veins, there are superÿ cial and deep lymphatic vessels, and their distribution is similar to that of the superÿ cial and deep venous system. ° e main communication between superÿ cial and deep lymphatic ˝ ows is conducted through the popliteal and inguinal lymph nodes (Latorre et al. 2005).

•

° e lymphatic system of the abdomen is formed by the lymphatic trunks, the parietal nodes, and the

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10 Figure 10.16 A

B

Lymphatic drainage areas. The arrows indicate the directions of lymphatic drainage. 1 Anterior view. 2 Posterior view A Area drained by the lymphatic duct B Area drained by the thoracic duct C Location of the lymphatic ducts D Location of the thoracic duct

C

D

1

2

visceral nodes. ° e lymph proceeding from the entire retroperitoneal plexus is collected by the lumbar trunks, which are the principal origin of the thoracic duct (Latorre et al. 2005).

performs a basic assessment of the lymphatic system in the areas a˛ ected by fascial dysfunction as outlined below.

•

▶ Inspection:

Biomechanics of lymphatic nodes

° abdomen: ascites (˝ uid collection in the perito-

In order to maintain continuous lymph ˝ ow, the presence of local, intermittent external forces acting on lymphatics is essential. According to Mallick & Bodenham (2003), these forces come from:

• •

muscle contraction

• •

arterial pulsation

neal cavity)

° lower extremities: color, edema, lesions, hair distribution, varicosities.

▶ Palpation of lymph nodes:

° location, size, mobility, consistency, delinea-

activities of parts of the body (e.g., breathing patterns)

tion, increased vascularity, shape, tenderness, warmth, erythema. ° e palpation of inguinal nodes is shown in Figure 10.17.

external forces acting on the body.

Assessment of the lower quadrant lymphatic system Given the fact that the lymphatic system (as other circulatory systems) interacts closely with the fascial system, fascial dysfunctions may a˛ ect its proper functioning. For this reason, it is recommended that the practitioner

Order of assessment:

▶ Ausculation.

•

Symptoms of dysfunction:

peripheral

vascular–lymphatic

▶ swelling ▶ limb pain

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The assessment process

10

Specific functional tests (Fig. 10.18) Speciÿ c functional tests are the routine tests frequently used in orthopedic exploration in various modalities of manual therapy. ° e objective of a functional test is to identify local dysfunctions linked to alterations in ROM, muscle strength, resistance, or speed, and it can be in the form of a movement or provocative test focused on pain. It is also recommended to analyze the quality of movement in relation to the presence of compensatory processes. Speciÿ c functional tests should be used to monitor the progress of a localized therapeutic process. However, it is recommended that the ÿ ndings of these tests be analyzed in relation to the global assessment. Examples of speciÿ c functional tests are shown in Figure 10.19 and will be explained in the chapters in Part 2 of this book.

Figure 10.17 Palpation of inguinal nodes

Palpatory tests

▶ changes in sensation ▶ fatigue.

Red flags

•

Persistent swollen lymph node or nodes for more than six weeks.

• • • •

Lymph node is ÿ rm, hard, and red.

• •

Exposure to HIV or hepatitis.

Lymph node is more than 2 cm in size. Lymph node is rapidly increasing in size. Signiÿ cant unintentional weight loss, night sweats, or loss of appetite. Unexplained fever in a returning traveler.

Functional assessment

Global functional tests

Neural tests

Palpatory assessment of the fascial system is an indispensable part of the analysis of body movement. ° ere is usually a correspondence between changes in the fascial system and alterations of its mechanical aspects and the quality of movement. It is clinically important to integrate the information obtained during palpation to assess changes in the temperature, humidity, consistency, sliding quality, and degree of tissue irritability. In this process the practitioner touches the patient’s body using di˛ erent degrees of pressure with speciÿ c parts of their hands. Progressive palpation is recommended beginning with the surface structures (skin and superÿ cial fascia) and moving on to the deeper structures. At the superÿ cial level, attention should be paid to the speed, range,

Visceral tests

Circulatory tests

Specific functional tests

Figure 10.18 Specific functional tests in the algorithm sequence

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10

A

B

C

Figure 10.19 A A modified Thomas test for assessing psoas muscle elasticity and the neuromechanics of the femoral nerve. B The Derifield–Thompson test for leg length inequality used to assess sacroiliac joint dysfunction. C The piriformis muscle test is used to rule out conflict with the sciatic nerve

facility, and continuity of movement of the skin in conjunction with the superÿ cial fascia. ° e sensitive areas should be palpated at the end. ° e deepest restrictions involve the deep fascia: myofascia, aponeuroses, tendons, and joint capsules. Taut bands and trigger points should be identiÿ ed. Generally, palpatory assessment focuses on the mechanical aspects of the fascial system and mechanosensitivity (Fig. 10.20).

• • • • •

° e mechanical aspects relate to: tissue texture hyposensitivity or hypersensitivity surface restrictions local range of movement end feel.

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The assessment process

Autonomic response

TPs in taut bands

Restriction at deep levels

Skin quality (Skin mobility)

Speed

10

Palpatory assessment

Range

Facility

Continuity

Figure 10.20 Assessment using selective tension. It is clinically important to use palpation as part of the assessment and integrate the information obtained during palpation to assess changes in the temperature, humidity, consistency, sliding quality, and degree of tissue irritability. TPs – trigger points

° e mechanosensitive aspects of the fascial system relate to:

•

•

Target tissue mechanosensitivity. Hypersensitivity or mechanical allodynia of the tissue (skin, superÿ cial fascia, muscle, viscera, or joint) that occurs before the progressive tensile loading of the fascial tissue. Neuroprotective response. A protective and/or premature muscular activation that occurs before the application of the tensile loading of the fascial tissue, and is associated with hypervigilance, avoidance, and fear relating to the application of the load.

Conclusion Assessment of the fascial system in relation to movement dysfunction is not an easy task. It has to be a patient-focused approach. Clinical reasoning should include three stages of learning:

•

▶ biomechanics based on an anatomical and mainly topographic approach ▶ evidence-based therapy focused on a theoretical framework

Analysis of the mechanical aspects of the fascial system includes:

•

•

Tensile load test. Segmental (osteocinematic), intersegmental (arthrokinematic) movement and target tissue manipulation are applied to explore the “availability” of fascial tissue deformation. Exploration of tension through palpation. ° is is the use of palpation to determine the state of tension of the fascial system.

As touch is linked to emotion, attention should also be paid to autonomic responses (see Chapter 8).

Orthodox or dogmatic reasoning:

▶ psychosocial aspects.

•

Advanced reasoning: ▶ biomechanics based on neurophysiology ▶ evidence-based therapy focused on the patient ▶ psychoneuroimmunological aspects.

•

Integrated reasoning: ▶ clinical orientation ▶ clinical experimental learning.

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10

REFERENCES

Aouizerat BE, Dodd M, Lee K, West C, Paul SM, Cooper BA, Wara W, Swi˙ P, Dunn LB, Miaskowski C (2009) Preliminary evidence of a genetic association between tumor necrosis factor and the severity of sleep disturbance and morning fatigue. Biol Res Nurs 11(1):27–41. Aruin A, Ota T, Latash ML (2001) Anticipatory postural adjustments associated with lateral and rotational perturbations during standing. JˇElectromyogr Kinesiol 11(1):39–51. Beales DJ, O’Sullivan PB, Bri˛ a NK (2009) Motor control patterns during an active straight leg raise in chronic pelvic girdle pain subjects. Spine (Phila Pa 1976) 34(9):861–870. Becker RE (1963) Diagnostic touch: Its principles and application (Pt. I). AAO Yearbooks. 63:32–40. Bernstein N (1967) ° e Coordination and Regulation of Movement. London: Pergamon Press. Bilzer M, Roggel F, Gerbes AL (2006) Role of Kup˛ er cells in host defense and liver disease. Liver Int 26(10):1175–1186. Binkley JM, Stratford PW, Lott SA, Riddle DL (1999) ° e Lower Extremity Functional Scale (LEFS): Scale development, measurement properties, and clinical application. North American Orthopaedic Rehabilitation Research Network. Phys ° er 79(4):371–383. Bongaardt R, Mejijer OG (2000) Bernstein’s theory of movement behavior: Historical development and contemporary relevance. J Mot Behav 32(1):57–71. Bullock-Saxton J (1993) Postural alignment in standing: A repeatability study. Aust J Physiother 39:25–29. Butler DS (1989) Adverse mechanical tension in the nervous system: A model for assessment and treatment. Aust J Physiother 35:227–238. Chmielewski TL, Hodges MJ, Horodyski M Bishop MD, Conrad BP, Tillman SM (2007) Investigation of clinician agreement in evaluating movement quality during unilateral lower extremity functional tasks: A comparison of 2 rating methods. J Orthop Sports Phys ° er 37(3):122–129.

Cobb SVG, Nichols SC (1998) Static posture tests for the assessment of postural instability a˙ er virtual environment use. Brain Res Bull 47(5):459–464.

Drossman DA (2016) Functional gastrointestinal disorders: History, pathophysiology, clinical features, and Rome IV. Gastroenterology 150(6):1262–1279.

Conrad JM, Stanitski CL (2003) Osteochondritis dissecans: Wilson’s sign revisited. Am J Sports Med 31(5):777–778.

Drossman DA (Senior Ed.) (2017) Rome IV. Functional Gastrointestinal Disorders: Disorders of Gut-Brain Interaction. 4th ed. Available: https://theromefoundation.org/romeiv/ [accessed October 14, 2019].

Cook CE (2007) Orthopedic Manual ° erapy: An Evidence-Based Approach. Upper Saddle River, NJ: Pearson Education. Coppieters MW, Crooke JL, Lawrenson PR Khoo SJ, Skulstad T, Bet-Or Y (2015). A modiÿ ed straight leg raise test to di˛ erentiate between sural nerve pathology and Achilles tendinopathy. A cross-sectional cadaver study. Man ° er 20(4):587–591. Crossley KM, Zhang WJ, Schache AG, Bryant A, Cowan SM (2011) Performance on the single-leg squat task indicates hip abductor muscle function. Am J Sports Med 39(4):866–873. Cueni LN, Detmar M (2008) ° e lymphatic system in health and disease. Lymphat Res Biol 6(3–4):109–122. Davies SC, Hill AL, Holmes RB, Halliwell M, Jackson PC (1994) Ultrasound quantitation of respiratory organ motion in the upper abdomen. Br J Physiol 67(803):1096–1102. Debaere F, Wenderoth N, Suaert S, Van Hecke P, Swinnen SP (2003) Internal vs external generation of movements: Di˛ erential neural pathways involved in bimanual coordination performed in the presence or absence of augmented visual feedback. Neuroimage 19(3):764–776. DiMattia MA, Livengood AL, Uhl TL, Mattacola CG, Malone TR (2005) What are the validity of the single-leg-squat test and its relationship to hip-abduction strength? J Sport Rehabil 14(2):108–123. D’Mello C, Swain M (2011) Liver–brain in˝ ammation axis. Am J Physiol Gastrointest Liver Physiol 301(5):G749–G761. Drossman DA (2006) ° e functional gastrointestinal disorders and the Rome III process. Gastroenterology 130(5):1377–1390.

Drossman DA, Hasler WL (2016) Rome IV-functional GI disorders: Disorders of gut-brain interaction. Gastroenterology 150(6):1257–1261. Eccles JC (1957) ° e Physiology of Nerve Cells. Baltimore: ° e Johns Hopkins Press, pp. ix+270. 30s. Ellis RF, Hing WA (2008) Neural mobilization: a systematic review of randomized controlled trials with an analysis of therapeutic eˆ cacy. JˇMan Manip ° er 16(1):8–22. Fedorak C, Ashworth N, Marshall J, Paull H (2003) Reliability of the visual assessment of cervical and lumbar lordosis: How good are we? Spine (Phila Pa 1976) 28(16):1857–1859. Ferguson CM (1990) Chapter 93 Inspection, auscultation, palpation, and percussion of the abdomen. In: Walker HK, Hall WD, Hurst JW (Eds.) Clinical Methods: ° e History, Physical, and Laboratory Examinations. 3rd ed. Butterworth-Heinemann. Flynn TW, Cleland JA, Whitman JM (2008) Users’ Guide to the Musculoskeletal Examination: Fundamentals for the Evidence-Based Clinician. Buckner, KY: Evidence in Motion. Foerster O (1936) ° e motor system in man in the light of Hughlings Jackson’s doctrines. Brain 59:135–159. Giamberardino MA (1999) Recent and forgottenˇaspects of visceral pain. Eur J Pain 3(2): 77–92. Giamberardino MA, A˛ aitati G, Lerza R, Fanò G, Fulle S, Belia S, Lapenna D, Vecchiet L (2003) Evaluation of indices of skeletal muscle contraction in areas of referred hyperalgesia from an artiÿ cial ureteric stone in rats. Neurosci Lett 338(3):213–216.

238

Pilat_Myofascial Induction.indb 238

03/12/21 4:15 PM

REFERENCES

Gibson JJ, Gibson E (1955) Perceptual learning: Di˛ erentiation or enrichment? Psychol Rev 62:32–41.

Key J (2013) ‘° e core’: Understanding it, and retraining its dysfunction. J Bodyw Mov ° er 17:(4)541–559.

Goldenberg G (2014) Apraxia – the cognitive side of motor control. Cortex 57:270–274.

Key J, Cli˙ A, Condie F, Harley C (2008) A model of movement dysfunction provides a classiÿ cation system guiding diagnosis and therapeutic care in spinal pain and related musculoskeletal syndromes: A paradigm shi˙ -Part 1. J Bodyw Mov ° er 12(1):7–21.

Gurney B (2002) Leg length discrepancy. Gait & Posture 15(2):195–206. Gurney B, Mermier C, Robergs R, Gibson A, Rivero D (2001) E˛ ects of limb-length discrepancy on gait economy and lower-extremity muscle activity in older adults. J Bone Joint Surg Am 83(6):907–915. Harris-Hayes M, Van Dillen LR, Sahrmann SA (2005) Classiÿ cation, treatment and outcomes of a patient with lumbar extension syndrome. Physiother ° eory Pract 21(3):181–196. Hematti H (2011) Anatomy of the thoracic duct. ° orac Surg Clin 21(2):229–238. Holten KB, Wetherington A, Bankston L (2003) Diagnosing the patient with abdominal pain and altered bowel habits: Is it irritable bowel syndrome? Am Fam Physician 67(10):2157–2162. Ishida H, Watanabe S (2013) Changes in lateral abdominal muscles’ thickness immediately a˙ er the abdominal drawing-in maneuver and maximum expiration. J Bodyw Mov ° er 17(2): 254–258. Janda V (1996) Evaluation of muscular imbalance. In: Liebenson C (Ed.) Rehabilitation of the Spine: A Practitioner’s Manual. Baltimore: Williams & Wilkins. Jänig W, Häbler H-J (1995) Visceral autonomic integration. In: Gebhart GF (Ed.) Visceral Pain. Progress in Pain Research and Management, Vol. 5. Seattle: IASP Press, pp. 311–348. Jones M (1992) Clinical reasoning in manual therapy. Phys ° er 72(12):875–884. Kartal (2014) Comparison of static balance in di˛ erent athletes. Anthropologist 18(3):811–815. Key J (2010) ° e pelvic crossed syndromes: A re˝ ection of imbalanced function in the myofascial envelope; a further exploration of Janda’s work. J Bodyw Mov ° er 14(3):299–301.

Kibler WB, Press J, Sciascia A (2006) ° e role of core stability in athletic function. Sports Med 36(3):189–198. Kulas AS, Hortobagyi T, DeVita P (2012) Trunk position modulates anterior cruciate ligament forces and strains during a single-leg squat. Clin Biomech (Bristol, Avon) 27(1):16–21. Latash ML (2008) Neurophysiological Basis of Movement. 2nd ed. Leeds, UK: Human Kinetics. Latash ML (2010) Motor synergies and the equilibrium-point hypothesis. Motor Control 14(3):294–322. Latash ML, Levin MF, Scholz JP, Schöner G (2010) Motor control theories and their applications. Medicina (Kaunas) 46(6):382–392. Latorre J, Ciucci J, Rosendo A (2005) Anatomía del sistema linfático del miembro inferior. Anales de Cirugía Cardíaca y Vascular 11(3):147–156. Liem T (Hrsg.) (2006) Morphodynamik in der Osteopathie. Stuttgart: Hippokrates-Verlag.

power of martial arts athletes. Med Biol Eng Comput 48(6):573–577. Mallick A, Bodenham AR (2003) Disorders of the lymph circulation: ° eir relevance to anaesthesia and intensive care. Br J Anaesth 91(2):265–272. Martin RL, Sekiya JK (2008) ° e interrater reliability of 4 clinical tests used to assess individuals with musculoskeletal hip pain. J Orthop Sports Phys ° er 38(2):71–77. Meadows JT (2000) Diagnóstico diferencial en ÿ sioterapia. Madrid: McGraw-Hill Interamericana. Mens JM, Vleeming A, Snijders CJ, Koes BW, Stam HJ (2001) Reliability and validity of the active straight leg raise test in posterior pelvic pain since pregnancy. Spine (Phila Pa 1976) 26(10):1167–1171. Oliver G, Detmar M (2002) ° e rediscovery of the lymphatic system: Old and new insights into the development and biological function of the lymphatic vasculature. Genes Dev 16:773–783. Olsen AL, Bloomer SA, Chan EP, Gaça MDA, Georges PC, Sackey B, Uemura M, Janmey PA, Wells RG (2011) Hepatic stellate cells require a sti˛ environment for myoÿ broblastic di˛ erentiation. Am J Physiol Gastrointest Liver Physiol 301(1):G110–G118. O’Toole M (2003) Miller-Keane Encyclopedia & Dictionary of Medicine, Nursing, & Allied Health. 7th ed. Saunders.

Lim JH, Ryu KN, Yoon Y, Lee SW, Ko YT, Choi WS, Lee DH (1990) Medial extent of the posterior renal fascia. An anatomic and computed tomography study. Clin Imaging 14(1):17–22; discussion 73–75.

Overduin SA, d’Avella A, Roh J, Bizzi E (2008) Modulation of muscle synergy recruitment in primate grasping. J Neurosci 28(4):880–892.

Longo UG, Loppini M, Denaro L, Ma˛ ulli N (2010) Rating scales for low back pain. Br Med Bull 94 (1):81–144.

Pavlů D, Novosádová K (2001) Contribution to the objectivization of the “method of sensomotor stimulation according to Janda and Vávrová” with regard to “evidence-based practice.” Rehabilitace a Fyzikalni Lekarstvi 8:178–181.

Luomajoki H, Kool J, de Bruin ED, Airaksinen O (2007) Reliability of movement control tests in the lumbar spine. BMC Musculoskelet Disord 8:90. Machado SM, Osório RA, Silva NS, Magini M (2010) Biomechanical analysis of the muscular

10

Perrott M, Pizzari T, Opar M, Cook J (2012) Development of clinical rating criteria for tests of lumbopelvic stability. Hindawi Publishing Corporation Rehabilitation Research and Practice 2012:803637; http://dx.doi.org/10.1155/2012/ 803637.

239

Pilat_Myofascial Induction.indb 239

03/12/21 4:15 PM

10

REFERENCES

Pilat A (2001) Principios del diagnóstico en terapia manual. Primer Congreso Nacional e Internacional de Fisioterapia, Caracas. Pilat A (2011) Myofascial induction approaches. In: Fernández-de-las-Peñas C, Cleland JA, Huijbregts PA (Eds.) Neck and Arm Pain Syndromes. Elsevier, pp. 455–475. Preece SJ, Willan P, Nester CJ, Graham-Smith P, Herrington L, Bowker P (2008) Variation in pelvic morphology may prevent the identiÿ cation of anterior pelvic tilt. J Man Manip ° er 16(2):113–117. Rivera M, Rioja ME, Burgos FJ, Ortuño J (2008) Dolor lumbar crónico e infecciones urinarias en una mujer joven [Chronic lumbar pain and urinary infections in a young woman]. Nefrologia 28(2):222–223. Ro˛ ey DM, Wai EK, Bishop P, Kwon BK, Dagenais S (2010) Causal assessment of awkward occupational postures and low back pain: Results of a systematic review. Spine J 10(1):89–99. Ross MD, Nordeen MH, Barido M (2003) Test-retest reliability of Patrick’s hip range of motion test in healthy college-aged men. J Strength Cond Res 17(1):156–161. Roussel N, Nijs J, Truijen S, Vervecken L, Mottram S, Stassijns G (2009) Altered breathing patterns during lumbo-pelvic motor control tests in chronic low back pain: A case-control study. Eur Spine J 18(7):1066–1077. Safavynia SA, Torres-Oviedo G, Ting LH (2011) Muscle synergies: Implications for clinical evaluation and rehabilitation of movement. Top Spinal Cord Inj Rehabil 17(1):16–24. Sahrmann SA (2002) Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis, MO: Mosby. Sergueef N, Greer MA, Nelson KE, Glonek T (2011) ° e palpated cranial rhythmic impulse (CRI): Its normative rate and examiner experience. Int J Osteopath Med 14(1):10–16. Shacklock M (2005) Improving application of neurodynamic (neural tension) testing and

treatments: A message to researchers and clinicians. Manual ° erapy 10(3):175–179. Shamsi M, Sarrafzadeh J, Jamshidi A, Arjmand N, Ghezelbash F (2017) Comparison of spinal stability following motor control and general exercises in nonspeciÿ c chronic low back pain patients. Clin Biomech (Bristol, Avon) 48:42–48. Shumway-Cook A, Woollacott MH (2007) Motor Control – Translating Research into Clinical Practice. Philadelphia: Lippincott Williams & Wilkins. Sikandar S, Dickenson AH (2012) Visceral pain: ° e ins and outs, the ups and downs. Curr Opin Support Palliat Care 6(1):17–26. Simpson R, Gemmell H (2006) Accuracy of spinal orthopaedic tests: A systematic review. Chiropr Osteopat 14:26. Standring S (Ed.) (2004) Gray’s Anatomy: ° e Anatomical Basis of Clinical Practice. 39th ed. Edinburgh: Churchill Livingstone, p. 1220. Stratford PW, Binkley JM, Riddle DL (2000) Development and initial validation of the back pain functional scale. Spine (Phila Pa 1976) 25(16):2095–2102. Stuge B, Garratt A, Krogstad Jenssen H, Grotle M (2011) ° e pelvic girdle questionnaire: A condition-speciÿ c instrument for assessing activity limitations and symptoms in people with pelvic girdle pain. Phys ° er 91(7):1096–1108. Suramo I, Paivansalo M, Myllyla V (1984) Cranio-caudal movements of the liver, pancreas and kidneys in respiration. Acta Radiol Diagn (Stockh) 25(2):129–131.

Vecchiet L, Giamberardino MA, Dragani, Albe-Fessard D (1989) Pain from renal/ureteral calculosis: Evaluation of sensory thresholds in the lumbar area. Pain 36(3):289–295. Vincenzino G, Twomey L (1993) Side˝ exion induced lumbar spine conjunct rotation and its in˝ uencing factors. Aust J Physiother 39(4): 299–306. Viel E (1999) Diagnóstico ÿ sioterapeutico. Barcelona: Masson. Vleeming A, Hanne B, Östgaard HO, Sturesson B, Stuge B (2008) European guidelines for the diagnosis and treatment of pelvic girdle pain, Eur Spine J 17(6):794–819. von Bertalan˛ y L (1951) General system theory; a new approach to unity of science. 1. Problems of general system theory. Hum Biol 23(4): 302–312. Weeks BK, Carty CP, Horan SA (2012) Kinematic predictors of single-leg squat performance: A comparison of experienced physiotherapists and student physiotherapists. BMC Musculoskelet Disord 13:207. Weir J, Darby H, Inklaar H, Koes BW (2010) Core stability: Inter-and intraobserver reliability of 6 clinical tests. Clin J Sport Med 20(1):34–38. Winter DA (1995) Human balance and posture control during standing and walking. Gait & Posture 3:193–214.

Tozzi P, Bongiorno D, Vitturini C (2011) Fascial release e˛ ects on patients with non-speciÿ c cervical or lumbar pain. J Bodyw Mov ° er 15(4): 405–416.

Woolsey et al. (2001) cited in Classiÿ cation of low back pain using Shirley Sahrmann’s movement system impairments, an overview of the concept. Available: https://www.physio-pedia.com/Classiÿ cation_Of_Low_Back_Pain_Using_Shirley_ Sahrmann%E2%80%99s_Movement_System_ Impairments,_An_Overview_Of_° e_Concept [accessed 2018].

Urban LM, MacNeil BJ (2015) Diagnostic accuracy of the slump test for identifying neuropathic pain in the lower limb. J Orthop Sports Phys ° er 45(8):596–603.

Youdas JW, Suman VJ, Garrett TR (1995) Reliability of measurements of lumbar spine sagittal mobility obtained with the ˝ exible curve. J Orthop Sports Phys ° er 21(1):13–20.

Vaticon D (2009) Sensibilidad miofascial libro de ponencias XIX. Jornadas de Fisioterapia EUF ONCE, Madrid, pp. 24–30.

Zamorano E (2013) Movilización Neuromenigea. Tratamiento de Trastornos mecano sensitivos delˇsistema nervioso, Panamericana, pp. 77–80.

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The objectives of Myofascial Induction Therapy ° e application of Myofascial Induction ° erapy (MIT) is recommended for therapeutic interventions that focus on the promotion and recovery of well-being at the same time as looking to improve the performance of activities that involve movement.

General procedures: Recommendations Taking this premise into account, the application of MIT procedures can be beneÿ cial in the following circumstances: 1. In the presence of pain (nociceptive, neuropathic, and mixed) and dysfunctions of the musculoskeletal system. In view of the mutability of painful clinical symptoms it is recommended that MIT be applied clinically and in subclinical stages as well as in cases of “uncomfortable” self-perception of the body state (anhedonia). 2. In painful syndromes that present with clinical features of central sensitization (ÿ bromyalgia, chronic fatigue, complex regional pain, etc.). 3. In patients that present with comorbidity along with clinical features linked to poorly adaptive social behaviors (depression) which are suspected to be related to dysfunctional performance of the body. 4. For the prevention of and recovery from sports injuries, for the optimization of performance, and to facilitate recovery from a state of transient immunosuppression induced by practicing physical exercise. 5. To stimulate the segmental and intersegmental stabilization of the spine, the lumbopelvic region, and the dynamics of peripheral joints. 6. Pain and craniofacial dysfunction syndromes. 7. Speech dysfunctions and swallowing disorders. 8. Degenerative processes of the locomotor system (arthrosis, aging process). 9. Chronic fatigue syndrome.

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10. Neurodegenerative disease dysfunctions. 11. Patients with postsurgical dysfunctions. 12. In syndromes where there is negative evaluation of a˛ ective body perception that could condition the feelings of subjective well-being of the individual. 13. Pediatric and neurodevelopmental motor disorders.

Complementary treatments ° e following complementary treatments or activities should be carried out, as applicable, in parallel with the application of MIT: 1. ° e practitioner should recommend appropriate nutrition and hydration. 2. ° e patient should be advised to follow optimal nutritional recommendations. 3. ° e patient should avoid proin˝ ammatory foods. 4. Global and functional exercise programs, adapted to the individual patient, are recommended to complement the treatment. 5. Breathing exercises and ventilatory re-education programs. 6. Pelvic ˝ oor re-education programs. 7. Self-performance of procedures focusing on the fascial system and following the practitioner’s instructions. 8. Postural care and daily activities, based on ergonomic principles. 9. Prevention and recovery of postural dysfunctions. 10. Muscle strengthening and neuromotor re-education programs should be carried out as a complementary activity, particularly in cases where joint instability is present. 11. Excessive anti-in˝ ammatory medication should be avoided unless prescribed by a doctor. 12. ° erapeutic swimming and other body work activities are recommended.

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11 13. ° e patient should be advised to practice low intensity activities that stimulate the metabolism through movement (walking, gentle running, cycling, etc.) once the treatment is ÿ nished. 14. Be aware of biorhythms, and pay particular attention to the patient’s sleeping patterns and the duration and quality of sleep.

Specific treatment goals ° e objectives of MIT are to:

connective structures, capacity for elastic deformation, and balanced transmission of forces. 6. Eliminate the allostatic load of the fascial system. 7. Facilitate the body’s immune response. 8. Facilitate the autonomous regulation of the neuroendocrine system. 9. Stimulate the dynamics and integration of the circulatory systems. 10. Improve the drainage of body ˝ uids.

1. Re-establish body homeostasis (main objective).

11. Restore the body’s electrolyte balance.

2. Focus on establishing an adequate state of pretension of the fascial system.

12. Contribute to the improvement of the functioning of the gastrointestinal tract, bronchopulmonary dynamics, and the genitourinary system.

3. Remodel the connective tissue matrix while establishing patterns of movement that re-educate altered patterns or aversive behaviors (kinesiophobia).

13. Modify the interoceptive allostatic load.

4. Restore the body’s communication processes.

14. Restore the patient’s hedonic perception of the body in relation to movement.

5. Normalize the variables that condition the optimal development of body movement: sliding between

15. Improve the patient’s body image.

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KEY POINTS •

The basis of the scientific approach to fascia

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Evidence from laboratory and clinical research

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Research from a philosophical viewpoint

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The systemic approach to the body as a basis for research

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Myofascial therapy and the evidence

Introduction Is it important to talk about fascia using scientific terminology? Is there sufficient reasoning to justify this? Do we have enough resources to be able to do this? ° ese days, the term research is employed in many contexts –from writing a new book to ÿ nding the car dealer with the best o˛ er. When used in the context of science, it refers to the progress of a scientiÿ c approach (the discovery and interpretation of facts). Scientiÿ c evidence in the health sciences is currently a prerequisite for all therapeutic procedures that involve the areas of clinical care, research, and education. All therapeutic protocols require a quantiÿ ed evaluation of their processes. By this means, our professional development can be supported, new therapeutic horizons can be discovered, and patients can be assured of increasingly safe and eˆ cient care. However, it is important to point out how diˆ cult it is to achieve this objective. In some therapeutic procedures, a lack of adequate assessment instruments, the diˆ culty of deÿ ning the accuracy of the procedures and measurable parameters, as well as the complexity of the e˛ ects derived from the therapy, make it almost impossible to quantify all the variables that are involved in a particular result, meaning it is diˆ cult to obtain research of high methodological rigor. ° e research

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model for pharmacological interventions allows an accurate quantiÿ cation of the results (changes). However, given the complexity of the processes derived from the application of manual therapy, unlike the application of drugs, it is diˆ cult to obtain similar methodological accuracy. Consequently, the majority of scientiÿ c trials focused on manual therapy do not reach the required levels of excellence, and the systematic review processes conclude with low evidence of therapeutic results. Simultaneously, laboratory research is referred to as scientiÿ c, leaving clinical evidence or experience to take second place, whereas the best approach would be to aim to match both activities (the research and the clinical) and, at the same time, allow for the active participation of the patient in the process. Ultimately, the achievement of the therapeutic process (patient satisfaction) is the goal we pursue. Recently, there have been impressive advances in our understanding of the importance of the role of fascia in body dynamics. Clinical experiences have been reinforced by the extent of progress in laboratory research. We are reÿ ning our hypotheses, attempting to remove the false truths, and perfecting assessment and treatment procedures. It is both an arduous and a fascinating task. ° ere is a long way to go. In this process, extensive collaboration between laboratory researchers and clinical scientists and mutual respect for hypotheses and the analyses of results are essential.

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12 We must not confuse scientiÿ c courage with dogmatic courage. A true scientist:

What does it mean that something has scientiÿ c validity?

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Is not one who is dedicated to statistically demonstrating the ine˛ ectiveness of something, but one who, moved by curiosity, investigates the possibilities which one way or another may be useful.

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In epistemology the validity of knowledge is the fact of its being recognized as a consistent set of true propositions by a given community – in this case the scientiÿ c community.

Knows that there are few absolute or universal truths and that at some point he or she will have to argue against them in some way.

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Is concerned with the quantitative reference value of statistics, analyzes data cautiously, and does not draw qualitative conclusions.

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Avoids bias in his or her research methodology and is open to results that are contrary to his or her intuition.

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Is aware that the number of parameters that in˝ uence a given event can be uncontrollable and experiments in the laboratory do not necessarily reproduce reality.

° e analysis of any phenomenon linked to life requires a philosophical framework. Without it we are le˙ in a vacuum without support. Greek philosophers, such as ° ales of Miletus (625–420 BC), observed the order and harmony present in nature and focused on how living organisms were assembled. ° ey associated the discovery of the functioning of the world with the functioning of the organism. ° ere is a reason why the philosophers of nature are called physiologists.

Evidence-based medicine within the framework of the philosophy of science The reality of a human being will be known only when his biological reality is understood. Evidence-based medicine (EBM), or evidence-based practice (EBP), has strongly in˝ uenced, in recent times, a kind of “judgment” on the validity or invalidity of physiotherapy and manual therapy interventions. MIT is naturally included in the professional practice of physiotherapy and other manual therapy approaches, and the research and validation process is common to all of these. By way of introduction to this subject it is useful to ask ourselves some questions.

Where do these true propositions come from? ° ey emerge from the cognitive processes of reality. ° e human being interprets reality, and in that interpretation there is an implicit bias that is derived, at least partly, from previous beliefs and ideas from their perceptive experience and their reasoning.

The philosophical basis of evidence-based practice Do previous beliefs have a philosophical basis? Scientiÿ c knowledge is based on a paradigm. A paradigm is a conceptual structure of methodological beliefs and intertwined theories that make up a concept of the world (worldview). From the Scientiÿ c Revolution to the present day, the mechanistic vision has been predominant. Rationalism, as deÿ ned by Descartes, has set the essential guidelines for the construction of the scientiÿ c paradigm. Do other epistemological streams exist to explain reality? Empiricism, phenomenology, and hermeneutics are part of the spectrum of epistemological streams that explain reality. ° ese forms of thinking are composed of other approaches to reality which sometimes can contradict the rationalist approach, but this does not mean they lack foundation or that they are far from reality. ° erefore, from a philosophical perspective science is a way of gaining access to an explanation of reality – if there is a way of gaining access – and it is not the only way. When explaining the nature of the human body, which is the main objective of biomedicine, we must bear in mind the type of approach used to explain it. Scientiÿ c method has a strong Aristotelian imprint in its reasoning. ° is can be seen in the implicit analytical logic applied to scientiÿ c research in which the isolation of the phenomenon to be studied is crucial in

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order not to “contaminate” or bias the interpretation of the results (Bassham 2016). ° is leads us to another question: Is it possible to isolate a process in the human body?

The systemic approach to scientific evidence According to von Bertalan˛ y (1951), the human body is a complex biological system (see Chapter 2). ° is means that it does not behave in an ordinary, logical sequence in which the “whole” is achieved by the sum of its parts, rather it acts in such a way that one part depends on the state of the others because it is not possible to isolate the parts from one other. We need to di˛ erentiate between a complicated system and a complex system. A complicated system has multiple elements; it can be assembled, disassembled, and reassembled without its operation being a˛ ected (e.g., a clock, an airplane). Complex systems are large networks, formed by elements that interact in a simple way, follow simple rules, and are capable of producing complex behaviors. Complex systems cannot be disassembled or reassembled. A complex system has to adapt to the interactions with or within the subsystems and at the same time it has the ability to adapt to environmental stimuli (suprasystem). It is in this complexity and in its role as a communicator that the fascial system participates, providing an environment that allows the integrated functioning of all body systems, thus facilitating the ÿ nal response. We can take as an example the fact that every year 60,000 studies are published in the exciting ÿ eld of neuroscience. Most studies are focused on a small corner of the brain: a molecule, a circuit, or a more or less known function. Only a minority of studies is dedicated to more ambitious or more inclusive projects. ° e scientiÿ c reality is that we still know too little about the functioning of the brain, and that current explanations are extremely speculative. However, this is not the impression that is conveyed to society. Neuroscience, as presented in the media, appears to be capable of dealing with and explaining the most complex issues ranging from antisocial behavior or the homosexual brain to decisions on economic matters or how to improve intellectual capacity.

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Evidence and the scientific method EBM, in addition to being critical, is criticized. Some authors, such as (Berwick 2005), estimate that EBM has surpassed its own brand, giving rise to an “intellectual hegemony” and leading to opacity in the methods of “pragmatic science” that are crucial to scientiÿ c discovery. British critical philosophers such as Howick (2011), Worrall (2007a, 2007b), and Cartwright (2012) have issues with “randomized double-blind systematic reviews” or ECA (gold standard EBM studies), claiming that these tests do not always control the biases they intend to control, do not produce generalizable reliable knowledge, or may apply unnecessary restrictions on clinical tests. Solomon (2011) referencing John Worrall states: John Worrall (2002, 2007a, 2007b) argues that randomization is just a way, and an imperfect way, of controlling the confounding factors that could produce bias. The problem is that randomization can control only most, but not all, confusing factors. When there are indefinitely many factors, both known and unknown, which can lead to a bias, it is likely that randomization does not succeed in eliminating all the factors. Most likely, any particular clinical trial has at least one type of bias, which makes the experimental group significantly different from the control group, just by accident. Another criticism of EBM is its practical transfer. Typically, RCTs are considered to provide 95ˇpercent conÿ dence levels and meta-analyses reach much higher conÿ dence levels. It follows that an RCT has a 5ˇpercent chance of producing a false positive (and a meta-analysis has a lower chance). However, Ioannidis (2005) conducted a study of 59 highly cited original research studies (in high-impact journals) and found that less than half (44ˇpercent) were replicated, 16ˇpercent were contradicted by later studies, and 16ˇ percent found that the e˛ ect is smaller than in the original study. ° ese data show quite a di˛ erent picture to the “incontrovertible” results shown in RCTs, or at least as declared by their many proponents. ° e interpretations of the results of research are not always of beneÿ t in clinical decision making. Other general criticisms of EBM are that it overlooks clinical expertise, intuition, the patient’s goals and values, and hermeneutical, political, and ethical aspects.

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12 Furthermore, when based on statistical results, critics emphasize that the application of these results to particular cases requires a set of skills that exceed statistics (Cohen et al. 2004). Some authors warn of the “distancing” of EBM from the basic sciences and advise caution in relation to “scientiÿ c superÿ ciality.” EBM does not model itself on or theorize about the entire organism, and even less so on its social and environmental context (Harari 2001). Charlton and Miles (1998) aˆ rm that EBM is “statistical rather than scientiÿ c.” Ashcro˙ (2004) ascribes that EBM is autonomous of the basic sciences” and “blind” to the mechanisms of explanation and causality. ° is “distancing” of EBM from the basic sciences has meant that in the last ÿ ve years a new approach to medical research has gained prominence internationally: “translational medicine” (not to be confused with alternative medicine). ° e objective of this current discipline is to facilitate greater interaction between basic science and clinical research. ° e fundamental goal is that researchers in basic sciences should have greater “physical proximity” to the clinic (Solomon 2011).

Scientific evidence and myofascial therapy Only a small number of systematic reviews of papers on the therapeutic e˛ ects of the application of myofascial therapy have been published. In a study carried out in 2019, Ajimsha and Shenoy state that a small number of systematic reviews have been carried out in this ÿ eld. ° ey also warn that existing systematic reviews are of moderate quality, and this is mostly due to the omission of the risk of bias. However, it is evident that there is a need to continue carrying out research that complies with the methodological suggestions established by critical reviews of systematic reviews in order to achieve quality papers that allow for the validation of “evidence-based myofascial therapy.” At present, when physical therapists (manual therapists) are beginning to enter the universe of basic sciences convincingly and with the aim of justifying our practices, we feel eclipsed by a “giant of truth” – a “truth” that o˙ en does not give rise to hypotheses that are justiÿ ed, based on basic sciences, and derived from high-impact research. Perhaps our lack of training in

philosophical and epistemological subjects does not encourage us to indiscriminately consume a reassuring formula from a deontological and conceptual point of view. Despite this, from the point of view of our evolution as a discipline, we have not yet been critical of our original fundamental bases. Shouldn’t we start there? Despite the enormous scientiÿ c progress of recent years, we are still unable to unravel the complexity of the functioning of organisms, and therefore we settle for a simpliÿ ed story to be able to explain it and reduce the anxiety of believing it to be incomprehensible and unpredictable. It is hard for us to admit to mistakes because that means giving up the security that these simpliÿ ed assumptions provide us with. Are we skipping a step? MIT as a practice of physical and manual therapy is currently (and this is re˝ ected in this publication) searching for its fundamental bases, which are the same as those of physical therapy and manual therapy. In the previous chapters of this book, the author has attempted to apply the basic sciences to clinical practice, which is the intention of translational health care today. An imminent scientiÿ c revolution in the knowledge of the body is anticipated. Little by little, it seems that systemic thought, the mind–body connection, the emotion–cognition relationship, the cell–extracellular matrix, etc. are remodeling the ruling and hegemonic mechanism. Interestingly, MIT practice focuses on the person in interaction with their biopsychosocial environment. We are convinced we do science and the proof is in our self-critical spirit, our focus on elementary biology and the philosophy of science, our continuing clinical practice, and above all our commitment to safety and ethics in professionally rendering physical and manual therapy. ° is does not mean that we should not carry out clinical trials, systematic reviews, etc. in parallel – quite the opposite in fact. It is vital for therapeutic evolution, the criteria of application, and the classiÿ cation of patients with the potential to beneÿ t from the myofascial approach to apply instruments that distance us from hypothetical speculations, anecdotal conclusions, and analytical biases (metacognition).

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Perhaps what is most relevant to the intervention is the criticism of the use of the results of EBM. ° ese results alone cannot direct a clinical or therapeutic intervention, cutting o˛ the necessary improvisation and creativity that the “therapeutic encounter” requires. What seems absurd in the face of scientiÿ c evidence today may not be absurd tomorrow. Future technology associated with the methodology may yield results that con˝ ict with those that we have today, and this applies both to results that are supported by EBM and those that are not.

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Scientific evidence for the application of MIT Speciÿ c studies about the e˛ ectiveness of MIT are in their incipient stages. However, similar therapies, such as myofascial release (MFR), contribute to our research. ° e conceptual and methodological di˛ erences between MIT and MFR are outlined in Chapter 1. Examples of clinical research into the e˛ ects of myofascial therapy on di˛ erent pathologies are outlined below.

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Neck and low back dysfunction and pain •

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Ünal et al. (2020) investigated the eˆ cacy of MIT versus pain neuroscience education (PNE) on pain and function (physical competence level, trunk mobility, fear-avoidance beliefs about physical activity and work) in patients with chronic low back pain (CLBP). To assess the outcome the authors applied objective measurement tools (ultrasound imaging of the thoracolumbar fascia) and commonly used measurement methods (“the fear-avoidance beliefs questionnaire (FABQ), Roland Morris disability questionnaire, McGill pain questionnaire, ÿ nger ˝ oor test, SF-36 quality-of-life questionnaire”). ° e authors concluded: “Although both MIT and PNE were found to be e˛ ective on pain and function in patients with CLBP, MIT techniques were substantially better in improving the mobility of trunk ˝ exion and quality of life in these patients.” Rodríguez-Fuentes et al. (2020) analyzed the cost-beneÿ t of myofascial therapy compared to manual therapy in occupational mechanical neck pain treatments. ° e variables in the outcomes of the intervention were intensity of neck pain, cervical

•

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disability, craniovertebral angle, ranges of cervical motion, and quality of life. ° e authors concluded that MIT appears to be more cost-e˛ ective for treating mechanical neck pain without the need to add any additional cost to obtain a better clinical beneÿ t. Arguisuelas et al. (2019) investigated 36 participants with chronic low back pain, randomly divided into two equal groups. ° e experimental group participants received four myofascial treatments and the participants in the control group received the sham treatment. ° e authors analyzed electromyographic and kinematic variables, as well as pain and disability questionnaires. ° e results showed that “the myofascial release protocol contributed to the normalization of the ˝ exion-relaxation response in individuals who did not show myoelectric silence before the intervention showing also a signiÿ cant reduction in pain and disability compared to the sham group.” In a review of the current literature on the e˛ ectiveness of manual therapy methods used to treat adolescent idiopathic scoliosis (AIS) Lotan and Kalichman (2019) concluded that manual therapy procedures such as myofascial release may potentially be e˛ ective in treating AIS in conjunction with other conservative treatments. However, they point out the need for more high-quality studies for deÿ nitive conclusions. Rodríguez-Huguet et al. (2018) investigated the efÿ cacy of myofascial therapy for improving pressure pain thresholds and pain permanence in patients with mechanical neck pain. ° e patients were randomly allocated to the myofascial therapy group and a multimodal physical therapy group (whose treatment included ultrasound therapy, transcutaneous electric nerve stimulation, and massage). ° e results were evaluated at the end of the treatment and a˙ er one month of follow-up. ° e study provides evidence of the superiority of myofascial therapy compared to the application of the multimodal physiotherapy treatment in the short-term improvement of pain and pressure pain thresholds (PPTs) in patients with neck pain. Gauns & Gurudut (2018) compared the e˛ ect of gross myofascial release of the upper limb and neck along with conventional physiotherapy against only

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•

•

•

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conventional treatment in subjects with mechanical neck pain referred to the upper limb in terms of cervical endurance, pain, range of motion, and function. ° e randomized, double-blind, controlled trial showed that fascial therapy was e˛ ective in changing all parameters, having a faster rate of improvement in relation to the control group. Kim and Lee (2018) conducted a study to see if pain could be reduced in the upper trapezius (UT) by applying interventions (so˙ tissue release) to the sternocleidomastoid (SCM) (which is innervated by the same nerves) in smartphone users with latent myofascial trigger points (MTrPs) in the UT. ° e study applied a single-blind, crossover design. Muscle hardness and the pressure pain threshold of the SCM and UT were assessed before and a˙ er the intervention. ° e researchers applied sternocleidomastoid so˙ tissue release and suboccipital release procedures. ° e authors concluded that to reduce pain in the UT it may be useful to apply interventions directly to the UT and also to the SCM, which is innervated by the same nerve. In a double-blind, randomized, parallel shamcontrolled trial with concealed allocation and intention-to-treat analysis Arguisuelas et al. (2017) investigated the e˛ ects of a myofascial release protocol on pain, disability, and fear-avoidance beliefs in patients with chronic lumbar pain. ° e researchers treated 54 participants and concluded that fascial therapy produced a signiÿ cant improvement in both pain and disability. Rodríguez-Fuentes et al. (2016), in a randomized, single-blind, parallel group study of patients with occupational mechanical neck pain, demonstrated that myofascial therapy appears to be more e˛ ective than manual therapy for correcting the forward head posture, recovering range of motion in side bending and rotation, and also improving quality of life. Chen et al. (2016) analyzed the tensional changes in the myofascial junctions of the transverse abdominal (TrA) muscle before and immediately a˙ er the application of sustained pressure (myofascial manual procedure) in patients with low back pain (LBP) and in asymptomatic participants. ° e assessment, using ultrasonography, demonstrated the immediate e˛ ect

of sustained manual pressure on the musculofascial junction of the TrA, thus supporting the concept of “the possible imbalanced tension of the myofascial corset of TrA in patients with LBP.”

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Tozzi et al. (2012) investigated nonspeciÿ c low back pain (LBP) in relation to kidney mobility. Using real-time ultrasound, this study demonstrated that “local osteopathic fascial manipulation decreased pain perception and improved renal mobility.”

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Tozzi et al. (2011) used dynamic ultrasound to test changes in sliding movements between the superÿ cial and deep fascial layers in a study of 30 patients with neck pain and 30 with low back pain of mechanical origin. ° e authors concluded that fascial therapy is an e˛ ective manual method to release an area of impaired fascial mobility and to improve pain perception for a short period in people with nonspeciÿ c neck and low back pain.

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In a double-blind study Urresti-López (2011) applied the suboccipital induction technique to 26 subjects with chronic neck pain. Electroencephalogram (EEG) changes were observed in the latency reduction in the experimental group, as compared to the control group. ° is result suggests that improvements in cognitive processes including concentration, memory activation, and associative states are associated with the P300 wave. Lack of changes in other EEG parameters discounted the in˝ uence of vascular modiÿ cations.

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Arguisuelas et al. (2010) demonstrated the e˛ ects of lumbar spine manipulation and thoracolumbar MIT on the spinae erector activation pattern.

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Signiÿ cant di˛ erences between the premeasurements and postmeasurements of pressure pain thresholds with decreasing sensitivity to myofascial trigger points were reported in various strained muscles, including the adductor longus (Roba & Pajaczkowski 2009), the upper trapezius muscle (Fryer & Hodgson 2005), and cervical muscle (Hou et al. 2002).

Pelvic floor dysfunction In recent years, there has been an increase in research that indicates the need to include fascia in the protocols for assessment, treatment, and prevention of pelvic

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˝ oor dysfunctions. Usually, pelvic ˝ oor dysfunctions are associated with women in relation to prolapse, incontinence, dysmenorrhea, sexual dysfunctions, or postpartum recovery complications. However, recent research has also included myofascial pelvic ˝ oor dysfunction in men and has discovered the usefulness of treatments focused on fascia in the therapeutic process. ° e research is broadly related to:

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chronic pelvic pain (Pastore & Katzman 2012);

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pelvic girdle joint hypermobility (Hastings et al. 2019);

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endometriosis (Aredo et al. 2017);

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chronic interstitial cystitis (Howard 2010);

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inclusion of myofascial release during pelvic ˝ oor physical therapy for overactive bladder (Wol˛ et al. 2020);

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sexual dysfunction in men (Anderson et al. 2006);

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chronic pelvic pain syndrome (CPPS) (Grinberg et al. [2019], analyzing the e˛ ectiveness of myofascial physiotherapy [MPT] procedures in treating CPPS, suggest inclusion of MPT as a mechanism-based

intervention, in light of the multisystemic [direct and indirect, anatomical, neurophysiological, and psychological] e˛ ects of MPT on CPPS multifactorial pain disorder).

Upper extremity dysfunction •

In a study of groups of computer professionals who were experiencing pain and the functional disability of lateral epicondylitis, Ajimsha et al. (2012) compared the results of myofascial procedures applied to one group with the results of a control group that received sham ultrasound therapy. ° e authors concluded that MFR is more e˛ ective than a control intervention for lateral epicondylitis in computer professionals.

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Vásquez (2011) demonstrated the e˛ ectiveness of MIT in treating swimmer’s shoulder with respect to articular balance and pain.

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Signiÿ cant di˛ erences between premeasurements and postmeasurements of pressure pain thresholds with decreasing sensitivity to myofascial trigger points were reported in various strained muscles, including the adductor longus (Roba & Pajaczkowski 2009), the upper trapezius muscle (Fryer & Hodgson 2005), and cervical muscles (Hou et al. 2002).

myofascial pain and pelvic ˝ oor dysfunction (Bassaly et al. 2011);

urological dysfunction (FitzGerald at al. 2009); interstitial cystitis or painful bladder syndrome (FitzGerald et al. 2012); pelvic organ prolapses (Dixon et al. 2019); common urological conditions (Itza et al. 2010); prostatitis (Wise & Anderson 2012); interstitial cystitis or bladder pain syndrome (Hanno et al. 2011);

female sexual dysfunction (Berghmans 2018); voiding dysfunction (Petrikovets et al. 2019);

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Lower extremity dysfunction •

Çil et al. (2019) compared the e˛ ectiveness of physical therapy treatment combined with a myofascial approach to the only home program in plantar fasciitis management. ° e authors concluded that the supervised management protocol had a superior clinical outcome.

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Ajimsha et al. (2014) investigated the response of myofascial therapy in relation to pain and functional disability associated with plantar heel pain compared to a control group receiving sham ultrasound therapy. ° e randomized, double-blind, controlled trial demonstrated that fascial therapy is more effective than a control intervention for patients with plantar heel pain.

constipation (Barros-Neto et al. 2017); nerve entrapment syndrome leading to perineal pain (Loukas et al. [2006] observed the relationship between the pudendal nerve and the sacrotuberous ligament and its relevance to pudendal nerve entrapment syndrome leading to perineal pain);

Fibromyalgia and chronic fatigue syndrome •

Wasserman et al. (2016) investigated chronically painful cesarean scars. ° ey performed four 30-minute

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12 fascial treatment sessions over a two-week period. ° e authors demonstrated that scar release techniques may help reduce chronic scar pain in women who have had C-section surgery.

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Using real-time sonoelastography to evaluate the application of MIT to muscular lesions, Martínez Rodríguez and Galán del Río (2013) were able to provide accurate evidence of the repair process.

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Liptan et al. (2013) compared two di˛ erent manual therapy techniques (myofascial release versus Swedish massage) in a parallel study of women with ÿ bromyalgia. ° e authors conclude that the myofascial release group reported consistent pain reductions in the neck and upper back regions.

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With the aim of determining the e˛ ects of MIT on pain symptoms, postural stability, and physical function, Castro-Sánchez et al. (2011a) conducted a randomized, placebo-controlled clinical trial with 86 patients. ° e results suggested that myofascial release techniques can be a complementary therapy for pain symptoms, physical function, and clinical severity but do not improve postural stability in patients with ÿ bromyalgia syndrome. Castro-Sánchez et al. (2011b), in a randomized, controlled clinical trial, analyzed the e˛ ectiveness of myofascial treatment versus sham treatment in a group of 74 ÿ bromyalgia patients. ° e intervention period was 20 weeks. ° e evaluated parameters were anxiety, quality of sleep, depression, and quality of life. ° e authors concluded that the myofascial approach improved pain and quality of life in patients with ÿ bromyalgia. Marshall et al. (2009) concluded that myofascial release helps reduce the severity and intensity of muscle pain in people with chronic fatigue syndrome.

Scars •

Chamorro Comesaña et al. (2017) investigated the e˛ ectiveness of MIT applied to post-C-section scars which have completed the repair process (with a minimum of a year and a half of evolution). Eight weekly MIT treatments were applied to the structure of the scar. Changes were observed on the structure of the scar fold at the deep level (through ultrasound) and at the superÿ cial level (by measuring the

scar fold). ° e US was carried out directly above the scar and along its entire length in order to see variations in the depth of the fatty tissue, aponeurosis, and muscular tissue compared to the healthy adjacent tissue. ° e functional improvement was determined using Schober’s test and the patients’ quality of life was measured using the SF-36 questionnaire. ° e authors concluded that MIT modiÿ es the structure of the scar even a˙ er the scar has completed its remodeling process.

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Hicks at al. (2009) reported that human ÿ broblasts secrete the soluble mediators of myoblast di˛ erentiation and that myofascial release can regulate muscle development.

Treatment of cancer survivors •

In a controlled, randomized trial Domaszewska et al. (2019) assessed the in˝ uence of myofascial therapy on pulmonary function, chest mobility, and pain in a group of 49 women su˛ ering from breast cancer. ° e authors consider that additional therapeutic methods such as myofascial induction or myofascial release have beneÿ cial e˛ ects on the eˆ ciency of the respiratory system of women undergoing treatment for breast cancer.

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Serra-Añó et al. (2019) analyzed the clinical impact of myofascial treatment on women who had survived breast cancer. ° e authors concluded that the myofascial treatment shows physical beneÿ ts (i.e., improvements in overall shoulder movement, functionality, and the perception of pain) in women who have had breast cancer surgery.

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Castro-Martín et al. (2017) performed a randomized, single-blind, placebo-controlled crossover study of 21 breast cancer survivors with stage I-IIIA cancer who were randomly allocated to an experimental group (receiving a 30-minute session of MIT) or a placebo control group (receiving 30 minutes of unplugged pulsed shortwave therapy). ° e results demonstrated that a single session of MIT reduces pain intensity and improves the neck–shoulder range of movement to a greater degree than placebo electrotherapy in patients with pain a˙ er breast cancer surgery. In a later analysis of this group, Castro-Martín et al. (2020) conÿ rmed that MIT can partially improve the mechanosensitivity of the median, radial, and

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ulnar nerves and also produces positive e˛ ects on symptoms, especially with respect to the ulnar nerve.

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Fernández-Lao et al. (2011) applied MIT to breast cancer survivors. ° e authors observed that myofascial release led to an immediate increase in the salivary ˝ ow rate, suggesting the parasympathetic e˛ ect of the intervention.

Cardiac and vascular dysfunction •

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Ratajska et al. (2020) evaluated the impact of myofascial therapy “on pulmonary function, postoperative pain, fatigue, breathing diˆ culties and physical ÿ tness, in patients during the early postoperative period a˙ er coronary artery bypass gra˙ ing and o˛ -pump coronary artery bypass gra˙ ing surgery.” ° e authors concluded that: “the implementation of myofascial release techniques in conventional cardiac rehabilitation may enhance patients’ improvement during the early postoperative period, a˙ er the revascularization of the coronary arteries.” In a study of 65 adult patients with hemophilia Cuesta-Barriuso et al. (2020) applied MIT for three consecutive weeks. ° e authors demonstrated the safety and e˛ ectiveness (improvement in ankle functionality and quality of gait) of MIT treatment in patients with hemophilic ankle arthropathy. A follow-up of the patients showed that the improvements were maintained at ÿ ve months. Pérez-Llanes et al. (2020) evaluated the safety of a physiotherapy program using MIT in patients with hemophilic elbow arthropathy. ° e authors concluded that MIT does not appear to produce elbow hemarthrosis in patients with hemophilia and can improve joint pain, range of motion, and elbow function in this group of patients. In a randomized, controlled trial Ramos-González et al. (2012) investigated the e˛ ects of myofascial therapy and kinesiotherapy on venous blood circulation, pain, and quality of life in 65 postmenopausal women with stage I or stage II venous insuˆ ciency. ° e authors concluded that the application of myofascial therapy in conjunction with kinesiotherapy improves the venous return blood ˝ ow, reduces

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pain, and improves quality of life in postmenopausal women with venous insuˆ ciency.

•

Leonard et al. (2009) reported that connective tissue manipulation improved peripheral circulation and enhanced wound healing processes in 20 patients with diabetic foot ulcers.

Gastroesophageal reflux •

Martínez-Hurtado et al. (2019) randomized 30 patients with nonerosive gastroesophageal re˝ ux disease (GERD) into fascial therapy and sham groups. ° e authors examined the quality of life and consumption of proton pump inhibitors (PPIs) in both groups. ° ey concluded that the application of fascial therapy decreased the symptoms and usage of PPIs and increased the quality of life of patients with nonerosive GERD for up to four weeks a˙ er the end of the treatment.

Neurological disorders •

Useros and Hernando (2008) concluded that myofascial induction has beneÿ cial e˛ ects on patients with brain damage and in particular beneÿ ts automatic posture control.

•

In patients with unilateral spatial neglect (alteration of the position of the head with respect to the median line) Vaquero Rodríguez (2012) observed signiÿ cant results for the sensitivity variable in the experimental group treated with MIT, as compared to the group treated with Bobath therapy.

Examples of clinical research conducted on healthy subjects •

Martínez-Jiménez et al. (2020) investigated the results of a single application of the MIT longitudinal gliding technique on the feet of 20 healthy participants. ° e procedure was directed to the plantar fascia and resulted in changes in balance and footprint variables. ° e authors reported: “° e immediate e˛ ects of the longitudinal technique of myofascial induction of the plantar fascia are the increase of surface and maximum pressure in fore foot.”

•

Astorga-Verdugo et al. (2019) evaluated the e˛ ectiveness of thoracolumbar myofascial release in relation

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12 to changes in muscular resistance of the bilateral sternocleidomastoid (SCM) and measurements of the angle of forward head posture in 35 young women with a sedentary lifestyle. As a result of the application the authors reported statistically signiÿ cant and immediate changes in the resistance of both SCM muscles and an average decrease in the angle of forward head posture.

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In a triple-blind, repeated measures, crossover design study of 12 healthy participants Cathcart et al. (2019) analyzed the immediate results of the application of myofascial procedures in relation to modiÿ cations in biomechanics (increased elasticity and range of motion [ROM]), systemic changes (local versus distal areas of pain threshold) and bodily awareness e˛ ects (interoception). ° e authors concluded that the increase in ROM suggested the myofascial techniques “may have caused a biomechanical change in tissue elasticity creating an increase in tissue ˝ exibility. ° e increase in both local and distal sites of the pain pressure thresholds suggest an overall systemic response to the therapy.” Shah et al. (2017) measured paraspinal blood ˝ ow at the L3 vertebral level (using near infrared spectroscopy [NIRS]) in 44 healthy participants divided into three groups. Di˛ erent modalities – integrated myofascial techniques (IMT), Kinesio Taping® (KT), or sham transcutaneous electrical nerve stimulation (TENS) – were applied to each group. ° e researchers demonstrated that “IMT increases peripheral blood ˝ ow at the paraspinal muscles in healthy participants compared to KT and sham TENS.” Heredia-Rizo et al. (2013) demonstrated that MIT (suboccipital muscle inhibition technique) immediately improved the position of the head with the subject seated and standing. Additionally, it immediately decreased the mechanosensitivity of the greater occipital nerve.

decrease in tension, anger status, and perceived pain in patients with chronic tension-type headache.

•

In a randomized, single-blind, placebo-controlled study Arroyo-Morales et al. (2009) reported that MIT might encourage recovery from a transient immunosuppression state induced by exercise in healthy, active women.

•

In a study of 35 subjects Saíz-Llamosas et al. (2009) investigated if the application of cervical MIT “targeted to the ligamentum nuchae resulted in changes in cervical range of motion and pressure pain thresholds (PPT) in asymptomatic subjects.” ° e results showed “an increase in cervical ˝ exion, extension, and le˙ lateral-˝ exion, but not rotation motion in a cohort of healthy subjects. No changes in PPT in either C5–C6 zygapophyseal joint (local point) or tibialis anterior muscle (distant point) were found.”

•

Arroyo-Morales et al. (2008a) stated that heart rate variability and blood pressure recovery a˙ er a physically stressful situation were improved by myofascial release compared with sham electrotherapy treatment.

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Arroyo-Morales et al. (2008b) reported that application of an active recovery protocol using whole body myofascial treatment reduces EMG amplitude and vigor when applied as a passive recovery technique a˙ er a high-intensity exercise protocol.

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In a study involving 41 healthy male volunteers who were randomly assigned to experimental or control groups, Fernández-Pérez et al. (2008) reported signiÿ cantly decreased anxiety levels in healthy young adults a˙ er the application of myofascial induction treatment. Additionally, signiÿ cantly lower systolic blood pressure values were observed, as compared to baseline levels.

•

Henley et al. (2008) demonstrated quantitatively that cervical myofascial release shi˙ s sympathovagal balance from the sympathetic to the parasympathetic nervous system.

Fernández-Pérez et al. (2013) observed major immunological modulations with an increased B lymphocyte count 20 minutes a˙ er the craniocervical application of MIT.

Conclusion

Toro et al. (2009) state that the application of a single session of manual therapy (including MIT) produces an immediate increase of heart rate variability and a

A long, arduous, and fascinating journey awaits us. In order to bring scientiÿ c evidence closer to clinical applications we need to do the following:

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Scientific evidence relevant to the MIT approach

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Identify the problems that concern us and prepare questions that can be answered. In this way, we will be able to convert clinical uncertainties into questions that can be answered through scientiÿ c research. Locate the best evidence in the scientiÿ c literature. ° is requires knowing how to search the scientiÿ c works that relate to our subject of interest (bibliographic search) exhaustively and eˆ ciently.

•

Learn how to critically evaluate the validity of a scientiÿ c work, and how to interpret the results and determine their applicability to the individual patient.

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Apply the results to clinical practice. Try to apply the improvements through assistance protocols based on the adaptation or development of clinical practice guidelines based on evidence.

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Evaluate the results obtained in practice and compare them with results referenced in the literature.

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REFERENCES

Ajimsha MS, Shenoy PD (2019) Improving the quality of myofascial release research – a critical appraisal of systematic reviews. J Bodyw Mov ° er 23(3):561–567. Ajimsha M, Chithra S, ° ulasyammal R (2012) E˛ ectiveness of myofascial release in the management of lateral epicondylitis in computer professionals. Arch Phys Med Rehabil 93(4):604–609. Ajimsha M, Binsu D, Chithra S (2014) E˛ ectiveness of myofascial release in the management of plantar heel pain: A randomized controlled trial. Foot 24(2):66–71. Anderson R, Wise D, Sawyer T, Chan C (2006) Sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome: Improvement a˙ er trigger point release and paradoxical relaxation training. J Urol 176(4):1534–1539. Aredo JV, Heyrana KJ, Karp BI, Shah JP, Stratton P (2017) Relating chronic pelvic pain and endometriosis to signs of sensitization and myofascial pain and dysfunction. Semin Reprod Med 35(1):88–97. Arguisuelas MD, Lisón JF, DomeénechFernandez J, Martínez-Hurtado P, Salvador P (2010) Efectos de la manipulación lumbar y técnica de inducción miofascial toracolumbar sobre el patrón de activación del erector espinal [E˛ ects of lumbar spine manipulation and thoracolumbar myofascial induction technique on the spinae erector activation pattern]. Fisioterapia 32(6):250–255. Arguisuelas MD, Lisón JF, Sánchez-Zuriaga D, Martínez-Hurtado I, Doménech-Fernández J (2017) E˛ ects of myofascial release in nonspeciÿ c chronic low back pain: A randomized clinical trial. Spine (Phila Pa 1976) 42(9):627–634. Arguisuelas MD, Lisón JF, DoménechFernández J, Martínez-Hurtado I, SalvadorColoma P, Sánchez-Zuriaga D (2019) E˛ ects of myofascial release in erector spinae myoelectric activity and lumbar spine kinematics in nonspeciÿ c chronic low back pain: Randomized controlled trial. Clin Biomech (Bristol, Avon) 63:27–33. Arroyo-Morales M, Olea N, Martínez M, Moreno-Lorenzo C, Díaz-Rodriguez L, Hidalgo-Lozano A (2008a) E˛ ects of myofascial release a˙ er high-intensity exercise. J Manipulative Physiol ° er 31(3):217–223.

Arroyo-Morales, M Olea N, Martinez MM, Hidalgo-Lozano A, Díaz-Rodriguez L (2008b) Psychophysiological e˛ ects of massagemyofascial release a˙ er exercise. JACM 14(10): 1223–1229. Arroyo-Morales M, Olea N, Ruíz C, del Castillo JDL, Martinez M, Lorenzo C, Díaz-Rodriguez L (2009) Massage a˙ er exercise – responses of immunologic and endocrine markers: A randomized single-blind placebo-controlled study. J Strength Cond Res 23(2):638–644. Ashcro˙ RE (2004) Current epistemological problems in evidence based medicine. J Med Ethics 30(2):131–135. Astorga-Verdugo S, Gonzalez-Silva S, RojasCabezas G, Martinez Araya A (2019) Efectividad de la técnica de liberación de la fascia toracolumbar sobre la resistencia muscular del esternocleidomastoideo bilateral y el ángulo de anteposición de cabeza y cuello [E˛ ectiveness of thoracolumbar myofascial release on increasing sternocleidomastoid resistance and reducing forward head posture angle]. Rehabilitación 53(3):162–168. Barros-Neto J, Santos T, Cortes M, Jesus R, Freitas M, Kraychete D (2017) Constipation in patients with myofascial pain syndrome as important aspect for clinical and nutritional treatment: A case-control study. Rev Nutr 30(5): 567–581. Bassaly R, Tidwell N, Bertolino S, Hoyte L, Downes K, Hart S (2011) Myofascial pain and pelvic ˝ oor dysfunction in patients with interstitial cystitis. Int Urogynecol J 22(4):413–418. Bassham G (2016) ° e Philosophy Book. From the Vedas to the New Atheists, 250 Milestones in the History of Philosophy. New York: Sterling Milestones. Berghmans B (2018) Physiotherapy for pelvic pain and female sexual dysfunction: An untapped resource. Int Urogynecol J 29(5):631–638. Berwick D M (2005) Broadening the view of evidence-based medicine. Qual Saf Health Care 14(5):315–316. Cartwright N (2012) Will this policy work for you? Predicting e˛ ectiveness better: How philosophy helps. Philos Sci 79(5):973–989.

Castro-Martín E, Ortiz-Comino L, GallartAragón T, Esteban-Moreno B, Arroyo-Morales M, Galiano-Castillo N (2017) Myofascial induction e˛ ects on neck-shoulder pain in breast cancer survivors: Randomized, single-blind, placebo-controlled crossover design. Arch Phys Med Rehabil 98(5):832–840. Castro-Martín E, Galiano-Castillo N, OrtizComino L, Cantarero-Villanueva I, LozanoLozano M, Arroyo-Morales M, Fernández-Lao C (2020) E˛ ects of a single myofascial induction session on neural mechanosensitivity in breast cancer survivors: A secondary analysis of a crossover study. J Manipulative Physiol ° er 43(4):394–404. Castro-Sánchez AM, Matarán-Peñarrocha GA, Arroyo-Morales M, Saavedra-Hernández M, Fernández-Sola C, Moreno-Lorenzo C (2011a) E˛ ects of myofascial release techniques on pain, physical function, and postural stability in patients with ÿ bromyalgia: A randomized controlled trial. Clin Rehabil 25(9):800–813. Castro-Sánchez AM, Matarán-Peñarrocha GA, Granero-Molin J, Aguilera-Manrique G, Quesada-Rubio JM, Moreno-Lorenzo C (2011b) Beneÿ ts of massage-myofascial release therapy on pain, anxiety, quality of sleep, depression, and quality of life in patients with ÿ bromyalgia. Evidence-based complementary and alternative medicine: eCAM, 561753; https:// doi.org/10.1155/2011/561753. Cathcart E, McSweeney T, Johnston R, Young H, Edwards DJ (2019) Immediate biomechanical, systemic, and interoceptive e˛ ects of myofascial release on the thoracic spine: A randomised controlled trial. J Bodyw Mov ° er 23(1): 74–81. Chamorro Comesaña A, Suárez Vicente MD, Docampo Ferreira T, Pérez-La Fuente Varela MD, Porto Quintáns MM, Pilat A (2017) E˛ ect of myofascial induction therapy on post-csection scars, more than one and a half years old. Pilot study. JˇBodyw Mov ° er 21(1):197–204. Charlton BG, Miles A (1998) ° e rise and fall of EBM. QJM 91(5):371–374. Chen YH, Chai HM, Shau YW, Wang CL, Wang SF (2016) Increased sliding of transverse abdominis during contraction a˙ er myofascial release in patients with chronic low back pain. Man ° er 23:69–75.

254

Pilat_Myofascial Induction.indb 254

03/12/21 4:16 PM

REFERENCES

Çil ET, aylı U, Subaşı F (2019) Outpatient vs home management protocol results for plantar fasciitis. Foot Ankle Int 40(11):1295–1303. Cohen AM, Stavri P S, Hersh WR (2004) A categorization and analysis of the criticisms of evidence-based medicine. Int J Med Inform 73(1):35–43. Cuesta-Barriuso R, Donoso-Úbeda E, Meroño-Gallut J, Pérez-Llanes R, López-Pina JA (2020) Functionality and range of motion in patients with hemophilic ankle arthropathy treated with fascial therapy. A randomized clinical trial. Musculoskelet Sci Pract 49:102194. Dixon AM, Fitzgerald CM, Brincat C (2019) Severity and bother of prolapse symptoms in women with pelvic ˝ oor myofascial pain. Int UrogynecolˇJ 30(11):1829–1834. Domaszewska K, Pieńkowski T, Janiak A, Bukowska D, Laurentowska M (2019) ° e in˝ uence of so˙ tissue therapy on respiratory eˆ ciency and chest mobility of women su˛ ering from breast cancer. Int J Environ Res Public Health 16(24):5092. Fernández-Lao C, Cantarero-Villanueva I, Fernández-de-las-Peñas C, Del-Moral-Ávila R, Nenjón-Beltrán S, Arroyo-Morales M (2011) Widespread mechanical pain hypersensitivity as a sign of central sensitization a˙ er breast cancer surgery. Pain Med 12(1):72–78. Fernández-Pérez AM, Peralta-Ramírez MI, Pilat A, Villaverde C (2008) E˛ ects of myofascial induction techniques on physiologic and psychologic parameters. JACM 14(7):807–811. Fernández-Pérez AM, Peralta-Ramírez MI, Pilat A, Villaverde C, Moreno-Lorenzo C, ArroyoMorales M (2013) Can myofascial techniques modify immunological parameters? JACM 19(1):24–28. FitzGerald MP, Anderson RU, Potts J, Payne CK, Peters KM, Clemens JQ, Kotarinos R, Fraser L, Cosby A, Fortman C, Neville C, Badillo S, Odabachian L, Sanÿ eld A, O’Dougherty B, Halle-Podell R, Cen L, Chuai S, Landis JR, Mickelberg K, Barrell T, Kusek JW, Nyberg LM, for the Urological Pelvic Pain Collaborative Research Network (UPPCRN) (2009) Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urologic chronic pelvic pain syndrome. JˇUrol 182(2):570–580.

FitzGerald MP, Payne CK, Lukacz ES, Yang CC, Peters KM, Chai TC, Nickel JC, Hanno PM, Kreder KJ, Burks DA, Mayer R, Kotarinos R, Fortman C, Allen TM, Fraser L, Mason-Cover M, Furey C, Odabachian L, Sanÿ eld A, Chu J, Huestis K, Tata GE, Dugan N, Sheth H, Bewyer K, Anaeme A, Newton K, Featherstone W, HallePodell R, Cen L, Landis JR, Propert KJ, Foster HE Jr, Kusek JW, Nyberg LM, Interstitial Cystitis Collaborative Research Network (2012) Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic ˝ oor tenderness. J Urol 187(6):2113–2118.

A, Herrera-Monge P (2013) Immediate changes in masticatory mechanosensitivity, mouth opening, and head posture a˙ er myofascial techniques in pain-free healthy participants. J Manipulative Physiol ° er 36(5):310–318.

Fryer G, Hodgson L (2005) ° e e˛ ect of manual pressure release on myofascial trigger points in the upper trapezius muscle. J Bodyw Mov ° er 9(4):248–255.

Hou CR, Tsai LC, Cheng KF Chung KC, Hong CZ (2002) Immediate e˛ ects of various physical therapeutic modalities on cervical myofascial pain and trigger point sensitivity. Arch Phys Med Rehabil 82(10):1406–1414.

Gauns SV, Gurudut PV (2018) A randomized controlled trial to study the e˛ ect of gross myofascial release on mechanical neck pain referred to upper limb. Int J Health Sci (Qassim) 12(5):51–59. Grinberg K, Weissman-Fogel I, Lowenstein L, Abramov L, Granot M (2019) How does myofascial physical therapy attenuate pain in chronic pelvic pain syndrome? Pain Res Manag 6091257; https://doi.org/10.1155/2019/6091257. Hanno P, Burks D, Clemens J, Dmochowski R, Erickson D, Fitzgerald M, Forrest J, Gordon B, Gray M, Mayer R, Newman D, Nyberg L, Payne C, Wesselmann U, Faraday M (2011) AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. J Urol 185(6):2162–2170. Harari E (2001) Whose evidence? Lessons from the philosophy of science and the epistemology of medicine. Aust N Z J Psychiatry 35(6):724–730. Hastings J, Forsters JE, Witzeman K (2019) Joint hypermobility among female patients presenting with chronic myofascial pelvic pain. PM R 11(11):1193–1199.

12

Hicks M, Meltzer K, Cao T, Standley PR (2009) Human ÿ broblast (HF) model of repetitive motion strain (RMS) and myofascial release. In: Huijing PA, Hollander P, Findley TW, Schleip R (Eds.) Fascia Research II: Basic Science and Implications for Conventional and Complementary Health Care. Munich: Elsevier GmbH, p. 259.

Howard FM (2010) When treating interstitial cystitis, address all sources of pain. OBG Manag 22(7):44–49. Howick J (2011) ° e Philosophy of Evidence-Based Medicine. Oxford: Wiley-Blackwell; BMJ. Ioannidis JP (2005) Contradicted and initially stronger e˛ ects in highly cited clinical research. JAMA 294(2):218–228. Itza F, Zarza D, Serra L, Gómez-Sancha F, Salinas J, Allona-Almagro A (2010) Myofascial pain syndrome in the pelvic ˝ oor: A common urological condition. Actas Urol Esp 34(4):318–326. Kim SJ, Lee JH (2018) E˛ ects of sternocleidomastoid muscle and suboccipital muscle so˙ tissue release on muscle hardness and pressure pain of the sternocleidomastoid muscle and upper trapezius muscle in smartphone users with latent trigger points. Medicine (Baltimore) 97(36):e12133.

Henley CE, Ivins D, Mills M, Wen FK, Benjamin BA (2008) Osteopathic manipulative treatment and its relationship to autonomic nervous system activity as demonstrated by heart rate variability. Osteopath Med Prim Care 2:7.

Leonard JH, Paungmali A, Dixon J, Holey L, Naicker AS, Htwe O (2009) Physiological e˛ ects of connective tissue manipulation on diabetic foot ulcer. In: Huijing PA, Hollander P, Findley TW, Schleip R (Eds.) Fascia Research II: Basic Science and Implications for Conventional and Complementary Health Care. Munich: Elsevier GmbH, p. 95.

Heredia-Rizo AM Oliva-Pascual-Vaca A, Rodríguez-Blanco C, Piá-Pozo F, Luque-Carrasco

Liptan G, Mist S, Wright C, Arzt A, Jones KD (2013) A pilot study of myofascial release therapy

255

Pilat_Myofascial Induction.indb 255

03/12/21 4:17 PM

12

REFERENCES

compared to Swedish massage in ÿ bromyalgia. J Bodyw Mov ° er 17(3):365–370. Lotan S, Kalichman L (2019) Manual therapy treatment for adolescent idiopathic scoliosis. J Bodyw Mov ° er 23(1):189–193. Loukas M, Louis RG Jr, Hallner B, Gupta AA, White D (2006) Anatomical and surgical considerations of the sacrotuberous ligament and its relevance in pudendal nerve entrapment syndrome. Surg Radiol Anat 28(2):163–169. Marshall R, Paul L, McFadyen AK, Wood L (2009) Evaluating the e˛ ectiveness of myofascial release to reduce pain in people with chronic fatigue syndrome (CFS). In: Huijing PA, Hollander P, Findley TW, Schleip R (Eds.) Fascia Research II: Basic Science and Implications for Conventional and Complementary Health Care. Munich: Elsevier GmbH, p. 305. Martínez-Hurtado I, Arguisuelas MD, Almela-Notari P, Cortés X, Barrasa-Shaw A, Campos-González JC, Lisón JF (2019) E˛ ects of diaphragmatic myofascial release on gastroesophageal re˝ ux disease: A preliminary randomized controlled trial. Sci Repˇ9:7273. Martínez-Jiménez EM, Becerro-de-BengoaVallejo R, Losa-Iglesias ME, Rodríguez-Sanz D, Díaz-Velázquez JI, Casado-Hernández I, Mazoteras-Pardo V, López-López D (2020) Acute e˛ ects of myofascial induction technique in plantar fascia complex in patients with myofascial pain syndrome on postural sway and plantar pressures: A quasi-experimental study. Phys ° er Sport 43:70–76. Martínez Rodríguez R, Galán del Río F (2013) Mechanistic basis of manual therapy in myofascial injuries. Sonoelastographic evolution control. J Bodyw Mov ° er 17(2):221–234. Pastore EA, Katzman WB (2012) Recognizing myofascial pelvic pain in the female patient with chronic pelvic pain. J Obstet Gynecol Neonatal Nurs 41(5):680–691. Pérez-Llanes R, Meroño-Gallut J, DonosoÚbeda E, López-Pina J, Cuesta-Barriuso R (2020) Safety and e˛ ectiveness of fascial therapy in the treatment of adult patients with hemophilic elbow arthropathy: A pilot study. Physiother ° eory Pract 30:1–10. Petrikovets A, Veizi IE, Hijaz A, Mahajan ST, Daneshgari F, Buˆ ngton CAT, McCabe P,

Chelimsky T (2019) Comparison of voiding dysfunction phenotypes in women with interstitial cystitis/bladder pain and myofascial pelvic pain: Results from the ICEPAC trial. Urology 126:54–58. Ramos-González E, Moreno-Lorenzo C, Matarán-Peñarrocha GA, Guisado-Barrilao R, Aguilar-Ferrándiz ME, Castro-Sánchez AM (2012) Comparative study on the e˛ ectiveness of myofascial release manual therapy and physical therapy for venous insuˆ ciency in postmenopausal women. Complement ° er Med 20(5):291–298. Ratajska M, Chochowska M, Kulik A, Bugajski P (2020) Myofascial release in patients during the early postoperative period a˙ er revascularisation of coronary arteries. Disabil Rehabil 42(23):3327–3338. Roba A, Pajaczkowski J (2009) Prospective investigation on hip adductor strains using myofascial release. In: Huijing PA, Hollander P, Findley TW, Schleip R (Eds.) Fascia Research II: Basic Science and Implications for Conventional and Complementary Health Care. Munich: Elsevier GmbH, p. 96. Rodríguez-Fuentes I, De Toro FJ, RodríguezFuentes G, de Oliveira IM, Meijide-Faílde R, Fuentes-Boquete IM (2016) Myofascial release therapy in the treatment of occupational mechanical neck pain: A randomized parallel group study. Am J Phys Med Rehabil 97(1):16–22. Rodríguez-Fuentes I, De Toro FJ, RodríguezFuentes G, de Oliveira IM, Meijide-Faílde R, Fuentes-Boquete IM (2020) Is myofascial release therapy cost-e˛ ective when compared with manual therapy to treat workers’ mechanical neck pains? J Manip Physiol ° er 43(7):683–690.

subjects. J Manipulative Physiol ° er 32(5): 352–357. Serra-Añó P, Inglés M, Bou-Catalá C, IraolaLliso A, Espí-López GV (2019) E˛ ectiveness of myofascial release a˙ er breast cancer surgery in women undergoing conservative surgery and radiotherapy: A randomized controlled trial. Support Care Cancer 27(7):2633–2641. Shah Y, Arkesteijn M, ° omas D, Whyman J, Passÿ eld L (2017) ° e acute e˛ ects of integrated myofascial techniques on lumbar paraspinal blood ˝ ow compared with kinesio-taping: A pilot study. J Bodyw Mov ° er 21(2):459–467. Solomon M (2011) Just a paradigm: Evidencebased medicine in epistemological context. Euro Jnl Phil Sci 1:451–466. Toro-Velasco C, Arroyo-Morales M, Fernándezde-las-Peñas C, Cleland JA, Barrero-Hernández FJ (2009) Short-term e˛ ects of manual therapy on heart rate variability, mood state, and pressure pain sensitivity in patients with chronic tension-type headache: a pilot study. J Manipulative Physiol ° er 32(7):527–535. Tozzi P, Bongiorno D, Vitturini C (2011) Fascial release e˛ ects on patients with non-speciÿ c cervical or lumbar pain. J Bodyw Mov ° er 15(4):405–416. Tozzi P, Bongiorno D, Vitturini C (2012) Low back pain and kidney mobility: Local osteopathic fascial manipulation decreases pain perception and improves renal mobility. J Bodyw Mov ° er 16(3):381–391. Ünal M, Evick E, Kocatür MZ, Algun C (2020) Investigating the e˛ ects of myofascial induction therapy techniques on pain, function and quality of life in patients with chronic low back pain. J Bodyw Mov ° er 24(4):188–195.

Rodríguez-Huguet M, Gil-Salú JL, RodríguezHuguet P, Cabrera-Afonso JR, Lomas-Vega R (2018) E˛ ects of myofascial release on pressure pain thresholds in patients with neck pain: A single-blind randomized controlled trial. Am J Phys Med Rehabil 97(1):16–22.

Urresti-López FJ (2011) Miodural bridge stimulation via suboccipital inhibition technique modiÿ es the electroencephalogram signiÿ cantly in reaction times producing cognitive changes that do not occur in the control group. [D.O. ° esis for Diploma in Osteopathy, SEFO-EOM].

Saíz-Llamosas JR, Fernández-Pérez AM, Fajardo-Rodríguez MF, Pilat A, ValenzaDemet G, Fernández-de-Las-Peñas C (2009) Changes in neck mobility and pressure pain threshold levels following a cervical myofascial induction technique in pain-free healthy

Useros AI, Hernando A (2008) Liberación miofascial aplicada en un paciente adulto con daño cerebral. Biociencias 6:1–7. Vaquero Rodríguez A (2012) In˝ uence of myofascial therapy applied to the cervical region of patients

256

Pilat_Myofascial Induction.indb 256

03/12/21 4:17 PM

REFERENCES

su˛ ering from unilateral spatial neglect and head deviation with respect to the median line. (ICNR 2012). In: Pons JL, Torricelli D, Pajaro M (Eds.) Converging Clinical and Engineering Research on Neurorehabilitation, Biosystems and Biorobotics. Volume 1. Berlin: Springer, pp. 371–374. Vásquez C (2011) Efectividad de la técnica de inducción miofascial en el hombro doloroso del nadador respecto al balance articular y dolor [E˛ ectiveness of the myofascial induction technique in swimmer’s shoulder with respect to the articular balance and pain]. Cuest Fisioter 40(3):177–184.

von Bertalan˛ y L (1951) General system theory; a new approach to unity of science. 1. Problems of general system theory. Hum Biol 23(4): 302–312. Wasserman JB, Steele-° ornborrow JL, Yuen JS, Halkiotis M, Riggins EM (2016) Chronic caesarian section scar pain treated with fascial scar release techniques: A case series. J Bodyw Mov ° er 20(4):906–913.ˇ Wise D, Anderson R (2012) A Headache in the Pelvis: A New Understanding and Treatment for Chronic Pelvic Pain Syndromes. 6th ed. New York: Harmony Books.

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Wol˛ BJ, Joyce CJ, McAlarnen LA, Brincat CA, Mueller ER, FitzGerald CM (2020) Consideration of pelvic ˝ oor myofascial release for overactive bladder. J Bodyw Mov ° er 24(2):144–150. Worrall J (2002) What evidence in evidence based medicine? Phil Sci 69(S3):S316–S330. Worrall J (2007a) Evidence in medicine and evidence based medicine. Philos Compass 2(6): 981–1022. Worrall J (2007b) Why there’s no cause to randomize. BJPS 58(3):451–488.

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PART 2

Practical applications of Myofascial Induction – the upper body CHAPTER 13 Myofascial Induction Therapy

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CHAPTER 14 Upper quadrant assessment

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CHAPTER 15 Craniofacial and neck dysfunctions related to the fascial system

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CHAPTER 16 Dysfunctions related to the thorax complex

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CHAPTER 17 Upper extremity dysfunctions related to the fascial system

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Myofascial Induction Therapy With a contribution from Mártin Pilat and Eduardo Castro-Martín

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THERAPEUTIC CONSIDERATIONS KEY POINTS •

Definition of Myofascial Induction Therapy (MIT)

•

Objectives of MIT

•

Context in which the approach is performed

•

Outline of the sequence and frequency of treatment

•

Analysis of touch

MIT is a process of continuous evaluation and treatment during which the practitioner transfers a force to the target tissue to facilitate recovery of the quality of the fascial system.

Introduction: MIT as a manual therapy approach MIT is a therapeutic concept belonging to manual therapy, aimed at the functional restoration of the altered fascial system. MIT is a process of evaluation and treatment in which the practitioner transfers a slight force (traction and/or compression) to the target tissue (Pilat 2012), facilitating recovery of the quality of the fascial system. ° e application of the procedures can be deÿ ned as a combination of sustained pressure, speciÿ c positioning, and very smooth glides. ° e term “induction” relates to the facilitation of movement rather than a passive stretching of the fascial system. ° e result is a reciprocal reaction from the body involving the biochemical, metabolic signaling reaction and, ultimately, the physiological responses. ° is process aims to reshape the quality of the extracellular matrix of the connective tissue to facilitate and optimize the transfer of information to and within the fascial system (Chiquet

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et al. 2003, Wheeler 2004, Pilat 2017). It is a process conducted by the central nervous system in which the practitioner acts as a facilitator. ° e fascial system is considered to be an architectural continuum that, as a network, structurally and functionally communicates with all of the body’s components. Based on this premise, the alteration of a speciÿ c fascial structure may have local or global repercussions on any body system. ° us, for example, an alteration in the locomotor system could a˛ ect the functioning of the respiratory system. Faced with a sudden need to walk fast (˝ ee from danger), a trauma to the quadriceps (with its consequent dysfunction) will be compensated by an excessive increase in the respiratory rate. ° e motor deÿ cit of the quadriceps, if maintained for a long time, would lead to overload of the respiratory system, eventually turning into a respiratory dysfunction. Dysfunction of the fascial system is deÿ ned as an alteration in the highly organized assortment of specialized movements and as an incorrect transfer of information through the matrix (Pilat 2003). ° e restrictions and altered physiological tension of the system will facilitate dysfunctional patterns of movement that will generate variations in the mechanotransduction response (conversion of mechanical impulse into chemical response) with consequent initiation of the molecular mechanisms that trigger disease (Ingber 2003) (see Chapter 9).

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13 In general, MIT is recommended mainly for patients with orthopedic, neuro-orthopedic, post-traumatic, and degenerative dysfunctions related to the myofascial system. ° e remodeling of restrictions and the recovery of the tensional equilibrium allows the fascial dynamics to be re-established. ° erapeutic action concentrates on the provision of resources for the prompt optimization of the body’s homeostasis. ° e ÿ nal objective is not the establishment of stable hierarchies but rather the facilitation of an optimal adaptation to the demands of the environment (Pilat 2014) in order to alleviate or eliminate painful symptoms and recover the altered function. ° e results (changes to body image, improvements in functional abilities) should be evaluated and valued not only by the practitioner but also by the patient. MIT aims to be a patient-centered, focused treatment (Pilat 2015).

Treatment objectives Main objective:

•

An optimal adaptation to the demands of the environment and optimization of the body’s homeostasis.

Speciÿ c objectives:

• •

Mobilize superÿ cial fascial restrictions.

•

Facilitate the recovery of the sliding and gliding properties of the components of the extracellular matrix.

•

Stimulate the physiological orientation in the mechanics of ÿ broblasts and other cells that perceive and respond to mechanical stimuli, such as tenocytes, telocytes, fasciacytes, and astrocytes.

• •

Avoid the formation of tissue adhesions.

•

Normalize the circulation of water in the extracellular matrix.

• • •

Facilitate a positive a˛ erent neurological stimulus.

Change the “stationary attitude” of collagen structures.

Acquire a more eˆ cient circulation of antibodies in the matrix.

Improve blood supply (histamine release). Improve blood supply to the nervous system.

Applying low-value load in the therapeutic process increases the range of clinical applications and enables the practitioner to apply the approach to a more extensive range of patients – from pediatric to geriatric groups. ° e procedures of myofascial induction are part of the great family of manual therapies. For this reason, several of the principles that are the basis for the application of manual techniques are also valid within the procedures applied in MIT. Although clinical reasoning applied to MIT is mainly linked to the treatment protocols of physical therapists, osteopaths, massage therapy professionals, and bodyworkers, its application should be useful for all health-care practitioners with competencies in the provision of physical therapy and manual therapy approaches. ° is means that a reader familiar with any of the schools of manual therapy will ÿ nd similarities in the principles of treatment described below. However, there are particular points relating to the application of MIT that need to be explained in more detail and that distinguish MIT procedures from other types of treatment (see Chapter 1).

Principles of treatment Environment and clothing ° e context in which the treatment is takes place is important to its development. In general, the environment should be pleasant and calm. ° e treatment room should be well ventilated and controlled to avoid the patient being in a dra˙ , and the temperature should be regulated according to individual preferences. ° e ˝ oor of the room should not be cold. Lighting should be indirect and not too bright. Generally, the session is conducted in silence, without background music. However, relaxing background music is acceptable at approximately 60 beats per minute, which reduces the heart rate to the level of the alpha waves of the brain (Bringman et al. 2009). The environment in which the treatment takes place is important to its development.

° e room should be spacious so that the practitioner can move freely around the table. With regard to clothing, the patient should wear underwear or sportswear

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that is comfortable (not tight) and does not restrict the body, so that the practitioner has access to the required areas. It is recommended that the patient remove accessories such as bracelets, necklaces, watches, etc., as these might interfere with the treatment. ° is also applies to the practitioner who should not wear items that hinder the application of manual therapy, and should also wear comfortable, loose-ÿ tting clothes. Short sleeves are recommended.

Ergonomics for the practitioner As mentioned above, MIT is a manual therapy and therefore its most important tools are the practitioner’s hands and body (and the brain, of course). It is important to start with the body in the correct position, so that the hands are able to perform the therapeutic touch. Induction techniques sometimes take a long time, and if the practitioner starts in an awkward position this will cause tension which will have an effect on manual eˆ ciency. During some movements the practitioner needs mechanical advantage which forces him to use his body to increase his strength. We must factor in variability in the size and shape (height, body weight) of the patient and practitioner. Having a height-adjustable table helps to maintain maximum biomechanical eˆ ciency. Correct positioning and use of the body allows the practitioner to be versatile and to avoid injuring himself during treatment. In the same way, the positioning of the patient also in˝ uences the position of the practitioner. ° e patient’s posture should be comfortable and neutral, and generally support elements will not be used unless required. For example, a neck pillow may be used in cases where there is a rigid and hyperlordotic cervical segment. ° e most common position of the patient during treatment is decubitus (prone, supine, or lateral), although the patient can also be treated in sitting or standing if the aim is to work with the e˛ ects of gravity. ° e e˛ ectiveness of the position is also determined by the need to access certain areas of the body and the mobility of the subject. Finally, to facilitate the treatment, it is recommended that both patient and practitioner have a relaxed attitude and maintain a state of calm. ° e channel of verbal communication remains open throughout the session, and asking the patient at the beginning of and during the treatment about their comfort and needs is very important. It is necessary to take care to minimize

13

intimate contact. For example, during some maneuvers the body of the practitioner and that of the patient may come into contact, and if the contact is close to an intimate region the use of a pillow or towel is recommended. Monitoring and maintaining the comfort of the process will in˝ uence the outcome. ° e practitioner’s hands require special care. In MIT there are many alternative contacts, for example, the tips of the triphalangeal ÿ ngers, the proximal interphalangeal knuckles, reinforced thumb contact, reinforced index ÿ nger contact, etc. In the ÿ ngers, interphalangeal or metacarpophalangeal (MCP) hyperextension must be avoided so as not to provoke irritative joint processes. Make sure that the neutral position of the wrist and the correct orientation of the forearm and trunk are maintained. ° e practitioner may also work with his forearm, or even with his elbow, and in this scenario the wrist must be relaxed. ° e process should be slow and the pressure light in order to evaluate if the maneuver is comfortable or if it is generating compensatory e˛ ects due to overload. Washing the hands in cold water for a couple of minutes a˙ er the session can help relieve the strain on the practitioner’s hands, in addition to practicing self-care of the ÿ ngers and palms of the hands. Finally, accessories such as rings, watches, bracelets, etc. should be removed, and nails should always be kept short.

Sequence of treatments ° e protocol for the application of treatment is individual to each patient, and depends on a multitude of factors, such as physical condition, age, gender, cognition, cultural issues, the degree to which the patient is a˛ ected, the chronicity of the process, the patient’s expectations, etc., and also the capability and therapeutic experience of the practitioner. In conclusion, this text cannot suggest a rigid protocol of treatment but rather it describes general rules for the application of treatment, leaving the ÿ nal decision in the hands of the practitioner. It is important that the practitioner is prepared to modify the schedule not only between sessions but also within a session. For example, at the end of the sliding techniques, an immediate change in the tissue will occur, this being more variable when the sustained applications are ÿ nished. ° us, the process requires a continuous review of the progress of the treatment in

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13 order to adapt it and achieve the optimum results. It should be a dynamic performance in its planning and application in which the patient is the protagonist. Regarding the treatment, it is best to start with the sliding applications as these facilitate the initiation of the MIT method. ° ey allow the patient to become familiar with the type of contact, so that they will be relaxed from the beginning. In addition, these procedures facilitate the elimination of restrictions and better rehydration in di˛ erent fascial planes, preparing the areas for the sustained techniques to follow. Usually, for each treatment, the number of sliding applications will be greater than the number of sustained applications. Applying light pressure, slow movements, and sustained loads can take the patient by surprise and make them tense. For this reason if the patient is not familiar with this kind of procedure, the practitioner should explain in advance how the treatment will be carried out. It is suggested that the treatment session begins with MIT procedures, and then other therapeutic approaches, such as postural correction, joint mobilization, etc., may be applied if necessary. In sessions with invasive approaches (such as dry needling or percutaneous electrolysis) it is recommended to start and end with MIT. In relation to neuromuscular taping, it should be remembered that it can condition the fascial response and keeping it in place for more than three consecutive days is not recommended. Likewise, therapeutic exercise guided by the practitioner may be performed. ° is should be of a conscious, non-impact nature, such as interoceptive work involving proprioceptive, motor control, and bodily expression.

Frequency of treatments It is diˆ cult to establish rigid rules, and the frequency of treatments will depend on factors such as the following:

•

history of the condition, and whether it is acute or chronic

• • • •

severity of the symptoms extent and location of the lesion presence of other conditions expectations, beliefs, and preferences of the patient

• • •

previous experiences of the patient and practitioner the region(s) involved in the dysfunction the physical characteristics of the patient.

Usually, in acute cases, treatments are carried out at intervals of at least 48 hours, but they can be carried out once a day or even twice a day (in exceptional cases). Excessive therapeutic stimulation can create fascial overstimulation with negative consequences for the patient, such as pain or lack of movement coordination. ° is intensive schedule lasts no more than one to three weeks, a˙ er which treatment can continue every three or ÿ ve days, although once a week is more usual. In chronic cases, the sessions are more spread out and a maintenance session may be needed (once every 10–15 days). ° e practitioner will use their experience to estimate the degree of stimulation induced in the fascial system and will decide on the time needed between sessions.

An analysis of touch In the hands and especially in the ÿ ngers there are many sensitive areas with a high degree of superposition of their receptive ÿ elds, thus causing very high tactile sensitivity. For example, in the ÿ ngertips the discrimination of two points is from 1 to 3 mm, and they are able to register a cut of 6 µm (Chaitow 2000). ° e proprioceptors of the hand, wrist, and forearm allow us to establish a ˝ ow of brain–hand information or interpretation which is key to palpation. It is about projecting the sense of touch, just as an artist (painter) extends it to the tip of their brush. In this way, we can perceive tension, temperature, edema, humidity, trophism, positioning, movement, traction, pulsations, tremors, vibrations, rhythms, and their variations when touching the patient. Over time, the practitioner will discover that he can perceive the “whole body” response.

The tools used in MIT are the therapist’s hands and body, touch, and intention.

However, touch cannot be understood solely in terms of mechanoreceptors; it is a very powerful form of communication that requires the participation of both the practitioner and the patient. It is the only reciprocal,

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bidirectional sense: When you touch you are touched. ° e therapeutic impulse received by the patient will feed back to the therapist on a conscious or unconscious level. It is a pure communication in which the practitioner’s intention (optimal state of mind) has a clear relevance. In order to achieve an evaluative and therapeutic touch, it is not enough to be familiar with anatomy and physiology; the practitioner must master the “intention” of touching. “Intention” means concentrating on listening to the condition and needs of the tissue and focusing on the body and the person. ° e practitioner has to facilitate the changes resulting from the therapy to attain healing at a more holistic level. ° is is explained by the following question. What do we touch: the body or the person? Touch is understood, humanistically and interpersonally, as being able to calm and heal (Carter & Drew 2012). For the patient there are various factors that in˝ uence how they feel touch, such as gender, age, culture, beliefs, expectations, previous experiences, the nature of the process, etc. ° e same applies to the practitioner. If the practitioner ÿ nds that they are uncomfortable or tense (physically and/or psychologically), it will be diˆ cult to respond to more subtle perceptions. ° e way the procedures are applied will be altered and the treatment will be less successful. It is important that the practitioner is comfortable, calm, and open to manual experience. ° is will allow them to identify the patient’s needs in order to personalize the treatment. Finally, it should be noted that there are some sensitive areas where contact can be dangerous, but the “danger” also means “opportunity.” ° ese areas, that usually contain important superÿ cial neurovascular structures or are areas of high sensitivity, should be touched with extreme respect and care in order not to upset the patient. ° e practitioner may come across areas with relevant restrictions that are related to more complex processes. In such cases, they should refrain from approaching these regions until they have suˆ cient clinical experience in MIT. Take care when touching sensitive areas of the body, such as:

• •

cavities ventral surfaces of the neck, chest, abdomen, hands and feet

• • • •

13

the face areas that have sustained trauma or surgery scars the wrist, popliteal fossa, inguinal region, etc. The treatment process is a dynamic performance in its planning and application in which the patient is the protagonist.

How to start and end the session ° ese details are important in any therapeutic method. It is recommended that the practitioner explains what myofascial induction is at the beginning of the session, so that the patient understands how this approach can help them. Ask the patient about their comfort and any special needs and invite them to express themselves during the session. ° is helps them to gain conÿ dence and pay more attention to the treatment. Concentration and calm are important, but make it clear that therapeutic dialogue (using a few, precise words) is allowed. ° e practitioner should be standing or sitting in a relaxed position to be able transmit calmness. Both patient and practitioner should synchronize their breathing rhythm by performing three to six breaths (slow and deep) in unison. ° is will allow them to relax and at the same time detect potential changes in the patient’s respiratory cycle during the session. Remember that the ÿ rst contact of any treatment is an initial tactile observation to examine the tissue, the region of the body, and the person for few seconds before the therapeutic process is started. ° ese preliminary steps are a key part of the process. At the end of the treatment, it is important to take few minutes to relax and to allow the e˛ ects to integrate. A˙ er therapy, the stimulated organism integrates a lot of neurobiological information. For this reason, it is necessary to keep the patient quiet in a comfortable position, either lying down or sitting. Do not allow them to move quickly or energetically or to leave abruptly. Invite the patient to share their views, and be open to questions and comments. ° en other recommendations and therapeutic exercise can follow, if required. It is important to allow enough time for these ÿ nal moments.

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13 BASIC TECHNIQUES AND PROCEDURES KEY POINTS •

Introduction to the manual procedures of MIT

•

Definition of sliding (stroking) applications

•

Definition of sustained applications

•

Contraindications

Sliding (stroking) and sustained applications are the two basic techniques of MIT.

Introduction During treatment the practitioner applies a low intensity manual impulse to the fascial system. A tensional impulse (traction and/or compression) that is prolonged in time is used (Barnes 1990). ° is facilitates the recovery of fascial tissue quality (Martínez Rodríguez & Galándel-Río 2013). ° is process is mediated by molecular mechanisms associated with cell mechanotransduction, piezoelectricity (Ahn & Grodzinsky 2009), viscoelasticity (Chaudhry et al. 2007), and controlled “in real time” by the CNS (Craig 2003, Urresti-López 2011). It is mainly an instructive process in the search for a new homeostatic level through the recovery of range of motion, adequate tension, strength, and coordination. ° e ÿ nal result is transmitted as improved function with a lower energy expenditure. ° e mechanical characteristics of MIT are (Pilat 2017):

• • •

gentle force application articular ROM is never forced facilitated movement is followed.

° rough mechanoreceptors, the fascial system is in a continuous process of internal communication (Vaticón 2009):

• • • • •

somatosomatic

•

visceropsychic (vagus nerve response, alteration of cognitive-behavioral response).

somatovisceral viscerovisceral viscerosomatic psychovisceral (stress and secretion of cortisol and adrenaline versus slowing peristalsis, increase in hydrochloric acid production, etc.)

° e individual needs of the patient, the characteristics of the dysfunction being treated, and the skills and experience of the practitioner determine the selection of the therapeutic procedures. MIT is applied using two basic types of maneuver: loading and sliding procedures and sustained force procedures (without sliding) (Fig. 13.1). The two strategies complement each other but are executed differently manually and for different purposes.

Sliding procedures (direct application) The main rule for sliding (stroking) procedures is to perform the movement in the direction of the restriction.

During the application of sliding procedures, the practitioner generates force and gives a sliding movement to the tissue which stimulates its intrinsic remodeling process and consequently modiÿ es the relationship between adjacent structures. ° e aim is to modify the pathological links between collagen bundles and to change cellular mechanobiological behavior to facilitate the passage of ˝ uids at the interstitial and capillary level. Collagen ÿ laments are not elastic in the sense of stretchable. Each individual collagen package is relatively rigid, but their spatial arrangement in the form of the reticular grid may provide them with the possibility of sliding against each other (Mense 2019). At the same time, the neurological input that involves a cascade of information that modulates mechanical and

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13

Treatment protocol

Sliding (stroking) procedures

Local sustained procedures

Global sustained procedures

Neuromeningeal procedures

Visceral procedures

Cross hands induction

Transverse plane induction

Single-hand induction

Fascial unwinding induction

J- stroke

Transverse stroke

Sustained systemic procedures

Figure 13.1 Longitudinal stroke

A flowchart showing the MIT procedures

Sliding procedures

chemical aspects at the tissue level is stimulated. As a result, a high mechanical load is generated which the practitioner must monitor so as not to irritate the local tissues. At the end of the application, an immediate optimization is observed in the evaluated parameters. ° ese procedures are applied to fascial structures that are easily and directly manually accessible, for example, tendons, ligaments, muscle belly, etc. Assessment or reassessment is carried out with precise palpation (kneading or mobilization) that identiÿ es a tensional change in the tissue related to the restriction. A lack of passive or active mobility in the structure may also indicate the need for treatment. ° e aim of the procedure is to apply light pressure that allows the practitioner to be at the appropriate level for the target they want to stimulate, for example, between the perimysium (within a muscle). While maintaining the load, a slow, stroking movement is performed. ° e mechanical force applied by

the practitioner added to the load of the sliding stroke should modify the conditions of the extracellular matrix and produce a ÿ brillar reorientation (Fig. 13.2). At all times it is the practitioner who is in charge of the process, accommodating the performance according to the expression of tissues to achieve an immediate change. It is possible that the patient may feel some pain during the treatment. If this is the case, the practitioner should modify the pressure and/or the rhythm of the procedure. If the patient wants to interrupt the process, they should be allowed to do so. ° e practitioner should not forget that the responses and pain experience are individualized. ° e main rule for these procedures is to perform the movement toward the restriction (Cantu & Grodin 2001, Sporel 1994, Pilat 2003). ° e most important contraindication is a tissue fragility that does not allow mechanical loading. ° e number of repetitions that may be applied is indicated by the results obtained and the irritability of the tissues. Some general considerations

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13

A

B

D

C

Figure 13.2 The physiological effects resulting from the application of the transverse stroke. The drawings in A, B and D show the fibroblast embedded in the collagen network. The forces applied to the fascial system generate tensional lines that modify the shape and location of the fibroblast (A). This in turn produces new collagen fibers (fibrillogenesis) that are added to the existing ones generating a denser and hypomobile tissue (dehydration of the matrix is key in this process) (B). Manual stimulation (e.g., during transverse stroke) (C) can redirect the fibers producing a more organized and mobile tissue (D)

relating to the application of stroking techniques are outlined in Figure 13.3. In general, these types of procedures must be applied before the sustained procedures, as they condition the tissue for the more demanding procedures. ° ey can be applied before other procedures, such as mobilizations, manipulations, stretching, massage, or exercises. ° e sliding techniques are applied directly on the skin. ° ere are three sliding (stroking) techniques: • J-stroke • transverse stroke • longitudinal stroke.

J-stroke ° e J-stroke focuses on the skin and superÿ cial fascia and should slide over the muscular level without penetrating it. ° e procedure begins with a visual evaluation and palpation of the skin to determine the dysfunction. Make sure there are no wounds or broken skin. Determine if the area involved is acute and hypersensitive. If this is the case, the procedure may be contraindicated. ° e main points relating to the J-stroke are outlined in Table 13.1. ° e palpatory evaluation and J-stroke procedure are shown in the Figures 13.4 and 13.5 respectively.

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Figure 13.3

Application of stroking movements

General considerations relating to the application of sliding procedures (stroking movements)

Objectives

Observations

Description

Stimulate fascial restrictions in the structures available for direct palpation

The movement is directed toward the restriction

A stroke is a passively applied movement of short duration, performed with or without sliding over the skin

The pain threshold should not be exceeded

Change the matrix quality (mechanotransduction process)

The movement may be applied with any finger reinforced by another finger, a knuckle, or the forearm or elbow

Change the "stationary attitude" of collagen Facilitate the recovery of the sliding properties/capacity of collagen

The main goal is the correction of subcutaneous restrictions related to superficial fascia and/or restrictions that affect muscles, tendons, or ligaments that can be felt directly below the skin

Avoid the formation of tissue adhesions Re-establish the dynamics of superficial fascial planes

Table 13.1

J-stroke

Assessment

Aims

Results

Procedure

Comments

Tissue texture

To balance the mobility of the superficial fascia

Generation of controlled posttraumatic hyperemia at subcutaneous level

Determine the location and direction of the restriction

The J-stroke is only applied at the depth of the superficial fascia

To facilitate the elimination of toxins (Kesson & Atkins 1999)

Generation of local vasodilatation

To optimize the quality of the skin

Opening of the pores of the epidermis

With the other hand apply the J-stroke using the index finger reinforced by the middle finger (or vice versa)

Temperature and humidity Hyposensitivity or hypersensitivity Superficial restrictions Range of movement Speed of displacement Ease of displacement Continuity of movement Quality of end feel

With one hand, hold the skin in position to apply counterpressure

The direction of movement is toward the restriction The sliding of the main stroke should be slow, otherwise the sliding of the tail of the J will be too fast The tail of the J is performed at the moment when increased tissue resistance is noted The average length of the line of the J-stroke is 4–5 cm The maneuver is repeated up to 7 times on the area being treated If the results are unsatisfactory, the 7-stroke cycle can be repeated up to 3 times on the same area Reassess the area that has been treated

This thickness of the superficial fascia can be different depending on the fascial morphology of different body areas and the morphology of the patient The tail of the J-stroke should always be performed with a supination movement of the hand (to the left with the right hand and to the right with the left hand) The technique may be slightly painful for the patient; however, the release of endogenous opioids calms the pain sensation (Goats 1994) In any event, the technique should not exceed the pain threshold of the patient The J-stroke can be used on any part of the body

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13

A

B

C

Figure 13.4 Assessment of the skin and superficial fascia through palpation. A Skin temperature assessment. B Palpatory examination. For large areas the entire palm of the hand is used, keeping the fingers in slight abduction. For small areas fingers are used. A gentle but energetic movement is performed with both hands at the same time and in the same direction. The hands should not slide about on the skin. The movement is performed in both directions in order to determine the side and direction of the restriction. C The parameters evaluated are amplitude, speed, resistance (end feel), continuity, and the general quality of skin movement

Transverse stroke

Longitudinal stroke

° e transverse stroke is an intervention that is reminiscent of deep transverse friction (Cyriax & Cyriax 1989), but in which the priority is the mobilization of very speciÿ c restrictions of a reduced surface area. ° e application may be slightly painful but should always be bearable for the patient. Maintaining low amplitude and a slow rhythm, the movement should never “jump” over the structure but be performed within it. ° e main points relating to transverse stroke are outlined in Table 13.2. Figure 13.6 shows the procedure.

° e longitudinal application of the glide allows the practitioner to stimulate hypomobile compartments that contain long structures (e.g., the trunk extensor or the hamstring muscles). ° e procedure is applied mainly to chronic conditions when marked hypomobility or adhesions are present. In subacute conditions, treatment prevents the formation of adhesions. Warning: the procedure should not be applied to “unconsolidated” scar tissue (Kesson & Atkins 1999, Laslett 1996). Lubricants may be used with this procedure, in particular for

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Figure 13.5 The J-stroke technique applied to a patient’s back. Note that the counterpressure contact is placed above the restricted area to stabilize the skin away from the restriction. The J-stroke is performed in the direction of the restriction using the index finger reinforced either by the middle finger or by one or two knuckles

Direction of restriction J-stroke Counterpressure

Table 13.2 Transverse stroke Assessment

Aims

Results

Procedure

Comments

Tissue texture

Remodeling of very specific restrictions of small surface areas (e.g., scars)

Mechanical forces change the tissue fibrosis (Langer 1861)

With the fingertips of both hands pressing downward into the tissue, the pressure is maintained and the movement is carried out

The force must be applied without producing excessive pain

Temperature and humidity Hyposensitivity or hypersensitivity Kneading over the structure or region to locate inner dysfunctions The goal is to find the area of greatest hypomobility

The procedure can be applied over the muscle bellies, tendons, and ligaments

Mechanotransduction process occurs (Agha et al. 2011) Micromovement of collagen crosslinks, (change from stationary attitude) (Kesson & Atkins 1999)

The practitioner performs the stroke in a transverse direction to the path of the muscle, tendon, or ligament fibers

Releasing of sliding properties (Hardy 1989)

The stroke is performed with the fingertips; alternatively, contact can be with the knuckles, elbow, or forearm

Stimulation of fiber orientation in regenerating connective tissue (Bulckwater & Crues 1991)

Generally, the movement of the practitioner’s hands is the MCP flexion– extension

Increase in the rate of phagocytosis (Evans 1980)

Approximately 3 sets of 15 cycles are applied. One of the cycles is the back-andforth movement

Analgesic effect occurs at between 0.4–5.1 minutes (De Bruijn 1984)

The estimated frequency is 1 cycle per second Low amplitude and a slow rhythm should be maintained All sites of entrapment should be treated

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13

A

B

C

D

Figure 13.6 Transverse stroke. Note that the hand contact is perpendicular to the tissue and is precisely located. The hands may be placed in one of three ways – either with one hand beside the other or with the palms facing each other or with the palms back to back. Pressure is applied with the tips of the first three fingers. The interphalangeal joints should not be hyperextended. The images show the transverse stroke applied to the lumbar vertebral region (A ( & B), the abdominal region (psoas major fascia procedure) (C & D), and the lateral lumbar region using the forearm (E)

E

patients with sensitive skin or in areas with hair. During the process it is important to work with the tissue, modulating the rhythm according to its requirements. ° e practitioner applies slow longitudinal sliding, stopping at each entrapment site for about 6–7 seconds to wait for

changes. It is a procedure that places great demands on the tissue, so take care to avoid too many repetitions. Usually 3 to 4 repetitions are enough. ° e main points relating to longitudinal stroke are outlined in Table 13.3, and the technique is shown in Figure 13.7.

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Table 13.3

13

Longitudinal stroke

Assessment

Aims

Results

Procedure

Comments

Tissue texture

To release the fascial compartments in a longitudinal direction

The longitudinal orientation of the muscle fibers is stimulated

Determine the base line

Do not remove either of the hands before reaching the end of each stroke to avoid a rebound effect

Temperature and humidity Hyposensitivity or hypersensitivity Test tissue elasticity (ROM) Palpate the structure or area to locate changes in stress and lack of mobility or flexibility

Hold the skin in place to apply counterpressure

The range of motion (ROM) is increased

Perform the stroke gradually

Tensile strength is increased

Perform the glide slowly, paying attention to the demands of the system

The formation of adhesions in acute processes is avoided

Stop in the presence of the restriction for approximately 6–7 seconds

The direction of movement depends on the orientation of the fascial fibers. (The direction of the fibers will be discussed and indicated for each technique)

Continue to the end Repeat the maneuver 3 times

A

B

C

D

E

F

Figure 13.7 Longitudinal stroke. Counterpressure is applied in the opposite direction to the sliding procedure. Contact can be reinforced by the index finger, middle finger, knuckle, fist, forearm, or elbow. The images show longitudinal strokes applied with the middle finger to the dorsal vertebral region (A); with the elbow to the anterior region of the leg (B); with the knuckles (of the index and middle fingers) to the cervical spinal region (C); to the posterior internal region of the thigh with the knuckles (D); with the forearm to the anterior region of the leg (E); and with the middle knuckles to the anterior region of the leg (F)

Sustained systemic procedures (indirect application) ° ese are the procedures that speciÿ cally involve the induction process. As explained in the Introduction to this chapter, the term “induction” relates to the facilitation of movement (in the search for improvement),

rather than a passive stretching of the fascial system. ° e pressure applied and the consequent tension in the tissue are maintained at the lowest level possible to modify the resistance of the elastic tissue components (previously treated with stroking techniques) up to the point when the barrier of tissue resistance is reached. A˙ er a minimum of 60 to 90 seconds the remodeling

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13 movement begins (Barnes 1990, Chaudhry et al. 2007), creating the sensation of facilitated movement.

The barrier When the practitioner applies compression and/or traction to the patient’s body, the tissue responds with reciprocal resistance, i.e., a “brake.” ° is barrier is considered to be the ÿ rst response of the fascial system to the load or stimulus that is being applied. It is a key sensation: the procedure will locate this barrier and, at this point, while maintaining the stimulus, will await the facilitated movement. ° is passively elongates the elastic properties of the tissue.

Facilitated movement In living organisms, movement is a condition that encompasses the entire organism at all levels of complexity – from the molecular level to interaction with the environment. ° e structure of the body integrates the dynamics of movement in an articulated and deeply integrated whole through the uninterrupted fascial network. It is not surprising that the system responds to the initial therapeutic impulse (force) with some form of movement – a movement that is the

expression of a correctly stimulated system. In this way, the body seeks a tensional equilibrium to obtain the maximum functional outcome with the minimum energy expenditure (eˆ ciency). ° roughout the application, the practitioner should follow this guiding movement with their hands. ° e result is a reciprocal reaction of the fascial system that involves the body with di˛ erent responses, i.e., electrical, electronic, metabolic, biochemical, metabolic, and physiological changes. Parallel changes occur at the neurological level and in the extracellular matrix of the tissue to facilitate and optimize the transfer of information to and within the fascial system. ° is ˝ ow of information is crucial for the proper functioning of the body, and through the mechanoreceptors the fascial system is in a continuous process of informational exchange (communication) (Vaticón 2009). ° ere are three routes of communication that conduct stimuli with surprising speed (Fig. 13.8) (see Chapters 5, 6, and 7). ° ese are:

• • •

mechanoelectronic (piezoelectricity) mechanochemical (gap junction and integrins) mechanoelectrical (sensory receptors).

Figure 13.8 Integrin Signal propagation

D

A

B

C

The processes of information transmission through the extracellular matrix. By applying manual stimulus we can activate the three routes of communication: mechanoelectronic, mechanochemical, and mechanoelectrical. Note the high speed of these processes A Piezoelectricity (mechanoelectronic) (real time) B Gap junction (mechanochemical) (real time) C Neurosensory receptors (mechanoelectrical) – 0.5–2.0 m/s α: 100/s D Integrins (mechanochemical) – 300 m/s

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Between the molecule and the organism Is it really possible that the application of simple manual contact triggers a set of reactions that ultimately brings altered information to the practitioner’s hand? Is this phenomenon manually detectable? ° e ÿ rst part of this book (Chapters 2, 4, 5, 7, and 9) analyzes the systemic view of the body’s construction and performance to attempt to explain the processes that occur during clinical application. ° is does not extend to macroscopic analysis; only corporeal phenomena at the microscopic level are considered. ° is is because it is impossible to clearly show at the macroscopic level the phenomena that result from treatment. Changes begin at the microscopic level of the body’s construction. It is not easy to understand or explain the complex processes that lead the patient to beneÿ t from treatment. ° ere are many processes and several of them occur simultaneously. ° e instruments currently available for testing do not allow us to monitor the changes that occur during the therapeutic process. For this reason, until science o˛ ers us this type of tool, and to avoid speculation, practitioners need to ÿ nd a solid theoretical framework for the rigorous analysis of clinical responses. Research into the behavior of biological microstructures, the fruit of the “marriage” between biology, physics, and engineering (not forgetting the omnipresent computer science), has discovered previously unsuspected links and behavioral similarities between solid structures and living biological elements, and biologists have been able to take advantage of the vast experience of physicists, leading to hitherto unsuspected results. Phenomena such as piezoelectricity, thixotropic changes, electrical or electronic responses, well studied by physicists, appear to be applicable to the analysis of body movement. Below is a brief review of the history of this research and the current state of knowledge.

Biology, crystals, and coherence In the ÿ eld of biology, at the end of the 1960s, a sudden interest in the detection of properties that until then were thought to be limited to the realm of the inorganic became more concrete in the scientiÿ c environment. ° e research of Lang (1966) and Athenstaedt (1968) are noteworthy in this regard.

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Some crystalline formations (usually elongated in shape) have a permanent electric dipole, i.e., a potential di˛ erence at their ends, which can be altered by exposure to heat (pyroelectricity) or by the application of a mechanical action (piezoelectricity). ° e parallel alignment of the molecules that make up these crystals produces an electrical charge di˛ erence across the opposite sides of the crystals, similar to what happens in some metals due to the e˛ ect of ferromagnetism. In particular, if the potential is increased, the piezoelectric crystal expands, and the opposite occurs (the crystal shrinks) if the potential is decreased. ° e complementary e˛ ect is also veriÿ ed: When compression is applied to the ends of the crystal, the potential difference increases, and when traction is applied, it decreases. ° e researchers cited documented pyroelectric and piezoelectric properties in organic structures (such as collagen ÿ brils, tendons, bones, teeth, nerves, and cellulosic components), obviously causing a stir in academic environments. It is interesting to note that although the biological piezoelectric activity (either direct or inverse) has been incontestably proven its origin has not been well established; it is thought to occur in the anisotropic regions of the reference material, for example in the collagen–apatite connections of the bones and is similar to the properties detected in semiconductor materials. Collagen fibrils, tendons, bones, and nerves exhibit pyroelectric and piezoelectric properties.

Piezoelectric behavior in organic structures was initially emphasized to explain Wol˛ ’s Law, which states that bone is deposited or reinforced in the areas most subjected to stress. Piezoelectricity apparently solved the problem of how organs could “feel” the mechanical action. Further analysis revealed that in relation to hydrated tissues the relaxation times of the electrical potential did not coincide with those foreseen in piezoelectric theory, whereas they were justiÿ ed according to another analogous theory – that of streaming potential. Ahn and Grodzinsky (2009) evaluated the role of piezoelectric activities in bones by studying in depth the phenomenon of mechanosensation in the processes that a˛ ect osteocytes and osteoblasts. Collagen (rigid) is supplemented by hydroxyapatite (elastic), and

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13 in the insertion zones between the two components a discrepancy in the amount of electrically charged ions is generated, but only under the viscosity and conductivity conditions foreseen for the ˝ ow potential. ° e authors propose a new line of research to verify their assumptions, and to prove with clinical evidence the results obtained so far.

Liquid crystals and energy medicine Also in the 1960s there was renewed interest in the discoveries of Vorländer (1924) and Weygand (1941), reinterpreted by Gray (1962), which underlined a behavior similar to piezoelectricity in liquid crystals of biological origin: Many organic substances (e.g., cell membranes) exhibit the spontaneous alignment of their molecular components, and thus permanent electrical polarization at the macroscopic level. ° eories soon emerged that related the directionality of such crystallike activities to the growth of tissues, organs, and even entire biological assemblages. Bassett and Becker (1962) glimpsed a detectable e˛ ect of electric ÿ elds on tissues and even within cells, anticipating Oschman (2000, 2003) who, reinterpreting Szent-Gyorgyi’s intuitions (1957), proposed the concept of energy medicine. According to Oschman (2003), any living entity generates energy ÿ elds of di˛ erent natures, and is in˝ uenced by force ÿ elds (those of the environment in which it operates, and even those generated by another living being). ° e energy in question is mainly electrical and magnetic in nature, but also optical, acoustic, thermal, chemical, gravitational, vibrational, and elastic; one of the advanced hypotheses is to interpret the living organism as a transformer from one form of energy to another.

Systems theory At the same time, systems theory (see Chapter 2) was established in the scientiÿ c community as a reaction to the excessive fragmentation and specialization of knowledge (reductionism). ° e pioneering work of Bertalan˛ y, Prigogine, Varela and Marturana, GellMann, and Capra emphasized – in a new classifying paradigm – the unifying characteristics of complex aggregates and the surprising properties of emerging phenomena: In each organism with a suˆ cient level of complexity, the sum is always greater than the constituent parts. In biology, this meant emphasizing the

globalizing functions of organisms as opposed to the analytical myopia generated by the shredding practice of the scalpel. From the 1980s onwards, interest in the body’s connective tissue system, which includes several subsystems, i.e., the neural (perineurium), vascular (circulatory), and ÿ brous (extracellular matrix, fascia, and muscles), has been growing steadily. ° e connective tissue itself can also be described as an integrated information system at various levels which manifests itself as a reciprocal control action between the extracellular matrix and the nuclear matrix of each cell, through the exchange of signals carried by the integrins and ÿ ltered by the cytoskeleton. ° e fascia, seen as an enveloping and continuous element that controls all three subsystems, is thus capable of exciting regulatory feats, beyond its “trivial” function of shaping the forms of the organs. Biological phenomena do not conform to the current laws of thermodynamics because they are based on the transduction of electronic, electrical, and electromagnetic energy, rather than thermal energy.

In recent years, a Chinese biochemical visionary and geneticist, Mae-Wan Ho (1941–2016), cofounder and former director of ISIS (Institute of Science in Society), has stood out in the panorama of new interpretations of physiological structures. In her ÿ rst book, ˜ e Rainbow and the Worm (1993), Ho deÿ nes life as “a process of being an organizing whole” and among the characteristics of life she praises the capacity to transform energy and to coordinate extraordinarily complex actions almost instantaneously, as well as to grow and reproduce. Biological phenomena do not conform to the current laws of thermodynamics because they are based on the transduction of electronic, electrical, and electromagnetic energy rather than thermal energy. Moreover, their outstanding quality is that of behaving as “coherent structures of space-time, kept away from thermodynamic equilibrium through the ˝ ow of energy.” ° is means that in order to describe life through the instruments of physics and chemistry it is necessary to infer the presence of quantum coherence in living organisms on a macroscopic scale. As in subatomic particles, all manifestations in living organisms are governed by the strict connection and correlation of all their components, and by the immediate transmission

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of signals between each of the same components. ° e molecules are organized in almost crystalline parallel patterns, and the individual dipoles merge into a global vibration, subject to excitation modes and collective wave patterns. Traces of this consistency can be seen in the chromatic variability and luminescence of a sample of living biological tissue, observed through a polarized light microscope (a phenomenon that increases in the presence of “liquid-crystalline water”). At the end of the book, Ho goes so far as to encourage the current instruments of scientiÿ c research to be integrated into a kind of universal participatory consciousness (formerly known as the “organic sentient whole”), so that life can continue to be involved without con˝ ict in the course of a responsive natural environment. All manifestations in living organisms are governed by the strict connection and correlation of all their components, and by the immediate transmission of signals between each of the same components.

In the article “Liquid crystalline morphogenetic ÿ eld” Ho (2011a) revisits the problem of cell di˛ erentiation from the embryo’s “multipotency” state. If the egg is considered as a liquid crystal (all the molecules are aligned and the corresponding dipoles contribute to create an overall electrical potential di˛ erence), an applied electromagnetic ÿ eld should, theoretically, in˝ uence the variations in shape and function of the developing organism. At the inorganic level, in a nematic liquid crystal sample, a polarized light microscope can show the emergence of patterns due to the presence of electromagnetic activity; it is reasonable to assume that the same occurs in the organic environment. In fact, tests carried out on Drosophila embryos show that static magnetic ÿ elds generate deformities and helical alterations in the larvae. In the article “Membrane potential rules” Ho (2011b) takes Oschman’s intuition into consideration: ° ere is a di˛ erence in electrical potential between the outside and the inside of the cell membrane, and it is quite possible that altering this potential can a˛ ect fundamental cell processes such as embryo growth, tissue healing, proliferation, cancerous degeneration, and apoptosis. In particular, evidence is beginning to emerge that electromagnetic ÿ elds of varying intensity can in˝ uence tissue morphogenesis: Recent studies conÿ rm that

13

natural or induced electrical activities in frog eggs can modify the position and distribution of the elements of the head, as well as the di˛ erentiation of the head–tail axis, during growth.

Mechanisms of the induction process Following the therapeutic applications, the fascial system will optimize its tensional balance to achieve the most eˆ cient distribution of forces and at the same time promote the immediate transmission of signals between each of its components and others it relates to thus improving its communication role. ° is will restore function. ° e changes can manifest in the short and medium term and the result can be appreciated immediately upon completion of the procedure or during a period of time (up to 72 hours). ° is aspect is important with regard to the reassessment. ° e sustained techniques represent a concentrated process controlled by the CNS in which the practitioner acts as a facilitator. Facilitator means that the practitioner will provide the necessary stimulus so that the tissue and the organism, as the protagonists of the process, reach their equilibrium. For this reason, the therapeutic action focuses on the provision of resources. ° e ÿ nal objective is not the establishment of stable hierarchies but rather the facilitation of an optimal adaptation to the demands of the environment. As stated above, induction refers to a mechanical stimulus (traction and/or compression) with a low load and of long duration which is looking for a barrier response and subsequently a facilitated movement as an expression of the search for homeostatic balance. ° e mechanisms that may lie behind the stimulation that produces these achievements are shown in Figures 13.9, 13.10, and 13.11 (see also Chapters 5, 6, and 7). During treatment the communication channels are activated through manual stimulation. ° e fascial system varies the response by switching from one communication channel to another (Fig. 13.12). ° e main processes involved are explained brie˝ y below.

Thixotropic reaction ° ixotropy is a phenomenon exhibited by several types of gelatinous substances in which the system exhibits the mechanical properties of a gelatin when it is not disturbed, but turns into liquid when it is mechanically

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13 MIT Manual stimuli Low load Long duration

PNS

Spinal cord

ANS

CNS

Neural response

Matrix remodeling

Modification of the physical and/or chemical characteristics of the tissue

↑ Movement

Pain modulation

Structural response

Improvement of cortical representation (body image)

Dynamic stability Allostasis or homeostasis

Functional improvement Changes in behavior

Figure 13.9 Mechanisms and consequences of induction on the fascial system. Note that there are two types of response: a structural response and a neural response. The two responses are always linked. The clinical context, expectations, psychological factors, and the therapeutic relationship influence the process. PNS – peripheral nervous system. ANS – autonomic nervous system. CNS – central nervous system

MIT Manual stimuli Low load Long duration

Neural response Matrix remodeling Hydration Repolarization Deformation Changes in the phenotype of fibroblasts Changes in gene expression

Mechanical stimuli with these characteristics could generate "time-dependent" deformation of the collagenous structures Release of TGF˜ 1 As a result of the change in fibroblast tension there would be a greater intercellular flow due to the opening of the paracellular channels or "pores" to the water The change in the connective matrix facilitates cellular mobility by influencing the distribution of fluids, including hyaluronic acid (HA) HA facilitates sliding, viscoelastic behavior, and the transmission of forces during movement The environment of the fibroblasts can decrease the rigidity of the matrix which can in turn alter the state of contraction of its cytoskeleton (myofilaments) and lead to a decrease in the production of collagen (change in gene expression)

↑ Movement Modification of the physical or chemical characteristics of the tissue

Structural response

Functional improvement with wide ranges of mobility and elastic end feel (facilitation of the hedonic perception of movement) Changes in the interstitial receptor environment (less stress) increase the mechanosensitivity threshold of the tissue. A decrease in nociceptive activity and interoceptive allostatic load due to low discharge of interstitial receptors is a product of connective tissue remodeling

Pain modulation

Improvement of cortical representation (body image)

Figure 13.10 The structural response to induction processes and its consequences

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13

MIT Manual stimuli Low load Long duration

PNS

ANS

Spinal cord

CNS

Neural response Matrix remodeling

Activation of a hedonic or pleasant touch through the C fibers Afferent pathway mechanisms: interoceptive homeostasis Afferent medullary impulses: lateral and ventral spinothalamic tracts Descending modulating responses (central and peripheral) Neuromuscular response: depolarization of the motor neuron and normalization of tone Neuroendocrine modification: cortisol; ↑ in intensity and frequency of alpha waves (relaxation); EEG activation of the left frontal region of the brain (relates to concentration and positive thoughts); ↑ in attention patterns (EEG); ↑ in serotonin and dopamine; ↑ in oxytocin secretion; ↓ in ACTH (adrenocorticotrophin); ↓ in cortisol; and ↓ in noradrenaline Neuroimmune modification: ↑ in the number and activity of NK, Th1, and Th2 cells, and chromogranin A; ↓ in inflammatory cytokines

↑ Movement

Pain modulation

Structural response

Improvement of cortical representation (body image)

Involvement of somatosensory cortex I and II, limbic system (cingulate cortex, insular cortex, orbitofrontal cortex, hippocampus, amygdala, hypothalamus), hypothalamus, and thalamus Somatosensory and sensory alternations: motor improvement Activation of pain modulator circuits Changes in vagal tone Modification of interoception, proprioception, and nociception

Figure 13.11 The neural response to induction processes and its consequences PNS – peripheral nervous system. ANS – autonomic nervous system. CNS – central nervous system

Feedback

Physiology

Organism

Metabolism

Organ

Signaling

Cell

Biochemistry

Genome

Molecule

Manual stimulation Macroscopic level

Microscopic level

Figure 13.12 Changes relating to and caused by manual stimulation during the application of MIT. Reproduced with permission from Pilat A. (2014) Myofascial induction approach. In: Chaitow L. (Ed.) Fascial Dysfunction: Manual Therapy Approaches. Edinburgh: Handspring Publishing

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13 stirred and is converted back into gelatin when it is still (Alger 1997). ° e viscosity of the thixotropic system depends on the extent of the previous mechanical agitations to which the material has been subjected. During the application of myofascial procedures it is possible that the fascial system, that exhibits these properties (the ECM being a colloid structure), could respond by becoming more ˝ uid, thus facilitating its search for tensional equilibrium.

Changes resulting from intercellular and intracellular communication ° e e˛ ects of mechanical loading on the matrix result in connections (communication) between cells or between the extracellular matrix and the cells. ° is communication is carried out through di˛ erent processes:

•

Piezoelectric response (cell mechanotransduction, mechanoelectronic reaction). ° is phenomenon has been explained in detail above.

•

Direct cell communication through gap junctions via integrin participation (cell mechanotransduction, mechanochemical reaction). Gap junctions (juxtacrine communication) (see Chapter 5) are present in between cells such as ÿ broblasts, telocytes, and glial cells (astrocytes). Gap junctions are sensitive to mechanical loading (mechanical signaling). ° e ÿ broblasts connect to their protoplasmic expansions by making contact points through gap junctions (connexin 43). ° e mechanical stimulation of connexin 43 can induce signaling processes mediated by the transfer of calcium waves – cell to cell – and through the paracrine release of ATP (adenosine triphosphate). Calcium waves act as mechanisms of intercellular signaling during the transmission of forces, for example, among myoÿ broblasts. ° ese waves seem to act as a chemical mechanism that helps to organize the contractile response between intercommunicating myoÿ broblasts (Hinz et al. 2012, Pilat 2012). ° ese forces can act at a distance to induce a mechanochemical conversion in the nucleus and alter the gene activity (Wang 2009), for example, to increase the synthesis of collagen and growth factors (TGFβ1).

•

Neurosensory receptors (cell mechanotransduction, mechanoelectric reaction). ° ese receptors interpret mechanical signals into biochemical signals

by opening the ion channels of the cell membrane (Jaalouk & Lammerding 2009).

•

Neurotransmission and other communication channels. Transmission via excitable cells (neurotransmission) is hegemonic; however, transmission can be modulated and conditioned by other forms of communication, such as through gap junctions.

Biotensegrity of the fascial system Connective tissue forms a body-wide communication net that acts as a complex mechanosensitive system. A signal generated by a connective tissue component in response to a speciÿ c stimulus can propagate over some distance. ° e three types of signals (electrical, cellular, and tissue remodeling) are sensitive to mechanical forces, which are transmitted at di˛ erent timescales and with the potential to interact with each other. ° e stability of the whole tensional structure is not due to the strength of its parts but to how it manages the mechanical stress to which it is subjected (Scarr 2014).

Remodeling of the extracellular matrix ° e application of manual stimulation can cause changes linked to mechanotransduction, such as the cleavage of the collagen matrix by the action of the metalloproteinases, tensional changes, release of growth factors (TGFβ1), and modiÿ cation of the density and orientation of the tissue (remodeling-replacement). ° is establishes changes in the mechanical properties of the fascial system (viscoelastic changes), generating a systemic response of homeostatic tensional adjustment in the fascial network which makes it possible to accommodate the demand for movement. ° ese “decentralized” events cause interoceptive changes which reshape the representation of the body to the brain (insular cortex) and regulate emotion and awareness of movement (see Chapter 8).

Viscoelastic response Changes in the extracellular matrix and its viscoelastic behavior relating to the production of hyaluronic acid (Roman 2013, Pratt 2021) optimize, over time, the mobility and sliding capacity of the connective intermediate levels of fascia (see Chapters 5 and 9). Neurological modulation produces greater ˝ uidity in the fundamental substance of the ECM. Research

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conÿ rms the presence of the viscoelastic properties of fascia (Yahia 1993, Chaudhry et al. 2007). However, it is diˆ cult to conclude whether this process occurs during treatment. ° is is because of the need to apply suˆ cient load to achieve the objective, which does not occur during therapeutic sessions as only low forces are applied. It is likely that the changes in hydration of the matrix, which improve its quality, facilitate the sliding and gliding properties of fascia.

Sensitivity to stimulation A mechanical load applied to the fascial system will inevitably in˝ uence its innervation. Specialized connective tissue contains mechanoreceptors that have rapid conduction pathways (Golgi body, Pacini and Ruˆ ni corpuscles). ° ere are also polymodal receptors – non-specialized free nerve endings in connective tissue – that can act as nociceptors. Of particular importance are the unmyelinated Cˇÿ bers that are able to activate the areas of the brain involved in emotional states, such as the insular cortex. ° ese directly stimulate the peripheral, medullary, and supramedullary modulating mechanisms and are able to in˝ uence any expression of the nervous system. Examples of this type of stimulation are: the activation of the interoceptive homeostatic a˛ erent pathway (Bordoni & Marelli 2017); the participation of the cannabinoid system (McPartland 2008, Fede et al. 2020); the response via “ideomotor movement” (Dorko 2003); and the involvement of the emotional motor system and pandiculation (Holstege 2002, Bertolucci 2011, Simmonds et al. 2012).

Sustained systemic applications: Modalities ° ere are di˛ erent procedures within the sustained modalities. In contrast to the sliding procedures, the sustained applications require more time and more prolonged attention. However, the changes obtained are worth the e˛ ort. ° e goal is to achieve homeostasis. ° e focus is on particular structures or regions and will frequently involve other areas of the body that are far from the initial focus. Sustained applications involve changing the speed, intensity, depth, amplitude, and coordination of movements. For the process to work, there has to be interaction between the patient, who has to agree to the changes, and the practitioner, who is applying the procedure. ° e practitioner has to gain

13

the trust and conÿ dence of the patient and, strange as it may seem, the conÿ dence of the tissue. ° e diversity of alterations to the system and the resulting changes in the therapeutic process suggest the possibility of an extensive response (adjustments) through a combination of facilitated movements the details of which can hardly be predicted. ° ese changes do not follow speciÿ c patterns of common muscle actions, rather there is a three-dimensional remodeling (or perhaps four-dimensional if we include the time factor required for medium- and long-term adjustments) (Pilat 2003). At the same time, the system can unfold in di˛ erent planes and di˛ erent directions. ° e way the practitioner accompanies the direction of the movement (facilitated movement), its amplitude and speed, with the appropriate force and always respecting the rhythm of the process, will be decisive in the success of the treatment. ° e tissue always leads, movement is expressed promptly, and the practitioner accompanies it, avoiding the creation of their own movement. ° e practitioner adjusts the treatment according to the response they receive from the tissue. ° e process is an interactive, feedback-based journey. ° e practitioner is not a spectator, but rather an active collaborator who invites decision making and supports the patient by providing reassurance during the process. ° e patient creates their own treatment aided by the practitioner. ° e ÿ nal movement will depend on the resources and goals of the patient and the trust placed in the practitioner’s hands. During treatment the pressure on the tissue must be constant, but the force applied by the practitioner can be modiÿ ed a˙ er the ÿ rst barrier has been overcome. ° e force applied should be reduced when abundant activity and/or pain is perceived. ° roughout the procedure, rest time is alternated with active time. ° e treatment begins with the release of the ÿ rst barrier (very slight resistance followed by calm). ° e practitioner must continue to apply the load of the stimulus in order to maintain the pressure produced by their hand on the patient’s tissue. A˙ er the facilitated movement has occurred, the tissue response changes, and the practitioner should modulate the load in order to maintain constant tension between the two active elements: the reaction of the tissue and the stimulus applied. ° e practitioner accompanies the

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13 movement until the next barrier is reached. ° e practitioner must stop at the barrier long enough to cause the tissue to reshape and continue with the facilitated movement. ° e process continues with progressive steps. Rest time can be brief (seconds) or very long (minutes). It is a time to reassess and make decisions (perhaps try a di˛ erent direction, depth, intensity, or amplitude). ° e practitioner has to be very attentive to this new path. ° e process can be compared with the execution of a piece of music by two professional musicians, two virtuosos, who, uniting through the melody, create a new and unique piece, understanding each other perfectly through sound and without words. ° e performance may at times seem to be uncontrolled, but in fact it is not. It is the ultimate application of professional knowledge and creative abilities. ° e therapeutic process is a form of extremely precise and reÿ ned communication, which only represents, externalizes, or expresses the multitude of actions and reactions at the cellular and subcellular level that generate the healing processes. If we could see what happens during the therapeutic application under an electron microscope, it would undoubtedly be something similar to what has been expressed here. It is solid, scientiÿ c, and carried out within a very precise framework. ° e practitioner does not set goals, but through touch stimulates and accompanies the response of the tissue and, using the full range of basic techniques, invites the tissue to perform the movement and ÿ nd the tensional balance of

the system. Concentration is important: ° e practitioner has to be attentive and must listen to their own body in order to detect the desired movement even before it happens. ° is will allow them to accompany the movement with precision. At the same time, the patient, if correctly treated, will relax and have more trust in the process. In fact, sometimes, the patient might fall asleep, but this will not prevent the fascial system from continuing to work. However, the patient’s mental participation in the treatment will enhance the results. For each application, at least three to six consecutive barriers must be overcome, and the minimum application time is 3 to 5 minutes. ° e treatment time should not exceed 20–25 minutes, to avoid overstimulation. ° e application is complete when the correct adjustments have occurred in the fascial system. Even if we continue to stimulate, the tissue will not respond to mechanical loading, by either releasing a barrier or in the form of movement. It will not respond because it is already in tensional equilibrium. ° e absence of a reaction in the face of further stimulus is the sensation that indicates the application is complete. ° e number of barriers and the length of the process are only approximate and are based on clinical statistics. Some general considerations relating to sustained systemic procedures are shown in Figure 13.13. Verbal communication is maintained to ensure the patient’s comfort. Simple language with few words should

Systemic sustained application

Figure 13.13 General considerations relating to systemic sustained applications

Objectives

Observations

Description

To induce tensional balance To improve communication of the fascial system

Movement can be built on at all levels of the system

A light mechanical impulse maintained over time

The application requires a high level of concentration on the part of the practitioner

Emergence of the "barrier" and accompanied by "facilitated movement"

The changes involve the entire fascial system linking regions and body systems

The practitioner is a facilitator

To restore dynamic stability To improve allostasis and restore homeostasis To restore and/or improve function

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be used when communicating with the patient. Instructions should be given in a so˙ tone of voice. During treatment there may be instances where pain occurs and these must be analyzed. ° e application should be suspended if the patient cannot tolerate the pain or if it spreads or increases in intensity or duration. Finally, the presence of a vagal response could be serious and should be monitored. If the patient’s heart rate and/or respiratory rate decreases, and there is profuse sweating, the pressure should be reduced and the procedure will probably have to be ended.

Sustained applications: The four basic modalities Local and global sustained procedures Local and global procedures are two sustained strategies that have similar characteristics and can be applied to speciÿ c structures. For local techniques the application time is usually shorter (2–5 minutes). Focusing on the speciÿ c tissue, the goal is a local change in a particular area (e.g., the rotator cu˛ ). For the global procedures the application time is usually longer (5–20 minutes),

Table 13.4

13

and the goal is the correction of an extensive area (e.g., the entire shoulder complex). With both types of procedure the shoulder is touched in a similar way, but the results are di˛ erent. Within these procedures there are four basic modalities: cross hands induction, transverse plane induction, single-hand contact, and fascial unwinding.

Cross hands induction Cross hands induction is one of the most versatile modalities used in MIT. ° e objective is to optimize mobility in and between the deep fascial structures at all levels of construction. Once a dysfunction in a speciÿ c region has been identiÿ ed using the assessment process (see Chapters 10 and 14), the practitioner crosses their hands, places them on the patient, and focuses their attention on feeling the barrier. Subsequently, the practitioner accompanies the facilitated movement to achieve all the necessary adjustments. An analogy might be drawn with smoothing out the wrinkles in a piece of cloth in that the resistance of the connective tissue is minimal. ° e main points relating to cross hands induction are outlined in Table 13.4. Figures 13.14 and 13.15 illustrate the procedure.

Cross hands induction

Assessment

Aims

Results

Procedure

Comments

Analyze the parameters of myofascial dysfunction (see Chapter 10)

To eliminate systemic constraints

Changes in connective tissue quality

Cross the hands and place them over the area

Accompany the process, and do not create arbitrary movements

To improve mobility within and between deep structures

Pain modulation Improved movement Return to dynamic stability

Perform the technique with the fingers and the palms of the hands

Cross hands induction can be used on any area of the body

Apply pressure and traction progressively to the area between the hands

Monitor the adjacent regions

Exhaust the pre-elastic stage

Detect systemic responses

Find the barrier and wait

Maintain concentration

When the facilitated movement occurs, follow it with both hands

Keep the patient at rest for several minutes after the treatment

The direction of the movement is toward facilitation Maintain constant pressure on the tissue Overcome 3 to 6 barriers

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13

A

B

C

Figure 13.14 The cross hands procedure applies force through compression and traction to the target tissue. The images show cross hands applied to the anterior region of the lower leg (A), the kyphotic region of the spine (B), and between the scapulae (C)

Single-hand contact ° e practitioner starts by placing one hand on the patient’s body over the dysfunctional region. ° is modality allows for a more accurate and sensitive approach and is recommended for highly sensitized and/or traumatized regions. Its application is also indicated for the induction of smaller structures. ° e main points relating to single-hand contact are summarized in Table 13.6 and its application is shown in Figure 13.17.

Fascial unwinding

Figure 13.15 Simulation of the cross hands procedure applied to the abdominal fascia

Transverse plane induction Transverse plane induction is designed to induce structures where the fascial system has a transverse projection and can be related to a muscle (diaphragm), a muscle group (˝ oor of the mouth, pelvic ˝ oor), or a peripheral joint (knee, ankle). ° ere is no anatomical limitation to its use, although the most common areas to which it is applied are the pelvic, diaphragmatic, respiratory, clavicular, and hyoidal transverse planes. ° e main points relating to transverse plane induction are outlined in Table 13.5. ° e procedure is shown in Figure 13.16.

° is is a whole-body procedure with various nuances. It is usually applied to the extremities. It can be performed locally (e.g., on one ÿ nger or one interphalangeal joint) or globally (on the entire extremity). It is indicated in cases of nonspeciÿ c dysfunctions with the presence of scattered clinical symptoms (e.g., di˛ use pain) in di˛ erent areas along the limb or in complex dysfunctions where the initial evaluation does not lead to a precise conclusion. To start the treatment, the practitioner applies a gentle, but sustained traction along the axis of the limb, suspending the gravitational load. Subsequently, when changes in the tension of the tissue become apparent, the practitioner follows the facilitated movement, taking care to avoid arbitrary movements. ° e process of application is complex and requires great concentration and dedication on the part of the practitioner. ° e outcome is o˙ en complex (several areas of movement can be activated simultaneously), allowing the practitioner to identify the precise location(s) of the dysfunction and to treat them at the same time. ° e body’s response during this

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Table 13.5

13

Transverse plane induction

Assessment

Aims

Results

Procedure

Comments

Analyze the parameters of myofascial dysfunction (see Chapter 10)

To eliminate systemic constraints

Changes in connective tissue quality

Place one hand underneath the body and the other hand, in a parallel position, on top of the body

Accompany the process

Pain modulation

The dominant hand (in prone) is the one on the top

To eliminate transverse restrictions To improve mobility within the tissue and between deep structures

Improved movement Restoration of dynamic stability

Monitor the adjacent regions The elbow of the lower hand (in supine) rests on the table Apply pressure with the upper hand while the lower hand maintains the tension (is active)

To treat viscerarelated restrictions

Do not create arbitrary movements

Detect systemic responses Maintain concentration Concentrate on the area between the hands

Exhaust the pre-elastic stage Find the barrier and wait

The rotational and translational movements are frequent

When the facilitated movement occurs, follow it with both hands The direction of the movement is toward facilitation

Keep the patient at rest for several minutes after the treatment

Maintain constant pressure on the tissue Overcome 3 to 6 barriers

A

B

C

Figure 13.16 The transverse plane procedure aims to change structures where the fascial system has a transverse projection inside the part of the body between the practitioner’s hands. A Transverse pelvic plane procedure applied to the lumbar area. B Keep in mind the large number of structures between the practitioner’s hands. This procedure is often used for visceral dysfunctions. C Transverse plane procedure applied to the wrist

procedure has caused many controversies of interpretation throughout the years among di˛ erent professions, for example, the medical sector, osteopaths, physiotherapists, and other manual therapy professions. ° e

term “unwinding” seems to have been coined by Dr. Viola M. Frymann (Kern 2001, Shea 2007), although Sills (Sills 2003) preferred the term “macromotions” to describe the process by which the body expresses

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13 Table 13.6 Single-hand contact Assessment

Aims

Results

Procedure

Comments

Analyze the parameters of myofascial dysfunction (see Chapter 10)

To eliminate systemic constraints

Changes in connective tissue quality

Apply targeted and light contact with the fingers or the whole hand

Can be used anywhere on the body

Pain modulation

Progressively introduce pressure

Improvement in movement

Find the barrier and wait

To improve mobility To restore dynamic stability to the myofascial system

Is recommended for small areas It recommended for sensitive areas Monitor the adjacent areas Accompany the facilitated movement Dynamic stability is restored

Detect systemic responses Follow the direction of the movement toward facilitation

Maintain concentration

Maintain a constant pressure on the tissue

Keep the patient at rest for several minutes after the treatment

Improved sensitization Pain modulation Improved fluid circulation

Overcome 3 to 6 barriers

itself with great movements. Some authors have used the expression “restructuring.” ° ere is speculation about the processes behind this activation of the body; the simple principle of the body’s ability to correct itself from mechanical disturbances is generally accepted, but it is thought that the procedure should contain something more complex. For example, Dorko (2003) suggests that “ideomotor movement” could be the answer. Ideomotor actions are unconscious and involuntary movements performed by an individual that may be caused by previous expectations, suggestions, or preconceptions. According to Minasny (2009), Halligan and Oakley’s view of consciousness (2000), and the neurobiological theory of Schleip (2003a, 2003b), fascia has to be the basic component of this process. In the opinion of the author of this book, the fascial unwinding process encompasses all of the above as mechanisms of the induction process, which is assumed to be a neurobiological process that involves fascial tissue as a linked system. ° e main points relating to the fascial unwinding process are outlined in Table 13.7. Telescopic unwinding performed on the upper limb is shown in Figure 13.18. Figure 13.17 Single-hand induction. This modality allows for a more accurate and sensitive approach

Neuromeningeal procedures ° e sustained procedures above can be applied in cases of neuromeningeal dysfunction. It should be remembered that meningeal structures and glial tissue represent the fascial structures in the central nervous system

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1

6

5

4

13

Fascial unwinding

2

3

Figure 13.18 Fascial unwinding applied to the upper extremity. Fascial unwinding is a characteristically dynamic process. The images represent the entire sequence

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13 Table 13.7

Fascial unwinding

Assessment

Aims

Results

Technique

Comments

Analyze the parameters of myofascial dysfunction. (see Chapter 10)

To recover limb dynamics

Changes in connective tissue quality

The stimulus is gentle traction along the longitudinal axis of the region to be treated

The traction stimulus is very subtle; it is fascial traction

To eliminate systemic constraints

Pain modulation

The limb is firmly gripped, but without causing pain

Avoid decoaptation (separation) of the joints

The practitioner pulls by moving his body weight back (as if he were hanging), with both elbows in extension

Your body weight provides the traction force

To improve mobility To restore motor control

Improvement in movement Dynamic stability is restored

Facilitate the movement Expect to overcome the barrier 3 times

Improved fluid circulation

Pain modulation

Accompany all forms of movement while maintaining the stimulus

Accompany the process, without creating your own movement Monitor the adjacent regions

The duration of the technique is 10–15 minutes

Detect systemic responses Keep the patient at rest for several minutes after the work is finished

A

B

C

Figure 13.19 Procedures that can be applied in cases of neuromeningeal dysfunction. A Induction of myodural bridges. B Transverse plane induction applied to the skull. C Spinal duramater induction

and also in the endoneural, perineural and epineural layers of the peripheral nervous system. ° ese structures also respond to manual stimulation (through mechanosensitivity and mechanotransduction mechanisms). Examples of these procedures are: the application of sustained pressure to the suboccipital region (to in˝ uence myodural bridge connections); transverse plane induction applied to the skull (to directly in˝ uence its meningeal system); and the spinal dura mater induction procedure (Fig. 13.19). Neuromeningeal

procedures require vast experience and an extensively trained therapeutic touch. During their application the practitioner has to perceive deep and subtle tensional changes and subtle movements.

Visceral procedures As noted earlier in the chapter, the fascial system of the viscera is vital to the functioning of the visceral system. Recent research by Co˛ ey and O’Leary (2016) focuses

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on the anatomy and function of mesenteric structures and their study suggests that “distinctive anatomical and functional features have been revealed that justify designation of the mesentery as an organ.” Sustained procedures (the most common being transverse plane induction) can be used to induce viscerofascial structures and can be applied to any cavity where the target viscera are located. Particular attention should be paid to deep responses from related structures. Systemic changes are frequent during these applications. ° e patient should be monitored for vagal response, however, visceral procedures are not the focus of this book.

MIT: Indications and contraindications Contraindications for MIT are similar to those applied to other manual therapy approaches, particularly in relation to manual lymphatic drainage procedures. Sometimes a contraindication is relative, and depends on the development of the disease; for example, treating a patient with lupus erythematosus in acute crisis is an absolute contraindication, but between crises, when the patient’s condition is stable, the contraindication is considered to be relative. ° e experience of the practitioner is also a factor in decision making; for example, for a physiotherapist not experienced in MIT to treat a patient with advanced spinal cord instability would be an absolute contraindication, but for a highly trained Table 13.8

13

and experienced physiotherapist, it would be a relative contraindication. Where evidence is not available in relation to pathology, the practitioner should act responsibly and use their common sense to establish the basis for decision making. When deciding on the indications for treatment the practitioner needs to focus on the important preventive role of MIT, and, ultimately, this will enable them to bring about improvement in a large number of dysfunctions. ° e extensive preventive beneÿ ts of MIT should be emphasized. Secondly, MIT contributes to the therapeutic processes of a wide range of disorders. MIT procedures can be used to restore function in systems that have been a˛ ected by traumatic and/or surgical processes, sports injuries, degenerative diseases, or neurological disturbances from central and peripheral processes. MIT procedures can also be applied to various other dysfunctions linked to respiratory, genitourinary, or circulatory disorders. ° e indications and contraindications for MIT are summarized in Table 13.8.

Other considerations With more advanced procedures, it is possible for the work to be shared between several practitioners at the same time (two, three or more practitioners during one MIT session). Before carrying out such procedures, make sure that the practitioners have received intensive practical training in the relevant method.

MIT: Indications and contraindications

Indications

Contraindications

Orthopedic disorders

Aneurysms

Neuro-orthopedic disorders

Systemic diseases

Postinjury or postsurgery disorders

Inflammatory soft tissue process in the acute phase

Degenerative diseases

Acute circulatory deficiency

Nervous system diseases (central and peripheral)

Advanced diabetes

Pelvic floor disorders Circulatory diseases

Anticoagulant therapy General contraindications to any manual therapy procedure

Temporomandibular jaw dysfunction Sports injures Respiratory disorders

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13 Conclusion

•

•

MIT is a process of continuous evaluation and treatment in which the practitioner transfers a force (traction and/or compression) to the target tissue, facilitating recovery of the quality of the fascial system.

Training and experience in MIT will allow for more complex and advanced achievements.

•

•

° e main objective is an optimal adaptation to the requirements of the environment and the restoration of the body’s homeostasis, improving the function and behavior of the patient. To achieve this, the practitioner uses their hands, body, knowledge, and intention. ° e treatment is interactive and a patient-centered approach is used.

° e underlying mechanisms behind MIT are complex and represent a neurobiological process that involves fascial tissue as a linked system in full intrinsic communication with the whole body, particularly the nervous system.

•

° e basic procedures are sliding and sustained stimulation techniques, and in combination they can be applied to any level of the fascial system.

•

° e contraindications for MIT are the same as those for manual therapy modalities.

•

° e details of the environment (privacy) and the approach to body biomechanics as well as the level of concentration are vital.

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REFERENCES

Ahn AC, Grodzinsky AJ (2009) Relevance of collagen piezoelectricity to “Wol˛ ’s Law”: A critical review. Med Eng Phys 31(7):733–741. Agha R, Ogawa R, Pietramaggiori G, Orgill DP (2011) A review of the role of mechanical forces in cutaneous wound healing. J Surg Res 171(2): 700–708. Alger M (1997) Polymer Science Dictionary. 2nd ed. Springer. Athenstaedt H (1968) Pyroelectric and Piezoelectric Properties of Vertebrates. Institute of Physical Chemistry, Nuclear Research Center and Department of Biophysics, University of Aachen.

Chaudhry H, Huang CY, Schleip R, Ji Z, Bukiet B, Findley T (2007) Viscoelastic behavior of human fasciae under extension in manual therapy. J Bodyw Mov ° er 11(2):159–167. Chiquet M, Renedo AS, Huber F, Flück M (2003) How do ÿ broblasts translate mechanical signals into changes in extracellular matrix production? Matrix Biol 22(1):73–80. Co˛ ey JC, O’Leary DP (2016) ° e mesentery: Structure, function, and role in disease. Lancet Gastroenterol Hepatol 1(3):238–247.

Gabbiani G (2012) Recent developments in myoÿ broblast biology: Paradigms for connective tissue remodeling. Am J Pathol 180(4):1340–1355. Ho M-W (1993) ° e Rainbow and the Worm. Singapore: World Scientiÿ c. Ho M-W (2011a) Liquid crystalline morphogenetic ÿ eld. Science in Society archive. Available: http://www.i-sis.org.uk/Liquid_Crystalline_ Morphogenetic_Field.php [accessed October 28, 2019].

Craig AD (2003) Interoception: ° e sense of the physiological condition of the body. Curr Opin Neurobiol 13(4):500–505.

Ho M-W (2011b) Membrane potential rules. Science in Society archive. Available: http:// www.i-sis.org.uk/Membrane_potential_rules. php [accessed October 28, 2019].

Barnes J (1990) Myofascial Release: ° e Search for Excellence. 10th ed. Rehabilitation Services Inc.

Cyriax JH, Cyriax PJ (1989) Illustrated Manual of Orthopaedic Medicine. London: Butterworths.

Holstege G (2002) Emotional innervation of facial musculature. Mov Disord 17(Suppl.ˇ 2): S12–16.

Bassett CA, Becker RO (1962) Generation of electric potentials by bone in response to mechanical stress. Science 137(3535):1063–1064.

De Bruijn R (1984) Deep transverse friction: Its analgesic e˛ ect. Int J Sports Med 5:35–36.

Ingber DE (2003) Mechanobiology and diseases of mechanotransduction. Ann Med 35(8):564– 577.

Bertolucci LF (2011) Pandiculation: Nature’s way of maintaining the functional integrity of the myofascial system? J Bodyw Mov ° er 15(3):268–80. Bordoni B, Marelli F (2017) Emotions in motion: Myofascial interoception. Complement Med Res 24(2):110–113. Bringman H, Giesecke K, ° örne A, Bringman S (2009) Relaxing music as pre-medication before surgery: A randomised controlled trial. Acta Anaesthesiol Scand 53(6):759–764. Bulckwater JA, Crues R (1991) Healing of musculoskeletal tissues. In: Rockwood CA, Green DP, Bucholz RW (Eds.) Rockwood and Green’s Fractures in Adults: 2. 3rd ed. Lippincott. Cantu RI, Grodin AJ (2001) Myofascial Manipulation: ° eory and Clinical Application. 2nd ed. Aspen Publishers Inc. Carter S, Drew L (2012) Touch in the consultation. Br J Gen Pract 62(596):147–148. Chaitow L (2000) Terapia manual: Valoración y diagnóstico. McGraw Hill Interamericana de España.

Dorko BL (2003) ° e analgesia of movement: Ideomotor activity and manual care. J Osteopath Med 6(2):93–95. Evans P (1980) ° e healing process at cellular level: A review. Physiotherapy 66(8):256–259. Fede C, Pirri C, Petrelli L, Guidolin D, Fan C, De Caro R, Stecco C (2020) Sensitivity of the fasciae to the endocannabinoid system: Production of hyaluronan-rich vesicles and potential peripheral e˛ ects of cannabinoids in fascial tissue. Int J Mol Sci 21(8):2936. Goats GC (1994) Massage–the scientiÿ c basis of an ancient art: Part 2. Physiological and therapeutic e˛ ects. Br J Sports Med 28(3):153–156. Gray G (1962) Molecular Structure and Property of Liquid Crystals. London and New York: Academic Press Inc. Halligan PW, Oakley DA (2000) Greatest myth of all. New Sci 168:34–39. Hardy MA (1989) ° e biology of scar formation. Phys ° er 69(12):1014–1023. Hinz B, Phan SH, ° annickal VJ, Prunotto M, Desmoulière A, Varga J, De Wever O, Mareel M,

13

Jaalouk DE, Lammerding J (2009) Mechanotransduction gone awry. Nat Rev Mol Cell Biol 10(1):63–73. Kern M (2001) Wisdom in the Body: ° e Craniosacral Approach to Essential Health. Berkeley, California: North Atlantic Books. Kesson M, Atkins E (1999) Orthopaedic Medicine: A Practical Approach. Oxford: ButterworthHeinemann. Lang S (1966) Pyroelectric e˛ ect in bone and tendon. Nature 212:704–705. Langer K (1861) [1978] On the anatomy and physiology of the skin. Br J Plast Surg 31(1):3–8 (translated from Langer K (1861) Zur Anatomie und Physiologie der Haut. I. Über die Spaltbarkeit der Cutis. Sitzungsbericht der Mathematischnaturwissenscha˙ lichen. Laslett M (1996) Mechanical Diagnosis and ° erapy: ° e Upper Limb. OPTP. Martínez Rodríguez R, Galán del Río F (2013) Mechanistic basis of manual therapy in myofascial injuries. Sonoelastographic evolution control. J Bodyw Mov ° er 17(2):221–234.

291

Pilat_Myofascial Induction.indb 291

03/12/21 4:22 PM

13

REFERENCES

McPartland JM (2008) Expression of the endocannabinoid system in ÿ broblasts and myofascial tissues. J Bodyw Mov ° er 12(2):169–182.

Pilat A (2017) Myofascial induction therapy. In: Liem T, Tozzi P, Chila A (Eds.) Fascia in the Osteopathic Field. Edinburgh: Handspring Publishing.

Mense S (2019) Innervation of the thoracolumbar fascia. Eur J Transl Myol 29(3):8297.

Pratt R (2021) Hyaluronan and the fascial frontier. Int J Mol Sci 22(13):6845.

Minasny B (2009) Understanding the process of fascial unwinding. Int J ° er Massage 2(3):10–17.

Roman M, Chaudhry H, Bukiet B, Stecco A, Findley TW (2013) Mathematical analysis of the ˝ ow of hyaluronic acid around fascia during manual therapy motions. JAOA 113(8):600–610.

Oschman JL (2000) Energy Medicine: ° e Scientiÿ c Basis. Churchill Livingstone Elsevier. Oschman JL (2003) Energy Medicine in ° erapeutics and Human Performance. Edinburgh: Butterworth-Heinemann Elsevier. Pilat A (2003) Terapias miofasciales: Inducción miofascial. Madrid: McGraw Hill Interamericana de España. Pilat A (2012) Myofascial induction approaches. In: Schleip R, Findley TW, Chaitow L, Huijing PA (Eds.) Fascia: ° e Tensional Network of the Human Body. Edinburgh: Churchill Livingstone Elsevier.

Szent-Gyorgyi, A (1957) Bioenergetics. New York: Academic Press. Urresti-López FJ (2011) Miodural bridge stimulation via suboccipital inhibition technique modiÿ es the electroencephalogram signiÿ cantly in reaction times producing cognitive changes that do not occur in the control group. D.O. ° esis for Diploma in Osteopathy, SEFO-EOM.

Scarr G (2014) Biotensegrity: ° e Structural Basis of Life. Edinburgh: Handspring Publishing.

Vaticón D (2009) Sensibilidad myofascial: El sistema craneosacro como la unidad biodinámica. In: Libro de Ponencias XIX Jornadas de Fisioterapia. Madrid: EUF ONCE Universidad Autónoma de Madrid.

Schleip R (2003a) Fascial plasticity: A new neurobiological explanation. Part 1. J Bodyw Mov ° er 7(1):11–19.

Vorländer, D. (1924) Chemische Kristallographie der Flussigkeiten. Leipzig: Akademische Verlagsgesellscha˙ .

Schleip R (2003b) Fascial plasticity: A new neurobiological explanation. Part 2. J Bodyw Mov ° er 7(2):104–116.

Wang N, Tytell JD, Ingber DE (2009) Mechanotransduction at a distance: Mechanically coupling the extracellular matrix with the nucleus. Nat Rev Mol Cell Biol 10(1):75–82.

Shea MJ (2007) Biodynamic Craniosacral ° erapy. Berkeley, CA: North Atlantic Books.

Pilat A (2014) Myofascial induction approach. In: Chaitow L (Ed.) Fascial Dysfunction: Manual ° erapy Approaches. Edinburgh: Handspring Publishing.

Sills F (2003) Craniosacral Biodynamics. Volume 2. ° e Primal Midline and the Organization of the Body. Berkeley, CA: North Atlantic Books.

Pilat A (2015) Myofascial induction approaches. In: Fernández-de-las-Peñas C, Cleland J, Dommerholt J (Eds.) Manual ° erapy for Musculoskeletal Pain Syndromes of the Upper and Lower Quadrants: An Evidence- and ClinicalInformed Approach. London: Elsevier.

Simmonds N, Miller P, Gemmell H (2012) A theoretical framework for the role of fascia in manual therapy. J Bodyw Mov ° er 16(1):83–93. Sporel J (1994) So˙ tissue mobilization techniques. JEMD Publications.

Weygand C (1941) Hand- und Jahrbuch der chem. Physik, Bd. 2, Leipzig, Abt. 3. Wheeler AR, Moon H, Kim CJ, Loo JA, Garrell RL (2004) Electrowetting-based micro˝ uidics for analysis of peptides and proteins by matrix-assisted laser desorption/ionization mass spectrometry. Anal Chem 76(16):4833– 4838. Yahia LH, Pigeon P, DesRosiers EA (1993) Viscoelastic properties of the human lumbodorsal fascia. J Biomed Eng 15(5):425–429.

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Upper quadrant assessment With a contribution from Eduardo Castro-Martín

14

KEY POINTS •

Principles of clinical reasoning

•

Definition of the optimum performance of the body

•

Definition of dysfunctions of the upper quadrant system

•

Establishing reliable rating criteria for the clinical assessment of myofascial dysfunctions of the upper quadrant

•

Importance of the history taking process

•

Local versus global assessment

•

Functional global assessment (myofascial components)

•

Stability and mobility

•

Dynamic balance and muscle synergy

•

Importance of assessing all systems linked to fascia

•

Importance of the patient’s appreciation of the assessment process

Introduction Principles of clinical reasoning In Chapter 10 clinical reasoning is described as a complex and nonlinear process. Its purpose is to understand, from a biopsychosocial dimension, what the patient’s situation is and what their problem is. It is necessary to understand the patient’s problem from the perspective of both the patient and the practitioner.

The assessment process It is only through a complete and systemic and systematic assessment that an accurate diagnosis can be made. During this process, the intertwined spirals of changing information should be analyzed, meaning that the process must be constantly veriÿ ed. In Jones’s clinical reasoning ˝ owchart (Jones et al. 2019, Jones & Rivett 2004), the route to metacognition is highlighted (Fig. 14.1).

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Metacognition is a concept introduced by John Flavell (1976) and it refers to “thinking about thinking” (the knowledge you have of your own thinking). The process consists of three parts: knowledge, experience, and strategies. Metacognition is the ability to reflect on a certain process by selecting and using appropriate strategies.

Well-developed metacognition is an asset, however, if metacognition is only based on incomplete information and presupposition, it can lead us down the wrong path. ° erefore, decision making should be inseparably linked with evidence in order to reduce errors in decisions based on critical thinking. Haskins et al. (2018) suggested that: “A notable advantage of statistical prediction tools over unassisted clinician judgment is the control of human biases that are common contributors to decision-making errors,” and which are the consequences of the limitations of human cognitive capacity (Grove et al. 2000, Graber et al. 2005,

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14 Clinical reasoning Practitioner/patient perspective

Practitioner

Figure 14.1

Patient

Clinical reasoning flowchart. After Jones M., Edwards I., Jenson G.M. (2019) Clinical reasoning in physiotherapy. In: Higgs J., Jensen G.M., Loftus S., Christensen N. (Eds.) Clinical Reasoning in the Health Professions. 4th ed. Elsevier, pp. 247–260

Information Perception Interpretation

Multiple hypotheses

Data History taking Assessment Complementary tests

Patient’s own hypotheses

Evolving concept of the person and problem Hypotheses modified

Evolving concept of the problem

Diagnostic management

Understanding of diagnosis and treatment proposal

Therapeutic procedure

Education Exercises Motor imagery

Reassessment

Self-management Self-efficacy

Knowledge Cognition Metacognition

Elstein & Schwarz 2002, all cited in Haskins et al. 2018). Digital technology is developing at a frenetic pace and is transforming the ÿ eld of health care. It is also increasing the number of distractions in health care settings, meaning it is necessary to have a strategic and systematic approach when adopting new technology. An evidence-based algorithm will require some adjustment. Statistical predictions do not form a clinical decision but instead inform a clinical decision (Haskins et al. 2018). Based on patient information, digital technology can generate alerts for interactions between therapeutic procedures and contraindications

that might otherwise be missed. It can also provide diagnostic recommendations as options with di˛ erent levels of probability for each. ° e algorithm can raise alerts but cannot replace the opinion of the practitioner. ° e diagnosis must be the decision of the treating practitioner who has the last word and (probably most importantly) takes responsibility. An algorithm offers support for clinical decisions but cannot replace them.

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Upper quadrant assessment

Characteristics of the upper quadrant Movement of the human body is related to nonlinear and self-organizing features. Both the bipedal position and locomotion are in˝ uenced by gravitational force. It has been suggested that inadequate transmission of gravitational force could be the starting point for changes in the extracellular matrix, the onset of dysfunctions, and the source of pain. Movement dysfunctions and consequent pain in the upper quadrant are estimated to a˛ ect about 70ˇpercent of the population (de-la-Llave-Rincón et al. 2011, Huisstede et al. 2006, Walker-Bone et al. 2003). Among work-related illnesses, upper quadrant dysfunctions are second only to low back pain (Palmer & Cooper 2006). ° e structures of the neck, shoulder, and arm (mostly on the dominant side; de-la-Llave-Rincón et al. 2011), are the most a˛ ected areas (Walker-Bone et al. 2003), with dysfunctions being related to a wide range of circumstances. It is diˆ cult to accurately identify the speciÿ c structure(s) that generate the symptoms. A wide range of terms is used to describe the symptomatology, i.e., cumulative trauma disorders, cervicobrachial disorders, repetitive strain injury, and work-related upper limb disorders (de-la-Llave-Rincón et al. 2011). It is not possible to designate simply one anatomical structure as the source of dysfunction and pain in the neck–shoulder– arm area; the input can have a variety of origins.

14

analysis of local anatomy does not always match the integral dysfunction of the fascial system. Local changes may re˝ ect di˛ erent underlying pathophysiological mechanisms that may be involved in the processes of peripheral or central sensitization and pain (dela-Llave-Rincón et al. 2011). Symptoms are not always re˝ ected through segmental distribution. Over time, patients with local pain usually also exhibit pain in distant areas. ° ese areas do not always correspond to peripheral distribution zones. ° is situation may simultaneously create mechanosensitivity, neurogenic in˝ ammation, and neuropathic pain and “neuroprotective” responses. Studies have reported increased sensitivity to pressure pain in both the original area of trauma and also distant areas without pain, suggesting an extrasegmental spread of sensitization in di˛ erent local syndromes. Research on the presence of free nerve endings (sensitive ÿ bers Aß, Að, and C) within the connective tissue matrix has changed the focus toward understanding neuropathic pain (Jensen & Baron 2003, Stecco et al. 2009, Tesarz et al. 2011, Corey et al. 2011, Stecco et al. 2013, Mense 2016). For more information see Chapters 8 and 15.

Cognitive aspects Life activities and experiences shape our brain.

Biomechanical aspects ° e main cause of disorders of mechanical origin is maintaining a forward head posture and remaining in a sitting position for long periods of time doing repetitive tasks, particularly when using an electronic device. Adults in the US spend an average of three hours per day on mobile devices (He 2019). ° e adaptive posture is usually an exaggerated ˝ exion of the cervical spine and simultaneous reduction of lumbar lordosis. Details of the biomechanical and neurological adaptations and unfavorable consequences related to this posture are summarized in Chapter 15 (see Tables 15.4 and 15.5).

Neurological aspects In Chapter 10 dysfunction was deÿ ned as a failure of stability and/or mobility, resulting in alteration in the freedom or quality of body movement. A biomechanical

Excessive and ever-increasing consumption of digital products via the screens of electronic devices, in particular those with touch screens, remodels the fascial system. More than two hours of daily use of a smartphone and/or a tablet can produce diverse changes (Uncapher & Wagner 2018, Dong & Potenza 2015, Kühn & Gallinat 2015, Ralph et al. 2014, Oulasvirta et al. 2012, Ophir et al. 2009, Small et al. 2009), for example:

• • • • •

decreased functioning of the hypothalamus loss of interpersonal skills reduction in abstract reasoning and reading capacity decrease in the ability to retain information appearance of withdrawal syndrome with manifestation of anxiety and panic disorders.

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14 According to Firth et al. (2019) the internet is in˝ uencing our brains and cognitive processes, particularly in the following respects:

•

Cortical representation in touch screen smartphone users di˛ ers compared to people who use conventional cell phones. ° e frequency of smartphone use in˝ uences cortical activity (Gindrat et al. 2014).

•

It leads to an alteration in attention span and encourages multitasking rather than a sustained (continued) approach.

•

° e ubiquitous and rapid access to objective online information competes with previous transactional systems and potentially even internal memory processes.

•

° e online social world exists in parallel with the cognitive processes of the “real world.” It confuses our offline sociality, introducing the possibility that the unique characteristics of social networks may impede our ability to deal with real life situations.

° e above points demonstrate why a biopsychosocial approach is necessary when assessing the patient’s problem, particularly as it relates to dysfunction of the fascial system. Hence the importance of the history taking process.

Assessment of the upper quadrant as a functional complex ° e role of fascia in the behavior of the upper quadrant is analyzed in more detail in Chapters 15, 16, and 17. A knowledge of myofascial links and the continuity of fascia will help the practitioner to understand the clinical manifestations of dysfunctions (and the consequent pathologies) and pain in the regions that may be far away from the area of initial trauma. Movements in the upper quadrant involve, directly or indirectly, the craniocervical segments, the shoulder complex, the thorax, and the upper extremities.

The assessment process (Fig. 14.2) It is only through a complete and systemic assessment that an accurate diagnosis can be made.

° e overall assessment process is discussed in detail in Chapter 10. ° e process is not exclusively used for

the assessment of fascial tissue; rather, it focuses on the functional assessment and eˆ ciency of body movement in which fascia is integrated. ° is process can be easily incorporated into other therapeutic concepts.

History taking History taking is the story of the patient’s illness narrated by its protagonist.

History taking is a procedure that should not be overlooked. It allows the practitioner to understand the disease from the patient’s viewpoint and ÿ nd out information that cannot be obtained from sophisticated tests. ° is part of the assessment is discussed in detail in Chapter 10. ° e focus is mainly on the quality of life, the performance of daily tasks (work, housework, leisure, sports, relationships, quality of sleep), questions about activities such as walking up and down stairs and daily movements involving the head, neck, and arm structures. ° e practitioner also checks for the presence and behavior of pain, restriction of mobility, increased muscle tone and myofascial tensions, dermalgia, myalgia, etc. Bear in mind the usefulness of functional scales (see Chapter 10), which are questionnaires about a person’s ability to perform daily tasks. ° ey are useful tools for monitoring the patient over time and evaluating the effectiveness of an intervention. Both analyses (of the antecedents as well as of the present signs and symptoms) should always be conducted within a framework of biomechanics, neurophysiology, and cognition (neuroscience). Remember to:

•

relate the results of history taking to the results of the whole assessment, contrasting the signs with the symptoms;

•

determine the degree of irritability, severity, and the possible nature of the process;

•

identify the presence of alterations in other myofascial structures that share the same levels of innervation as the a˛ ected region (an in-depth neuroanatomical and myofascial knowledge is essential);

•

check the initial assessments with the results of complementary tests, if they are available;

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14

Upper quadrant assessment

Stage or phase

Irritability

Severity

Stability

ASSESSMENT Signs and symptoms

Subjective experience

Exteroception

Interoception

Proprioception

Biomechanics Neurophysiology Neuroscience

Background

Misuse

Disuse

Autonomic response

TPs in taut bands

Restriction at deep levels

History taking

Abuse

Skin quality (Skin mobility)

Global functional assessment

Functional assessment

Neural tests

Circulatory tests

Specific functional tests

Static stability

Postural control Gravitational load Postural neuroprotection pattern

Dynamic stability

Motor control Force Resistance

ROM

Internal: local ROM related to each of the segments External: entire ROM related to the external environment

Movement synergy

Synergistic redistribution of energy generated by the muscles

Stability

Palpatory assessment Global functional assessment

MRI, EMG, US imaging, etc.

Visceral tests

Mobility

Complementary assessment

Patient and practitioner interpretation

Figure 14.2 The assessment process algorithm

•

identify psychological and emotional aspects, such as anxiety, depression, catastrophism, or kinesiophobia;

viscerofascial tests, circulatory tests, and speciÿ c functional tests. ° is chapter:

•

determine possible yellow ˝ ags that can chronify dysfunctional processes.

•

Functional assessment Functional assessment is divided into di˛ erent blocks: global functional assessment, neural tests,

Focuses mainly on global tests as they are the basis of functional assessment (see Tables 14.1–14.4.) As mentioned in Chapter 10, it is recommended that these tests be performed before speciÿ c functional tests (that focus on a particular structure) or pain provocation tests.

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14 • • • •

Describes the main neural components and discusses the most likely ÿ ndings in the assessments. Outlines important points relating to viscerofascial components (see also Chapter 10). Outlines the most clinically relevant tests associated with vascular structures. ° e speciÿ c functional tests are described in the sections on clinical applications in Chapters 15, 16 and 17.

Mobility assessment ▶ Range of movement

° internal: local ROM related to each of the segments ° external: global ROM related to the external environment

▶ Movement synergy

° Synergistic redistribution of energy generated by the muscles.

Global functional assessment ° e reader should refer to Chapter 10 for more detailed information on the parameters of functional assessment. Global functional assessment is divided into two main parts: stability assessment and mobility assessment (Fig. 14.3):

•

•

Stability assessment ▶ Static stability

° postural control ° gravitational load distribution ° postural neuroprotection pattern ▶ Dynamic stability

° motor control ° force

Stability assessment As indicated in Chapter 10, there is no clear scientiÿ c consensus on the choice of a speciÿ c test or its means of application. In this area, the scientiÿ c evidence is inconclusive and there are many versions of each test. Depending on the training (practitioner’s experience) and clinical demands (patient category: age, sex, beliefs, etc.), the individual practitioner has the freedom to select the tests that they consider to be necessary for the assessment of musculoskeletal dysfunction.

Static stability assessment (Fig. 14.4, Table 14.1) For the practitioner the analysis of static stability is a useful starting point in the assessment process. However, remember that the body is not symmetrical and

° resistance Static stability

Postural control Gravitational load Postural neuroprotection pattern

Stability

Global functional assessment

Static stability

Postural control Gravitational load Postural neuroprotection pattern

Dynamic stability

Motor control Force Resistance

ROM

Internal: local ROM related to each of the segments External: entire ROM related to the external environment

Movement synergy

Synergistic redistribution of energy generated by the muscles

Stability Dynamic stability

Motor control Force Resistance

ROM

Internal: local ROM related to each of the segments External: entire ROM related to the external environment

Mobility Movement synergy

Global functional assessment

Mobility

Synergistic redistribution of energy generated by the muscles

Figure 14.3

Figure 14.4

Global functional assessment flowchart

Static stability assessment

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14

Table 14.1 Static stability assessment. Postural control – gravitational load distribution – postural neuroprotection pattern Test

Aim

Description

Interpretation (positive sign)

Clinical analysis

References

Postural control

Assessment of postural control (which maintains the body in an upright position) in relation to stability and orientation (Shumway-Cook & Woollacott 2007)

The patient stands barefoot in a relaxed position

Asymmetry between C and D suggests a tendency to lateral flexion (on the side of the triangle with the larger volume)

Presence of alteration of automatic reflexes and responses. Functional asymmetry between the right and left sides of the body represents a much higher risk factor for injury (Kartal 2014)

Bullock-Saxton 1993

Front and rear views

A

B

C

D E

F

Lateral view G F D

E C

B A

Observe the patient from the ground upwards from the front, rear, and sagittal views Front and rear views Check for asymmetries in the distribution of gravitational loading. Reference points: lateral inclination of the head (A*), lateral rotation of the head (B*), volume of the waist triangles (C and D), position of the hands in relation to the lateral thigh (E and F)

The asymmetry ratio of the hand position in relation to the lateral thigh (E and F) suggests a tendency to rotation; e.g., the right hand over the right anterior thigh indicates a leftward rotary trend Tendency to lateral bending and rotation

Preece et al. 2008 Kartal 2014 Shumway-Cook & Woollacott 2007

A consistent postural alignment is assumed (in terms of spinal curvature and pelvic inclination) when an individual is asked to stand comfortably erect (Bullock-Saxton 1993) Anterior pelvic tilt is associated with a loss of core stability, and therefore the degree of pelvic tilt is used to assess core strength (Preece et al. 2008)

Lateral view Assess for the following: A Feet. Achilles tendon verticality B Tendency to genu flexum or genu recurvatum C Pelvic tilt D Forward abdominal muscles E Dorsal kyphosis F Depressed sternum G Forward head posture

A*, B* These are the positions of the head, not active movements

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14 Table 14.1 continued Test

Aim

Gravitational load distribution E D C

H

B

G

A

F

Postural neuroprotection pattern

Assessment of gravitational load distribution in standing. All muscles must be activated to work in complete synergy

Description

The patient stands in a relaxed position Observe the patient from the ground upwards

Postural control requires the production of movements or muscular contraccontrac tions that help keep the body upright in space

To determine the presence of a compensatory postural strategy as a mechanism to protect the mechanosensitivity of the nervous system

Interpretation (positive sign) Front view A Position of the feet (excessive eversion) B Position of the knees: Up or down? Right or left displacement? C Thigh fold symmetry D Superior pubic position E ASIS position Rear view F Achilles tendons verticality G Popliteal fossa position H Gluteal fold symmetry

The patient stands barefoot in a relaxed position Assess the craniocervical posture in the sagittal plane

Occasionally, cephalic protrusion may be a postural strategy to accommodate the mechanosensitivity of the nervous system. The forward head posture approximates the cervical roots to the trajectory of the cervical plexus and the brachial area. Physiologically the nerve roots emerge posteriorly, and in the forward head posture the degree of their mechanical load is reduced

Clinical analysis

References

Loss of balance between the feedback and feedforward actions. This also affects the cellular level. Each individual molecule in the body experiences gravitational force that is distributed throughout the body (see Chapter 9). The changes show how the body copes with its weight and has adapted over time

Winter 1995

Extension in the upper cervical segment results in an effective shortening of the medulla (meninges) structures in cases of neural tension

Butler 1991

Latash 2008 Aruin et al. 2001

Shacklock 2005

In cases of stenosis of the spinal canal or intervertebral foramen flexion of the middle and lower cervical segments can relieve symptoms

also that symmetry does not guarantee optimal performance of the body in the face of daily tasks.

in a scenario of alteration of the neuromyofascial system.

Static stability assessment tests the following: postural control, gravitational load distribution, and the postural neuroprotection pattern. ° e static postural analysis can serve as an indicator, together with the symptoms and other tests, to situate the patient

° e static stability assessment enables the practitioner to analyze the distribution of gravitational load and discover the areas that require more precise attention and further conÿ rmation using other tools of exploration. ° e procedure is described below.

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Upper quadrant assessment

•

Assess the patient anteriorly, posteriorly, and laterally. It would also be useful to see the patient from above to determine how the body is placed spatially (three-dimensionally). Perhaps in the future drone technology will make this possible.

•

° e patient should stand normally in a relaxed position, barefoot, and in minimal underwear (with the patient’s consent) to allow for assessment of the anatomical points and lines.

•

Observe how the patient deals with their body weight and how the body adapts to the gravitational load with the passage of time.

•

First, it is recommended that you check the volume symmetry (not the exact geometrical symmetry) of the waist triangles and then the position of the patient’s hands in relation to the corresponding thighs.

•

Next, note the relationships between the di˛ erent parts of the body.

Do not relate marked asymmetry to a speciÿ c symptomatology. ° is procedure can also be useful to a newly qualiÿ ed professional as a point of reference for reassessment.

Dynamic stability assessment (Fig. 14.5, Table 14.2) To understand why we move in a speciÿ c way relates to the following question: How does the central nervous system produce purposeful, coordinated movements in

Static stability

Postural control Gravitational load Postural neuroprotection pattern

Dynamic stability

Motor control Force Resistance

ROM

Internal: local ROM related to each of the segments External: entire ROM related to the external environment

Movement synergy

Synergistic redistribution of energy generated by the muscles

14

its interaction with the rest of the body and with the environment (Latash et al. 2010)? With this in mind, the dynamic stability assessment examines three basic areas:

• • •

motor control force resistance.

° e various theories relating to motor control are discussed in Chapter 10. Motor control dysfunctions are manifested by mechanical deÿ cit and/or a feeling of instability; however, mechanical input is not required for this to happen (see Chapter 10). Motor impairment can be expressed in three areas:

• •

action (muscle tone and muscle strength)

•

cognition (attention, emotions, motivation).

perception (registration or integration of sensory information)

° e assessment of function should not be based on a single static test – in the same way that a radiographic examination cannot tell us how bones move. An assortment of tests is needed. ° e ÿ ndings of individual tests should be analyzed together and not in isolation. Each piece of information must be examined in relation to the whole.

Figure 14.5 Dynamic stability assessment

Stability

Global functional assessment

Mobility

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14 Table 14.2 Dynamic stabilty assessment – motor control – force resistance Test

Aim

Description

Interpretation (positive sign)

Clinical analysis

References

Motor behavior during craniocervical flexion

To evaluate motor synergy during neck flexion

The patient performs craniocervical flexion (with the chin directed toward the sternal manubrium) from the neutral position

The test is positive if there is excessive participation of the sternocleidomastoid muscles when performing the movement and also if the movements of rolling the head on the neck and the neck toward the sternum fail. Recruitment of the abdominal muscles and the momentary inspiratory stop are also observed

Weakness of the deep flexor muscles of the neck

Cagnie et al. 2008

Possible cervical instability

O’Leary et al. 2006

To establish if there is weakness of the deep flexor muscles of the neck

The head is lifted slightly and the neck flexes in the infrahyoid region The progressive lifting of the head over the neck and the neck toward the thorax is observed

Scapular dyskinesis test (Kibler classification)

This test is used to monitor the scapular stabilizer muscles It involves measuring the distance from the inferior angle of the scapula to the nearest vertebral spinous process

The patient stands and moves the upper extremities through three positions: 1 With the arms hanging by the sides 2 With the hands resting on the hips and the thumbs placed posteriorly 3 With the arms abducted 90 degrees with full shoulder internal rotation

Severe alteration of the motor synergy of the neck

Jull et al. 2004

Falla et al. 2003 Jull et al. 2008 Jull & Falla 2016

When the head is raised, the chin is advanced significantly

The injured or deficient side exhibits a greater scapular distance than the uninjured side and a bilateral difference of 1.5 cm should be the threshold for deciding whether scapular asymmetry is present

Excessive lateral sliding and winging of the medial border are signs of inefficiency of the scapular stabilizing muscles

Kibler et al. 2013

An asymmetrical position may indicate the presence of thoracic scoliosis or glenohumeral capsular retraction Pain or inability to adopt positions 2 and 3 may indicate injury or inflammation of the rotator cuff

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14

Table 14.2 continued Test

Deep squat test

Aim

This test challenges total body mechanics when performed properly. It is mainly used to assess bilateral, symmetrical, and functional mobility of the hips, knees, and ankles The dowel held overhead helps in the assessment of bilateral and symmetrical mobility of the shoulders as well as the thoracic spine The ability to perform a deep squat requires appropriate pelvic rhythm, dorsiflexion of the ankles, flexion of knees and hips, and extension of the thoracic spine, as well as flexion and abduction of the shoulders

Description

Interpretation (positive sign)

Clinical analysis

References

The patient stands with the feet flat on the floor shoulderwidth apart and extends the arms toward the ceiling. A dowel is held with both hands (so that the behavior of the scapular girdle can also be tested)

Overall impression What is the ROM? Can the patient complete the squat?

Lower crossed syndrome is present

“It is a practical and useful clinical tool to assist diagnosis and help better understand the development and perpetuation of most spinal related disorders” Key 2010

Maximum triple flexion is required (hip, knee, and ankle). The knees should not extend beyond the feet and the trunk should be parallel with the tibia

Lateral view The arms move up and down excessively. There is an excessive forward tilt in the lumbopelvic-hip complex The lower back hyperextends

Instruct the patient to squat slowly as far as they can (without pain) and return to the start position

Front view The feet turn in or out too much The knees move inward or outward

Rear view The heels elevate

To assess the range of motion and eccentric activity of the deep flexor muscles of the neck

In a neutral standing or sitting position, the patient is asked to perform cervical extension. The movement is performed progressively

Knee orthopedic dysfunctions or pathology (ACL, meniscus) Hypomobility and/or instability of the ankle structures

Key 2013

Other alterations of balance

Moran et al. 2016

Limited mobility in the upper torso can be attributed to poor glenohumeral and/or thoracic spine mobility

Ishida et al. 2013

Mitchell et al. 2016 Teyhen et al. 2012 Cook et al. 1998 Cook et al. 2010

Limited mobility in the lower extremity, including poor closed-kinetic chain dorsiflexion of the ankle and/or poor flexion of the hip may also cause poor test performance

The patient performs three repetitions. Observe the movement from the front, rear, and lateral views Observe the feet, ankles, and knees anteriorly and posteriorly and the lumbopelvic-hip complex, shoulder, and cervical complex laterally

Motor behavior during cervical extension

There is core muscle instability

Overactivation of the SCM alters the recruitment sequence

Limitation in ROM of the lower neck segment

When the effects of gravity increase the mechanical demands during extension the movement is accelerated and the cervical segment causes a cessation of movement. This usually occurs when cervical pain is present

Inhibition of the prevertebral and deep flexor muscles

Jull et al. 2008

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14 Mobility assessment Mobility assessment – range of movement (Fig. 14.6, Table 14.3) It can be assumed that a patient’s homeostasis is a decisive factor in relation to dynamic balance and range of movement (ROM). However, it should be remembered that the body does not move in isolation. Its movement is also closely related to the external environment and its contents. Range of movement can be deÿ ned as:

• •

by borrowing the range from another, inappropriate, structure (or structures). Research shows that when the movement is guided by external factors there are di˛ erent neural pathways, which are activated in relation to the movement guided by internal stimuli, which means that there are separate pathways that guide the two groups of impulses. ° e existence of separate networks of action leads to three considerations:

•

Movement distortion can be linked to the inadequacy or failure of internal (structural) factors and/ or deÿ ciency in uptake or interpretation of external factors.

•

° e learning process (recovery of range) requires internal and external stimulus.

•

In the therapeutic process the diˆ culty or impossibility of using one of the reception channels (internal or external) does not prevent the possibility of action, but rather suggests promotion of external generation of movements, which may be a helpful strategy (Debaere et al. 2003). Since range is part of performance then performance can never remain constant.

internal: local ROM relating to one part of the body; external: global ROM relating to the external environment.

In ROM tests, both internal and external ranges are examined. Internal ROM is deÿ ned as the amplitude of movement of individual parts of the body and their relationship to other parts. External ROM is the movement of the whole body in relation to external factors, such as the type and quality of the support surface (e.g., rock or sand, rain or snow, high or low temperature). ° us, alterations in ROM (hypo- or hypermobility) are not only related to local events (capsular retractions, muscle shortening) but are also associated with the external environment. ° e measurement and analysis of ROM should not be limited to quantiÿ cation. Even if the external ROM is appropriate, it may be due to an internal compensatory process, meaning that the deÿ ciency in local amplitude was corrected (compensated)

Static stability

Postural control Gravitational load Postural neuroprotection pattern

Dynamic stability

Motor control Force Resistance

ROM

Internal: local ROM related to each of the segments External: entire ROM related to the external environment

Movement synergy

Synergistic redistribution of energy generated by the muscles

To assess the in˝ uence of the neuroconnective tissue on ROM, the application of neural tension tests is recommended. ° e assessment of mobility and range of movement is summarized in Figures 14.8 and 14.19.

Figure 14.6 Mobility assessment – range of motion (ROM)

Stability

Global functional assessment

Mobility

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Upper quadrant assessment

14

Table 14.3 Mobility assessment – range of movement (ROM) Test

Aim

Description

Interpretation (positive sign)

Clinical analysis

References

Assessment of basic neck movements

To assess the basic movements of the craniocervical junction

Assessment parameters can be found in numerous articles and books. For further details see Tables 15.4 and 15.5 in Chapter 15

This assessment is a quick way to track the progress of treatment. The patient should be involved in consecutive reassessments

A diagnosis cannot be made from this assessment alone. The results should be examined in conjunction with other diagnostic tests

Norkin & White 2016

Mouth opening Measuring maximum comfortable mouth opening: The test focuses on the increase in vertical dimension and the degree of opening The distance between the incisal edge of the upper and lower incisors is noted

The normal width of the mandibular opening in an interincisal measurement is 53–58 mm

The test identifies temporomandibular mobility

Okeson 2013

To observe the range of motion and to check for asymmety and, in particular, compensatory changes. To test for the presence of symptoms such as pain, paresthesia, tinnitus, etc.

Mouth opening

To assess the range of motion and quality of mandibular movements To identify the presence of pain during the movement

Lower than normal width is less than 40 mm

A lower than normal measurement (reduced opening) is usually related to intracapsular or extracapsular alterations

Measuring maximum mouth opening: Subsequently, the patient performs an active maximum opening of the mouth, even if pain is present

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14 Table 14.3 continued Test

Aim

Laterotrusion

To assess the extent of lateral movement of the jaw

Protrusion

To assess the extent of mandibular condylar movement

Apley scratch test

B

A

To test for ROM of the upper extremity structures: Shoulder extension and flexion (A) Internal and external rotation of the humerus at the shoulder Scapular abduction and adduction (B) The test should be performed bilaterally to facilitate comparison

Description

Interpretation (positive sign)

Clinical analysis

References

Neumann 2010

Laterotrusion The distance between the upper and lower central incisors is noted. The maximum laterotrusion movement is performed in both directions (right and left). The displacement is measured in relation to the first measurement

The normal width of mandibular laterotrusion is 10 mm

The test identifies temporomandibular mobility

Laterotrusion of less than 8 mm is considered to be outside the normal range

A measurement below the normal measurement (reduced opening) is usually mostly related to intracapsular changes

Protrusion At the end of the movement, the displacement of the lower incisors beyond the upper incisors is measured

The normal width of mandibular protrusion is 10–12 mm

The test identifies temporomandibular mobility

Protrusion of less than 8 mm is considered to be outside the normal range

A measurement below the normal measurement (reduced opening) is usually mostly related to intracapsular changes

The patient is asked to place one arm behind their head and reach behind the neck to touch the upper back. Observe their ability to touch the medial border of the contralateral scapula (A)

The degree of difficulty in reaching the positions indicates limitations in the range of the aforementioned movements

Limitation of ROM may indicate glenohumeral dysfunction, increased mechanosensitivity of the brachial plexus, and dysfunction of the fascial system of the upper quadrant

Neumann 2010

Konin et al. 2006 Hoving et al. 2002 Edwards et al. 2002

The patient is instructed to reach for the opposite shoulder with the other hand. Observe the patient’s ability to touch the opposite inferior angle of the scapula (B)

Mobility assessment – movement synergy (Fig. 14.7, Table 14.4) Muscle activity represents the functional outcome of the nervous system. ° e assessment of underlying neural strategies, which result in movement and function, is a very complicated task. It cannot be measured

directly, especially in patients with motor disorders. ° us, the exploration of muscle activation may re˝ ect the condition of neural mechanisms (Safavynia et al. 2011). ° e analysis of muscle synergies (˝ exibility and adaptability) may provide a better understanding of functional deÿ ciency of the nervous system. Research

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Upper quadrant assessment

Static stability

Postural control Gravitational load Postural neuroprotection pattern

Dynamic stability

Motor control Force Resistance

ROM

Internal: local ROM related to each of the segments External: entire ROM related to the external environment

Movement synergy

Synergistic redistribution of energy generated by the muscles

14

Figure 14.7 Mobility assessment – movement synergy

Stability

Global functional assessment

Mobility

by Overduin et al. (2012) supports that clinical output is related to the neural organization of muscle synergies both at the spinal and cortical levels. ° us, the assessment of abnormalities with di˛ erent muscle coordination patterns allows deÿ ciencies in movement planning and execution to be identiÿ ed.

Final observations on global functional assessment ° is assessment should primarily focus on the whole (big) picture, and patterns should be analyzed rather than speciÿ c parts of the body. Speciÿ c components can be assessed later using the local (speciÿ c functional) tests. ° e tests need to be simple so that they can be easily administered. ° e static stability and dynamic stability assessments should not be omitted. ° ey can be used to complement the global and local functional tests in the analysis of the presence of pain and its behavior. ° e interpretation of pain is essential in the assessment process (see Chapters 8 and 10); however, we should bear in mind that the mere presence of pain does not tell us the whole story of the patient’s health-related quality of life and their perspective on the outcome (see Chapter 1). ° e global functional assessment will not disclose an exact picture of the patient’s problem. It is simply a momentary re˝ ection of the patient´s reality. ° e neurofascial components involved in dysfunction can distort the mechanical analysis.

Neurofascial components An accurate diagnosis of dysfunctions and pain syndromes of the upper quadrant is diˆ cult because of its complex anatomy and biomechanics. ° e diagnosis has to be precise. ° e pain, for example, may be nonspeciÿ c (with considerable overlap of its sensory distribution) and diˆ cult to identify, and there may be person-toperson variations. Note that neural entrapment can generate neuroprotective and neuroe˛ ector responses with signiÿ cant consequences for body mechanics. ° e cervical plexus and the brachial plexus are in charge of the innervation of the upper quadrant.

The cervical plexus ° e cervical plexus is a network of nerve ÿ bers of the anterior rami of the ÿ rst four spinal nerves (C1– C4) which arises from the spinal cord through the intervertebral foramina of the cervical spine. ° ese nerves meet in front of the transverse processes of the ÿ rst three cervical vertebrae in the posterior triangle of the neck (for more information see Chapter 15), halfway up the sternocleidomastoid muscle, and rest upon the levator scapulae and scalenus medius, splenius cervicis muscles, and the deep layer of the deep fascia of the neck. ° e plexus is divided into superÿ cial and deep branches. ° e superÿ cial (cutaneous) branches are sensitive (Brazis et al. 2007) and supply the skin of the neck, upper thorax, scalp, and ear (Campbell 2005). ° e nerves

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14 Table 14.4 Mobility assessment – movement synergy Test

Aim

Description

Interpretation (positive sign)

Clinical analysis

References

Forward and backward head posture

To assess the features of head movement in the sagittal plane

The patient is standing or sitting and performs the protrusion and retraction movements of the head. The flexion–extension movement should be avoided

Analyze the range of movement (correct movement is without compensation). Incorrect movement might be: raising the shoulders performing cervical extension the presence of pain (retraction) adaptations to dorsal kyphosis advanced position of shoulders (protrusion)

Impaired muscle performance due to stretched and weak lower cervical and upper thoracic erector spinae and scapular retractor muscles (rhomboids, middle trapezius), anterior throat muscles (suprahyoid and infrahyoid muscles), and capital flexors

Kim et al. 2018

Muscle control during swallowing

To assess coordination of cervical and hyoid behavior during swallowing

The craniocervical and hyoid regions are palpated without impeding swallowing

A slow and upward movement of the hyoid bone (as opposed to the normal rapid up-and-down movement) and concurrent contraction of the suboccipital muscles suggest a tongue thrust and indicate hyperactivity of the masticatory muscles

Poor hyoid glide

Kraus 1994

Excessive cervical coupling motion

Petty & Moore 2001

A small amount of cervical extension is normal at the end of the mouth-opening movement

Craniocervical motor control may be altered

The patient swallows water several times

Craniocervical motor behavior during mouth opening

To assess coordination of cervical and temporomandibular behavior during mouth opening

Assess the patient from the side Request maximum mouth opening Look for associated compensatory movement: cervical hyperextension and/or a forward head

Associated hyperextension or a forward head indicates overload of the cervical structures with a high energy expenditure

Altered masticatory muscle behavior

La Touche 2017

Possible dysfunctional movement strategy

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14

Table 14.4 continued Test

Aim

Description

Interpretation (positive sign)

Clinical analysis

References

Alterations in the opening path

To assess mandibular behavior during mouth opening

Assess the patient from the front

Along the buccal opening the jaw should move without deviating from the straight line between the first upper and first lower incisors

A decrease in mandibular movement is due to extracapsular or intracapsular alterations

Okeson 2013

A Deviation The opening path is altered, but returns to the midline on reaching the maximum mouth opening

A

To assess facial behavior during mandibular laterotrusion

Assess the patient from the front Request maximum mandibular laterotrusion on each side Analyze the recruitment of facial musculature during movement

Janda’s test of shoulder muscle recruitment patterns

Any deviation from this line implies an alteration of movement

B Deflection The opening path deviates to one side and increases as the opening increases The deflection is at its greatest when the mouth is completely open

B

Facial behavior test during mandibular lateroretrusion

Request maximum mouth opening

To assess muscular activation (motor synergy of the scapular girdle) during shoulder abduction

The patient performs an active and progressive arm abduction up to 90 degrees Palpate the trapezius, supraspinatus, infraspinatus, and paravertebral muscles, and the quadratus lumborum contralaterally. Determine the rhythms of muscle recruitment sequencing involved in arm abduction

There should be no other facial movement while the jaw is being moved Facial musculature is activated only on one side, coinciding with limitation on the other side

The sequence of muscular activation should first be the supraspinatus region along with the deltoid, then the neck muscles, infraspinatus, and finally the contralateral lumbar region (quadratus lumborum muscle)

Deviations are usually due to a muscular disorder Deflections are usually associated with dysfunction of the condylar disc complex and the surrounding ligaments

Facial dyskinesia during mandibular lateroretrusion can be a sign of altered motor strategy

La Touche 2017

Disturbances (in the sequence) of motor synergy can be correlated with dyskinesia of the shoulder girdle, especially if there is a deficit in the dynamic stabilization of the glenohumeral and scapulothoracic joints

Janda 1996

A change in this sequence may indicate a deficit in muscular behavior

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14 reach the skin in the middle of the posterior border of the sternocleidomastoid muscle (Erb’s point (Landers & Maino 2012). ° e superÿ cial branches are:

•

the lesser occipital nerve (C2), which innervates the skin and the posterosuperior region of the scalp behind the auricle;

•

the great auricular nerve (C2–C3), which innervates the parotid gland and the area behind the ear;

•

the transverse cervicis (C2–C3), which innervates the anterior triangle of the neck;

•

the supraclavicular nerves (C3–C4), which innervate the skin of the superolateral part of the thorax (over the clavicle, outer trapezius, and deltoid).

° e deep (muscular) branches are located deep to the sensory branches (° ompson 2010) and are as follows:

•

the ansa cervicalis (C1–C3) which innervates the infrahyoid muscles (sternohyoid, sternothyroid,

A B C D E

omohyoid), which depress the hyoid bone during speech and swallowing;

•

the phrenic nerve (C3–C5, primarily C4) which passes over the anterior scalene muscle into the thorax between the subclavian artery and vein; it also supplies the sensory innervation of the pericardium and mediastinum and the motor innervation of the diaphragm.

The brachial plexus (Bowen et al. 2004) ° e brachial plexus is an intercommunicating network of nerves with a complex intraneural and interneural anatomy (Figs. 14.8 & 14.9). ° e plexus begins with the roots, which are continuous with the ventral branches of the spinal nerves. In the most common conÿ guration of the plexus, there are ÿ ve roots: C5, C6, C7, C8, and T1. Continuing peripherally the roots form three trunks: the upper (roots of C5 and C6), middle ( root of C7), and lower (roots of C8 and T1) trunks. ° e nerve roots pass between the anterior and medial scalene muscles

C3 C4 C5 C6 C7

F

C8

G

T1

H I

Figure 14.8

J

Brachial plexus distribution A Dorsal scapular nerve B Subclavian nerve C Suprascapular nerve D Lateral pectoral nerve E Upper subscapular nerve F Axillary nerve G Radial nerve H Thoracodorsal nerve I Lower subscapular nerve J Musculocutaneous nerve K Median nerve L Ulnar nerve M Medial cutaneous nerve of arm N Medial cutaneous nerve of forearm O Medial pectoral nerve P Long thoracic nerve Q Supraclavicular nerve

K L M N O P Q

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14

Cranial Lateral

Medial Caudal

Figure 14.9 Right lateral view of the neck and arm. The cadaver is placed in supine and the arm is in abduction to 90 degrees. The sternocleidomastoid and pectoralis muscles have been removed The circled area is the brachial plexus

and along with the subclavian artery enter the base of the neck where they converge to form the three trunks, each of which divides into two branches in the posterior triangle of the neck. ° e root divisions continue toward the axilla combining to form the cords of the brachial plexus. Each trunk is separated into an anterior and posterior division, resulting in a total of six divisions. ° e divisions form three cords: lateral (consisting of the anterior divisions of the upper and middle trunks), posterior (consisting of the three posterior divisions), and medial (consisting of the anterior division of the inferior trunk). On the lateral side of the axilla each cord is divided into two terminal branches: the musculocutaneous nerve and the lateral root of the median nerve (lateral cord); the axillary nerve and the radial nerve (posterior cord); and the ulnar nerve and the medial root of the median nerve (medial cord). ° e upper branches of the plexus that arise in the neck, rather than in the axilla, include the dorsal scapular nerve, the suprascapular

nerve and long thoracic nerves, and the subclavian nerve (Thompson 2010). ° e branches of the lateral and medial cords innervate the anterior muscles of the upper limbs, and the branches of the posterior cord innervate the posterior muscles. ° is pattern can also be expressed in terms of plexus divisions: the anterior divisions innervate the anterior muscles and the posterior divisions innervate the posterior muscles of the upper limb; the ulnar nerve is the only nerve derived from the medial cord. A knowledge of the distribution of sensitive areas is very useful in the therapeutic process and will help the practitioner to identify referred symptoms (including multifocal symptomatology). ° e sensory distributions of the branches of the brachial plexus are illustrated in Figure 14.10.

Nerve entrapment syndrome Nerve entrapment syndrome can be a cause of pain and or dysfunction in the upper quadrant ( see Chapter 8 for a more detailed discussion of this topic). A knowledge

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14 A

A A Supraclavicular nerves B Superior lateral cutaneous nerve of arm

B

D

C Intercostobrachial nerve D Medial brachial cutaneous nerve E Inferior lateral brachial cutaneous nerve

D

E

F Lateral antebrachial cutaneous nerve

E

B

(cutaneous branch of axillary nerve)

C

(radial nerve)

(musculocutaneous nerve)

G Cutaneous antebrachial medial nerve (C8–T1)

F

H Cutaneous antebrachial posterior nerve

F

G

I Cutaneous antebrachial lateral nerve

G

(radial nerve) (radial nerve)

J Ulnar nerve K Palmar and digital branch (ulnar nerve) L Palmar and digital branch (median

I

J

H I

nerve)

K K

L Anterior

Posterior

L Figure 14.10 Cutaneous sensory innervation of the upper limb

of the nerves that may be involved, their anatomy, motor and sensory functions, and the etiology of their dysfunction helps the practitioner to manage these complex problems. Nerve entrapment may be responsible for several pain syndromes in the thorax, shoulder, and upper extremity.

Tables 14.8–14.10 summarize the main aspects of sensory and motor distribution of the components of the brachial plexus, as well as the most common deÿ ciencies. Figure 14.11 shows the distribution of areas a˛ ected by radiculopathy.

Tables 14.5–14.7 show the locations of the most common entrapments of the brachial plexus and its branches.

When assessing for myofascial dysfunctions it is recommended that neural tests be carried out in order to determine whether or not neural entrapment is involved

Neural tests

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14

Table 14.5 Median nerve entrapment syndrome (Guo & Wang 2014, Gunther et al. 1993) Arm and forearm

Causes

A Supracondylar process syndrome

Anatomical variables

B Pronator teres muscle (dysfunction

Heavy manual tasks

(median nerve entrapment through Struthers’ ligament)

A B C D

when moving the forearm from pronation to supination)

Repetitive strain injury

C Biceps brachii lacertus fibrosus

Myofascial restriction of the biceps brachii fascia

D Compression in pronator syndrome

Heavy manual tasks

(fibrous arch of the flexor digitorum superficialis)

Repetitive strain injury Myofascial restriction of the antebrachial fascia

E Wrist and hand

Causes

E Carpal tunnel

Heavy manual tasks Repetitive strain injury Palmar fascia restriction Decreased mobility of the median nerve

Table 14.6 Radial nerve entrapment syndrome (Miller & Reinus 2010) Forearm

Causes

A Radial tunnel

Repetitive strain injury (sports) Lateral epicondylalgia

A

B Entrapment of the superficial branch of the radial nerve (Wartenberg’s syndrome)

Intense manual work (thumb) Repetitive strain injury De Quervain’s syndrome Tight-fitting bracelet

B

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14 Table 14.7 Ulnar nerve entrapment syndrome (Spinner 2006)

Arm and forearm

Causes

A Ulnar tunnel syndrome

Heavy manual tasks Repetitive strain injury Medial epicondylalgia

A B

B Deep aponeurosis of the

epitrochlear musculature

Heavy manual work Repetitive strain injury Spasticity

C

Wrist and hand

Causes

C Guyon's canal

History of pisiform fracture symptoms Repetitive microtrauma (cyclists)

in the patient’s symptomatology. ° e basic neural tests relating to possible neural entrapment of the brachial plexus components are summarized in Figure 14.12, Table 14.11, and Figure 14.13. How to perform neural tests is not explained in this book, and the reader is referred to the extensive specialized literature on this subject.

Red flags: Assessment of neural components (Waddell 2004)

• • • • •

Cancer Unexplained weight loss Immunosuppression Prolonged use of steroids Intravenous drug use

• • • • • • • • • • •

Pain that is increased or unrelieved by rest Fever Signiÿ cant trauma related to age Bladder or bowel incontinence Urinary retention (with over˝ ow incontinence) Saddle anesthesia Major motor weakness in the upper extremities Fever Vertebral tenderness Limited spinal range of motion Neurologic ÿ ndings persisting beyond one month.

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14

Table 14.8 Peripheral nerves – 1 Peripheral nerve

Nerve roots

Terminal branches

Motor innervation

Sensory distrIbution

Deficiency

Median nerve Anterior interosseus nerve Palmar cutaneous nerve (A)

C5–T1

Recurrent branch Palmar cutaneous branch

Deep layer of ventral forearm muscles: flexor pollicis longus flexor digitorum profundus (radial portion) pronator quadratus

Deep part of the joint capsule of the distal, radiocarpal, and carpal radioulnar joints

Deep pain with nociceptive features on the anterior aspect of the elbow and the proximal third of the forearm (Rehak 2001)

All muscles of the thenar eminence except the adductor pollicis

Lateral aspect of the palm

Kiloh–Nevin syndrome (anterior interosseous nerve syndrome – failure to make the “OK” sign) (Akhondi & Varacallo 2019)

A Recurrent branch Palmar digital branch

Palmar cutaneous branch (B)

Palmar surface and fingertips of the lateral three and half digits

B

Digital cutaneous branch (C)

C

Innervation of the thenar and middle palmar areas

Neuropathic signs and symptoms in the thenar eminence (pronator teres syndrome) (Rehak 2001) Intermittent paresthesia or pain in the index, middle and ring fingers, palmar and wrist area (Sluiter et al. 2001) (carpal tunnel syndrome) Lack of sensation over the areas innervated by the median nerve Weakness in resisted abduction of the thumb or atrophy of the abductor pollicis brevis muscle

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14 Table 14.9 Peripheral nerves – 2 Peripheral nerve

Nerve roots

Radial nerve

C5–T1

Terminal branches

Motor innervation

Sensory distrIbution

Extensor and supinator muscles of the upper extremity

Superficial sensory branch

Nociceptive pain at the lateral aspect of the elbow and at the proximal third of the dorsum of the forearm (radial tunnel syndrome)

Innervates the triceps brachii and the extensor muscles in the forearm

Superficial sensory branch

Deficiency

Weakness in extension of the wrist and fingers Dorsum of the wrist Lateral dorsal surface of the hand Dorsum of the thumb

Pain, paresthesia, and dysesthesia on the back of the first commissure of the hand (Robson et al. 2008)

Dorsum of the index and middle fingers (Johnson et al. 2006, Robson et al. 2008)

Deep motor branch

Extensor carpi radialis brevis, supinator, extensor digitorum, extensor carpi ulnaris, abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, extensor digiti minimi, and extensor indicis

Dorsal wrist crease (Williams 1998)

Lability of some of the innervated muscles

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14

Table 14.10 Peripheral nerves – 3 Peripheral nerve

Nerve roots

Ulnar nerve

C8–T1

Terminal branches

Motor innervation

Sensory distrIbution

Deficiency Intermittent paresthesia (tingling, burning, hypersensitivity) in the little finger and at the ulnar border of the ring finger. Deep pain in the medial aspect of the elbow (Mazurek & Shin 2001) Cubital tunnel syndrome

Palmar cutaneous branch

Skin of the medial half of the hand and the distal part of the forearm

Dorsal cutaneous branch

Skin of the medial dorsal side of the hand, the posterior side of the little finger and part of the ring and middle fingers (Williams 1998, Mazurek & Shin 2001) (bottom image)

Muscular superficial branch

Palmar side of the little finger and half of the ring finger (Robertson & Saratsiotis 2005) (top image)

Muscular deep branch

Intrinsic muscles of the hypothenar area (Johnson et al. 2006)

Local nociceptive pain and motor disability of the innervated muscles (Sluiter et al. 2001) Guyon’s canal syndrome

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14 Figure 14.11 Distribution of areas affected by radiculopathy between levels C5–C8. The darkest colors indicate the areas of intense irradiated pain. The clear areas indicate areas of dull pain, which can also be related to sensations of paraesthesia and sensory impairment (Harting 1997)

Functional assessment

C5

C6

C7

C8

Global functional tests

Neural tests

Visceral tests

Circulatory tests

Specific functional tests

Figure 14.12 Neural test applied to the neck

Viscerofascial components It is not within the scope of this book to provide a detailed analysis of either viscerofascial anatomy or the clinical approaches for treating viscerofascial structures. ° is is an extremely complex issue that requires

extensive analysis. However, in clinical practice, in relation to the thoracic region, the practitioner should be aware of the need to identify signs and symptoms originating from the viscerofascial system (particularly in relation to respiratory disturbances) and should be able to recognize red ˝ ags.

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14

Table 14.11 Global functional assessment – neural test Test

Aim

Description

Interpretation (positive sign)

Clinical analysis

References

Neurodynamic test for the mandibular nerve

This is a neural tension test which is used to detect altered neurodynamic or neural tissue sensitivity

Right mandibular branch test: upper cervical flexion left upper cervical lateral flexion left laterotrusion with open mouth (10 mm)

The symptoms of irritation of the mandibular ramus appear to be recognized by the patient

Specific pretreatment neurological assessment is needed to exclude the presence of possible serious pathology, such as vertebral artery dissection, injury to the spinal cord or cervical myelopathy, neoplasm, systemic disease (herpes zoster, ankylosing spondylitis, inflammatory arthritis, rheumatic arthritis) (Bier et al. 2018)

von Piekartz 2007

Reproduction of the symptoms coincides with a response of limited mobility Structural differentiation tests are applied to sensitize and desensitize the nerve

Geerse & Piekartz 2015

Median nerve tension test

Radial nerve tension test

Ulnar nerve tension test

Figure 14.13 Upper limb neural tests

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14 Viscerofascial dysfunctions criteria in myofascial induction approaches Fascial dysfunctions and entrapments can create disorder in the viscerofascia and subsequently lead to the formation of, for example, gastrointestinal or breathing dysfunctions. ° is does not merely suggest the presence of speciÿ c pathologies (e.g., visceral) but rather disorder in the dynamics of movement between and within the viscera, as well as between the viscerofascial and myofascial structures. Sti˛ ness or decreased mobility of viscera may encourage the formation of ÿ brosis. An example of this process is the response of Kup˛ er cells (stellate macrophages), through the process of mechanotransduction, recognizing an increasing tension in the cellular environment. ° is process has also been linked with sleep abnormalities, fatigue, and mood disorders (Aouizerat et al. 2009). ° rough the mechanoreceptors the fascial system is in a continuous process of response, adjustment, and feedback (Vaticon 2009) which is:

• • • • •

somatosomatic

•

visceropsychic (vagus nerve response, alteration of cognitive-behavioral response).

somatovisceral viscerovisceral viscerosomatic psychovisceral (stress and secretion of cortisol and adrenaline versus slowing peristalsis, increase in hydrochloric acid production, etc.)

Visceral dysfunction has the potential to change the body’s overall mechanosensitivity (illness behavior) through neuroimmunological mechanisms. One example is the release of cytokines in the brain stimulated by a vagal response related to liver toxicity (Olsen et al. 2011, Bilzer et al. 2006).

The lymphatic and superficial circulatory system of the upper quadrant As mentioned in Chapter 10, the lymphatic system is a network of tissues and organs which helps the body to expel toxins, waste, and other unwanted materials (Fig. 14.14). ° is extensive system takes care of three major body functions (Cueni & Detmar 2008):

•

drainage of excess interstitial ˝ uid (regulation of tissue pressure) and proteins back to the systemic circulation;

•

regulation of immune responses by both cellular and humoral mechanisms;

•

absorption of lipids from the digestive system.

Fascia provides support for the glandular tissue of the breasts in the form of a “net” consisting of bands called suspensory ligaments (or Cooper’s ligaments) (Fig. 14.14-2), which pass through the breast from the skin up to the pectoralis major muscle fascia. ° e structure of the superÿ cial fascia (see Chapter 3) also creates compartments in which fat nodules develop. In this way the quantity, shape, size, interrelation between the fat lobes and the shape of the structure (for example the volume and shape of the breasts) is deÿ ned by the lobes within the fascial compartments. ° e right thoracic duct drains most of the right upper quadrant area of the substances which come from the lymph nodes (Fig. 14.14-1). ° e lymph nodes are small structures that work as ÿ lters for harmful substances. ° ey contain immune cells that can help ÿ ght infection by attacking and destroying germs that are carried in through the lymph ˝ uid. ° e node system consists of anterior (pectoral) nodes which drain the anterior chest wall and breasts, posterior (subscapular) nodes which drain the posterior chest wall and part of the arms, lateral (brachial) nodes which drain most of the arms, and central (midaxillary) nodes which receive drainage from the anterior, posterior, and lateral lymph nodes. In cases of infection, injury, or cancer, the nodes in that area may swell or enlarge as they work to ÿ lter out the a˛ ected cells. ° us, the lymphatic system can also contribute to the development of diseases such as lymphedema, cancer metastasis, and diverse in˝ ammatory disorders (Mallick & Bodenham 2003). It is useful to refer to the breast quadrants when describing the location of ÿ ndings. ° ey are distinguished as follows: the upper inner quadrant, the upper outer quadrant (tail of Spence), which extends into the axillary area (most breast tumors occur in this quadrant), the lower inner quadrant, and the lower outer quadrant (Fig. 14.14-3).

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Upper quadrant assessment

Functional assessment

Global functional tests

Neural tests

Specific functional tests

Circulatory tests

Visceral tests

14

A A

B

C

D

3

1

2

Figure 14.14 Lymphatic system of the upper quadrant. 1 The right lymphatic duct (A). The green color indicates its area of drainage. 2 Sagittal view of the lymphatic system of the upper quadrant with an ultrasound scan of the breast. The white lines on the scan are Cooper’s ligaments. 3 The quadrants of the left breast. A Upper inner quadrant B Upper outer quadrant C Lower inner quadrant D Lower outer quadrant Red oval – axillary tail of Spence

° e assessment of the upper quadrant should include a Clinical Breast Examination (CBE). ° e National Cancer Institute (2019) stresses the value of the CBE and recommends:

• •

a manual check for unusual texture or lumps an assessment of any suspicious area.

° e utility of the CBE has been questioned for several years because it was considered that there was little evidence to support it (Nelson et al. 2009). However, recent research conÿ rms the great e˛ ectiveness of this procedure (Laufer et al. 2017, Nelson et al. 2016). “Our recent work discovered a signiÿ cant, linear relationship between palpation force and CBE accuracy” (Laufer etˇal. 2017).

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14 Red flags: Lymphatic and superficial circulatory system

• • • • • • • • • • • • • • • • • • •

Hemoptysis Acute breathlessness Pleuritic chest pain Obstruction of the airways Blurred vision High fever Respiratory rate of more than 30 breaths per minute High blood pressure

• • • • • • • •

Pneumothorax Upper cervical instability Cervical arterial dysfunction Acute fracture Acute so˙ tissue injury Ligamentous instability Osteoporosis Recent surgery.

Persistent unilateral hearing loss or tinnitus

Conclusion

Facial nerve palsy

•

In practice, the assessment process will depend on the experience and skills of the individual practitioner, the patient’s proÿ le, and the demands of the therapeutic procedures.

•

° e speciÿ c functional tests are explained in Chapters 15, 16 and 17 which focus on clinical dysfunctions of speciÿ c areas.

•

° e patient’s expectations, fears, and beliefs in˝ uence how the assessment is conducted. ° ese aspects must be considered in order to achieve a correct interpretation of the tests.

•

° e patient’s understanding of the process is essential to treatment planning.

Blood-stained mucous Epiphora Cerebrospinal ˝ uid leak Dysphonia persisting for longer than four weeks Dysarthria Dysphagia Odynophagia Myocardial infarction Aortic syndromes

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REFERENCES

Akhondi H, Varacallo M (2019) Anterior Interosseous Syndrome. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; PMID: 30247831. Available: https://www.ncbi.nlm.nih .gov/books/NBK525956/ [accessed September 18, 2021]. Aouizerat BE, Dodd M, Lee K, West C, Paul SM, Cooper BA, Wara W, Swi˙ P, Dunn LB, Miaskowski C (2009) Preliminary evidence of a genetic association between tumor necrosis factor alpha and the severity of sleep disturbance and morning fatigue. Biol Res Nurs 11(1):27–41. Aruin A, Ota T, Latash ML (2001) Anticipatory postural adjustments associated with lateral and rotational perturbations during standing. J Electromyogr Kinesiol 11(1):39–51. Bier JD, Scholten-Peeters WGM, Bart Staal J, Pool J, Tulder MW, Beekman E, Knoop J, Meerho˛ G, Verhagen AP (2018) Clinical practice guideline for physical therapy assessment and treatment in patients with nonspeciÿ c neck pain. Phys ° er 98(3):162–171. Bilzer M, Roggel F, Gerbes AL (2006) Role of Kup˛ er cells in host defense and liver disease. Liver Int 26(10):1175–1186. Bowen BC, Pattany PM, Saraf-Lavi E, Maravilla KR (2004) ° e brachial plexus: Normal anatomy, pathology and MR imaging. Neuroimaging Clin N Am 14(1):59–85. Brazis PW, Masdeu JC, Biller J (Eds.) (2007) Cervical, brachial, and lumbosacral plexi. In: Localization in Clinical Neurology. Philadelphia, PA: Lippincott Williams & Wilkins, pp. 73–89. Butler DS (1991) Mobilisation of the Nervous System. London: Churchill Livingstone.

Cook G, with Burton L, Kiesel K, Rose G, Bryant MF (2010) Movement: Functional Movement Systems: Screening—Assessment—Corrective Strategies. Aptos, CA: Lotus Publishing. Corey S, Vizzard M, Badger G, Langevin H (2011) Sensory innervation of the nonspecialized connective tissues in the low back of the rat. Cells Tissues Organs 194(6):521–530. Cueni LN, Detmar M (2008) ° e lymphatic system in health and disease. Lymphat Res Biol 6(3–4):109–122. Debaere F, Wenderoth N, Sunaert S, Van Hecke P, Swinnen SP (2003) Internal vs external generation of movements: Di˛ erential neural pathways involved in bimanual coordination performed in the presence or absence of augmented visual feedback. Neuroimage 19(3):764–776. de-la-Llave-Rincón AI, Puentedura EJ, Fernándezde-las-Peñas C (2011) Clinical presentation and manual therapy for upper quadrant musculoskeletal conditions. J Man Manip ° er 19(4):201–211. Dong G, Potenza MN (2015) Behavioural and brain responses related to Internet search and memory. Eur J Neurosci 428(8):2546–2554. Edwards TB, Bostick RD, Greene CC, Baratta RV, Drez D (2002) Inter-observer and intraobserver reliability of the measurement of shoulder internal rotation by vertebral level. J Shoulder Elbow Surg 11(1):40–42. Falla DL, Campbell CD, Fagan AE, ° ompson DC, Jull GA (2003) Relationship between craniocervical ˝ exion range of motion and pressure change during the cranio-cervical ˝ exion test. Man ° er 8(2):92–96.

Cagnie B, Dickx N, Peeters I, Tuytens J, Achten E, Cambier D, Danneels L (2008) ° e use of functional MRI to evaluate cervical ˝ exor activity during di˛ erent cervical ˝ exion exercises. J Appl Physiol 104(1):230–235.

Firth J, Torous J, Stubbs B, Firth JA, Steiner GZ, Smith L, Alvarez-Jimenez M, Gleeson J, Vancampfort D, Armitage CJ, Sarris J (2019) ° e “online brain”: How the Internet may be changing our cognition. Am J Geriatr Psychiatry 18(2): 119–129.

Campbell W (Ed.) (2005) Peripheral neuroanatomy and focal neuropathies. In: ° e Neurologic Examination. Philadephia, PA: Lippincott Williams & Wilkins, pp. 548–564.

Flavell JH (1976) Metacognitive aspects of problem solving. In: Resnik LB (Ed.) ° e Nature of Intelligence. Hillsdale, NJ: Erlbaum, pp. 231–235.

Cook G, Burton L, Fields K, Kiesel K (1998) The Functional Movement Screen. Danville, VA: Athletic Testing Services Inc.

Geerse WK, von Piekartz HJ (2015) Ear pain following temporomandibular surgery originating from the temporomandibular joint or the

14

cranial nervous tissue? A case report. Man ° er 20(1):212–215. Gindrat AD, Chytiris M, Balerna M, Rouiller EM, Ghosh A (2015) Use-dependent cortical processing from ÿ ngertips in touchscreen phone users. Curr Biol 25(1):109–116. Guo B, Wang A (2014) Median nerve compression at the ÿ brous arch of the ˝ exor digitorum superÿ cialis: An anatomic study of the pronator syndrome. Hand (NY) 9(4):466–470. Gunther SF, DiPasquale D, Martin R (1993) Struthers’ ligament and associated median nerve variations in a cadaveric specimen. Yale J Biol Med 66(3):203–208. Harting JK (1997) ° e Global Spinal Cord ’97. Radiculopathies [Online resource]. University of Wisconsin Medical School. Available: http:// www.neuroanatomy.wisc.edu/SClinic/Radiculo/Radiculopathy.htm [accessed July 26, 2021]. Haskins R, Cook CE, Osmotherly PG, Rivett DA (2018) Clinical prediction rules: ° eir beneÿ ts and limitations in clinical reasoning. In: Jones M, Rivett DA (Eds.) Clinical Reasoning in Musculoskeletal Practice. 2nd ed. Elsevier, pp. 89–100. He A (2019) Average US time spent with mobile in 2019 has increased: US adults spend more time on mobile than they do watching tv. eMarketer. Available: https://www.emarketer.com/ content/average-us-time-spent-with-mobile-in2019-has-increased [accessed March 8, 2021]. Hoving JL, Buchbinder R, Green S, Forbes A, Bellamy N, Brand C, Buchanan R, Hall S, Patrick M, Ryan P, Stockman A (2002) How reliably do rheumatologists measure shoulder movement? Ann Rheum Dis 61(7):612–616. Huisstede BM, Bierma-Zeinstra SM, Koes BW, Verhaar JA (2006) Incidence and prevalence of upper-extremity musculoskeletal disorders. A systematic appraisal of the literature. BMC Musculoskelet Disord 7:7. Ishida I, Hirose R, Ono K, Kobashi J, Shinohara S, Watanabe S (2013) Maximum isometric abduction of contralateral hip during single-leg standing induces activity of the gluteus medius on the weight-bearing side. Rigakuryoho Kagaku 28:(5):631–633.

323

Pilat_Myofascial Induction.indb 323

03/12/21 4:26 PM

14

REFERENCES

Janda V (1996) Evaluation of muscular balance. In: Liebenson C (Ed.) Rehabilitation of the Spine. Baltimore, MD: Williams and Wilkins. Jensen TS, Baron R (2003) Translation of symptoms and signs into mechanisms in neuropathic pain. Pain 102(1):1–8. Johnson EO, Vekris MD, Zoubos AB, Soucacos PN (2006) Neuroanatomy of the brachial plexus: ° e missing link in the continuity between the central and peripheral nervous systems. Microsurgery 26(4):218–229. Jones MA, Rivett DA (2004) Clinical Reasoning for Manual ° erapists. Elsevier, pp. 3–24. Jones M, Edwards I, Jenson GM (2019) Clinical reasoning in physiotherapy. In: Higgs J, Jensen GM, Lo˙ us S, Christensen N (Eds.) Clinical Reasoning in the Health Professions. 4th ed. Elsevier, pp. 247260. Jull G, Falla D (2016) Does increased superÿ cial neck ˝ exor activity in the craniocervical ˝ exion test re˝ ect reduced deep ˝ exor activity in people with neck pain? Man ° er 25:43–47. Jull G, Kristjansson E, Dall’Alba P (2004) Impairment in the cervical ˝ exors: A comparison of whiplash and insidious onset neck pain patients. Man ° er 9(2):89–94. Jull GA, O’Leary SP, Falla DL (2008a) Clinical assessment of the deep cervical ˝ exor muscles: ° e craniocervical ˝ exion test. J Manipulative Physiol ° er 31(7):525–533. Jull G, Sterling M, Falla D, Treleaven J, O’Leary S (2008b) Whiplash, Headache and Neck Pain: Research-based directions for physical therapies. Edinburgh: Churchill Livingstone Elsevier. Kartal (2014) Comparison of static balance in di˛ erent athletes. Anthropologist 18(3):811815.

Kibler WB, Ludewig PM, McClure PW, Michener LA, Bak K, Sciascia AD (2013) Clinical implications of scapular dyskinesis in shoulder injury: ° e 2013 consensus statement from the ‘scapular summit’. Br J Sports Med 47(14):877–885. Kim DH, Kim CJ, Son SM (2018) Neck pain in adults with forward head posture: E˛ ects of craniovertebral angle and cervical range of motion. Osong Public Health Res Perspect 9(6):309–313. Konin JG, Wiksten DL, Isear JA, Brader H (2006) Special Tests for Orthopedic Examination. 3rd ed. ° orofare, NJ: SLACK Incorporated. Kraus S (1994) Temporomandibular Disorders. 2nd ed. Edinburgh: Churchill Livingstone. Kühn S, Gallinat J (2015) Brains online: Structural and functional correlates of habitual Internet use. Addict Biol 20(2):415–422. Landers JT, Maino K (2012) Clarifying Erb’s point as an anatomic landmark in the posterior cervical triangle. Dermatol Surg 38(6):954–957. Latash ML (2008) Neurophysiological Basis of Movement, 2nd ed. Leeds, UK: Human Kinetics. Latash ML, Levin MF, Scholz JP, Schöner G (2010) Motor control theories and their applications. Medicina (Kaunas) 46(6):382–392. La Touche R (2017) Physiotherapy in craniomandibular disorders and orofacial pain: Neuro-orthopedic manual therapy and biobehavioral physiotherapy. Master Class. Madrid, 2017. Laufer S, D’Angelo AD, Kwan C, Ray RD, Yudkowsky R, Boulet JR, McGaghie WC, Pugh CM (2017) Rescuing the clinical breast examination: Advances in classifying technique and assessing physician competency. Annals of Surgery 266(6):1069–1074.

Key J (2010) ° e pelvic crossed syndromes: A re˝ ection of imbalanced function in the myofascial envelope; a further exploration of Janda’s work. J Bodyw Mov ° er. 14(3):299–301.

Mallick A, Bodenham AR (2003) Disorders of the lymph circulation: ° eir relevance to anaesthesia and intensive care. Br J Anaes 91(2):265–272.

Key J (2013) ‘° e core’: Understanding it, and retraining its dysfunction. J Bodyw Mov ° er 17(4):541–559.

Mazurek MT, Shin AY (2001) Upper extremity peripheral nerve anatomy: Current concepts and applications. Clin Orthop Relat Res 383:7–20.

Mense S (2016) Evidence for the existence of nociceptors in rat thoracolumbar fascia. J Bodyw Mov ° er 20(3):623–628. Miller TT, Reinus WR (2010) Nerve entrapment syndromes of the elbow, forearm, and wrist. AJR Am J Roentgenol 195(3):585–594. Mitchell UH, Johnson AW, Vehrs PR, Feland JB, Hilton SC (2016) Performance on the functional movement screen in older active adults. J Sport Health Sci 5(1):119–125. Moran RW, Schneiders AG, Major KM, Sullivan J (2016) How reliable are Functional Movement Screening scores? A systematic review of rater reliability. Br J Sports Med 50(9):527–536. Nelson HD, Tyne K, Naik A, Bougatsos C, Chan BK, Humphrey L, US Preventive Services Task Force (2009) Screening for breast cancer: An update for the U.S. Preventive Services Task Force. Ann Intern Med 151(10):727–737, W237–242. Nelson HD, Fu R, Cantor A, Pappas M, Daeges M, Humphrey L (2016) E˛ ectiveness of breast cancer screening: Systematic review and meta-analysis to update the 2009 US Preventive Services Task Force Recommendation. Ann Intern Med 164(4):244–255. Norkin CC, White DJ (2016) Measurement of Joint Motion: A Guide to Goniometry. 5th ed. Philadelphia, PA: FA Davis Company. Neumann DA (2010) Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. 6th ed. St. Louis, MO: Mosby Elsevier. Okeson JP (2013) Tratamiento de oclusión y afecciones temporoman-dibulares. 7th ed. Barcelona: Elsevier. O’Leary S, Falla D, Jull G, Vicenzino B (2006) Muscle speciÿ city in tests of cervical ˝ exor muscle performance. J Electromyogr Kinesiol 17(1):35–40. Olsen AL, Bloomer SA, Chan EP, Gaça MD, Georges PC, Sackey B, Uemura M, Janmey PA, Wells RG (2011) Hepatic stellate cells require a sti˛ environment for myoÿ broblastic di˛ erentiation. Am J Physiol Gastrointest Liver Physiol 301(1):G110–118.

324

Pilat_Myofascial Induction.indb 324

03/12/21 4:26 PM

REFERENCES

Ophir E, Nass C, Wagner AD (2009) Cognitive control in media multitaskers. Proc Natl Acad Sci 106 (37):15583–15587. Oulasvirta A, Rattenbury T, Ma L, Raita E (2012) Habits make smartphone use more pervasive. Pers Ubiquit Comput 16:105–114. Overduin SA, d’Avella A, Carmena JM Bizzi E (2012) Microstimulation activates a handful of muscle synergies. Neuron 76(6):1071–1077. Palmer KT, Cooper C (2006) Work-related disorders of the upper limb. Arthritis Research Campaign: Topical Reviews 10:1–7. Petty NJ, Moore AP (2001) Neuromusculoskeletal Examination and Assessment: A Handbook for ° erapists. 2nd ed. Edinburgh: Churchill Livingstone. Preece SJ, Willan P, Nester CJ, Graham-Smith P, Herrington L, Bowker P (2008) Variation in pelvic morphology may prevent the identiÿ cation of anterior pelvic tilt. J Man Manip ° er 16(2):113–117. Ralph BC, ° omson DR, Cheyne JA, Smilek D (2014) Media multitasking and failures of attention in everyday life. Psychol Res 78(5):661–669. Rehak DC (2001). Pronator syndrome. Clin Sports Med 20(3):531–40. Robertson C, Saratsiotis J (2005) A review of compressive ulnar neuropathy at the elbow. J Manipulative Physiol ° er 28(5):345. Robson AJ, See MS, Ellis H (2008) Applied anatomy of the superÿ cial branch of the radial nerve. Clin Anat 21(1):38–45.

Safavynia SA, Torres-Oviedo G, Lena H (2011) Ting muscle synergies: Implications for clinical evaluation and rehabilitation of movement. Top Spinal Cord Inj Rehabil 17(1):16–24.

° ompson JC (2010) Netter’s Concise Orthopaedic Anatomy. 2nd ed. Philadelphia, PA: Saunders Elsevier.

Shacklock M (2005) Clinical Neurodynamics: A New System of Musculoskeletal Treatment. Edinburgh: Butterworth-Heinemann Elsevier.

Uncapher MR, Wagner AD (2018) Minds and brains of media multitaskers: Current ÿ ndings and future directions. Proc Natl Acad Sci 115(40):9889–9896.

Shumway-Cook A, Woollacott MH (2007) Motor Control – Translating Research into Clinical Practice. Philadelphia, PA: Lippincott Williams & Wilkins.

von Piekartz HJM (2007) Craniofacial Pain: Neuromusculoskeletal Assessment, Treatment and Management. Oxford: ButterworthHeinemann Elsevier.

Sluiter JK, Rest KM, Frings-Dresen MH (2001) Criteria document for evaluating the workrelatedness of upper-extremity musculoskeletal disorders. Scand J Work Environ Health 27(Suppl. 1):1–102.

Vaticon D (2009) Sensibilidad miofascial libro de ponencias XIX. Jornadas de Fisioterapia EUF ONCE, Madrid, pp. 24–30.

Small GW, Moody TD, Siddarth P, Bookheimer SY (2009) Your brain on Google: Patterns of cerebral activation during internet searching. Am J Geriatr Psychiatry 17(2):116–126. Spinner RJ (2006) Outcomes for peripheral nerve entrapment. Clin Neurosurg 53:285–294. Stecco A, Gesi M, Stern R (2013) Fascial components of the myofascial pain syndrome. Curr Pain Headache Rep 17(8):352.

14

Waddell G (2004) ° e Back Pain Revolution. 2nd ed. Edinburgh: Churchill Livingstone. Walker-Bone KE, Palmer KT, Reading I, Cooper C (2003) So˙ -tissue rheumatic disorders of the neck and upper limb: Prevalence and risk factors. Semin Arthritis Rheum 33(3):185–203. Williams PL (1998) Anatomía de Gray. Madrid: Harcourt Brace. Winter DA (1995) Human balance and posture control during standing and walking. Gait & Posture 3(4):193–214.

Stecco A, Macchi V, Stecco C, Porzionato A, Day JA, Delmas V, De Caro R (2009) Anatomical study of myofascial continuity in the anterior region of the upper limb. J Bodyw Mov ° er 13(1):53–62. Teyhen DS, Sha˛ er SW, Lorenson CL, Halfpap JP, Walker MJ, Dugan JL, Cilds JD (2012) ° e Functional Movement Screen: A reliability study. J Orthop Sports Phys ° er 42(6):530–540.

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Craniofacial and neck dysfunctions related to the fascial system With a contribution from Eduardo Castro-Martín

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CRANIOFACIAL REGION KEY POINTS •

Description of the craniofacial region including the temporomandibular area

•

Functional relationships between the craniofacial, thoracic, and cervical structures

•

Anatomical and functional complexity of the fascial system in the craniofacial area

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Interrelation of the anatomical components in the fascial system

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Clinical implications

The craniofacial region is closely related to the neck, the thorax, and the shoulder girdle.

Introduction Anatomically the craniofacial region has the most complex structure of all the areas of the body. It contains 28 bones, 34 muscles, 16 salivary glands, eight compartments (cranial, ears, orbits, nasal, and oral), the brain, 12 cranial nerves, and ÿ ve sense organs – smell, vision, taste, audition, and vestibular function – which are responsible for oral and facial communication and the intake of oxygen, food, and water (Moore et al. 2013, Standring et al. 2008). ° ese related structures are called on to perform their demanding tasks with great precision. A great deal of our survival in the environment (e.g., eˆ ciency of breathing or swallowing) depends on them. ° ere are two advantageous circumstances that help the structures to carry out these tasks. ° e ÿ rst is the dynamic connections of the craniofacial complex with the cervical segment which enable the structures to respond quickly to the adaptation demands of vision and/or hearing. ° e second is the ability of the complex fascial system to transmit information through the extracellular matrix (ECM) and its complex cellular networks

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(see Chapter 5). ° e intrinsic and extrinsic dynamics of the skull (the orientation of the senses, the beginning of the digestive and breathing processes, as well as the neurovascular relationships) requires an active and eˆ cient participation of the cervical spine. Norton (2007) and Standring et al. (2008) recommend considering the cervical and craniofacial region as a unit and studying it as such. However, it should be remembered that the challenge of this book is to establish a systemic approach to fascia. ° erefore, we should not disentangle the skull and cervical segments from the shoulder girdle and trunk, but rather analyze them as an anatomical and functional unit (Fig. 15.1). A complex fascial system envelops the entire skull and facial region, containing all its structures and providing support for the muscles and glands, unfolding in diverse intercommunicating spaces, enclosing fatty deposits, and facilitating gliding between structures. ° is design continues toward the neck linking it to the trunk and upper extremities. ° e orientation of the senses and the protection and facilitation of movement would not be possible without the presence of the meningeal fascia on the inside and the neuroconnective and vascular bonds on the outside. In reference to the dura mater Scarr (2008) suggests that it acts as a tensile mediator between the brain and the bony structures of the skull. Such analysis brings us closer to the concept of tensegrity applied to the neurobiodynamic model of the skull. In this model, the meninges in the skull

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15 2017, Pilat & Castro-Martín 2018). ° e challenge is to understand the behavior of this region (keep in mind the multitude of other structures that participate in tasks – such as chewing, swallowing, phonation, breathing, and facial expression – in which the TMJ participates) in addition to the clinical approach to its dysfunctions. ° e following overview of these structures will help with the analysis of clinical processes in the craniofacial region and their relationship with alterations (dysfunctions) of the fascial system.

Craniofacial fascial system ° e fascial system expands from the cranial vertex as a kind of a triple-layered “cap” (Norton 2007) (Figs. 15.4 & 15.5). ° e layers are:

Figure 15.1 Areas of the upper quadrant that are connected structurally and functionally (head, face, temporomandibular area, shoulder girdle, and chest)

create a multifunctional tensional system designed to protect the intracranial contents as well as mediate the complex process of tissue development and reorganization, particularly in the ÿ rst months of extrauterine life (Pilat 2003). Control of the complex mobility of the head is shared between two areas: the craniomandibular and the temporomandibular areas. ° e temporomandibular joint (TMJ) is a ginglymoarthrodial complex (Okeson 2013) (Figs. 15.2 & 15.3) that simultaneously allows for the performance of two movements, hinging and sliding, making it the most used joint in the body (Ferreira et al. 2016). It is characterized by instability and constant adaptability, under the control of the nervous system (Pilat 2003). Once again, the concept of biotensegrity can be applied to the dynamics of this complex and demanding structure (Scarr & Harrison

•

Dense connective tissue containing fat is located under the skin. It is strongly vascularized with free anastomoses derived from the internal and external carotid arteries and the occipital artery. ° e emissary veins connect this layer with the venous sinuses of the dura mater. ° is fascial layer is richly innervated by the three trigeminal branches, the branches of the cervical plexus, and the posterior cervical branches (C2 and C3).

•

Epicranial aponeurosis (galea aponeurotica) is a tight structure, due to the presence of two muscles that join it anteriorly (frontal muscle) and posteriorly (occipital muscle). ° is fascial relationship converts both muscles into a single occipitofrontalis muscle. Sideways, the epicranial aponeurosis gives the origin to the anterior, superior, and posterior auricular muscles. In this location it loses its aponeurotic character and the temporal fascia continues toward the zygomatic arch as a layer of laminated areolar tissue.

•

Loose areolar connective tissue, the deepest, thinnest and most mobile layer, extends from the eyebrows to the upper nuchal line and the external occipital protuberance. ° e next stratum is the pericranium/ periosteum.

° is fascial “cap” expands into a “ski mask” and behind to the nape region where it becomes the posterior cervical fascia, contributing to the nuchal ligament, and subsequently expanding toward the scapula and the

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Figure 15.2

C

E

B

Posterior Sagittal

view

Temporomandibular joint (TMJ) A TMJ disc B Condyle C Glenoid fossa D Capsule attachments E Retrodiscal tissue

A

Anterior

C A D

Medial

posterior region of the shoulder. At the front, the fascia of the frontalis muscle continues downward to cover the nasal, palpebral, and orbital structures. From there it transforms into a single myofascial layer (the superÿ cial fascia transforms into deep fascia) linking the mimetic muscles and the skin and reaching the buccal and mandibular region (facial fascia) where it becomes continuous with the cervical superÿ cial fascia and the platysma. Finally, laterally the cranial fascia expands toward the temporal region, becoming the temporoparietal fascia (Demirdover et al. 2011). ° e cutaneous ligaments arise from the skin to ensure suspension and stabilization of certain areas and in relation to the face they promote facial expression. ° e highest density of cutaneous ligaments is present in the head, the neck, the trunk (upper and lateral regions), and in the upper and lower extremities (see Chapter 3). In the face, zygomatic ligaments are oriented mainly perpendicularly to the skin (RossellPerry & Paredes-Leandro 2013). In general, between

B

Coronal view

D

Lateral

these ligaments emerge free areas in which sliding is facilitated, allowing facial mobility (Gassner et al. 2008). For this purpose, the fascial structures establish the creation of superÿ cial and deep compartments that will determine the location and distribution of the fat lobules. ° is fascial network, which extends threedimensionally, deÿ nes the anatomical limits of the fascial spaces from the surface to the deeper levels (Pessa 2016). In addition, an interconnective framework is created that limits shear forces. ° is framework provides a “retention system” for the human face (Rohrich & Pessa 2008). Aging processes can a˛ ect the fascial and ligamentary system of the face, in˝ uencing its support and antigravity properties (Hînganu et al. 2018).

The fascial system of the face compartmentalizes, sustains, and links the facial structures to stabilize and benefit facial expression.

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15 Figure 15.3

Anterior

Posterior

TMJ dissection (sagittal view) A TMJ disc B Condyle C Glenoid fossa D Masseter

C A B

D

Figure 15.4 The craniofacial fascial system extends to the neck, trunk, and shoulder girdle. A Lateral view. B Frontal view

A

B

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A

15

B C D

Figure 15.5 Cranial fascial distribution A Skin and superficial fascia (loose connective tissue) B Epicranial aponeurosis C Loose areolar connective tissue D Pericranium and periosteum

Main features of the fascial system of the craniofacial region Superficial musculoaponeurotic system

In the face there is a reÿ ned mechanism of subcutaneous connection between the mimetic muscles and the skin (Lockwood 1991) (see also Chapter 3). ° e superÿ cial fascia of the face is known as the superÿ cial musculoaponeurotic system (SMAS). Mitz and Peyronie (1976) described the anatomical basis of the SMAS and since then it has become the object of study by anatomists and plastic surgeons (Kang et al. 2017, Guyuron et al. 2018). ° e term SMAS was introduced in Medical Subject Headings (MeSH), deÿ ning it as a “layer between the superÿ cial fat compartment and the superÿ cial facial muscles of the head and neck” (MeSH

2018). However, the most accepted deÿ nition is limited to the anterior-lateral area of the face (Hwang & Choi 2018). ° e SMAS is described as an organized ÿ brous network derived from the platysma, the parotid fascia, and the ÿ bromuscular layer that covers the cheek. It connects the dermis with the mimetic muscles (orbicularis oculi, zygomaticus minor, depressor anguli oris, depressor labii inferioris, risorius, zygomaticus major, levator labii superioris, alaeque nasi, platysma, orbicularis oris) and envelops them (Marur et al. 2014, Whitney et al. 2020) (Fig. 15.6). In addition to containing muscle structures, it is signiÿ cant that muscle cells have been found in the fascia of this region (Hwang & Choi 2018, Hînganu et al. 2018). Several authors suggest that the SMAS has important functional implications, such as intervening in the masticatory act

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15 constructs the motor endings of the facial nerve and the sensory trigeminal pathways (Hînganu et al. 2018, Whitney et al. 2020). ° e surgical procedures of facial rejuvenation and revitalization of the oral sphincter are based on the presence of this functional musculoaponeurotic facial system (Pidgeon et al. 2017).

Temporoparietal fascia ° is is the fascia of the temporalis muscle which consists of a double layer (superÿ cial and deep) of ÿ brous but ˝ exible fascia. ° e temporal surface layer (also known as the temporoparietal fascia or TPF) originates in the temporal line and follows it up to the zygomatic arch, from where it expands to become the parotideomasseteric fascia. Ferreira et al. (2016), like Macchi et al. (2010), consider that temporoparietal fascia is located in the same plane as the SMAS, since both fascial sheets are the same structure but have di˛ erent names depending on their location. ° ese two structures are continuous with the platysma in the neck, creating a uniÿ ed fascial layer from the scalp to the clavicle (Bohr et al. 2021).

Figure 15.6 Location of the superficial musculoaponeurotic system

by pulling the skin in the direction of the movements of the muscles of mastication and acting as a “distributor and facial ampliÿ er of muscle contraction” (Owsley 1983, Hînganu et al. 2018, Whitney et al. 2020). Macchi et al. (2010) describe the SMAS as a “central tendon” for the coordinated contraction of the muscles of the face, collaborating functionally during expression. ° e SMAS also builds a connective passage for neurovascular components, the branches of the angular and buccal arteries, the transverse facial artery, and small lymphatic vessels that will mainly drain into the preauricular or submandibular lymph nodes. It also

° e deep layer is directly related to the temporalis muscle, providing a ÿ brous wrapping that accompanies the muscle up to its insertion in the jaw and therefore participating in li˙ ing the jaw during closure of the mouth. Between the two layers of the TPF and the deep fascia, just above the zygomatic arch, is located the temporary fat pad that can be extended to become oral fat. Of note is the presence, between both fascial sheets, of an areolar and avascular plane that facilitates the sliding and mobility of the scalp (Bohr et al. 2021), the presence of the middle temporal artery and veins, and also a branch of the facial nerve (Figs. 15.7–15.9) (Beheiry & Abdel-Hamid 2007, Schleicher et al. 2013).

Masseteric fascia ° e TPF advances inferiorly to the face until it reaches the masseteric, parotid, and tympanic fascia. A complex fascial connection is constructed in front of the atrial tragus (Green Sanderson et al. 2020, Jeon et al. 2019). At the deeper level, the system contains the masseter (masseteric fascia), which in turn envelops the parotid gland (parotid fascia) and from there it expands to the tympanomastoid cle˙ generating the tympanoparotid

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Figure 15.7 Temporal fascia 1 The superficial layer has been removed A Deep layer, directly related to the temporalis B Cranium C Zygomatic arch D Superficial layer, separated 2 The muscle tissue is located inside the fascial envelope. Collagen is distributed in several directions that are sometimes very different to the directions of muscle fibers Image 1 is reproduced with permission from Pilat A., Castro-Martín E. (2018) Myofascial induction approaches in temporomandibular disorders. In: Fernández-de-las-Peñas C., Mesa-Jiménez J. (Eds.) Temporomandibular Disorders: Manual Therapy, Exercise, and Needling. Edinburgh: Handspring Publishing

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Figure 15.8

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Continuity of the temporoparietal fascia with the masseteric fascia (1) and with the TMJ dissected (2) White dot – orbital area A Superficial layer, separated B Deep layer, directly related to the temporalis C Masseteric fascia D TMJ

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fascia (Hwang et al. 2008). ° e risorius muscle and the SMAS originate in the parotid fascia. From the masseteric fascia, the system continues to the platysma and cervical fascia.

Platysma ° e myofascial unit of the platysma extends from the upper region of the pectoralis major and deltoid. Its ÿ bers cross the clavicle and ascend medially through

the neck. ° e anterior ÿ bers are intertwined through the midline with the ÿ bers of the contralateral muscle. ° e remaining ÿ bers attach to the lower edge of the jaw or join the skin and subcutaneous tissue of the face (Standring et al. 2008). It can be described as a broad fascial reinforcement of the muscle ÿ bers (Fig. 15.10). Its relationship with the SMAS and the TPF demonstrates the regional continuity that was established at the beginning of this chapter. ° e platysma’s function is related to facial expression and mobility but in a

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A B

Figure 15.10 The platysma. Myofascia is continuous from the jaw to the trunk (for permissions information see page 556)

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somewhat complex way. In a histological and immunohistochemical study carried out with cadavers, May et al. (2018) identiÿ ed the presence of a large number of muscle spindles in the platysma, placing it functionally between the muscles of mastication and the hyoid muscles, attributing to it an a˛ erent neuronal regulation di˛ erent to that of the rest of the mimetic muscles and considering it especially sensitive to stretching. Its innervation depends on the cervical branch of the facial nerve or the cervical branch and mandibular branch of the facial nerve (Hwang et al. 2017).

Fascial relations of the buccinator muscle, pharynx, and skull Figure 15.9 Coronal view of the temporomandibular area. Modified with permission from Schleicher W., Feldman M., Rhodes J. (2013) Review of facial nerve anatomy: Trauma to the temporal region. Eplasty 13:ic54 A Temporoparietal fascia: superficial layer B Temporoparietal fascia: deep layer C Superficial temporal fat pad D Temporalis muscle E Temporal branch of facial nerve F Deep temporal fat pad G Masseteric, parotid, and tympanic fascia H Masseter I Parotid gland

° e aponeurosis of the buccinator originates in the pterygomandibular raphe where it constitutes the buccinopharyngeal fascia and is related to the constrictor muscle of the pharynx. ° e pharyngobasilar fascia that emerges from the occipital basilar portion is integrated in this fascial location (Harn & Shackelford 1982, Sobotta 2000). It gives attachment to the muscles of facial expression, the pharynx, and the skull.

Myofascia of the occipitofrontalis ° e occipitofrontalis muscles are uniÿ ed across the epicranial aponeurosis providing stability to the surface of the head. ° is aponeurotic muscle system expands laterally to continue with the TPF. However,

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although they now constitute a single muscle they do not lose their own functions and are able to stretch the scalp forward or backward, activating the movements individually at di˛ erent times or coordinating both simultaneously. If the eyebrow is raised, the frontal portion is activated, but if the eye is raised further, then occipitofrontal activation facilitated by the fascial connection occurs (Kushima et al. 2005).

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Aponeurosis of the orbicularis oculi

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Considered a functional anatomical entity, orbicularis oculi areolar connective tissue is an important suspending mechanism of the eyelids that cooperates closely with other ocular structures (Koornneef 1979).

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Fascial compartments of the maxillofacial and anterior regions of the neck ° e continuous and extensive fascial system contains compartments for the location of fatty deposits and other structures. Aside from the presence of muscles, these locations suggest a further role of containment, distribution, and, at the same time, interconnection between regions. ° rough their complex architectural design, these compartment systems facilitate movements of the facial and cervical segments. In relation to medical procedures, the fascial spaces are signiÿ cant as they act as transmission routes for infectious processes (Kitamura 2018). Figure 15.11 illustrates the relationships of the fascial compartments of the maxillofacial and anterior regions of the neck.

Fascial relations of the chewing muscles ° e aponeurosis of the internal pterygoid muscle inserts into the periosteum of the angle of the jaw to join the masseter aponeurosis. ° us, the fascial system envelops both muscles relating them to the bone and allows them to act by suspending the bone against depressive forces (Neumann 2010, Pilat 2003) (Fig. 15.12). ° e maximum biting force in this region is approximately 422 N (95 lb) in an adult, twice the amount generated between the incisor teeth (Lafrenière 1997); the temporalis muscle also collaborates during this action. Another example of fascial connection is shown in the aponeurotic envelope of the external and internal pterygoid muscles in the pterygoid fossa through the interpterygoid fascia which in turn contains the

Figure 15.11 Fascial compartments of the maxillofacial and anterior regions of the neck A Infraorbital tissue space – related to the orbital fascia, superficial facial fascia, pterygoid and temporal fascia B Oral tissue space – related to the superficial facial fascia, oral tissue, pterygoid, parotid, and masseteric fascia C Sublingual, submental, and submandibular spaces – related to the superficial facial fascia, oral and parotid tissue, and cervical fascia D Pterygomandibular space – related to the orbital fascia, superficial facial fascia, pterygoid, parotid, masseteric, and temporal fascia E Parotid space – related to the pterygoid, parotid, and masseteric fascia, cervical fascia F Carotid sheath – related to the cervical fascia G Pretracheal space – related to the cervical fascia H Retrovisceral space – related to the cervical fascia

sphenomandibular ligament (Perlemuter & Waligora 1971) (Fig. 15.13).

Cervical fascia ° e fascial cervical relationships (see below) are continuous with the craniofacial fascial system, representing a dynamic link between the head and the trunk (Pilat & Castro-Martín 2018).

Stylomandibular ligament Most of the ligaments are part of the fascia; they are integrated into its structure anatomically and functionally (Pilat 2003, van der Wal 2009). An example is the stylomandibular ligament that results from the folding

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15 Figure 15.12 A

Continuity of the fascial system between the medial pterygoid muscle and masseter (frontal view of left side). The black arrows indicate the projection of the three chewing muscles during the closing function A Sphenoid bone (cross-section) B Lateral pterygoid (both heads) C Medial pterygoid D Angle of mandible (cross-section) E Temporalis F Zygomatic arch (cross-section) G Masseter

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and densiÿ cation of the deep cervical fascia (Norton 2007) (Fig. 15.14).

Behavior of craniomandibular and cervical myofascial structures ° e craniomandibular myofascial structures must comply with the demanding functions of biting, chewing, swallowing, speaking, breathing, and the activity of facial expression. For this reason the practitioner should focus on the thoracic-cervical-cranial-mandibular system. ° is is supported by the structural and fascial connections with adjacent and previously described structures, as well as the regional behavior and formation (of the fascia). ° e theory of biomechanical models, which established the connection between the craniomandibular and cervical muscles and neuromuscular balance, was developed in the 1940s and 1950s by ° ompson and Brodie (° ompson & Brodie 1942, Brodie 1950). According to these models, the connection between the craniomandibular and cervical muscles is important in maintaining neuromuscular balance during the development of cervical and mandibular movements. ° ese concepts have

been investigated in recent years by di˛ erent authors using biomechanical and mathematical models (Rocabado 1983, Gillies et al. 1998, Suzuki et al. 2003, Koolstra & van Eijden 2004). ° ese authors demonstrated that erect posture of the head is maintained due to the neuromuscular balance of the anterior and posterior craniocervical muscles, which includes the activity of the craniomandibular muscles and their synergism with the mimetic and hyoid muscles (Fig. 15.15). The craniomandibular myofascial system coordinates with the cervical myofascial structures which enables it to meet dynamic demands and achieve postural equilibrium.

Currently, following several in vivo studies of the postural relationship between the cervical segment and the TMJ (Solow & Tallgren 1976, Higbie at al. 1999, Visscher at al. 2000, Ohmure at al. 2008, La Touche etˇal. 2011, Rocabado 2011, Moon & Lee 2011) (see also Table 15.5), we know that:

•

In cervical extension the mouth tends to open, the hyoid ascends (modifying the behavior of the hyoid), the occlusal plane rises, and the dental contacts are

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A

A B

Figure 15.13

Figure 15.14

Sphenomandibular ligament (A)

Stylomandibular ligament A Joint capsule B Stylomandibular ligament

which causes hyperpressure to be generated in the retrodiscal space while the disc is positioned anteriorly facilitating subluxation and deformation due to lengthening of the retrodiscal tissue.

posteriorized (leading to occlusal disorder to which the central nervous system responds by making demands on the muscles of mastication).

•

If a cervical ˝ exion posture is adopted (as when looking at the ˝ oor), the opposite occurs.

•

With cervical latero˝ exion the occlusal plane is inclined and follows the plane of the craniocervical inclination and the plane of the atlas.

•

In cephalic protrusion (forward head posture) buccal opening and posterior sliding of the jaw occur

•

If temporomandibular open-mouth behavior or posture is adopted (e.g., during buccal respiration), the cervical spine compensates and goes into hyperlordosis. ° is happens, for example, during the use of dental discharge splints that increase the vertical dimension and generate cervical hyperlordosis.

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15 Figure 15.15 Muscles of the thoracic craniocervical mandibular system. Lateral and frontal views

° e concomitance of coordinated movements is another form of relationship between the regions (Eriksson et al. 1998, Yamabe et al. 1999, Kohno etˇal. 2001, Torisu et al. 2002, Häggman-Henriksson & Eriksson 2004, Miyaoka et al. 2004, Kuroda et al. 2011). Optimal mandibular function requires coordinated actions between the TMJ and the craniocervical region:

•

° e craniocervical movements of extension and ˝ exion are associated with actions such as phonation and chewing and this association is modiÿ ed according to the words articulated and the size of the food bolus. In particular, jaw opening is accompanied by extension. To obtain wider mouth opening, children perform more craniocervical extension.

•

Cervical movements recruit the craniomandibular muscles (Funakoshi et al. 1976, Forsberg et al. 1985, Ballenberger et al. 2012). Performing lateral ˝ exion, rotation, and ˝ exion–extension recruits the temporalis and especially the masseter muscles, perhaps as an antigravity strategy of the jaw.

•

° e forward head craniocervical movement recruits the masseter, temporalis, digastric, and genioglossus muscles (Milidonis et al. 1993, McLean 2005, Ohmure et al. 2008), generating an anterior position of lingual rest (which can lead to lingual, masticatory, and swallowing disorders).

•

Mandibular dynamics also recruit cervical muscles (Clark et al. 1993, Häggman-Henrikson et al. 2013, Armijo-Olivo & Magee 2007, Davies 1979, Venegas et al. 2009, Rodriguez et al. 2011, Hellmann et al. 2012). When chewing or opening the mouth against resistance and while clenching the teeth (bruxism) the sternocleidomastoid (SCM), splenius, complexus, multiÿ dus, and levator scapula muscles are activated.

° e muscles of facial expression also facilitate the performance of the masticatory system during crushing and orientation of the food bolus, thus providing regional stability (Pilat & Castro-Martín 2018, Norton 2007). ° e functional relationship between the cervicocranial and the temporomandibular areas is clear and it extends to the shoulder girdle, thorax, and all the anterior cervical structures, including the suprahyoid and infrahyoid muscles and the tongue itself (Figs. 15.16 & 15.17). In this context, Messina (2017) describes a tongue–mandible–hyoid system which connects the skull, the oral and nasal cavities, the pharynx, the hyoid and the jaw in a complex biomechanical relationship involving a multitude of ligaments, 34 muscles, ÿ ve cranial nerves (V, VII, IX, X, and XII), and the nerve root that emerges from C2 level (Fig. 15.18). ° e dynamics of the tongue-mandible-hyoid system are managed by a dense and complex neural network, which is not o˙ en found in other body structures. As

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Figure 15.16 Diagram of the hyoid bone and the suprahyoid and infrahyoid muscle attachments. The arrows indicate the direction of action of the specific muscles Suprahyoid: A Digastric B Stylohyoid C Mylohyoid D Geniohyoid Infrahyoid: E Thyrohyoid F Omohyoid G Sternothyroid H Sternohyoid

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Figure 15.17 The myofascial relationships of the hyoid region A Sternohyoid muscle B Omohyoid muscle C Hyoid bone D Digastric muscle E Mylohyoid muscle

Figure 15.18

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Myofascial system of the tongue A Palatoglossus B Body of tongue C Genioglossus D Hyoglossus E Geniohyoid F Mylohyoid G Superior pharyngeal constrictor H Styloglossus I Middle pharyngeal constrictor J Thyrohyoid

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15 a result of this, they are able to fulÿ ll the demands of phonation, breathing, swallowing, and chewing. To achieve this, coordination between the chewing muscles and the tongue is essential (Carlson et al. 1997, Takahashi et al. 2005, Kakizaki et al. 2002).

Craniofacial and cervical innervation ° e majority of craniofacial and temporomandibular innervation is related to the three trigeminal divisions: the ophthalmic nerve (V1), the maxillary nerve (V2), and the mandibular nerve (V3). ° ey provide sensitivity to the face, scalp, eye, dura mater, external auditory canal, eardrum, TMJ, oral cavity, two-thirds of the tongue, and the teeth and motility to the muscles of mastication. ° e anterior and posterior cervical branches of C1 to C4 also give sensitivity to the posterior region of the skull and mandible (angle of the jaw) (Fig. 15.19) (Bogduk 2001, Sessle 2005a, Sanders 2010).

V1 C2

V2 C2 V3

C3 C3 C4

C4

Figure 15.19 Distribution of dermatomes of the cervical roots and trigeminal nerve. Dark brown – area supplied by posterior branches; light brown – area supplied by anterior branches V1 Ophthalmic distribution V2 Maxillary distribution V3 Mandibular distribution

Motor innervation of the mimetic muscles is from the facial nerve (VII) (Marur et al. 2014). ° e cervical and craniofacial regions are also neurologically related. ° e ophthalmic division of the trigeminal nerve and C2 are anastomosed to innervate the entire scalp. And, more importantly, there is a place of neurological convergence at the medullary level (the trigeminocervical complex [TCC]), between the trigeminal and the upper cervical roots (Bogduk 2001, Bartsch 2005).

Trigeminocervical complex Sensory information related to superÿ cial and deep orofacial sensitivity enters the caudal subnucleus of the TCC and then proceeds to the somatosensory cortex, connecting with the posteromedial ventral thalamic nucleus and the anterior cingulate cortex (a˛ ective– emotional dimension). At this medullar level the roots of C1, C2, and C3 also have access. In this way, the TCC is conÿ gured as an anatomical functional unit composed of the three dorsal horns of the ÿ rst three cervical nerves and the trigeminal caudal nucleus, converging the nociceptive neurons of both regions (Fig. 15.20) (Bogduk 2001, Busch et al. 2004, Bartsch 2005, Goadsby et al. 2008). ° e sensitization of the TCC facilitates the process of trigeminal irritation, triggering symptoms in the trigeminal and cervical territory. Similarly, cervical irritation (C1, C2, and C3) could induce symptoms in the cervical and trigeminal territory. ° ese changes are not limited to the nociceptive process but also involve muscular behavior. Svensson et al. (2004) observed that a˙ er generating sensory irritation in the masseter there was an increase in the electromyographic activity of the sternocleidomastoid and splenius muscles of the neck (Svensson et al. 2004). Komiyama showed that inciting an experimental pain in the trapezius muscle caused a momentary limitation of mandibular opening (Komiyama et al. 2005). ° ese authors postulate that the TCC could be the key to understanding the complex sensory and motor relationships of the craniofacial and cervical regions.

Clinical implications ° e craniofacial region is prone to su˛ ering fascial alterations caused by traumatic and cicatricial processes, dysfunctions of temporomandibular dynamics, and cervical disturbances. It can present symptomatology

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15

essential in patients with burns. It has to start early and continue for a long period of time (15–30 minutes per day for more than three months) (Rumbach et al. 2011b, Parry et al. 2013, Clayton et al. 2017. Zhang et al. 2017). People who have had cle˙ lip surgery show an asymmetry of the magnitude of motion as well as asymmetry of the path of the motion itself. Video stereophotogrammetry can help identify the status and changes in the post-intervention region (Hallac et al. 2017). Scar tissue can generate adhesions, decrease the range of oral movement, decrease the strength of the orbicularis oris muscle, and cause asymmetry of the oral region leading to low self-esteem. McKay (2014) demonstrated in these patients that manual treatment of the scar can increase range of motion and strength, reduce restrictions (palpable and subjective), and improve symmetry. In general, manual treatment of scars reduces hypersensitivity, decreases thickness, controls itching, providing ˝ exibility as well as an improvement in function (Helm et al. 2004, Cho et al. 2014, Ault et al. 2018). Figure 15.20 Trigeminocervical complex. The circled area is where the three dorsal antlers of the first three cervical nerves and the caudal nucleus of the trigeminal nerve converge, making up the anatomical functional unit known as the trigeminocervical complex

of local and/or referred origin, mainly pain. In addition, fascial alterations incite functional deÿ cits and can have an e˛ ect on aesthetics and the social and emotional aspects of a person’s life by altering their social relationships.

Wound healing processes As already mentioned in Chapter 9, the presence of post-traumatic, postsurgical, or postburn scarring can cause signiÿ cant contractures and ÿ brosis (rigidities) in the fascial tissue, thereby generating a postural and movement deÿ ciency that conditions the body’s behavior. ° e sequelae of craniofacial burns (scars) create alterations and decrease oral mobility even a˙ er years of treatment (Magnani et al 2015, Clayton et al. 2015); speciÿ cally, diˆ culty in opening and closing the mouth due to contractures can cause dysphagia. Eleven percent of patients with facial burns develop this dysfunction (Rumbach et al. 2011a). ° e treatment of fascial contractures is

Craniofacial injuries may cause craniomandibular dysfunctions, including orofacial pain.

Temporomandibular disorder Temporomandibular disorder (TMD) is a complex and multifactorial condition that includes a group of disorders of the masticatory system and a˛ ects myofascial structures, the TMJ, and associated components (Butts et al. 2017a, Lomas et al. 2018). TMD is a common disorder that a˛ ects up to 60– 70ˇpercent of the population (Sharma et al. 2011), representing the second most common musculoskeletal condition (a˙ er LBP) that causes pain and disability (National Institute of Dental and Craniofacial Research 2014). However, the reported prevalence that requires treatment occurs only in 5ˇpercent to 12ˇpercent of the population. TMD occurs in all age groups, although it mostly a˛ ects young people and adults and is more common between the ages of 20–40 (LeResche 1997), with a higher prevalence in women than in men (4:1) (Jerolimov 2009, Sharma et al. 2011). Its exact etiology is still unknown, although trauma, repetitive activities

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15 (parafunctional habits), and anatomical, genetic, hormonal and psychosocial factors are considered to be possible causes (Peck et al. 2008, Pihut et al. 2016, Ivković etˇal. 2018), with the latter being particularly related to pain. Cole & Carlson (2018) stated that there was a strong association between TMD, orofacial pain, and psychological dysfunction. ° ey suggested that there are likely to be reciprocal relationships between emotions, cognition, behaviors, and pain experiences, meaning that dysfunction in one area increases the odds of dysfunction in another. In general terms, TMD is presented as an alteration of multifactorial origin that causes myofascial disorders, disturbances in the TMJ, otological symptoms, and sensorimotor changes in the trigeminal and cervical areas (including orofacial and cervical pain). Conservative treatment is indicated for most patients. Up to 50–90 percent will improve with this therapy (Indresano & Alpha, 2009). In this context, it is usual to work with manual therapy, including Myofascial Induction ° erapy (MIT), to modulate pain, control in˝ ammation, restore mobility, and improve function (Armijo-Olivo et al. 2016). ° e treatment of so˙ tissues is important in these patients due to its signiÿ cance in all diagnostic classiÿ cations of TMD. It is recommended to treat the contractile structures of mastication: the muscles (temporalis, masseter, medial, and lateral pterygoid) and the myofascial structures of the cervical region (Sha˛ er et al. 2014, Butts et al. 2017b). Of particular signiÿ cance are modiÿ cations in the upper cervical segment where changes may occur at the neuroanatomical connection of the trigeminocervical complex (TCC) or in the biomechanical relationship between the cervical and orofacial regions (Zafar et al. 2000, Bartsch & Goadsby 2003, Gil-Martínez et al. 2018). ° erefore, the high comorbidity of TMD with headache and cervical pain is understandable (Gra˛ -Radford & Abbott 2016). It is worth remembering the presence in this region of the connections of the fascial system with the dura mater through the so˙ tissue to dura mater connections (myodural bridges) (Palomeque-Del-Cerro et al. 2017). Yuan et al. (2017), in a population of 235 patients (115 with chronic headache and 120 asymptomatic), analyzed the suboccipital region with magnetic resonance imaging (MRI) and conÿ rmed that the headache group showed greater hypertrophy of the rectus capitis minor (RCPmi). ° e

RCPmi has a connective relationship with the dura as a form of myodural bridge. ° e conclusion of this study was that RCPmi hypertrophy may be the pathogenesis for chronic headaches (due to dura mater sensitization) (Yuan et al. 2017). Myofascial treatment applied to the dural connections could improve the functionality of the region and modulate the mechanical load that may be irritating the dura mater.

Pain related to the orofacial area or cervical spine Orofacial pain (OP) refers to pain experienced in the regions of the mouth, face, and head (De Leeuw & Klasser 2018). It is estimated that 25 percent of the population has experienced some form of OP (Bender 2018). ° is phenomenon can be due to neuropathic or neurovascular disorders, local in˝ ammation processes (such as sinusitis or dental pulpitis), dentomaxillofacial treatments, the presence of TMD and general musculoskeletal (myofascial) alterations of the temporomandibular and craniocervical region (Benoliel et al. 2011, Okeson 2014, Rakhshan et al. 2017). OP that is of high intensity or persistent can have an e˛ ect on the subject’s work and social life leading to a reduction in the quality of life (Boggero et al. 2016). OP of myofascial origin represents the most common cause, being able to a˛ ect the whole temporomandibular, facial, oral, and craniofascial system, and it can also a˛ ect cervical connections. Pain can be expressed locally and/or frequently, can a˛ ect referred areas such as the TMJ region, temporalis muscle, face, eyes, forehead, ear area, cranial vertex, and the occipital and cervical regions. ° us, it can also manifest during actions such as opening and closing the mouth, chewing, facial expression movements, and cervical mobility (Macfarlane et al. 2001, Spierings & Mulder 2017). ° e usual characteristics of this type of pain are that it is deep, di˛ use, and clearly related to muscle function and the associated movements (Fernández-de-lasPeñas et al. 2010, Fernandes et al. 2018). An example of a myofascial alteration that could cause OP would be an increase in tension of the muscles of mastication, for example, the masseter muscles. Sonoelastography (strain and shear wave elastography) can help identify this alteration (Ariji & Ariji 2017). Myofascial induction treatment can help to reduce

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this state of rigidity in the myofascial structures (Pilat 2017). In all cases, painful experience begins with an excitation of the free nerve endings of the primary a˛ erent trigeminal ÿ bers that are present in all the craniofacial tissues, including the fascial system (Sessle 2005b). ° ese ÿ bers can function as nociceptors and can be activated by mechanical, thermal, or chemical stimuli (Takemura et al. 2006). Neuropeptides and other substances speciÿ c to in˝ ammation (tumor necrosis factor, interleukins, cytokines) have been found in this nociceptive process (see Chapter 8). Cê et al. (2018) recorded high salivary levels of the proin˝ ammatory cytokine interleukin-1β in patients with TMD and OP. ° ese ÿ bers can function as a peripheral response, accompanied by neurogenic in˝ ammation that could trigger hyperexcitability and hypersensitivity as well as peripheral sensitization. ° is behavior can generate hyperreactivity and synaptic changes at the medullar level (spinothalamic tract) and at the central level, ÿ nally triggering a central sensitization process. ° is alters the central processing of pain, in˝ uencing the cognitive, behavioral, and emotional aspects of the individual (Fernández-de-las-Peñas et al. 2009, La Touche et al. 2017, Milam et al. 1998, Gerstner et al. 2011, Ichesco et al. 2012, Lin 2014). It is obvious that patients with OP require a biopsychosocial approach to enable them to understand and accept their problems. ° e International Association for the Study of Pain (IASP) describes OP of myofascial origin as occurring in chronic tension headache, painful craniomandibular disorders, craniomandibular disorders with pain and joint involvement, dystonia and facial dyskinesia (neuromuscular disorders), and craniofacial trauma (Merskey & Bogduk 1994). ° ere is a high association of OP pain with cervical pain. Anderson et al. (2011) reported that signs and symptoms overlapped between patients with OP, headache, and neck pain. In a study of patients with chronic and episodic migraine, it was identiÿ ed that 64 percent of the subjects presented with sensitivity to palpation of the cervical myofascial structures, 63 percent with sensitivity to palpation of the TMJ, and 73 percent with sensitivity to palpation of the myofascial structures of chewing (Stuginski-Barbosa et al. 2010). A review of the clinical manifestations linked to the diverse dysfunctional and pathological conditions

15

related to OP and the craniocervical area is presented in Table 15.1 (IHS 2013, Bajwa et al. 2016, Ghurye & McMillan 2017, Tait et al. 2017, Weiss et al. 2017, Banigo et al. 2018, Christoforou 2018, Al Khalili et al. 2021).

Cervical, craniomandibular, and ear disorders (otalgia) ° e most common cause of otalgia is an acute ear infection (of otogenic origin). However, secondary or referred otalgia (of nonotogenic origin) may also occur. In fact, in an adult, nonotogenic otalgia is more prevalent (Majumdar et al. 2009). In this scenario, cervical disorders can cause pain in the ear due to the related innervation between the regions (Jaber et al. 2008). From a structural analysis, an increase in tension of the muscles of mastication could re˝ exively cause an increase in tension in the tensor of the hammer (malleus) muscles: ° e tensor tympani and tensor veli palatini can in˝ uence the middle ear and cause an otognatic or otomandibular syndrome (Myrhaug 1964), which can exhibit as tinnitus, otalgia, dizziness, clogged ear, or a sensation of hearing loss. ° is symptomatology can be reversed during the acts of chewing and swallowing. Changes in the dynamics of the TMJ could involve alterations of the discomalleolar ligament leading to otalgia (Fig. 15.21). ° is ligament is an embryonic continuation of the external pterygoid fascia (it connects the posterior part of the capsule and the TMJ disc with the malleus bone (hammer) and is a possible pathway for otologic alteration (Ogütcen-Toller 1995, Ramírez et al. 2009). In a study of 485 patients with TMD, Kusdra et al. found a signiÿ cant correlation between the degree of temporomandibular dysfunction and otologic symptoms, with prevalence (mainly tinnitus and sensation of tamponade) in 87 percent of patients (Kusdra et al. 2018). From a neurological perspective, alterations of the cervical and facial regions imply changes in the somatosensory a˛ erents (TCC and dorsal roots of C2) that would have a disinhibitory e˛ ect on the dorsal cochlear nucleus (location where the processing of sounds begins), which would explain the appearance of tinnitus (Levine 1999).

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15 Table 15.1 Clinical pictures of orofacial pain – 1 Type of orofacial pain

Migraine

Tension-type headache

Site of pain

Unilateral with pain on one side of the head

A diffuse headache, described as a band around the head

Unilateral

Facial

Starts from the neck and extends to the fronto-oculotemporal area

Dental

Typically has a pulsating quality

Nonpulsatile pain

Continuous, starting in the neck

Continuous in pulpitis

Pattern of pain severity

Moderate to severe levels of pain severity 15 or more headache days a month

Pain descriptors

Migraine with aura (classic) and migraine without aura (common) Moderate to severe levels of pain severity

Also presents with coexisting neck pain with associated myofascial tenderness in the cervical region

Mild to moderate pain

Cervicogenic headache

Dental pain

Temporomandibular disorders

TMJ, masticatory muscles and ear May include pain radiating to the head and neck Usually intermittent If exacerbated, pain can become continuous

Associated with reduced neck movement Pericranial muscle tenderness on the painful side

Routine physical activity

Continuous in infectious processes Intermittent in temporomandibular and cervical processes Otorrhea, otic fullness or low hearing suggest primary otalgia

Mild to severe pain

Related to tooth decay resulting from untreated dental disease

Aching, sharp pain

Chewing

Prolonged chewing

Infectious process

Percussion sensitivity

Bruxism

Cervical movement

Poor sleep

Talking

Changes in the weather

Jaw movements

Temporomandibular movements

No vomiting Usually episodic

Stress Fatigue

Neck movements

Continuous and severe in infectious processes Intermittent and moderate in temporomandibular and cervical processes

Nausea, vomiting, and sensitivity to light and sound

Aggravating factors

Auricular pavilion, auditory canal, temporal region and mastoid

Severe pain

No nausea

Moderate to severe pain, but not excruciating

Otalgia

Poor health Long working hours and/or frequent traveling

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15

Table 15.1 Clinical pictures of orofacial pain – 2 Type of orofacial pain

Glossopharyngeal neuralgia

Trigeminal neuralgia

Cluster headache

Site of pain

Deep in the throat, ear, and pharynx

Along the distribution of the 2nd and 3rd divisions of the trigeminal nerve

Unilateral pain in the orbital, supraorbital, and/or temporal regions

Nasal cavity and sinuses

Pain in the forehead, periorbital region, retro-orbital region, cheeks, or nose

Labial mucosa (frequently the tip of the tongue), lips, buccal mucosa, palate, pharynx, and the floor of the mouth

Paroxysmal

Paroxysmal

Continuous

Attacks last seconds to minutes

Symptoms are episodic and gradually become persistent

Continuous

Attacks last seconds to minutes

Pain is short-lived (lasts about an hour) and can occur in “clusters” for up to 8 times a day for weeks

Pattern of pain severity

Many attacks – up to 30 attacks a day

Pain descriptors

Moderate to high severity

Moderate to high severity

Stabbing, sharp pain

Usually unilateral Stabbing or electrical shooting pain

Nasal congestion, eye watering, ptosis, and sweating

High severity Unilateral Sharp, piercing, burning, and pulsating pain Patients are usually restless or agitated and unable to lie still

Aggravating factors

Swallowing, chewing, talking, coughing, and yawning Residual aching pain

Chewing, a light touch (touching the face), talking, brushing the teeth, or cold air Pain is sometimes spontaneous Residual dull pain in the affected area

Not associated with triggers, such as food, hormonal changes, or stress

Rhinosinusitis

Associated with fever and nasal obstruction. In cases of acute maxillary rhinosinusitis there can be dental pain

Midfacial segment pain

Burning mouth syndrome

Increasing in severity during the day

Tenderness and swelling over the cheeks Recurs daily for more than 2 hours a day for more than 3 months

Severe and usually unilateral Associated with nasal blockage, congestion or obstruction, nasal discharge, and reduced sense of smell

Increase in severity while lying supine, flying, or skiing

Similar characteristics to tension-type headache and can be seen as a category of tension-type headache

Mild to moderate severity

Sometimes burning pain

Usually bilateral

Not described

Hot or spicy food

Burning, stinging, scalding pain, numbness

May be aggravated by stress

Once the period of flare-ups begins, drinking alcohol can aggravate the symptoms

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A

B

A

C B

B C

Figure 15.21 Discomalleolar ligament A TMJ disc B Discomalleolar ligament C Malleus bone

Neural exit foramina ° e three trigeminal nerve branches (ophthalmic, maxillary, and mandibular) exit the skull through foramina (Fig. 15.22). In their paths, along their ducts, the cranial nerves are almost always accompanied by an artery and a vein and are enveloped by the dura mater. Following the positional changes of the head the cranial nerves modify their tension, which suggests the need for a microsliding movement in the foramen (von Piekartz 2007). ° is activity facilitates the meningeal system. ° e optimal performance of the process requires free sliding through the foramen and depends on tension-free fascial tissue. Occasionally, cicatricial processes, trauma, and also excessive loads on the myofascial structures of the mimic muscles can generate mechanical load in these oriÿ ces which leads to trigeminal nerve mechanosensitivity. In such cases, myofascial induction could enhance the behavior of the fascial structures by improving gliding and

Figure 15.22 The foramina of the three branches of the trigeminal nerve A Supraorbital nerve foramen B Infraorbital nerve foramen C Mental nerve foramen

coordination of the nerve branches and their vascular content (Pilat 2003, Barral & Croibier 2009). Changes in the fascial system can cause sensory motor alterations of the craniofacial and cervical region.

As already outlined above, the craniofacial region is closely linked to the cervical segment. ° e excitation of a˛ erent ÿ bers in conjunction with fascial changes in the same area may be the impulse that triggers the sensory and motor changes that result in cervicocranial mandibular dysfunction. ° e MIT approach proposes a therapeutic strategy to recover or improve the function of the cervicocranial mandibular region (Pilat 2003, Pilat & Castro-Martín 2018).

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CRANIOCERVICAL STRUCTURES

platform concerning topography and terminology but includes a clinical background by many different fields such as anesthesiology, ENT surgeons (ear, nose, throat) dentists, plastic surgery and traumatology. (Feigl 2015)

KEY POINTS •

Description of the fascial anatomy of the neck

•

Functional fascial connections between the structures of the head, neck, and thorax

•

The anatomical and functional complexity of the fascial system in the hyoidal and suboccipital areas

•

Contraindications

15

° e craniocervical region is the body’s most complex system from an anatomical and clinical (functional) perspective (Fig. 15.23). ° e variety of anatomical elements that are integrated in a relatively small space requires a precise analysis and careful clinical conclusions. A knowledge of fascial anatomy and the way in which it is integrated with multiple anatomical structures will assist with the processes of clinical reasoning and therapeutic procedures. For this reason, it should again be emphasized that trauma does not only a˛ ect a speciÿ c fascial structure but also extends to other individual anatomical component(s) or the interrelationships between them.

Anatomical considerations related to the continuity of the fascial structures of the neck The interpretation of fascias and spaces of the neck is a still ongoing debate not only on the anatomical

A

B

C

D

E

F

G

H

I

J

Figure 15.23 Anatomical components of the craniocervical fascial system. A Skin. B Skin showing Langer’s lines. C Superficial fascia with fatty lobes. D Lymphatic system. E Deep fascia. F Myofascia. G Vascular components. H Visceral structures. I Osseous components. J The central and peripheral nervous system

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15 Chapters 1 and 3 of this book refer to the continuity of the fascial system throughout the body. As described earlier in this chapter, the relationships between craniofacial and neck structures suggests the presence of dynamic fascial links between the head and trunk (Pilat & Castro-Martín 2018). ° ese links participate in force transmission between the cranium, hyoid, mandible, sternum, clavicles, scapula, the ÿ rst two ribs, and the cervical spine. In parallel, the fascial system of the neck connects the endocranium with the endothorax, in˝ uencing not only the mechanics of the temporomandibular joint, cervical area, and the upper limb structures but also breathing behavior and the regulation of vascular input to the cephalic region (Pilat 2009). A precise understanding of the arrangement of fascia in the cervical area is essential to following fascial functional continuity through the body. It is also feasible that fascial dysfunctions in the cervical area might distort the exchange of information through the system and subsequently lead to the onset of pathology (Pilat 2009).

viscera, vascular vessels, and peripheral nerves. It can be compared to a system of cylinders, with di˛ erent radii concentrically placed inside one another and all interconnected at di˛ erent levels and through a variety of paths (Pilat 2003, Pilat & Castro-Martin 2018) (Fig. 15.24). ° ese interconnections, which unfold between the muscles, establish mechanical connections that participate in the direction, range, and sequence of movement (Bochenek & Reicher 1997). It is the

Fascial anatomy of the neck Although understanding the arrangement of cervical fascia is important for anatomists and clinicians, how the components are deÿ ned is still the subject of an ongoing debate. ° e deÿ nition of layers, paths, and compartments (fascial spaces) in the neck is inconsistent and unclear and it is diˆ cult to classify the fascial anatomy exactly with regard to its trajectory and interrelations. ° ere are discrepancies in the anatomical descriptions associated with similar terms and also the same terms can be used variably (e.g., two di˛ erent fasciae with the same name) in di˛ erent texts (Guidera, et al. 2012, Feigl 2015). Indeed, the anatomical ÿ ndings relating to the cervical fascia and their interpretation have created more divergence than for other parts of the body and this has caused signiÿ cant confusion. ° e following analysis is based on the author’s own experience of dissections of unembalmed cadavers (see also Chapter 3) and is supported by international anatomical terminology (FIPAT 2019). ° e fascial system of the neck is arranged in several compartments with a longitudinal orientation (Bienfait 1987, Bochenek & Reicher 1997, Pilat 2003) which divide, envelop, support, and connect muscles, bones,

Figure 15.24 Schematic of the fascial system of the neck. The fascial architecture of the neck resembles an assemblage of concentric tubes of different radii inserted into each other and intercommunicating in different ways and at different levels Blue – superficial lamina of the deep fascia of the neck Purple – middle lamina of the deep fascia of the neck (muscular lamina of infrahyoid fascia Light red – middle lamina of the deep fascia of the neck (visceral lamina of pretracheal fascia) Yellow – deep layer of the deep fascia of the neck (prevertebral fascia) Dark red – alar fascia

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pathway for vascular, visceral, and neural components. ° e compartments contain fat and loose connective tissue which facilitates lubrication and ensures considerable freedom of movement (particularly sliding) of the fascial system in the given area (Pilat 2009). ° e classiÿ cation and distribution of the fascial system of the neck are outlined below (Figs. 15.25–15.27):

B

• •

15

Superÿ cial fascia of the neck ▶ Platysma Deep fascia of the neck ▶ Superÿ cial lamina of the deep fascia of the neck (investing layer) ▶ Middle lamina of the deep fascia of the neck

C

A

D

E

Figure 15.25 Distribution of the layers of the deep fascia of the neck. A Superficial lamina of the deep fascia of the neck. B Middle lamina of the deep fascia of the neck (muscular lamina of infrahyoid fascia). C Middle lamina of the deep fascia of the neck (visceral lamina of pretracheal fascia). D Deep layer of the deep fascia of the neck (prevertebral fascia). E Alar fascia

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15 3

1 2 T

SCM

E

4 6 C7 M

Anterior

TR

2

Figure 15.26 Transverse section of the neck at the C7 level from an embalmed cadaver C7 Body of the 7th cervical vertebra E Esophagus M Medulla SCM Sternocleidomastoid SP Spinous process T Trachea TR Trapezius 1 Superficial fascia of the neck (platysma) 2 Superficial lamina of the deep fascia of the neck 3 Middle lamina of the deep fascia of the neck (muscular lamina of infrahyoid fascia) 4 Middle lamina of the deep fascia of the neck (visceral lamina of pretracheal fascia) 5 Deep lamina of the deep fascia of the neck (prevertebral fascia) 6 Alar fascia Image courtesy of Prof. Dr. Horacio Conesa

SP 5

Posterior

° Muscular lamina (infrahyoid fascia) ° Visceral lamina (pretracheal fascia) ▶ Deep lamina of the deep fascia of the neck (prevertebral fascia)

° Alar lamina.

Superficial fascia of the neck ° e superÿ cial fascia of the neck (subcutaneous connective tissue; subcutaneous fat pad, Latin: panniculus adiposus) is an elastic structure located under the skin and is penetrated by the neurovascular structures that supply the skin of the neck. It creates a ÿ rm bond (Pilat 2009) between the dermis and the deep cervical fascia and closely surrounds the entire structure of the neck, varying in thickness, form, elasticity, resistance, and fat content. How much fat there is depends on body mass index, sex, and the location of the fat; generally, fat is more generously distributed at the submental layer and thinly distributed distally (Fig. 15.28). ° is is one of the reasons why some anatomists assign to it the name panniculus adiposus, without considering this structure to be fascia itself. However, its continuity

1

with the superÿ cial fascia in the pectoral, deltoid, and back areas justiÿ es assigning it the name of superÿ cial fascia of the neck (Figs. 15.29 & 15.30). In the anterior cranial aspect, the superÿ cial fascia is continuous with the superÿ cial musculoaponeurotic system (SMAS) of the face (Whitney et al. 2020, De la Cuadra-Blanco et al. 2013, Macchi et al. 2010, Gardetto et al. 2003) (see above for more information). Subsequently, it extends distally beyond the clavicle to the level of the 2nd and 3rd ribs, integrating into the manubrium of the sternum and reaching the pectoral and deltoid fasciae (Fig. 15.31). At the cranial nuchal aspect, the superÿ cial fascia of the neck is continuous with the occipitofrontalis fascia in the scalp (galea capitis). Distally it integrates with the superÿ cial fascia of the back (Fig. 15.32). In its vertical path it is inserted along the ligamentum nuchae, joining the deep fascia of the neck (see Figs. 15.25 & 15.30).

The platysma Along its anterolateral path, the superÿ cial fascia of the neck provides a fascial sleeve for the platysma and also

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Craniofacial and neck dysfunctions related to the fascial system

H

D A

Hy

F

C B A C7

Md Tp

E Tp

B Th

E F

C Ao

D G

1

Sp

2

Figure 15.27 Fascial layers. 1 Sagittal view. 2 Horizontal view at the level of C7 Ao Aorta C7 7th cervical vertebra Hy Hyoid bone Md Mandible Sp Spinous process St Sternum Th Thyroid gland Tp Transverse process A Superficial lamina of the deep fascia of the neck (investing layer) B Esophagus C Trachea D Deep lamina of the deep fascia of the neck (prevertebral fascia) E Visceral lamina (pretracheal fascia) F Muscular lamina (infrahyoid fascia) G Pericardium H Platysma

incorporates the superÿ cial veins (e.g., the external jugular vein), capillaries, cutaneous nerves, lymphatic vessels, and superÿ cial lymph nodes. ° e platysma is a paired muscle that completely covers both sides of the neck and overlaps the sternocleidomastoid muscle (Figs. 15.33 & 15.34). ° e platysma may cover large parts of the masseter. In its proximal insertion the platysma initiates its path from the organized ÿ brous network of the SMAS (manifesting itself as an indispensable element for the proper functioning of the facial expression

muscle group: (buccal, temporalis, zygomatic muscles, and the platysma itself) (De la Cuadra-Blanco et al. 2013, Whitney & Zito 2021). (° e platysma’s relations with the muscles of expression are discussed earlier in this chapter.) Subsequently, the platysma, a thin, scarf-like muscle, descends medially enveloping the mandible and, in its distal insertion, extends below the clavicle and, approximately at the level of the 2nd rib, integrates into the deltoid and pectoralis major fasciae. ° e ÿ bers of the le˙ and right sides interweave under and behind the mandibular symphysis

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15 C

A

B

A

B C7

C D Cranial

E Caudal

D Figure 15.30

Figure 15.28 Dissection of the anterior region of the neck. The skin has been removed revealing the subcutaneous fat. Note the large amount of the fat in the submental area. The red line indicates the midline of the cervical fascial system where the superficial and deep fascia meet A Mental protuberance B Thyroid cartilage C Platysma D External jugular vein E Left clavicle

Posterior view of the superficial fascia of the neck and upper back. Note the continuity of the fascia between the neck, back, and shoulders and also the abundant vascularization of this area A Occiput B Skin, dissected and lifted C Superficial fascia of the neck D Superficial fascia of the back

A B

B

A

C D E C F D G

Figure 15.31 E

Figure 15.29 Superficial fascia on the anterior aspect of the neck and thorax. Note the continuity of the fascia between the neck, pectoral, and deltoid areas A Thyroid cartilage B Sternum C Neck area D Pectoral area E Deltoid area

Superficial fascia on the lateral (right) aspect of the head, neck, and upper thorax. Note the continuity of the fascia through these areas A Mental protuberance B Manubrium of sternum C Pectoral fascia D Angle of the mandible E Platysma F Retinacula cutis, connecting the skin to the superficial fascia G Skin, dissected and lifted Reproduced with permission from Pilat A. Castro-Martín E. (2018) Myofascial induction approaches in temporomandibular disorders. In: Fernández-delas-Peñas C, Mesa-Jiménez J. (Eds.) Temporomandibular Disorders: Manual Therapy, Exercise, and Needling. Edinburgh: Handspring Publishing

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Figure 15.32 Superficial and deep fascia of the back A Skin and the superficial fascia, dissected and lifted B Muscle fibers of the trapezius C Deep epimysial fascia over the trapezius D Occiput E The broken line marks the line of the spinous processes of the cervical vertebrae which is the path of the nuchal ligament where the superficial fascia and the superficial lamina of the deep fascia are inserted

A B C

D E

A

B C D E

F G H I

J K 1

2

Figure 15.33 Dissection of the anterior aspect of the neck 1 Anterior view of the platysma with the skin and subcutaneous fat removed 2 Deep structures of the anterior aspect of the neck A Mental protuberance D External jugular vein B Submandibular salivary glands E Thyroid cartilage C Hyoid bone F Sternohyoid muscle Images courtesy of Prof. Dr. Horacio Conesa

G Platysma fibers H Sternocleidomastoid muscle I Clavicle

J Pectoralis major K Sternum

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15 A

B C D E F G

H I 1

2

Figure 15.34 Dissection of the left lateral aspect of the neck 1 Lateral aspect of the platysma 2 Deep view of the lateral aspect of the neck A Mental protuberance B Submandibular salivary gland C Hyoid bone D Thyroid cartilage E External jugular vein F Greater auricular nerve G Sternocleidomastoid, covered by the platysma in image 1 H Left clavicle I Pectoralis major Images courtesy of Prof. Dr. Horacio Conesa

(symphysis menti) (Standring et al. 2008). ° e muscular ÿ bers of platysma bind intimately to the superÿ cial fascia constituting an inseparable functional unit. Under the platysma is found the loose connective tissue containing nerves and vessels. ° e platysma is most commonly innervated by the cervical branch of the facial nerve (38.2 percent) or the cervical and mandibular branches of the facial nerve (60.5 percent) (Hwang et al. 2017). ° e lesser occipital nerve passes superÿ cial to the SCM and deep to the

platysma to innervate the skin over the anterior cervical triangle.

Deep fascia of the neck Ever since the classic descriptions of the deep fascia of the neck by Charpy (1912) and Grodinsky & Holyoke (1938), the debate about the deep fascial layers of the neck and their interconnections has generated a lot of confusion (Feigl 2015), particularly in relation to the visceral, vascular, and nervous structures and their

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Figure 15.35 Dissection of the right anterolateral aspect of the neck A Superficial musculoaponeurotic system (SMAS) B Mental protuberance C Body of right mandible D Thyroid cartilage E Sternocleidomastoid covered by the superficial lamina of the deep fascia F Clavicle G Pectoralis major H Manubrium of sternum

A B C

D

E

F

G

H

relationship to the fascia. ° e reader who is interested in furthering their knowledge of this subject is referred to the references at the end of this chapter.

Cranial

° e deep fascia of the neck is divided into three laminae (superÿ cial, middle, and deep) enclosing the neck muscles, as well as the mandible and the muscles of chewing and swallowing.

Caudal

Superficial lamina of the deep fascia of the neck (investing layer) ° e superÿ cial lamina of the deep fascia of the neck is covered by the skin, the superÿ cial fascia, and the platysma. It is a thin lamina that envelops the neck like a collar, thus connecting numerous bone structures, such as some of the bones of the cranium and the mandible, hyoid, clavicle, scapula, sternum, cervical vertebrae, and upper ribs (Figs. 15.35 & 15.36). (Sutcli˛ e & Lasrado 2021, Gavid et al. 2018, Feigl 2015, Stecco et al. 2013, Guidera et al. 2012, Standring et al. 2008). Its attachments are as follows:

•

Cranially it attaches to the superior nuchal line, the occipital external protuberance, the mastoid process of the temporal bone, the external acoustic meatus, the inferior border of the body of the mandible, and, enclosing the parotid gland, it reaches the zygomatic arch (parotideomasseteric fascia).

•

Caudally it is continuous with the periosteum of the acromion and the spinous processes of the scapulae,

A

B

C

D

Figure 15.36 Posterior aspect of the neck and trunk A Superficial lamina of the deep fascia of the neck and trunk B Trapezius C Occiput D Line of the spinous processes

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15 • •

sternocleidomastoid muscles (Figs. 15.38 & 15.39). Both sides merge anteriorly. However, for researchers, whether fascia is present between the sternocleidomastoid and trapezius muscles is unclear (Zhang & Lee 2002). Below the midline, fascia is divided and joins the anterior and posterior aspects of the manubrium. At the anterior border of the trapezius, fascia expands into a ÿ brotic lamina that covers the scalene muscles. Lateral to the sternum, fascia is transformed into the periosteum of the upper margin of the clavicle and continues to the spine of the scapula.

the clavicle, and the manubrium of the sternum. It is continuous with the thoracic portion of the trapezius and latissimus dorsi muscles. Anteriorly it attaches to the hyoid bone and encloses the submandibular salivary gland, inserting into the inferior surface of the mandible. Posteriorly it joins the spinous process of the cervical vertebrae through the nuchal and supraspinous ligaments.

° rough its posterior insertions in the nuchal ligament, the superÿ cial lamina of the deep fascia of the neck is divided into two symmetrical compartments which bilaterally envelop the upper trapezius muscle (Fig. 15.37). Next, it crosses the posterior triangle of the neck and is divided again to enclose both

° e sternocleidomastoid fascial envelope is asymmetric and in its deep trajectory is thin and therefore low-load resistant. ° e superÿ cial layer is thicker and stronger, particularly at the superior part of the muscle

A

B

A

C B 2

B C

C

C 1 Figure 15.37 Anterior and right side of the superficial lamina of the deep fascia of the neck (investing layer) 1 Frontal view 2 Right lateral view, upper side 3 Right lateral view, lower side A Mental protuberance B Thyroid cartilage C Sternocleidomastoid D Clavicle E Pectoralis major

D

E

3

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A

B

C

D

Figure 15.38 Right anterolateral aspect of the face and neck A Sternocleidomastoid covered by deep fascia B Superficial lamina of the deep fascia of the neck, dissected and lifted C Thyroid cartilage D Sternocleidomastoid covered by epimysial fascia

A

B

C D

15

belly. At the superior border the cervical fascia of the sternocleidomastoid forms several ÿ brotic trabeculae crossing the subcutaneous tissue to the dermis. ° e sternocleidomastoid and the upper trapezius muscles envelop the borders of the neck, establishing several “free” spaces which allow access to the deepest lamina of the cervical fascial system. Furthermore, the cranial and clavicle insertions of the two muscles appear as only one muscle. ° is may be due to the fact that both muscles come from the same embryonic lamina and are innervated by the same cranial nerve (CN XI). Finally, other structures mechanically controlled by the superÿ cial lamina of the deep cervical fascia are the submandibular glands (see Figs. 15.33-2 & 15.34-2) and the ÿ brotic capsule of the parotid gland. ° is span forms a complex structure that harmonizes the dynamics of the shoulder girdle.

Middle lamina of the deep fascia of the neck ° e middle lamina expands in the anterior aspect of the neck between the hyoid and the thorax and encloses the anterior neck. Its attachments are as follows:

•

Cranially it joins the hyoid bone to the thyroid cartilage.

•

Caudally it continues with the fascia of the subclavius muscle through the periosteum of the posterior aspect of the clavicle.

•

Anteriorly it extends from the periosteum of the sternum.

•

Posteriorly it is continuous with the prevertebral fascia.

° e middle lamina can be divided into two parts: the (anterior) muscular lamina (infrahyoid fascia) and the (posterior) visceral lamina (pretracheal fascia).

E Figure 15.39 Deep view of the right lateral aspect of the neck A Thyroid cartilage B Muscle bellies of the right sternocleidomastoid C Clavicle D Pectoralis major E Deltoid

° e muscular lamina ensheathes the infrahyoid muscles (omohyoid, sternohyoid, and sternothyroid), and inferiorly it extends behind the sternum and merges with the pericardium and the great vessels in the upper mediastinum. It is continuous with the middle lamina of the thorax (Stecco et al. 2013). Cranially it continues toward the thyroid cartilage and the hyoid bone. Laterally from the sternum, it expands toward the clavicle and the scapula (Figs. 15.40 & 15.41).

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15 A

B

° e visceral lamina passes on both sides, behind the infrahyoid muscles, in front of the trachea and, like a tube, encircles the trachea, thyroid gland, esophagus, larynx, and pharynx. It then passes to the arch of the aorta, is continuous with the anterior mediastinum and attaches to the ÿ brous pericardium and great vessels.

C

D E

F

Figure 15.40 Right anterolateral aspect of the neck A Anterior belly of digastric muscle B Hyoid bone C Thyroid cartilage D Sternohyoid muscle E Omohyoid muscle F Levator scapulae

A B

Above the hyoid bone the pretracheal fascia forms the sling (loop) through which passes the intermediate tendon of the digastric muscle that supports the hyoid bone and therefore the larynx (Fig. 15.42). Under the sternocleidomastoid muscle the fascia continues downward from the omohyoid muscle to the 1st rib. Above the clavicle it forms a focal thickening of the pretracheal fascia that divides to enclose the omohyoid muscle, thus changing its path. Movement of the hyoid bone and the infrahyoid muscles during swallowing elevates the fascia so that thyroid nodules move on deglutition. Particular attention should be paid to the behavior of the hyoid bone which is a mobile bone. It ˝ oats in front of the spine, wrapped in fascial structures. From breathing to eating hyoid movements keep us alive. ° e hyoid is the intermediary between the skull and the rest of the skeleton and is located in front of C3, below the tonsils A

C D E F G

B

H

C

D Figure 15.41 Right anterolateral aspect of the neck (for permissions information see page 556) A Thyroid cartilage B Anterior belly of digastric muscle C Pathological fascia entrapment D Muscular lamina of the middle deep fascia of the neck E Fibrous sling (loop) of digastric muscle F Mylohyoid muscle G Posterior belly (tendon) of digastric muscle H Angle of mandible

Figure 15.42 Muscles of the floor of the mouth A Anterior belly of digastric muscle B Mylohyoid muscle C Fibrous sling (loop) of digastric muscle D Posterior belly (tendon) of digastric muscle

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and the epiglottis. ° e hyoid articulates with other bones by ligaments and muscles in the same way as a sesamoid bone. ° e stylohyoid ligament (on both sides) suspends the hyoid from the temporal styloid process (Auvenshine & Pettit 2020). ° e hyoid is attached to the cervical spine posteriorly via the deep fascia of the neck. Two groups of muscles are inserted into the hyoid (see Fig. 15.16) – the suprahyoid group (stylohyoid, mylohyoid, digastric, geniohyoid) and the infrahyoid group (sternohyoid, sternothyroid, thyrohyoid, omohyoid) – both coordinating its mechanical stability. ° ese muscles are innervated by the cranial nerves V, IX, X, XII and the nerve root that emerges from C2 (see Table 15.2). ° e hyoid essentially serves as prolongation of the tongue. Of the extrinsic muscles of the tongue – genioglossus, hyoglossus, palatoglossus, and styloglossus – only the latter is not inserted into the hyoid. ° e intrinsic muscles of the tongue (which a˛ ect the shape and size of the tongue) are inserted into the extrinsic muscles of the tongue. For this reason, language-related functions

15

are closely linked to the behavior of the hyoid (de Bakker et al. 2018). ° e infrahyoid muscles connect the hyoid to the sternum both directly, through the attachment of the sternohyoid, and indirectly, through the thyroid cartilage of the larynx and the scapula (omohyoid muscle). ° e role of the infrahyoid muscles is particularly important in relation to the participation of the hyoid in functions such as speech, breathing (maintaining the airway patency between the oropharynx and tracheal rings) (Osman et al. 2018), mastication, and swallowing. ° e hyoid is involved in the same functions as the larynx. Dysfunction of the hyoid can be related to obstructive sleep apnea syndrome (Sforza et al. 2000), tension-type headache, shoulder dysfunction, or forward head posture (Silva et al. 2014, Armijo-Olivo et al. 2011, Cuccia & Caradonna 2009). ° e craniocervical mandibular system has usually been considered to be a functional system that manages

Table 15.2 The muscles of the anterior triangle of the neck

Muscle

Function

Innervation

Stylohyoid

Pulls the hyoid upward in a posterosuperior direction initiating the action of swallowing

Facial nerve (CN VII)

Digastric anterior belly

Opens the mouth by lowering the mandible (the hyoid bone is held in place by the infrahyoid muscles and the masseter and temporalis are relaxed) Elevates the hyoid bone

Mylohyoid nerve, which branches from the inferior alveolar nerve (a branch of the mandibular nerve)

Digastric posterior belly

As above

Facial nerve (CN VII)

Mylohyoid

Elevates the hyoid Participates in the elevation of the floor of the mouth

The mylohyoid nerve which branches from the inferior alveolar nerve of the mandibular division of the trigeminal nerve (CN V, V3 branch)

Geniohyoid

Elevates and pulls the hyoid forward while the mandible is held in place Widens the pharynx Depresses the mandible while the hyoid is held in place

Anterior ramus of C1 within the hypoglossal nerve (CN XII)

Sternohyoid

Depresses the hyoid after swallowing

Anterior rami of C1–C3 through the ansa cervicalis

Omohyoid

Depresses the hyoid and larynx

Anterior rami of C1–C3 through the ansa cervicalis

Thyrohyoid

Depresses the hyoid Raises the larynx while the hyoid is held in place

Anterior rami of C1 within the hypoglossal nerve

Sternothyroid

Depresses the thyroid cartilage

Anterior rami of C1–C3 through the ansa cervicalis

CN – cranial nerve; CN V – trigeminal nerve; V3 – mandibular nerve; C1 – cervical nerve 1; C3 – cervical nerve 3

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15 the postural control of the neck (Cuccia & Caradonna 2009). However, some authors suggest that this model “does not hold anatomical connections with the posterior region of the cranium, thus it should not be referred to as a craniocervical arrangement.” ° ey suggest modifying the usual nomenclature by naming it “the tongue, mandible, hyoid” system (Messina 2017). ° e dynamic interaction between the tongue, mandible, hyoid, and occipital area as well as traumatic impacts in any of these areas can be re˝ ected in the rest of the system. A direct anatomical connection is not always involved since the functional uniÿ cation between the elements mentioned above also has an embryological basis. ° e tongue, the occipital area, and the hyoid bone are derived from the hyoid arch (the second pharyngeal/branchial arch) (Meruane et al. 2012, Grevellec & Tucker (2010). ° e aforementioned complex also processes a˛ erent and e˛ erent Table 15.3

information. Most of the motor innervation of the tongue is supplied by the hypoglossal nerve (CN XII), since it innervates all the muscles of the tongue except the palatoglossus. Sensory innervation is through part of the lower maxillary nerve, the facial nerve (CN VII), the glossopharyngeal nerve (CN IX), and the vagus nerve (CN X). ° e ˝ oor of the mouth is innervated by the trigeminal system through a˛ erent ÿ bers. ° e innervation of the hyoid muscles is the charge of the cranial nerves V, IX, X, XII, and the nerve root that emerges from C2. ° e suboccipital muscles receive innervation from the suboccipital nerve (posterior ramus of C1) (Table 15.3). Approaching the tongue, hyoid, and occipital area as an interconnected system will facilitate the practitioner’s understanding of the speciÿ c clinical conditions related to swallowing and the dynamics of the temporomandibular joint.

Muscles of the posterior triangle of the neck

Muscle

Function

Innervation

Sternocleidomastoid – sternal head

Acting together as a pair: flexes the neck extends the atlanto-occipital joint (head extension) and superior cervical spine Individually: rotates the head to the opposite side or obliquely rotates the head Elevates the clavicle and manubrium of sternum

Spinal accessory nerve XI Branches (sensory supply) from posterior rami C2–C3

Sternocleidomastoid – clavicular head

As above

As above

Trapezius

Elevates the pectoral girdle and scapula Retracts the scapula Depresses the scapula Upwardly rotates the scapula Extends the neck

Motor accessory nerve (CN XI) Cervical nerves C3–C4 (proprioception)

Splenius capitis

Extends the head and neck Laterally flexes the neck

Posterior rami spinal nerves C3–C6

Levator scapulae

Elevates the scapula Tilts the glenoid cavity inferiorly by rotating the scapula downward

Anterior rami C3–C4 Dorsal scapulae nerve, branch of C5

Anterior scalene

Elevates the 1st rib

Brachial plexus C5–C7

Middle scalene

Elevates the 1st rib

Brachial plexus C3–C8

Posterior scalene

Elevates the 2nd rib

Brachial plexus C7–C8

Omohyoid

Depresses the hyoid and larynx bone

Ansa cervicalis C1–C3

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Craniofacial and neck dysfunctions related to the fascial system

Deep lamina of the deep fascia of the neck (prevertebral fascia) ° e deepest level of the deep fascia of the neck (prevertebral fascia) encloses the posterior, lateral, and anterior contents of the neck like a tube. It envelops all the cervical muscles (excluding the sternocleidomastoid, the upper trapezius, and the infrahyoid muscles). Its attachments are as follows:

•

Cranially it attaches to the base of the cranium and extends caudally to the level of the 3rd thoracic vertebrae along the longus colli muscle.

•

Caudally it merges with the endothoracic fascia of the rib cage and blends with the anterior longitudinal ligament.

•

Anterolaterally below the trapezius muscle, it attaches to the transverse processes of the cervical vertebrae and joins up with itself in front of the vertebral bodies.

•

Posteriorly it is attached along the ligamentum nuchae to the vertebral spinous processes.

In its lateral path the prevertebral fascia extends bilaterally to the axillary fascia and, at its anterior– inferior border, continues toward the vertebral anterior longitudinal ligament and the posterior border of the mediastinum. Laterally it covers the anterior, middle, and posterior scalene muscles (Fig. 15.43) (see Fig. 15.27D). Posteriorly, it covers the longissimus and semispinalis muscles, the rectus longus capitis, and the sympathetic nerves. Anteriorly it covers the longus colli and longissimus cervicis muscles. It separates the lower neck and the thorax by extending from the transverse process of C7 to attach to the medial surface of the 1st rib, covering the dome of the pleura (Stecco 2013, Pilat 2011, Bochenek & Reicher 1997, Gallaudet 1931). It forms the ˝ oor of the posterior triangles and allows the pharynx to glide during deglutition. ° e alar fascia (see Fig. 15.27E) lies anteriorly to the prevertebral fascia and forms the posterior wall of the retropharyngeal space. It extends from the skull base down to the level of the C6–T4 vertebrae. ° e alar fascia is also the anterior wall of the danger space, which extends downward to the level of the diaphragm in the posterior mediastinum.

Cranial

Caudal

A D E F B C

Figure 15.43 Right anterolateral aspect of the face and neck A Mental protuberance B Angle of mandible C Sternocleidomastoid D Sternocleidomastoid, sectioned and lifted E Omohyoid F Scalenes

The suboccipital region and myodural connections ° e anatomical complexity of the suboccipital area is well known. An increasing amount of high-quality research has focused on the macro- and microstructure of this region, leading to surprising results that require revision of current anatomical models and clinical processes. Researchers report the presence of a myofascial network that anatomically and functionally links the articular, muscular, nervous, and vascular structures. Worthy of special attention are fascial connections between the suboccipital muscles and the meninges, particularly with the dura mater. ° e anatomical and histological analysis of this area allows us to better understand common dysfunctions (such as tensional cervicogenic headache) and stimulates the development of new clinical strategies.

Basic anatomy of the suboccipital region ° e suboccipital muscles extend between the skull and the upper neck. ° ey are responsible for the most common movements performed during daily

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15 A B C

C7

D E F G Caudal Cranial

activities andˇrelated to our senses. We carry out slight craniocervical movements of rotation and ˝ exion– extension of the head to see better, hear better, or smell better or when we talk, swallow, breathe, yawn, laugh, or chew. To achieve these movements, the muscles described above need to coordinate with one another perfectly. A deÿ ciency in their performance creates the need for compensatory movements, involving large muscles such as the trapezius or the SCM, generating excess energy expenditure, tissue overload, and a decrease in the quality of movements. Early recognition of dysfunction of these muscles can prevent the development of pathology or reduce its severity. In addition, dysfunction of the suboccipital muscles, due to their attachment with the meninges (cervical dural sleeve), may trigger diˆ culty in the “unfolding” (stretching) of the neuroaxis during craniocervical movements. ° e suboccipital muscles are the deepest muscles of the neck. ° ey are protected by the superÿ cial fascia which contains a thick pad of subdermal fat (particularly in the elderly and in individuals with a repetitive and prolonged forward head posture habit) (Fig. 15.44). Following deeper dissection, the next structure is the superÿ cial level of the deep fascia of the neck (Fig. 15.45) that envelops the upper trapezius muscle, having already enveloped the SCM muscles in a similar way (see Fig. 15.26B). Of particular interest is the presence of the ligamentum nuchae (LN) that manifests as a triangular, two-layered, fibroelastic septum located centrally between the dorsal muscles of the cervical spine. It

Figure 15.44 Posterolateral aspect of the right side of the neck. The cadaver is in a prone position with the thorax slightly raised and the head hanging A Superficial fascia of the back with fatty lobes B Skin C Superficial fascia and fat at the back of the neck. Notice the thick and very compacted fatty structure inside the superficial fascia D Superficial layer of the deep fascia of the neck. Note the fibrous appearance. The upper trapezius muscle is visible in the transparent area E Occiput F Levator scapulae G Skin of the neck, dissected and lifted

A B C D E F G

H Figure 15.45 Posterior aspect of the back, neck, and trapezius A Occiput B Superficial fascia from the posterior aspect of the neck, dissected and lifted C Right trapezius D Superficial layer of the deep fascia of the neck E Supraspinous ligament F Superficial layer of the deep fascia of the neck, dissected and lifted G Epimysial fascia of the left trapezius H Skin, dissected and lifted

extends from the posterior tubercle of the atlas to the spinous process of C7 (with a ÿ rm attachment) and is continuous with the supraspinous ligament (Fielding et al. 1975). ° e LN interdigitates the aponeuroses of the trapezius muscle. ° e superÿ cial fascia of the neck

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Craniofacial and neck dysfunctions related to the fascial system

Figure 15.46 Upper and middle trapezius A Supraspinous ligament B Spinous process of C7 C Latissimus dorsi D Ligamentum nuchae. At the inferior end of the ligament the aponeurotic fibers of the trapezius interdigitate at the midline E Occiput

A

B C D E

and the deep lamina of the deep fascia of the neck (prevertebral fascia) are inserted into the LN creating a mechanical bond between the superÿ cial fascia and the deep muscles of the neck (Figs. 15.46 & 15.47). According to Johnson et al. (2000), the muscles that form the LN through their aponeuroses are the trapezius (along the entire length of the LN), rhomboid minor, serratus posterior superior, and splenius capitis; the latter is inserted into the caudal end of the ligament. ° ese anatomical features suggest that the LN in˝ uences movement in the lower cervical spine (Johnson et al. 2000). ° e well-deÿ ned attachments of the LN to the C6 and C7 vertebrae allow it to reduce excessive load on the upper and middle cervical segment. Takeshita et al. (2004) demonstrated the biomechanical properties of the LN in relation to cervical spine dynamics. Researchers applied cervical ˝ exion movements to 12 human cadavers while looking for changes in range of motion and sti˛ ness. Samples were tested under three conditions: with all cervical ligaments intact, a˙ er resection of the LN, and a˙ er additional resection of the supraspinous and interspinous ligaments and ligamentum ˝ avum. ° e ÿ ndings showed that the resection of the LN produced an increase in ˝ exion of 28 percent and a decrease in sti˛ ness of the spine of 27 percent, while the resection of the three ligaments resulted in an increase in ˝ exion of only 24 percent and

an increase in loss of sti˛ ness of only 8 percent. ° us, the results demonstrated that the LN participates in the maintenance of the cervical lordosis curve. ° ey concluded that damage to the LN could increase the

A

B

C

D

E

Figure 15.47 Posterolateral left side of the neck and dorsum A Greater occipital nerve B Nuchal ligament C Spinous process of C7 D Rhomboid E Trapezius, dissected and lifted

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15 risk of instability of the cervical spine and consequently overuse. ° is is another example of how the fascial system participates in the body’s dynamics and helps muscle behavior.

A B C

A˙ er li˙ ing the trapezius from the thorax (having previously dissected it from its insertions in the LN and supraspinous ligament), the inner layer of the fascial envelope of the trapezius is revealed. ° is layer contains loose connective tissue (which facilitates gliding on underlying structures), fat lobules, and neurovascular bundles (Fig. 15.48). ° e rhomboid muscle is found at the dorsal level below these structures (see Chapter 16).

D E F H

Figure 15.48 Dorsal aspect of the thorax. The trapezius has been dissected and lifted. Loose connective tissue between the trapezius and rhomboid muscles facilitates the gliding movement between them. This fascial layer contains blood vessels and peripheral nerves (for permissions information see page 556) A Left trapezius, dissected and lifted. Note the presence of the epimysial fascia fibers B Fat nodules inside the deep fascia (loose connective tissue) between the trapezius and rhomboid muscles C Arteries and veins between the trapezius and rhomboid muscles D Peripheral nerve E Loose connective tissue between the trapezius and rhomboid muscles F Rhomboid muscle covered by fascia G The spinous process line: the line of dissection of the trapezius H Right trapezius covered by deep fascia

A˙ er dissecting the splenius capitis and separating its attachment from the skull, the semispinalis capitis is more clearly visualized and the suboccipital muscles can be observed (Fig. 15.50). When the semispinalis capitis is dissected, the four suboccipital muscles can be observed (Fig. 15.51). B

C

D Cranial

F

G

H

Caudal

G

Once the trapezius has been dissected and separated from the body, the medial lamina of the deep fascia of the neck (the prevertebral fascia) that covers the deep cervical muscles – the splenius capitis and semispinalis capitis – are visualized (Fig. 15.49).

A

Cranial

E

Figure 15.49 Posterior left aspect of the neck. The trapezius muscle has been dissected from the midline and lifted A External occipital protuberance B Greater occipital nerve C Nuchal ligament D 7th cervical vertebra (C7) E Rhomboid minor F Trapezius insertion line G Superficial fascia of the neck, dissected and lifted H Line of dissection of the trapezius I Trapezius, dissected and lifted J Prevertebral fascia over the splenius capitis K Levator scapulae

Caudal

I

J

K

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15

Myodural connections and their clinical relevance

A

B

C

D

Figure 15.50 Deep muscles of the neck A Superior nuchal line B Semispinalis capitis

C Longissimus capitis D Splenius capitis, dissected and lifted

A B C

D

It has been many years since the ÿ rst (and little-known) publication by Lazorthes et al. (1953), the widely disseminated research by Hack et al. (1995) and the consequent inclusion in anatomy textbooks of the myodural bridge (MDB), meaning the link between the rectus capitis posterior minor muscle (RCPmi) and the dura mater (Fig. 15.52). In the years following these publications con˝ icting data have been reported in relation to the existence and importance of this structure. However, recent studies have described MDBs not only in relation to the RCPmi but also in relation to the other suboccipital muscles – the rectus capitis posterior major (RCPma), obliquus capitis inferior (OCI), and rectus capitis anterior (RCA) – and also the upper trapezius (UT), rhomboid minor (Rmi), serratus posterior superior (SPS), and splenius capitis (SC) by means of the ligamentum nuchae (LN) and the dura mater of the cervical spine (Palomeque-Del-Cerro et al. 2017, Yuan et al. 2016, Zumpano et al. 2006, Scali et al. 2011, Scali et al. 2013, Pontell et al. 2013b, Kahkeshani & Ward 2012, Pontell et al. 2013a, Mitchell et al. 1998, Johnson et al. 2000, Dean & Mitchell 2002). Since myodural connections may play an important role in physiological functions, clinical symptoms, and cervical neuromuscular control, it is recommended that analysis of the behavior of myodural connections is included in the assessment and treatment of upper body dysfunctions.

E

Anatomical and physiological findings

F

•

In their systematic review Palomeque-Del-Cerro et al. (2017) presented strong evidence “of the existence of physiological so˙ tissue connections” between the dura mater and the RCPmi, RCPma, and OCI muscles.

•

Richmond et al. (1999) observed the nonuniformity of ÿ ber-type composition in the primate OCI suggesting that it “has implications for the way that the muscle is studied anatomically and physiologically.”

•

Zheng et al. (2014) identiÿ ed the presence of a dense ÿ brous fascial band in the nuchal ligament. ° is fascial structure arises from the posterior border of the nuchal ligament and continues anteriorly and superiorly toward the atlantoaxial interspace. ° e authors

G H

Figure 15.51 Deep muscles of the left side of the neck. Dotted lines indicate the four suboccipital muscles A Superior nuchal line B Rectus capitis posterior minor C Obliquus capitis superior D Rectus capitis posterior major E Longissimus capitis F Obliquus capitis inferior G Semispinalis capitis H Splenius capitis, dissected and lifted

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15 Figure 15.52 Sagittal section of the head and upper neck showing the myodural bridge A Falx cerebri B Pons C Cerebellum D Occipital bone E Myodural bridge F Posterior tubercle of the arch of atlas G Dura mater H Spinal cord I Tongue Photograph by Dr. Nicolás Barbosa. Reprinted with permission

A

B C D E F G H

I

designated this as “to be named ligament (TBNL).” A second connection was found, the “vertebrodural ligament” (VDL), which manifests as “a ÿ brous connection between the posterior aspect of the dura mater and the posterior wall of the spinal canal from the atlas to the axis.” “° ese two structures, TBNL and VDL, ÿ rmly link the posterior aspect of cervical dura mater to the rear of the atlas-axis and the nuchal region”, and the authors speculated that “the movements of the head and neck are likely to a˛ ect the shape of the cervical dural sleeve via the TBNL and VDL. It is hypothesized that the muscles directly associated with the cervical dural sleeve, in the suboccipital region, may work as a pump providing an important force required to move the CSF in the spinal canal.”

•

MDBs might act as a pump to provide power for cerebrospinal ˝ uid (CSF) circulation (Xu et al. 2016).

•

“° e MDB is mainly formed by parallel running type I collagen ÿ bers; thus, the suboccipital muscle could

pull SDM [spinal dura mater] strongly through the e˛ ective force propagated by the MDB during head movement” (Zheng et al. 2018).

•

Scali et al. (2013) suggest that the suboccipital muscles create a mechanical advantage by protecting the spinal cord from dural enfolding.

•

MDBs could be involved in a feed-forward mechanism which monitors dural tension during head and neck movements (Scali et al. 2013).

•

Muscle spindle ÿ bers found in the RCPma and OCI are a source of primary a˛ erents, representing major contributors to cervical spine neuromuscular control (Kulkarni et al. 2001).

•

Xu et al. (2016) observed that “a˙ er the head rotations, the maximum and average CSF ˝ ow rates during ventricular diastole were signiÿ cantly increased, and the CSF stroke volumes during diastole and during entire cardiac cycle were signiÿ cantly increased.” ° e authors suggest a close relationship

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between head movements and CSF ˝ ow. ° ey believe that MDBs can manage the force generated by the suboccipital muscles and might be involved in this mechanism.

•

° e RCPma and RCPmi serve to monitor dural tension (Scali et al. 2011).

•

° e posterior muscles of the neck integrate the ÿ ne movements of the atlanto-occipital joint in coordination with the upper cervical spine (Pontell et al. 2013a).

•

° e re˝ exive myotatic response of suboccipital muscles has been proposed by several authors as a likely mechanism to place the dura under tension (Alix & Bates 1999).

Clinical implications

•

Alix & Bates (1999) state that MDBs may provide anatomical and physiological answers to the cause of the cervicogenic headache.

•

Over time excessive dural tension can produce hypertrophy of the suboccipital muscles and a consequent excessive tension in the dura mater through the MDBs, manifesting clinically as cervicogenic cephalgia (Hack et al. 1995, Alix & Bates,1999, Hack & Hallgren 2004, Scali et al. 2011).

•

According to Bogduk (2001), the presence of the convergence between the upper three cervical nerves and the trigeminal nucleus can be related to the pain arising from the cervical dura due to excess of tension and may be referred through the distribution of the trigeminal nerve. Tension in the dura can be produced by hypertrophy of the MDBs.

•

A loss of proprioceptive inhibition of nociceptors at the dorsal horn of the spinal cord can result in chronic pain (Enix et al. 2014).

•

° e function of the MDBs may be to monitor stresses on the cervical dura mater, re˝ exively preventing dural infolding (Enix et al. 2014).

Slumping, forward head posture, and cervicogenic pain Craniocervical dysfunctions are frequently encountered by practitioners due to the increasing use of high technology, particularly smartphones and other electronic

15

devices with a touch screen. A high level of addiction to smartphones can cause forward head posture and increase scapular dyskinesia, facilitating cervical and scapular girdle pain (Akodu et al. 2018). ° e behavior of craniocervical structures can be a˛ ected by poor physical activity and maladaptive sedentary postures. Cervicalgia and cervicogenic headache are among the common secondary conditions associated with craniocervical dysfunctions. As mentioned above, it is obvious that patients will require a biopsychosocial approach to recognize their problems (Huang et al. 2011, Carney et al. 2010, Gindrat et al. 2015, Fernández-de-las-Peñas et al. 2009, La Touche et al. 2017, Milam et al. 1998, Gerstner et al. 2011, Ichesco et al. 2012, Lin 2014, Martin 2016, Firth et al. 2019).

Basic biomechanical analysis A typical maladaptive posture is sitting in front of a screen (TV, PC, tablet or smartphone) with a ˝ attened lumbar lordosis, exaggerated dorsal kyphosis, and a double deformation of the neck, i.e., hyperextension in the upper segment and reduced extension in the lower segment (Pilat 2003, Caneiro et al. 2010). Biomechanical analysis of the consequences of this maladaptive posture focuses on the local and peripheral symptoms according to peripheral cervical nerve distribution and its relationship with certain components of the musculoskeletal system (joints, ligaments, muscles, viscera, and vertebral arteries) and the changes associated with trauma or aging. However, there is no consensus on, for example, whether cervical spondylosis can cause cervicogenic headache or if the headache is or is not associated with neck pain. When a patient presents with a headache, remember the red flags (severe trauma, intracranial neoplasms, intracerebral haemorrhage, epileptic seizures, craniotomy, infections). Patients who may have these conditions should be referred to a specialist for assessment.

On analysis of X-rays of the neck taken in lateral projection in the ÿ ve basic positions (neutral, ˝ exion, extension, protrusion, retraction) (Table 15.4) it can be observed that it is the protrusion position which mostly alters the physiological parameters seen in the

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15 neutral position by leading the upper cervical segment to hyperextension and the lower segment to ˝ exion with a consequent progressive reduction and ÿ nally disappearance of the cervical lordosis. It is logical to think that this posture, if maintained and repeated for prolonged periods of time, could facilitate instability in the intervertebral discs between the lower cervical vertebrae, leading to the formation of osteophytes.

Simultaneously, hyperextension in the upper cervical segment could a˛ ect the behavior of the craniocervical segment (C0–C3). In this situation, pain in the cranial and facial area could be due to overstimulation of the trigeminocervical complex (Bogduk 2001). ° e process of changes linked to slump and forward head posture is progressive, cumulative, and individualized. ° e sequence of dysfunction is summarized in (Table 15.5).

Table 15.4 Radiological findings in the sagittal plane for the five basic postures of the head–neck complex Posture

X-rays

Comments In neutral and well-balanced posture of the cervical spine the occiput, the anterior arch and posterior arch of the atlas, the vertebral bodies, and the spinous processes from C2 to C7 are well defined. The intervertebral discs are visible between each pair of vertebrae, with the exception of the spaces between the occiput and the atlas and the atlas and the axis. The zygapophyseal joints are also visible.

Neutral

Flexion

Functionality in neutral posture • C3 slides anteriorly and is not visible when performing extension and protraction. • The spinous process of C7 is not visible in hyperextension, compared to the T1 process which is visible. This allows for them to be easily differentiated Functionality in flexion • Anterior sliding of the occipital bone and posterior displacement of the occipital condyles on the superior articular facets of the atlas occur. • The distance between the occiput, the posterior arch of the atlas, and the lamina of the axis is slightly increased. • The posterior ligaments become tense and the anterior ligaments relax. • Distraction of the zygapophyseal joints can be observed in the lower segment. • Relaxation and slight bulging of the anterior aspect of the intervertebral disc and the consequent stretching and tension of the posterior aspect of the annulus fibrosus are present. • The nucleus pulposus moves backward. • The loss of cervical lordosis leads to lengthening of the spinal canal, increasing tension in the spinal cord and its meninges and in the nerve roots, but at the same time the transverse section of the intervertebral foramen is increased. There is also a slight anterior and stepped displacement of the superior vertebra over the inferior vertebra

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15

Table 15.4 continued Posture

Extension

Protrusion (forward head posture)

X-rays

Comments Functionality in extension • The occiput moves back while the occipital condyles move anteriorly on the upper articular surfaces of the atlas. • The occiput, posterior arc of the atlas, and lamina of the axis move closer together. • The anterior ligaments are stretched and the posterior ligaments relaxed. The vertebral canal is shortened and its structures are relaxed. • In the lower segment, there is compression of the posterior aspect and stretching of the anterior aspect of the annulus fibrosus. • Anterior displacement of the nucleus pulposus is present Functionality in protrusion (forward head posture) • Two opposite movements occur in the two cervical spine segments – extension in the upper segment and flexion in the lower segment. • The range of cervical extension that begins in the protruding position of the head exceeds the range that begins in the neutral position by 10 percent. • Tension on the posterior ligaments increases. • The range and coordination of the rotation or lateral flexion movements of the head are altered if they start from the forward head posture. In parallel, the tension on the posterior ligaments can increase by up to 300 percent

Functionality in retraction • The movements are opposite to those of protrusion, being upper cervical flexion and lower cervical extension. • The separation between the occiput, the atlas, and the axis is greater than in the simultaneous joint flexion between the upper and lower segments of the cervical spine

Retraction Modified from Pilat A. (2003) Terapias miofasciales: Inducción miofascial. Madrid: McGraw Hill Interamericana de España

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15 Table 15.5 Chronology of development of forward head posture Clinical findings

Interpretation As a result of this posture, an anterior inclination of the articular facets (flexion pattern) develops in the middle cervical spine. The lower cervical spine tends to flex

Progressive decrease in lordotic curvature of the middle cervical spine

In optimal conditions the ocular, olfactory, and occlusal planes should be in parallel. Excessive flexion of the lower cervical spine alters this behavior, and compensation develops. The subject adopts an exaggerated extension of the upper cervical spine in order to maintain horizontal gaze to recover functionality. Since 30 percent of flexion–extension movements and 50 percent of rotation movements are performed in the upper cervical spine, the functional stability of this area begins to be affected

Tendency to posterior inclination and extension of the upper cervical spine (particularly at C0–C1 and C1–C2 levels) Forward head posture causes progressive hypomobility and consequent shortening of the suboccipital muscles (rectus capitis posterior minor, rectus capitis posterior major, obliquus capitis superior, and obliquus capitis inferior) which control the movements of the occiput and the first two cervical vertebrae. These muscles coordinate the interactions of the eye–head movements and are considered to be among the most important muscles of postural control (André-Deshays et al. 1988)

Shortening of the suboccipital muscles

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Table 15.5 Chronology of development of forward head posture continued Clinical findings

Interpretation The myodural bridges (fascial connections between the dura mater and the rectus capitis posterior minor, the rectus capitis posterior major, the obliquus capitis inferior, and the ligamentum nuchae) transmit reciprocal tension between the neurofascial system and the myofascial system of the cervical region. Through the latter tension is transmitted to the rest of the fascial system (Enix et al. 2014, Zheng et al. 2014)

Alterations in dura mater tension in the suboccipital region The shortening of the suboccipital muscles can affect the zygapophyseal joints and also the occipital nerves (greater occipital nerve and lesser occipital nerve) generating neuralgia (Blake & Burstein 2019). The intra-articular space in the zygapophyseal joints is narrow and long-term overload can lead to hypertrophic arthrosis. The greater occipital nerve originates on the medial branch of the dorsal ramus of C2. Its complex path continues between the atlas and axis and then runs between the inferior oblique and the semispinalis capitis muscles (Son et al. 2013). It perforates the trapezius muscle and aponeurosis posteriorly, ascending subcutaneously to the skin that covers the vertex of the skull as well as the musculature of the neck. The lesser occipital nerve, after branching from the ventral ramus of C2, surrounds the posterior border of the sternocleidomastoid and is distributed through the skin of the occiput, communicating laterally with the greater occipital nerve (Feneis & Dauber 2000). Occipital neuralgia related to the occipital nerves

Additionally, the spinal path of the 5th cranial nerve extends down to the medulla and to the level of C2 or C3. The effects of prolonged tension on the myofascial system can stimulate the trigeminal nerve and trigger the symptoms associated with its pathology (Rocabado 1983)

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15 Table 15.5 Chronology of development of forward head posture continued Clinical findings

Interpretation This alteration leads to mouth breathing and progressive loss of the usual resting position of the tongue. It encourages forward head posture and increases the activity of the breathing accessory muscles; this process is reciprocal (Harvold et al. 1981, Proffit 1978). In a subject with mouth breathing as the main pattern of respiration, the upper and middle cervical vertebrae are progressively pushed forward and downward through the activity of the muscles that are firmly attached to the thorax. This process leads to movement of the position of the occiput, placing it in front of the line of gravity (which is its regular position). Ultimately, this action leads to excessive rigidity of the suboccipital muscles (Darnell 1983, Rocabado 1981, Kapandji 1977, Chaves et al. 2010, Cuccia et al. 2008, Neiva et al. 2008)

Alteration in the usual resting position of the mandible

In normal biomechanical activity, the superior trapezius and the SCM are in charge of the movements of the head. In forward head posture, the trapezius mostly supports the weight of the head leading to functional overload in the SCM (Kim et al. 2008)

Alterations in synergism between the sternocleidomastoid (SCM) and the superior trapezius

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Table 15.5 Chronology continued of development of forward head posture continued Clinical findings

Interpretation Forward head posture modifies the behavior of the neck flexors, particularly the infrahyoid muscles, causing them to progressively elongate and become weaker. As a result, the hyoid bone becomes more elevated and the suprahyoid muscles are progressively shortened. This process leads to strengthening and shortening of the suboccipital muscles (Rocabado 1981)

Excessive stretching of the prevertebral muscles

I a forward head posture condition the performance of the cervical spine, In the behavior of the masticatory muscles, range of mouth opening, and the resting position of the tongue all change. The craniovertebral extension increases the interocclusal distance (Urbanowicz 1991) and consequently leads the jaw to the backward position. Maintaining forward head posture excessively increases tension in the suprahyoid and infrahyoid muscles.

Chewing dysfunction

When the omohyoid muscle is under excessive and prolonged tension this affects the relationship between the scapula and the hyoid bone into which it is inserted. The condyles of the mandible are moved back and the upper head of the lateral pterygoid is elongated excessively, which consequently, through a reflex reaction, pushes the TMJ disc forward. This process affects the mechanics of the TMJ and the functioning of the tongue by modifying swallowing patterns (Visscher et al. 2000, Ohmure et al. 2008, La Touche et al. 2011)

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15 Table 15.5 Chronology of development of forward head posture continued Clinical findings

Interpretation Progressive forward head posture increases the muscle imbalance of the paravertebral and prevertebral muscles (Falla et al. 2003) and consequently affects the movement of the scapula and arm. The upper thorax flattens and this posture is compensated by excessive elevation of the shoulder girdle (Ruivo et al. 2014)

Muscle imbalance caused by progressive weakening of the prevertebral muscles and progressive shortening of the paravertebral muscles

Protrusion of the shoulders with internal rotation of the arms

Forward head posture leads to entrapment of the dorsal scapular nerve. This nerve arises directly from C5, passes through the lateral part of the intervertebral foramen, and perforates the middle scalene; then it continues to the lower part of the levator scapulae and the rhomboids. Dorsal scapular nerve entrapment may lead to the development of progressive weakness of the levator scapulae and the rhomboids. Scapular nerve dorsal neuropathy is related to cervicogenic dorsalgia, notalgia paresthetica (with symptoms of localized pruritus of the unilateral infrascapula), scapular dyskinesia, and a posterolateral arm pain pattern (Muir 2017). This process causes the shoulder joint complex to protrude. As a result, internal rotation of the arms and an adaptive forward head posture develop to facilitate the completion of tasks performed in front of the trunk

Repetitive strain injury affecting the pectoral muscles (Hosseini et al. 2007) increases the tension on the suprascapular nerve which arises from the C5–C6 roots, passes over the brachial plexus toward the great scapular notch, and continues to the supraspinatus and infraspinatus muscles. This nerve entrapment and consequent neuropathy can also affect the glenohumeral and acromioclavicular joints, leading to the subsequent functional limitation of both structures

Shortening of the pectoral muscles

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Table 15.5 Chronology of development of forward head posture continued Clinical findings

Interpretation Due to muscle imbalance, the subject’s posture adapts and an exaggerated kyphotic position is gradually assumed when carrying out the majority of daily activities. This adaptation leads to flattening of lumbar lordosis with its negative consequences on the mechanics of the intervertebral discs (McKenzie 1981). The “collapsed” sitting posture, which automatically leads to forward head posture, triggers a decrease in prevertebral muscle activity (Falla et al. 2007)

Alteration (increase) of thoracic kyphosis and flattening of lumbar lordosis

This phenomenon occurs due to deficient diaphragmatic activity (Kolář et al. 2012) and limited movement of the ribs because of the exaggerated kyphotic position. During inspiration (in the normal breathing pattern) the ribs should rise to the plane of the intervertebral disc. This plane is excessively inclined because the exaggerated kyphotic position automatically limits the movement of the ribs which are unable to rise sufficiently

Increase in activity of the breathing accessory muscles

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15 Table 15.5 Chronology of development of forward head posture continued Clinical findings

Interpretation Forward head posture causes the scalenes to be in a state of constant tension. As mentioned above, the dorsal scapular nerve, that comes directly from C5, perforates the middle scalene. Due to increased tension in the lateral muscles of the neck the 1st and 2nd ribs rise excessively

Exaggerated elevation of the 1st rib due to hyperactivity of the scalenes

Due to the elevated position of the 1st and 2nd ribs the neurovascular bundle (subclavian artery, vein, and brachial plexus) are compressed. As a result, hyperesthesia or hypoesthesia can develop at the lateral aspect of the neck with the symptomatology referred to the shoulder and arm area (thoracic outlet syndrome) (Urschel & Kourlis 2007)

Tendency to develop pathology of the thoracic outlet

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Table 15.5 Chronology of development of forward head posture continued Clinical findings

Interpretation Limitation of the anteroposterior movement of the 1st rib caused by myofascial imbalance may distort breathing patterns

Limitation of the anteroposterior movement of the 1st rib Persistent forward head posture behavior and the consequent excessive load on the middle cervical spine lead to premature development of a degenerative process that affects the C5–C6 and C6–C7 levels

Tendency to degenerative joint changes from C5–C7

As the initiation of trigger points is one of the phases in the development of myofascial dysfunction syndrome their presence at this stage of the adaptation is usual

Development of trigger points in the involved muscles

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15 Table 15.5 Chronology of development of forward head posture continued Clinical findings

Interpretation Changes that are initially functional become structural changes over time. Progressive shortening of the joint capsules limits the movement of the articular structures of the cervical spine and shoulder girdle. This can lead to ankylosis. In a lot of cases the changes are irreversible

Reduction of proprioceptive sensitivity and shortening of the joint capsules

Obstruction of the passage of air through the nasal cavities forces the tongue to lower its position inside the mouth in order to increase the space between the tongue and the hard palate. The tongue moves forward which stimulates opening of the mouth and depression of the jaw. As a result, the extended craniocervical position adapts and the head position becomes more protruded (Vig et al. 1980, Milidonis et al. 1993, Ohmure et al. 2008)

Obstruction of the upper respiratory airways

Changes in the position of the head are related to changes in craniofacial morphology (Wenzel et al. 1985, Rocabado & Iglarsh 1991, Solow & Tallgren 1976, von Piekartz & Bryden 2001). Forward head posture is related to the extended position of the craniocervical segment and consequent changes in the vertical diameters of the face (greater in the anterior part and reduced in the posterior part). It is associated with reduced anteroposterior craniofacial dimensions, inclination of the cribriform plate, and reduced nasopharyngeal space

Changes in craniofacial morphology Modified from Pilat A. (2003) Terapias miofasciales: Inducción miofascial. Madrid: McGraw Hill Interamericana de España

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Biomechanical reasoning is clinically very useful. Fernández-de-las-Peñas et al. (2006) state that all adaptive postures seem to be the dominant trigger in tension-type and cervicogenic headaches. However, Mingels et al. (2019) formulated the following question: “Is there support for the paradigm ‘Spinal posture as a trigger for episodic headache?’”

Mechanoreception and proprioception of the suboccipital fascial system As mentioned in Chapter 8, recent research reveals that fascia is richly innervated by type III and IV mechanoreceptors (Mense & Hoheisel 2016, Mense & Gerwin 2010, Stecco et al. 2007, Corey et al. 2011, Tesarz et al. 2011). ° ey are free nerve endings that can act as nociceptors. It is considered that a part of these mechanoceptors can act as proprioceptors (Stecco et al. 2007, Mense & Hoheisel 2016). ° ese receptors are present in the MDBs and are considered to fulÿ ll the function of monitoring the tension changes in the dura mater. ° is ÿ nding conÿ rms the dynamic properties of MDBs. Failure of this system could result in altered cerebral spinal ˝ uid ˝ ow, changes in sensorimotor function, cervicocephalic headaches, and dura-related pathologies.

Myodural bridges and the behavior of cerebrospinal fluid Craniocervical injuries can generate, in the medium and long term, alterations that involve the behavior of MDBs. Over time they can become dura-related pathologies that a˛ ect the ˝ ow of the cerebrospinal ˝ uid (CSF). Zheng et al. (2014) suggested a signiÿ cant relationship between MDBs and CSF behavior. Studies conducted with MRI showed that muscles related to the MDBs are morphologically and functionally a˛ ected in patients with a history of whiplash-associated disorder (Xu et al. 2016). In patients with chronic WAD, fat inÿ ltration in the suboccipital (RCPmi, RCPma) and cervical multiÿ dus muscles was evidenced, unlike in patients who presented with cervical dysfunctions without a history of trauma. Damadian & Chu (2011) analyzed the dynamics of CSF ˝ ow in individuals with multiple sclerosis (MS), who presented with a history of serious prior cervical trauma which resulted in signiÿ cant cervical pathology. ° e authors, using UPRIGHT® Multi-Position™

15

MRI, veriÿ ed an alteration in velocity, pressure, and signiÿ cant obstructions to CSF ˝ ow. ° is alteration seems to cause an increase in the volume of the lateral ventricles to the extent that the intracranial pressure (ICP) rises due to CSF accumulation. ° e authors hypothesize that this process could facilitate a ÿ ltering of the CSF into the parenchyma resulting in the formation of sclerotic “gaps” (damaged areas of the brain parenchyma) that “can be the source of the MS lesions in the brain that give rise to MS symptomatology” (Damadian & Chu 2011). ° ese data seem to coincide with the CSF ˝ ow alterations described in research on reactive gliosis carried out in the cellular and experimental ÿ elds. Reactive gliosis is a cellular process guided by astrocytes. ° ese large CNS cells, which greatly outnumber neuron populations, act in response to ischemic and traumatic injuries to the nervous system. ° e reactive cellular behavior of the astrocytes implies their hypertrophy (increase in intermediate ÿ laments of their cytoskeleton), an increase in proliferation (number of cells), and an altered management of ˝ uid behavior between the intra- and extracellular spaces (Pekny & Nilsson 2005) (see Chapter 8). Astrocytes have been strongly implicated in the phenomena of di˛ usion, ˝ ow, and drainage of CSF. In the absence of lymphatic tissue in the cerebral parenchyma, (not in its envelope, but in the cranial meninges) the brain disposes of waste products through a mechanism called the glymphatic system. ° is system is composed of a network of astrocytes which, through sophisticated molecular mechanisms and the presence of aquaporins in their “sucking feet,” trigger a liquid di˛ usion gradient that mobilizes the CSF from the perivascular arterial spaces toward the perivascular venous spaces, giving rise to the control of CSF and interstitial ˝ uid at the cellular level (see Chapter 5). ° is mechanism can be a˛ ected in reactive gliosis which reduces the e˛ ectiveness of glymphatic ˝ ow, through cessation of the ˝ ow of convection, leading to the stagnation of ˝ uids (CSF and interstitial ˝ uid), deregulation in the reuptake of neurotransmitters (e.g., glutamate), and inadequate disposal of waste products (Plog & Nedergaard 2018). ° is cellular mechanism, as described brie˝ y here, underlies the abnormalities of CSF circulation which are detectable (observable) through MRI in patients

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15 with MS. ° is development invites us to review the traditional clinical concepts that are linked to the interpretation of the dynamics of the CSF, such as the “Pressurized Model” which is applied in di˛ erent therapeutic approaches. Research at the cellular and subcellular level opens up new perspectives of reasoning about the physiology and pathophysiology of CSF ˝ ow. A detailed study of cell mechanobiology, speciÿ cally regarding the behavior of astrocytes in the face of mechanical trauma and their altered role in the control of CSF di˛ usion, is essential in order to fully and accurately understand the dynamics of the liquids in the CNS and their relationship with the MDBs.

2 A 4

3 C D

B

1

Cervical fascial spaces Fascial compartments that lie between several layers of fascia (usually made up of loose connective tissue) are present in the head and neck. ° ese are called spaces (Fig. 15.53). In 1950 Shapiro et al. published a review of “the fasciae and fascial spaces of the head and neck.” ° e authors analyzed four fascial spaces and concluded that the basic anatomy of the spaces is related to infections of dental origin. In subsequent years, other authors (Singh et al. 2000, Guidera et al. 2012, Feigl 2015, Guidera et al. 2012) conÿ rmed these observations. ° ese spaces are described as follows:

•

° e pretracheal (visceral) space is enclosed by the visceral division of the middle layer of the deep cervical fascia and lies immediately anterior to the trachea. It extends from the thyroid cartilage to the superior mediastinum.

•

° e retropharyngeal space extends superiorly to the base of the skull and inferiorly to the posterior mediastinum to the level of the tracheal bifurcation.ˇ

•

° e danger space lies between the alar fascia, which forms the posterior border of the retropharyngeal space, and the prevertebral fascia.

•

° e carotid sheath (prevertebral space) extends from the base of the skull to the aortic arch. It transverses the suprahyoid and infrahyoid areas of the neck and extends into the anterior mediastinum.

° ese layers of fascia can limit the spread of infections which can cause dysphagia and odynophagia, pain, fever, and possibly hoarseness and obstruction of the airway.

Figure 15.53 Fascial compartments (spaces) of the neck A Middle lamina of the deep fascia of the neck (muscular) B Deep lamina of the deep fascia of the neck (prevertebral fascia) C Superficial lamina of the deep fascia of the neck (investing layer) D Middle lamina of the deep fascia of the neck (visceral lamina of pretracheal fascia) 1 Pretracheal (visceral) space 2 Retropharyngeal space 3 Carotid sheath (prevertebral space) 4 Danger space (containing the vena cava, arch of the aorta, thoracic duct, trachea, and esophagus)

Triangles of the neck ° e “triangles” refer to the topographic areas of the neck. ° ey enable us to locate anatomical structures (such as arteries, veins, lymphatics, nerves, viscera) in a speciÿ c area of the neck. ° eir topography and path vary from person to person due to the individuality of the architecture between the neurovascular structures. However, the location of a structure in a given triangle provides invaluable assistance in surface anatomical and clinical assessment.

Major triangles of the neck and their divisions ° e anterolateral area of the neck resembles a quadrilateral shape and is delimited superiorly by the lower border of the body of the mandible and a line that continues from the angle of the mandible to the mastoid

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Figure 15.54 The anterior and posterior triangles of the neck

Submandibular triangle Carotid triangle Submental triangle Occipital triangle Muscular triangle Supraclavicular triangle

process; inferiorly by the upper border of the clavicle; anteriorly by the middle line of the neck; and posteriorly by the anterior aspect of the trapezius muscle. ° e sternocleidomastoid muscle divides this area into two major neck triangles (Fig. 15.54) known as the anterior and posterior triangles, each of which contains its own divisions.

• • •

•

superiorly: the lower border of the body of the mandible and a line extending from the angle of the mandible to the mastoid process;

•

posteriorly: the anterior sternocleidomastoid;

• •

anteriorly: sagittal line down the midline of the neck;

border

of

the

inferiorly: jugular notch in the manubrium of the sternum.

Divisions: ° e anterior triangle can be divided into four triangles. Above the hyoid bone are found the following:

•

submandibular (digastric) triangle

carotid triangle muscular triangle.

Contents:

•

Muscles: the stylohyoid, digastric, mylohyoid, geniohyoid, sternohyoid, omohyoid, thyrohyoid, and sternothyroid muscles (for details see Table 15.2).

•

Vessels:

Anterior triangle (Moore et al. 2010, Drake et al. 2015) ° e anterior triangle expands over the area anterior to the sternocleidomastoid muscle. Boundaries: ° e anterior triangle is located at the front of the neck and has the following boundaries:

submental triangle

▶ artery: external carotid artery branches (superior thyroid, lingual, facial, and occipital); ▶ veins: internal and anterior jugular vein and tributaries; ▶ lymphatics: superÿ cial and deep lymph nodes.

•

Nerves: the internal and external laryngeal nerves (located within the carotid sheath posteriorly to the vessels), hypoglossal nerve, and transverse cervical nerve (receives sensation from the skin of the anterior triangle).

•

Viscera: the thyroid and larynx, and submental and submandibular glands.

Observations:

•

° e anterior triangle contains the jugular chain of lymph nodes.

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15 • •

° e skin over the anterior triangle is freely movable.

•

In the submental triangle submental lymph nodes are present. ° ese drain the ˝ oor of the mouth.

•

° e thyroid gland is hidden under the sternohyoid and sternothyroid muscles.

Investing fascia covers the roof of the triangle, while visceral fascia covers its ˝ oor.

Posterior triangle (Rea 2016, Ihnatsenka & Boezaart 2010, Moore et al. 2010, Drake et al. 2015) ° e posterior triangle is a clinically signiÿ cant anatomical region that contains many important vascular and neural structures. Boundaries: ° e posterior triangle is located at the lateral aspect of the neck with the following boundaries:

•

apex: the superior nuchal line of the occipital bone (the meeting point between the sternocleidomastoid and trapezius muscles);

•

anteriorly: the posterior border of the sternocleidomastoid muscle;

•

posteriorly: the anterior border of the trapezius muscle;

•

inferiorly: the middle third of the clavicle.

Divisions: ° e inferior belly of the omohyoid muscle divides the posterior triangle into two triangles:

• •

•

occipital triangle (upper, larger) supraclavicular (omoclavicular) triangle (smaller).

Contents:

•

Muscles: the sternocleidomastoid, trapezius, splenius capitis, levator scapulae, scalenes, and omohyoid muscles (for details see Table 15.3).

•

Vessels: ▶ veins (external jugular vein, subclavian vein, transverse cervical, and suprascapular veins); ▶ arteries (subclavian, suprascapular, and axillary); ▶ lymphatics

° supraclavicular lymph nodes ° thoracic ducts ° right lymphatic duct.

Nerves: the most relevant is the spinal accessory nerve (CN XI) (high susceptibility to injury) and these branches of the brachial plexus: ▶ phrenic nerve C3–C5 ▶ dorsal scapular nerve C5 ▶ long thoracic nerve C5–C7 ▶ suprascapular nerve C5–C6.

Observations:

•

° e posterior triangle of the neck is covered by a superÿ cial layer of the deep cervical (investing) fascia and its ˝ oor is formed by the superÿ cial layer of the deep cervical (prevertebral) fascia.

•

° e accessory nerve is located beneath the superÿ cial layer of the deep cervical fascia; it is the danger space in the posterior triangle.

•

° e supraspinatus nerve is vulnerable to blunt or penetrating trauma in the posterior triangle of the neck and will cause loss of both the supraspinatus and the infraspinatus functions; both abduction and external rotation of the arm will be weaker (Neal & Fields 2010).

•

Myofascial dysfunction of the scalene muscles is relevant (Neal & Fields 2010). ° ese are multiarticular muscles positioned deeply and laterally in the neck. ° eir architecture constitutes a very narrow scalene triangle which contains structures that are essential to the functions of the upper extremity. ° e sides of the scalene triangle are the anterior and middle scalene muscles and the 1st rib is at the base of the triangle. ° is area is protected by a layer of loose connective tissue (superÿ cial fascia) and fat called the scalene fat pad. ° e omohyoid muscle crosses this area. ° e neurovascular bundle passes through the triangle. ° e ÿ ve spinal nerve roots (C5, C6, C7, C8, and T1) are grouped and interconnected to form the brachial plexus that crosses the triangle. ° e phrenic nerve accompanies them and in the vicinity is the path of the long thoracic nerve. ° e subclavian artery accompanies the nerve structures. Several branches arise from the subclavian artery just before it passes through the scalene triangle, including the vertebral artery (to the back of the brain) and the thoracic artery (to the inside of the anterior chest).

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° e axillary vein passes under the clavicle and becomes the subclavian vein which crosses up and over the 1st rib in front of the scalene triangle.

•

° e scalene muscles are involved in the movements of ˝ exion and rotation of the neck, elevation of the 1st and 2nd rib, and breathing. Dysfunction of the scalenes could generate pathological patterns, for example: ▶ scalene myofascial pain syndrome, which is a regional syndrome where pain originates over the neck area and radiates down to the shoulder, arm, and wrist (Abd Jalil et al. 2010);

15

▶ thoracic outlet syndrome, which is discomfort and vascular symptoms accompanied by loss of sensation in the shoulder and arm caused by a scalene muscle compressing the subclavian artery and part of the brachial plexus; ▶ a decrease in ventilatory capacity. ° is complex fascial system continues to the thorax and upper extremities and is further examined in Chapters 16 and 17.

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REFERENCES

Abd Jalil N, Awang MS, Omar M (2010) Scalene myofascial pain syndrome mimicking cervical disc prolapse: A report of two cases. Malays J Med Sci 17(1):60–66. Akodu A, Akinbo S, Young Q (2018) Correlation among smartphone addiction, craniovertebral angle, scapular dyskinesis, and selected anthropometric variables in physiotherapy undergraduates. J Taibah Univ Med Sci 13(6):528–534. Al Khalili Y, Ly N, Murphy PB (2021) Cervicogenic Headache. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; PMID: 29939639. Available: https://pubmed.ncbi.nlm. nih.gov/29939639/ [accessed September 9, 2021]. Alix ME, Bates DK (1999) A proposed etiology of cervicogenic headache: ° e neurophysiologic basis and anatomic relationship between the dura mater and the rectus posterior capitis minor muscle. J Manip Physiol ° er 22(8):534–539. Anderson GC, John MT, Ohrbach R, Nixdorf DR, Schi˛ man EL, Truelove ES, List T (2011) In˝ uence of headache frequency on clinical signs and symptoms of TMD in subjects with temple headache and TMD pain. Pain 152(4):765–771.

manual therapy and therapeutic exercise for temporomandibular disorders: Systematic review and meta-analysis. Phys ° er 96(1):9–25.

Blake P, Burstein R (2019) Emerging evidence of occipital nerve compression in unremitting head and neck pain. J Headache Pain 20(1):76.

Ault P, Plaza A, Paratz J (2018) Scar massage for hypertrophic burns scarring—A systematic review. Burns 44(1):24–38.

Bochenek A, Reicher M (1997) Anatomia czlowieka. Warszawa: PZWL.

Auvenshine RC, Pettit NJ (2020) ° e hyoid bone: An overview. Cranio 38(1):6–14. Bajwa ZH, Smith SS, Khawaja SN, Scrivani SJ (2016) Cranial neuralgias. Oral Maxillofac Surg Clin North Am 28(3):351–370. Ballenberger N, von Piekartz H, Paris-Alemany A, La Touche R, Angulo-Diaz-Parreño S (2012) In˝ uence of di˛ erent upper cervical positions on electromyography activity of the masticatory muscles. J Manipulative Physiol ° er 35(4): 308–318. Banigo A, Watson D, Ram B, Ah-See K (2018) Orofacial pain. BMJ 361:k1517. Barral J, Croibier A (2009) Manual ° erapy for the Cranial Nerves. Churchill Livingstone Elsevier. Bartsch T (2005) Migraine and the neck: New insights from basic data. Curr Pain Headache Rep. 9(3):191–196.

André-Deshays C, Berthoz A, Revel M (1988) Eye-head coupling in humans. I. Simultaneous recording of isolated motor units in dorsal neck muscles and horizontal eye movements. Exp Brain Res 69(2):399–406.

Bartsch T, Goadsby PJ (2003) Increased responses in trigeminocervical nociceptive neurons to cervical input a˙ er stimulation of the dura mater. Brain 126(Pt.ˇ8):1801–1813.

Ariji Y, Ariji E (2017) Magnetic resonance and sonographic imagings of masticatory muscle myalgia in temporomandibular disorder patients. Jpn Dent Sci Rev 53(1):11–17.

Beheiry EE, Abdel-Hamid FA (2007) An anatomical study of the temporal fascia and related temporal pads of fat. Plast Reconstr Surg 119(1):136–144.

Armijo-Olivo S, Magee DJ (2007) Electromyographic activity of the masticatory and cervical muscles during resisted jaw opening movement. J Oral Rehabil 34(3):184–194.

Bender SD (2018) Orofacial pain: Where we are and where we are going. Dent Clin North Am 62(4):ix–x.

Armijo-Olivo S, Rappoport K, Fuentes J, Gadotti IC, Major PW, Warren S, ° ie NM, Magee DJ (2011) Head and cervical posture in patients with temporomandibular disorders. J Orofac Pain 25(3):199–209. Armijo-Olivo S, Pitance L, Singh V, Neto F, ° ie N, Michelotti A (2016) E˛ ectiveness of

Benoliel R, Svensson P, Heir GM, Sirois D, Zakrzewska J, Oke-Nwosu J, Torres SR, Greenberg MS, Klasser GD, Katz J, Eliav E (2011) Persistent orofacial muscle pain. Oral Dis 17(Suppl. 1):23–41. Bienfait M (1987) Estudio e tratamento do esqueleto ÿ broso: Fascias e pompages. Summus Editorial, Sao Paulo.

Bogduk N (2001) Cervicogenic headache: Anatomic basis and pathophysiologic mechanisms. Curr Pain Headache Rep 5(4):382–386. Boggero IA, Rojas-Ramirez MV, de Leeuw R, Carlson CR (2016) Satisfaction with life in orofacial pain disorders: Associations and theoretical implications. J Oral Facial Pain Headache 30(2):99–106. Bohr C, Bajaj J, Soriano RM, Shermetaro C (2021) Anatomy, Head and Neck, Temporoparietal Fascia. [Updated 2020 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available: https:// w w w.ncbi.nlm.nih.gov/books/NBK507912/ [accessed September 9, 2021]. Brodie AG (1950) Anatomy and physiology of head and neck musculature. Am J Orthod 36(11):831–844. Busch V, Frese A, Bartsch T (2004) ° e trigeminocervical complex. Integration of peripheral and central pain mechanisms in primary headache syndromes. Review. Schmerz 18(5):404–410. Butts R, Dunning J, Perreault T, Mettille J, Escaloni J (2017a) Pathoanatomical characteristics of temporomandibular dysfunction: Where do we stand? (Narrative review part 1). J Bodyw Mov ° er 21(3):534–540. Butts R, Dunning J, Pavkovich R, Mettille J, Mourad F (2017b) Conservative management of temporomandibular dysfunction: A literature review with implications for clinical practice guidelines (Narrative review part 2). J Bodyw Mov ° er 21(3):541–548. Caneiro JP, O’Sullivan P, Burnett A, Barach A, O’Neil D, Tveit O, Olafsdottir K (2010) ° e in˝ uence of di˛ erent sitting postures on head/ neck posture and muscle activity. Man ° er 15(1):54–60. Carlson CR, Sherman JJ, Studts JL, Bertrand PM (1997) ° e e˛ ects of tongue position on

384

Pilat_Myofascial Induction.indb 384

03/12/21 4:37 PM

REFERENCES

mandibular muscle activity. J Orofacial Pain 11(4):291–297.

ized connective tissues in the low back of the rat. Cells Tissues Organs 194(6):521–530.

Carney DR, Cuddy AJ, Yap AJ (2010) Power posing: Brief nonverbal displays a˛ ect neuroendocrine levels and risk tolerance. Psychol Sci 21(10):1363–1368.

Cuccia A, Caradonna C (2009) ° e relationship between the stomatognathic system and body posture. Clinics 64(1):61–66.

Cê PS, Barreiro BB, Silva RB, Oliveira RB, Heitz C, Campos MM (2018) Salivary levels of interleukin-1β in temporomandibular disorders and ÿ bromyalgia. J Oral Facial Pain Headache 32(2):130–136. Charpy A (1912) Aponevroses du cou. In: Poirier P (Ed.) Traite d’anatomie humaine. Paris: Maison et cie, pp. 258–280. Chaves TC, de Andrade e Silva TS, Monteiro SA, Watanabe PC, Oliveira AS, Grossi DB (2010) Craniocervical posture and hyoid bone position in children with mild and moderate asthma and mouth breathing. Int J Pediatr Otorhinolaryngol 74(9):1021–1027. Cho YS, Jeon JH, Hong A, Yang HT, Yim H, Cho YS, Kim DH, Hur J, Kim JH, Chun W, Lee BC, Seo CH (2014) ° e e˛ ect of burn rehabilitation massage therapy on hypertrophic scar a˙ er burn: A randomized controlled trial. Burns 40(8):1513–1520.

Cuccia AM, Lotti M, Caradonna D (2008) Oral breathing and head posture. ° e Angle Orthodontist 78(1):77–82. Dahlstrom KA, Olinger AB (2012) Descriptive anatomy of the interscalene triangle and the costoclavicular space and their relationship to thoracic outlet syndrome: A study of 60 cadavers. J Manipulative Physiol ° er 35(5):396–401. Damadian RV, Chu D (2011) ° e possible role of cranio-cervical trauma and abnormal csf hydrodynamics in the genesis of multiple sclerosis. Physiol Chem and Phys Med NMR 41:1–17. Darnell MW (1983) A proposed chronology of events for forward head posture. J Craniomandibular Pract 1(4):49–54. Davies PL (1979) Electromyographic study of superÿ cial neck muscles in mandibular function. J Dental Res 58:537–538.

Christoforou J (2018) Neuropathic orofacial pain. Dent Clin North Am 62(4):565–584.

Dean NA, Mitchell BS (2002) Anatomic relation between the nuchal ligament (ligamentum nuchae) and the spinal dura mater in the craniocervical region. Clin Anat 15(3):182–185.

Clark GT, Browne PA, Nakano M, Yang Q (1993) Co-activation of sternocleidomastoid muscles during maximum clenching. J Dental Res 72(11):1499–1502.

de Bakker BS, de Bakker HM, Soerdjbalie Maikoe V, Dikkers FG (2018) ° e development of the human hyoid–larynx complex revisited. Laryngoscope 128(8):1829–1834.

Clayton NA, Ward EC, Maitz PK (2015) Full thickness facial burns: Outcomes following orofacial rehabilitation. Burns 41(7):1599–1606.

De la Cuadra-Blanco C, Peces-Peña MD, Carvallo-de Moraes LO, Herrera-Lara ME, MéridaVelasco JR. (2013) Development of the platysma muscle and the superÿ cial musculoaponeurotic system (human specimens at 8–17 weeks of development). Sci World J 2013:716962.

Clayton NA, Ward EC, Maitz PK (2017) Intensive swallowing and orofacial contracture rehabilitation a˙ er severe burn: A pilot study and literature review. Burns 43(1):e7–e17. Cole HA, Carlson CR (2018) Mind-body considerations in orofacial pain. Dent Clin North Am 62(4):683–694. Corey S, Vizzard M, Badger G, Langevin H (2011) Sensory innervation of the nonspecial-

De Leeuw R, Klasser GD (2018) Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management. ° e American Academy of Orofacial Pain. 6th ed. Illinois: Quintessence Publishing. Demirdover C, Sahin B, Vayvada H, Oztan HY (2011) ° e versatile use of temporoparietal fascial ˝ ap. Int J Medical Sci 8(5):362–368.

15

Drake RL, Wayne A, Mitchell A (2015) Gray’s Atlas of Anatomy, 2nd ed. Philadelphia PA: Elsevier. Enix DE, Scali F, Pontell ME (2014) ° e cervical myodural bridge, a review of literature and clinical implications. J Can Chiropr Assoc 58(2):184–192. Eriksson PO, Zafar H, Nordh E (1998) Concomitant mandibular and head–neck movements during jaw opening–closing in man. J Oral Rehabil 25(11):859–870. Falla D, Jull G, Dall’Alba P, Rainoldi A, Merletti R (2003) An electromyographic analysis of the deep cervical ˝ exor muscles in performance of craniocervical ˝ exion. Phys ° er 83(10):899–906. Falla D, O’Leary S, Fagan A, Jull G (2007) Recruitment of the deep cervical ˝ exor muscles during a postural-correction exercise performed in sitting. Man ° er 12(2):139–143. Feigl G (2015) Fascia and spaces on the neck: Myths and reality. Medicina Fluminensis 51(4):430–439. Feneis H, Dauber W (2000) Pocket Atlas of Human Anatomy: Based on the International Nomenclature. 4th ed. Stuttgart: ° ieme. Fernandes G, Gonçalves DAG, Conti P (2018) Musculoskeletal disorders. Dent Clin North Am 62(4):553–564. Fernández-de-las-Peñas C, Galán-del-Río F, Fernández-Carnero J, Pesquera J, ArendtNielsen L, Svensson P (2009) Bilateral widespread mechanical pain sensitivity in women with myofascial temporomandibular disorder: Evidence of impairment in central nociceptive processing. J Pain 10(11):1170–1178. Fernández-de-las-Peñas C, Galán-del-Río F, Alonso-Blanco C, Jiménez-García R, ArendtNielsen L, Svensson P (2010) Referred pain from muscle trigger points in the masticatory and neck-shoulder musculature in women with temporomandibular disorders. J Pain. 11(12): 1295–1304. Ferreira LA, Grossmann E, Januzzi E, de Paula MV, Carvalho AC (2016) Diagnosis of temporomandibular joint disorders: Indication on imaging exams. Braz J Otorhinolaryngol 82(3):341–352.

385

Pilat_Myofascial Induction.indb 385

03/12/21 4:37 PM

15

REFERENCES

Fielding JW, Burstein AH, Frankel VH (1976) ° e nuchal ligament. Spine 1(1):3–14. FIPAT (2019) Terminologia Anatomica. 2nd ed. International Anatomical Terminology. Federative International Programme for Anatomical Terminology. Available: https://ÿ pat.library.dal.ca/ [accessed April 6, 2021]. Firth J, Torous J, Stubbs B, Firth JA, Steiner GZ, Smith L, Alvarez-Jimenez M, Gleeson J, Vancampfort D, Armitage CJ, Sarris J (2019) ° e “online brain”: How the Internet may be changing our cognition. World Psychiatry 18(2):119–129. Forsberg CM, Hellsing E, Linder-Aronson S, Sheikholeslam A (1985) EMG activity in neck and masticatory muscles in relation to extension and ˝ exion of the head. Eur J Orthodont 7(3):177–84. Funakoshi M, Fujita N, Takehana S (1976) Relations between occlusal interference and jaw muscle activities in response to changes in head position. J Dental Res 55(4):684–690. Gallaudet BB (1931) A Description of the Planes of Fascia of the Human Body. New York: Columbia University Press. Gardetto A, Dabernig J, Rainer C, Piegger J, Piza-Katzer H, Fritsch H (2003) Does a superÿ cial musculoaponeurotic system exist in the face and neck? An anatomical study by the tissue plastination technique. Plast Reconstr Surg 111(2):664–672; discussion 673–675. Gassner HG, Raÿ i A, Young A, Murakami C, Moe KS, Larrabee WF Jr. (2008) Surgical anatomy of the face: Implications for modern face-li˙ techniques. Arch Facial Plast Surg 10(1):9–19. Gavid M, Dumollard JM, Habougit C, Lelonge Y, Bergandi F, Peoc’h M, Prades JM (2018) Anatomical and histological study of the deep neck fasciae: Does the alar fascia exist? Surg and Radiol Anat 40(8):917–922. Gerstner G, Ichesco E, Quintero A, SchmidtWilcke T (2011) Changes in regional gray and white matter volume in patients with myofascial-type temporomandibular disorders: A voxel-based morphometry study. J Orofac Pain 25(2):99–106.

Ghurye S, McMillan R (2017) Orofacial pain – an update on diagnosis and management. Br Dent J 223(9):639–647. Gillies GT, Broaddus WC, Stenger JM, Taylor AG (1998) A biomechanical model of the craniomandibular complex and cervical spine based on the inverted pendulum. J Med Eng Technol 22(6):263–269. Gil-Martínez A, Paris-Alemany A, López-de-Uralde-Villanueva I, La Touche R (2018) Management of pain in patients with temporomandibular disorder (TMD): Challenges and solutions. J Pain Res 11:571–587. Gindrat AD, Chytiris M, Balerna M, Rouiller, EM, Ghosh A (2015) Use-dependent cortical processing from ÿ ngertips in touchscreen phone users. Curr Biol 25(1):109–116. Goadsby PJ, Bartsch T, Dodick DW (2008) Occipital nerve stimulation for headache: Mechanisms and eˆ cacy. Headache. 48(2):313–318. Gra˛ -Radford SB, Abbott JJ (2016) Temporomandibular disorders and headache. Oral Maxillofac Surg Clin North Am 28(3):335–349. Green Sanderson K, Conti A, Colussi M, Connolly CA (2020) Simple clinical application for locating the frontotemporal branch of the facial nerve using the zygomatic arch and the tragus. Aesthet Surg J 40(5):NP223–NP227. Grevellec A, Tucker AS (2010) ° e pharyngeal pouches and cle˙ s: Development, evolution, structure and derivatives. Semin Cell Dev Biol 21(3):325–332. Grodinsky M, Holyoke E (1938) ° e fasciae and fascial spaces of the head, neck and adjacent regions. Am J Anat 63(3):367–408. Guidera AK, Dawes PJ, Stringer MD (2012) Cervical fascia: A terminological pain in the neck. ANZ J Surg 82(11):786–791.

the rectus capitis posterior minor muscle and the dura mater. Spine 20(23):2484–2485. Hack GD, Hallgren RC (2004) Chronic headache relief a˙ er section of suboccipital muscle dural connections: A case report. Headache 44(1):84–9. Häggman-Henrikson B, Eriksson PO (2004) Head movements during chewing: Relation to size and texture of bolus. J Dent Res 83(11):864–868. Häggman-Henrikson B, Nordh E, Eriksson PO (2013) Increased sternocleidomastoid, but not trapezius, muscle activity in response to increased chewing load. Eur J Oral Sci 121(5):443–449. Hallac RR, Feng J, Kane AA, Seaward JR (2017) Dynamic facial asymmetry in patients with repaired cle˙ lip using 4D imaging (video stereophotogrammetry). J Craniomaxillofac Surg 45(1):8–12. Harn SD, Shackelford LS (1982) Further evaluation of the superÿ cial and deep tendons of the human temporalis muscle. Anat Rec 202(4): 537–548. Harvold EP, Tomer BS, Vargervik K, Chierici G (1981) Primate experiments on oral respiration. Am J Orthod 79(4):359–372. Headache Classiÿ cation Committee of the International Headache Society (IHS) (2013) ° e International Classiÿ cation of Headache Disorders, 3rd ed. (beta version). Cephalalgia. 33(9):629–808. Hecker P (1922) Appareil ligamenteux occipito-atloïdo-axoïdien étude d’anatomie comparée. Archives d’Anatomie, d’Histologie et d’Embryologie 1:419. Hellmann D, Giannakopoulos NN, Schmitter M, Lenz J, Schindler HJ (2012) Anterior and posterior neck muscle activation during a variety of biting tasks. Eur J Oral Sci 120(4):326–334.

Guyuron B, Seyed Forootan NS, Katira K (2018) ° e super-high SMAS faceli˙ technique with tailor tack plication. Aesthetic Plast Surg 42(6):1531–1539.

Helm P, Kowalske K Head M (2004) Burn rehabilitation. In: DeLisa JA, Gans BM, Walsh NE (Eds.) Physical Medicine and Rehabilitation Medicine: Principles and Practice. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins.

Hack G, Koritzer R, Robinson W, Hallgren R, Greenman P (1995) Anatomic relation between

Herisson F, Frodermann V, Courties, Rohde D, Sun Y, Vandoorne K, Wojtkiewicz GR, Masson

386

Pilat_Myofascial Induction.indb 386

03/12/21 4:37 PM

REFERENCES

GS, Vinegoni C, Kim J, Kim DE, Weissleder R, Swirski FK, Moskowitz M, Nahrendorf M (2018) Direct vascular channels connect skull bone marrow and the brain surface enabling myeloid cell migration. Nat Neurosci 21(9):1209–1217. Higbie EJ, Seidel-Cobb D, Taylor LF, Cummings GS (1999) E˛ ect of head position on vertical mandibular opening. J Orthop Sports Phys ° er 29:127–130. Hînganu D, Scutariu MM, Hînganu MV (2018) ° e existence of labial SMAS – anatomical, imaging and histological study. Ann Anat 218:271–275. Hosseini H, Agneskirchner JD, Tröger M, Lobenho˛ er P (2007) Arthroscopic release of the superior transverse ligament and SLAP reÿ xation in a case of suprascapular nerve entrapment. Arthroscopy 23(10):1134.e1–4. Hwang K, Choi JH (2018) Superÿ cial fascia in the cheek and the superÿ cial musculoaponeurotic system. J Craniofac Surg 29(5):1378–1382. Hwang K, Nam YS, Kim DJ, Han SH (2008) Anatomy of tympanoparotid fascia relating to neck li˙ . J Craniofacial Surg 19(3):648–651. Huang L, Galinsky A, Gruenfeld D, Guillory L (2011) Powerful postures versus powerful roles. Psychol Sci 22(1):95–102. Hwang K, Kim JY, Lim JH (2017) Anatomy of the platysma muscle J Craniofac Sur 28(2): 539–542. Ichesco E, Quintero A, Clauw DJ, Peltier S, Sundgren PM, Gerstner GE, Schmidt-Wilcke T (2012) Altered functional connectivity between the insula and the cingulate cortex in patients with temporomandibular disorder: A pilot study. Headache 52(3):441–454. Ihnatsenka B, Boezaart A (2010) Applied sonoanatomy of the posterior triangle of the neck. Int J Shoulder Surg 4(3):63. Indresano A, Alpha C (2009) Nonsurgical management of temporomandibular joint disorders. In: Fonseca RJ, Marciani RD, Turvey TA (Eds.) Oral and Maxillofacial Surgery. 2nd ed. St. Louis, MO: Saunders Elsevier.

Ivković N, Racic M, Lecic R, Bozovic D, Kulic M (2018) Relationship between symptoms of temporomandibular disorders and estrogen levels in women with di˛ erent menstrual status. J Oral Facial Pain Headache 32(2):151–158.

Kohno S, Matsuyama T, Medina RU, Arai Y (2001) Functional-rhythmical coupling of head and mandibular movements. J Oral Rehabil 28(2):161–167.

Jaber JJ, Leonetti JP, Lawrason AE, Feustel PJ (2008) Cervical spine causes for referred otalgia. Otolaryngol Head Neck Surg 138(4):479–485.

Kolář P, Sulc J, Kyncl M, Sanda J, Cakrt O, Andel R, Kumagai K, Kobesova A (2012) Postural function of the diaphragm in persons with and without chronic low back pain. J Orthop Sports Phys ° er 42(4):352–362.

Jeon A, Ahn H, Seo CM, Lee JH, Kim WS, Lee JH, Han SH (2019) Relationship of the lobular branch of the great auricular nerve to the tympanoparotid fascia: Spatial anatomy for salvage during face and neck li˙ . PLOS One. 14(10):e0222324.

Komiyama O, Arai M, Kawara M, Kobayashi K, De Laat A (2005) Pain patterns and mandibular dysfunction following experimental trapezius muscle pain. J Orofac Pain 19(2):119–126.

Jerolimov V (2009) Temporomandibular disorders and orofacial pain. Medical Sciences 33:53–77. Johnson GM, Zhang M, Jones DG (2000) ° e ÿ ne connective tissue architecture of the human ligamentum nuchae. Spine 25(1):5. Kahkeshani K, Ward PJ (2012) Connection between the spinal dura mater and suboccipital musculature: Evidence for the myodural bridge and a route for its dissection – a review. Clin Anat 25(4):415–422. Kakizaki Y, Uchida K, Yamamura K, Yamada Y (2002) Coordination between the masticatory and tongue muscles as seen with di˛ erent foods in consistency and in re˝ ex activities during natural chewing. Brain Res 929(2):210–217. Kang HG, Youn KH, Kim IB, Nam YS (2017) Bilayered structure of the superÿ cial facial fascia. Aesthet Surg J 37(6):627–636. Kapandji IA (1977) Cuadernos de ÿ siología articular, miembro superior [Notebooks of articular physiology, upper limb]. Barcelona: Toray-Masson. Kim MH, Yi CH, Kwon OY, Cho SH, Yoo WG (2008) Changes in neck muscle electromyography and forward head posture of children when carrying schoolbags. Ergonomics 51(6): 890–901. Kitamura S (2018) Anatomy of the fasciae and fascial spaces of the maxillofacial and the anterior neck regions. Anat Sci Int 93(1):1–13.

15

Koolstra JH, van Eijden TM (2004) Functional signiÿ cance of the coupling between head and jaw movements. J Biomech 37(9):1387–1392. Koornneef L (1979) Orbital septa: Anatomy and function. Ophthalmology 86(5):876–880. Kulkarni V, Chandy MJ, Babu KS (2001) Quantitative study of muscle spindles in suboccipital muscles of human fetuses. Neurol India 49(4):355–359. Kuroda K, Saitoh I, Inada E, Takemoto Y, Iwasaki T, Iwase Y, Yamada C, Shinkai M, Matsumoto Y, Hasegawa H, Yamasaki Y, Hayasaki H (2011) Head motion may help mouth opening in children. Arch Oral Biol 56(1):102–107. Kusdra PM, Stechman-Neto J, Leão BLC, Martins PFA, Lacerda ABM, Zeigelboim BS (2018) Relationship between otological symptoms and TMD. Int Tinnitus J 22(1):30–34. Kushima H, Matsuo K, Yuzuriha S, Kitazawa T, Moriizumi T (2005) ° e occipitofrontalis muscle is composed of two physiologically and anatomically di˛ erent muscles separately a˛ ecting the positions of the eyebrow and hairline. Br J Plast Surg 58(5):681–687. Lafrenière CM, Lamontagne M, el-Sawy R (1997) ° e role of the lateral pterygoid muscles in TMJ disorders during static conditions. Cranio 15(1):38–52. La Touche R, París-Alemany A, von Piekartz H, Mannheimer JS, Fernández-Carnero J, Rocabado M (2011) ° e in˝ uence of cranio-cervical posture on maximal mouth opening and pressure

387

Pilat_Myofascial Induction.indb 387

03/12/21 4:37 PM

15

REFERENCES

pain threshold in patients with myofascial temporomandibular pain disorders. Clin J Pain 27(1):48–55. La Touche R, Paris-Alemany A, Hidalgo-Pérez A, López-de-Uralde-Villanueva I, Angulo-DiazParreño S, Muñoz-García D (2017) Evidence for central sensitization in patients with temporomandibular disorders: A systematic review and meta-analysis of observational studies. Pain Practice 18(3):388–409. Lazorthes G, Poulhes J, Gaubert J (1953) La dure-mère de la charnière crânio-rachidienne. Bull Assoc Anat 78:169–172.

Magnani DM, Sassi FC, Vana LP, Alonso N, Andrade CR (2015) Evaluation of oral-motor movements and facial mimic in patients with head and neck burns by a public service in Brazil. Clinics (Sao Paulo) 70(5):339–345. Majumdar S, Wu K, Bateman ND, Ray J (2009) Diagnosis and management of otalgia in children. Arch Dis Child Educ Pract Ed 94(2):33–36. Martin P (2016) Classiÿ cation of Headache Disorders: Extending to a multiaxial system. Headache 56(10):1649–1652. Marur T, Tuna Y, Demirci S (2014) Facial anatomy. Clin Dermatol 32(1):14–23.

Milam SB, Zardeneta G, Schmitz JP (1998) Oxidative stress and degenerative temporomandibular joint disease: A proposed hypothesis. J Oral Maxillofacial Surg 56(2):214–223. Milidonis MK, Kraus SL, Segal RL, Widmer CG (1993) Genioglossi muscle activity in response to changes in anterior/neutral head posture. Am J Orthod Dentofacial Orthop 103(1):39–44. Mingels S, Dankaerts W, Granitzer M (2019) Is there support for the paradigm ‘Spinal posture as a trigger for episodic headache’? A comprehensive review. Curr Pain Headache Rep 23(3):17.

LeResche I (1997) Epidemiology of temporomandibular disorders: Implications for the investigation of etiologic factors. Crit Rev Oral Biol Med 8(3):291–305.

May A, Bramke S, Funk RHW, May CA (2018) ° e human platysma contains numerous muscle spindles. J Anat 232(1):146–151.

Mitchell BS, Humphreys BK, O’Sullivan E (1998) Attachments of the ligamentum nuchae to cervical posterior spinal dura and the lateral part of the occipital bone. J Manipulative Physiol ° er 21(3):145–148.

Levine RA (1999) Somatic (craniocervical) tinnitus and the dorsal cochlear nucleus hypothesis. Am J Otolaryngol 20(6):351–362.

McKay E (2014) Assessing the e˛ ectiveness of massage therapy for bilateral cle˙ lip reconstruction scars. Int J ° er Massage Bodywork 7(2):3–9.

Mitz V, Peyronie M (1976) ° e superÿ cial musculoaponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg 58(1):80–88.

McKenzie R (1981) Mechanical Diagnosis and ° erapy of the Cervical and ° oracic Spine. Waikanae, New Zealand: Spinal Publications Ltd.

Miyaoka S, Hirano H, Miyaoka Y, Yamada Y (2004) Head movement associated with performance of mandibular tasks. J Oral Rehabil 31(9):843–850.

Lin CS (2014) Brain signature of chronic orofacial pain: A systematic review and meta-analysis on neuroimaging research of trigeminal neuropathic pain and temporo-mandibular joint disorders. PLOS One 9(4):e94300. Lockwood TE (1991) Superÿ cial fascial system (SFS) of the trunk and extremities: A new concept. Plast Reconstr Surg 87(6):1009–1018. Lomas J, Gurgenci T, Jackson C, Campbell D (2018) Temporomandibular dysfunction. Aust J Gen Pract 47(4):212–215. Ma Y, Tang W, Gong DZ, Li XY, Zhang JH, Sun JH, Wang B, Zhang Y, Chen YX, Zhang ZH, Zheng N, Okoye CS, Chi YY, Wu CW, Yu SB, Sui HJ (2021) ° e morphology, biomechanics, and physiological function of the suboccipital myodural connections. Sci Rep 11(1):8064. Macchi V, Tiengo C, Porzionato A, Stecco C, Vigato E, Parenti A, Azzena B, Weiglein A, Mazzoleni F, De Caro R (2010) Histotopographic study of the ÿ broadipose connective cheek system. Cells Tissues Organs 191(1):47–56. Macfarlane TV, Glenny AM, Worthington HV (2001) Systematic review of population-based epidemiological studies of oro-facial pain. J Dent 29(7):451–467.

McLean L (2005) ° e e˛ ect of postural correction on muscle activation amplitudes recorded from the cervicobrachial region. J Electromyogr Kinesiol 15(6):527–535. Mense S, Gerwin RD (2010) Muscle Pain: Understanding the Mechanisms. Springer Heidelberg.

Moon HJ, Lee YK (2011) ° e relationship between dental occlusion/temporomandibular joint status and general body health: part 1. Dental occlusion and TMJ status exert an in˝ uence on general body health. J Altern Complem Med 17(11):995–1000.

Mense S, Hoheisel U (2016) Evidence for the existence of nociceptors in rat thoracolumbar fascia. J Bodyw Mov ° er 20(3):623–628.

Moore KL, Dalley AF, Agur AMR (2010) Clinically Oriented Anatomy. 6th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Merskey H, Bogduk N (1994) Classiÿ cation of Chronic Pain: Descriptions of Chronic Pain Syndromes and Deÿ nitions of Pain Terms. Seattle: IASP Press.

Moore KL, Dalley AF, Agur AMR (2013) Anatomía humana con orientación clínica. 7a ed. Barcelona: Wolters Kluwer Health España S.A.

Meruane M, Smok C, Rojas M (2012) Desarrollo de cara y cuello en vertebrados. Int J Morphol 30(4):1373–1388. MeSH (2018) US National Library of Medicine National Institutes of Health. MeSH databases. Available: https://www.ncbi.nlm.nih.gov/mesh /?term=smas [accessed March 2, 2021]. Messina G (2017) ° e tongue, mandible, hyoid system. Eur J Transl Myol 27(1):6363.

Muir B (2017) Dorsal scapular nerve neuropathy: A narrative review of the literature. J Can Chiropr Assoc 61(2):128–144. Myrhaug H (1964) ° e incidence of ear symptoms in cases of malocclusion and temporomandibular joint disturbances. Br J Oral Surg 2(1):28–32. National Institute of Dental and Craniofacial Research (2014) Facial pain. National Institutes of Health. Available: https://www.nidcr.nih.gov/

388

Pilat_Myofascial Induction.indb 388

03/12/21 4:37 PM

REFERENCES

research/data-statistics/facial-pain February 2, 2021].

[accessed

early versus late intervention a˛ ect outcome? JˇBurn Care Res 34(5):569–575.

Neal S, Fields KB (2010) Peripheral nerve entrapment and injury in the upper extremity. Am Fam Physician 81(2):147–155.

Peck C, Murray G, Gerzina T (2008) How does pain a˛ ect jaw muscle activity? ° e Integrated Pain Adaptation Model. Aust Dent J 53(3):201–207.

Neiva PD, Kirkwood RN, Godinho R (2009) Orientation and position of head posture, scapula and thoracic spine in mouth-breathing children. Int J Pediatr Otorhinolaryngol 73(2):227–236.

Pekny M, Nilsson M (2005) Astrocyte activation and reactive gliosis. Glia 50(4):427–434.

Neumann D (2010) Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. 2nd ed. St. Louis, MO: Mosby Elsevier. Norton NS (2007) Netter. Anatomía de cabeza y cuello para odontólogos. Barcelona: Elsevier Masson. Ogütcen-Toller M (1995) ° e morphogenesis of the human discomalleolar and sphenomandibular ligaments. J Craniomaxillofac Surg 23(1):42–46. Ohmure H, Miyawaki S, Nagata J, Ikeda K, Yamasaki K, Al-Kalaly A (2008) In˝ uence of forward head posture on condylar position. JˇOral Rehabil 35(11):795–800. Okeson JP (2013) Tratamiento de oclusión y afecciones temporomandibulares. 7th ed. Barcelona: Elsevier. Okeson J P (2014). Bell’s Oral and Facial Pain, 7th ed. Chicago, Illinois: Quintessence Publishing. Osman AM, Carter SG, Carberry JC, Eckert DJ (2018) Obstructive sleep apnea: Current perspectives. Nat Sci Sleep 10:21–34. Owsley J (1983) SMAS-platysma faceli˙ . A bidirectional cervicofacial rhytidectomy. Clin Plast Surg 10(3):429–440. Palomeque-Del-Cerro L, Arráez-Aybar LA, Rodríguez-Blanco C, Guzmán-García R, Menendez-Aparicio M, Oliva-Pascual-Vaca Á (2017) A systematic review of the so˙ -tissue connections between neck muscles and dura mater. Spine 42(1):49–54. Panjabi M, Dvorak J, Crisco J, Oda T, Wang P, Grob D (1991) E˛ ects of alar ligament transection on upper cervical spine rotation. J Orthop Res 9(4):584593. Parry I, Sen S, Palmieri T, Greenhalgh D (2013) Nonsurgical scar management of the face: Does

Perlemuter L, Waligora J (1971) Cahiers d´anatomie. Préparation aux concours. Tête et cou. Paris: Masson & Cie. Pessa JE (2016) SMAS fusion zones determine the subfascial and subcutaneous anatomy of the human face: Fascial spaces, fat compartments, and models of facial aging. Aesthet SurgˇJ 36(5):515–526.

Pilat A, Castro-Martín E (2018) Myofascial induction approaches in temporomandibular disorders. In: Fernández-de-las-Peñas C, MesaJiménez J (Eds.) Temporomandibular Disorders: Manual ° erapy, Exercise, and Needling. Edinburgh: Handspring Publishing. Plog BA, Nedergaard M (2018) ° e glymphatic system in central nervous system health and disease: Past, present and future. Annu Rev Pathol 13(1):379–394. Pontell ME, Scali F, Enix DE, Battaglia PJ, Marshall E (2013a) Histological examination of the human obliquus capitis inferior myodural bridge. Ann Anat 195(6):522–526. Pontell ME, Scali F, Marshall E, Enix D (2013b) ° e obliquus capitis inferior myodural bridge. Clin Anat 26(4):450–454.

Pidgeon T, Boca R, Fatah F (2017) A technique for facial reanimation: ° e partial temporalis muscle-tendon transfer with a fascia lata sling. JˇPlast Reconstr Aesthet Surg 70(3):313–321.

Proˆ t WR (1978) Equilibrium theory revisited: Factors in˝ uencing position of the teeth. Angle Orthod 48(3):175–186.

Pick M (1999) Cranial Sutures: Analysis, Morphology & Manipulative Strategies. Seattle: Eastland Press.

Protasoni M, Sangiorgi S, Cividini A, Culuvaris GT, Tomei, Dell’Orbo C, Raspanti M, Balbi S, Reguzzoni M (2011) ° e collagenic architecture of human dura mater. J Neurosurg 114(6):1723–1730.

Pihut M, Ferendiuk E, Szewczyk M, Kasprzyk K, Wieckiewicz M (2016) ° e eˆ ciency of botulinum toxin type A for the treatment of masseter muscle pain in patients with temporomandibular joint dysfunction and tension-type headache. J Headache Pain 17:29. Rome, Italy. Pilat A (2003) Terapias miofasciales: Inducción miofascial. Madrid: McGraw Hill Interamericana de España. Pilat A (2009) Myofascial induction approaches for headache. In: Fernández-de-las-Peñas C, Arendt-Nielsen L, Gerwin RD (Ed.) Tension Type and Cervicogenic Headache: Pathophysiology, Diagnosis and Treatment. Boston: Jones & Bartlett Publishers. Pilat A (2011) Myofascial induction approaches. In: Fernández-de-las-Peñas C, Cleland JA, Huijbregts PA (Eds.) Neck and Arm Pain Syndromes. Churchill Livingstone Elsevier, pp. 455–475. Pilat A (2017) Myofascial induction therapy. In: Liem T, Tozzi P, Chila A (Eds.) Fascia in the Osteopathic Field. Edinburgh: Handspring Publishing.

15

Rakhshan V, Bianchi FA, Quintans-Júnior LJ, Alonso AA (2017) Orofacial Pains. Pain Res Manag 2017:1915691. Ramírez LM, Ballesteros AL, Sandoval OG (2009) A direct anatomical study of the morphology and functionality of disco-malleolar and anterior malleolar ligaments. Int J Morphol 27(2):367–379. Rea P (2016) Chapter 3. Neck. In: Rea P (Ed.) Essential Clinically Applied Anatomy of the Peripheral Nervous System in the Head and Neck. Academic Press, Elsevier. pp. 131–183. Available: https://doi.org/10.1016/B978-0-12803633-4.00003-X [accessed March 2, 2021]. Richmond FJR, Singh K, Corneil B (1999) Marked non-uniformity of ÿ ber-type composition in the primate suboccipital muscle obliquus capitis inferior. Exp Brain Res 125(1):14–18. Rocabado M (1981) Head, Neck and Temporomandibular Joint Dysfunctions. Tacoma, WA: Rocabado Institute. Rocabado M (1983) Biomechanical relationship of the cranial, cervical, and hyoid regions. JˇCraniomandibular Pract 1(3):61–66.

389

Pilat_Myofascial Induction.indb 389

03/12/21 4:37 PM

15

REFERENCES

Rocabado M (2011) Atlas Clínico 2, Congruencia cráneo-cervico-mandibular, aplicación práctica clínica. Santiago, L.C: Ed. CEDIME.

Scali F, Pontell ME, Enix DE, Marshall E (2013) Histological analysis of the rectus capitis posterior major’s myodural bridge. Spine J 13(5):558–563.

Sobotta J (2000) Atlas de anatomía humana. Tomo 1. 21aˇ ed. Madrid: Editorial Médica Panamericana.

Rocabado M, Iglarsh ZA (1991) Musculoskeletal Approach to Maxillofacial Pain. Philadephia: PA: Lippincott.

Scarr G (2008) A model of the cranial vault as a tensegrity structure and its signiÿ cance to normal and abnormal cranial development. Int J Osteop Med 11(3):80–89.

Solow B, Tallgren A (1976) Head posture and craniofacial morphology. Am J Phys Anthropol 44(3):417–435.

Rodríguez K, Miralles R, Gutiérrez MF, Santander H, Fuentes A, Fresno MJ, Valenzuela S (2011) In˝ uence of jaw clenching and tooth grinding on bilateral sternocleidomastoid EMG activity. Cranio 29(1):14–22.

Scarr G, Harrison H (2017) Examining the temporo-mandibular joint from a biotensegrity perspective: A change in thinking. J Appl Biomed 15: 55–62.

Rohrich RJ, Pessa JE (2008) ° e retaining system of the face: Histologic evaluation of the septal boundaries of the subcutaneous fat compartments. Plast Reconstr Surg 121(5):1804–1809.

Schleicher W, Feldman M, Rhodes J (2013) Review of facial nerve anatomy: Trauma to the temporal region. Eplasty 13:ic54. eCollection 2013.

Rossell-Perry P, Paredes-Leandro P (2013) Anatomic study of the retaining ligaments of the face and applications for facial rejuvenation. Aesthetic Plast Surg 37(3):504–512.

Sessle BJ (2005a) Orofacial pain. In: Merskey H, De Loeser J, Dubner R (Eds.) ° e Paths of Pain 1775–2005. Seattle: IASP Press.

Ruivo RM, Pezarat-Correia P, Carita AI (2014) Cervical and shoulder postural assessment of adolescents between 15 and 17 years old and association with upper quadrant pain. Braz J Phys ° er 18(4):364–371. Rumbach A, Ward E, Cornwell P, Bassett L, Khan A, Muller M (2011a) Incidence and predictive factors for dysphagia a˙ er thermal burn injury: A prospective cohort study. J Burn Care Res 32(6):608–616. Rumbach A, Ward E, Cornwell P, Bassett L, Spermon M, Plaza A, Muller MJ (2011b) Dysphagia rehabilitation a˙ er severe burn injury: An interdisciplinary and multidisciplinary collaborative. J Med Speech-Lang Pathol 19(1):25–34. Russo MV, Latour LL, McGavern DB (2018) Distinct myeloid cell subsets promote meningeal remodeling and vascular repair a˙ er mild traumatic brain injury. Nat Immunol 19(5):442–452. Sanders RD (2010) ° e trigeminal (V) and facial (VII) cranial nerves: Head and face sensation and movement. Psychiatry (Edgmont) 7(1): 13–16. Scali F, Marsili ES Pontell ME (2011) Anatomical connection between the rectus capitis posterior major and the dura mater. Spine (Phila Pa 1976) 36(25):E1612–E1614.

Sessle BJ (2005b) Peripheral and central mechanisms of orofacial pain and their clinical correlates. Minerva Anestesiol 71(4):117–136. Sforza E, Bacon W, Weiss T, ° ibaut A , Petiau Ch , Krieger J (2000) Upper airway collapsibility and cephalometric variables in patients with obstructive sleep apnea. Am J Respir Crit Care Med 161(2):347–352. Sha˛ er SM, Brismée JM, Sizer PS, Courtney CA (2014) Temporomandibular disorders. Part 2: Conservative management. J Man Manip ° er 22(1):13–23. Shapiro HH, Sleeper EL, Guralnick WC (1950) Spread of infection of dental origin; anatomic and surgical considerations. Oral Surg Oral Med Oral Pathol 3(11):1407–1430 Sharma S, Gupta DS, Pal US, Jurel SK (2011) Etiological factors of temporomandibular joint disorders. Natl J Maxillofac Surg 2(2):116–119. Silva VG, Pinheiro LA, Silveira PL, Duarte AS, Faria AC, Carvalho EG, Zancanella E, Crespo AN (2014) Correlation between cephalometric data and severity of sleep apnea. Braz J Otorhinolaryngol 80(3):191–195. Singh TP, Bala S, Kalsey G, Singla Rajan K (2000) Applied anatomy of fascial spaces in head and neck. J Anat Soc India 49(1):78–88.

Son B, Kim D, Lee S (2013) Intractable occipital neuralgia caused by an entrapment in the semispinalis capitis. J Korean Neurosurg 54(3):268–271. Spierings ELH, Mulder MJHL (2017) Persistent orofacial muscle pain: Its synonymous terminology and presentation. Cranio 35(5):304–307. Standring S, Shah JP, Patel SG (2008) Head and neck. In: Standring S (Ed.) Gray’s Anatomy: ° e Anatomical Basis of Clinical Practice. 40th ed. Edinburgh: Churchill Livingstone Elsevier. Stecco C, Gagey O, Belloni A, Pozzuoli A, Porzionato A, Macchi V, Aldegheri R, Caro R, Delmas V (2007) Anatomy of the deep fascia of the upper limb. Second part: Study of innervation. Morphologie 91(292):38–43. Stecco A, Meneghini A, Stern R, Stecco C, Imamura M (2013) Ultrasonography in myofascial neck pain: Randomized clinical trial for diagnosis and follow-up. Surg Radiol Anat 36(3):243–253. Stuginski-Barbosa J, Macedo HR, Bigal ME, Speciali JG (2010) Signs of temporomandibular disorders in migraine patients: A prospective, controlled study. Clin J Pain 26(5):418–421. Sutcli˛ e P, Lasrado S (2020) Anatomy, Head and Neck, Deep Cervical Neck Fascia. [Updated 2020 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available: https://pubmed.ncbi.nlm.nih.gov/31082135/ [accessed April 20, 2021]. Suzuki S, Matsubara N, Hisano M, Soma K (2003) Investigation of cervical muscle mechanisms during jaw movement--using a prototype head-jaw-neck model. Med Dent Sci 50(4): 285–290. Svensson P, Wang K, Sessle BJ, Arendt-Nielsen L (2004) Associations between pain and neuromuscular activity in the human jaw and neck muscles. Pain 109(3):225–232.

390

Pilat_Myofascial Induction.indb 390

03/12/21 4:38 PM

REFERENCES

Tait RC, Ferguson M, Herndon CM (2017) Chronic orofacial pain: Burning mouth syndrome and other neuropathic disorders. J Pain Manag Med 3(1):120. Takahashi S, Kuribayashi G, Ono T, Ishiwata Y, Kuroda T (2005) Modulation of masticatory muscle activity by tongue position. Angle Orthod 75(1):35–39. Takemura M, Sugiyo S, Moritani M, Kobayashi M, Yonehara N (2006) Mechanisms of orofacial pain control in the central nervous system. Arch Histol Cytol 69(2):79–100. Takeshita K, Peterson E, Bylski-Austrow D, Crawford A, Nakamura K (2004) ° e nuchal ligament restrains cervical spine ˝ exion. Spine (Phila Pa 1976) 29(18):E388–E393. Tesarz J, Hoheisel U, Wiedenhöfer B, Mense S (2011) Sensory innervation of the thoracolumbar fascia in rats and humans. Neuroscience 194:302–308. ° ompson J, Brodie A (1942) Factors in the position of the mandible. J Am Dent Assoc 29:925–941. Torisu T, Suenaga H, Yoshimatsu T, Kanaoka R, Yamabe Y, Fujii H (2002) Anticipatory and re˝ exive neck muscle activities during voluntary rapid jaw opening and passive jaw depression in humans. J Oral Rehabil 29(10):961–968. Tubbs RS, Kelly DR, Humphrey ER, Chua GD, Shoja MM, Salter EG, Acakpo-Satchivi L, Wellons 3rd JC, Blount JP, Oakes WJ (2007) ° e tectorial membrane: Anatomical, biomechanical, and histological analysis. Clin Anat 20(4):382–386. Urbanowicz M (1991) Alteration of vertical dimension and its e˛ ect on head and neck posture. Cranio 9(2):174–179. Urschel HC, Kourlis H (2007) ° oracic outlet syndrome: A 50-year experience at Baylor University Medical Center. Proc (Bayl Univ Med Cent) 20(2):125–135. van der Wal J (2009) ° e architecture of the connective tissue in the musculoskeletal system— an o˙ en overlooked functional parameter as to proprioception in the locomotor apparatus. Int J ° er Massage Bodywork. 2(4):9–23.

Venegas M, Valdivia J, Fresno MJ, Miralles R, Gutiérrez MF, Valenzuela S, Fuentes A (2009) Clenching and grinding: Effect on masseter and sternocleidomastoid electromyographic activity in healthy subjects. Cranio 27(3): 159–166. Vig PS, Showfety BC, Phillips C (1980) Experimental manipulation of head posture. Am J Orthod 77(3):258–268. Visscher CM, Huddleston Slater JJ, Lobbezoo F, Naeije M (2000) Kinematics of the human mandible for di˛ erent head postures. J Oral Rehabil 27(4):299–305. von Piekartz HJM (2007) Craniofacial Pain: Neuromusculoskeletal Assessment, Treatment and Management. Oxford: Butterworth-Heinemann Elsevier. von Piekartz H, Bryden L (Eds.) (2001) Craniofacial Dysfunction and Pain: Manual ° erapy, Assessment and Management. Oxford: Butterworth-Heinemann. Weiss AL, Ehrhardt KP, Tolba R (2017) Atypical facial pain: A comprehensive, evidence-based review. Curr Pain Headache Rep 21(2):8. Wenzel A, Højensgaard E, Henriksen J (1985) Craniofacial morphology and head posture in children with asthma and perennial rhinitis. Eur J Orthod 7(2):83–92. White A, Panjabi M (1990) Clinical Biomechanics of the Spine. 2nd ed. Philadelphia, PA: J.B. Lippincott Company. Whitney ZB, Jain M, Zito PM (2020) Anatomy, Skin, Superÿ cial Musculoaponeurotic System (SMAS) Fascia. [Updated Nov 23, 2020] In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. PMID: 30085556. Available: https://pubmed.ncbi.nlm. nih.gov/30085556/ [accessed April 20, 2021]. Xu Q, Yu SB, Zheng N, Yuan XY, Chi YY, Liu C, Wang XM, Lin XT, Sui HJ (2016) Head movement, an important contributor to human cerebrospinal ˝ uid circulation. Sci Rep 6:31787.

15

Yuan XY, Yu SB, Li YF, Chi YY, Zheng N, Gao HB, Luan BY, Zhang ZX, Sui HJ (2016) Patterns of attachment of the myodural bridge by the rectus capitis posterior minor muscle. Anat Sci Int 91(2):175–179. Yuan XY, Yu SB, Liu C, Xu Q, Zheng N, Zhang JF, Chi YY, Wang XG, Lin XT, Sui HJ (2017) Correlation between chronic headaches and the rectus capitis posterior minor muscle: A comparative analysis of cross-sectional trail. Cephalalgia 37(11):1051–1056. Zafar H, Nordh E, Eriksson PO (2000) Temporal coordination between mandibular and headneck movements during jaw opening-closing tasks in man. Arch Oral Biol 45(8):675–682. Zhang M, Lee AS (2002) ° e investing layer of the deep cervical fascia does not exist between the sternocleidomastoid and trapezius muscles. Otolaryngol Head Neck Surg 127(5):452–457. Zhang YT, Li-Tsang CWP, Au RKC (2017) A systematic review on the e˛ ect of mechanical stretch on hypertrophic scars a˙ er burn injuries. Hong Kong J Occup ° er 29(1):1–9. Zheng N, Yuan XY, Li YF, Chi YY, Gao HB, Zhao X, Yu SB, Sui HJ, Sharkey J (2014) Deÿ nition of the to be named ligament and vertebrodural ligament and their possible e˛ ects on the circulation of CSF. PLOS One 9(8):e103451. Zheng N, Chi YY, Yang XH, Wang NX, Li YL, Ge YY, Zhang LX, Liu TY, Yuan XY, Yu SB, Sui HJ (2018) Orientation and property of ÿ bers of the myodural bridge in humans. Spine J 18(6):1081–1087. Zheng N, Chung BS, Li YL, Liu TY, Zhang LX, Ge YY, Wang NX, Zhang ZH, Cai L, Chi YY, Zhang JF, Samuel OC, Yu SB, Sui HJ (2020) ° e myodural bridge complex deÿ ned as a new functional structure. Surg Radiol Anat 42(2):143–145. Zumpano MP, Hartwell S, Jagos CS (2006) So˙ tissue connection between rectus capitus posterior minor and the posterior atlanto-occipital membrane: A cadaveric study. Clin Anat 19(6):522–527.

Yamabe Y, Yamashita R, Fujii H (1999) Head, neck and trunk movements accompanying jaw tapping. J Oral Rehabil 26(11):900–905.

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MIT procedures for common craniocervical and neck dysfunctions

Craniofacial and myodural bridge complex Assessment of the craniofacial complex Views of the skull structures The cranial vault, meninges, and nervous system Myofascial induction of the ocular area Myofascial induction of the zygomatic area Myofascial induction of the scalp Transverse stroke applied to the temporal area Myofascial induction of the temporal area Myofascial induction of the masseter Intraoral induction of the masseter Myofascial induction of the external pterygoid muscle Myofascial induction of the internal pterygoid muscle Myofascial induction of the hard palate Myofascial induction of the vomer Temporomandibular induction Postisometric induction Sagittal section of the head and upper neck showing the myodural bridge Myofascial induction of the suboccipital triangle Myofascial bridge induction

395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413

Cervical complex Assessment of the cervical complex Fascial anatomy of the anterolateral cervical area Anterolateral cervical area: Myofascial induction of the sternocleidomastoid Anterolateral cervical area: Myofascial induction of the deep neck flexors (retrohyoid procedure) Anterolateral cervical area: Myofascial induction of the scalenes Myofascial induction of the craniocervical area Myofascial relationships of the hyoid region Longitudinal stroke applied to the external mouth floor Induction of the myofascial complex of the tongue Myofascial induction of the omohyoid Suprahyoid, infrahyoid, and transverse plane hyoid induction Transverse stroke applied to the posterior cervical complex Longitudinal stroke applied to the posterior cervical complex

414 415 416 417 418 419 420 421 422 423 424 425 426

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Craniofacial and myodural bridge complex

Neuroprotection (Prophylactic measure)

Avoids

Supports

Hypoxic or ischemic insult

Increase in neuronal tolerance and improvement in neuronal survival

Neuroprotection refers to sensory and motor mechanisms that act in response to disorders in the mechanosensitivity of the nervous tissue (neuritis). The sensory manifestations can be the result of the activation of nociceptive mechanisms, with the presence or absence of pain, which can trigger antagonistic motor activity to condition where the nerve can be subjected to mechanical stress. Protective muscle response can lead to changes in movement patterns involving fear-avoidance behavior and maladaptive posture.

Key to level of irritability or dysfunction Irritability/type of dysfunction

Levels

Irritability

High: presence of fear-avoidance and neuropathic features (negative psychosocial factors††) Moderate: presence of fear-avoidance and mixed features (negative psychosocial factors) Low: absence of fear-avoidance and predominant nociceptive features (positive psychosocial factors*)

Neuroprotection

High: presence of fear-avoidance and neuropathic features (negative psychosocial factors††) Moderate: presence of fear-avoidance and mixed features† (negative psychosocial factors) Low: absence of fear-avoidance and predominant nociceptive features (positive psychosocial factors*)

Rigidity/stiffness

High: absence of elastic deformation of tissue during palpatory assessment Moderate: small range of elastic deformation of tissue during palpatory assessment Low: decreased range of elastic deformation during palpatory assessment

Glide/gliding impairment

High: absence of gliding/sliding between fascial planes during palpatory assessment Moderate: decrease in gliding/sliding between fascial planes during palpatory assessment Low: absence of impairment in gliding/sliding of fascial layers

* The patient’s positive thinking about their condition and/or prognosis † Fluctuating (alternating/changing) neuropathic or nociceptive manifestation †† The patient’s erroneous and/or catastrophic thoughts about their condition and/or prognosis

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ASSESSMENT OF THE CRANIOFACIAL COMPLEX

Laterotrusion Static stability

Opening

Protrusion

Functional Movement Screen (FMS)

Stability Dynamic stability

Global functional assessment

ROM Muscle control during swallowing

Mobility

Craniocervical motor behavior during mouth opening

Movement synergy

Mandibular behavior during mouth opening

Facial behavior during mandibular laterotrusion

Figure 15.1.1

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Craniofacial and myodural bridge complex

VIEWS OF THE SKULL STRUCTURES

Figure 15.1.2 Views of the skull structures (see Box 15.1.1)

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Box 15.1.1 The cranial vault, meninges, and nervous system Before applying therapeutic procedures to the craniofacial complex the practitioner is highly recommended to read this brief overview of the cranial vault (bones and sutures), meninges, and nervous system and the structural and functional links between them. Particular attention should be paid to the extensive network of cranial sutures and its surprisingly complex and diverse architecture, which is unique to the craniofacial skeleton and does not occur in unions of bones in other parts of the body. The most common suture shapes are (according to Pick 1999): serrated sutures (e.g., the sagittal suture), denticulate sutures (e.g., the lambdoid suture), squamous sutures (e.g., between the parietal and temporal bones), limbous sutures (e.g., the coronal suture), plane sutures (e.g., the intermaxillary suture), schindylesis (between the rostrum of the sphenoid and the vomer), synchondroses (e.g., the sphenobasilar symphysis). This complex network of sutures, in conjunction with the meninges, forms a tensegrity structure which is indicative of its purpose (Scarr 2008). This system has the following attributes: • multistability (controls all of its components which allows for continuous and efficient functional interactions); • independence (the shape of the skull remains independent of intracranial pressure); • dynamic coherence (sutures are in a state of continuous pre-tension, independent of brain growth); • selectivity (through a continuous process of adjustment the dynamics of the musculoskeletal system – the demands resulting from myofascial stresses – are able to function independently from the dynamics of the brain); • multifunctionality (functional optimization and inherent stability). There is anatomical continuity throughout the central and peripheral nervous systems at all levels of their construction (see Chapter 7), both at the macroscopic level, in the continuity between the meninges and the peripheral neuroconnective tissue (neurofascia), and at the microscopic level, through the systematic “link” between neurons and neuroglia (i.e., the “transition zone”). This continuity is significant because of its impact both on the transmission of forces and on the hydrodynamics of cerebrospinal fluid and interstitial fluid. The meningeal system and the peripheral nerves, in addition to being integrated with each other, make up an integral part of the osteoarticular, myofascial, glymphatic, lymphatic, and visceral systems. The analysis of the anatomical continuity of the meninges below is intended to complement the conceptual framework developed in this book. A more detailed approach to this topic is beyond the scope of this book.

Continuity of the meninges with the osteoarticular system Continuity of the meninges with sutures There are three layers of meninges, known as the dura mater, arachnoid, and pia mater. Several studies have shown that the meninges have a role in the modulation of immune response and severe inflammation processes (Herisson et al. 2018, Russo et al. 2018).

The outermost layer is the dura mater and it consists of dense and strong connective tissue with abundant amounts of collagen fibers which participate in force transmission (connective tissue with dense collagen architecture) (Protasoni at al. 2011). Its architecture consists of three layers: the endosteal (periosteal) layer, the meningeal layer (tectorial membrane), and the dural border cell layer. The outermost layer (periosteal layer) covers the internal surface of the skull to which it is strongly attached mainly at the base of the skull. The outermost part of the periosteal layer is continuous with the scalp through the emissary veins. Within the skull there is no epidural space as is present throughout the spinal canal. The periosteal layer has no communication with the dura of the spinal cord (thecal sac) but it is continuous with the periosteum at the external surface of the skull bones at the level of its foramina and with the cranial suture ligaments. The meningeal layer of the dura mater is weaker in its structure and is firmly attached to the endosteal layer except at the sites where the venous sinuses are located and in the dural reflection sites. This layer communicates with the dura of the spine at the level of the foramen magnum. At sites where the cranial nerves and blood vessels perforate the meningeal dura mater the meningeal layer becomes continuous with its epineurium (see Chapter 7).

Continuity of the meninges with the craniocervical unit Upon reaching the craniocervical joint, the meningeal layer manifests as a thin structure in three distinct layers. It continues along the atlantoaxial ligament and along the posterior aspect of the cruciform ligament, merging with the latter. Subsequently it reaches and fuses with the posterior longitudinal ligament. Some authors, such as Hecker (1922), Panjabi (1991) and White (1991), have found that the tectorial membrane plays an important role in the maintenance of the stability of the craniocervical joint, in particular, by limiting flexion movement. The posterior part of the tectorial membrane is continuous with the posterior atlanto-occipital membrane, which forms a broad and thin ligament that connects the lower border of the posterior arch of the atlas to the posterior superior edge of the foramen magnum. The tectorial membrane does not limit cervical flexion per se but rather helps to ensure that the odontoid process does not impinge into the cervical canal (Tubbs et al. 2007). This summary highlights the anatomical continuity and functional integration of the meningeal system with cranial sutures and the craniocervical junction. As a consequence of this continuity, alterations in meningeal tension can lead to reciprocal changes in the dynamics of the osteoarticular system. The anatomical continuity of the suboccipital structures in relation to the connections of the myodural bridge and the nuchal ligament with the tectorial membrane could lead to physiological repercussions related to the circulation of cerebrospinal fluid. According to research by Xu et al. (2016), Zheng et al. (2020), and Ma et al. (2021), craniocervical movements, through the connections of the myodural bridge and the nuchal ligament with the dura mater, could be an important factor in the dynamics of circulation of cerebrospinal fluid. These findings could open up a new therapeutic perspective.

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Craniofacial and myodural bridge complex

MYOFASCIAL INDUCTION OF THE OCULAR AREA

Objective To restore mobility to the fascial structures of the ocular area

Objective

Type of procedure Sustained systemic procedure (indirect application)

A

Irritability/type of dysfunction

Type of procedure

Indications Dysfunctions of the facial fascia; pain and craniomandibular dysfunction; sequelae of facial nerve injury (paresis); trigeminal nerve neuralgia; headache Irritability/type of dysfunction Irritability: high Neuroprotection: high Rigidity/stiffness: low Glide: moderate

Indications

B

Figure 15.1.3

A Longitudinal induction. B Transverse induction

Patient position

Supine

Practitioner position

Sitting or standing at the side of the patient level with the patient´s head (A) or at the patient’s head (B)

Hand contacts

Place the index fingers above and below the eye (A) or on both sides of the orbit (B).

Procedure

Perform gentle compression and stretching to find the barrier of restriction. This should be followed by barrier release applied 3 to 6 times over 3–5 minutes.

Observations/ contraindications

The patient should remove contact lenses before this procedure is applied. The procedure should not be applied if inflammation is present, if there is an injury, or following recent ocular surgery.

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MYOFASCIAL INDUCTION OF THE ZYGOMATIC AREA Objective To restore mobility to the structures of the zygomatic area

Objective

Type of procedure Sliding: longitudinal stroke (direct application) Irritability/type of dysfunction

Type of procedure

Indications Facial mobility dysfunctions; alterations of facial expression; altered mandibular mobility; craniomandibular pain and dysfunction; sequelae of facial nerve injury (paresis); trigeminal neuralgia Irritability/type of dysfunction Irritability: low Neuroprotection: low Rigidity/stiffness: moderate Glide: moderate

Indications

Patient position

Supine

Practitioner position

Sitting at the head of the table

Hand contacts

Bend the middle and ring fingers at the middle joint and place the pads of the fingers below the zygomatic arches at the level of the nostrils.

Procedure

Perform 3 longitudinal gliding strokes below and along the zygomatic arch. It is important to maintain the hook-like position of the fingers. The principles of the longitudinal stroke should be adhered to (see Table 13.3).

Observations/ contraindications

Take care not to obstruct breathing. Remember that the gliding stroke has to be performed slowly, maintaining a constant pressure, and it must be stopped for about 6–7 seconds at each fascial entrapment.

Figure 15.1.4

Nails should be kept short.

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Craniofacial and myodural bridge complex

MYOFASCIAL INDUCTION OF THE SCALP

Objective To restore mobility to the fascial complex of the scalp

Objective

Type of procedure Sustained systemic procedure (indirect application) Irritability/type of dysfunction

Type of procedure

Indications Tension headache; Arnold’s neuralgia; generalized hyperalgesia; forward head posture Irritability/type of dysfunction Irritability: low Neuroprotection: low Rigidity/stiffness: moderate Glide: low

Indications

Patient position

Supine

Practitioner position

Sitting at the head of the table

Hand contacts

The fingers are entwined with the patient’s hair close to the skull.

Procedure

Pull the patient’s hair gently but firmly. Maintain this traction for about 3–5 minutes. Follow the spontaneous movement of the neck as it occurs.

Observations/ contraindications

If the patient is bald or has very short hair the fingertips will be in direct contact with the scalp.

Figure 15.1.5

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TRANSVERSE STROKE APPLIED TO THE TEMPORAL AREA

Objective To mobilize the temporal fascia and improve the functional behavior of the temporal muscle

Objective

Type of procedure Transverse stroke (direct application) Irritability/type of dysfunction

Type of procedure

A

Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate Rigidity/stiffness: low Glide: moderate

Indications

B

Indications Temporomandibular disorder: hypermobility, inflammatory conditions, internal derangement. Cervical postural disorders, temporal tendinopathy

Patient position

Supine

Practitioner position

Sitting at the head of the table

Hand contacts

Place the hands (with the fingertips slightly apart) on the superior area of the belly of the temporalis muscles (A & B).

Procedure

Apply 15 cycles of very gentle transverse strokes at intervals of 2–2.5 cm (B & C). The principles of transverse stroke should be adhered to (see Table 13.2). In the presence of a unilateral restriction a sustained induction procedure should be performed, focusing on the specific (more restricted) point. To apply this procedure, place the index finger directly on the restriction point in the temporal muscle tendon (D) and ask the patient to gently open their mouth and move the jaw slightly to the opposite side. This procedure produces greater tension in the fascia of the temporal tendon facilitating its subsequent induction. Apply gentle and progressive pressure until the barrier or restriction is reached. Maintain the pressure until the movement is facilitated. Continue for 3 to 6 adjustments. Follow up with the single-hand contact procedure (see Table 13.6).

C

Observations/ contraindications

Take great care when pressing on this area as it is usually extremely sensitive. Reduce the pressure when the patient’s mouth is open and the tendon is in tension.

D Figure 15.1.6 Craniofacial complex: transverse stroke applied to the temporal area. A Hand position on the cadaver. B Starting position of the hands on the patient’s head. C Final position of the hands on the patient’s head. D Unilateral restriction approach.

Image A is reproduced with permission from Pilat A. Castro-Martín E. (2018) Myofascial induction approaches in temporomandibular disorders. In: Fernández-de-las-Peñas C, Mesa-Jiménez J. (Eds.) Temporomandibular Disorders: Manual Therapy, Exercise, and Needling. Edinburgh: Handspring Publishing

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Craniofacial and myodural bridge complex

MYOFASCIAL INDUCTION OF THE TEMPORAL AREA

Objective Induction of the temporal fascia. To achieve functional symmetry of the temporalis muscles

Objective

Type of procedure Sustained systemic procedure (indirect application) Irritability/type of dysfunction

Type of procedure

Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate Rigidity/stiffness: low Glide: moderate

Indications

Figure 15.1.7

Indications Temporomandibular dysfunction: hypermobility, inflammatory conditions, internal derangement. Cervical postural disorders, temporal tendinopathy. Craniocervical dysfunction at C2 metameric level

Patient position

Supine

Practitioner position

Sitting at the head of the table

Hand contacts

Hold the patient’s ear lobes between the index fingers and thumbs.

Procedure

With the hands at a 45-degree angle, perform gentle traction (pulling) of the lobes, working with any direction of movement that arises and spending a long time on the application of the procedure (5–15 minutes).

Observations/ contraindications

Use the table to support the forearms. Be careful not to lose grip. Focus on the temporal fascia. Only very gentle traction should be applied.

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MYOFASCIAL INDUCTION OF THE MASSETER Objective To optimize the dynamics of the fascia-related structures of the masseter

Objective

Type of procedure Sustained systemic procedure (indirect application) Irritability/type of dysfunction

A

Type of procedure

Indications Temporomandibular dysfunction: hypermobility, inflammatory conditions, cervical postural disorders. Trigeminal neuralgia Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate Rigidity/stiffness: low Glide: moderate

Indications

Patient position

Supine

Practitioner position

Standing or sitting at the patient’s head

Hand contacts

Procedure A: vertical induction Place the fingers of the cranial hand on the zygomatic arch at the point of insertion of the masseter. Position the thumb of the caudal hand at the belly of the masseter, just below the fingers of the cranial hand. Procedure B: horizontal induction Place the tips of the middle and ring fingers of both hands bilaterally and symmetrically at the point of insertion of the masseter into the zygomatic arch.

B

Procedure

Procedure A: vertical induction Apply gentle pressure with the cranial hand in the cranial direction and with the caudal hand in the caudal direction. After the release, the caudal hand should move toward the maxillary angle. Procedure B: horizontal induction Apply sustained pressure toward the midline of the patient’s body. Sustained systemic procedures should be followed (see Chapter 13).

Observations/ contraindications

The application may be continued for longer in the presence of further restrictions.

Figure 15.1.8

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Craniofacial and myodural bridge complex

INTRAORAL INDUCTION OF THE MASSETER Objective To optimize the dynamics of the fascia-related structures of the masseter

Objective

Type of procedure Sustained systemic procedure (indirect application) Irritability/type of dysfunction

A

Indications

Type of procedure

Indications Temporomandibular dysfunction: hypermobility, inflammatory conditions, cervical postural disorders. Trigeminal nerve mechanosensitivity Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate Rigidity/stiffness: low Glide: moderate

Patient position

Supine. With the mouth open, the patient is asked to move the jaw to the side (the side to be treated)

Practitioner position

Standing beside the patient at the side to be treated

Hand contacts

A glove should be worn for this procedure. Using the right hand to treat the right side and the left hand to treat the left side, place the index finger intraorally on the masseter just below the zygomatic arch. To ensure the position is correct, ask the patient to attempt to close their mouth. Once the muscle is correctly located, the patient should immediately relax the masseter.

Procedure

Compress the masseter between the index finger and the thumb. Wait for the release to occur (overcoming 3–6 barriers of restriction).

Observations/ contraindications

Avoid pressing on the parotid gland.

Figure 15.1.9

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MYOFASCIAL INDUCTION OF THE EXTERNAL PTERYGOID MUSCLE

Objective To improve the functional behavior of the external pterygoid muscle, optimize the pterygoid fascia, and improve the mechanics of the TMJ and the fascia-related structures of the masseter

Objective

Irritability/type of dysfunction

Indications

Figure 15.1.10

Type of procedure

Type of procedure Sustained systemic procedure (indirect application) Indications Disturbances of jaw mobility and occlusion Dysfunctions of the disc and temporomandibular joint Irritability/type of dysfunction Irritability: high Neuroprotection: high Rigidity/stiffness: moderate/high Glide: moderate

Patient position

Supine. With the mouth open, the patient is asked to move the jaw to the side (the side to be treated)

Practitioner position

Standing at the patient’s head

Hand contacts

Palpate the TMJ with the index finger or middle finger of the nondominant hand. Place the index finger of the other hand inside the mouth on the pterygoid muscle, with the fingernail against the upper teeth. A glove should be worn for this procedure.

Procedure

Apply light and progressive pressure until the barrier is reached. Maintain the pressure until facilitated movement occurs. The principles of sustained induction should be adhered to (see Chapter 13).

Observations/ contraindications

This area is extremely sensitive. Great care should be taken when applying pressure.

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Craniofacial and myodural bridge complex

MYOFASCIAL INDUCTION OF THE INTERNAL PTERYGOID MUSCLE

Objective To improve the functional behavior of the external pterygoid muscle, optimize the pterygoid fascia, and improve the mechanics of the TMJ

Objective

Type of procedure Sustained systemic procedure (indirect application) Irritability/type of dysfunction

Type of procedure

Indications Craniofacial and temporomandibular dysfunctions Irritability/type of dysfunction Irritability: high Neuroprotection: high Rigidity/stiffness: moderate Glide: low

Indications

Patient position

Supine

Practitioner position

Standing beside the patient at the side to be treated

Hand contacts

The index finger of the external hand palpates the TMJ. The tip of the index finger of the other hand is placed on the belly of the internal pterygoid muscle. A glove should be worn for this procedure.

Procedure

Apply light and progressive pressure until the barrier of restriction is reached. Maintain the pressure until facilitated movement occurs. The principles of sustained induction should be adhered to (see Chapter 13).

Observations/ contraindications

This area is extremely sensitive. Great care should be taken when applying pressure. Take care to avoid stimulating the gag reflex.

Figure 15.1.11

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MYOFASCIAL INDUCTION OF THE HARD PALATE

Objective To optimize the force distribution capacity of the hard palate

Objective

Type of procedure Sustained systemic procedure (indirect application) Irritability/type of dysfunction

Type of procedure

Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate Rigidity/stiffness: high Glide: low

Indications

Figure 15.1.12

Indications Craniofacial and temporomandibular dysfunctions; dental hypersensitivity; sinusitis; trigeminal nerve mechanosensitivity

Patient position

Supine

Practitioner position

Standing next to the patient’s head

Hand contacts

Place the cranial hand under the patient’s head (with the fingers pointing in the caudal direction). This keeps the nuchal ligament in a fixed position. A glove should be worn on the caudal hand. Place the index and middle fingers of the caudal hand on the chewing surfaces of the back molars of the upper dental arch.

Procedure

The cranial hand holds the skull and the nuchal ligament still in the first phase of the technique. With the “intraoral” fingers of the caudal hand exert a gentle but firm pressure in the cranial direction. Facilitate any combination of consecutive releases with the fingers placed on top of the molars. In the second phase of the procedure (after about 60 seconds of application), slight adjustments in the positioning of the head can be detected.

Observations/ contraindications

If the patient has a dental prosthesis or a dental piece, work directly against the gum. A glove should be worn for this procedure.

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Craniofacial and myodural bridge complex

MYOFASCIAL INDUCTION OF THE VOMER

Objective To relieve pressure on the hard palate through vomer induction

Objective

T of pprocedure Type Sustained systemic procedure (indirect application) Irritability/type of dysfunction

Type of procedure

Indications Craniofacial and temporomandibular dysfunctions; dental hypersensitivity; neuralgia or hypersensitivity of the trigeminal nerve Irritabili Irritability/type of dysfunction Irritability: moderate Neuroprotection: high Rigidity/stiffness: high Glide: low

Indications

Patient position

Supine

Practitioner position

Standing at the side of the table next to the patient’s head

Hand contacts

Place the cranial hand under the patient’s head (with the fingers pointing in the caudal direction). Place the middle finger or index finger of the dominant hand on the posterior part of the cruciform suture.

Procedure

Apply very gentle pressure in the cranial direction. Sustained systemic procedures should be adhered to (see Chapter 13).

Observations/ contraindications

The pressure applied should be extremely gentle. A glove should be worn for this procedure.

Figure 15.1.13

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TEMPOROMANDIBULAR INDUCTION A

B

Objective To optimize the functional behavior of the temporomandibular area

Objective

Type of procedure Sustained systemic procedure (indirect application) Irritability/type of dysfunction

Type of procedure

Indications Temporomandibular disorder; neuralgia or hypersensitivity of the trigeminal nerve Irritability/type of dysfunction Irritability: high Neuroprotection: high Rigidity/stiffness: low Glide: moderate

Indications

Patient position

Supine

Practitioner position

Sitting at the head of the table

Hand contacts

First phase: compression (A) The hands are placed bilaterally on the jaw so the tips of the index and middle fingers are positioned on the chin part of the jaw. Second phase: decompression (B) The index and middle fingers are placed on the angle of the mandible. The rest of the hand is adjusted to the patient’s head.

Procedure

First phase: compression Apply gentle pressure in the cranial direction. Wait until release occurs. This usually takes about 60 seconds. Second phase: decompression Apply gentle caudal traction. The principles of sustained systemic procedures should be adhered to (see Chapter 13).

Figure 15.1.14 Middle image in part B is reproduced with permission from Pilat A. Castro-Martín E. (2018) Myofascial induction approaches in temporomandibular disorders. In: Fernández-de-las-Peñas C., Mesa-Jiménez J. (Eds.) Temporomandibular Disorders: Manual Therapy, Exercise, and Needling. Edinburgh: Handspring Publishing

Observations/ contraindications

The pressure or traction applied should be very gentle. At the end of the procedure ask the patient to progressively open and close their mouth and repeat the action 3 to 5 times.

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Craniofacial and myodural bridge complex

POSTISOMETRIC INDUCTION

Objective To optimize the mobility of the fascial components involved in craniomandibular dysfunctions

Objective

Type of procedure Sustained systemic procedure (indirect application) Irritability/type of dysfunction

Indications

Type of procedure

Indications Temporomandibular dysfunction; neuralgia or hypersensitivity of the trigeminal nerve Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate Rigidity/stiffness: low Glide: moderate

Patient position

Sitting beside the table with the elbows resting on the table. Tissues are provided in case there is excessive salivation during the procedure.

Practitioner position

Sitting facing the patient

Hand contacts

Gloves should be worn for this procedure. Place the thumbs inside the mouth on the chewing surfaces of the lower molars. Place the index fingers along the mandibular ramus and the flexed middle fingers at the lower edge of the jaw close to the angle of the mandible in order to stabilize the mandible.

Procedure

First phase: contraction The patient performs an isometric contraction (without closing the mouth) with the masseters against the resistance applied by the practitioner. Second phase: relaxation After relaxation of the contraction, the practitioner performs consecutive releases on three barriers of restriction. The direction of the movement is downward and slightly forward. The practitioner should follow the facilitated movement.

Observations/ contraindications

Figure 15.1.15

The main movement is the release of the TMJ structures, however, spontaneous head movements may occur many times. The practitioner should follow these movements without creating resistance.

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SAGITTAL SECTION OF THE HEAD AND UPPER NECK SHOWING THE MYODURAL BRIDGE

A

B C D E F G H

I

Figure 15.1.16 Sagittal section of the head and upper neck showing the myodural bridge A B C D E

Falx cerebri Pons Cerebellum Occipital bone Myodural bridge

F G H I

Posterior tubercle of the arch of atlas Dura mater Spinal cord Tongue

Photograph by Dr. Nicolás Barbosa. Reprinted with permission

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Craniofacial and myodural bridge complex

MYOFASCIAL INDUCTION OF THE SUBOCCIPITAL TRIANGLE

Objective To restore mobility to the myofascial structures of the suboccipital triangle area. To improve the dynamics of the nuchal ligament

Objective

Type of procedure Sustained systemic procedure (indirect application) Irritability/type of dysfunction

Type of procedure

A

Irritability/type of dysfunction Irritability: high Neuroprotection: high Rigidity/stiffness: high Glide: low

Indications

B

Indications Temporomandibular and cervical dysfunction (forward head posture); alterations in cerebrospinal fluid circulation; Arnold’s neuralgia; headache

Patient position

Supine

Practitioner position

Sitting at the head of the table

Hand contacts

Place the cranial hand under the patient’s head (with the fingers pointing in the caudal direction). The caudal hand (forming a bridge with the thumb on one side and the fingers on the other side) holds the cervical spine.

Procedure

With the cranial hand, perform very light traction on the occipital area in the cranial direction while the caudal hand holds the upper cervical region in position. A facilitated movement of the head should occur, allowing a gentle, small-amplitude release. The application time ranges from 3–5 minutes.

Observations/ contraindications

The procedure can be applied even in cases of high sensitivity in the region. Take care if vertebrobasilar syndrome is present. Red flags: myelopathy; vertebral instability; ventriculoperitoneal shunts.

C

Figure 15.1.17 A Position of the hands demonstrated on the skeleton. B Suboccipital triangle area (white lines). C Application of suboccipital triangle induction

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MYOFASCIAL BRIDGE INDUCTION

Objective To restore mobility to the myofascial bridges of the suboccipital region

Objective

Type of procedure Sustained systemic procedure (indirect application) Irritability/type of dysfunction

Type of procedure

Indications Forward head posture; temporomandibular disorder; alterations in cerebrospinal fluid circulation; Arnold’s neuralgia; headache Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate Rigidity/stiffness: high Glide: low

A Indications

Patient position

Supine

Practitioner position

Sitting, at the head of the table, level with the patient’s head

Hand contacts

Place both hands under the patient’s head. Support at least the middle part of the forearms on the table. Place the ring and middle fingers of both hands on the suboccipital region. Extend the thumbs, index fingers, and little fingers toward the table; they are not used in this phase of the procedure.

Procedure

Flex the middle and ring fingers at the metacarpophalangeal joints, pointing the fingertips toward the ceiling. The interphalangeal joints remain in extension. If interphalangeal extension is not possible, semiflexion can be used instead. With these hand contacts, the patient’s head should be suspended in the air. During the myofascial induction, the head gradually moves into extension. This position is maintained for approximately 4 minutes.

B

Next, remove the middle fingers from the neck, so that they rejoin the extended index fingers. Bring the fingers together at the occipital condyles. Then, very gently, push in the cranial and anterior direction. The final phase lasts only a couple of seconds. It is the phase of “disengagement” of the occipital condyles. Finally, slowly remove the hands laterally from the patient’s head.

C

Observations/ contraindications

The vertebral artery test should be performed before this procedure. The procedure cannot be performed if the result of the test is positive. The patient should remain on the table for at least 2 minutes after completion of the procedure.

Figure 15.1.18

A Position of the hands in relation to the cervical spine. B Position of the hands in relation to the cervical skull. C Performance of myofascial bridge induction

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Cervical complex

ASSESSMENT OF THE CERVICAL COMPLEX

Static stability

Motor behavior during craniocervical flexion

Motor behavior during craniocervical extension

Stability Dynamic stability

Global functional assessment

ROM Assessment of basic neck movements Mobility Movement synergy

Muscle control during swallowing

Craniocervical motor behavior during mouth opening

Figure 15.2.1

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FASCIAL ANATOMY OF THE ANTEROLATERAL CERVICAL AREA

B D

A C

D

1

2

3

Figure 15.2.2 1 Superficial fascia of the head and neck. Note the continuity of the fascial tissue 2 Anterior muscles of the neck A Suprahyoid muscles B Cricoid cartilage C Sternocleidomastoid D Infrahyoid muscles 3 Frontal view of the deep cervical fascia

Image 2 courtesy of Prof. Dr. Horacio Conesa and reproduced with permission from Pilat A. (2010) Myofascial induction approaches for patients with headache. In: Fernández-de-las-Peñas C., Arendt-Nielsen L., Gerwin R.D. (Eds.) Tension-Type and Cervicogenic Headache: Pathophysiology, Diagnosis, and Management. Sudbury, MA: Jones and Bartlett Publishers

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Cervical complex

ANTEROLATERAL CERVICAL AREA: MYOFASCIAL INDUCTION OF THE STERNOCLEIDOMASTOID Objective To restore mobility to the anterolateral myofascial structures

Objective

Type of procedure Sliding: transverse stroke (direct application) A

B

Irritability/type of dysfunction

Type of procedure

Irritability/type of dysfunction Irritability: moderate Neuroprotection: high Rigidity/stiffness: high Glide: low

Indications

D

C

E

Patient position

Supine

Practitioner position

Sitting at the head of the table

Hand contacts

Identify the sternocleidomastoid side with greater hypomobility in advance through a palpatory assessment. Next, place one hand on the patient’s head on the unaffected side and turn the head to the compromised side. This maneuver allows the other hand to access the sternocleidomastoid more easily. With this hand hold the area of greatest entrapment (rigidity) firmly between the flexed index finger and thumb.

Procedure

Apply small amplitude transverse strokes (with a range of 1–1.5 cm) to all restricted areas. Up to 3 sets of 15 transverse strokes should be applied to each entrapment, usually in 3 or 4 different sites. The movement must be contained within the muscle belly.

Observations/ contraindications

If the restriction manifests in the area nearest to the clavicular insertion, the depth of the hold is reduced and the contact is with the tips of the index finger and thumb. Take care to avoid active trigger points. The rhythm of the sliding movement is slow and must be adapted to changes in texture. The procedure is applied bilaterally.

F

Figure 15.2.3 A Sternocleidomastoid. B Palpatory assessment. C Position of fingers on the muscle belly shown on the cadaver. D Position of fingers on the muscle insertion shown on the cadaver. E Position of fingers on the patient’s muscle belly. F Position of fingers on the patient’s tendon. Image D is reproduced with permission from Pilat A. (2010) Myofascial induction approaches for patients with headache. In: Fernández-de-las-Peñas C., Arendt-Nielsen L., Gerwin R.D. (Eds.) Tension-Type and Cervicogenic Headache: Pathophysiology, Diagnosis, and Management. Sudbury, MA: Jones and Bartlett Publishers

Indications Forward head posture; headaches; cerebrospinal fluid circulation disturbances; deficient expansion on inspiration; torticollis (wryneck syndrome)

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ANTEROLATERAL CERVICAL AREA: MYOFASCIAL INDUCTION OF THE DEEP NECK FLEXORS (RETROHYOID PROCEDURE) A

B Objective To restore mobility to the deep neck flexor. To improve the movement of the hyoid bone. To facilitate movements related to swallowing, phonation, and breathing

Objective

Irritability/type of dysfunction

Type of procedure

1

Figure 15.2.4

1 Continuity of the superficial fascia of the head, face, and neck A Hyoid bone B Sternocleidomastoid 2 Retrohyoid procedure performed on the patient

Indications Temporomandibular and cervical dysfunctions; phonation and swallowing dysfunctions; weakness of the deep flexor muscles; restrictions of cervical mobility; dynamic cervical instability Irritability/type of dysfunction Irritability: high Neuroprotection: high Rigidity/stiffness: low Glide: moderate

Indications

2

Type of procedure Sustained systemic procedure (indirect application)

Patient position

Supine

Practitioner position

Sitting at the head of the table next to the side to be treated

Hand contacts

Using one hand, rotate the patient’s head slightly to one side. This hand controls the position of the patient’s head during the application of the procedure. Place the other hand, pronated, on the space below the mass of the sternocleidomastoid muscle, above the vertebral bodies, and over the prevertebral fascia.

Procedure

Apply progressive pressure toward the anterior cervical midline with the tips of the first three fingers of the pronated hand. On reaching the barrier, wait for the release and follow the direction of the facilitated movement.

Observations/ contraindications

The trachea and carotid sheath are very vulnerable structures. To successfully perform the procedure requires advanced skills in soft tissue techniques. The procedure is performed without gloves. Red flags: Avoid pressing on the trachea and the carotid sheath.

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Cervical complex

ANTEROLATERAL CERVICAL AREA: MYOFASCIAL INDUCTION OF THE SCALENES

Objective To restore mobility to the scalene muscles. To improve breathing dynamics

Objective

A

Irritability/type of dysfunction

Type of procedure

Type of procedure Sustained systemic procedure (indirect application) Indications Temporomandibular dysfunction; neuralgia or hypersensitivity of the trigeminal nerve Irritability/type of dysfunction Irritability: low Neuroprotection: moderate Rigidity/stiffness: high Glide: low

Indications

Patient position

Supine

Practitioner position

Sitting at the head of the table

Hand contacts

One hand holds and controls the position of the patient’s head. The treatment hand is placed in one of three positions: A On the anterior scalene: in prone position with two or three fingers behind the belly of the sternocleidomastoid muscle. B On the middle scalene: in prone position with two or three fingers below the middle third of the clavicle. C On the posterior scalene: with the flexed thumb below the distal third of the clavicle.

Procedure

The treatment hand exerts progressive pressure caudally and in the direction of the insertion of the muscle to be treated. Follow the facilitated movement when the barrier is reached. Head movement is expected; allow for a gentle, small-amplitude movement to occur. The application lasts 5–10 minutes.

Observations/ contraindications

Depending on the morphology of the patient or practitioner, the thumb, index finger, or middle finger may be used. Be careful when touching the area of the brachial plexus. Avoid pressing on the trachea, subclavian artery, and carotid sheath. The procedure should be performed gently to avoid irritating neurovascular structures.

B

C

Figure 15.2.5

Treatment positions. A Anterior scalene. B Middle scalene. C Posterior scalene

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MIT procedures for common craniocervical and neck dysfunctions

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MYOFASCIAL INDUCTION OF THE CRANIOCERVICAL AREA

Objective To restore mobility to the craniocervical area

Objective

Type of procedure Sustained systemic procedure (indirect application)

Irritability/type of dysfunction

A Indications

B

B

Figure 15.2.6

Type of procedure

Indications Dysfunctions of the fascial system in the area between the skull and the neck; dynamic instability; mechanosensitivity of the superficial cervical plexus Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate Rigidity/stiffness: low Glide: moderate

Patient position

Supine without a pillow and with the head rotated slightly on the contralateral side

Practitioner position

Standing at the head of the table, facing the rotated side (of the patient’s head)

Hand contacts

Cross the hands and place the cranial hand on the temporal region and the other hand on the patient’s face. The hands should be over the zygomatic arch.

Procedure

The cranial hand exerts pressure cranially and the caudal hand exerts pressure in the caudal direction (A). Wait until three barriers have been released. Then allow the caudal hand to glide slightly in the caudal direction on the belly of the platysma until it reaches the upper pectoral region (B). This is not a stretching procedure but rather a movement accompanied by the rhythm of myofascial induction. You should feel a deep release before starting the glide as the caudal hand moves at the clavicular level. In the presence of resistance, stop the movement and wait until the barrier releases.

Observations/ contraindications

The procedure must be applied bilaterally. Do not force the rotation or lateral inclination of the patient’s head. The procedure should not result in resisted movement between the hand and the patient’s head. The force applied should be very gentle.

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Cervical complex

MYOFASCIAL RELATIONSHIPS OF THE HYOID REGION

A

B

C D

1

Figure 15.2.7 1 Lateral view of the cervical deep fascia A Chin B Angle of the mandible C Cricoid cartilage D Clavicle Arrow – platysma muscle fiber orientation 2 Inframandibular area A Mylohyoid muscle B Anterior belly of the digastric muscle C Hyoid bone D Intermediate tendon of the digastric muscle E Cricoid cartilage F Fascial band between the digastric and hyoid muscles G Posterior belly of the digastric muscle

A B

C D E F G

2

Image 2 is reproduced with permission from Pilat A. (2010) Myofascial induction approaches for patients with headache. In: Fernández-de-las-Peñas C., Arendt-Nielsen L., Gerwin R.D. (Eds.) Tension-Type and Cervicogenic Headache: Pathophysiology, Diagnosis and Management. Sudbury, MA: Jones and Bartlett Publishers

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MIT procedures for common craniocervical and neck dysfunctions

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LONGITUDINAL STROKE APPLIED TO THE EXTERNAL MOUTH FLOOR

Objective To mobilize the fascial system of the floor of the mouth

Objective

Type of procedure Sliding: longitudinal stroke (direct application) Irritability/type of dysfunction

1 A

B

C Indications

B

Indications Dysfunctions of swallowing and phonation; temporomandibular disorders; parafunctions of the tongue; shoulder dysfunction due to dynamic stability compensation Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate Rigidity/stiffness: low Glide: low

Patient position

Supine, without a pillow

Practitioner position

Sitting or standing at the head of the table

Hand contacts

With the distal phalanges flexed, place the tips of the middle and ring fingers of both hands in the insertion of the digastric muscle under the jaw.

Procedure

Slowly and progressively slide the fingers of both hands laterally. The movement of the hands stops when the restriction manifests on either side. The edge of the horizontal branch of the jaw serves as a guide. When the mandibular angle is reached, the hands are removed. Resume the starting position and repeat the procedure 7 times.

Observations/ contraindications

The procedure should be applied bilaterally. Take care in the presence of pain. Take care not to irritate the submandibular glands.

2 A

Type of procedure

3 Figure 15.2.8 1 Lateral aspect of the neck and mandible A Ear B Angle of the mandible C Base of mandible

2 Anterior aspect of the neck A Chin B Base of mandible 3 Performance of the procedure

Image 2 is reproduced with permission from Pilat A. (2010) Myofascial induction approaches for patients with headache. In: Fernández-de-las-Peñas C., Arendt-Nielsen L., Gerwin R.D. (Eds.) Tension-Type and Cervicogenic Headache: Pathophysiology, Diagnosis, and Management. Sudbury, MA: Jones and Bartlett Publishers

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Cervical complex

INDUCTION OF THE MYOFASCIAL COMPLEX OF THE TONGUE

Objective To restore mobility to the myofascial hyoid complex

Objective

Type of procedure Sustained systemic procedure (indirect application) Tongue

Mandible

Irritability/type of dysfunction

Type of procedure

Hyoid bone

A

Irritability/type of dysfunction Irritability: low or moderate Neuroprotection: low or moderate Rigidity/stiffness: low Glide: low

Indications

B

Figure 15.2.9 A Sagittal section of the mandibular area. B Application of the procedure

Indications Hyoid dysfunction; dysfunctions of swallowing and phonation; temporomandibular disorders; parafunctions of the tongue; shoulder dysfunction due to dynamic stability compensation

Patient position

Supine

Practitioner position

Standing at the head of the table

Hand contacts

With the nondominant hand, turn the patient’s head slightly to one side. With the other (gloved) hand, grip the patient’s tongue between the flexed index finger and thumb.

Procedure

The practitioner applies very gentle and sustained traction to the tongue. Approximately 5 minutes is required to obtain the correcting (facilitating) movement.

Observations/ contraindications

The practitioner should use a disposable gauze pad to prevent the tongue from slipping. Red flag: Do not lose grip of the tongue or allow it to roll back.

Blue arrows – tongue traction vector White arrow – hyoid–tongue link

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MIT procedures for common craniocervical and neck dysfunctions

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MYOFASCIAL INDUCTION OF THE OMOHYOID

Objective To improve the dynamics of the hyoid through fascial adjustment of the omohyoid

Objective

Irritability/type of dysfunction

Indications

Type of procedure

Type of procedure Sustained systemic procedure (indirect application) Indications Hyoid dysfunction; dysfunctions of swallowing and phonation; temporomandibular disorders; parafunctions of the tongue; shoulder dysfunction due to dynamic stability compensation

Patient position

Sitting on a chair

Practitioner position

Standing behind the patient

Hand contacts

Place the index finger of the treatment hand on the body of the hyoid on the most affected (hypomobile) side. Place the other hand on the ipsilateral suprascapular area. Do not touch the hyoid with the other fingers.

Procedure

The hand placed over the scapula holds the shoulder while pushing in the caudal direction (thick arrow), while the hand placed over the hyoid bone very gently pushes the hyoid in the cranial direction (thin arrow) until the barrier is felt. Follow the facilitated movement for up to 5 minutes.

Observations/ contraindications

The pressure applied should be extremely gentle. The main movement during treatment is in the hyoid. The scapula should not be overstimulated. If the patient has had recent thyroid surgery wait about 2 months before applying the procedure.

Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate Rigidity/stiffness: low Glide: moderate

Figure 15.2.10

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Cervical complex

SUPRAHYOID, INFRAHYOID, AND TRANSVERSE PLANE HYOID INDUCTION

Objective To restore mobility to the myofascial hyoid complex

Objective

Type of procedure Sustained systemic procedure (indirect application)

Irritability/type of dysfunction

A

Irritability/type of dysfunction Irritability: high Neuroprotection: moderate Rigidity/stiffness: low Glide: moderate

Indications

Patient position

Supine

Practitioner position

Standing next to the patient

Hand contacts

A Suprahyoid induction: Place the caudal hand above the hyoid bone, encircling the neck area gently between the thumb and index finger. Flex the tips of the index and middle fingers of the other hand and place them under the patient’s chin, touching the mandible. B Infrahyoid induction: Cross the hands and place the caudal hand on the upper thoracic region and the cranial hand below the hyoid bone, holding the patient’s neck gently between the thumb and index finger. C Transverse plane hyoid induction: Place the nondominant hand (in supine) across the cervical region. Gently hold the hyoid bone with the thumb and index finger of the dominant hand.

Procedure

A Suprahyoid induction: Gentle traction is exerted caudally with the caudal hand and cranially with the cranial hand. Bear in mind that the pressure should be very gentle and exerted three-dimensionally. Traction should be applied for 3 to 5 minutes following the release. B Infrahyoid induction: The cranial hand applies gentle cranial traction and the caudal hand applies traction in the opposite direction. The pressure should be three-dimensional and be applied for 3 to 5 minutes following the release. C Transverse plane hyoid induction: The hand placed under the neck serves as support while the other hand performs gentle compression to find the barrier. Accompany 3 to 6 barrier releases over 3 to 5 minutes.

Observations/ contraindications

The hyoid fascial system has remarkable laxity; it should be stimulated using only light pressure.

B

C

Type of procedure

Indications Hyoid dysfunction; dysfunctions of swallowing and phonation; temporomandibular disorders; parafunctions of the tongue; shoulder dysfunction due to dynamic stability compensation

Take care not to cause pain by applying too much pressure. The practitioner´s hands should not slide over the skin.

Figure 15.2.11

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MIT procedures for common craniocervical and neck dysfunctions

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TRANSVERSE STROKE APPLIED TO THE POSTERIOR CERVICAL COMPLEX Objective To restore mobility to the posterior cervical myofascial structures

Objective

Type of procedure Sliding: transverse stroke (direct application)

Irritability/type of dysfunction

A

B

Indications

Type of procedure

Indications Dysfunctions of neck mobility, especially limitation of flexion; alterations of the dynamics of the nuchal ligament; regional hypersensitivity; alterations in cerebrospinal fluid circulation; Arnold’s neuralgia; headache; masticatory dysfunctions Irritability/type of dysfunction Irritability: high or low Neuroprotection: high or low Rigidity/stiffness: high Glide: low

Patient position

Prone with the head in neutral position

Practitioner position

Standing at the patient's side

Hand contacts

Grip one side of the patient's neck with the pads of the thumbs and the other side with the pads of the fingers.

Procedure

The transverse stroke procedure should be followed in all the restricted areas. Apply 3 sets of 15 repetitions.

Observations/ contraindications

The transverse strokes should be applied slowly.

C

Figure 15.2.12 A Posterior aspect of the cervical complex and the upper part of the back. Note the fibrous aponeurotic structure of the upper and middle parts of the trapezius. B Cross-section of the cervical segment at the level of C5. The red dots indicate the area of contact. C Application of the procedure on the patient

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Cervical complex

LONGITUDINAL STROKE APPLIED TO THE POSTERIOR CERVICAL COMPLEX

A

Objective To restore mobility to the posterior cervical myofascial structures

Objective

1

Type of procedure Sliding: longitudinal stroke (direct application)

B

2

B

Irritability/type of dysfunction

A

Indications

Indications Neck mobility dysfunctions, especially limitation of flexion; alterations in the dynamics of the nuchal ligament; regional hypersensitivity; alterations in CSF circulation; Arnold's neuralgia; headache Irritability/type of dysfunction Irritability: high or low Neuroprotection: high or low Rigidity/stiffness: high Glide: low

Patient position

Supine or prone, with the head in neutral position

Practitioner position

Sitting or standing at the head of the table

Hand contacts

First option: Hold the patient’s head with both hands and passively bring the craniocervicothoracic segment to flexion. Then, hold the patient’s head at the occipital region with one hand, with the elbow resting on the table to support the weight of the head. Second option: Hold the patient’s head in position with the cranial hand. Using the caudal hand, grip the upper cervical spine at C2 level with the thumb and proximal interphalangeal joint of the index finger. The spinous process of C2 should be between the thumb and index finger.

Procedure

First option: One hand holds the head in position and the other hand performs craniocaudal longitudinal sliding, starting from the upper to middle cervical region (C2–C3), which is gripped between the thumb and the proximal interphalangeal joint of the flexed forefinger. The line of the spinous processes is between the index and middle fingers. Light, rotary positional adjustment movements are allowed. Second option: With the caudal hand, perform longitudinal strokes in the caudal direction. The principles of the longitudinal stroke should be applied (see Chapter 13). The longitudinal strokes should be continued up to the level of T5.

Observations/ contraindications

Longitudinal strokes should be applied slowly. Avoid excessive craniocervical flexion movements (do not push the head forward; gently pull it toward the ceiling). Take care in the presence of pain.

3

4

5

Type of procedure

Figure 15.2.13 1 Panoramic view of the upper part of the back 3 Cross-section of the cervical segment at the level of C5. A Line of the spinous processes The red dots indicate the area of contact 2 Panoramic view of the lower cervical spine and the upper part of the back 4 Procedure applied to the patient in supine position A Occiput 5 Procedure applied to the patient in prone position B Trapezius

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Dysfunctions related to the thorax complex

16

KEY POINTS •

Identification and description of the fascial system of the thoracic complex

•

Functional relationships between the thoracic cage and the superficial and deep fascial structures

•

The anatomical and functional complexity of the breast area

•

Fascia and breathing

•

Clinical implications

Introduction

interclavicular) and synchondrosis (manubriosternal and xiphosternal). All of these have to respond together to the needs of the organs and neurovascular components that are housed in the thorax. Dysfunction of a structure belonging to the rib cage is capable of modifying the mobility and motility of both the rib cage itself and the viscera within it, and vice versa.

° e thorax complex (thoracic cage) constitutes a sophisticated tensegrity system through which the various components – the dorsal spine, 12 pairs of ribs, sternum, clavicles, and the main engine of its dynamics, the diaphragm – communicate with each other. ° e factors that in˝ uence the morphological development of the rib cage di˛ er in the embryonic and postnatal periods. In the embryonic period, the forces transmitted by the surrounding anatomical structures and also the heart and liver are decisive, whereas in the postnatal stage the in˝ uence of the respiratory pattern is the most deÿ ning factor (Okuno et al. 2019). Very precise coordination between the bony, myofascial, visceral, circulatory, and nervous systems is essential to ensure the optimal behavior of the rib cage (Fig. 16.1). ° is complex process can be observed, for example, in the suspension system of the pleural dome or in the ligament system of the pericardium. To achieve this coordination, the thorax complex must fulÿ ll four basic functions:

•

•

Protection. It protects the structures that are essential to sustain life (the trachea, esophagus, lungs, blood vessels, heart, parts of the spleen, stomach, and kidneys) from traumatic injury. Intrinsic mobility. It coordinates movements of the small joints related to numerous ligaments and muscles (costotransverse, costochondral, interchondral, sternocostal, costoxiphoid, sternoclavicular, and

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•

Breathing. It optimizes the behavior of the diaphragm, not only in its role as the main respiratory muscle, but also as the dynamic link between the thoracic–abdominal–lumbar regions.

•

Connection. It provides dynamic links (attachments) for the myofascial structures between the neck, abdomen, back, and upper extremities.

Analyses of fascial anatomy and its behavior in the thorax complex conÿ rm the continuity of the fascial network and its active participation in the distribution of information.

Anatomical considerations related to the thorax complex Structure

“° e thoracic wall is bounded anteriorly by the sternum and costal cartilages; laterally by the ribs and intercostal spaces; posteriorly by the thoracic vertebrae and intervertebral discs; superiorly by the suprapleural membrane and inferiorly by the respiratory diaphragm” (Hussain & Burns 2020). ° e intrinsic structures of the

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16

A

B

C

D

E

F

Figure 16.1 Anatomical components related to the fascial pectoral wall of the thorax. A Fat lobes embedded in the superficial pectoral thoracic fascia. B The cutaneous innervation of the anterior portion of the thoracic wall extends from lateral and anterior cutaneous nerves via ventral rami forming a segmental dermatomal pattern. C Lymphatic system of the thoracic area. D Pattern of the superficial layer of the deep fascia of the pectoral thoracic wall. E Epimysial (deep) layer of the deep pectoral thoracic fascia. Note the continuity of the deep fascia of the neck, pectoralis fascia, and deltoid fascia up to the brachial fascia. F Visceral, neural, and circulatory systems protected by the thorax structures

thorax are located in three spaces: the mediastinum (containing the heart and great vessels) and two pleural cavities (containing the lungs) (Clemens et al. 2011). All these structures are connected together to form a strong and protective dynamic system, which also facilitates the connection with the upper extremities through the axillary and superÿ cial fascia of the shoulder.

The thorax as an integrated system It is suggested that the thorax is integrally linked to its constituent parts and, as part of the locomotor, respiratory, cardiac, digestive, and urogenital systems it in˝ uences their behavior (Lee 2015). From a biomechanical perspective, the analysis by Panjabi et al. (1976) presents the most extensive and accurate model of the integral dynamics of the thorax. ° e authors describe the coupled movement between the dorsal vertebrae and the costovertebral and costotransverse joints. However, it is evident that by not considering the functional continuity of these components

with the anterior part of the thorax (manubriosternal, costochondral, sternochondral, and interchondral joints) the analysis is partial in relation to the anatomical evidence. An anatomical analysis of the fascial components of the thoracic region suggests a full structural and functional integration of the thorax with the other bodily components. Likewise, it is logical and is re˝ ected in clinical practice that biomechanical alterations of proper alignment, e˛ ective movement, and control of coordination can a˛ ect regions of the body far from the thorax (Lee 2015).

The thorax as an integrated system Ignoring the clinical connections between “benign” changes in chest movement (˝ at back, kyphosis, functional scoliosis, etc.) and congenital deformities (pectus excavatum, pectus carinatum, etc.), the latter can serve as markers against which systemic dysfunctional

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Dysfunctions related to the thorax complex

outcomes associated with chest deformity and sti˛ ness can be measured. Pectus excavatum is the most common congenital malformation that directly a˛ ects the sternum and all components of the anterior thoracic wall. It is characterized by a deep funnel-shaped depression, with its apex over the lower end of the sternum, which makes the ribs on each side protrude more anteriorly than the sternum. It is caused by shortening of the central part of the diaphragm which pulls the sternum backward during inhalation. Depression of the cartilage and sternum causes a reduction in the prevertebral space leading to le˙ -shi˙ and axial rotation of the heart. Recent literature suggests that many patients experience some cardiovascular and respiratory physiological changes as they mature. ° e exact ratio remains elusive but the cause may be decreased chest wall ˝ exibility with aging (Al-Qadi 2018, Mak et al. 2016). Pulmonary compliance is used as a measure of the elastic resistance of the system. In cases of functional deÿ ciency of the thorax of noncongenital origin, it is important to be aware that the response to assessment of cardiorespiratory capability may be asymptomatic or subclinical. It should also be noted that if there are comorbidities such as obstructive pulmonary diseases, it is fundamental to preserve the dynamic behavior of the chest. Pathological remodeling of the thoracic wall as well as the surrounding muscles can severely compromise breathing in patients with chronic obstructive pulmonary disease (COPD). As Campbell and Howell (1963) conÿ rmed, the imbalance between the forces generated by the respiratory muscles and the changes in their length can generate dyspnea. Kakizaki et al. (1999) demonstrated that lengthening the respiratory muscles could improve thoracic expansion and decrease dyspnea in patients with COPD. Montaldo et al. (2000) suggest that the mechanoreceptors which respond to mechanical changes (length, tension, or movement) due to increased ventilation and which are located in the thoracic wall and in respiratory muscles can play a signiÿ cant role in the creation of dyspnea. ° erefore, increased thoracic expansion could improve the length–tension relationship of the respiratory muscles, decrease a˛ erent stimuli for central respiratory control, and reduce dyspnea (Paulin et al. 2003).

16

Neurovasculature and the lymphatic system Innervation ° e innervation of the thoracic wall extends from the intercostal nerves. ° e anterior rami of spinal nerves (T1–T11) and the subcostal nerve (anterior ramus of T12) form the segmental patterns of dermatomes and myotomes that can be seen in Figure 16.1B. Since the thorax houses several organs, the main innervation is autonomic and appears in the form of visceral plexuses located close to each respective organ. ° ese include the esophageal, cardiac, and thoracic aortic plexuses. ° ese are formed by contributions from the sympathetic trunk, thoracic splanchnic nerves, recurrent laryngeal nerve, and the vagus nerve.

Blood supply ° e blood to the intercostal spaces is supplied by the posterior intercostal artery and two branches of the anterior intercostal arteries and runs along the intercostal groove together with the intercostal veins and nerves (Fig. 16.1F).

The lymphatic system In the human body the lymphatic system is organized in the form of vessels, lymph nodules, and nodes (see Chapter 10). Lymphatic capillaries join to form lymph venules and veins that drain via regional lymph nodes into the thoracic duct on the le˙ side or into the right lymphatic duct; from there, lymph ˝ ows back into the bloodstream (Fig. 16.1C) (Mallick & Bodenham 2003, Hematti 2011). ° e lymphatics of the thoracic wall drain into parasternal lymph nodes and intercostal lymph nodes. ° e parasternal lymph nodes and intercostal lymph nodes from the upper thorax drain into the bronchomediastinal trunk, whereas the intercostal nodes from the lower thorax drain into the thoracic duct (Riquet et al. 2013, Hussain & Burns 2020).

Mechanics ° e thorax system is characterized by incessant movement related to pulmonary ventilation (providing the oxygen needed for metabolism and removing the by-product of these reactions – carbon dioxide) and cardiac eˆ ciency (the ability of the heart to meet the metabolic demands of the body) (Courtney 2009). ° e

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16 integrity of the fascial system is crucial to maintaining and controlling this behavior.

Anterior thoracic wall ° e sternum deÿ nes the anterior thoracic wall, acting as a bridge between its two sides. Its development begins during the sixth week of the embryonic period, coinciding with the development of the heart and pectoral girdle (Weston et al. 2006). Ossiÿ cation of the sternum is usually complete by the 30th year, and it acquires an average length of 209 mm in men and 183 mm in women (Gandhi 2019). ° e sternum forms a link between the bilaterally arranged ribs that enclose the thoracic cavity and provide a ÿ xed point that allows the passage of resistive forces derived from breathing movements, from the thorax itself and also from activity of the upper limbs. ° e behavior of the sternum allows the rib cage to be ˝ exible, and simultaneously the eˆ cient rigidity of its anterior wall provides a similar stability, as if the sternum was a “second spine” (Denis 1983, Berg 1993). ° is arrangement indirectly prevents exaggeration of thoracic kyphosis, deviation from an upright posture, and excessive compression loads on both the thoracic spine and lumbar region (Chao etˇal. 2007). ° e costochondral junctions of the ÿ rst seven ribs represent viscoelastic structures that function as torsion bars, storing elastic tension energy during inspiration. At the end of the inspiratory phase, the stored energy is released facilitating the passive caudal descent of the sternum during expiration (Gandhi 2019) – an excellent strategy to save energy. ° e sternum helps to distribute symmetrically the tensional elastic energy in the sagittal plane, orients the symmetry of the rib cage, and maintains the required rigidity of the chest. ° is process facilitates the viscoelastic behavior of the thorax to increase the eˆ ciency of the respiratory pump. It is also worth noting the hematopoietic function of the sternum which houses red bone marrow in its spongy bone tissue. ° us, the behavior of the sternum as the core (dynamic center) is essential to the (functional) stability of the thorax complex (Figs. 16.2, 16.14, and 16.15).

Superficial fascia of the anterior thoracic wall ° e superÿ cial fascia of the thorax is continuous with the superÿ cial fascia of the neck (Figs. 16.3, 16.4-1, 16.5, 16.10-1) and its anatomical arrangement is similar

Figure 16.2 The sternum as a core structure. The pectoralis major has been dissected from the sternum and clavicle and moved laterally

A

B

C

D

E

F

G

H

Figure 16.3 Superficial and deep fascia of the thoracic area. Note the continuity with the superficial fascia of the neck and the composition (fibroadipose tissue) A Deep fascia on the sternocleidomastoid muscle B Right clavicle C Skin, dissected and lifted D Epimysial fascia on the pectoralis major E Sternum F Superficial fascia G Xiphoid process area H Skin over the abdominal area

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Dysfunctions related to the thorax complex

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Figure 16.4 A

Anterior aspect of the thorax 1 Superficial fascia of the thorax A Superficial fascia of the neck B Superficial fascia of the shoulder C Pectoral superficial fascia D Dissected skin, pulled back E Lowest ribs 2 Deep fascia of the thorax A Sternocleidomastoid muscle B Sternum C Epimysial fascia on the pectoralis major D Dissected superficial fascia, pulled back E Xyphoid process

A

B

C

B C

D D E

1

E

2

C

D E F

Figure 16.5 Anterior aspect of the neck A Sternocleidomastoid muscles covered by the deep fascia of the neck. Note the continuity of the deep cervical fascia of the neck with the pectoral fascia B Deep epimysial fascia of the pectoralis major C Chin D Deep fascia of the neck E Thyroid cartilage F Continuity of the superficial fascia of the neck. The fascia has been dissected and lifted G Continuity of the superficial fascia of the thorax. The fascia has been dissected and lifted

A

G

B

Clavicles

to the superÿ cial fascia in the rest of the body (Rehnke et al. 2018) (see Chapter 3), i.e., it is ÿ rmly connected to the skin. In its proximal third (just below the clavicles) the superÿ cial fascia may include the ÿ bers of the platysma muscle (Fig. 16.6) and in the pectoral region the

mammary structures are embedded in the superÿ cial fascia. ° ere is a link between the platysma, clavicle, and mammary gland. ° e superÿ cial fascia is thicker in the infraclavicular area and resembles the suspensory ligament of Giraldés (Riggio et al. 2000). Its function

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16 suspensory system of the breast (ligaments and fasciae) to keep the gland in a relatively constant position leads to a viscoelastic response which deforms the structure of the breast and eventually leads to ptosis.

The breast

A

° e breast occupies space between the lateral border of the sternum to the midaxillary line and between the 2nd and 6th intercostal cartilages. It lies superÿ cially to the pectoralis major and serratus anterior. It is characteristic of female milk-producing activity and is present in a nonfunctional form in males. ° e breast is encased in a three-dimensional fascial network that shapes and supports it and helps to maintain its structural integrity and function (Fig. 16.7). ° e mammary gland is separated from the deep (muscular) fascia by a thin layer of almost horizontally oriented retinacula joined by elastic septa and adipose lobules (Riggio et al. 2000).

The fascial network of the breast Vesalius (1543) in his research (Richardson & Carman 2007, Brinkman & Hage 2016, Rehnke at al. 2018) stated that the superÿ cial fascial system of the breast resembles (with certain modiÿ cations) the superÿ cial fascial system that surrounds the other structures of the body. ° e superÿ cial fascial web of the breast connects the skin to the deep fascia. Since the nineteenth century we have been familiar with the suspensory system described by Cooper (1840). However, the location, amount, and paths of Cooper’s ligaments are up for debate. ° ere is no consensus in studies on fascial anatomy in this area.

B Figure 16.6 Platysma integrated into the superficial fascia. A Platysma. B Superficial fascia of the neck and the platysma muscle fibers

is to maintain the correct positioning of the mammary gland. Due to aging and the progressive deterioration of collagen structures, involution occurs that alters the shape and volume of the breast. ° e failure of the

Cardoso et al. (2015) performed dissections of 14 breasts, having previously removed excess fat by liposuction in order to identify fascial structures more easily. ° e authors identiÿ ed Cooper’s ligaments arranged in a tent shape with the apex toward the nipple, the suspensory ligament of the axilla, and the inframammary ligament. ° ey concluded that “as a whole, these ligaments form a regularly uniform structure with an evident shaping and suspensory e˛ ect” and that “the tension distributed itself throughout the whole breast, reinforcing the ligamentous structure of the breast as an intricate network.” Rohrich et al. (2001) described zones of adherence between the superÿ cial and the deep fascia thus underlining their role in shaping the breast.

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Figure 16.7 Mammograms showing the anatomy of the breast. Note the distribution of the fascial net 1 Normal breast A Lymph node B Pectoralis major C Glandular tissue D Inframammary fold E Skin edge region F Vessels G Breast parenchyma (glandular tissue and fat) H Nipple – areolar complex I Cooper’s ligament. Cooper’s ligaments are the curved lines around the fatty lobes between the skin and the parenchyma 2 Microcalcifications and significant breast ptosis Images courtesy of Javier Álvarez González

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In their study of both cadaver breast dissections and clinical cases of breast surgery Rehnke at al. (2018) concluded that the superÿ cial fascia system “surrounds the corpus mammae, and encases it in two layers of fat and fascia” and that: its anchorage to the deep fascia of the chest at the breast’s perimeter is the circummammary ligament. The Cooper ligaments, which are specialized vertical cutaneous ligaments, travel from the posterior lamina fascia, through the breast gland and anterior lamina, to anchor in the skin. Stecco et al. (2010) refer to the superÿ cial adipose tissue (SAT) and deep adipose tissue (DAT) superÿ cial fascial model and propose that a network of septa (retinaculum cutis superÿ cialis) extends from the subdermal plane downward until it reaches a ÿ brous sheet – the superÿ cial fascia. ° e fat trapped between the ÿ bers is called SAT. ° e ÿ bers that connect the superÿ cial fascia with the deep fascia are called retinaculum cutis profundus and the adipose tissue of the deep fascia is called DAT (Stecco et al. 2010). According to this model “fascia is always deeper to the mammary gland” and the mammary gland maintains its contact with the skin through the areolar region (Stecco 2015). Stecco also conÿ rms the presence of Cooper’s ligaments inside the mammary glands. Discrepancies in anatomical explanations probably occur because of the fact that the superÿ cial fascia on

the breast has a ÿ ne and fragile structure which could be overlooked in dissections of embalmed (formalized) or frozen cadavers (Rehnke et al. 2018) and even during surgery (Haagenson 1971). ° is author’s knowledge of superÿ cial fascia of the anterior wall of the chest is based on dissections of unembalmed male cadavers. For this reason, the observations in this chapter may not always apply to the anatomy of the female body. However, there are some aspects of fascial anatomy that are common to both genders (see Figs. 16.4-1 and 16.10-1), namely:

•

° ere is continuity between the superÿ cial fascia of the neck and the anterior thoracic wall.

•

° e thickness of the fascia di˛ ers in relation to the anatomical area.

•

° e shape, quantity, size, and interrelation of the fat lobes is deÿ ned by the network of fascial compartments.

The inframammary fold ° e inframammary fold is an intrinsic dermal structure “consisting of regular arrays of collagen held in place by a zone of adherence that is a specialized area of the superÿ cial fascial system” (Boutros et al. 1998). It is a zone of adherence of the superÿ cial fascial system to the underlying chest wall and consists of a ridge of

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16 dense nodular tissue developing an arc at the caudal circumferential edge of the breast (Gui et al. 2004). It represents the most critical visual landmark at the level of the 6th rib. Its characteristics may change depending on sex, age, breast size, weight, and adiposity. “Here the mammary tissue is bound down tightly to the deep fascia of the thoracic wall, compressed between the anterior and posterior lamellae of the superÿ cial fascia” (Rehnke et al. 2018).

on a three-dimensional system distributed among three layers: the superÿ cial layer (pectoralis fascia), the middle layer (clavipectoral fascia), and the deep layer (intercostal fascia).

Blood supply of the breast

•

° e clavipectoral axillary aponeurosis does not exist as such.

•

° ree fascial structures were identiÿ ed:

° e blood to the breast structures is supplied through the axillary and intercostal vessels. ° e innervation arises from branches of the 4th, 5th, and 6th intercostal nerves. ° e breast shows considerable mobility over the pectoralis major fascia because of the presence of loose connective tissue. Progressive elongation (viscoelastic response) resulting from aging, postural disturbance, obesity, or a˙ er surgery can lead to breast ptosis.

However, some authors deny the existence of this system (its continuity) and propose a di˛ erent model. For example, Poitevin et al. (2016) in their study carried out on the upper limbs of 34 unformalized cadavers conclude with the following observations:

▶ a thin, prepectoral major fascia ▶ an anterior or interpectoral neurovascular fascia ▶ a posterior, retropectoral, minor neurovascular fascia.

•

° e lymph from the breast drains mainly into the axillary lymph nodes (about 75ˇpercent) (Pan et al. 2009). ° e skin of the breast drains to the axillary and infraclavicular nodes. ° e nipple and areolar area drain to the subareolar lymphatic plexus.

° e subclavian muscle did not appear to be encompassed by any of these fasciae.

•

° e pectoralis major and minor muscles are not housed in closed cells but have fascial lamina intercalated between both muscles and behind the pectoralis minor.

Innervation of the breast

° is author’s approach to the anatomical and functional continuity of the fascial system is closer to the conventional anatomical approach and recognizes the three layers of the deep thoracic fascial architecture. Note that the presence of loose connective tissue facilitates gliding between these layers. In addition, as is o˙ en seen, the layers of this multilayered design facilitate the transfer of forces between the interconnected segments (upper limbs, ribs, and sternum), thus facilitating the dynamic behavior of the thoracic structures.

Lymphatics of the breast

° e breast is innervated by the anterior and lateral cutaneous branches of the intercostal nerves. “° e skin surface of the breast is innervated by the ÿ rst to sixth intercostal nerves and a supraclavicular branch of the superÿ cial cervical plexus. ° e nipple is innervated by the fourth intercostal nerve” (Zucca-Matthe et al. 2016). ° ese nerves contain both sensory and autonomic nerve ÿ bers (the autonomic ÿ bers regulate smooth muscle and blood vessel tone).

Deep fascia of the anterior thoracic wall As mentioned above, the deep fascia of the thorax is continuous with the deep fascia of the neck (see Chapter 15); the clavicular region is the linking area between the fasciae (Figs. 16.4, 16.9, 16.10, and 16.12). (A similar area can be observed in the iliac crest between the latissimus dorsi and the deep gluteal fascia.) ° e majority of authors analyze the architecture of the deep fascia of the anterior thoracic wall focusing

Pectoralis fascia ° e pectoralis fascia is located in the superÿ cial layer and is shaped by the pectoralis major (Fig. 16.4-2). Its superÿ cial (outer) layer is continuous with the deep fascia of the neck and is characterized by its epimysial structure (adhered to the muscle) (see Fig. 16.4). In its construction the epimysium (thin lamina) launches septa that penetrate and compartmentalize the muscle, creating spaces for muscular fascicles (bundles) of the pectoralis major (see Figs. 16.4-2 and 16.10-2).

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Figure 16.8

Proximal

A

B

Distal

C

Insertion of the pectoral fascia into the sternum. The superficial fascia has been slightly dissected from the sternum and lifted. Note the fusion of the periosteum and the deep fascia A Superficial pectoral fascia with fatty lobes B Superficial fascia, underside C Deep pectoral fascia D Cross-links of the collagen fibers of the pectoral fascia E Xiphoid area F Skin over the abdominal area

D

Proximally its deep (inner) layer initiates from the periosteum of the clavicle. ° e two layers enclose the body of the pectoralis major muscle. Distally both laminae of the pectoral fascia become the serratus anterior muscle fascia. Posteriorly the latter divides again into two layers that enclose the latissimus dorsi muscle. Medially the superÿ cial layer crosses the midline of the body and continues with the contralateral pectoralis fascia; the deep layer becomes the periosteum of the sternum (Fig. 16.8) (also see Figs. 16.14 and 16.15). Laterally the pectoral fascia becomes the deltoid fascia, enveloping the deltoid muscle, and continues as the brachial fascia through its ÿ brous expansion (Stecco et al. 2009) (Fig. 16.9) (also see Chapter 17). ° e compartmental architecture of the pectoralis major muscle allows its muscle ÿ bers to contract locally which tightens the septa; however, the contractile force is not only transmitted locally but rather expands to the whole system.

Clavipectoral fascia Research on the anatomy and function of the clavipectoral fascia is extensive due to the fact that its structure is frequently linked to traumatic processes and medical and surgical procedures such as reconstructive surgery or breast implants. ° e clavipectoral fascia protects the neurovascular structures located in the space between the clavicle and the pectoralis minor and also suspends the floor of the axilla. Due to its proximity to sensitive anatomical structures, such as the components of the brachial plexus (lateral, posterior, and medial cords), lymph nodes, and the axillary artery and vein, procedures carried out in this area require precise knowledge of anatomy.

E

F

A

B

C

D E

Figure 16.9 Continuity of the deep fascia of the anterior aspect of the thorax and upper limb A Deep fascia of the neck B Deep pectoral fascia C Deep deltoid fascia D Deep brachial fascia E Deep fascia of the serratus anterior

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16 ° e clavipectoral fascia is located in the middle layer of the anterior thoracic wall below the pectoralis major muscle. It is a continuous, thick and ÿ brous sheet that extends from the inferior aspect of the clavicle, distally

and laterally to the axillary fascia (Fig. 16.10). From the clavicle it divides into two laminae (anterior and posterior) that enclose the subclavius. When both sheets reach the lower edge of the subclavius, they merge into

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2 Figure 16.10 Fascial layers of the right anterior pectoral wall 1 Superficial layer. The skin has been dissected and lifted. The fascial network organizes the shape, size, and quantity of the fatty lobes and the interrelation between them A Nipple area depression B Fatty lobes within the fascial network C Skin, dissected from the superficial fascia and turned down 2 Deep fascia A Sternocleidomastoid muscle covered by the superficial lamina of the deep fascia of the neck B Clavicle C Pectoralis major enveloped by epimysial fascia. Note the fatty lobes embedded in the loose connective tissue that facilitate gliding between the superficial and deep fascia D Serratus anterior covered by epimysial fascia E Fibrous septa between the superficial and deep fascia F Superficial fascia, dissected from deep fascia, lifted, and turned down 3 Dissection of the pectoralis major A Sternocleidomastoid muscle B Pectoralis minor C Clavipectoral fascia, sectioned to separate the pectoralis major from the pectoralis minor D Serratus anterior covered by epimysial fascia E Pectoralis major, detached from the sternum and flipped F Superficial fascia, dissected, lifted, and turned down 4 Anatomical links of the pectoralis minor A Sternocleidomastoid muscle B Collagen fiber bundles on the sternal area C Ribs D Intercostalis fascia E Pectoralis minor F Clavipectoral fascia G Pectoralis major, dissected and lifted. Note the fragments of the clavipectoral fascia

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a single sheet which continues to the pectoralis minor. ° en, its divides again into two laminae that enclose the pectoralis minor, joining the serratus anterior fascia and posteriorly becoming the rhomboid fascia. Finally, it reaches the intermediate level of the cervical fascia, thus creating a mechanical link with the scapula (Fig. 16.11) (Stecco 2015). Medially it extends over the anterior part of the sternum and joins the deltoid fascia laterally. Distally the clavipectoral fascia becomes the fascia of the internal abdominal oblique.

Clavipectoral triangle (Figs. 16.12 and 16.13) In the area between the pectoralis major, deltoid muscles, and the clavicle extends the clavipectoral triangle (deltopectoral triangle). It is pierced by the cephalic

16

vein, anterior thoracic artery, and lateral thoracic nerve. Proximally the clavipectoral triangle expands from the costochondral joints and the coracoid process to shape the costocoracoid sheet above the pectoralis minor and the suspensory ligament of axilla below it. Its deep lamina is ÿ rmly integrated with the intercostal muscles and ribs. ° e subclavian vein and the subclavian artery run underneath it. ° e medial pectoral nerve transects the pectoralis minor. ° e clavipectoral fascia and its components are involved in important body functions:

•

° e suspensory ligament drags the axillary fascia upward when the arm is raised forming the hollow of the axilla (armpit), which is seen when the arm is abducted. Figure 16.11

A

J

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M N 0

C D E F G H

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P Q R S T U

Sagittal section through the thorax 1 Clavicle 2 Scapula A Trapezius B Brachial plexus B1 Lateral cord B2 Posterior cord B3 Medial cord C Supraspinatus D Subscapular artery E Subscapularis F Infraspinatus G Teres minor muscle H Teres major muscle I Latissimus dorsi J Omohyoid K Subclavius L Cephalic vein M Thoracoacromial artery N Clavipectoral fascia O Axillary artery P Lateral pectoral nerve Q Axillary vein R Medial pectoral nerve S Pectoralis minor T Pectoralis major U Gerdy’s ligament V Axillary fascia

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16 A

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Figure 16.12 Anterior thoracic wall and location of the clavipectoral triangle 1 Panoramic view of the pectoral area A Deltoid muscle B Thoracodorsal artery C Long thoracic nerve D Thoracodorsal nerve E Serratus anterior muscle F Pectoralis major G Sternum H Pectoralis major, dissected and lifted from the sternum and separated from the ribs 2 Pectoralis minor A Clavipectoral fascia B Medial pectoral nerve piercing the pectoralis minor C Pectoralis minor D Superior thoracic artery

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Figure 16.13 Anterior aspect of the right pectoral and shoulder area 1 Clavipectoral fascia dissection A Deltoid muscle B Clavipectoral fascia C Loose connective tissue below the pectoralis major D Pectoralis major, dissected and lifted 2 Clavipectoral and axillar area dissection A Pectoralis major, dissected and lifted B Deltoid muscle C Clavipectoral fascia D Loose connective tissue below the pectoralis major. This tissue facilitates gliding between the pectoral and clavipectoral fasciae E Tendon of the pectoralis major F Biceps brachii muscle G Thoracodorsal artery H Latissimus dorsi tendon I Thoracodorsal nerve J Long thoracic nerve K Serratus anterior L Pectoral superficial fascia, dissected and lifted

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•

•

° e clavipectoral fascia covers and provides protection to the vessels that extend from the thorax into the axillary region. ° ese vessels are the thoracoacromial blood and lymph vessels, the cephalic vein, and the lateral pectoral nerve.

•

It protects the vessels that extend from the thorax into the axillary region.

•

It enables the pectoralis major to glide over the pectoralis minor.

16

Intercostal fascia

As the clavipectoral fascia surrounds the clavicle, the nerve endings of the clavicle penetrate this fascia (Atalay et al. 2019).

° e intercostal fascia joins the adjacent ribs becoming its periosteum (Fig. 16.14). It forms a thin, ÿ brous, and

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Figure 16.14 Clavipectoral fascia 1 Panoramic view of the right clavipectoral fascia (for permissions information see page 557) A Sternum B Sternocleidomastoid muscle covered by the deep fascia of the neck C Right clavicle. Attachment of the pectoralis major, dissected and separated D Clavipectoral fascia E Pectoralis minor F Serratus anterior G Pectoralis major, dissected and separated from the clavipectoral fascia H Superficial pectoral fascia, dissected and lifted 2 Insertion of the pectoralis minor into the ribs F Clavipectoral fascia I Intercostal fascia Pm Pectoralis minor insertion. Note the continuity of the periosteum of the ribs and the pectoralis minor tendon with the intercostal fascia R Ribs S Sternum. Note the fibrotic costosternal links 3 Intercostal fascia 4 Ribs Blue circle – fusion of the pectoralis minor tendon with the periosteum of the rib Red circle – fusion of the intercostal fascia with the periosteum of the rib

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16 strong structure. ° e 11 pairs of intercostal spaces hide a sophisticated architecture of intercostal (internal, external and innermost) muscles, nerves, arteries, and veins. All these structures are enveloped, interconnected, and protected by the intercostal fascia on the outside and internally by the endothoracic fascia, along with the pleura. ° is creates a direct link with the visceral fascia. ° rough this link the parietal pleura directly follows the movement of the intercostal muscles (expansion of the thoracic wall through muscle contraction) and thus optimizes breathing (Stecco 2015). ° e endothoracic fascia assembles a thin lamina that surrounds the internal aspect of the ribs as well as the internal intercostal muscles. Distally the endothoracic fascia continues into the diaphragmatic fascia. To summarize, the intercostal fascia extends to the following boundaries:

•

anteriorly to the sternum, superÿ cial aspect of the ribs, and intercostal spaces;

• • •

internally to the endothoracic fascia;

•

distally to the transversus abdominis muscle, internal abdominal oblique, and the rectus sheet, thus directly involving the rectus abdominis and pyramidalis muscles.

posteriorly to the vertebral column; medially to the intercostal fascia which fuses with the periosteum of the sternum;

Intercostal muscles ° ere are three groups of intercostal muscles which are located between adjacent ribs. ° ese are the external muscles, internal muscles, and innermost intercostal muscles, which are interposed between the two planes of muscular ÿ bers. ° e activity of the intercostal muscles increases the transverse and anterior–posterior dimensions of the thorax complex (“bucket handle” and “pump handle” movement) and helps to facilitate voluntary deep breathing and breathing when exerting e˛ ort. ° e intercostal muscles are innervated by the intercostal nerves (T1–T11). ° e characteristics of these muscles are described below:

•

° e external intercostal muscles are involved in inhalation. ° ey extend posteriorly from the tubercles of the ribs and anteriorly to the costochondral

junction. ° eir ÿ bers are oriented obliquely. At the end of their path, between the two lower intercostal spaces, the ÿ bers join the ÿ bers of the external oblique muscle.

•

° e internal intercostal muscles are involved in exhalation and lie deep to the external intercostals in the intermediate layer. Like the external intercostals, they extend from the superior to the inferior rib and from the sternum to the costal angle. Inferiorly they are continuous with the internal oblique muscle of the abdominal wall. ° e ÿ bers of the internal intercostal muscles are arranged orthogonally to those of the external intercostals. ° ey are separated from the internal intercostals by the intercostal neurovascular bundle and are found in the most lateral portion of the intercostal spaces.

•

° e innermost intercostal muscles make up the deepest layer of the intercostal muscles and are lined internally by the endothoracic fascia, which in turn is lined internally by the parietal pleura (Miller 2007).

•

Distally the intercostal system joins the abdominal muscles. Figure 16.15 shows the continuity of the deep fascia with the abdominal fascia.

Diaphragm ° e structures described above participate in the movement that is central to life – breathing – through the dynamics of the diaphragm. Although the diaphragm is the major muscle of breathing, it also contributes to many other functions of the body, such as expectoration, vomiting, swallowing, urination, and defecation.

It facilitates the venous and lymphatic return and helps viscera located above and below the diaphragm to work properly. Its activity is fundamental in the maintenance of posture and body position changes. It can affect the pain perception and emotional state. (Bordoni et al. 2016) ° e diaphragm has complex fascial connections which link it to many other structures. ° ere is continuity from the deep cervical fascia (originating from the cranial base) toward the endothorax up to the

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Figure 16.15 Anterior thoracic wall. Note the continuity of the deep thoracic fascia with the abdominal deep fascia

mediastinum. Distally fascia continues its path to become fascia transversalis (the endoabdominal structure that becomes the epimysium of the transversus abdominis) and is ultimately related to the diaphragm. ° is relationship continues with the abdominal myofascial structures down to the pelvic ˝ oor. Finally, the medial and lateral arcuate ligaments of the diaphragm act as a bridge between the thoracolumbar fascia and the fascia transversalis (Mihalache et al. 1996, Peiper et al. 2004, Skandalakis et al. 2006, Loukas et al. 2007, Willard et al. 2012). Fascial anatomy is consistently associated with the nervous system. ° e innervation of the diaphragm is supplied by the phrenic nerve which derives from the cervical and brachial plexus and which anastomoses with the vagus nerve and contacts the trigeminal spinal nuclei through a˛ erent links (Pickering & Jones 2002, Drake et al. 2009, Messlinger et al. 2011, Nicaise et al. 2012). Hemodynamics are intimately linked with the behavior of the diaphragm. ° e cardiac and respiratory rhythms are synchronized in the pumping of the heart. ° rough the phrenopericardial ligaments the ÿ brous pericardium is fused with the endothoracic fascia that covers the diaphragmatic convexity. Also signiÿ cant is the fact that the diaphragm is crossed by large vessels (the aorta, vena cava, azygos vein, hemiazygos vein, and the thoracic duct) and therefore directly in˝ uences the regulation of ˝ uids. For all these reasons, it is recommended in clinical care to assess the condition of the diaphragm when

patients present with thoracic, respiratory, gastrointestinal, pelvic ˝ oor, lumbar, or cervical dysfunctions or dysfunctions of the craniomandibular area. Finally, psychoemotional aspects in relation to breathing should not be overlooked.

The dorsal thoracic fascial system ° ere are no clear boundaries between the myofascial structures that belong exclusively to the thorax in relation to the pelvic girdle and those that link it to the shoulder girdle. Fascial layers are merged and complement each other in their shared functions (Fig. 16.16) (see Chapter 17). ° e dorsal thoracic fascia is an integral part of the fascia of the back because of its area of distribution. ° is system anatomically and functionally links the seven extrinsic muscles of the back (trapezius, latissimus dorsi, levator scapulae, rhomboid major, rhomboid minor, serratus posterior superior, and serratus posterior inferior) and also the intrinsic erector spinae muscles (Fig. 16.17). One of the most important connections is formed by this fascial complex – that of the trunk with the upper extremities.

Superficial dorsal thoracic fascia ° e superÿ cial fascia on the dorsal thoracic wall is a ÿ brous structure and, as in other parts of the body, it is ÿ rmly attached to the dermis. ° e superÿ cial fascia is elastic and strong with the fatty lobes submerged and distributed in a fascial network of compartments that are irregular in size and shape and vary in number (Fig. 16.18). Gil et al. (2011, quoted by Stecco 2015)

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Figure 16.16 Fascial layers on the dorsal wall of the thorax. A Fat lobes embedded in the superficial dorsal thoracic fascia. B The cutaneous innervation of the dorsal thoracic wall. C Lymphatic system of the thoracic area and drainage routes. D Pattern of the superficial layer of the deep fascia of the dorsal thoracic wall. E Epimysial (deep) layer of the deep dorsal thoracic fascia. F Visceral system protected by the thorax cage

reports the presence of brown adipose tissue in the interscapular area, assigning to it metabolic properties (heat dissipation) and a role in body thermoregulation. ° e density of vascularization along the path of the superÿ cial fascia changes depending on the area. For example, the parascapular superÿ cial fascia is richly

vascularized, however, at a medium, lower thoracic level, vascularization is scarce (Figs. 16.19 and 16.20). Both characteristics (the presence of brown adipose tissue and rich vascularization) make the parascapular fascia a preferred structure (free ˝ ap) in reconstructive surgery. At the body’s midline (along the spinous

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A

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16

Figure 16.17 Sequence of dissections of the back from the superficial fascia to the deep layer of the deep fascia. A, B Superficial fascia layer. C Superficial layer of the deep fascia. D Epimysial layer. E Muscles of the superficial layer of the deep fascia. F Middle and deep layer muscles of the deep fascia

processes) the superÿ cial fascia adheres to the deep fascia (Fig. 16.21) (see Chapter 3).

movement) through this communication/interaction (synergism) network.

Deep dorsal thoracic fascia

° e distribution of the muscles related to the deep dorsal thoracic fascia is divided between three layers as follows (Fig. 16.24):

° e deep dorsal thoracic fascia is a heterogeneous structure which consists of layers of dense collagenous networks interleaved with loose connective tissue (Fig. 16.22). ° is architecture facilitates sliding between dense layers, speeds up muscle movements, and consequently the dynamics of the spine and its coordination with the upper extremities and the head. Sliding between fascial layers is important for optimal movement, but this action is not as simple as it looks. At di˛ erent, speciÿ c locations between the layers fusion zones between the adjacent myofascial layers can be observed (Fig. 16.23). ° ese structures can manifest as speciÿ c points, areas, or lines. Optimization (eˆ ciency) of a given movement is associated with dynamic coordination (of the muscles involved in the

•

the superÿ cial layer – trapezius and latissimus dorsi muscles (the gluteus maximus muscle is located in the lumbopelvic area in this layer);

•

the middle layer – rhomboid and serrati posterior muscles;

•

the deep layer – intertransversarii, interspinalis, longissimus, multiÿ dus, and iliocostalis muscles.

The superficial layer On the posterior thoracic wall the superÿ cial layer of the deep fascia surrounds the trapezius and latissimus dorsi muscles which are both covered by a thin

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16 A B

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Figure 16.18 Superficial fascia of the left side of the back. Note the difference in the amount of fat and its distribution between the dorsal areas (black circles) and lower back areas (blue circles). Also, note the differences in intensity of vascularity between the dorsal (richly vascularized) and the lumbar (poorly vascularized) regions (see Chapter 3). The rectangles indicate the area of adherence of the dermis and superficial fascia 1 Continuity of the superficial fascia of the neck, dorsum, and back. The superficial fascia is firmly attached to the dermis, and they can only be separated with a scalpel A Superficial fascia of the neck B Superficial fascia of the back C Skin on the right side of the thorax D Skin on the left side of the thorax, dissected and lifted E Fat lobules attached to the skin 2 Macroscopic view of the connections between the skin and the superficial fascia in the dorsum A Superficial fascia C Underside of the skin B Skin ligaments D Fusion of the dermis and superficial fascia 3 Macroscopic view of the connections between the skin and the superficial fascia in the lower back A Superficial fascia B Skin ligaments C Underside of the skin

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Figure 16.19 Superficial layer of deep fascia of the back 1 Panoramic view of the deep fascia of the left dorsal wall of the thorax A Superficial layer of the deep fascia of the interscapular area B Scapula C Superficial fascia and skin, dissected and lifted D Inferior angle of the scapula E Latissimus dorsi muscle fibers 2 Macroscopic view of the superficial layer of the deep fascia. Note the fat nodules and abundant vascularization

epimysial fascia (Figs. 16.25 and 16.26, Video 16.1); this layer also includes the posterior (superÿ cial) layer of thoracolumbar fascia (TLF). Distally this layer also includes the gluteus maximus muscle. Proximally it initiates in the cranium (superior nuchal line of the occipital bone), ligamentum nuchae (external occipital protuberance, spinous process of C7), and supraspinous ligament (C7–L4). Laterally it is continuous with the superÿ cial layer of the deep fascia of the neck. At the proximal end of the back it is attached to the acromion and the spine of the scapula. Medially it follows the path of the supraspinous ligament reaching the spinous processes and fusing with the superÿ cial fascia (see Fig. 16.21). Video 16.1 shows the insertion of the trapezius into the spine of the scapula and the gliding between the infraspinatus fascia and latissimus dorsi.

Video 16.1 Mechanical links between the trapezius and scapula

Video 16.2 Scapular and rhomboid dynamics

Although the three layers are well deÿ ned by the precise location of the speciÿ c muscles (as described above), together they amount to a functional complex, integrated through the fascial structures, that allows for coordination between the layers (Figs. 16.27–16.29).

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16 Figure 16.20 Panoramic view of the superficial and deep fasciae of the back 1 Deep fascia of the left side of the back A Deep fascia B Superficial fascia, dissected from its insertion in the spinous processes and separated from the deep fascia C Skin, dissected and turned down 2 Macroscopic view of the vascularization of the deep fascia of the scapular area 3 Macroscopic view of the adhesion between the superficial and deep fascia A Deep fascia B Adhesion between the superficial and deep fasciae C Superficial fascia

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Figure 16.21 The midline of the body (along the spinous processes) in the distal thoracic spine 1 Deep fascia of the lower thoracic area (right side) A Deep fascia of the distal thoracic spine, dissected and lifted B Trapezius covered by epimysial fascia C Latissimus dorsi covered by epimysial fascia 2 Link between the distal end of the trapezium and the latissimus dorsi (left side) A Trapezius covered by epimysial fascia B Latissimus dorsi covered by epimysial fascia 3 Macroscopic view of the subcutaneous area of the thoracic spine (left side) A Fusion between the superficial and deep fascia along the spinous processes B Trapezius aponeurosis

The middle layer ° e middle layer of the deep fascia encloses the rhomboids and serrati posterior muscles. ° e rhomboid fascia (Fig. 16.29 and Fig. 16.30, Video 16.2) originates at the inner edge of the scapulae. In its superÿ cial path, the fascia extends over the supraspinatus and infraspinatus areas. In the deep layer it is continuous with the fascia of the serratus anterior muscles and it extends proximally as the fascia of the splenius

capitis, splenius cervicis, and levator scapulae muscles. Medially the middle layer of the deep dorsal fascia fuses with the spinous processes of the vertebrae and with the interspinous ligaments. Laterally it is continuous with the fascia of the serratus anterior and the clavipectoral fascia. ° rough its relationship with the internal scapular border it is also linked with the subscapular fascia and the infraspinous fascial system. ° us, it can participate not only in

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16 A

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Medial B

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*

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* D E

Figure 16.23 Left parascapular area A Trapezius with its perimysial fascia B Line of the spinous processes C Fascial insertion between the trapezius and infraspinous fasciae D Infraspinous aponeurotic fascia E Latissimus dorsi with its perimysial fascia

Figure 16.22 Left scapular area A Spinous processes of the proximal dorsal spine B Rhomboid, detached from the spine and turned down C Deep layer of the deep dorsal thoracic fascia D Inferior angle of the scapula E Latissimus dorsi Asterisks – fascia subscapularis

scapulothoracic dynamics but also in glenohumeral dynamics (see Chapter 17). ° e serrati fascia enclose the fascicles of the serratus posterior superior (SPS) and serratus posterior inferior (SPI) muscles. Stecco (2015) states “It is impossible to divide the fascia from these muscles because they are completely embedded within the fascia.” Although the attachments of the two muscles might indicate their participation in the forced breathing process (the SPS raises the upper ribs during forced inhalation and the SPI draws the lower ribs downward and backward during exhalation), in anatomy texts the function of the two muscles in relation to breathing is controversial. Some researchers suggest that there is no evidence

A

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Figure 16.24 The left side of the dorsal thoracic area and the muscles related to the deep thoracic fascia A The left trapezius, detached from the spinous processes, elevated and separated from the rhomboids and ribs B The inner side of the right trapezius, detached from the right scapula and ribs then lifted and transferred to the left side C Infraspinatus muscle covered by the aponeurotic fascia D Superficial lamina of the thoracolumbar fascia E Latissimus dorsi muscle F Erector spinae muscles G Line of the spinous processes H Iliac crest

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AA

B

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Figure 16.25 Fascia of the back. A Trapezius covered by the superficial fascia of the back. Note the difference in the intensity of vascularization in the different areas. B Trapezius. In the interscapular area, the aponeurosis crosses the midline of the body structurally and dynamically joining the two sides of the muscle. C The left trapezius has been removed to show the rhomboids and splenius capitis

Lateral

* * 2

1 A

B

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D

E

Figure 16.26 1 Left lateral aspect of the back (see Video 16.1, page 445). 2 Macroscopic view of the fascial attachments of the spine of the scapula (area indicated by the black asterisk in image 1). 3 Aponeurotic infraspinous fascia (area indicated by the white asterisk in image 1). Note the multilayered structure and the different directions of the collagenous fibers which allow for multidirectional movements of the entire structure A Trapezius B Supraspinous muscle covered by the trapezius aponeurosis C Spine of the scapula D Infraspinatus muscle covered by aponeurotic fascia E Latissimus dorsi

3

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Figure 16.27

Distal Proximal Medial

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Left trapezius separated from the latissimus dorsi (see Video 16.1, page 445) A Latissimus dorsi aponeurosis B Right trapezius belly with epimysial fascia C Line of the spinous processes D Latissimus dorsi fibers E Trapezius (underside) F Trapezius fascia (deep layer) G Trapezius (outer side)

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1 A

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Figure 16.28

Distal Proximal

Right parascapular area 1 Fascial link of the right trapezius and rhomboid A Line of the spinous processes B Trapezius, dissected and lifted C Rhomboid epimysial fascia 2 Neurovascular bundle entrapment between the trapezius and rhomboid

supporting their respiratory role. Vilensky et al. (2001) state that there are even discrepancies on this subject between the British and American editions of Gray´s Anatomy. Loukas et al. (2008), a˙ er having compared

the cadavers of 50 patients with chronic obstructive pulmonary disease with controls, suggest that “no respiratory function be attributed to either of the serratus posterior superior and inferior muscles.” ° e SPS and

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Figure 16.29 The left trapezius, dissected, separated from the scapula, and lifted (see Video 16.2, page 445) A Splenius capitis B Spine of the scapula C Rhomboid with epimysial fascia D Trapezius (underside) E Trapezius fascia (underside) F Latissimus dorsi

Lateral A

B

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D

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Distal Proximal

SPI are located in the same layer “forming a unique ÿ bromuscular layer” (Stecco 2015). Below the focus is on the behavior of the SPS in relation to its fascia but the synergistic action of the two muscles (SPS and SPI) in relation to the middle layer of the deep thoracic fascia should not be overlooked. ° e SPS originates at the nuchal ligament (at about C6), the supraspinous ligament, and the spinous processes from C7 to T2–T3, enveloping the 2nd and 3rd thoracic vertebrae. It is inserted into the superior aspect of the 2nd to 5th ribs (just lateral to the angle of the ribs). ° e fascia covers the entire structure of the SPS. Its close insertion into the ribs and the spine and also the proximity of the scapula could be said to create a kind of sliding platform that is used by the muscles that connect the spine with the upper extremities (rhomboid and trapezius) and also by muscles from the superÿ cial layer (e.g., trapezius) and the deep layer (longissimus thoracis and iliocostalis thoracis). In light of its location, it is worth considering if the SPS has a role in dyskinesia (alterations in the resting position and loss of control of normal scapular motion that predispose to shoulder injuries). Although the SPS may not be able to directly a˛ ect the movements of the scapula, it may act as a proprioceptor to the scapulothoracic joint. Vilensky et al. (2001) suggest that “SPS and SPI

have re˝ ex connection with the respiratory muscles such that overstretching results in compensatory movements.” Li˙ ing objects with the hands outstretched or other activities carried out with a sustained forward head posture (e.g., bending forward and working on a laptop while reclining on a couch) causes the scapula to exert pressure on the SPS and may produce or increase pain (scapulocostal syndrome). Fourie (1991) states that in scapulocostal syndrome “the pain originates mainly from an enthesopathy of the serratus posterior superior muscle.” In Travell, Simons & Simons’ Myofascial Pain and Dysfunction, Donnelly et al. (2019) point out the presence of painful shoulder syndrome relating it to the presence of SPS trigger points. It is considered that proprioception can play an important role in contributing to joint stability. However, it has not been conÿ rmed that proprioceptive prophylaxis has a signiÿ cant role in the prevention of injuries linked to our contemporary lifestyle (Lephart & Jari 2002).

The deep layer ° e deep layer of the deep fascia of the thorax is composed of two sheets. ° e superÿ cial sheet is the posterior (aponeurotic) layer of the thoracolumbar fascia that covers the paraspinal muscles from behind and separates them from the quadratus lumborum. ° e deep sheet is

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16 A

B

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A B

C D

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3 Figure 16.30

Lateral Proximal

Dissection of the successive fascial layers in the parascapular area 1 Superficial layer of the deep thoracic fascia A Epimysial fascia over the trapezius B Trapezius fibers 2 Fascial links between the trapezius and the infraspinous aponeurotic fascia (see Video 16.2, page 445) A Trapezius fibers covered by epimysial fascia B Inferior angle of the scapula C Infraspinous aponeurotic fascia D Teres major and teres minor muscles E Trapezius–infraspinous fascia link 3 Middle layer of the deep thoracic fascia A Inferior angle of the scapula B Rhomboid aponeurosis C Line of the spinous processes D Rhomboid attachment at the medial border of the scapula Asterisk – rhomboid–infraspinous fascia link

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Figure 16.31 Fascial continuity of the middle layer of the deep fascia of the thorax. Note the continuity of the fasciae of the rhomboid, latissimus dorsi, and the erector spinae structures (circled area) A Left trapezius B Left trapezius, dissected from the spine and turned down C Right trapezius D Left rhomboid E Latissimus dorsi aponeurosis F Line of the spinous processes G Latissimus dorsi fibers

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Figure 16.32 The deep layer of the left posterior thoracic fascia 1 Panoramic view A Splenius capitis B Deep layer of the posterior thoracic fascia C Levator scapulae D Supraspinatus covered by aponeurotic fascia E Spine of scapula F Infraspinatus covered by aponeurotic fascia 2 Macroscopic view of the subscapular space A Inferior angle of the scapula B Subscapular fascia linked to the deep posterior thoracic fascia C External intercostal muscles covered by fascia D Ribs

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Distal

Figure 16.33 Deep layer of the posterior deep thoracic fascia (left side) A Line of the spinous processes B Ribs C Thoracolumbar fascia D Erector spinae muscles covered by epimysial fascia

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Distal Medial

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Figure 16.34 Intrinsic muscles of the back A Trapezius B Transversospinales C Thoracolumbar fascia D Multifidus

the epimysium that surrounds the erector spinae muscles. (Figs. 16.31–16.34).

Conclusion

a correct functional performance of the clavicular and pelvic girdle and the appropriate distribution of load on the spine.

° e optimal mobility of the thorax (breathing and range and coordination of movements) is essential for

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REFERENCES

Al-Qadi MO (2018) Disorders of the chest wall: Clinical manifestations. Clin Chest Med 39(2):361–375. Atalay YO, Mursel E, Ci˙ ci B, Iptec G (2019) Bloqueo del plano de la fascia clavipectoral para analgesia tras cirugía de clavícula. Rev Esp Anestesiol Reanim 66(10):562–563. Berg EE (1993) ° e sternal-rib complex. A possible fourth column in thoracic spine fractures. Spine (Phila Pa 1976) 18(13):1916–1919. Bordoni B, Marelli F, Morabito B, Sacconi B (2016) Manual evaluation of the diaphragm muscle. Int J Chron Obstruct Pulmon Dis 11:1949–1956. Boutros S, Kattash M, Wienfeld A, Yuksel E, Baer S, Shenaq S (1998) ° e intradermal anatomy of the inframammary fold. Plast Reconstr Surg 102(4):1030–1033. Brinkman RJ, Hage JJ (2016) Andreas Vesalius’ 500th anniversary: First description of the mammary suspensory ligaments. World J Surg 40(9):2144–2148. Campbell EJ, Howell JB (1963) ° e sensation of breathlessness. Br Med Bull 19(1):36–40. Cardoso A, Santos D, Martins J, Coelho G, Barroso L, Costa H (2015) Breast ligaments: an anatomical study. Eur J Plast Surg 38:91–96. Chao AC, Lin RT, Liu CK, Wang PY, Hsu HY (2007) Mechanisms of cough syncope as evaluated by valsalva maneuver. Kaohsiung J Med Sci 23(2):55–62.

Denis F (1983) ° e three column spine and its signiÿ cance in the classiÿ cation of acute thoracolumbar spinal injuries. Spine (Phila Pa 1976) 8(8):817–831. Donnelly JM, Fernández-de-las-Peñas C, Finnegan M, Freeman JL (2019) Travell, Simons & Simons’ Myofascial Pain and Dysfunction: ° e Trigger Point Manual. 3rd ed. Philadelphia, PA: Wolters Kluwer. Drake R, Vogl AW, Mitchell AWM (2009) Gray’s Anatomy for Students. 2nd ed. New York: Churchill Livingstone Elsevier. Fourie LJ (1991) ° e scapulocostal syndrome. SˇAfr Med J 79(12):721–724. Gandhi HS (2019) Rationale and options for choosing an optimal closure technique for primary midsagittal osteochondrotomy of the sternum. Part 1: A theoretical and critical review of functional anatomy, biomechanics, and fracture healing. Crit Rev Biomed Eng 47(1):1–25. Gil A, Olza J, Gil-Campos M, Gomez-Llorente C, Aguilera CM (2011) Is adipose tissue metabolically di˛ erent at di˛ erent sites? Int J Pediatr Obes 6 (Suppl. 1):13–20. Gui GP, Behranwala KA, Abdullah N, Seet J, Osin P, Nerurkar A, Lakhani SR (2004) ° e inframammary fold: Contents, clinical significance and implications for immediate breast reconstruction. Br J Plast Surg 57(2):146–149.

chronic obstructive pulmonary disease. Respir Care 44(6):409–414. Lee DG (2015) Biomechanics of the thorax – research evidence and clinical expertise. J Man Manip ° er 23(3):128–138. Lephart SM, Jari R (2002) ° e role of proprioception in shoulder instability. Oper Tech Sports Med 10(1):2–4. Loukas, M, Shoja MM, ° urston T, Jones VL, Linganna S, Tubbs RS (2007) Anatomy and biomechanics of the vertebral aponeurosis part of the posterior layer of the thoracolumbar fascia. Surg Radiol Anat 30(2):125–129. Loukas M, Louis RG, Wartmann CT, Tubbs RS, Gupta AA, Apaydin N, Jordan R (2008) An anatomic investigation of the serratus posterior superior and serratus posterior inferior muscles. Surg Radiol Anat 30(2):119–123. Mak SM, Bhaludin BN, Naaseri S, Di Chiara F, Jordan S, Padley S (2016) Imaging of congenital chest wall deformities. Br J Radiol 89(1061):20150595. Mallick A, Bodenham AR (2003) Disorders of the lymph circulation: ° eir relevance to anaesthesia and intensive care. Br J Anaesth 91(2):265–272. Messlinger K, Fischer MJ, Lennerz JK (2011) Neuropeptide e˛ ects in the trigeminal system: Pathophysiology and clinical relevance in migraine. Keio J Med 60(3):82–89.

Haagenson CD (1971) Anatomy of the mammary gland. In: Harris JR, Lippman ME, Morrow M Osborne CK (Eds.) Diseases of the Breast. 2nd ed. Philadelphia: Saunders, pp. 16–17.

Mihalache G, Indrei A, Tăranu T (1996) ° e anterolateral structures of the neck and trunk. Rev Med Chir Soc Med Nat Iasi 100(1–2):69–74.

Hematti H (2011) Anatomy of the thoracic duct. ° orac Surg Clin 21(2):229–238.

Miller JI (2007) Muscles of the chest wall. ° orac Surg Clin 17(4):463472.

Cooper AP (1840) On the Anatomy of the Breast, Volume 1. London: Longman, Orme, Green, Brown, and Longmans. Available: https://jdc. je˛ erson.edu/cooper/60/ [accessed March 26, 2021].

Hussain A, Burns B (2020) Anatomy, ° orax, Wall. [Updated 2020 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available: https://www. ncbi.nlm.nih.gov/books/NBK535414/ [accessed April 18, 2021].

Montaldo BC, Gleeson K, Zwillich CW (2000) ° e control of breathing in clinical practice. Chest 117(1):205–225.

Courtney R (2009) ° e functions of breathing and its dysfunctions and their relationship to breathing therapy. Int J Osteopath Med 12(3):78–85.

Kakizaki F, Shibuya M, Yamazaki T, Yamada M, Suzuki H, Homma I (1999) Preliminary report on the e˛ ects of respiratory muscle stretch gymnastics on chest wall mobility in patients with

Clemens MW, Evans KK, Mardini S, Arnold PG (2011) Introduction to chest wall reconstruction: Anatomy and physiology of the chest and indications for chest wall reconstruction. Semin Plast Surg 25(1):5–15.

16

Nicaise C, Hala TJ, Frank DM, Parker J, Authelet M, Leroy K, Brion JP, Wright MC, Lepore AC (2012) Phrenic motor neuron degeneration compromises phrenic axonal circuitry and diaphragm activity in a unilateral cervical contusion model of spinal cord injury. Exp Neurol 235(2):539–552.

455

Pilat_Myofascial Induction.indb 455

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16

REFERENCES

Okuno K, Ishizu K, Matsubayashi J, Fujii S, Sakamoto R, Ishikawa A, Yamada S, Yoneyama A, Takakuwa T (2019) Rib cage morphogenesis in the human embryo: A detailed threedimensional analysis. Anat Rec (Hoboken) 302(12):2211–2223. Pan WR, Rozen WM, Stella DL, Ashton MW (2009) A three-dimensional analysis of the lymphatics of a bilateral breast specimen: A human cadaveric study. Clin Breast Cancer 9(2):86–91. Panjabi MM, Brand RA, White AA (1976) Mechanical properties of the human thoracic spine as shown by three-dimensional load-displacement curves. J Bone Joint Surg Am 58(5):642–652. Paulin E, Brunetto, AF, Carvalho CRF (2003) E˛ ects of a physical exercises program designed to increase thoracic mobility in patients with chronic obstructive pulmonary disease. J Pneumol 29(5):287–294. Peiper C, Junge K, Prescher A, Stumpf M, Schumpelick V (2004) Abdominal musculature and the transversalis fascia: An anatomical viewpoint. Hernia 8(4):376–380.

Rehnke RD, Groening RM, Van Buskirk ER, Clarke JM (2018) Anatomy of the superÿ cial fascia system of the breast: A comprehensive theory of breast fascial anatomy. Plast Reconstr Surg 142(5):1135–1144.

Stecco A, Masiero S, Macchi V, Stecco C, Porzionato A, De Caro R (2009) ° e pectoral fascia: Anatomical and histological study. JˇBodyw Mov ° er 13(3):255–261.

Richardson WF, Carman JB (Trans.) (2007) On the Fabric of the Human Body. Book V: ° e Organs of Nutrition and Generation. Andreas Vesalius. Novato, CA: Norman Publishing.

Stecco C, Macchi V, Porzionato A, Morra A, Parenti A, Stecco A, Delmas V, De Caro R (2010) ° e ankle retinacula: Morphological evidence of the proprioceptive role of the fascial system. Cells Tissues Organs 192(3):200–210.

Riggio E, Quattrone P, Nava M (2000) Anatomical study of the breast superÿ cial fascial system: ° e inframammary fold unit. Eur J Plast Surg 23(6):310–315.

Vilensky JA, Baltes M, Weikel L, Fortin JD, Fourie LJ (2001) Serratus posterior muscles: Anatomy, clinical relevance, and function. Clin Anat 14(4):237–241.

Riquet M, Mordant P, Pricopi C, Achour K, Le Pimpec Barthes F (2013) Anatomy, microanatomy and physiology of the lymphatics of the lungs and chest wall. Rev Pneumol Clin 69(2):102–110.

Weston AD, Ozolinš TRS, Brown NA (2006) ° oracic skeletal defects and cardiac malformations: A common epigenetic link? Birth Defects Res C Embryo Today 78(4):354–370.

Rohrich RJ, Smith PD, Marcantonio DR, Henkel JM (2001) ° e zones of adherence: Role in minimizing and preventing contour deformities in liposuction. Plast Reconstr Surg 107(6):1562–1569.

Pickering M, Jones JF (2002) ° e diaphragm: Two physiological muscles in one. J Anat 201(4):305–312

Skandalakis PN, Zoras O, Skandalakis JE, Mirilas P (2006) Transversalis, endoabdominal, endothoracic fascia: Who’s who? Am Surg 72(1):16–18.

Poitevin LA, Postan D, Forlizzi V (2016) Axilla fasciae. New research on 34 cases. Revista Argentina de Anatomía Online 7(2):70–75.

Stecco C (2015) Functional Atlas of the Human Fascial System. Edinburgh: Churchill Livingstone Elsevier.

Willard FH, Vleeming A, Schuenke MD, Danneels L, Schleip R (2012) ° e thoracolumbar fascia: Anatomy, function and clinical considerations. J Anat 221(6):507–536. Zucca-Matthe G, Urban C, Vallejo A (2016) Anatomy of the nipple and breast ducts. Gland surgery 5(1):32–36.

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MIT procedures for common dysfunctions of the thorax complex

Assessment of thoracic dysfunction Longitudinal stroke applied to the thoracolumbar fascia with the patient in the sitting position Longitudinal stroke applied to the thoracolumbar fascia with the patient in the quadruped position Longitudinal stroke applied to the intercostal spaces Cross hands induction applied to the back Cross hands induction applied to the chest Myofascial induction of the breathing structures: Longitudinal stroke Myofascial induction of the breathing structures: Transverse plane procedure

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16 Neuroprotection (Prophylactic measure)

Avoids

Supports

Hypoxic or ischemic insult

Increase in neuronal tolerance and improvement in neuronal survival

Neuroprotection refers to sensory and motor mechanisms that act in response to disorders in the mechanosensitivity of the nervous tissue (neuritis). The sensory manifestations can be the result of the activation of nociceptive mechanisms, with the presence or absence of pain, which can trigger antagonistic motor activity to condition where the nerve can be subjected to mechanical stress. Protective muscle response can lead to changes in movement patterns involving fear-avoidance behavior and maladaptive posture.

Key to level of irritability or dysfunction Irritability/type of dysfunction

Levels

Irritability

High: presence of fear-avoidance and neuropathic features (negative psychosocial factors††) Moderate: presence of fear-avoidance and mixed features (negative psychosocial factors) Low: absence of fear-avoidance and predominant nociceptive features (positive psychosocial factors*)

Neuroprotection

High: presence of fear-avoidance and neuropathic features (negative psychosocial factors††) Moderate: presence of fear-avoidance and mixed features† (negative psychosocial factors) Low: absence of fear-avoidance and predominant nociceptive features (positive psychosocial factors*)

Rigidity/stiffness

High: absence of elastic deformation of tissue during palpatory assessment Moderate: small range of elastic deformation of tissue during palpatory assessment Low: decreased range of elastic deformation during palpatory assessment

Glide/gliding impairment

High: absence of gliding/sliding between fascial planes during palpatory assessment Moderate: decrease in gliding/sliding between fascial planes during palpatory assessment Low: absence of impairment in gliding/sliding of fascial layers

* The patient’s positive thinking about their condition and/or prognosis † Fluctuating (alternating/changing) neuropathic or nociceptive manifestation †† The patient’s erroneous and/or catastrophic thoughts about their condition and/or prognosis

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MIT procedures for common dysfunctions of the thorax complex

16

ASSESSMENT OF THORACIC DYSFUNCTION

Spinal cord compression assessment Static stability Stability

Breathing dysfunction assessment

Assessment of stiffness in the thoracic spine

Dynamic stability

Global functional assessment

Breathing capacity: inhalation and exhalation tests ROM Mobility Movement synergy

Breathing dysfunction assessment

Breathing rhythm: thoracoabdominal test

Dorsal spine flexibility test

Figure 16.1.1

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16 LONGITUDINAL STROKE APPLIED TO THE THORACOLUMBAR FASCIA WITH THE PATIENT IN THE SITTING POSITION

Objective To restore mobility to the thoracolumbar fascial links in the paravertebral structures

Objective

Type of procedure Sliding: longitudinal stroke (direct application) Irritability/type of dysfunction

Indications

Type of procedure

Indications Thoracic and lumbar spine dysfunction; prior to scoliosis treatment; kyphotic posture; breathing dysfunctions; neural mechanosensitivity Irritability/type of dysfunction Irritability: low Neuroprotection: moderate (dura mater) Rigidity/stiffness: high Glide: low

Patient position

Sitting on a chair with clothing removed from the back

Practitioner position

Standing behind the patient, with one foot placed in front of the other

Hand/elbow contacts

Place the knuckles of the index, middle, and ring fingers symmetrically in the paraspinous canal and the thumbs in the midcervical area. Alternative contact: the elbow may be used for this procedure.

Procedure

Initially, very gentle pressure is applied. The patient progressively flexes the trunk (head–neck–shoulders). At the same time, the practitioner slides their hands in a caudal direction until the level of T2 is reached. The practitioner stops the movement while maintaining the forward foot position and extended elbows. The patient resumes the movement progressively: arms–dorsal spine–lumbar spine (and pauses for 6–7 seconds in the presence of an entrapment on either side). The practitioner’s hands slide downward due to the movement of the patient’s back and not because of active sliding of the practitioner's hands. The procedure is repeated 3 times. Alternative technique using the elbow: this is performed on the more restricted side, moving from T2 to T8.

Observations/ contraindications

This procedure is the first step of the longitudinal stroke in prone (see Fig. 13.7A) and is applied when the previous procedure has not produced the expected result. The return to the vertical position should be progressive (lumbar spine–dorsal spine–cervical spine–head). Contraindications: advanced osteoporosis, osteoarthritis, spinal arthrodesis, disc or vascular dysfunction that increases with trunk flexion. Take care generally when treating the elderly.

Figure 16.1.2

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LONGITUDINAL STROKE APPLIED TO THE THORACOLUMBAR FASCIA WITH THE PATIENT IN THE QUADRUPED POSITION

Objective

Irritability/type of dysfunction

Indications

Type of procedure

Objective To elongate the posterior structures of the thoracolumbar fascia and the back extensors

Patient position

On the table, bending over with the arms stretched forward while kneeling and sitting on their heels

Practitioner position

Standing at the side to be treated, with the feet pointing toward the patient’s pelvis

Type of procedure Sliding: longitudinal stroke (direct application)

Hand/forearm contacts

Indications Thoracic and lumbar spine dysfunction; prior to scoliosis treatment; kyphotic posture; dysfunction and scapular instability

Hold the sacrum area in position with the caudal hand. If required, the forearm can be used to do this. Place the cranial hand (with the proximal interphalangeal joints flexed) in the space between the spinous processes and paravertebral muscles at the upper dorsum. Use the thumb as a guide during the movement but without applying pressure.

Procedure

Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate (dura mater) Rigidity/stiffness: high Glide: low

Apply gentle downward pressure toward the table and longitudinal sliding in the caudal direction until you reach the lower edge of the scapula. After this level is reached the patient “walks” using alternate hands, without lifting the pelvis. The practitioner resumes the movement by slowly sliding their hand to the level of L4. Repeat 3 times on each side.

Observations/ contraindications

This procedure is the next step after the sliding stroke has been applied to the patient when sitting. It is applied when the previous procedure has not produced the expected result. Place a pillow between the lower legs and the thighs to protect the meniscus. Do not allow pelvic movement. Take care when treating patients with omalgia. Red flags: advanced osteoporosis, osteoarthrosis, orthosis, spinal arthrodesis, and disc or vascular problems that worsen during trunk flexion. Take care generally when treating the elderly. The procedure is not recommended if the patient has a knee problem.

Figure 16.1.3

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16 LONGITUDINAL STROKE APPLIED TO THE INTERCOSTAL SPACES A B C

D

E

F

G

Objective To restore chest wall dynamics. To improve respiratory dynamics

Objective

Type of procedure Sliding: longitudinal stroke (direct application) Irritability/type of dysfunction

Type of procedure

Irritability/type of dysfunction Irritability: moderate Neuroprotection: low or moderate Rigidity/stiffness: high Glide: low

1 Indications

2

Indications Costal contusions; postsurgery or post-traumatic dysfunctions; whiplash; respiratory dysfunctions that generate thoracic hypomobility; glenohumeral dysfunction; entrapments in the thoracic outlet

Patient position

Supine

Practitioner position

Standing at the side to be treated level with the patient’s trunk

Hand contacts

With the thumb of the nondominant hand hold the skin medially close to the sternum. Place the index finger of the other hand, along with the middle finger, in the intercostal space close to the sternum.

Procedure

Press down slightly with the index finger and perform longitudinal sliding from medial to lateral for 2–4 cm. Pause for 6–7 seconds at each restriction. Repeat 3 times.

Observations/ contraindications

Do not press on the breast. If necessary, slide the finger along the entire intercostal space. Do not treat if the patient has had a recent rib fracture.

3 Figure 16.1.4 1 Anterolateral aspect of the pectoral area A Pectoralis minor muscle belly B Pectoralis minor aponeurosis C External intercostal aponeurosis D Ribs E Sternum F Clavipectoral fascia G Sternocleidomastoid muscle belly 2 Longitudinal stroke applied to the intercostal spaces demonstrated on a cadaveric sample 3 The procedure applied to the patient

Video 16.3

Longitudinal stroke applied to the intercostal spaces

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CROSS HANDS INDUCTION APPLIED TO THE BACK Objective To restore mobility to the thoracolumbar fasciarelated muscles

Objective

Type of procedure Sustained systemic procedure (indirect application)

Irritability/type of dysfunction

Type of procedure

A

Indications Scoliosis; postsurgery dysfunctions; breathing dysfunctions; post-traumatic dysfunctions; hyperkyphosis; forward head posture. Thoracic pain (A). Headache, interscapular pain (trapezius dysfunction) (B) Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate Rigidity/stiffness: high Glide: low

Indications

Patient position

Prone

Practitioner position

Standing at the patient’s side or next to the patient's head

Hand contacts

Cross the hands and place them along the dorsal spine or on the interscapular area.

Procedure

The principles of sustained systemic procedures should be followed (see Chapter 13).

Observations/ contraindications

Take care not to restrict the patient's breathing.

B

Figure 16.1.5

A Longitudinal stroke. B Transverse stroke

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16 CROSS HANDS INDUCTION APPLIED TO THE CHEST Objective To restore mobility to the pectoral fascia-related structures

Objective

Type of procedure Sustained systemic procedure (indirect application)

A

Irritability/type of dysfunction

Type of procedure

Indications Scoliosis; postsurgery dysfunctions; breathing dysfunctions; post-traumatic dysfunctions; hyperkyphosis; forward head posture; shoulder complex dysfunction; esophageal and gastroduodenal dysfunctions; cervical pain syndrome; craniomandibular dysfunction and pain; thoracic outlet entrapments Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate Rigidity/stiffness: high Glide: low

Indications

B

C

Patient position

Supine

Practitioner position

Standing at the patient's side or at the head of the table

Hand contacts

Cross the hands and place them on the anterior segment of the thorax. Position the hands according to the area being treated (see photos A–D).

Procedure

The principles of the sustained cross hands procedure should be followed (see Chapter 13).

Observations/ contraindications

Avoid applying excessive pressure with the hands.

D

Figure 16.1.6

A Unilateral pectoral induction. B Bilateral pectoral induction. C Longitudinal pectoral induction. D Serratus anterior fascia induction

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16

MYOFASCIAL INDUCTION OF THE BREATHING STRUCTURES: LONGITUDINAL STROKE

Objective To restore mobility to the diaphragm-related structures

Objective

Irritability/type of dysfunction

Indications

Type of procedure

Type of procedure Sliding: longitudinal stroke (direct application) Indications Breathing or diaphragmatic dysfunction related to the fascial system; pelvic girdle dysfunctions related to breathing problems; gastroduodenal disorders; nonspecific LBP; forward head posture; kyphotic posture Irritability/type of dysfunction Irritability: moderate Neuroprotection: low (vagus nerve) Rigidity/stiffness: moderate Glide: low

Patient position

Sitting on the table with the legs dangling, leaning against the practitioner. The head position should be relaxed. Avoid an excessive kyphotic position.

Practitioner position

Standing behind the patient in a stable position. A pillow should be placed between the patient and the practitioner.

Hand contacts

Position the hands between the patient’s trunk and arms. Place the flexed index fingers slightly below the xiphoid process. The middle and ring fingers are placed alongside the index fingers.

Procedure

With the fingers of both hands flexed under the lowest ribs, perform a longitudinal sliding movement until the lateral recesses are reached. At each restriction pause the movement for 7 seconds. Repeat 3 times.

Observations/ contraindications

Take care to avoid touching the patient with the fingernails. Red flags: pregnancy, suspected pregnancy, recent surgery (less than 6 weeks since surgery), acute abdominal pain or swelling, considerable digestive disorders, unexplained high fever, liver problems, or hiatal hernia.

Figure 16.1.7

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16 MYOFASCIAL INDUCTION OF THE BREATHING STRUCTURES: TRANSVERSE PLANE PROCEDURE Objective Induction of fascial restrictions in the diaphragmatic and interclavicular area

Objective

Type of procedure Sustained systemic procedure (indirect application)

A

Irritability/type of dysfunction

Type of procedure

Indications

Irritability/type of dysfunction Irritability: low Neuroprotection: moderate (vagus nerve) Rigidity/stiffness: high Glide: moderate (associated with adjacent viscera)

B

C

Indications Breathing dysfunctions related to the fascial system; diaphragmatic block related to lumbopelvic dysfunction (nonspecific, persistent LBP); pelvic girdle dysfunction related to breathing problems; dysfunction of the pelvic floor (incontinence); gastroduodenal dysfunction (vagus nerve); forward head posture; kyphotic posture; dysfunctions of the shoulder structure

Patient position

Supine

Practitioner position

Sitting in a chair at the patient’s side

Hand contacts

Place the nondominant hand (supine) on the low thoracic region or in the superior interscapular area. With the dominant hand in prone position, place the metacarpophalangeal joint of the index finger on the xiphoid process of the sternum or on the interclavicular area. The fingers should be slightly separated and the thumbs are directed cranially.

Procedure

Apply downward pressure with the dominant hand until the barrier is felt. Allow a minimum of 60–90 seconds for the release. Follow the facilitated movement for between 3–6 consecutive barriers (3–5 minutes).

Observations/ contraindications

Avoid arbitrary stimulus application. Remove the hands slowly when finishing. The patient should remain on the table for 2 minutes after the procedure has ended. Red flags: pregnancy, suspected pregnancy, recent abdominal surgery, undiagnosed abdominal pain or swelling, considerable digestive disorders, unexplained high fever, recent thoracic and heart surgery, and undiagnosed thoracic pain or swelling. Do not place the hand over the pacemaker area.

Figure 16.1.8

A Diaphragmatic transverse plane induction. B Interclavicular transverse plane induction. C Interclavicular transverse plane induction demonstrated on a cadaveric sample

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17

KEY POINTS •

Description of the fascial system of the upper extremity

•

Anatomical continuity (links) between the superficial and deep fascial structures of the neck, thorax, arm, forearm, and hand

•

Neural and vascular components related to the fascial system of the upper extremity

•

Clinical features of myofascial dysfunction in the upper extremity

Introduction ° e complex movements of the upper extremity require the coordinated participation of 32 bones mobilized by 45 muscles. Between these structures run the neurovascular bundles (the blood supply is via the branches of the axillary artery; the main veins are the cephalic, basilic, and axillary veins; the motor and sensory supply of the upper extremity is provided mainly by the brachial plexus). ° erefore, the brain has to coordinate almost 100 di˛ erent muscles to operate both upper extremities during daily tasks, and yet it performs these functions with apparent ease. Evidence suggests that “the brain may control the limbs by scaling, o˛ setting, and temporally dilating fundamental movements encoded in the sensorimotor system” (Burns et al. 2017). ° ese patterns of motion have been developed into the concept of synergies, which can be deÿ ned as “a collection of relatively independent degrees of freedom that behave as a single functional unit” (Turvey 2007). ° e presence of two types of synergies is suggested: kinematic synergies, which refer to joint dynamics, and neuromuscular synergies (Burns at al. 2017). ° e brain manages the control of movements through a process called “degrees of freedom” (Latash et al. 2007). Fascia plays an important role in these tasks. Fascia actively participates in the development of movements in its search for optimal eˆ ciency of function through intra- and intermuscular links as well as through its extensive network of mechanoreceptors. As mentioned in Chapter 3, in classical anatomy textbooks the topographic description of fascia prevails,

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and speciÿ c names are allocated to fascia based on the other structures with which it is topographically associated (mainly muscles). ° is division of “the fasciae” of each segment is clearly evident in the fascial nomenclature of the upper extremity (e.g., pectoralis fascia, deltoid fascia, bicipital fascia). Although this analysis is topographically accurate, at the same time it is abstract, isolated, and with a limited functional correlation between anatomical elements. Anatomical studies of embalmed cadavers do not allow us to fully understand the fascial condition, fascial links, and fascial continuity or fascia’s interrelationships with other structures. ° is chapter focuses on the continuity of the fascial structures of the upper extremities. It highlights the principal anatomical features that contribute to this continuity and how they relate to the most common movement dysfunctions (Fig. 17.1).

Synergy as part of General System Theory General System ° eory (von Bertalan˛ y 1968) is described in Chapter 2. ° is theory emphasizes the totality of the system whose components and attributes can only be understood as functions of the whole system. ° is complex architecture consists of a group of interdependent elements where the behavior and expression of each element in˝ uences and is in˝ uenced by all the others, constituting a reality that goes beyond the linear logic of cause and e˛ ect.

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17

A

B

C

D

E

F

Figure 17.1 Anatomical components related to the fascial structures of the upper extremity. Note the continuity of the deep fascia of the neck, pectoralis fascia, and deltoid fascia with the brachial fascia. A Langer’s lines on the skin. B Fat lobes embedded in the superficial fascia. C The cutaneous innervation of the anterior region extends from the lateral and anterior cutaneous nerves via ventral rami, forming a segmental dermatomal pattern. D Lymphatic system. E Vascular system. F Epimysial (deep) layer of the deep fascia

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Upper extremity dysfunctions related to the fascial system

The usefulness of muscle synergies One of the characteristics of a system is synergy, understood to be the combined action of several elements, which produces a greater total outcome than the outcome of each element separately. In relation to body movement, the participation of the central nervous system (CNS) (decision making) will have a transcendental importance on the ÿ nal performance. Previously, researchers have pointed out that the CNS controls movement coordination by modulating multiple skeletal muscles (Gottlieb 1998). d’Avella et al. (2003) assert that modular structures organize and change the degree of multiple freedom between muscles. Hu et al. (2018) state: “° e central nervous system (CNS) controls the limb movement by modulating multiple skeletal muscles with synergistic modules and neural oscillations with di˛ erent frequencies between the activated muscles.” It is important to understand how the CNS behaves to control the complex architecture of the motor system (along with multiple joints and muscles) in the acquisition or adaptation of motor skills patterns used to activate di˛ erent motor functions. Research supports the hypothesis that motor control has a modular organization (d’Avella & Bizzi 2005, d’Avella 2016). In the last decade, research on muscle synergies has made an interesting advance in the ÿ eld of robotics and artiÿ cial intelligence (d’Avella et al. 2015). Although this area of research is still developing, it is worth summarizing some concepts that expand our theoretical knowledge of synergies and allow us to better understand the importance of the fascia in body movement. DeRugy et al. (2013) assert that muscle synergies provide an e˛ ective strategy for motor coordination. After testing the isometric forces of the hand muscles, Borzelli et al. (2013, cited in d’Avella et al. 2015) observed that: “° e minimum e˛ ort recruitment of synergies predicts the observed muscle patterns better than the minimum e˛ ort recruitment of individual muscles.” Frère & Hug (2012) demonstrate the consistency of muscle synergies, even during a skilled motor task that requires learning. ° is research was carried out with an experienced gymnast. ° e authors conclude that synergy disorder inevitably introduces signiÿ cant errors in movement behavior. In this author’s

17

opinion, the grouping and behavior of motor synergies are linked to the transmission of information to/from the fascial system and to/from the other body systems. In any given movement, the CNS does not activate the full potential of a single muscle contraction but rather uses optimal synergies to adapt to extrinsic and intrinsic requirements, which are modiÿ ed according to the circumstances every time the movement is performed. D’Avella (2016) states: A modular architecture may simplify control by embedding features of both the dynamic behavior of the musculoskeletal system and of the task into a small number of modules and by directly mapping task goals into module combination parameters. Several studies of the electromyographic (EMG) activity recorded from many muscles during the performance of different tasks have shown that motor commands are generated by the combination of a small number of muscle synergies, coordinated recruitment of groups of muscles with specific amplitude balances or activation waveforms, thus supporting a modular organization of motor control. Modularity may also help [with] understanding motor learning. In a modular architecture, acquisition of a new motor skill or adaptation of an existing skill after a perturbation may occur at the level of modules or at the level of module combinations. As learning or adapting an existing skill through recombination of modules is likely faster than learning or adapting a skill by acquiring new modules, compatibility with the modules predicts learning difficulty. A recent study in which human subjects used myoelectric control to move a mass in a virtual environment has tested this prediction. By altering the mapping between recorded muscle activity and simulated force applied on the mass, as in a complex surgical rearrangement of the tendons, it has been possible to show that it is easier to adapt to a perturbation that is compatible with the muscle synergies used to generate hand force than to a similar but incompatible perturbation. This result provides direct support for a modular organization of motor control and motor learning. ° ese observations allow us to better understand the development of fascial dysfunction, its analysis, and the choice of appropriate therapeutic procedures focused more on a systemic process rather than on a single anatomical structure.

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17 Types of synergies Every movement we perform is in some way related to synergy. In the neuromuscular synergy group, there are two types of synergies: absolute and relative (Zembaty 2003).

Absolute synergies Absolute synergies are inborn (innate) and persist throughout human development. For example, resisted extension in the wrist, with the forearm in pronation, causes tension of the triceps brachii; resisted cervical ˝ exion causes tension of the rectus abdominis; and resisted dorsi˝ exion in the ankle causes tension in the rectus femoris.

Relative synergies Relative synergies are not related exclusively to the strength of the appropriate muscle and optimal joint mobility. ° ey are mostly related to the eˆ ciency (synergy) of the fascial micro- and macrostructures (see Chapter 7) following requests and guidelines from the CNS in search of maximum movement eˆ cacy.

The upper extremity as a synergistic structure ° e upper extremity is a good example of the synergy phenomenon, particularly the structures of the shoulder complex (shoulder girdle). ° e biomechanics of the upper extremity is one of the most sophisticated and at the same time mechanically complicated systems in the human body. ° is tensegrity complex, consisting of three bones (scapula, clavicle, humerus) and ÿ ve joints (sternoclavicular, acromioclavicular, glenohumeral, scapulothoracic, subdeltoid), requires precise coordination of the large number of the myofascial components that directly or indirectly participate in its behavior. Among the components of this complex the scapula stands out. It is frequently an underestimated component of the kinematics of the shoulder girdle, despite being the key structure in glenohumeral dynamics and being vital to the eˆ cient functioning of the upper extremity as a whole. ° e location of the scapula deÿ nes the behavior of the upper extremity. It emerges as the core – a dynamic

center (a mobile platform for upper extremity dynamics) – which is essential for the movements of a harmonious tensegrity structure that assembles the upper extremity response. In the presence of a lesion at the macroscopic level (functional limitation of a certain structure, e.g., a muscle or ligament) or at the microscopic level (e.g., a cell) this tensegritic system uses its own adaptive resources to maintain its functionality (resilience). ° is phenomenon is beneÿ cial in emergent situations (e.g., allostasis) (see Chapter 8), but over time it may create con˝ ict with other segments. Prolongation of this con˝ ict (the allostatic load that accumulates as a result of potential and real dangers) can a˛ ect the harmony between the dynamic (movement) and the static (location and architecture) creating an overload and progressive deterioration of other structures. Actually, this complementarity is revealed in tendencies (the movement to be carried out) rather than in states (preservation of structural integrity of the whole system). It means that accomplishing a goal (e.g., having a cup of co˛ ee) could put the integrity (e.g., intervertebral disc protection) at risk. ° us, the behavior of the scapula as the core (dynamic center) of the upper extremity is essential to the (functional) stability of the upper extremity complex. ° e idea of the “sliding platform” – the participation of loose connective tissue in the movement between muscle layers in relation to the scapula – is discussed brie˝ y in Chapter 16. Alterations in gliding behavior can generate alteration in physiological (optimal) synergies and consequently alter movement patterns. As an example, these alterations could lead to scapulohumeral dyskinesis such as snapping scapula syndrome (“washboard syndrome”) (de Carvalho et al. 2019, Percy et al. 1988). ° is syndrome was underestimated for a long time and was o˙ en only associated with speciÿ c osseous abnormalities (Merolla et al. 2013).

Scapular dyskinesis Most dysfunctions related to the scapula are due to it lacking an adequate resting position and alterations in its dynamics (synergism) which lead to scapular dyskinesis (altered dynamic motion of the scapula). It is

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present in 67–100ˇpercent of patients with shoulder injuries (Kibler & Sciascia 2010). Scapular dyskinesis is a nonspeciÿ c response to a painful condition in the shoulder, i.e., it is not a response to any speciÿ c pathology. It has many causative factors which may include: osteoligamentous injury, muscle and nerve injury, muscle weakness, altered muscle activation patterns (myofascial imbalance), or proprioceptive dysfunction.

•

° e study by Ramaswamy et al. (2011) presents the ÿ rst experimentally determined lateral force measurements from intact mammalian muscle.

•

° e research by Findley et al. (2015) shows that substantial stress is transmitted to fascia during muscular exercise. ° is has implications for exercise therapies when they are designed for fascial as well as muscular stress.

° e fact that the upper extremity is not subject to gravitational loads could mean a lower possibility of injury. However, the high demands of precision, speed, force, resistance, and velocity in frequent daily tasks require optimal synergy of a large number of muscles. Local dysfunctions of any of the participating structures will cause overload in the whole system which will lead to pathologies (see Chapter 9). As an example, texting requires the activation of 38 muscles. ° e muscles of the forearm and hand must work in perfect harmony. It is not so much the muscles of the ÿ ngers that perform this task but the muscles of the forearms that control the movement of the ÿ ngers.

•

Myofascial loading can take place without changes in the length of the fascicle. ° is suggests that the changes observed in the forces exerted on the tendons are the result of forces transmitted from the surrounding muscles and not due to changes in the ability to generate strength of a given muscle (Tijs et al. 2018).

•

Yoshitake et al. (2018) tested (in vivo) the mechanical relationship between the biceps brachii (the mechanically stimulated muscle) and brachialis (muscle at rest) which are neighboring muscles inside the anterior compartment. ° ese were chosen because the two muscles have independent tendons that insert onto di˛ erent bones in the forearm. ° e biceps brachii was mechanically stimulated and changes in the transverse diameter of the brachialis were measured using shear-wave elastography. ° e authors conclude that “epimuscular myofascial force transmission may be facilitated at stretched muscle lengths.”

° erefore, the question as to why we move in a specific manner is related to “how the central nervous system produces purposeful, coordinated movements in its interaction with other body structures and with the environment” (Latash 2010, Latash et al. 2010) (see Chapter 10). Considering that the fascial system is a continuum of connective tissues present throughout the body (including in the intermediate layers between the muscle bellies, muscles and tendons, and muscles and neurovascular tracts), scapular dyskinesis could be related to the two characteristics already described in Chapter 7: force transmission and fascia’s role in proprioception.

Myofascial force transmission Force transmission through the fascia is discussed in more detail in Chapter 7. Below is some further information related to the lateral force transmission phenomena:

•

Huijing (2009) states that: “In the last decade, the potential of force transmission between skeletal muscles via inter- and extramuscular connective tissues has been demonstrated. Investigators have deÿ nitively shown that epimuscular pathways can transmit substantial force.”

17

Proprioception Proprioception/kinesthesia is the body’s ability to sense its location, movements, and actions. It is a continuous loop of feedback between sensory receptors throughout the body and the nervous system. It is the reason we are able to move freely without consciously thinking about our environment. When we move our brain senses the e˛ ort, force, and heaviness of our actions and positions through the sensory receptors located on the skin, joints, and muscles and responds accordingly (Proske & Allen 2019). Below is some further information on this subject:

•

Researchers demonstrated the presence of Ruˆ ni and Pacinian corpuscles in fascia suggesting their proprioceptive function (Stecco et al. 2007, Mense & Hoheisel 2016). ° e distribution of the corpuscles varies according to their location with a greater

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17 presence (number) being in the vicinity of the joints and particularly in the retinacula.

•

Stecco et al. (2007) describe the type of innervation of certain fascial structures according to their function and in relation to the movement performed.

•

In some fascial structures (e.g., the TLF) the corpuscular receptors (e.g., Pacini, Ruˆ ni) are absent. ° is fact could lead to the conclusion that fascia does not participate in proprioception. However, it is worth remembering the information that we have about the innervation of the fascia (see Chapter 8) and the presence of the free nerve endings (Stecco et al. 2007, Taguchi et al. 2008, Tesarz et al. 2011, Corey et al. 2011, Mense 2019).

•

Similarly, Mense and Hoheisel (2016) suggest that some free nerve endings can act as proprioceptors, and a lack of corpuscular proprioceptors in the determinate fascial structure is not an argument against a possible proprioceptive function of fascia.

•

Pacini corpuscles, Golgi–Mazzoni corpuscles, and free endings have been found in the palmar fascia, indicating that the palmar fascia is essential for proprioception of the hand (Stecco et al. 2018).

•

In particular locations (e.g., around the joints) the superÿ cial fascia fuses with the deep fascia and the latter uses the information received from the corpuscular receptors of the former. In this way, this assemblage of fascia acts as a proprioceptive structure.

•

Spatial mechanical sensitization di˛ ers between muscle and fascia (Weinkauf et al. 2015). ° is book aims to focus on localized disorders involving the fasciae of the musculoskeletal system and their appearance in MRI scans. In the same fascial structure and in the di˛ erent layers of its construction there are di˛ erent types and numbers of receptors, which indicate the specialization of each layer in the transmission of movement, as well as in proprioception. (Tesarz et al. 2011).

•

Kirchgesner et al. (2019) state that the fascial system can be involved in traumatic disorders (myoaponeurotic injuries and muscle hernias), septic disorders (nonnecrotizing cellulitis and fasciitis), and neoplastic disorders (superÿ cial ÿ bromatosis, desmoid tumors, and sarcomas).

Fascia and proprioception Recent histological and electrophysiological studies, as analyzed above, focused on the search for a proprioceptive “apparatus” inside the fascia. However, the important role of muscle spindles in the proprioception process and their relationship to fascia should not be overlooked.

Perimysium and neuromuscular spindles ° e fascial sensory substrate, its relevance to body movement, and the role of neuromuscular spindles, which are deÿ ned as mechanosensory receptors encapsulated within skeletal muscles, are described in Chapter 8. ° e main function of the neuromuscular spindles is to inform the CNS about the contractile behavior of the muscles. ° is information is essential for carrying out coordinated movements and for optimal postural development. ° e involvement of neuromuscular spindles in motor control is well known. However, recent studies also reveal their extensive participation in the “appropriate realignment of fractured bones, successful regeneration of spinal cord axons a˙ er injury and spinal alignment” (Kröger 2018). Neuromuscular spindles may act as nociceptors in healthy muscles and in diseases through muscle in˝ ammation. ° e presence of pain in polymyalgia rheumatica can be associated with changes in the neuromuscular spindle capsule (Partanen 2017). ° e mechanotransduction process (see Chapters 6 and 9), that is so much a part of Myofascial Induction ° erapy applications, involves the molecular basis of neuromuscular spindles and points again to the signiÿ cance of the connective tissue matrix and the proprioceptive sensory neurons. ° ere is an intimate relationship between the perimysium and neuromuscular spindles (Garofolini & Svanera 2019). Neuromuscular spindles are structurally connected to the perimysium (Moreno 2015). In their study of the structures of the sternocleidomastoid muscle, Giuriati et al. (2018) state that neuromuscular spindles “are embedded in perimysium, whose changes may in˝ uence their re˝ ex activity.” Wilke et al. (2017) have described rigidity of the perimysium as having an impact on the behavior of neuromuscular spindles and Golgi tendon organs. ° e authors suggest that the mechanical properties (sti˛ ness) of the perimysium

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in˝ uence the response of neuromuscular spindles to muscle stretching. Rigidity of the perimysium means that neuromuscular spindles, and also Golgi tendon organs, cannot change their length and consequently cannot be activated. ° is compromises the regulation of muscle tone and alters the contraction of extrafusal muscle ÿ bers (the major force-generating structures), although alpha motor neurons (skeletal motor neurons) adequately stimulate muscle ÿ bers. ° ese changes result in decreased muscle strength, limited movement, and altered postural control (Li et al. 2015, Wilke et al. 2017). Tesarz et al. (2011) state that fascia disorders (alteration of the mechanical properties of the perimysium) distort the information sent by neuromuscular spindles to the central nervous system, interfering with the coordination of movements. Muscle immobilization, especially in a shortened position, triggers an increase in the sensitivity of the neuromuscular spindles, which makes them more “reactive” (decreased threshold) to static and dynamic stretching (Gioux & Petit 1993). Järvinen et al. (2002) (on the basis that the collagen ÿ ber network is a major contributor to the coherence and tensile strength of normal skeletal muscle) studied the structure of the intramuscular connective tissue by immunohistochemistry, polarization microscopy, and scanning electron microscope in the rat skeletal muscles in a normal situation and a˙ er three weeks of disuse (immobilization). ° e researchers observed severe alterations of neuromuscular spindles trapped in the three-dimensional collagenous network a˙ er immobilization. Consequently, in the perimysium: the number of longitudinally oriented collagen fibers was increased, the connective tissue was very dense, the number of irregularly oriented collagen fibers was markedly increased, and consequently, the different networks of collagen fibers could not be distinguished from each other. ... quantitative and qualitative changes in the intramuscular connective tissue are likely to contribute to the deteriorated function and biomechanical properties of the immobilized skeletal muscle. We can conclude that alterations of the perimysium due to trauma, postural alterations, sequelae of surgery, or overuse would make normal stretching of neuromuscular spindles impossible leading to distorted feedback from the CNS.

17

° e results of the available research, and the hypotheses for the future, are encouraging regarding the proprioceptive role of the fascial system and suggest that the mechanical properties of fascia can modify the behavior of the receptors embedded in it. ° is brief analysis of neuromuscular spindles follows the line of reasoning developed in Chapter 8 and is related to the role of fascia in nociception.

Anatomical considerations related to the continuity of the fascial system of the upper extremity ° e anatomical continuity of the fascial system of the upper extremity involves the lower neck, upper back, and thorax. It is evidenced equally at the superÿ cial and deep layers. ° e speciÿ c muscles show clear characteristics of being covered by one of the two fascial structures: epimysium or aponeurosis (in some locations a mixed epimysial and aponeurotic appearance may be present; this phenomenon occurs when the epimysial fascia covers the surface of more than one muscle, e.g., the infraspinatus fascia). Along its path, fascia accompanies the neurovascular bundles, ensuring their optimal mobility and at the same time providing them with maximum protection (Fig. 17.1).

Neurovascular and lymphatic structures Innervation

° e innervation of the upper extremity is almost entirely supplied by the branches of the brachial plexus: the musculocutaneous, axillary, radial, median, and ulnar nerves. A knowledge of the topography of the distribution of sensory nerve endings is very useful to the therapeutic process. It enables the practitioner to identify connections to referred symptoms and multifocal symptomatology (see also Chapter 14).

Blood supply ° e arterial supply to the upper limb is delivered via ÿ ve main vessels: the subclavian artery, axillary artery, brachial artery, radial artery, and ulnar artery. ° e venous system of the upper limb drains deoxygenated blood from the arm, forearm, and hand. It can be divided anatomically into the superÿ cial and deep venous systems. ° e major superÿ cial veins are the cephalic and

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17 basilic veins which are located in the superÿ cial fascia layer. ° e deep venous system of the upper extremity is located underneath the deep fascia and consists of pairs of veins that accompany the paths of arteries and share their names. ° e proximity of the brachial veins and the brachial artery allows the pulsations of the artery to aid venous return. Communication between the superÿ cial and deep veins is through the perforating veins.

Lymphatics ° e superÿ cial lymphatic vessels of the upper extremity arise from lymphatic plexuses in the extracellular spaces in the skin of the hand. ° e lymphatic vessels that accompany the route of the basilic vein continue toward the cubital lymph nodes terminating in the lateral axillary lymph nodes. ° e vessels that accompany the route of the cephalic vein continue toward the apical axillary lymph nodes terminating in the deltopectoral lymph nodes. ° e deep lymphatic vessels of the upper limb follow the path of the radial, ulnar, and brachial veins terminating in the humeral axillary lymph nodes. ° ey drain lymph from joint capsules, periosteum, tendons, and muscles (for more on the lymphatic system see Chapter 10).

Superficial fascia of the upper extremity ° e superÿ cial fascia of the upper extremity is located below the skin. It is an elastic structure which easily adapts to the tensional changes of the deep fascia and also to the demands of external forces. Proximally it spreads from the superÿ cial fascia of the lower neck, upper back, and thorax, enveloping the shoulder (Fig. 17.2). It invests the path of the pectoralis major, upper and middle trapezius, and deltoid muscles. ° e critical area of its path is the axillary fossa (Fig. 17.3), where the superÿ cial fascia merge and follow its path up to the hand. ° e thickness of the superÿ cial fascia varies according to the location and the amount of fat (e.g., fat is abundant in the posterior area of the arm and almost absent in the elbow area) (Fig. 17.4). Along the shoulder and arm fat content is signiÿ cant, particularly in women. In the forearm the fat content, which depends on the physical makeup of the individual, gradually reduces along its path toward the hand (Fig. 17.5). In the hand there is a signiÿ cant di˛ erence between the dorsal and palmar regions as a result of the di˛ erent

A

B

Figure 17.2 Continuity of the superficial fascia of the neck, thorax, and arm. Note the presence of fat lobules embedded in the superficial fascia. The skin has been dissected from the superficial fascia using the tubular technique and folded back over the arm in the direction of the hand A Superficial fascia B Skin, dissected and separated from the superficial fascia Reproduced with permission from Pilat A. (2017) Fascial anatomy of the limbs. In: Liem T., Tozzi P., Chila A. (Eds.) Fascia in the Osteopathic Field. Edinburgh: Handspring Publishing

functions assigned to each area. In the hand’s dorsal area, the fascia is loose and thin, which enables considerable mobility for ˝ exing the ÿ ngers. ° e amount of fat in the hand varies depending on the morphology of the individual. In the palmar region fascia is ÿ rmly adhered to the skin; however, the superÿ cial fascia is looser and thinner where it runs through the thenar and hypothenar eminence (Fig. 17.6). ° at distribution facilitates the gripping movement of the two eminences. Nerves, arteries, and veins are submerged into or pass through the superÿ cial fascia, and their behavior varies widely depending on the degree of tension exerted on them by the fascia (Fig. 17.7).

Deep fascia of the upper extremity ° e main dynamic fascial link between the neck and the hand is through the path of the deep fascia which follows the superÿ cial layer of the deep fascia of the neck (which covers the upper trapezius and sternocleidomastoid muscles) and continues to the hand (Fig. 17.8). ° e deep fascia develops compartments which deÿ ne the location and interrelations between bones, muscles, and neurovascular tract. ° e compartments of the arm,

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Anterior

3

Medial

Lateral Posterior

1

2

A

B

C

D

E

Figure 17.3 Axillary fossa 1 Superficial fascia in the axillary fossa. Note the continuity of the fascia between the thorax and the arm 2 Deep layers of superficial fascia in the axillary fossa showing the irregularity and discontinuity of its path. This construction facilitates the transit of the nerves and vessels through the fascia 3 Deep layer of the axillary fossa A Adipose tissue between the superficial and deep fasciae B Serratus anterior muscle covered by epimysial fascia C Pectoralis major covered by epimysial fascia D Latissimus dorsi E Superficial fascia, dissected and turned down

forearm, and hand are highlighted in Figure 17.9 (see also Tables 17.1 and 17.2).

Fascial compartments Along its pathway, the deep fascia creates folds (by means of the intermuscular septa) thus creating compartments that organize the location of the anatomical components. ° is arrangement facilitates the distribution of muscles and the lateral transmission of muscular force between them and/or between muscles and the neurovascular tract (see Chapter 7). ° e bone components are also submerged within compartments (see Fig. 17.9). Changes in fascial behavior can elevate pressure within the ÿ bro-osseous spaces of compartments and may result in decreased tissue perfusion which in turn may create a painful condition.

Deltopectoral area (Fig. 17.10) ° e deltoid fascia covers the deltoid and is continuous with the pectoral and infraspinatus fascia. ° ree septa arise from the deltoid fascia to compartmentalize the three fascicles. Di˛ erent pressures have been registered inside the anterior, middle, and posterior compartments, which conÿ rms their anatomical independence (Rohde & Goitz 2006). Note the presence of the deltotrapezoid fascia at the proximal end of the deltopectoral area. It is a ÿ brous expansion that connects the lateral margin of the upper trapezius with the central and upper deltoid area. Located on the acromioclavicular joint, it participates in its stabilization through the connection with the joint capsule (Pastor et al. 2016, Czerwonatis et al. 2020).

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A

B

C

D

Figure 17.4 The path of the superficial fascia along the upper extremity. Note the irregular distribution of fat. A Deltopectoral cross-section. C Elbow cross-section. Over the olecranon the superficial fascia adheres to the deep fascia.

B Arm cross-section. D Forearm cross-section

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Figure 17.5 Superficial and deep layers of fascia of the arm 1 Posterolateral aspect of the right upper extremity. Note the incision lines 2 The skin has been dissected from the superficial fascia on the right side of both samples. Posteriorly, the superficial fascia has been removed to reveal the deep fascia 3 Forearm: elbow area A Skin, dissected and folded over B Deep fascia C Superficial fat lobes 4 Upper arm area A Deep fascia B Loose connective tissue facilitates the sliding movement of the skin–fat–superficial fascia complex over the deep fascia C Superficial fat lobes D Skin, dissected and folded over

° e fascial transition between deltoid, clavicle, and pectoral region topographically involves the deltopectoral triangle and the deltopectoral groove, which contains the cephalic vein and deltoid artery. From a functional perspective, this transition facilitates the ˝ exion and adduction of the pectoralis major

(clavicular ÿ bers) and the anterior deltoid ÿ bers and allows them to act as a single, integrated structure.

Compartments of the arm (Table 17.1) Two intermuscular septa (lateral and medial) divide the arm structures into compartments: the anterior and

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A

B

C

D

Figure 17.6 The skin and superficial fascial connections of the hand. Note the dense fascial structures of the palm of the hand. A Dorsal aspect. B Close-up of the dorsal aspect. C Palmar aspect. D Close-up of the palmar aspect

posterior compartments (also known as the ˝ exor and extensor compartments) (Fig. 17.11). Both septa extend from the deep fascia of the arm which covers the arm like a sleeve. On the medial side of the arm the medial intermuscular septum is attached to the medial supracondylar ridge of the humerus. On the lateral side of the arm the lateral intermuscular septum is attached to the lateral supracondylar ridge of the humerus. ° e anterior compartment contains the long and short heads of the biceps brachii, the brachialis and coracobrachialis muscles, the musculocutaneous, median, and ulnar nerves, the brachial artery, and the basilic vein. ° e radial nerve is located in the lower part of the compartment. ° e posterior compartment contains the long, short, and medial heads of the triceps brachii and the anconeus muscle and the radial nerve (which pierces the lateral

intermuscular septum). ° e blood supply is through the profunda brachii and ulnar collateral arteries. ° e radial and ulnar nerves pass through the compartment (Fig. 17.12). Compartment syndrome in the arm is rare. ° e low incidence of compartment syndrome in the arm (compared to the forearm and leg) could be due to its reduced thickness and therefore its greater capacity to distend (° omas & Cone 2017, Ridings & Gault 1994).

Compartments of the forearm (Table 17.2) ° e forearm is the most common site of compartment syndrome in the upper extremity (Fig. 17.13). ° e pressure increase inside the compartment generates a vascular con˝ ict causing cellular anoxia (Jimenez & Marappa-Ganeshan 2020). In the majority of acute cases a fasciotomy is necessary (Hanandeh et al. 2019).

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Figure 17.7 Superficial vascular and nervous structures related to the superficial fascia of the arm and forearm 1 Ventral aspect of the forearm A Deep fascia B Underside of the superficial fascia with fat lobes C Attachments between the superficial and deep fascia 2 Veins and nerves embedded in the superficial fascia of the forearm. Note the close mechanical relations between the nerve, veins, and fascia. Pulling the nerve with the forceps deforms the fascia A Nerve B Veins 3 Neurovascular structures embedded in superficial fascia and protected by fat nodules (for permissions information see page 557) A Veins, dissected from the fascia B Nerves, dissected from the fascia C Deep fascia D Superficial fat 4 Deep and superficial fascia of the forearm A Neurovascular structures, dissected from the fascia B Neurovascular structures embedded inside superficial fascia and protected by fat lobes C Deep fascia structures

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B

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Figure 17.8 Deep fascia of the upper extremity A Path of the deep fascia of the upper extremity. B Anatomical expansions of the pectoral and deltoid fascia to the brachial fascia. C Deep fascia on the ventral aspect of the forearm. D Cubital fossa with superficial neurovascular structures. E Palmar fascia

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17

Figure 17.9 The compartments of the upper extremity (see Tables 17.1 and 17.2)

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17 Figure 17.10 Deltopectoral cross-section

Pectoralis major Axillary artery

Humerus

Deltoid

Scapula Subscapularis

Table 17.1 Compartments of the arm and their characteristics Compartment Anterior (flexor) compartment

Boundaries and function

Anatomical components

Boundaries Medial and lateral intermuscular septum

Muscles Long and short heads of the biceps brachii Brachialis Coracobrachialis

Periosteum of the humerus Deep fascia of the arm Function Forearm flexion and supination

Posterior (extensor) compartment

Boundaries Medial and lateral intermuscular septum Periosteum of the humerus Deep fascia of the arm Function Forearm extension and pronation

Signs and symptoms

References

Arm compartment syndrome History of swelling Hematoma and pain after injury Anticoagulation

Duckworth & McQueen 2017

Innervation Musculocutaneous nerve Blood supply Brachial artery

Muscles Triceps brachii (long, short, medial heads) Anconeus Innervation Radial nerve Blood supply Profunda brachii artery

Toomayan et al. 2006

Nerve dysfunction Numbness Tingling Weakness Paralysis Reduced reflex or tendon areflexia Paresthesia

Note: the neurovascular structures in the arm are embedded in superficial fascia on the medial side of the humerus

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2

A

B

Anterior 1

A

B

Lateral

Medial Posterior

Figure 17.11 Arm cross-section 1 Compartments of the arm A Biceps 2 Intermuscular septum of the arm A Medial intermuscular septum

B Triceps B Lateral intermuscular septum

Anterior

Radial nerve Brachioradialis Extensor carpi radialis longus

Capitellum Brachialis Anconeus

Brachial artery and veins

Lateral

Medial Posterior

Median nerve Pronator teres Common flexor tendon Trochlea Ulnar nerve

Olecranon Figure 17.12 Cross-section of the left elbow in supine position

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17 Table 17.2 Compartments of the forearm and their characteristics Compartment Anterior (flexor) superficial compartment

Boundaries and function

Anatomical components

Boundaries* Radius Ulna Interosseous membrane

Muscles Pronator teres Flexor carpi radialis Palmaris longus Flexor carpi ulnaris Flexor digitorum Superficialis

Function Wrist flexion Digit flexion Forearm pronation

Posterior superficial compartment

Boundaries* Radius Ulna Interosseous membrane

Muscles Flexor digitorum profundus Flexor pollicis longus Pronator quadratus

Function Wrist flexion Digit flexion Forearm pronation

Innervation Median nerve

Boundaries* Radius Ulna Interosseous membrane

Muscles Extensor digitorum Extensor digiti minimi Extensor carpi ulnaris Extensor pollicis longus Abductor pollicis longus Anconeus

Function Wrist extension Digit extension

References

Arm compartment syndrome History of swelling, hematoma, and pain after a minor injury Can be exacerbated by anticoagulation medication Neurological deficits are the most common complications

Duckworth & McQueen 2017

Innervation Median and ulnar nerves Blood supply Ulnar artery

Anterior (flexor) deep compartment

Signs and symptoms

Blood supply Ulnar artery

Prasarn & Ouellette 2011 Kalyani et al. 2011

Nerve dysfunction Numbness Tingling Weakness Paralysis Reduced reflex or tendon areflexia Paresthesia

Innervation Deep branch of the radial nerve Blood supply Ulnar artery Radial artery Interosseous artery

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Table 17.2 continued Compartment Posterior deep compartment

Boundaries and function Boundaries* Transversely: Radius Ulna Interosseous membrane Proximally: Lacertus fibrosus Pronator teres Distally: Carpal tunnel Function Extension Supination Extension and abduction of the thumb Forearm supination

Mobile wad

Note: the mobile wad is a group of three muscles found in the posterior compartment

Anatomical components

Signs and symptoms

References

Arm compartment syndrome History of swelling, hematoma, and pain after a minor injury Can be exacerbated by anticoagulation medication Neurological deficits are the most common complications

Duckworth & McQueen 2017

Muscles Supinator Abductor pollicis longus Extensor pollicis brevis Extensor pollicis longus Extensor indicis Innervation Radial nerve Blood supply Ulnar artery Radial artery

Muscles Brachioradialis Extensor carpi radialis longus Extensor carpi radialis brevis

Prasarn & Ouellette 2011 Kalyani et al. 2011

Nerve dysfunction Numbness Tingling Weakness Paralysis Reduced reflex or tendon areflexia Paresthesia

*The muscles of the forearm, in a similar way to those of the arm, are grouped in anterior and posterior compartments. However, in the forearm, for the convenience of anatomical description, the compartments are usually divided into superficial and deep compartments. The respective divisions relate to the transverse septa that detach from the anterior and posterior surfaces of the forearm and which separate the deep layer from the superficial layer of muscles.

In anatomical texts there are discrepancies relating to the number of compartments in the forearm, the structures contained within them, and their nomenclature. ° e forearm has been assigned two, three, or four muscular compartments in addition to the osseous (radial and ulnar) compartments. One characteristic of the deep fascia of the forearm is the presence of an interosseous membrane that connects the radius and ulna and forms a syndesmosis. ° is membrane performs two

basic functions: It serves as an insertion for numerous muscles, transmitting contractile forces between the ulna, radius and humerus and it organizes the forearm structures into two large compartments (anterior and posterior). ° e anterior compartment is divided into superÿ cial and deep levels. ° e posterior compartment is subdivided into superÿ cial and deep levels and the mobile wad (the latter is frequently included in the posterior compartment). ° e divisions are complemented

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1

A

B

C

D E

2 Figure 17.13 1 Cross-section through the middle of the forearm A Anterior superficial compartment B Anterior deep compartment C Posterior deep compartment D Posterior superficial compartment E Interosseous membrane 2 Close-up of the interosseous membrane

by the presence of the lateral intermuscular septum. ° e compartments are interconnected. Nine tendons and the median nerve run throught the carpal tunnel at the distal end of the forearm. ° e nine tendons are the four tendons of the ˝ exor digitorum profundus, the four tendons of the ˝ exor digitorum superÿ cialis, and the tendon of the ˝ exor pollicis longus. ° e location of the muscles and neuromuscular structures in the compartments is summarized in Table 17.2.

Shoulder complex structures (shoulder girdle fascial system) ° e deep fascia of the shoulder girdle is divided into two layers – the superÿ cial and deep layers – and integrates 17 muscles which have the ability to optimize scapular positioning. ° e superÿ cial layer is similar to

epimysium. In some areas it is closely attached to the muscle belly and is so thin that during dissection it is diˆ cult to separate it from the muscle belly without tearing it. ° e deep layer is characterized by a resistant aponeurotic architecture that has multiple links with neighboring structures, providing the shoulder girdle with great freedom of movement, optimal coordination, and speed. ° e main bone structure of the shoulder girdle is the scapula. Due to the variety of ways in which it can quickly change position it acts as a mobile platform, which optimizes the behavior of the upper extremity and ultimately hand positioning in daily tasks. ° e fascial system that accompanies the movements of the scapula is one of the most complex in the body and should be included in the clinical analysis of shoulder girdle mechanics and pathomechanics. A dysfunction of scapular dynamics causes mechanical compensation in the distal structures of the extremity with the consequent overload of the given structures leading to the development of pathological processes. As discussed earlier in this chapter and in Chapter 16, most dysfunctions related to the scapula are due to an inadequate resting position and alterations in its movement dynamics (alterations in synergism). ° is is known as scapular dyskinesis, which is altered dynamic motion of the scapula. It is hypothesized that the fascial system plays a relevant role in this process.

Superficial layer of the deep fascia of the shoulder girdle Anteriorly covering the clavicle, the deep fascia of the shoulder girdle continues as the pectoralis fascia (investing the pectoralis major and the clavicular portion of the deltoid muscle) (Fig. 17.14-1). Posteriorly it covers the superÿ cial back muscles (trapezius, spinal portion of the deltoid, latissimus dorsi, and infraspinous muscle) (Fig. 17.14-2). Medially it is ÿ rmly inserted into the sternum (see Fig. 17.14-1). Laterally it covers the trapezius and spinal portion of the deltoid muscles investing the scapular girdle. Inferiorly it enfolds the lower edge of the pectoralis major and is continuous with the fascia of the anterior abdominal wall. Toward the axilla it merges with the fascia of the latissimus dorsi and the teres major muscle fasciae. All the muscles related to this layer merge in the brachial fascia. Around the elbow this becomes the antebrachial fascia and ends as the fascia of the hand (see Fig. 17.8 and Fig. 17.14-1).

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2

A B C D E F

G

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1 Figure 17.14 Deep fascia of the shoulder girdle 1 Expansion of the pectoral girdle in the brachial fascia A Mental protuberance B Superficial layer of the deep cervical fascia C Clavicle D Deltoid fascia E Superficial layer of the deep pectoralis fascia covering the pectoralis major. Note its perimysial characteristics F Sternum G Brachial fascia 2 Expansion of dorsal fascia in the shoulder girdle A Fibers of the latissimus dorsi B Epimysial fascia covering the latissimus dorsi C Epimysial fascia covering the trapezius D Infraspinatus fascia (aponeurotic fascia) E Spine of the scapula F Deltoid G Upper trapezius

Deltoid fascia ° e deltoid epimysial fascia (see Fig. 17.14-1) invests the entire muscle belly. Anteriorly it is continuous with pectoral fascia. Superiorly it is attached to the clavicle, acromion, and the crest of the scapular spine. Inferiorly it is continuous with the brachial fascia. Posteriorly it is continuous with the infraspinatus fascia. As with other bulky muscles (pectoral major, gluteus maximus), the epimysial fascia that covers the muscle releases septa deep into the muscle creating compartments that accommodate the muscle fascicles.

Deep layer of the deep fascia of the shoulder girdle Anteriorly, below the clavicle, the deep fascia enfolds the subclavius muscle and continues as clavipectoral fascia, which is suspended on the front edge of the clavicle, the coracoid process, and the coracoclavicular

ligament (see Chapter 16). ° e clavipectoral fascia is perforated by a lower pectoral nerve, cephalic vein, and thoracoacromial artery (branch of the axillary artery). It covers the pectoralis minor, the tendon of the short head of the biceps brachii, and the coracobrachialis muscle. It continues to the axillary fossa to join the deep sheet of the pectoralis fascia. It extends toward the axillary fascia, which in turn becomes the fascia of the latissimus dorsi. Laterally it covers the serratus anterior muscles and joins the clavicular part of the deltoid muscle. Medially it continues over the front part of the sternum (see Chapter 16). Posteriorly it covers the supraspinatus, the infraspinatus, and the teres minor muscles. Toward the neck it is continuous with the levator scapulae, omohyoid, and rhomboid muscles. Inferiorly its deep span is ÿ rmly integrated into the intercostal muscles and the ribs. ° us, the axillary space is framed and links the anterior fascial system (related to the pectoralis muscles) with the posterior fascial

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17 system (associated with the latissimus dorsi and muscles related to the scapula). Its surface spans the lower border of the pectoralis fascia up to the lower end of the teres major and latissimus dorsi muscles (see Fig. 17.3). It constitutes a sort of square, suspended from the lower border of the pectoralis minor, which runs along the axillary edge of the scapula, entering the insertions of the subscapularis, teres major, and teres minor muscles and ÿ nally reaching the glenoid cavity. In its medial span, it continues to the anterior serratus muscles. Within this description, the presence of a complex network of connections of the supraspinatus,

infraspinatus, and subscapular fasciae should be noted. Tensile and contractile structures form a dynamic architecture and segregation between them is possible only with the scalpel (see Fig. 16.3).

Supraspinatus fascia ° e supraspinatus fascia has an aponeurotic appearance (Figs. 17.15-4 and 17.15-6). It enfolds the supraspinatus muscle enclosing it in its osseous cover – the supraspinatus fossa – which constitutes its osteofascial compartment. Superior to the scapular spine, the supraspinatus fascia is covered by the trapezius muscle which inserts into the superior lip of the posterior border of the spine

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Figure 17.15 Posterior aspect of the shoulder girdle (left side) showing the sequence of fascial layers 1 Superficial fascia over the shoulder girdle A Inferior angle of the scapula 2 Superficial layer of the deep fascia of the shoulder girdle A Spine of the scapula B Infraspinatus fascia C Insertion of inferior fibers of the trapezius into the scapular spine D Trapezius E Inferior angle of the scapula covered by the latissimus dorsi belly F Latissimus dorsi 3 The latissimus dorsi has been removed to display the overlap of the trapezius and the spinal portion of the deltoid on the supraspinatus fascia A Trapezius B Spinal portion of the deltoid C Trapezius insertion into the scapular spine. Note the continuity of its aponeurosis with the infraspinatus fascia D Infraspinatus fascia E Teres minor F Teres major 4 Dissection of trapezius from the spine of the scapula A Spine of the scapula B Infraspinatus fascia C Fusion of the deep fascia of the trapezius and the supraspinatus fascia D Trapezius, dissected and lifted to show the underside 5 Rhomboid fascia. The trapezius has been dissected from the spine and removed A Rhomboid fascia B Levator scapulae fascia C Supraspinatus fascia D Infraspinatus fascia E Teres minor F Teres major 6 Levator scapulae fascial links. The rhomboid has been removed A Spine of the scapula B Levator scapulae C Infraspinatus fascia D Supraspinatus fascia E Inferior angle of the scapula F Erector spine muscles

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of the scapula through a ÿ brous insertion (Fig. 17.154). At some points in its path, the supraspinatus fascia inserts directly into the ÿ bers of the supraspinatus muscle. Detaching the deep fascia of the trapezius from the supraspinatus fascia is diˆ cult and the fascia can easily be torn (Fig. 17.15-4). Proximally the supraspinatus fascia joins the fascia of the levator scapulae muscle (Fig. 17.15-6), inferiorly it converts into infraspinatus fascia, and medially it continues as the rhomboid fascia (Fig. 17.15-5). At a deeper level we ÿ nd the superior transverse scapular ligament (spinoglenoid ligament) which can be implicated in compression of the suprascapular nerve. Apparently, the ligament is made up of “a septum formed by the thickening of the fascial cover of the distal third of the supraspinatus and infraspinatus muscles” (Betkas et al. 2003). ° e suprascapular

nerve runs through the foramen between the scapular notch and the transverse scapular ligament (Fig. 17.16). ° is ligament (septa) may be the cause of dynamic compression of the suprascapular nerve (see below). ° e transverse scapular vessels cross over the ligament.

Infraspinatus fascia ° e infraspinatus fascia is located in the scapular triangle. It is one of the body’s most complex fascial structures in relation to its morphological diversity, for example, its multiple layers (Stecco 2015), intricate network, and the density of it collagen ÿ ber bundles (Figs. 17.17-4 and 17.17-5). ° ese features, together with its privileged location, point to the infraspinatus fascia as the key structure in the eˆ cient performance of the dynamics of the upper extremity.

A

B C D

Posterior Medial

Lateral Anterior

E F G H I J K L M N

Figure 17.16 Posterior view of the left scapular area. The infraspinatus and supraspinatus have been detached from the scapular spine A Inferior angle of the scapula B Middle border of the scapula C Infraspinatus fossa D Infraspinatus insertion into the infraspinatus fossa E Rhomboids F Supraspinatus fossa G Infraspinatus, dissected and pulled aside H Spine of the scapula I Suprascapular nerve: infraspinatus branch J Suprascapular nerve K The superior transverse ligament (spinoglenoid ligament) converts the scapular notch into a foramen (opening) L Supraspinatus branch of the suprascapular nerve M Supraspinatus muscle, dissected from the supraspinatus fossa and pulled aside N Levator scapulae fascia

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2

3 A

B

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A

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1 A

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Figure 17.17 Posterolateral view of the left scapular area 1 Bundles of the infraspinatus fascia and their connections to the surrounding muscles (for permissions information see page 557) A Upper trapezius B Spinal belly of the deltoid C Insertion of the middle and inferior trapezius into the scapular spine D Infraspinatus fascia E Trapezius belly F Rhomboid muscle G Inferior angle of the scapula covered by the latissimus dorsi H Latissimus dorsi belly 2 Close-up of the scapular spine. Note the continuity of the fibers from the trapezius aponeurosis to the infraspinatus fascia A Spine of the scapula B Trapezius aponeurosis C Infraspinatus fascia 3 Fascial relations of the deep fascia of the trapezius and the supraspinatus fascia A Spine of the scapula B Infraspinatus fascia C Supraspinatus D The trapezius aponeurosis has been sectioned with a scalpel from the spine of the scapula and pulled aside. Note the fusion of the fibers of the trapezius with the supraspinatus. The supraspinatus fascia has been dissected E Trapezius 4 Infraspinatus fascia 5 Close-up of infraspinatus fascia. Note the multilayered and multidirectional fibers

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Superiorly the infraspinatus fascia joins the spine of the scapula and is continuous with the trapezius fascia at the superÿ cial layer and the supraspinatus fascia at the deep layer (Figs. 17.18 and 17.17-5). Medially the infraspinatus fascia is deep to the trapezius muscle. Laterally it is deep to the spinal belly of the deltoid muscle. Inferiorly it is usually located deep to the latissimus dorsi muscle (Fig. 17.17-1). ° e infraspinatus fascia has an epimysial and aponeurotic appearance (Stecco 2015), covering not only the

17

infraspinatus but also the teres minor muscle (Chaÿ k et al. 2013) (Fig. 17.18-3), and creating the retinacula which separate the infraspinatus from the teres minor muscle. ° is and other retinacula could be associated with compartment syndromes (Moccia et al. 2015). ° e infraspinatus fascia is a dense, resistant tissue that is highly hydrated and abundantly vascularized. ° e infraspinatus fascia is ÿ rmly integrated with the medial and lateral borders of the scapula by means of strong and multidirectional ÿ brous connections.

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3 A

B

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A

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Figure 17.18 Left scapular area 1 Infraspinatus fascial links 2 Close-up of the links between the trapezius fascia and the infraspinatus fascia A Trapezius aponeurosis B Spine of the scapula (trapezius insertion) C Infraspinatus fascia 3 Insertions of the teres minor and teres major muscles into the lower edge of the scapula A Teres minor B Teres major C Inferior angle of the scapula D Ribs

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17 Due to its location, the multidirectional organization of its ÿ bers, and its density and resistant quality, the infraspinatus fascia is a key fascial structure in the transmission of forces that travel from the thoracic region to the upper limb. ° e main links of the infraspinatus fascia are as follows: (Moccia et al. 2016) (Fig. 17.19):

Proximal

•

Distal

° e “deltofascial” bridge. ° e spinal portion of deltoid muscle transmits its force to the spine of the scapula through the infraspinatus fascia. ° is connection could contribute to the protraction of the scapula during shoulder ˝ exion. ° is network also creates a dynamic link between the spinal portion of the deltoid and the teres major.

Figure 17.19 Tension line structures of the infraspinatus fascia 1 Left posterolateral scapulothoracic area. The rectangle indicates the reflex zone of the deltofascial bridge 2 Distribution of tension lines on the infraspinatus fascia A Superomedial band B Insertion of inferior fibers of the trapezius into the scapular spine C Infraspinatus fascia covering the infraspinatus 3 Infraspinatus fascia covering the infraspinatus

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Upper extremity dysfunctions related to the fascial system

•

° e latissimus dorsi fascia is continuous with the fascia of the teres major and is strengthened inferiorly by the deep layer of axillary fascia.

•

° e fascia of the levator scapulae is a thin sheet that covers the entire length of the muscle.

A B

Subscapular fascia

C

° e fascia of the subscapularis covers the area of the subscapularis fossa and is attached to its entire circumference. It separates the subscapularis and serratus anterior muscles. Some ÿ bers at the proximal end of the subscapularis insert directly into the fascia. Subscapular fascia is a thin, aponeurotic structure that facilitates sliding between the two muscles (Fig. 17.20). ° e quality of this sliding is essential to the correct movement of the scapula. Eˆ cient sliding ability (range, speed, continuity) optimizes glenohumeral dynamics and helps to minimize friction between the bony components of the shoulder.

D

Proximal

Scapulothoracic bursae As already mentioned, the scapula is the core component that coordinates the behavior of the upper extremity. It is helped in this task by the architecture of the scapulothoracic joint which facilitates smooth gliding between the scapula and the thoracic cage. ° e scapula is suspended by a number of muscles that form dynamic connections with the adjacent bones of the shoulder girdle. ° ese muscles are divided into three groups: the scapulothoracic muscles, which coordinate scapulothoracic motion; the rotator cu˛ muscles, which regulate activities of the glenohumeral joint; and the scapulohumeral muscles, which are in charge of the dynamics of the humerus. However, there are a few areas of possible friction between the muscles, bones, and joint capsules. Di˛ erent bursae are distributed in critical locations to allow a smooth, gliding scapulothoracic motion (Frank et al. 2013, Osias et al. 2018). ° e main bursae are the scapulothoracic (infraserratus) bursa (between the serratus anterior muscle and the thoracic wall) and the subscapularis (supraserratus) bursa (between the subscapularis and serratus anterior muscles). ° ese bursae are anatomically well recognized (Williams et al. 1999). In the literature there is some confusion about the existence, identiÿ cation, and nomenclature of

Lateral

Medial Distal

Figure 17.20 Subscapular fossa A Medial border of the scapula B Rhomboid C Inferior angle of the scapula (below the finger) D Subscapularis fascia

other bursae in the scapulothoracic space. Some authors (Percy et al. 1988, Conduah et al. 2010, Gong et al. 2017) describe secondary (pathoanatomical) bursae: “However, minor bursae that have been identiÿ ed are adventitial, arising as a response to abnormal biomechanics of the scapulothoracic articulation” (Percy et al. 1988 cited in Conduah et al. 2010). Percy et al. (1988) identify four minor bursae: two at the superomedial angle of the scapula, one at the inferior angle of the scapula, and one at the medial base of the spine of the scapula, underneath the trapezius (Fig. 17.21). ° e in˝ ammatory response of these bursae may be related to snapping scapula and dyskinesis processes (Kuhn et al. 1998, Warth et al. 2015).

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17 Figure 17.21

A B A B

C

C

Suprascapular bursae (scapulothoracic space) 1 Posterior view A Scapulothoracic (infraserratus) bursa B Trapezoid (scapulotrapezial) bursa C Subscapularis (supraserratus) bursa D Scapulothoracic (infraserratus) bursa 2 Cross-section at the glenohumeral level A Scapulothoracic (infraserratus) bursa B Trapezoid (scapulotrapezial) bursa C Subscapularis (supraserratus) bursa

2

D

1

Rhomboid fascia ° e rhomboid fascia (see Fig. 17.15-5) originates at the inner edge of the scapulae. Along its superÿ cial path, the fascia extends over the supraspinatus and infraspinatus. In the deep layer it is continuous with the fascia of the serratus anterior muscle and it extends proximally as the fascia of the splenius capitis, splenius cervicis, and levator scapulae (Fig. 17.22). Medially the rhomboid fascia fuses with the spinous processes of the vertebrae and with the interspinous ligaments. Laterally it is continuous with the fascia of the serratus anterior muscle and the clavipectoral fascia. Its relationship with the internal scapular border also allows it to connect to the subscapular fascia and the infraspinous fascial system (also see Chapter 16). ° e rhomboid fascia contributes to scapular stability, helping to anchor the scapula and prevent winging (Lee et al. 2006, Farrell & Kiel 2020).

Arm and forearm structures ° e path and features of the superÿ cial fascia of the arm and forearm are described earlier in this chapter (see Figs. 17.3–17.5). Resembling the sleeve of a sweater, the superÿ cial fascia is continuous and runs the entire length of the upper extremity. Along its path at the deep layer, the deep fascia of the arm and forearm

also forms a single and inseparable continuous dynamic structure and its names change along its path. ° e structural anatomy of the deep fascia and how it relates to the behavior of the upper extremities is analyzed below.

Brachial fascia Proximally the deep brachial fascia is continuous with the axillary fascia, which covers the latissimus dorsi, deltoid, and pectoralis major muscles (Fig. 17.23A) (see also Figs. 17.8 and 17.14). It forms a thin, membranous (aponeurotic) sleeve that covers the muscles of the arm and forearm. A clear continuity can be observed between the pectoral, deltoid, and brachial fascia – no interruption is present. Distally the deep fascia of the arm is continuous with the antebrachial fascia, and they blend together (Fig. 17.23E). Posteriorly it is continuous with the thoracolumbar fascia. ° rough the continuity of the TLF with the aponeuroses of the muscles such as the trapezius and latissimus dorsi, a dynamic link is created between the back, the scapular girdle, and the upper extremity. ° e brachial fascia is characterized by its ÿ brous architecture. ° e ÿ bers are arranged in layers with a curved or oblique orientation (Fig. 17.23D) and its thickness and the density of the ÿ bers change along its

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and helps to stabilize the muscles during contraction. It slides relatively freely over the subjacent muscular structures, however, in some locations it forms a ÿ rm attachment to the bone. For example, at the elbow the deep fascia is attached to the epicondyles of the humerus and the olecranon of the ulna (Fig. 17.24). Along its path, two septa extend from the brachial fascia – the medial intermuscular septum and the lateral intermuscular septum. ° ese septa separate two main groups of muscles, the ˝ exors and the extensors, from each other (Fig. 17.25) (see also Table 17.1). ° e medial intermuscular septum extends along the medial supracondylar ridge from the lesser tubercle of the humerus to the medial epicondyle (Gray 1918). ° e coracobrachialis, triceps brachii, and brachialis muscles are attached to it. ° is septum is perforated by the ulnar nerve, the superior ulnar collateral artery, and the posterior branch of the inferior ulnar collateral artery (Gray 1918). ° e lateral intermuscular septum extends along the lateral supracondylar ridge from the lower part of the crest of the greater tubercle to the lateral epicondyle (Gray 1918). Numerous muscles are attached to this septum, for example, the deltoid, triceps brachii, brachialis, brachioradialis, and extensor carpi radialis longus. It is perforated by the radial nerve and profunda branch of the brachial artery (Gray 1918).

1

2 A

B

C

D

E

F

Figure 17.22 Muscles associated with the left scapula 1 Fascial continuity of the levator scapulae. The levator scapulae has been elevated at the distal ends (circle). Note the multidirectional orientation of the fibers of the supraspinatus fascia 2 Fascial links of the levator scapulae (for permissions information see page 557) A Spine of the scapula B Levator scapulae C Infraspinatus fascia D Supraspinatus fascia E Inferior angle of the scapula F Erector spinae muscle

path. It is looser on the anterior side where it covers the biceps brachii, which allows the latter to expand easily. Elsewhere, on the posterior aspect above the triceps brachii, the brachial fascia is denser and thicker

° e anterior compartment contains the biceps brachii, brachialis, and coracobrachialis muscles and also the musculocutaneous nerve and brachial artery. During contraction, some of the muscle bundles tense the intermuscular septa and indirectly strengthen the brachial fascia. Stecco et al. (2008) suggest that these expansions and attachments stretch selective portions of the brachial fascia, which may increase the e˛ ectiveness of arm movements. Anatomical studies demonstrate the presence of “septa” that, for example, separate the brachial plexus or axillary sheath. Partridge et al. (1987) state that: “Dissection demonstrated that the sheath consists of multiple layers of thin connective tissue surrounding the various elements of the neurovascular bundle.” ° ey also suggest that “there are connections between compartments within the sheath.” ° e humerus is also located in its own fascial compartment. Just below the middle of the arm, on its medial side, is an oval opening

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A

B

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D

E

Figure 17.23 The path of the deep fascia of the arm and forearm. A Path of the deep fascia of the left upper extremity. B Transition between the deep pectoral fascia, deltoid fascia, and brachial fascia. C Close-up of the pectoralis deltoid and brachial fasciae transition. D Elbow area. Note the abundant vascular system in the cubital fossa. E Transition between the brachial and antebrachial fascia. Note the continuity and distribution of the multidirectional and multilayered fibers

A

Figure 17.24 Posterior

Medial

O H

Lateral

Cross-section of the elbow A Deep fascia attachment to the olecranon O Olecranon H Humerus

Anterior

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in the deep fascia through which pass the basilic vein and some lymphatic vessels (see Fig. 17.23E)

1

The elbow At the elbow area fascia is reinforced by the anterior and posterior retinaculum structures that participate in muscular and articular behavior (Stecco 2015).

Anterior elbow retinaculum (lacertus fibrosus)

Anterior Lateral

Medial Posterior

2

A

B

3

Figure 17.25 Intermuscular septa of the arm 1 Cross-section of the arm 2 The relationship of the septa with the adjacent muscles and the periosteum 3 Deep fascia and its continuity with the septum A Deep fascia B Septum

On the ventral side of the arm and forearm there is very special connection through the bicipital aponeurosis (lacertus ÿ brosus) (Joshi et al. 2004) (Fig. 17.26). ° e lacertus ÿ brosus is a retinacular expansion on the anterior aspect of the elbow. It extends in a fanlike shape from the distal attachment of the biceps brachii (the bicipital tuberosity on the proximal part of the radius) and, crossing the elbow, is continuous with the proximal end of the antebrachial fascia. ° en, it inserts in the cubital region of the common mass of the epitroclear muscles creating an important link between the brachial and the antebrachial fascia (Blemker & Delp 2005, Chew & Giu˛ rè 2005). ° e lacertus ÿ brosus consists of two groups of ÿ bers – oblique and longitudinal ÿ bers. ° e oblique ÿ bers integrate into the fascia of the forearm. Some muscular ÿ bers are inserted into them. ° e longitudinal ÿ bers follow the path of the muscular ÿ bers and integrate into the antebrachial fascia between the ˝ exor radialis and brachioradialis muscles (Stecco 2015). ° e lacertus ÿ brosus has been found to have two main functions: protection of the underlying neurovascular bundle in the cubital fossa (median nerve and the brachial artery) which pass deep to it (Bernabei et al. 2016, Benjamin 2009, Nayak et al. 2016) and participation in movement (Eames et al. 2007). ° e e˛ ects of the contractile force of the biceps are distributed to its tendon insertion into the radius and to the lacertus ÿ brosus (the latter provides the fascial continuity between the brachial and antebrachial fasciae). ° is phenomenon creates two tensional lines of force transmission from the biceps to the forearm. Pronator teres syndrome can be associated with lacertus ÿ brosus dysfunction (Malagelada et al. 2014). ° e lacertus ÿ brosus link is perhaps one of the best examples of a dynamic network, where the muscle

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17 Figure 17.26 Anteromedial elbow area: bicipital fascia (lacertus fibrosus of the biceps brachii) A Median nerve B Cubital nerve C Tendon of the biceps brachii D Medial epicondyle E Lacertus fibrosus – longitudinal fibers F Lacertus fibrosus – oblique fibers G Antebrachial deep fascia

A

contraction is transmitted directly from the fascia to the fascia and reinforces the bone–tendon connection. At the superÿ cial layer, several vascular structures run through the cubital fossa (see Fig. 17.8).

Posterior elbow retinaculum ° e posterior elbow retinaculum is located in the posterior and posterolateral aspect of the elbow and enables the triceps brachii to expand to the antebrachial fascia, thus reinforcing the attachment of the triceps brachii tendon in the olecranon (Fig. 17.27). Anatomical research conÿ rms this ÿ nding. Windisch et al. (2006) assert that “the ÿ bers le˙ the olecranon to reach the posterior border of the ulna.” Keener et al. (2010) indicate that lateral expansion of the triceps reaches 70ˇpercent of the width of the central tendon. Stecco (2015) reports that, a˙ er sectioning the antebrachial fascia, the direct attachment of the extensor carpi ulnaris and extensor digitorum minimi muscles can be observed. ° e fascial continuity between the arm and forearm is maintained through the fascia that covers the anconeus, thus ensuring force transmission and the stability of the elbow.

Antebrachial fascia Proximally the antebrachial fascia is a direct continuation of the brachial fascia and surrounds the forearm like a dense membranous sleeve (Fig. 17.28). It is denser at the back compared to the ventral surface and also

B

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its density decreases distally. At the dorsal aspect of the extremity there is a direct link between the triceps and the antebrachial fascia. As mentioned previously, one part of the triceps tendon is ÿ rmly inserted in the olecranon and the other part continues to the antebrachial fascia. ° ere is usually not much subcutaneous fat on the dorsal aspect of the forearm. ° e lateral epicondyle area is a clear example of the anatomical/functional fascial links between muscles. Briggs and Elliott (1985), in their analysis of the dissections of 139 limbs, found that the extensor carpi radialis brevis was directly attached to the epicondyle (its insertion is indicated in the classic anatomy texts) in only 29 of the samples. In the other 110 limbs it was attached via the fascia to the extensor carpi radialis longus, extensor digitorum communis, and supinator, and the radial collateral ligament. Benjamin (2009) describes this masterfully: One of the most striking examples of how fascia links muscles together concerns the extensor muscles of the forearm in the region of the lateral epicondyle. Although standard anatomy texts often simplify the position greatly by saying that the extensor muscles attach to the common extensor origin, the reality is rather more complex. Clearly, the area of bone provided by the lateral epicondyle is insufficient to attach the numerous muscles on the back of the forearm that arise from the common extensor origin. What happens instead is that the muscles attach to each

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17

other in this region via fascia and by this means they can be crowded onto a limited surface of bone. Alterations in gliding between the epimysia of the adjacent muscles can alter the coordination between the muscles, facilitating overload on the small surface of the lateral epicondyle (approx. 0.5 cm2), leading over time to dysfunction and consequent epicondylopathy (tennis elbow) (Stasinopoulos & Johnson 2006). Balasuburamaniam & Kandaswamy (2016) report that application of myofascial procedures “produces signiÿ cant reduction of pain and improvement of the function in lateral epicondylitis.”

1

On the ventral surface, there is direct continuity between the arm and forearm through the bicipital fascia. Distally on the ventral side, the antebrachial fascia is continuous with the transverse carpal ligament. ° e tendon of the palmaris longus muscle (wrapped in its own protective sheath) crosses the transverse carpal ligament and becomes the palmar aponeurosis. ° e forearm contains 17 muscles that cross the wrist joint. ° e internal expansions of the antebrachial fascia surround the individual muscles and also separate the deep layer of muscles from the superÿ cial layer. ° ere are no real “intermuscular septa”; however, each muscle is enclosed in its own envelope. ° ese envelopes are mechanically interrelated through connections between muscle epimysia (Fig. 17.29). In this way, lateral links are created that determine the behavior of the muscles in forearm and hand movements. ° e term that deÿ nes this process is called lateral force transmission (discussed earlier in this chapter and extensively in Chapter 7).

2

° ere are three recognizable (main) compartments in the forearm. ° ese are the ˝ exor, extensor, and lateral compartments. Both the ˝ exor and extensor compartments are further divided into the superÿ cial and deep compartments (Table 17.2). Various neurovascular structures pass superÿ cially over the area of the cubital fossa (see Fig. 17.8D).

3 A

Figure 17.27 Posterior elbow retinaculum 1 Continuity of the deep fascia of the arm and forearm A Superficial fascia, dissected and turned down B Lateral head of the triceps brachii covered by the deep fascia of the arm C Superficial to deep fascia attachment D Triceps brachii tendon E Deep fascia of the forearm F Olecranon 2 Triceps brachii insertion 3 The deep fascia of the arm, sectioned A Triceps aponeurosis

Hand structures ° e deep palmar fascia is a direct continuation of the antebrachial fascia. It is ÿ rmly attached to the palmar skin. It is a thick, ÿ brous and resistant structure that fans out to the palmar area of the hand. It protects the underlying tendon and neurovascular structures. Its ÿ bers are arranged in longitudinal, transverse, oblique, and vertical directions and it is reinforced by the

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17 Figure 17.28 Ventral aspect of the deep antebrachial fascia A Carpal tunnel level B Flexor tendons covered by deep fascia C Brachioradialis covered by epimysial fascia D Medial epicondyle E Median nerve F Biceps brachii covered by deep fascia

Medial A

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Distal Lateral

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Figure 17.29 Ventral aspect of the forearm 1 Lateral links of the extramuscular connective tissue 2 Close-up of the intertendinous fascial link 3 Deep layer of the ventral part of the forearm A Median nerve B Median nerve crossing the pronator teres 4 Close-up of the distal ventral aspect of the forearm A Fibrous attachment between the median nerve and the flexor carpi radialis

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palmaris longus muscle (dynamic tensor of the palmar aponeurosis). It forms a type of complex system within which numerous muscle ÿ bers are attached. ° e longitudinal ÿ bers originate on the palmaris longus tendon in the wrist and continue to the base of each ÿ nger, playing a part in the movement of the ÿ ngers. ° e transverse ÿ bers are concentrated in the mid palm together with the longitudinal ÿ bers. ° ey A

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D E

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17

fuse with the tendon sheaths on the palmar, medial, and lateral sides and stabilize the ˝ exor tendons. At the metacarpophalangeal level the fascia extends and forms channels for the ˝ exor tendons, the lumbrical muscles, and the neurovascular bundles (Fig. 17.30-1). Laterally the fascia fuses with the thenar and hypothenar eminences and manifests as a thin structure (Fig. 17.30). ° e deep ÿ bers of the palmar aponeurosis relate to the terminal branches of the median nerve and the

H I

2 F

3

4 A

A

Figure 17.30 Sequence of dissections of the ventral aspect of the wrist through the median nerve 1 Superficial layer A Palmaris longus tendon B Ulnar artery C Ulnar nerve D Fascial expansion of the palmaris longus into the thenar fascia E Hypothenar fascia F Thenar fascia G Palmar aponeurosis H Oblique fibers of the palmar aponeurosis I Transverse fibers of the palmar aponeurosis 2 The palmaris longus and palmar fascia have been removed (rectangle) 3 Transverse ligament (A) 4 Median nerve, exposed (A)

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17 superÿ cial branch of the ulnar nerve and form a type of complex system in which numerous muscle ÿ bers are attached. ° e palmar fascia is richly innervated by free nerve endings. Stecco et al. (2018) reported a higher density of these receptors in samples of the palmar aponeurosis and related this to Dupuytren’s disease. ° ey stated “that the nervous structures are implicated in the ampliÿ ed ÿ brosis of Dupuytren’s disease.” Once the palmar fascia has been sectioned, the transverse carpal ligament (TCL), which lies proximal to the scaphoid and pisiform and distal to the trapezius and hamate, can be observed (Figs. 17.30-2, 17.30-3, and 17.30-4). ° e thickness of the TCL varies along the path of the median nerve, with the thickest parts being distal ulnarly and proximal radially. ° e predominant ÿ ber orientation is transverse (Goitz et al. 2014).

Between the bone structures and the transverse ligament lies the carpal tunnel, through which the ˝ exor tendons of the digits and the median nerve pass (Figs. 17.30-2 and 17.30-3). In this area compression of the median nerve can occur under a sheet of transverse carpal ligamentous tissue just beyond the wrist joint. ° is is known as carpal tunnel syndrome and is the most common entrapment neuropathy (see the section below carpal tunnel syndrome). ° e dorsal fascia of the hand is continuous with that of the forearm. It covers the tendons of the extensor muscles and becomes thicker in the form of the extensor retinaculum over a transversal span of ÿ bers. ° e main function of the retinaculum is to maintain tendons and bones in an optimal relationship to one another and stabilize them (Fig. 17.31).

Figure 17.31 Dorsal aspect of the forearm and hand 1 Superficial layer of the deep fascia of the forearm and hand A Reinforcements of the antebrachial fascia B Extensor retinaculum C Tendons of the extensor digitorum D Intertendinous connection 2 Deep layer of the dorsal aspect of the forearm and hand A Antebrachial fascia B Superficial lamina of the deep dorsal fascia of the hand C Retinacula of the extensors, sectioned D Tendons of the extensor digitorum E Deep lamina of the deep dorsal fascia of the hand Image 1 is reproduced with permission from Pilat A. (2016) Myofascial induction approaches. In: Fernández-de-las-Peñas C., Cleland J., Dommerholt J. (Eds.) Manual Therapy for Musculoskeletal Pain Syndromes: An Evidence- and ClinicalInformed Approach. Elsevier

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Clinical features of myofascial dysfunction in the upper extremity Recent research has highlighted a worrying increase in upper-extremity musculoskeletal disorders in the active population. Roquelaure et al. (2006) reported that a high proportion of upper-extremity musculoskeletal disorders could be classiÿ ed as probably work-related (95% in men and 89% in women aged ˇ50). ° e common physical ÿ ndings in this painful condition (as the result of direct trauma, in˝ ammation, or systemic disease) o˙ en lead to direct diagnoses (e.g., carpal tunnel syndrome, epicondylalgia). By contrast, the absence of a clear conÿ rmation of physical ÿ ndings can be confusing when trying to identify the origins of the symptoms, making it diˆ cult to diagnose and select an appropriate treatment. In parallel, there is little scientiÿ c evidence available to assist with determining the prognosis and treatment required to enable a patient to return to work activities (Hagberg 2007). ° e high frequency of nonrecovery in nontraumatic conditions of the upper extremity re˝ ects the limited success of diagnosis, treatment, and prevention (Feleus et al. 2007). Health and wellbeing are a˛ ected by many factors. In relation to injuries or diseases of the upper extremity, systematic reviews have indicated that repetitive manual daily tasks with poor postural ergonomics result in risk factors for shoulder and elbow dysfunctions (van Rijn et al. 2009, van Rijn et al. 2010). Moreover, the Swedish Council on Health Technology Assessment (2012) states that the level of evidence linking these disorders with job activity is low. ° e two points seem to be contradictory, but this is actually not the case. ° e di˛ erence is between the risk factor and the determining factor. ° e ÿ rst considers a job activity with respect to upper extremity involvement as a risk factor; however, it is not decisive. Many individuals who are subjected to these activities do not have painful symptoms. In cases when the presence of pain is not related to active injury, it is classiÿ ed as “nonspeciÿ c.” Nevertheless, Hagberg (2007) states that: The use of terms such as RSI (repetitive strain injuries) and CTD (cumulative trauma disorders) should be avoided.

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If the different musculoskeletal symptoms and signs do not completely comply with criteria for a disease, it is recommended to choose an ICD (International Classification of Disease) label that focuses on the symptoms rather than the pathology. At the same time, the requirement to determine a speciÿ c diagnosis notably increases the tendency to relate the aforementioned painful processes with psychosocial factors to the point of triggering a kind of stigmatization of patients who su˛ er from them (Jepsen 2018). ° ese limitations are re˝ ected in the application of various “diagnostic labels” that attempt to label painful, nonspeciÿ c conditions of the upper extremities with names ranging from Cumulative Trauma Disorders, Occupational Cervicobrachial Disorder, Cervicobrachial Refractory Pain Syndrome (Cohen et al. 1992), and Repetitive Strain Injury, which seem to cover, at least partially, the same clinical conditions (Szabo & King 2000).

Characteristic symptoms in nonspecific arm pain Pain described by the patient as “pulling,” “penetrating,” “burning,” or “a feeling of electricity” with symptoms such as paresthesia and dysesthesia, “prompt fatigue,” sti˛ ness, cramps, heaviness, or tingling are common features of nonspeciÿ c upper extremity dysfunction (Cohen et al. 1992, Greening & Lynn 1998, Quintner & Bove 2001, Moloney et al. 2013). ° e diagnosis of nonspeciÿ c upper extremity dysfunction is confusing due to the clinical characteristics described above; it means sensory abnormalities and apparent absence of tissue damage. Although, even the results of nerve conduction studies in nonspeciÿ c cases report absence of clear nerve injury, clinicians consider entrapment of nerve structures to be part of the pathogenesis (Boocock et al. 2009). Clinical arguments prevail: ° e increased mechanosensitivity (allodynia) to palpation of the nerve trunk (Greening et al. 2005) and the positive response (allodynic reactions, paraesthesia, or pain) to provocative tests modifying tissue tension, both actively or passively (van der Heide et al. 2001), are adequate arguments for clinical decision making. Positive responses to neurodynamic tests re˝ ecting abnormal neuronal mechanosensitivity were

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17 observed in 78–88ˇpercent of patients with nonspeciÿ c upper limb pain (Moloney et al. 2013).

long thoracic nerve neuropathy, median neuropathy, ulnar neuropathy at the elbow, and radial neuropathy.

As evidenced in previous chapters, nervous tissue is an integrated part of the neurofascial system (see Chapters 3, 5, 7, and 8). ° erefore, a lack of objective clinical conclusions based on conventional diagnostic tests should not exclude the possibility that the fascial system of the upper extremity, which is subject to constant, repetitive movements during daily activities, could a˛ ect neural dynamics and trigger symptoms, even in the absence of clear anatomopathological causes. Considering the anatomical and functional indivisibility of the fascia and neural structures, prolonged allostatic load (an excessive, repetitive and/ or prolonged tensional behavior on the neurofascial system) can condition the integrity of the peripheral nerves in response to mechanical demands. Despite facing the same movement and posture demands in work activities, an underlying tensional state could mean that some individuals develop symptoms whereas others remain asymptomatic.

Peripheral neuropathy is accompanied by neuropathic pain, dysesthesia, and paresis. Compression neuropathy exhibits deÿ ciency in the sensory and motor distribution of the a˛ ected nerve and muscular atrophy in chronic processes (Doughty & Bowley 2019). To properly diagnose entrapment neuropathy, a thorough sensory and motor examination is essential. Objective diagnoses using electromyography (EMG), nerve conduction study (NCS), ultrasound scan, and magnetic resonance imaging (MRI) are helpful in correlating physical ÿ ndings in most patients (Karri et al. 2019, Zakrzewski et al. 2019).

° erefore, for a therapeutic intervention to be successful it is essential to perform a sensory and mechanosensory assessment in order to detect and establish a condition of compromised neural structures as a possible source of the underlying painful symptoms. Finally, it should be noted that nervous “irritation” is a common cause of central sensitization. According to Helme et al. (1992), this issue may even be responsible for symptoms in the upper extremity on the contralateral side that are frequently reported by patients experiencing pain.

Entrapment neuropathies Entrapment neuropathies are a group of disorders of the peripheral nerves (see Chapter 8). Upper extremity entrapment neuropathies are common and are characterized by pain and/or loss of motor and/or sensory function that lead to functional disability (Wendt et al. 2018, Dong et al. 2012, Miller & Reinus 2010). ° ey can be of degenerative or post-traumatic origin (Wichelhaus et al. 2017). Nerves can become compressed or trapped in “tunnel” regions, where they may be predisposed or vulnerable to compression. ° e most common neuropathies in the upper extremity are suprascapular nerve neuropathy, axillary nerve neuropathy,

A nerve entrapment can manifest itself in any segment of the nerve path and can be secondary to any local structural or in˝ ammatory damage; however, the usual location of the entrapment and the clinical characteristics relating to each nerve in the most common entrapment neuropathies are described below.

Suprascapular nerve entrapment Entrapment of the suprascapular nerve is frequently overlooked in the di˛ erential diagnosis of shoulder pain. ° e suprascapular nerve (a mixed nerve) supplies two muscles on the posterior aspect of the scapula – the infraspinatus (external rotator of the arm) and the supraspinatus (initiator of arm abduction). Its sensory territory, which varies widely, is located at the posterior and superior aspect of the shoulder over the glenohumeral joint space. In addition, a posterior capsular branch contributes to sensation from the glenohumeral joint, particularly its proprioception (Clavert & ° omazeau 2014). ° e suprascapular nerve arises from the C5–C6 nerve roots of the brachial plexus and continues inferolaterally underneath the trapezius advancing toward the suprascapular (supraglenoid) notch. It then passes under the superior transverse scapular ligament and joins the supraspinatus muscle (Partridge et al. 1987). Finally, a˙ er passing through the spinoglenoid notch it innervates the infraspinatus muscle (Bigliani et al. 1990) (see Fig. 17.16). Nerve dysfunction is generally related to overhead motion of the arm, during which pressure is placed on the caudal cervical or shoulder area (e.g., traction injuries in

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sports activities), and also compression along the nerve path at the cervical spine and superior posterior shoulder area. Nerve entrapment may also be secondary to paralabral cysts in the glenoid labrum or massive rotator cu˛ tears caused by retraction of tendons. Entrapment can be produced in the suprascapular notch by the superior transverse scapular ligament or in the spinoglenoid notch by the spinoglenoid ligament (Dong et al. 2012, Jerosch et al. 2012) (see Fig. 17.16). ° e superior transverse notch is the most common but not the only entrapment location. In post-traumatic conditions, a˙ er a hematoma, the supraspinatus fascia may be retracted and the fat tissue may undergo ÿ brosis. ° e subfascial position of the suprascapular nerve runs along an osteoÿ brous canal. ° e entrapment of the nerve along its course is thought to be a tunnel syndrome (Duparcˇetˇal. 2010). ° e suprascapular entrapment usually manifests with persistent pain on the dorsal aspect of the shoulder, deÿ cits in abduction and external rotation of the arm, and atrophy of the supraspinatus and infraspinatus muscles (Karri et al. 2019).

Axillary nerve entrapment Axillary nerve entrapment is part of quadrilateral space syndrome (Cahill & Palmer 1983). ° e nerve is vulnerable throughout its passage through the quadrilateral space, which is a space bounded by the humerus laterally, the long head of the triceps medially, the teres minor superiorly, and the teres major inferiorly. ° e axillary nerve innervates the teres minor and deltoid muscles (abductors and external rotator of the arm). Overuse (repetitive overload, the impact of overhead movement) of these muscles can injure the nerve. Compression of the axillary nerve is rare; however, it is recommended that an assessment is carried out to exclude con˝ icts with the nerves that share the same trunk of origin, such as the radial nerve (Chen & Narvaez 2015, McClelland & Paxinos 2008). It should be noted that the symptomatology of axillary nerve injury could involve neurogenic or vascular features. ° e main neurogenic symptoms are paresthesia (of the lateral and posterior arm), fasciculation, weakness (of lateral abduction and external rotation of the arm), or pain with no speciÿ c pattern. ° e vascular symptoms are signs of acute ischemia, thrombosis or embolism (Brown et al. 2015).

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Long thoracic nerve entrapment ° e long thoracic nerve (motor nerve) arises from the roots of the cervical spinal nerves C5–C7. It innervates the serratus anterior which pulls the scapula forward around the rib cage (see Figs. 16.12 and 16.13). Weakness of the serratus anterior caused by injury to the long thoracic nerve results in scapular winging during forward elevation of the arm. ° e di˛ use shoulder and/ or neck pain mainly occurs during overhead activities and can be the result of sudden or repetitive external biomechanical forces or prolonged shoulder depression (Kaplan 1980, Hester et al. 2000). In their research on an unembalmed cadaver Hester et al. (2000) observed that “a tight fascial band of tissue arose from the inferior aspect of the brachial plexus, extended just superior to the middle scalene muscle insertion on the ÿ rst rib, and presented a digitation that extended to the proximal aspect of the serratus anterior muscle.” When applying progressive abduction and simultaneous external rotation, it was observed that the nerve lines up with the bow-shaped fascial band. Scapulothoracic dyskinesia and fatigue of the scapular stabilizer muscles can exacerbate the pressure on the nerve (Hester et al. 2000).

Median nerve entrapment Pronator teres syndrome At the level of the elbow, the median nerve can be compressed between the two heads of the pronator teres muscle, below the ÿ brous arch of the ˝ exor digitorum superÿ cialis (Low et al. 2019). A tight lacertus ÿ brosus may exacerbate the syndrome (Dididze et al. 2020) (see Figs. 17.26 and 17.29). Repetitive pronation of the forearm with elbow extension and also rapid, repeated gripping may cause muscle hypertrophy and nerve entrapment. ° e most common symptoms are aching and sensory loss over the thenar eminence, weakness of ˝ exion of the thumb and the index and middle ÿ ngers (Cass 2014). Di˛ erential diagnosis is suggested to avoid confusion with nerve entrapment in the carpal tunnel, brachial plexus injury, or cervical radiculopathy.

Carpal tunnel syndrome Carpal tunnel syndrome is the most common nerve entrapment injury and the most frequently occurring median nerve entrapment syndrome. It is produced by

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17 compression of the median nerve under the transverse carpal ligament caused by increased pressure in the carpal tunnel (Ochoa 2012) (Fig. 17.32). Pressure can be raised by wrist ˝ exion, wrist extension, and ÿ nger ˝ exion (Gelberman et al. 1981). Sometimes carpal tunnel syndrome is caused by repetitive wrist movements (Miller & Reinus 2010). It usually manifests with pain and paresthesia (abnormal sensations such as burning or general tightening) of the thumb, index ÿ nger, and middle ÿ nger (Wilson et al. 2017). ° e presence of paresis when ˝ exing the index and middle ÿ ngers may be related to deterioration in motor conduction involvement. Some patients also present with pain in the forearm. Fernández-de-las-Peñas et al. (2017) compared the e˛ ectiveness of manual therapy (including myofascial therapeutic procedures) versus surgery for improving self-reported function, cervical range of motion, and pinch-tip grip force in women with carpal tunnel syndrome. ° ey concluded that performing “manual therapy and surgery had similar e˛ ectiveness for improving A

B

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self-reported function, symptom severity, and pinchtip grip force on the symptomatic hand in women with CTS.ˇ... Neither manual therapy nor surgery resulted in changes in cervical range of motion.”

Ulnar nerve entrapment Ulnar nerve entrapment is the second most common peripheral mononeuropathy (An et al. 2017). It can occur in di˛ erent locations. ° e two main sites are at the elbow and at the wrist. At the elbow it is usually at the cubital tunnel, which is formed by the medial epicondyle medially, the olecranon, and the arcuate ligament of Osborne laterally (Miller & Reinus 2010, Hargreaves & Fetouh 2020) and enclosed by the deep fascia which covers the top of the ˝ exor carpi (see Fig. 17.12). Symptoms may appear as a result of prolonged full bending of the elbow, which stretches the nerve, or when there is direct pressure on the nerve caused by leaning the elbow on a hard surface. Symptoms are characterized by muscle weakness and consequent atrophy, localized pain in the elbow, dysesthesia in the index and little ÿ ngers, and paresis of ˝ exion and abduction in the same ÿ ngers, especially during ˝ exion of the elbow (Miller & Reinus 2010). Entrapment of the ulnar nerve at the wrist occurs in the Guyon’s canal, which extends between the pisiform and uncinate bones and the palmar carpal and transverse retinacular ligaments (Schulte-Mattler & Grimm 2015). It is caused by repeated overuse of the wrist and is therefore common in professional cyclists (as a result of repetitive and continuous pressure on the hypothenar eminence) and weight li˙ ers. It also originates from pathological processes (trauma, arthritis) in the Guyon’s canal. It is characterized by pain and paresthesia on the tip of the little ÿ nger and half of the ring ÿ nger. Sometimes weakness of ˝ exion can occur in the same ÿ ngers and also abduction paresis of all ÿ ngers.

Radial tunnel and posterior interosseous nerve syndromes Figure 17.32 Median nerve, exposed A Median nerve B Palmaris longus tendon C Palmar retinaculum

Radial tunnel syndrome is caused by entrapment of the posterior interosseous nerve, which is an exclusive motor branch of the radial nerve at the level of the radial tunnel (Moradi et al. 2015). ° e radial tunnel is located in the proximal third of the radius. It can be identiÿ ed by the arcade of Frohse (a ÿ brous arch between the two

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heads of the supinator muscle and the bone). ° ere are ÿ ve sites in which compression may occur but the arcade of Frohse is the most common site (see Fig. 17.12) (Clavert et al. 2009). When there are no motor or sensory deÿ cits symptoms are usually pain in the lateral aspect of the forearm, and sometimes in the dorsal hand and wrist, that is exacerbated by repetitive extension and pronation of the forearm or hand (Cass 2014). Localized tenderness on the supinator muscle mass (immediately distal to the lateral epicondyle) is usually present. In cases of motor dysfunction (posterior interosseus nerve syndrome), extension of the ÿ ngers and wrist and radial deviation of the wrist are a˛ ected (Cass 2014).

and its global biomechanical behavior in relation to the MIT approach were discussed. Recent clinical ÿ ndings suggest this knowledge should be incorporated into clinical reasoning which usually focuses mainly on common entrapment areas.

Conclusion

° e inclusion of the possibility that the peripheral neural system could be trapped in other areas (away from con˝ ict zones) could make the diagnosis more precise and facilitate therapeutic decisions.

In Chapters 7, 8, and 9 the continuity and three-dimensionality (not the linearity) of the neurofascial system

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Global ine˛ ectiveness of the neurofascial system can restrict the mechanical behavior (elongation) of nerves by limiting their ability to glide. Prolonged mechanical incompetence of the adjacent structures (muscles, tendons, aponeurosis, or vascular tracts) can transmit excessive load to the path of the neurovascular tracts. ° is systematic adaptive deÿ ciency inhibits the e˛ ectiveness of the neurofascial system and leads to its injury.

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REFERENCES

An TW, Evano˛ BA, Boyer MI, Osei DA (2017) ° e prevalence of cubital tunnel syndrome: A cross-sectional study in a U.S. metropolitan cohort. J Bone Joint Surg Am 99(5):408–416.

McPhail IR (2015) Quadrilateral space syndrome: ° e Mayo Clinic experience with a new classiÿ cation system and case series. Mayo Clin Proc 90(3):382–394.

Balasuburamaniam A, Kandaswamy M (2016) E˛ ect of myofascial release therapy and active stretching on pain and grip strength in lateral epicondylitis. JRCRS 4(1):3–6.

Burns MK, Patel V, Florescu I, Pochiraju K, Vinjamuri R (2017) Low-dimensional synergistic representation of bilateral reaching movements. Front Bioeng Biotechnol 5:2.

Benjamin M (2009) ° e fascia of the limbs and back--a review. J Anat 214(1):1–18.

Cahill BR, Palmer RE (1983) Quadrilateral space syndrome. J Hand Surg Am 8(1):65–69.

Borzelli D, Berger DJ, Pai DK, d’Avella A (2013) E˛ ort minimization and synergistic muscle recruitment for three-dimensional force generation. Front Comput Neurosci 7:186.

Cass S (2014) Upper extremity nerve entrapment syndromes in sports: An update. Curr Sports Med Rep 13(1):16–21.

Bernabei M, van Dieën JH, Maas H (2016) Altered mechanical interaction between rat plantar ˝ exors due to changes in intermuscular connectivity. Scand J Med Sci Sports 27(2): 177–187. Betkas U, Ay S, Yilmaz C, Tekdemir I, Elhan A (2003) Spinoglenoid Septum: A New Anatomic Finding. J Shoulder Elbow Surg 12(5):491–492. Bigliani LU, Dalsey RM, McCann PD, April EW (1990) An anatomical study of the suprascapular nerve. Arthroscopy 6(4):301–305. Blemker SS, Delp SL (2005) ° ree-dimensional representation of complex muscle architectures and geometries Ann Biomed Eng 33(5):661–673 [Original article]; 33(8):1134 [Erratum to article]. Boocock MG, Collier JM, McNair PJ, Simmonds M, Larmer PJ, Armstrong B (2009) A framework for the classiÿ cation and diagnosis of workrelated upper extremity conditions: Systematic review. Semin Arthritis Rheum 38(4):296–311. Borzelli D, Berger DJ, Pai DK, d’Avella A (2013) E˛ ort minimization and synergistic muscle recruitment for three-dimensional force generation. Front Comput Neurosci 7:186. Briggs CA, Elliott BG (1985) Lateral epicondylitis. A review of structures associated with tennis elbow. Clin Anat 7(3):149–153. Brown SA, Doolittle DA, Bohanon CJ, Jayaraj A, Naidu SG, Huettl EA, Renfree KJ, Oderich GS, Bjarnason H, Gloviczki P, Wysokinski WE,

Clavert P, Lutz JC, Adam P, Wolfram-Gabel R, Liverneaux P, Kahn JL (2009) Frohse’s arcade is not the exclusive compression site of the radial nerve in its tunnel. Orthop Traumatol Surg Res 95(2):114–118. Clavert P, ° omazeau H (2014) Peri-articular suprascapular neuropathy. Orthop Traumatol Surg Res 100(8 Suppl.):S409–411. Cohen ML, Arroyo JF, Champion GD, Browne CD (1992) In search of the pathogenesis of refractory cervicobrachial pain syndrome. A deconstruction of the RSI phenomenon. Med J Aust 156(6):432–436. Conduah AH, Baker III CL, Baker Jr. CL (2010) Clinical management of scapulothoracic bursitis and the snapping scapula. Sports Health 2(2):147–155. Corey S, Vizzard M, Badger G, Langevin H (2011) Sensory innervation of the nonspecialized connective tissues in the low back of the rat. Cells Tissues Organs 194(6):521–530. Czerwonatis S, Dehghani F, Steinke H, Hepp P, Bechmann I (2020) Nameless in anatomy, but famous among surgeons: ° e so called “deltotrapezoid fascia.” Ann Anat 231:151488. Chaÿ k D, Galatz LM, Keener JD, Kim HM, Yamaguchi K (2013) Teres minor muscle and related anatomy. J Shoulder Elbow Surg 22(1):108–114. Chen H, Narvaez VR (2015) Ultrasound-guided quadrilateral space block for the diagnosis of quadrilateral syndrome. Case Rep Orthop 2015:378627.

Chew ML, Giu˛ rè BM (2005) Disorders of the distal biceps brachii tendon. Radiographics 25(5):1227–1237. d’Avella A (2016) Modularity for motor control and motor learning. Adv Exp Med Biol 957:3–19. d’Avella A, Bizzi E (2005) Shared and speciÿ c muscle synergies in natural motor behaviors. Proc Natl Acad Sci U.S.A. 102(8):3076–3081. d’Avella A, Saltiel P, Bizzi E (2003) Combinations of muscle synergies in the construction of a natural motor behavior. Nat Neurosci 6(3):300–308. d’Avella A, Giese M, Ivanenko YP, Schack T, Flash T (2015) Editorial: Modularity in motor control: From muscle synergies to cognitive action representation. Front Comput Neurosci 9:126. de Carvalho SC, Castro ADAE, Rodrigues JC, Cerqueira WS, Santos DDCB, Rosemberg LA (2019) Snapping scapula syndrome: Pictorial essay. Radiol Bras 52(4):262–267. deRugy A, Loeb GE, Carroll TJ (2013) Are muscle synergies useful for neural control? Front Comput Neurosci 7:19. Dididze M, Ta˙ i D, Sherman Al (2020) Pronator Teres Syndrome. [Updated May 26, 2020]. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available: https://www.ncbi.nlm. nih.gov/books/NBK526090/ [accessed December 29, 2020]. Dong Q, Jacobson JA, Jamadar DA, Gandikota G, Brandon C, Morag Y, Fessell DP, Kim SM (2012) Entrapment neuropathies in the upper and lower limbs: Anatomy and MRI features. Radiol Res Pract 2012:230679. Doughty CT, Bowley MP (2019) Entrapment neuropathies of the upper extremity. Med Clin North Am 103(2):357–370. Duckworth AD, McQueen MM (2017) ° e diagnosis of acute compartment syndrome: A critical analysis review. JBJS Rev 5(12):e1. Duparc F, Coquerel D, Ozeel J, Noyon M, Gerometta A, Michot C (2010) Anatomical basis of the suprascapular nerve entrapment, and clinical relevance of the supraspinatus fascia. Surg Radiol Anat 32(3):277–284.

508

Pilat_Myofascial Induction.indb 508

03/12/21 4:59 PM

REFERENCES

Eames MH, Bain GI, Fogg QA, van Riet RP (2007) Distal biceps tendon anatomy: A cadaveric study. J Bone Joint Surg Am 89(5):1044–1049. Farrell C, Kiel J (2020) Anatomy, Back, Rhomboid Muscles. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available: https://www.ncbi.nlm.nih.gov/books/ NBK534856/ [accessed December 29, 2020]. Feleus A, Bierma-Zeinstra SM, Miedema HS, Verhagen AP, Nauta AP, Burdorf A, Verhaar JAN, Koes BW (2007) Prognostic indicators for non-recovery of non-traumatic complaints at arm, neck and shoulder in general practice--6 months follow-up. Rheumatology (Oxford) 46(1):169–176. Fernández-de-las-Peñas C, Cleland J, PalaciosCeña M, Fuensalida-Novo S, Pareja JA, AlonsoBlanco C (2017) ° e e˛ ectiveness of manual therapy versus surgery on self-reported function, cervical range of motion, and pinch grip force in carpal tunnel syndrome: A randomized clinical trial. J Orthop Sports Phys ° er 47(3):151–161. Findley T, Chaudhry H, Dhar S (2015) Transmission of muscle force to fascia during exercise. J Bodyw Mov ° er 19(1):119–123. Frank RM, Ramirez J, Chalmers PN, McCormick FM, Romeo AA (2013) Scapulothoracic anatomy and snapping scapula syndrome. Anat Res Int 635628. Frère J, Hug F (2012) Between-subject variability of muscle synergies during a complex motor skill. Front Comput Neurosci 6:99. Garofolini A, Svanera D (2019) Fascial organisation of motor synergies: A hypothesis Eur J Transl Myol 29(3):185–194. Gelberman RH, Hergenroeder PT, Hargens AR, Lundborg GN, Akeson WH (1981) ° e carpal tunnel syndrome. A study of carpal canal pressures. J Bone Joint Surg Am 63(3):380–383. Gioux M, Petit J (1993) E˛ ects of immobilizing the cat peroneus longus muscle on the activity of its own spindles. J Appl Fisiol 75(6):2629–2635. Giuriati W, Ravara B, Porzionato A, Albertin G, Stecco C, Macchi V, Caro R, Martinello T, Gomiero C, Patruno M, Coletti D, Zampieri S,

Nori A (2018) Muscle spindles of the rat sternomastoid muscle. Eur J Trans Myol 28(4):7904. Goitz RJ, Fowler JR, Li ZM (2014) ° e transverse carpal ligament: Anatomy and clinical implications. J Wrist Surg 3(4):233–234. Gong JC, Chen N, Chen JF, Xu Z, Wu Y, Li JQ, Tang KL (2017) Subscapular bursa: Anatomy and magnetic resonance appearance. Chin Med J (Engl) 130(14):1739–1740. Gottlieb GL (1998) Muscle activation patterns during two types of voluntary single-joint movement. J Neurophysiol 80(4):1860–1867. Gray H (1918) Anatomy of the Human Body. [20th U.S. edition of Gray’s Anatomy of the Human Body] Ed. Warren H. Lewis. New York: Bartleby.com, 2000. Available: http://www. bartleby.com/107/ [accessed December 29, 2020]. Greening J, Lynn B (1998) Vibration sense in the upper limb in patients with repetitive strain injury and a group of at-risk oˆ ce workers. Int Arch Occup Environ Health 71(1):29–34. Greening J, Dilley A, Lynn B (2005) In vivo study of nerve movement and mechanosensitivity of the median nerve in whiplash and non-speciÿ c arm pain patients. Pain 115(3):248–253. Hagberg M (2007) Clinical assessment, prognosis and return to work with reference to work related neck and upper limb disorders. G Ital Med Lav Ergon 27(1):51–57. Hanandeh A, Mani VR, Bauer P, Ramcharan A, Donaldson B (2019) Identiÿ cation and surgical management of upper arm and forearm compartment syndrome. Cureus 11(10):e5862. Hargreaves D, Fetouh S (2020) Common and uncommon nerve compression syndromes around the elbow. Orthop Trauma 34(4):228–234. Helme RD, LeVasseur SA, Gibson SJ (1992) RSI revisited: Evidence for psychological and physiological di˛ erences from an age, sex and occupation matched control group. Aust New Zeal J Med 22(1):23–29 Hester P, Caborn D, Nyland J, Lexington KY (2000) Cause of long thoracic nerve palsy: A possible dynamic fascial sling cause. J Shoulder Elbow Surg 9(1):31–35.

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Hu G, Yang W, Chen X, Qi W, Li X, Du Y and Xie P (2018) Estimation of time-varying coherence amongst synergistic muscles during wrist movements. Front Neurosci 12:537. Huijing PA (2009) Epimuscular myofascial force transmission: A historical review and implications for new research. International Society of Biomechanics Muybridge Award Lecture, Taipei. J Biomech 42(1):9–21. Järvinen TA, Józsa L, Kannus P, Järvinen TL, Järvinen M (2002) Organization and distribution of intramuscular connective tissue in normal and immobilized skeletal muscles. An immunohistochemical, polarization and scanning electron microscopic study. J Muscle Res Cell Motil 23(3):245–254. Jepsen JR (2018) Studies of upper limb pain in occupational medicine, in general practice, and among computer operators. Dan Med J 65(4):B5466. Jerosch J, Filler T, Mertens T (2012) ° e spinoglenoid ligament – an anatomic study [Article in German]. Z Orthop Unfall 150(2):142–148. Jimenez A, Marappa-Ganeshan R (2020) Forearm Compartment Syndrome. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available: https://www.ncbi.nlm.nih.gov/books/ NBK556130/ [accessed December 29, 2020]. Joshi SD, Yogesh AS, Mittal PS, Joshi SS (2004) Morphology of the bicipital aponeurosis: A cadaveric study. Folia Morphol (Warsz) 73(1):79–83. Kalyani BS, Fisher BE, Roberts CS, Giannoudis PV (2011) Compartment syndrome of the forearm: A systematic review. J Hand Surg Am 36(3):535–543. Kaplan PE (1980) Electrodiagnostic conÿ rmation of long thoracic nerve palsy. J Neurol 43(1):50–52. Karri J, Chang Chien GC, Abd-Elsayed A (2019) Nerve entrapments of the upper extremity. In: Abd-Elsayed A (Ed.) Pain: A Review Guide. Springer, Cham, pp. 753–756. [Online] Available: https://doi.org/10.1007/978-3-319-99124-5_161 [accessed September 21, 2021]. Keener JD, Chaÿ k D, Kim HM, Galatz LM, Yamaguchi K (2010) Insertional anatomy of the

509

Pilat_Myofascial Induction.indb 509

03/12/21 4:59 PM

17

REFERENCES

triceps brachii tendon. J Shoulder Elbow Surg 19(3):399–405. Kibler WB, Sciascia A (2010) Current concepts: Scapular dyskinesis. Br J Sports 44(5):300–305. Kirchgesner T, Tamigneaux C, Acid S, Perlepe V, Lecouvet F, Malghem J, Vande Berg B (2019) Fasciae of the musculoskeletal system: MRI ÿ ndings in trauma, infection and neoplastic diseases. Insights Imaging 10(1):47. Kröger S (2018) Proprioception 2.0: Novel functions for muscle spindles. Curr Opin Neurol 31(5):592–598. Kuhn JE, Plancher KD, Hawkins RJ (1998) Symptomatic scapulothoracic crepitus and bursitis. J Am Acad Orthop Surg 6(5):267–273. Latash ML (2010) Motor synergies and the equilibrium-point hypothesis. Motor Control 14(3):294–322. Latash ML, Scholz JP, Schoner G (2007) Toward a new theory of motor synergies. Motor Control 11(3):276–308.

McClelland D, Paxinos A (2008) ° e anatomy of the quadrilateral space with reference to quadrilateral space syndrome. J Shoulder Elbow Surg 17(1): 162–164. Mense S (2019) Innervation of the thoracolumbar fascia. Eur J Transl Myol 29(3):8297. Mense S, Hoheisel U (2016) Evidence for the existence of nociceptors in rat thoracolumbar fascia. J Bodyw Mov ° er 20(3):623–628. Merolla G, Cerciello S, Paladini P, Porcellini G (2013) Snapping scapula syndrome: Current concepts review in conservative and surgical treatment. Muscles Ligaments Tendons J 3(2):80–90. Miller TT, Reinus WR (2010) Nerve entrapment syndromes of the elbow, forearm, and wrist. Am J Roentgenol 195(3):585–594. Moccia D, Nackashi AA, Schilling R, Ward PJ (2015) Fascial bundles of the infraspinatus fascia: Anatomy, function, and clinical considerations. J Anat 228(1):176–183.

Latash ML, Levin MF, Scholz JP, Schöner, G (2010) Motor control theories and their applications. Medicina (Kaunas, Lithuania) 46(6):382–392.

Moccia D, Nackashi AA, Schilling R, Ward PJ (2016) Fascial bundles of the infraspinatus fascia: Anatomy, function, and clinical considerations. J Anat 228(1):176–183.

Lee SG, Kim JH, Lee SY, Choi IS, Moon ES (2006) Winged scapula caused by rhomboideus and trapezius muscles rupture associated with repetitive minor trauma: A case report. J Korean Med Sci 21(3):581–584.

Moloney N, Hall T, Doody C (2013) Sensory hyperalgesia is characteristic of nonspeciÿ c arm pain: A comparison with cervical radiculopathy and pain-free controls. Clin J Pain 29(11): 948–956.

Li S, Zhuang C, Hao M, He X, Marquez JC, Niu CM, Lan N (2015) Coordinated alpha and gamma control of muscles and spindles in movement and posture. Front Comput Neurosci 9:122.

Moradi A, Ebrahimzadeh MH, Jupiter JB (2015) Radial tunnel syndrome, diagnostic and treatment dilemma. Arch Bone Jt Surg 3(3): 156–162.

Low YL, Singbal SB, Zhang J (2019) Pronator syndrome: An uncommon median nerve entrapment syndrome. Am J Phys Med Rehabil 98(1):e6–e7. Malagelada F, Dalmau-Pastor M, Vega J, Golanó P (2014) Elbow anatomy. In: Doral MN, Karlsson J (Eds.) Sports Injuries: Prevention, Diagnosis, Treatment and Rehabilitation. Berlin, Heidelberg: Springer, pp. 1–30. [Online] Available: https://doi.org/10.1007/978-3-642-36801-1_38-1 [accessed September 21, 2021].

Moreno F (2015) Descripción histológica del huso neuromuscular. Salutem Scientia Spiritus 1(1):48–52. Nayak SB, Swamy RS, Shetty P, Maloor PA, Dsouza MR (2016) Bifurcated bicipital aponeurosis giving origin to ˝ exor and extensor muscles of the forearm – A case report. J Clin Diagn Res 10(2):AD01–AD2. Ochoa JL (2012) Genesis of the structural pathology of myelinated ÿ bers in median nerve entrapment. Muscle Nerve 46(6):978.

Osias W, Matcuk Jr GR, Skalski MR, Patel DB, Schein AJ, Hatch GFR, White EA (2018) Scapulothoracic pathology: Review of anatomy, pathophysiology, imaging ÿ ndings, and an approach to management. Skeletal Radiol 47(2):161–171. Partanen JV (2017) Muscle pain and muscle spindles. In: Korhan O (Ed.) Anatomy, Posture, Prevalence, Pain, Treatment and Interventions of Musculoskeletal Disorders. IntechOpen. [Online] Available: doi: 10.5772/intechopen.72223 [accessed September 21, 2021]. Partridge BL, Katz J, Benirschke K (1987) Functional anatomy of the brachial plexus sheath: Implications for anesthesia. Anesthesiology 66(6):743–747. Pastor MF, Averbeck AK, Welke B, Smith T, Claassen L, Wellmann M (2016) ° e biomechanical in˝ uence of the deltotrapezoid fascia on horizontal and vertical acromioclavicular joint stability. Arch Orthop Trauma Surg 136(4):513–519. Percy EC, Birbrager D, Pitt MJ (1988) Snapping scapula: A review of the literature and presentation of 14 patients. Can J Surg 31(4):248–250. Prasarn ML, Ouellette EA (2011) Acute compartment syndrome of the upper extremity. JˇAm Acad Orthop Surg,19(1):49–58. Proske U, Allen T (2019) ° e neural basis of the senses of e˛ ort, force and heaviness. Exp Brain Res 237(3):589–599. Quintner JL, Bove GM (2001) From neuralgia to peripheral neuropathic pain: Evolution of a concept. Reg Anesth Pain Med 26(4):368–372. Ramaswamy KS, Palmer ML, van der Meulen JH, Renoux A, Kostrominova TY, Michele DE, Faulkner JA (2011) Lateral transmission of force is impaired in skeletal muscles of dystrophic mice and very old rats. J Physiol 589(5):1195–1208. Ridings P, Gault D (1994) Compartment syndrome of the arm. J Hand Surg Br 19(2):147–148. Rohde RS, Goitz RJ (2006) Deltoid compartment syndrome: A result of operative positioning. J Shoulder Elbow Surg 15(3):383–385. Roquelaure Y, Ha C, Leclerc A Touranchet A, Sauteron M, Melchior M, Imbernon E,

510

Pilat_Myofascial Induction.indb 510

03/12/21 4:59 PM

REFERENCES

Goldberg M (2006) Epidemiologic surveillance of upper-extremity musculoskeletal disorders in the working population. Arthritis Rheum 55(5):765–778. Schulte-Mattler WJ, Grimm T (2015) Common and not so common nerve entrapment syndromes: Diagnostics, clinical aspects and therapy. Nervenarzt 86(2):133–141 Stasinopoulos D, Johnson MI (2006) ‘Lateral elbow tendinopathy’ is the most appropriate diagnostic term for the condition commonly referred-to as lateral epicondylitis. Med Hypotheses 67(6):1400–1402. Stecco C (2015) Functional Atlas of the HumanFascial System. Edinburgh: Churchill Livingstone Elsevier. Stecco C, Gagey O, Belloni A, Pozzuoli A, Porzionato A, Macchi V, Aldegheri R, De Caro R, Delmas V (2007) Anatomy of the deep fascia of the upper limb. Second part: Study of innervation. Morphologie 91(292):38–43. Stecco C, Porzionato A, Macchi V, Stecco A, Vigato E, Parenti A, Delmas V, Aldegheri R, De Caro R (2008) ° e expansions of the pectoral girdle muscles onto the brachial fascia: Morphological aspects and spatial disposition. Cells Tissues Organs: 188(3):320–329. Stecco C, Macchi V, Barbieri A, Tiengo C, Porzionato A, De Caro R (2018) Hand fasciae innervation: ° e palmar aponeurosis. Clin Anat 31(5):677–683. Swedish Council on Health Technology Assessment (2012) Occupational exposures and neck and upper extremity disorders: A systematic review [Internet]. SBU Yellow Report No. 210. SBU Systematic Review Summaries. Available from: https://www.ncbi. nlm.nih.gov/books/NBK285323/ [accessed September 21, 2021]. Szabo RM, King KJ (2000) Repetitive stress injury: Diagnosis or self-fulÿ lling prophecy? JˇBone Joint Surg Am 82(9):1314–1322.

Taguchi T, Mense S, Hoheisel U (2008) Dorsal horn neurons having input from low back structures in rats. Pain 138(1):119–129. Tesarz J, Hoheisel U, Wiedenhöfer B, Mense S (2011) Sensory innervation of the thoracolumbar fascia in rats and humans. Neuroscience 194: 302–308. ° omas N, Cone B (2017) Acute compartment syndrome in the upper arm. Am J Emerg Med 35(3):525.e1–525.e2 Tijs C, Bernabei M, van Dieën JH, Maas H (2018) Myofascial loads can occur without fascicle length changes. Integr Comp Biol 58(2):251–260. Toomayan GA, Robertson F, Major NM, Brigman BE (2006) Upper extremity compartmental anatomy: Clinical relevance to radiologists. Skeletal Radiol 35(4):195–201. Turvey MT (2007) Action and perception at the level of synergies. Hum Mov Sci 26(4):657–697. van der Heide B, Allison GT, Zusman M (2001) Pain and muscular responses to a neural tissue provocation test in the upper limb. Man ° er 6(3):154–162.

Weinkauf B, Deising S, Obreja O, Hoheisel U, Mense S, Schmelz M, Rukwied R (2015) Comparison of nerve growth factor-induced sensitization pattern in lumbar and tibial muscle and fascia. Muscle Nerve 52(2):265–272. Wendt M, Novak CB, Anastakis DJ (2018) Prevalence of cold sensitivity in upper extremity nerve compression syndromes. J Hand Surg Eur 43(3):282–285. Wichelhaus A, Emmerich J, Mittlmeier T (2017) Posttraumatic nerve entrapment syndromes in the upper extremities. Unfallchirurg 120(4):329–343. Wilke J, Schleip R, Klingler W, Stecco C (2017) ° e lumbodorsal fascia as a potential source of low back pain: A narrative review. Biomed Res Int 2017:5349620. Williams GR Jr, Shakil M, Klimkiewicz J, Iannotti JP (1999) Anatomy of the scapulothoracic articulation. Clin Orthop Relat Res 359: 237–246. Wilson KE, Tat J, Keir PJ (2017) E˛ ects of wrist posture and ÿ ngertip force on median nerve blood ˝ ow velocity. Biomed Res Int 2017: 7156489.

van Rijn RM, Huisstede BM, Koes BW, Burdorf A (2009) Associations between work-related factors and speciÿ c disorders at the elbow: A systematic literature review. Rheumatology (Oxford) 48(5):528–536.

Windisch G, Tesch NP, Grechenig W, Peicha G (2006) ° e triceps brachii muscle and its insertion on the olecranon. Med Sci Monit 12(8):BR290– BR294.

van Rijn RM, Huisstede BM, Koes BW Burdorf A (2010) Associations between work-related factors and speciÿ c disorders of the shoulder--A systematic review of the literature. Scand J Work Environ Health 36(3):189–201.

Yoshitake Y, Uchida D, Hirata K, Mayÿ eld DL, Kanehisa H (2018) Mechanical interaction between neighboring muscles in human upper limb: Evidence for epimuscular myofascial force transmission in humans. J Biomech 74:150–155.

von Bertalan˛ y L (1968) General System ° eory: Foundations, Development, Applications. New York: George Braziller.

Zakrzewski J, Zakrzewska K, Pluta K, Oleg Nowak, Miłoszewska-Paluch A (2019) Ultrasound elastography in the evaluation of peripheral neuropathies: A systematic review of the literature. Pol J Radiol 84:e581–e591.

Warth RJ, Spiegl UJ, Millett PJ (2015) Scapulothoracic bursitis and snapping scapula syndrome: A critical review of current evidence. Am J Sports Med 43(1):236–245.

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Zembaty A (2003) Kinezyterapia, Vol. II. Krakow: Wydawnictwo Kasper Sp. z o.o.

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MIT procedures for common upper extremity dysfunctions

Hand Assessment of the hand structures Myofascial induction of the palmar fascia Telescopic induction applied to the fingers Myofascial induction of the intermetacarpal space Transverse stroke applied to the synovial sheaths of the thumb Longitudinal stroke applied to the thumb

515 5 16 517 518 519 520

Carpal tunnel Carpal tunnel syndrome assessment Anatomy of the carpal tunnel Transverse stroke applied to the carpal tunnel Sustained procedure applied to the carpal tunnel Telescopic procedure applied to the carpal tunnel

521 522 523 524 525

Forearm Assessment of the upper extremity Transverse stroke applied to the flexors of the forearm Longitudinal stroke applied to the flexors of the forearm Longitudinal stroke applied to the extensors of the forearm Cross hands procedure applied to the forearm Myofascial induction of the cubital fossa

526 527 528 529 530 531

Arm Assessment of the upper extremity Transverse stroke applied to the biceps brachii Myofascial induction applied to the bicipital groove: “Hourglass biceps” Cross hands procedure applied to the biceps brachii Transverse stroke applied to the triceps brachii Longitudinal stroke applied to the triceps brachii Cross hands procedure applied to the triceps brachii

532 533 534 535 536 537 538

Shoulder Assessment of the scapular triangle Shoulder complex: Basic anatomy of the scapular triangle Myofascial induction of the scapular triangle Rotator cuff assessment Rotator cuff: Myofascial induction of the subscapular fascia Rotator cuff: Myofascial induction of the infraspinatus fascia Rotator cuff: Myofascial induction of the supraspinatus fascia Assessment of myofascial structures associated with the shoulder Myofascial induction of the levator scapulae Myofascial induction of the pectoral and clavipectoral fascia Myofascial induction of the serratus anterior muscle Global pectoral induction

539 540 541 542 543 544 545 546 547 548 550 551

Upper limb Telescopic induction of the upper limb

552

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17 Neuroprotection (Prophylactic measure)

Avoids

Supports

Hypoxic or ischemic insult

Increase in neuronal tolerance and improvement in neuronal survival

Neuroprotection refers to sensory and motor mechanisms that act in response to disorders in the mechanosensitivity of the nervous tissue (neuritis). The sensory manifestations can be the result of the activation of nociceptive mechanisms, with the presence or absence of pain, which can trigger antagonistic motor activity to condition where the nerve can be subjected to mechanical stress. Protective muscle response can lead to changes in movement patterns involving fear-avoidance behavior and maladaptive posture.

Key to level of irritability or dysfunction Irritability/type of dysfunction

Levels

Irritability

High: presence of fear-avoidance and neuropathic features (negative psychosocial factors††) Moderate: presence of fear-avoidance and mixed features (negative psychosocial factors) Low: absence of fear-avoidance and predominant nociceptive features (positive psychosocial factors*)

Neuroprotection

High: presence of fear-avoidance and neuropathic features (negative psychosocial factors††) Moderate: presence of fear-avoidance and mixed features† (negative psychosocial factors) Low: absence of fear-avoidance and predominant nociceptive features (positive psychosocial factors*)

Rigidity/stiffness

High: absence of elastic deformation of tissue during palpatory assessment Moderate: small range of elastic deformation of tissue during palpatory assessment Low: decreased range of elastic deformation during palpatory assessment

Glide/gliding impairment

High: absence of gliding/sliding between fascial planes during palpatory assessment Moderate: decrease in gliding/sliding between fascial planes during palpatory assessment Low: absence of impairment in gliding/sliding of fascial layers

* The patient’s positive thinking about their condition and/or prognosis † Fluctuating (alternating/changing) neuropathic or nociceptive manifestation †† The patient’s erroneous and/or catastrophic thoughts about their condition and/or prognosis

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MIT procedures for common upper extremity dysfunctions: Hand

17

ASSESSMENT OF THE HAND STRUCTURES

Assessment of the carpal tunnel

Static stability Stability

Assessment of the anatomical snuffbox Dynamic stability

Global functional assessment

ROM Mobility Movement synergy

Assessment of the anatomical snuffbox (radial fossa)

Figure 17.1.1

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17 MYOFASCIAL INDUCTION OF THE PALMAR FASCIA

Objective To restore mobility to the palmar fascia-related structures

Objective

Type of procedure Sustained systemic procedure (indirect application) Irritability/type of dysfunction

A

Indications

Type of procedure

Indications Palmar fascia dysfunction related to overuse of the hand, post surgery, Dupuytren’s contracture Irritability/type of dysfunction Irritability: low Neuroprotection: low Rigidity/stiffness: moderate Glide: moderate

Patient position

Supine or sitting with the forearm in flexion and the hand in neutral position

Practitioner position

Sitting or standing at the side to be treated

Hand contacts

Using the hands as a clamp, place the thumbs on the dorsum of the patient’s hand and the radial edges of the flexed index fingers on the palm of the patient’s hand. The contact is below the metacarpophalangeal joints of the patient’s hand. At the beginning of the procedure the index fingers should be touching each other.

Procedure

Grip the patient’s hand and gradually move your own hands apart, without sliding over the skin, for 5–10 minutes’ duration.

Observations/ contraindications

Considerable pressure may be maintained as required (the force should be the minimum that can be applied without the fingers sliding over the patient’s skin). If the fingers slip, wipe the hands and fingers to dry them and then resume the position.

Figure 17.1.2 A Palmar fascia

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MIT procedures for common upper extremity dysfunctions: Hand

17

TELESCOPIC INDUCTION APPLIED TO THE FINGERS

Objective To release myofascial restrictions in the interphalangeal and metacarpophalangeal joints

Objective

Type of procedure Telescopic procedure: three-dimensional traction along the axis of the finger or phalanx Irritability/type of dysfunction

A

Indications

Type of procedure

Indications Interphalangeal and metacarpophalangeal dysfunctions of post-traumatic, postsurgical, or degenerative origin Irritability/type of dysfunction Irritability: low Neuroprotection: low Rigidity/stiffness: moderate Glide: low

Patient position

Sitting or supine

Practitioner position

Sitting or standing at the side to be treated

Hand contacts

With the nondominant hand, stabilize the metacarpal bone or phalanx of the finger to be treated. With the thumb and index finger of the other hand, hold the corresponding phalanx (of the patient’s hand).

Procedure

Continue with the procedure following the principles of the telescopic induction technique (axial traction and accompanying the facilitation response in the direction of “elongation” of the joint, adjustments in rotation and flexion–extension).

Observations/ contraindications

Adjust the hand contacts accordingly if the treatment is for: • the proximal phalanx (A) • the middle phalanx (B) • the distal phalanx (C).

B

C Figure 17.1.3 Different hand contacts are used depending on the area being treated. Treatment applied to the metacarpophalangeal joint (A), the proximal interphalangeal joint (B), and the distal interphalangeal joint (C)

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17

MYOFASCIAL INDUCTION OF THE INTERMETACARPAL SPACE

Objective To restore mobility to interosseous structures

Objective

Type of procedure Sustained systemic procedure (indirect application)

Irritability/type of dysfunction

Type of procedure

Indications Dysfunctions at the intermetacarpal level Irritability/type of dysfunction Irritability: moderate Neuroprotection: low Rigidity/stiffness: moderate Glide: moderate

Indications

Patient position

Sitting or supine

Practitioner position

Sitting or standing at the side to be treated

Hand contacts

Place the tips of the distal phalanges of the thumbs (flexed) on the palmar side of the intermetacarpal space of the patient’s hand, keeping a space between them.

Procedure

Three-dimensional pressure is applied with the thumbs. The sustained procedure should be followed.

Observations/ contraindications

The same procedure can be performed on the dorsal side of the hand.

Figure 17.1.4

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MIT procedures for common upper extremity dysfunctions: Hand

17

TRANSVERSE STROKE APPLIED TO THE SYNOVIAL SHEATHS OF THE THUMB

Objective To induce the release of myofascial restrictions of the synovial sheaths of the abductor pollicis longus and extensor pollicis brevis muscles

Objective

Type of procedure Transverse stroke (direct application) Irritability/type of dysfunction

A

Indications

Figure 17.1.5

Indications De Quervain syndrome Irritability/type of dysfunction Irritability: moderate Neuroprotection: low Rigidity/stiffness: moderate Glide: moderate

Patient position

Sitting or supine

Practitioner position

Sitting or standing at the side to be treated

Hand contacts

Stabilize the tendons of the abductor pollicis longus and extensor pollicis brevis muscles between the index finger and thumb of one hand. With the other hand, stabilize the tendons between the thumb and middle finger, so that the index finger is free to perform the procedure.

Procedure

Transverse gliding over the synovial coverage. 7 to 15 cycles are applied in 3 sets.

Observations/ contraindications

Avoid excessive force in the acute phase.

B

A The abductor pollicis longus and extensor pollicis brevis tendons. B Transverse stroke applied to the synovial sheaths of the thumb

Type of procedure

When performing transverse sliding do not skip over the tendons. Take care when touching the area where the radial artery crosses the floor of the anatomical snuffbox.

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17

LONGITUDINAL STROKE APPLIED TO THE THUMB

Objective To restore mobility to the thumb

Objective

Type of procedure Longitudinal stroke (direct application)

Irritability/type of dysfunction

Indications

Type of procedure

Indications Myofascial dysfunctions of thumb structures of post-traumatic, postsurgical, or degenerative origin; De Quervain syndrome in the acute phase Irritability/type of dysfunction Irritability: low Neuroprotection: low Rigidity/stiffness: moderate Glide: moderate

Patient position

Sitting or supine

Practitioner position

Sitting or standing at the side to be treated

Hand contacts

With the nondominant hand, gently stabilize the patient’s thumb. Place the index finger of the other hand on the space between the abductor pollicis longus and extensor pollicis longus.

Procedure

The index finger performs the longitudinal stroke starting at the anatomical snuffbox in the intertendinous space.

Observations/ contraindications

This is a dynamic procedure in which the practitioner follows the facilitated movement with the thumb while performing the longitudinal strokes. Take care in the presence of pain.

Figure 17.1.6

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MIT procedures for common upper extremity dysfunctions: Carpal tunnel

17

CARPAL TUNNEL SYNDROME ASSESSMENT

Carpal tunnel syndrome assessment

Static stability Stability

Carpal compression test

Carpal tunnel syndrome assessment Dynamic stability

Global functional assessment

ROM Phalen's test

Mobility Movement synergy

Carpal tunnel syndrome assessment

Tinel's test

Figure 17.2.1

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17 ANATOMY OF THE CARPAL TUNNEL

A

C

B TE

TE D TE

B

Figure 17.2.2 Ventral aspect of the distal third of the forearm and the palm of the hand D Transverse carpal ligament A Tendon of the palmaris longus TE Thenar eminence B Palmar fascia C Innervation territory of the median nerve White dot – median nerve

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MIT procedures for common upper extremity dysfunctions: Carpal tunnel

17

TRANSVERSE STROKE APPLIED TO THE CARPAL TUNNEL

Objective To restore mobility to the carpal tunnel structures

Objective

Type of procedure Sliding transverse stroke (direct application)

Irritability/type of dysfunction

Indications

Type of procedure

Indications Dysfunctions related to overuse of the hand or wrist; median nerve entrapment; after surgical interventions for carpal tunnel syndrome Irritability/type of dysfunction Irritability: high Neuroprotection: moderate or high Rigidity/stiffness: moderate Glide: moderate

Patient position

Supine or sitting

Practitioner position

Sitting or standing at the side to be treated

Hand contacts

With the nondominant hand gently hold the palm of the patient’s hand in position. Place the index and moderatefingers of the dominant hand at the level of the carpal tunnel.

Procedure

Transverse stroke is applied in 3 sets of 7 to 15 cycles.

Observations/ contraindications

Take care in the presence of pain.

Figure 17.2.3

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17 SUSTAINED PROCEDURE APPLIED TO THE CARPAL TUNNEL

Objective To restore mobility to the carpal tunnel structures and to optimize the neuromechanics of the brachial plexus

Objective

Type of procedure Sustained systemic procedure (indirect application) Irritability/type of dysfunction

A Indications

Type of procedure

Indications Dysfunctions of the carpal tunnel; medial nerve entrapment; post surgery Irritability/type of dysfunction Irritability: high Neuroprotection: high Rigidity/stiffness: moderate Glide: moderate

Patient position

Supine, with the upper extremity in slight abduction, the elbow extended, and the forearm in supine position

Practitioner position

Sitting or standing at the side to be treated

Hand contacts

Carpal tunnel area (A): Place the radial borders of the thumbs on the anterior region of the patient’s wrist so that the distal phalanges of both thumbs extend just beyond the fold of flexion of the wrist. Transverse carpal ligament (B): Place the tips of the thumbs at the end of the carpal canal. The flexed index fingers are placed on the back of the wrist. This hand contact focuses on more serious entrapment in the carpal tunnel.

Procedure

Apply sustained pressure with the thumbs. After the first release, the thumbs should be moved slightly apart (without sliding over the skin). The recommended duration is 10–15 minutes.

Observations/ contraindications

In the presence of paresthesia, or an increase in the intensity or the area of pain, the pressure applied must be reduced. The hand contacts need to be adjusted with precision.

B

Figure 17.2.4

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MIT procedures for common upper extremity dysfunctions: Carpal tunnel

17

TELESCOPIC PROCEDURE APPLIED TO THE CARPAL TUNNEL

Irritability/type of dysfunction

Indications

Patient position

Supine, with the upper extremity in abduction (30–40 degrees), the elbow extended, and the forearm in supine position

Practitioner position

Standing at the side to be treated

Hand contacts

The practitioner holds the patient’s arm at the level of the wrist. The thumbs and fingers are positioned to form a clamp. The thumbs are placed at the level of the carpal tunnel and the slightly flexed fingers are placed on the dorsum of the hand at the level of the wrist.

Indications Acute dysfunctions of the carpal tunnel

Procedure

Irritability/type of dysfunction Irritability: high Neuroprotection: moderate or high Rigidity/stiffness: moderate Glide: moderate

With the thumbs, perform a gentle telescopic traction with simultaneous sustained compression on the wrist. Follow the facilitation at the carpal tunnel with simultaneous telescopic adjustment. The application time ranges from 10–15 minutes.

Observations/ contraindications

In the presence of paresthesia, or if there is an increase in the intensity or the area of pain, the pressure applied should be reduced. Adjustment movements may occur in the craniocervical segment.

Objective To restore mobility to the carpal tunnel structures and to optimize the neuromechanics of the brachial plexus

Objective

Type of procedure

Type of procedure Sustained systemic procedure (indirect application)

Figure 17.2.5

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17

ASSESSMENT OF THE UPPER EXTREMITY

Assessment for lateral epicondylitis (tennis elbow)

Static stability Stability

Assessment of upper extremity mobility Dynamic stability

Global functional assessment

ROM Mobility Movement synergy

Figure 17.3.1

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MIT procedures for common upper extremity dysfunctions: Forearm

17

TRANSVERSE STROKE APPLIED TO THE FLEXORS OF THE FOREARM

Objective To restore mobility to the flexor compartments of the forearm

Objective

Type of procedure Sliding transverse stroke (direct application) Irritability/type of dysfunction

Indications

AC

Type of procedure

Indications Lateral intermuscular force transmission dysfunction; entrapment of the neurovascular bundle Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate or high Rigidity/stiffness: low Glide: moderate

Patient position

Supine, with the upper extremity in slight abduction, and the forearm extended and supine

Practitioner position

Standing at the side to be treated

Hand contacts

Place the fingertips in position (as shown) with the hands next to each other to form a fan shape. The hands support each other and the thumbs are interlocked.

Procedure

Apply the transverse stroke between the epimysia in all restricted areas (having first carried out a palpation assessment to select the areas).

PC

Apply 3 sets of 7–15 transverse strokes for each restriction. Observations/ contraindications

Take care not to apply pressure to neurovascular structures. Support (e.g., a folded towel) can be placed under the distal third of the patient’s forearm.

Figure 17.3.2 AC Anterior compartment. PC Posterior compartment

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17 LONGITUDINAL STROKE APPLIED TO THE FLEXORS OF THE FOREARM

Objective To restore mobility to the flexor compartments of the forearm

Objective

Type of longitudinal Sliding longitudinal stroke (direct application)

A Irritability/type of dysfunction

Indications

B

Type of procedure

Indications Lateral intermuscular force transmission dysfunction; entrapment of the neurovascular bundle; post surgery and long-term immobilization (fracture) Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate Rigidity/stiffness: moderate Glide: high

Patient position

Supine, with the upper extremity in slight abduction, and the forearm extended and supine

Practitioner position

Standing at the side to be treated

Hand contacts

Place the thumbs on the distal third of the patient’s forearm near the wrist. Place the fingers on the radial edge and ulnar border of the forearm to provide support.

Procedure

Apply the longitudinal stroke in the cranial direction. The direction of the movement path depends on the location of the restriction (previously determined by a palpation assessment).

C

Apply 3 longitudinal slides, stopping for 6–7 seconds at each restriction. Observations/ contraindications

Take care not to apply pressure to neurovascular structures. Support (e.g., a folded towel) can be placed under the distal third of the patient’s forearm. In cases of dysfunctions that affect the actions of the hand, the assisted procedure is recommended (D). In this scenario, when applying the longitudinal stroke the practitioner simultaneously facilitates slight movements of the patient’s hand to assist the procedure.

D

Figure 17.3.3 A Starting position showing the location of the thumbs. B Longitudinal stroke: intermediate phase. C Position of the thumbs on the patient’s arm. D Assisted procedure

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MIT procedures for common upper extremity dysfunctions: Forearm

17

LONGITUDINAL STROKE APPLIED TO THE EXTENSORS OF THE FOREARM Objective To restore mobility to the extensor compartments of the forearm

Objective

Type of procedure Longitudinal stroke (direct application)

Irritability/type of dysfunction

Indications

A

Type of procedure

Indications Lateral intermuscular force transmission dysfunction; post surgery and long-term immobilization (fracture); lateral epicondylitis (tennis elbow); radial tunnel syndrome Irritability/type of dysfunction Irritability: low Neuroprotection: low Rigidity/stiffness: moderate Glide: low Irritability: low

Patient position

Supine, with the upper extremity in slight abduction, and the forearm extended and prone

Practitioner position

Standing at the side to be treated

Hand contacts

Place the nondominant hand on the dorsum of the patient’s hand and the dominant hand on the distal third of the forearm.

Procedure

Apply the longitudinal stroke along the dorsal aspect of the forearm using one of the following: • the knuckles • the index finger supported by the middle finger • the thenar eminence. Perform 3 longitudinal strokes.

B

Observations/ contraindications

According to the degree of irritation and restriction the practitioner may assist the procedure by positioning the patient’s wrist in slight dorsiflexion.

C

Figure 17.3.4 A Assisted procedure. B Application with the fingers. C Application with the thenar eminence

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17 CROSS HANDS PROCEDURE APPLIED TO THE FOREARM

Objective To restore mobility to the flexor or extensor compartments of the forearm

Objective

Type of procedure Sustained systemic technique (cross hands) Irritability/type of dysfunction

Indications

Type of procedure

Indications Lateral intermuscular force transmission dysfunction; post surgery and long-term immobilization (fracture); lateral and medial epicondylitis Irritability/type of dysfunction Irritability: low Neuroprotection: low Rigidity/stiffness: low Glide: low

Patient position

Supine, with the upper extremity in slight abduction, and the forearm extended in supine or prone position

Practitioner position

Standing or sitting at the side to be treated

Hand contacts

Cross the hands and place the cranial hand on the upper third of the ventral or dorsal side of the forearm and the other hand above the wrist.

Procedure

Perform the technique, following the principles of the cross hands procedure (see Chapter 13).

Observations/ contraindications

The hands should not extend to the elbow or wrist flexure.

Figure 17.3.5

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MIT procedures for common upper extremity dysfunctions: Forearm

17

MYOFASCIAL INDUCTION OF THE CUBITAL FOSSA Objective To restore mobility to the components of the cubital fossa

Objective

Type of procedure Sustained systemic technique (cross hands)

A

Type of procedure

Irritability/type of dysfunction

Indications

B

Indications Intermuscular force transmission dysfunction; post surgery and long-term immobilization (fracture); entrapments of the cubital fossa nerve Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate Rigidity/stiffness: moderate Glide: high

Patient position

Supine, with the upper extremity in slight abduction and the forearm extended and supine

Practitioner position

Standing or sitting at the side to be treated

Hand contacts

Place the cranial hand on the upper third of the ventral side of the forearm and the other hand on the lower third of the arm.

Procedure

Place the hands (without crossing them) on each side of the cubital fossa. Perform according to the principles of the cross hands procedure but with the force directed toward the fossa.

Observations/ contraindications

The hands should not be over the area of the cubital fossa.

Figure 17.3.6 C

This area is important to the dynamics of the upper extremity because of the intersection of numerous structures: the brachialis, biceps brachii and bicipital aponeurosis, brachioradialis, and pronator teres (muscles); the median nerve; and the brachial, radial, and ulnar arteries. A Superficial fascia with fatty lobes. Note the high level of hydration. B Presence of cutaneous veins and nerves (circle). C Direct transmission of the contractile impulse of the biceps brachii through the lacertus fibrosus (see Chapter 3). D Hand position for the cubital fossa induction procedure

Video 17.1

Cubital fossa neurovascular tract components and their links to the brachial and antebrachial fascia

Video 17.2

D

Cubital fossa induction procedure

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17

ASSESSMENT OF THE UPPER EXTREMITY Biceps brachii assessment

Static stability Stability

Assessment of upper extremity mobility Dynamic stability

Global functional assessment

Speed's test

ROM Mobility Movement synergy

Apley scratch test

Figure 17.4.1

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MIT procedures for common upper extremity dysfunctions: Arm

17

TRANSVERSE STROKE APPLIED TO THE BICEPS BRACHII

Objective To restore mobility to the flexor compartment of the arm

Objective

Type of procedure Sliding: transverse stroke (direct application) Irritability/type of dysfunction

Indications Local dysfunctions of bicipital fascia

Type of procedure

Irritability/type of dysfunction Irritability: low Neuroprotection: low Rigidity/stiffness: low Glide: moderate Indications

Patient position

Supine with the elbow extended and the arm slightly abducted

Practitioner position

Standing or sitting

Hand contacts

Hold the patient’s arm with both hands, placing the thumbs on each side of the middle third of the biceps and the fingers on the triceps brachii.

Procedure

Press firmly with the thumbs and apply transverse strokes to the middle of the biceps muscle belly. Perform 3 sets of 15 cycles.

Observations/ contraindications

The transverse stroke should be applied to all locations of biceps entrapment. Take care not to apply pressure to neurovascular structures.

AC

PC

Video 17.3

Figure 17.4.2

Biceps brachii induction: Hand position and performance of the procedure

AC Anterior compartment PC Posterior compartment

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17 MYOFASCIAL INDUCTION APPLIED TO THE BICIPITAL GROOVE: “HOURGLASS BICEPS”

Objective To restore mobility to the bicipital groove

Objective

Type of procedure Sliding: transverse stroke (direct application)

Irritability/type of dysfunction

Type of procedure

Indications Dysfunctions of the long portion of the biceps Irritability/type of dysfunction Irritability: moderate Neuroprotection: low Rigidity/stiffness: moderate Glide: moderate

Indications

Patient position

In supine position with the arm slightly abducted

Practitioner position

Sitting or standing at the side to be treated

Hand contacts

With the caudal hand, flex the patient’s forearm to approximately 90 degrees. With the tip of the cranial thumb press the long tendon of the biceps brachii in the bicipital groove while applying pressure to the back of the shoulder with the fingers.

Procedure

Maintain pressure on the biceps tendon with the thumb of the cranial hand. At the same time, with the hand that is holding the patient’s forearm, perform internal–external rotation of the arm cyclically. Perform 3 sets of 15 cycles.

Observations/ contraindications

Be careful in the acute stage.

Video 17.4

Bicipital groove induction procedure

Figure 17.4.3

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MIT procedures for common upper extremity dysfunctions: Arm

17

CROSS HANDS PROCEDURE APPLIED TO THE BICEPS BRACHII

Objective To restore mobility to the brachial fascia and adjacent muscles

Objective

Type of procedure Sustained systemic procedure (indirect application) Irritability/type of dysfunction

Indications

Type of procedure

Indications Dysfunction of the anterior region of the arm structures Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate Rigidity/stiffness: low Glide: moderate

Patient position

In supine position with the arm extended, with the forearm in supination

Practitioner position

Standing at the side to be treated

Hand contacts

With the hands crossed, place the cranial hand on the patient’s shoulder and the other hand on the distal third of the biceps but without covering the ulnar fold.

Procedure

Using the cross hands procedure, three-dimensional pressure is applied for a minimum of 3 to 5 minutes. (see Chapter 13).

Observations/ contraindications

Do not apply excessive force. Take care to avoid the neurovascular tract. Support (e.g. a folded towel) can be placed under the distal third of the patient’s forearm.

Figure 17.4.4

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17

TRANSVERSE STROKE APPLIED TO THE TRICEPS BRACHII

Objective To restore mobility to the extensor compartment of the arm

Objective

Type of procedure Sliding: transverse stroke (direct application) Irritability/type of dysfunction

Type of procedure

Indications Local dysfunctions at the triceps brachii insertion Irritability/type of dysfunction Irritability: low Neuroprotection: low Rigidity/stiffness: moderate Glide: moderate

Indications

Patient position

In prone position, with the arm abducted to 90 degrees and the forearm flexed to 90 degrees

Practitioner position

Standing at the side to be treated

Hand contacts

With the pulp of the thumb, apply gentle pressure to the end of the insertion of the tendon of the triceps brachii.

Procedure

With the thumb, apply smooth transverse gliding over the tendon of the triceps brachii. Repeat the movement 7 to 15 times in 3 sets.

Observations/ contraindications

Do not press on the ulnar nerve.

Figure 17.4.5

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MIT procedures for common upper extremity dysfunctions: Arm

17

LONGITUDINAL STROKE APPLIED TO THE TRICEPS BRACHII

Objective To restore mobility to areas of restriction of the brachial fascia (extensor compartments)

Objective

Type of procedure Sliding: transverse stroke (direct application) Irritability/type of dysfunction

Type of procedure

Indications Myofascial dysfunction of the triceps brachii Irritability/type of dysfunction Irritability: low Neuroprotection: low Rigidity/stiffness: moderate Glide: moderate

Indications

Patient position

In prone position, with the arm abducted to 90 degrees and the forearm flexed to 90 degrees

Practitioner position

Standing at the side to be treated

Hand contacts

Place one hand on the patient’s elbow to hold it in position. Place the other hand on the caudal third of the triceps, near the tendon.

Procedure

Perform longitudinal strokes toward the shoulder.

Observations/ contraindications

The longitudinal stroke can be performed using one of three hand contacts: • with the index finger and the middle finger • with the knuckles • with the thenar eminence.

PC

AC

Figure 17.4.6 AC Anterior compartment PC Posterior compartment

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17 CROSS HANDS PROCEDURE APPLIED TO THE TRICEPS BRACHII

Objective

Irritability/type of dysfunction

Indications

Type of procedure

Objective To restore the performance of the brachial fascia (forearm extensors)

Patient position

In prone position, with the arm abducted at 90 degrees and the elbow flexed at 90 degrees

Practitioner position

Standing at the side to be treated

Type of procedure Sustained systemic procedure (indirect application)

Hand contacts

First cross the hands and then place them on the proximal end of the arm and on the distal third of the triceps.

Procedure

Using the cross hands technique, three-dimensional pressure is exerted for at least 3 to 5 minutes. The principles of the cross hands procedure should be applied (see Chapter 13).

Observations/ contraindications

It is common for the position of the forearm to be adjusted during the procedure. This movement should not be resisted.

Indications Dysfunction of the posterior region of the arm Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate Rigidity/stiffness: low Glide: moderate

Figure 17.4.7

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MIT procedures for common upper extremity dysfunctions: Shoulder

17

ASSESSMENT OF THE SCAPULAR TRIANGLE Assessment of the scapular triangle

Static stability Stability

Kibler's test Dynamic stability

Global functional assessment

Assessment of the scapular triangle Assessment of the scapular triangle ROM Mobility Movement synergy

Scapula dyskinesis test Apley scratch test Assessment of the scapular triangle

Janda’s test of shoulder muscle recruitment patterns

Figure 17.5.1

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17 SHOULDER COMPLEX: BASIC ANATOMY OF THE SCAPULAR TRIANGLE

1

2

3

A

4

B

5 A

A

B

C

A

B

C

6 A B

C

D

E

D

Figure 17.5.2 The scapula is a sort of mobile platform that articulates with the humerus which serves as an attachment to muscles that indirectly contribute to movements of the hand. Although these dynamics are in charge of the contractile structures, analysis of dissections of unembalmed cadavers indicates that nonspecialized loose connective tissue (abundant in the intermediate planes; see Chapters 16 and 17) has a role in this process as it allows the scapula to glide smoothly 1 Superficial fascia of the scapular area. Note the high level of hydration 2 Posterior aspect of the thorax A Sliding area between the trapezius and infraspinatus fossa B Insertion of the teres major and teres minor on the scapula 3 Rhomboid fascia. The trapezius has been dissected from the spine and removed A Rhomboid B Spine of scapula C Infraspinous fascia 4 The subscapular space A Loose connective tissue 5 Posterior view of the scapula. The supraspinatus and infraspinatus have been removed A Spine of scapula B Supraspinous fossa C Infraspinatus path of the suprascapular nerve D Infraspinous fossa E Inferior angle of the scapula 6 Posterior view of the scapula A Supraspinous path of the suprascapular nerve B Spine of scapula C Infraspinous fossa D Inferior angle of the scapula

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MIT procedures for common upper extremity dysfunctions: Shoulder

17

MYOFASCIAL INDUCTION OF THE SCAPULAR TRIANGLE

A

B

C E

4

D F 3

G

3 5

H

5

1

2 4

Objective To restore mobility to the structures of the scapular triangle

Objective

Irritability/type of dysfunction

Type of procedure

Type of procedure Sliding: longitudinal stroke (image 3) and transverse stroke (image 4) (direct applications). Cross hands sustained systemic procedure (indirect application) (image 5) Indications Scapulothoracic dyskinesis

Indications

Figure 17.5.3

Patient position

Side lying with the knees slightly bent to maintain the lateral decubitus position.

Practitioner position

Standing facing the patient, beside their upper body. A small cushion is placed between the patient and practitioner to avoid direct contact. Part of the cushion is placed between the patient’s body and arm

Hand contacts

Medial border: The hands are placed on the scapula and the fingertips are introduced into the subscapularis space. Upper border: The hands are placed above the spine of the scapula (in the supraspinatus space). Lateral border: Crossed hands are placed on the lateral border of the scapula and the posterior aspect of the shoulder.

Procedure

Medial border: Perform dynamic transverse strokes along the inner edge of the scapula in the cranial-caudal direction. Apply 7 to 15 cycles in 3 sets. Upper border: Perform transverse strokes, applying firm pressure to the suprapinatus space. Apply 7 to 15 cycles in 3 sets. Lateral border: Using the cross hands procedure, apply three-dimensional pressure for a minimum of 3–5 minutes.

Observations/ contraindications

Take care to maintain the correct position in relation to the patient. The third phase of the protocol usually produces a dynamic response.

Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate Rigidity/stiffness: moderate Glide: high

The reason for treating the scapular triangle is to facilitate sliding between the fascial planes of the area 1 Main dynamic (muscular) stabilizers of the shoulder joint complex A Upper trapezius B Serratus anterior (upper fibers) C Levator scapulae D Deltoid E Rhomboids F Rotator cuff (supraspinatus, infraspinatus, teres minor, and subscapularis)

G Trapezius (middle and lower) H Serratus anterior (lower fibers) 2 Schematic representation of the procedures applied to the scapular triangle. The continuous arrows illustrate the transverse stroke and the short arrows the sustained systemic procedure. The numbers correspond to the images on the right 3 Medial border: transverse stroke 4 Upper border: transverse stroke 5 Lateral border: cross hands induction

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17 ROTATOR CUFF ASSESSMENT

Rotator cuff assessment • Infraspinatus • Teres minor

Static stability Stability

External rotation lag sign Dynamic stability

Global functional assessment

Rotator cuff assessment • Supraspinatus Force

ROM Mobility Movement synergy

Abduction

Resistance to downward pressure

Empty can test

Rotator cuff assessment • Subscapularis

Resisted internal rotation test

Lift-off test

Figure 17.5.4

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MIT procedures for common upper extremity dysfunctions: Shoulder

17

ROTATOR CUFF: MYOFASCIAL INDUCTION OF THE SUBSCAPULAR FASCIA

Objective To restore mobility to the subscapularis muscle; to improve the internal rotation movement of the arm

Objective

Type of procedure Sustained systemic procedure (indirect application) Irritability/type of dysfunction

1

Indications

2 A

B

C

D

E

Type of procedure

Indications Dysfunctions of glenohumeral dynamics, frozen shoulder dysfunction, mechanosensitivity of the radial nerve, scapular dyskinesis Irritability/type of dysfunction Irritability: moderate or high Neuroprotection: moderate Rigidity/stiffness: moderate Glide: high

Patient position

Supine, with the arm raised to 60–90 degrees, depending on the amount of movement restriction

Practitioner position

Standing or sitting level with the patient’s head at the side to be treated

Hand contacts

With the cranial hand, hold the patient’s arm and perform very gentle traction. For the caudal hand, choose one of the following positions for the hand contacts. Option 1 (acute phase): Place the ulnar side of the thenar eminence of the caudal hand on the outer edge of the scapula, as close as possible to the glenohumeral joint, until it reaches the scapulothoracic space. Option 2 (chronic phase): With the caudal hand, in prone position, slowly penetrate the scapulothoracic space with the tips of the fingers.

3

Figure 17.5.5

Procedure

Pull gently with the cranial hand while the caudal hand gently pushes into the subscapular space. With both hands follow the facilitated movement for 3–5 minutes.

Observations/ contraindications

The procedure should be applied bilaterally. If pain occurs during treatment the pressure should be progressively reduced. The procedure can be continued provided the patient is able to tolerate the pain.

1 Subscapular fascia induction: acute phase 2 Subscapular fascia induction: chronic phase 3 Lateral aspect of the trunk A Costal arch B Serratus anterior C Pectoralis major muscles. The right muscle is dissected from the sternum D Sternum E Latissimus dorsi White dot – contact area

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17 ROTATOR CUFF: MYOFASCIAL INDUCTION OF THE INFRASPINATUS FASCIA

Objective To restore mobility to the infraspinatus muscle. To optimize shoulder stability by keeping the head of the humerus in its optimal position against the scapula

Objective

Irritability/type of dysfunction

1

Type of procedure

Type of procedure Acute phase (1): sliding: transverse stroke (direct application) Chronic phase (2): sustained systemic procedure (indirect application) Indications Dysfunctions of glenohumeral dynamics, frozen shoulder dysfunction, tendinopathy of the rotators of the arm

Indications

2

A B

Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate Rigidity/stiffness: moderate Glide: moderate

Patient position

Prone, with the arm off the table

Practitioner position

Standing or sitting level with the patient’s head at the side to be treated

Hand contacts

Place the whole thumb of the dominant hand in the infraspinous fossa just below the spine of the scapula. The thumb of the other hand is used to reinforce the position.

Procedure

Acute phase: Perform transverse strokes along the spine of the scapula. Apply 7–15 cycles in 3 sets. Chronic phase: Three-dimensional pressure is applied and maintained for 3–5 minutes after each barrier is released for up to 3 barriers.

Observations/ contraindications

Beware of pain in the acute stage.

C

Spontaneous arm movement may be incorporated in the second part of the procedure.

3

Figure 17.5.6 1 Infraspinatus fascia induction: acute phase of rotator cuff tear 2 Infraspinatus fascia induction: chronic phase of rotator cuff tear 3 Posterior aspect of the thorax: the trapezius muscle has been removed A Supraspinatus fascia B Infraspinatus fascia C Spine of the sacpula

Video 17.5

Infraspinatus fascia induction

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MIT procedures for common upper extremity dysfunctions: Shoulder

17

ROTATOR CUFF: MYOFASCIAL INDUCTION OF THE SUPRASPINATUS FASCIA

Objective To induce the release of restrictions of the supraspinatus muscle

Objective

Type of procedure Sustained systemic procedure (indirect application) Irritability/type of dysfunction

1

Indications

A

B

C

D

E

F

Type of procedure

Indications Dysfunctions of glenohumeral dynamics, frozen shoulder dysfunction, rotator tendinopathy, subacromial impingement Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate Rigidity/stiffness: moderate Glide: moderate

E Patient position

Supine, with the arm slightly abducted and the forearm flexed and resting on the patient’s body

Practitioner position

Sitting level with the patient’s shoulder at the side to be treated

Hand contacts

Place one hand over the glenohumeral region and reinforce this position with the other hand.

Procedure

Gentle and sustained pressure should be applied three-dimensionally toward the glenoid cavity and maintained for about 5 minutes after each barrier is released for up to 3 barriers.

Observations/ contraindications

Beware of pain. In the second phase the movement can be very dynamic.

Figure 17.5.7 A Line of the spinous processes B Rhomboid C Medial border of the scapula D Supraspinatus E Scapular spine F Infraspinatus fascia G Inferior angle of the scapula

3

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17 ASSESSMENT OF MYOFASCIAL STRUCTURES ASSOCIATED WITH THE SHOULDER

Assessment of muscles associated with the scapula

Static stability Stability Dynamic stability

Global functional assessment

Winged scapula test for serratus anterior, middle trapezius, and lower trapezius weakness

ROM Mobility Movement synergy

Pectoralis minor length test

Latissimus dorsi length test

Levator scapulae length test

Pectoralis major length test

Figure 17.5.8

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MIT procedures for common upper extremity dysfunctions: Shoulder

17

MYOFASCIAL INDUCTION OF THE LEVATOR SCAPULAE

Objective To restore mobility to the structures of the scapular triangle

Objective

Type of procedure Sustained systemic procedure (indirect application)

1

Irritability/type of dysfunction

Indications

2

3

4

Figure 17.5.9

Type of procedure

Indications Dysfunctions of the neck–back–shoulder complex, alterations of the cervical plexus Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate Rigidity/stiffness: moderate Glide: high

Patient position

Supine, with the arm resting along the trunk

Practitioner position

Standing or sitting at the head of the table

Hand contacts

One hand is placed under the patient’s scapula with the fingertips surrounding the lower angle of the scapula and gently pulling it in a cranial direction. This maneuver releases access to the upper angle of the scapula, which allows the index and middle fingers of the other hand to touch the insertion of the levator scapulae in the shoulder blade.

Procedure

Sustained pressure is increased in the levator scapulae insertion, while the hand placed on the scapula follows the facilitated, small-amplitude movement.

Observations/ contraindications

The procedure should be applied bilaterally. This procedure produces some pain and should only be continued if the patient is able to tolerate the pain.

1 Position of the hands on the patient (with the body rotated slightly to the right to provide a better view) 2 Position of the treating hand 3 Position of the hands on the cadaver (with the cadaver in prone position to provide the best view) 4 Dissection of the levator scapulae. The oval illustrates the area of its insertion on the scapula

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17 MYOFASCIAL INDUCTION OF THE PECTORAL AND CLAVIPECTORAL FASCIA

1

2 A

3

4

5

6

Video 17.6

Performance of pectoralis major induction

B

C

Video 17.7

Clavipectoral fascia induction

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MIT procedures for common upper extremity dysfunctions: Shoulder

17

Continued

Objective To restore mobility to the fascia-related structures of the pectoralis muscle

Objective

Type of procedure Pectoralis major fascia: sliding: transverse stroke (direct application) (images 1–3) Clavipectoral fascia: sustained systemic procedure (indirect application) (images 4–6) Irritability/type of dysfunction

Indications

Type of procedure

Indications Shoulder dysfunction, clavipectoral fascia dysfunction, thoracic outlet syndrome, breast surgery, breathing dysfunctions Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate Rigidity/stiffness: moderate Glide: moderate

Patient position

Supine, with the arm abducted to 60–90 degrees. If there is any difficulty with abducting the arm (e.g., pain), the forearm can be flexed and the hand placed on the chest area.

Practitioner position

Standing or sitting at the side to be treated

Hand contacts

Pectoralis fascia/pectoralis major muscle(1–3): Place the hands side by side with the thumbs and fingers acting as a clamp. The thumbs are placed on the posterior aspect of the pectoralis major, in the axillary fossa, and the fingers extend over the mass of the pectoralis major. Clavipectoral fascia/pectoralis minor muscle (4–6): Hold the patient’s arm in place with the cranial forearm. The caudal hand, in prone position with the metacarpophalangeal and interphalangeal joints extended, locates the myotendinous junction of the pectoralis minor in the space between the ribs and the pectoralis major.

Procedure

Pectoralis fascia/pectoralis major muscle: Apply transverse strokes in the mediolateral direction in the areas of greatest restriction. Perform 15 cycles in 3 sets. Transverse strokes should be performed in 3–5 different sites. Clavipectoral fascia/pectoralis minor muscle: Press deeper toward the midline until resistance is felt. Subsequently direct the fingertips toward the coracoid apophysis. Sustain the pressure until 3 consecutive barriers have been released.

Observations/ contraindications

The procedure should be applied bilaterally. Be cautious when treating the areas of the mammary gland, brachial plexus, and lymphatic structures and in the presence of pain. The fingers should not slide over the skin.

Figure 17.5.10 1 Pectoralis major fascia induction 2 Pectoralis major fascia induction: hand positions shown on a cadaver 3 Pectoralis major fascia induction: close-up showing the position of the thumbs 4 Dissection of the clavipectoral fascia A Pectoralis major, dissected and turned down B Clavipectoral fascia C Pectoralis minor Hand – position of the hand when treating the clavipectoral fascia 5 Clavipectoral fascia induction 6 Clavipectoral fascia induction: hand position shown on a cadaver

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17 MYOFASCIAL INDUCTION OF THE SERRATUS ANTERIOR MUSCLE

Objective

Irritability/type of dysfunction

Indications

Type of procedure

Objective To restore mobility to the serratus anterior fascia

Patient position

Side lying

Practitioner position

Standing, facing the patient

Type of procedure Sustained systemic procedure (indirect application)

Hand contacts

Cross the hands and place them on the lateral aspect of the patient’s thorax. Position the cranial hand below the axilla and the caudal hand over the lowest ribs.

Procedure

The principles of the sustained cross hands procedure should be followed (see Chapter 13).

Observations/ contraindications

The procedure should not be applied if the patient has chest pain. Avoid applying excessive pressure. It is important for the patient to maintain neutral body posture during the application.

Indications Breathing dysfunctions, rib pain, noncardiac chest pain, shoulder complex dysfunction, interscapular pain, winged scapula, golfer’s elbow pain Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate Rigidity/stiffness: moderate Glide: low

Figure 17.5.11

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MIT procedures for common upper extremity dysfunctions: Shoulder

17

GLOBAL PECTORAL INDUCTION

Objective

Irritability/type of dysfunction

Indications

Type of procedure

Objective To restore mobility to the shoulder complex

Patient position

Supine, with the upper extremity in abduction to 120–160 degrees

Practitioner position

Behind the patient at the corner of the head of the table

Type of procedure Sustained systemic procedure (indirect application)

Hand contacts

Place the caudal hand on the upper pectoralis area and hold the patient’s arm with the cranial hand.

Procedure

With the caudal hand apply gentle pressure toward the table and caudally while the cranial hand pulls the arm slightly. Follow the principles of the sustained procedure for 3–5 minutes, accompanying the facilitated movement.

Observations/ contraindications

Movement of the patient’s head and upper limb may occur, particularly in the last phase of the application.

Indications Breathing dysfunctions, shoulder dysfunction, multifocal alterations affecting different segments of the upper extremity, cervical plexus-related dysfunction, thoracic outlet syndrome Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate Rigidity/stiffness: low Glide: moderate

Figure 17.5.12

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17 TELESCOPIC INDUCTION OF THE UPPER LIMB

1

2

3

4

5

6

7

8

9

10

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MIT procedures for common upper extremity dysfunctions: Upper limb

17

Continued

Objective To improve the dynamic stability of the myofascial system of the upper extremity

Objective

Type of procedure Telescopic procedure: three-dimensional traction along the axis of the extremity Irritability/type of dysfunction

Type of procedure

Indications

Indications Multifocal and complex dysfunctions of post-traumatic, postsurgical and neurological origin (see contraindications) Irritability/type of dysfunction Irritability: moderate Neuroprotection: moderate or high Rigidity/stiffness: moderate Glide: moderate

Patient position

Supine with the arm extended along the trunk

Practitioner position

Standing at the side to be treated

Hand contacts

The practitioner firmly holds the distal third of the patient’s forearm. The practitioner’s elbows should be extended.

Procedure

Step 1: With one hand pull on the patient’s upper limb and wait for 3 consecutive elongations (1.5–3 minutes). Step 2: Accompany the facilitation with an external rotation of the patient’s arm. Step 3: To the external rotation add a spontaneous movement of abduction and slight flexion of the arm to achieve 90 degrees of abduction. Step 4: The movement continues with internal–external rotation adjustments of the arm. Steps 5 and 6: The extension–abduction movement continues until approximately 180 degrees of elevation is reached. Step 7: When 180 degrees of elevation is reached, the patient’s head tends to turn to the contralateral side and the arm advances over the head. This movement is permitted and should be accompanied. Step 8: Protect the position of the patient’s body on the table in relation to the trunk rotation movement. Step 9: The 360-degree arc is completed. Step 10: Gradually reduce the traction as you complete the procedure over a period of 10–15 minutes.

Observations/ contraindications

Do not interrupt the traction. It should be constant. The technique must be slow and progressive. The practitioner accompanies the facilitated movement and should not make passive movements. Red flag: shoulder prostheses.

Figure 17.6.1

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PERMISSIONS AND SOURCES Figure 3.2 Reproduced with permission from Pilat A. (2012) Myofascial Induction Approaches. In: Schleip R., Findley T.W., Chaitow L., Huijing P.A. (Eds.) Fascia: ˜ e Tensional Network of the Human Body. Churchill Livingstone Elsevier. Figure 3.6 Distribution of Langer´s lines. Redrawn from Langer, K. (1908) [1978] On the anatomy and physiology of the skin. British Journal of Plastic Surgery 31(1):38. Figure 3.13 Reproduced with permission from Pilat A., Fascial anatomy of the limbs. In: Liem T., Tozzi P., Chila A. (Eds.) Fascia in the Osteopathic Field. Edinburgh: Handspring Publishing. Figure 3.24 Images courtesy of Javier Álvarez González. Figure 3.27 Image courtesy of Javier Álvarez González. Figure 3.57 Image courtesy of Dr. Maribel MiguelPérez. Figure 3.58 Image courtesy of Javier Álvarez González. Figure 3.60 Image courtesy of Javier Álvarez González. Figure 3.61 Images courtesy of Javier Álvarez González. Figure 3.76 Reproduced with permission from Lesondak D. (2017) Fascia: What It Is and Why It Matters. Edinburgh: Handspring Publishing. Figure 3.96 Reproduced with permission from Pilat A., Fascial anatomy of the limbs. In: Liem T., Tozzi P., Chila A. (Eds.) Fascia in the Osteopathic Field. Edinburgh: Handspring Publishing. Figure 3.120 Image courtesy of Dr. Albert PérezBellmunt. Figure 4.3 A˙ er Prokop A., Beaven R., Qu Y., Sánchez-Soriano N. (2013) Using ˝ y genetics to dissect the cytoskeletal machinery of neurons during axonal growth and maintenance. Journal of Cell Science 126 (Pt. 11): 2331–2341. Figure 4.4 Modiÿ ed with permission from ÁlvarezMiguel I.S., Miguel-Lasobras E.M., Martín-Romero F.J., Domínguez-Arroyo J.A., González-Carrera E. (2006) Polarity during early embryo development. ASEBIR 2(2):35. Figure 4.7B Reproduced with permission from Scarr G. (2018) Biotensegrity: ˜ e Structural Basis of Life. 2nd ed. Edinburgh: Handspring Publishing.

Figure 4.8 A˙ er Garcia K.E., Kroenke C.D., Bayly P.V. (2018) Mechanics of cortical folding: Stress, growth and stability. Philosophical Transactions of the Royal Society B 373:20170321. Figure 6.3 Reproduced with permission from ArtefactPro. Figure 6.7 Reproduced with permission from ArtefactPro. Figure 6.10B Reproduced with permission from ArtefactPro. Figure 7.10 Modiÿ ed from Pilat A. (2003) Terapias miofasciales: Inducción miofascial. Madrid: McGraw Hill Interamericana de España. Figure 7.11 A˙ er Maas H., Sandercock T. (2008) Are skeletal muscles independent actuators? Force transmission from soleus muscle in the cat. Journal of Applied Physiology (1985) 104(6):15571567. Figure 7.15 Image courtesy of Javier Álvarez González. Figure 8.2 Reproduced with permission from Lesondak D. (2017) Fascia: What It Is And Why It Matters. Edinburgh: Handspring Publishing. Figure 10.2 A˙ er Jones M., Edwards I., Jenson G.M. (2019) Clinical reasoning in physiotherapy. In: Higgs J., Jensen G.M., Lo˙ us S., Christensen N. (Eds.) Clinical Reasoning in the Health Professions. 4th ed. Elsevier, pp. 247–260. Figure 13.12 Reproduced with permission from Pilat A. (2014) Myofascial induction approach. In: Chaitow L. (Ed.) Fascial Dysfunction: Manual ˜ erapy Approaches. Edinburgh: Handspring Publishing. Figure 14.1 A˙ er Jones M., Edwards I., Jenson G.M. (2019) Clinical reasoning in physiotherapy. In: Higgs J., Jensen G.M., Lo˙ us S., Christensen N. (Eds.) Clinical Reasoning in the Health Professions. 4th ed. Elsevier, pp. 247–260. Figure 15.7 Image 1 is reproduced with permission from Pilat A. Castro-Martín E. (2018) Myofascial induction approaches in temporomandibular disorders. In: Fernández-de-las-Peñas C, Mesa-Jiménez J. (Eds.) Temporomandibular Disorders: Manual ˜ erapy, Exercise, and Needling. Edinburgh: Handspring Publishing.

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PERMISSIONS AND SOURCES continued Figure 15.9 Modiÿ ed with permission from Schleicher W., Feldman M., Rhodes J. (2013) Review of facial nerve anatomy: Trauma to the temporal region. Eplasty 13:ic54. Figure 15.10 Image courtesy of Prof. Dr. Horacio Conesa. Reproduced with permission from Pilat A. (2010) Myofascial induction approaches for patients with headache. In: Fernández-de-las-Peñas C., Arendt-Nielsen L., Gerwin R.D. (Eds.) Tension-Type and Cervicogenic Headache: Pathophysiology, Diagnosis, and Management. Sudbury, MA: Jones and Bartlett Publishers. Figure 15.25 Image courtesy of Prof. Dr. Horacio Conesa. Figure 15.31 Reproduced with permission from Pilat A. Castro-Martín E. (2018) Myofascial induction approaches in temporomandibular disorders. In: Fernández-de-las-Peñas C, Mesa-Jiménez J. (Eds.) Temporomandibular Disorders: Manual ˜ erapy, Exercise, and Needling. Edinburgh: Handspring Publishing. Figure 15.33 Images courtesy of Prof. Dr. Horacio Conesa. Figure 15.34 Images courtesy of Prof. Dr. Horacio Conesa. Figure 15.41 Reproduced with permission from Pilat A. (2010) Myofascial induction approaches for patients with headache. In: Fernández-de-las-Peñas C., ArendtNielsen L., Gerwin R.D. (Eds.) Tension-Type and Cervicogenic Headache: Pathophysiology, Diagnosis, and Management. Sudbury, MA: Jones and Bartlett Publishers. Figure 15.48 Reproduced with permission from Pilat A. (2010) Myofascial induction approaches for patients with headache. In: Fernández-de-las-Peñas C., ArendtNielsen L., Gerwin R.D. (Eds.) Tension-Type and Cervicogenic Headache: Pathophysiology, Diagnosis, and Management. Sudbury, MA: Jones and Bartlett Publishers. Figure 15.52 Photograph by Dr. Nicolás Barbosa. Reprinted with permission. Figure 15.1.6A Reproduced with permission from Pilat A. Castro-Martín E. (2018) Myofascial induction approaches in temporomandibular disorders. In: Fernández-de-las-Peñas C, Mesa-Jiménez J. (Eds.) Temporomandibular Disorders: Manual ˜ erapy, Exercise, and Needling. Edinburgh: Handspring Publishing.

Figure 15.1.14B (middle image) Reproduced with permission from Pilat A. Castro-Martín E. (2018) Myofascial induction approaches in temporomandibular disorders. In: Fernández-de-las-Peñas C, Mesa-Jiménez J. (Eds.) Temporomandibular Disorders: Manual ˜ erapy, Exercise, and Needling. Edinburgh: Handspring Publishing. Procedure 15.1.16 Photograph by Dr. Nicolás Barbosa. Reprinted with permission. Procedure 15.2.2 Image 2 courtesy of Prof. Dr. Horacio Conesa and reproduced with permission from Pilat A. (2010) Myofascial induction approaches for patients with headache. In: Fernández-de-las-Peñas C., ArendtNielsen L., Gerwin R.D. (Eds.) Tension-Type and Cervicogenic Headache: Pathophysiology, Diagnosis, and Management. Sudbury, MA: Jones and Bartlett Publishers. Procedure 15.2.3 Image D is reproduced with permission from Pilat A. (2010) Myofascial induction approaches for patients with headache. In: Fernándezde-las-Peñas C., Arendt-Nielsen L., Gerwin R.D. (Eds.) Tension-Type and Cervicogenic Headache: Pathophysiology, Diagnosis, and Management. Sudbury, MA: Jones and Bartlett Publishers. Procedure 15.2.7 Image 2 is reproduced with permission from Pilat A. (2010) Myofascial induction approaches for patients with headache. In: Fernándezde-las-Peñas C., Arendt-Nielsen L., Gerwin R.D. (Eds.) Tension-Type and Cervicogenic Headache: Pathophysiology, Diagnosis, and Management. Sudbury, MA: Jones and Bartlett Publishers. Procedure 15.2.8 Image 2 is reproduced with permission from Pilat A. (2010) Myofascial induction approaches for patients with headache. In: Fernándezde-las-Peñas C., Arendt-Nielsen L., Gerwin R.D. (Eds.) Tension-Type and Cervicogenic Headache: Pathophysiology, Diagnosis, and Management. Sudbury, MA: Jones and Bartlett Publishers. Table 15.4 Modiÿ ed from Pilat A (2003) Terapias miofasciales: Inducción miofascial. Madrid: McGraw Hill Interamericana de España. Table 15.5 Modiÿ ed from Pilat A (2003) Terapias miofasciales: Inducción miofascial. Madrid: McGraw Hill Interamericana de España. Figure 16.7 Images courtesy of Javier Álvarez González.

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Figure 16.14 Image 1 is reproduced with permission from Pilat A. (2016) Myofascial induction approaches. In: Fernández-de-las-Peñas C., Cleland J., Dommerholt J. (Eds.) Manual ˜ erapy for Musculoskeletal Pain Syndromes: An Evidence- and Clinical-Informed Approach. Elsevier. Figure 17.2 Reproduced with permission from Pilat A. (2017) Fascial anatomy of the limbs. In: Liem T., Tozzi P., Chila A. (Eds.) Fascia in the Osteopathic Field. Edinburgh: Handspring Publishing. Figure 17.7 Image 1 is reproduced with permission from Pilat A. (2017) Fascial anatomy of the limbs. In: Liem T., Tozzi P., Chila A. (Eds.) Fascia in the Osteopathic Field. Edinburgh: Handspring Publishing.

Liem T., Tozzi P., Chila A. (Eds.) Fascia in the Osteopathic Field. Edinburgh: Handspring Publishing. Figure 17.22 Image 2 is reproduced with permission from Pilat A. (2016) Myofascial induction approaches. In: Fernández-de-las-Peñas C., Cleland J., Dommerholt J. (Eds.) Manual ˜ erapy for Musculoskeletal Pain Syndromes: An Evidence- and Clinical-Informed Approach. Elsevier. Figure 17.31 Image 1 is reproduced with permission from Pilat A. (2016) Myofascial induction approaches. In: Fernández-de-las-Peñas C., Cleland J., Dommerholt J. (Eds.) Manual ˜ erapy for Musculoskeletal Pain Syndromes: An Evidence- and Clinical-Informed Approach. Elsevier.

Figure 17.7 Image 3 is reproduced with permission from Pilat A. (2017) Fascial anatomy of the limbs. In:

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INDEX Please note that references to Tables will contain the letter ‘t’ following the page number, and that references to Figures will show the letter ‘f’.

A

Aδ (group III) fibers, 179, 183f Abdollahi, I, 161 abdomen abdominal fascial system, 80f abdominal wall, 227, 440 anterior abdominal wall, 35, 228–9, 230f, 486 adipose tissue, 42, 55f assessment, 221f, 223, 227, 228–9, 230f dissecting, 58 external oblique muscle, 31f fascia, 31f, 58f, 59f, 80f, 126, 223 interconnection of muscles, 80 intra-abdominal structures, 223 lower abdomen, 35 lymphatic system, 233–4 mobility assessment, 221t muscles, 80, 154, 163, 164, 212 palpation, 228 shape, 227 skin incision along midline, 58f surgical scarring, 31f venous network, 38f viscera, 223 viscerofascial dysfunctions, 229t Abu-Hijleh, MF, 39, 40 Achilles tendon, 162 acromioclavicular ligament (ACL), 164 actin, 8, 130 adaptive response and injury, 191 adenosine triphosphate (ATP), 280 adipose tissue, 41, 42, 43t abdominal, 42, 55f brown, 442 cuboid-shaped, 56 deep adipose tissue (DAT), 39 distribution by gender, 45f superficial adipose tissue (SAT), 39 surgical scarring, 58f adolescent idiopathic scoliosis (AIS), 247 Adstrum, S, 10, 15 afferent homeostatic pathway, 182 aging and ECM, 195f Ahn, AC, 275 Ajimsha, MS, 246, 249 alar fascia, 361, 380 Albers, J, 140 AlHamdi, A, 33 Alix, ME, 367 allodynia, 175 allostasis and fascial system, 181–2, 191 allostatic loading, 191, 202 American Physical Therapy Association (APTA), 6 anabolic response, 134 Anderson, GC, 343 angiogenesis, 197

angiosomes, 69, 70f ankle, 67f dorsiflexion, 166, 216t homophylic arthropathy, 251 Myofascial Induction Therapy (MIT), 251 passive stiffness of joint, 159 positional changes, 162 retinacula structure, 92f rigidity of aponeurosis, 159 rotations of, 161 see also leg anomalous stress, 202 anorectal disorders, 231 ansa cervicalis, 310 antebrachial fascia, 90, 92f, 498–9, 500f anterior abdominal wall, 35, 228–9, 230f anterior cingulate cortex (ACC), 182, 184 anterior elbow retinaculum (lacertus fibrosus), 497–8 anterior pectoral wall, fascial layers, 436f anterior thoracic wall, 430–41 breast, 432–3 clavipectoral fascia, 435–7 clavipectoral triangle, 437, 438f, 439 deep fascia, 434–41 diaphragm, 440–1 inframammary fold, 433–4 innervation, 429 intercostal fascia, 439–40 intercostal muscles, 440 pectoralis fascia, 434–5 superficial fascia, 430–4 see also thorax complex anterolateral cervical area fascial anatomy, 415f myofascial induction of the deep neck flexors, 417f of the scalenes, 418f of the sternocleidomastoid, 416f anterolateral ligament, 164 anteroposterior axis (A–P), embryology, 103 antidromic fibers, 179 aponeurosis ankle, 159 aponeurotic envelope of pterygoid muscles in pterygoid fossa, 335 bicipital, 87f epicranial, 328 orbicularis oculi, 335 palmar, 501, 502 of tibialis anterior muscle, 159 see also aponeurotic fascia; myoaponeurotic junction; superficial musculoaponeurotic system (SMAS) aponeurotic fascia deep fascia, 78, 79f, 80–1, 82f force transmission, 80 at front and back of body, 79f pectoral area, 82f apoptosis, 200, 202 aquaporins, 136, 379

arachnoid mater, 179, 397 see also dura mater; meninges; pia mater arcade of Frohse, 506–7 arcuate ligament of Osborne, 506 areolar connective tissue, 131 Arguisuelas, MD, 247, 248 arm assessment, 532f biceps brachii cross hands procedure applied to, 535f transverse stroke applied to, 533f cross-section, 96f, 483f deep fascia, 477f, 496f fascial compartments, 477, 478, 482t, 483f intermuscular septa, 495, 497f lateral aspect, 82f nonspecific pain, 503–4 right lateral view, 311f structures, 475f, 476f, 477f, 494–9 superficial fascia, 121f, 477f with fat lobules, 116, 121f superficial vascular and nervous structures, 479f transverse stroke applied to biceps brachii, 533f applied to triceps brachii, 536f triceps brachii longitudinal stroke applied to, 537f transverse stroke applied to, 536f see also elbow; forearm; upper limb arm compartment syndrome, 482t Arroyo-Morales, M, 252 arterial vascularization, 69–70, 85f assessment of dysfunctions abuse, 211 algorithm, 209f arm, 532f carpal tunnel syndrome, 521f cervical complex, 414f clinical reasoning process, 208–9 disuse, 211 dynamic stability, 212–13, 216–17t functional scales, 210 global, 208–35 global functional assessment, 211–18 hand structures, 515f history taking, 209–11 lymphatic and superficial circulatory components, 232–5 misuse, 211 mobility, 207, 217–18 myofascial dysfunction syndrome, 210–11 neural see neural tests overuse, 211 palpatory tests, 235–7 process of, 207–40, 293–4, 296–322 purpose, 208 rating criteria, 207–8 specific functional tests, 235, 236f stability see stability assessment stage of disease, 211 static stability, 212–13, 214t

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INDEX continued assessment of dysfunctions (Continued) thorax complex, 459f upper extremity, 526f upper quadrant see upper quadrant visceral see visceral tests see also lymphatic system Astorga-Verdugo, S, 251–2 astrocytes and diffusion of brain fluids, 136 and fibroblasts, 133–4 forming a border, 180 myodural bridges and CSF, 379 Ates¸, F, 161 Athenstaedt, H, 275 atlantoaxial ligaments, 397 atrophic scar (AS), 201 autocrine communication, 130 autonomic nervous system (ANS) group III and IV muscle afferents, 9 vascularization of the fascial system, 177 autonomy, 208 axillary fossa, 44f, 475f axillary nerve entrapment, 505 axonopathy, 171 axons, 109, 110

B

back cross hands induction, 463f deep fascia, 353f, 445f, 446f dissections, 443f fascia of, 449f intrinsic muscles of, 454f left lateral aspect, 445, 449f left side, deep and superficial fascia, 446f low back pain (LBP), 223, 247–8 superficial fascia, 353f, 446f Balasuburamaniam, A, 499 Barnes, JF, 10 Baron, R, 176 barycenter, 139 Bassett, CA, 276 Bates, DK, 367 Becker, RO, 276 Benias, PC, 135 Benjamin, M, 498–9 Bernabei, M, 82 Betz, T, 109 Beyer, C, 70 biceps brachii cross hands procedure applied to, 535f transverse stroke applied to, 533f bicipital aponeurosis, 87f bicipital groove, myofascial induction, 534f biology biological entities, 22 biological systems, 22–3 mechanobiology and embryogenesis, 103–5 mechanobiology of nervous system, 111–12 and physics, 115

systemic procedures, sustained, 275 tensegrity, 144–8 biomechanics biomechanical body, 5 biomechanical carcinogenic properties, 135 forward head posture and slumping, 367–8 lymphatic nodes, 234 upper quadrant, 295 biomedical model, 4 biopsychosocial model, 4–5, 367 biotensegrity, 144–8, 280, 328 biting force, 335 blastocyst and trilaminar embryonic disc, 105, 106f blood supply breast, 434 neurovascular and lymphatic structures, 473–4 thorax complex, 428f, 429 blood–nerve barrier, 171, 180 Bobath therapy, 251 Bodenham, AR, 63 body autoperception phenomena, 184 body awareness, 190 body image, 6 body movement see movement, body body schema, 6 Bogduk, N, 367 bones, collagen–apatite connections, 275 Borzelli, D, 469 bowel disorders, 231 brachial fascia, 487f, 494–5, 496f, 497, 497f biceps brachii, 495, 533f, 535f septa extending from, 495 brachial plexus, 310–11, 312f C5–C6 nerve roots, 504 cords, 311 distribution, 310f brain brain–fascia connection, 202 brain–skin connection, 202 central sensitization and pain, 176 damage to, 251 diffusion of fluids, 136 dura mater as mediator with skull, 109, 327 folding of, 110–11 hippocampus, 182 integration with neurocranium, 109 Sylvian fissure, 182 brainstem, homeostatic region, 182 breast blood supply, 434 fascial network, 432–3 innervation, 434 lymphatics, 434 normal mammogram result (X-ray), 49f see also thorax complex breathing structures, 427 myofascial induction longitudinal stroke, 465f transverse plane procedure, 466f Briggs, CA, 498 Brodie, A, 336

brown adipose tissue, 442 buccinator muscle, 334 Buckminster Fuller, R, 140, 142, 143, 147 Synergetics, 141 buckyballs (molecules), 143 Burkhardt, RW, 142 burns, craniofacial, 341 Butler, DS, 5 Byard, RW, 32

C

C (group IV) fibers, 9, 183f cadherins, 123 Cajal–Retzius cells, in the ECM, 112 Calder, A, 140 Campbell, EJ, 429 Camper’s fascia, 35 cancer assessment of upper quadrant, 321 growth factors in, 135 progression of, and ECM, 135 trauma to fascial system, 194f treatment for survivors, 250–1 canonic tensegrity, 142, 149 Cantu, RI, 10 Carbone, FR, 199 cardiac dysfunction, scientific evidence for MIT, 251 Carmichael, S, 32–3 carotid sheath (prevertebral space), 380 carpal ligaments, 156f carpal tunnel anatomy of, 522f assessment of carpal tunnel syndrome, 521f carpal tunnel syndrome, 502, 505–6 sustained procedure applied to, 524f telescopic procedure applied to, 525f transverse stroke applied to, 523f Cartwright, N, 245 Carvalhais, VO, 80, 162 Carver, W, 191 Castro-Martín, R, 250–1 Castro-Sánchez, AM, 250 catabolic enzymes, 134 catastrophizing, 191 Cathcart, E, 252 cause and effect, 467 cell differentiation, 191 cell migration, 191 cell proliferation, 197 cell therapy, 108 cellular biotensegrity, 144–7 cellular communication gap communication, 132 gap junctions and collagen synthesis, 132–3 interstitial, 132 mechanochemical, 144 mechanochemical coupling of myofibroblasts, 132 standard and functional, of fibroblasts, 131–2 telocytes, 132 types, 129–31

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cellular focal points, 108 cellulite, 47f central nervous system (CNS), 5, 10, 21, 23, 30, 108, 231, 261 development, 110 dynamic stability assessment, 301 fascial structures in, 286–7 glial cells, 134 motor control, 153, 213, 216t, 217t muscle synergies, usefulness, 469 neurodynamics of fascia, 177, 179, 202 neuromeningeal procedures, 286–7 and occlusal disorder, 337 pain, 174, 175, 176 perimysium and neuromuscular spindles, 472 self-optimization, 215 tensegrity concept, 148, 150 upper extremity, 469, 473 vascularization of the fascial system, 177 see also peripheral nervous system (PNS) central sensitization “brain-centerd” vision versus “extremely cognitivist” focused analysis, 176 epistemological perspective, 176–7 and interoception, 184–5 nervous irritation, 504 neuroethical warning signs, 177 and pain, 175–7 centripetal microdeformation, 203 cephalic protrusion, 337 see also forward head posture and slumping cerebral palsy, 160, 161 cerebrospinal fluid (CSF), flow of, 366, 367, 379–80 cervical complex anterior aspect of cervical area, 91f anterolateral cervical area fascial anatomy, 415f myofascial induction of the deep neck flexors, 417f myofascial induction of the scalenes, 418f myofascial induction of the sternocleidomastoid, 416f assessment, 414f fascial anatomy of the anterolateral cervical area, 415f hyoid region, myofascial relationships, 420f longitudinal stroke applied to the external mouth floor, 421f applied to the posterior cervical complex, 426f myofascial induction of the craniocervical area, 419f of the deep neck flexors, 417f of the omohyoid, 423f of the scalenes, 418f of the sternocleidomastoid, 416f posterior longitudinal stroke applied to, 426f transverse stroke applied to, 425f suprahyoid, infrahyoid, and transverse plane hyoid induction, 424f transverse stroke, applied to the posterior cervical complex, 425f

cervical extension, 336–7 cervical fascia/cervical fascial spaces, 335, 380 cervical flexion posture, 336 cervical pain, 343 cervical plexus, 307, 310 cervical spine, 343 cervicopectoral and arm regions, 116, 121f Chaitow, L, 11 Chamorro Comesaña, A, 203, 250 Charpy, A, 354 chemistry mechanochemical reaction, 280 myofibroblasts, mechanochemical coupling, 132 organic, tensegrity in, 143 chemoattractants and axons, 109 concentration gradients of, 103 stiffness of ECM, modifying, 105 chemokines, 196 chemotaxis, 103, 105 Chen, YH, 248 chest changes in movement, 428 cross hands induction, 464f deep fascia, 433 deformity, 429 dynamic behavior, 429 rigidity, 429 see also chest wall chest wall anterior, 320, 433 decreased flexibility, 429 inframammary fold, 433–4 posterior, 320 childhood functional GI disorders, 231, 232 Choi, HW, 164 chronic fatigue syndrome, scientific evidence for MIT, 249–50 chronic low back pain (CLBP), 184, 247 chronic obstructive pulmonary disease (COPD), 429, 450 chronic pelvic pain syndrome (CPPS), 249 chronic venous insufficiency (CVI), 65 Chu, D, 379 Çil, ET, 249 circulatory system, and superficial fascia, 60–70 arterial vascularization, 69–70, 85f blood vessels, 60 circulatory deficiencies, 70–2 functionality of the venous and lymphatic systems, 60–1 lymphatic system, 61–3, 322 lower quadrant, 234 upper quadrant, 320–1 venous system, 63–8 clavipectoral fascia, 435–7, 439 myofascial induction, 548f, 549f clavipectoral triangle, 437, 438f, 439 cleavage lines see Langer’s lines

cleft lip, 341 Clinical Breast Examination, 321 clinical reasoning process assessment, 208–9, 293–4 flowchart, 210f, 294f metacognition, 293 organic autonomy, 208 physical autonomy, 208 sensory autonomy, 208 CNS see central nervous system (CNS) Coffey, JC, 287, 289 cognition “brain-centerd” vision versus “extremely cognitivist” focused analysis, 176 as embodied action, 6 enactive approach to, 5–6 interoceptive information, 182 metacognition, 293 social, 182 upper quadrant, cognitive aspects, 295–6 collagen, 125–6 collagenous network, 8 cross-linking, 126 degradation, 135 excess production, 127 fibers, 125, 126 fibrils, 125, 126–7 filaments, 145 gap junctions and collagen synthesis, 132–3 intersutural permeability, 109 mechanical induction of remodeling, 135 remodeling, 134, 135, 198 reticulin (type III collagen), 126–7 rigidity, 275 transcription of procollagen, 126 triple helix, 126f triple-helical glycoprotein, 125 types, 125–6, 127, 131, 200–1 collagen–apatite connections, 275 collagenase, 131 collagenous features ligaments, 165 collective remodeling, 132 Colles’ fascia, 35 Colloca, CJ, 165 compartment syndrome, 478, 482t complex regional pain syndrome (CRPS), 184 compression neuropathy, 504 compression therapy, 202 compression-based structures, 139–40 floating compression, 142 computed tomography (CT), 164, 223 conceptual analysis and terminology, 3–6, 7 biomedical model, 4 biopsychosocial model, 4–5 body perception and movement, 6 enactive approach, 5–6 fascia as a system, 7, 16 functional definition of fascia, 15–16 morphological definition of fascia, 15 standard terms, 28 superficial fascia, 35

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INDEX continued connective tissue (CT) areolar, 131 classification, 116, 117f components submerged within the ECM, 122 composition, 116, 118t craniofacial fascial system, 328 dense, 125, 328 embryology, 108 intramuscular, 159 loose areolar, 328 purposes and functions, 119t types, 116, 120f, 121f, 122f connexin, 43, 131 continuity, fascial continuity, 218 lower quadrant, 37f myofascial architecture, 155, 156f neck, 347–8 throughout the body, 27–8 upper extremity, 468f, 473–6 upper quadrant, 37f visceral fascia, 218, 223 Cooper, AP, 432 Cooper’s (suspensory) ligaments, 35, 45, 320, 321f, 433 coracoclavicular ligament, 487 coronary artery bypass grafting, 251 covalent bonding, 123 cranial fascia, 329 cranial vault, 397 craniocervical area continuity of the meninges with unit, 397 mandibular system, 359–60 myofascial induction, 419f craniofacial burns, 341 craniofacial region, 327–426 assessment of complex, 395f biomechanical models, 336 cervical fascia, 335 cervical fascial spaces, 380 cervical spine, 343 chewing muscles, fascial relations, 335, 336f, 337f clinical implications, 340–1 complexity, 327 cranial fascial distribution, 328, 331f cranial vault, meninges, and nervous system, 397 craniocervical structures, 347–83 craniofacial and cervical innervation, 340 craniomandibular and cervical myofascial structures, 336–8, 339f, 340 dense connective tissue, 328 dynamic connections of complex, 327 epicranial aponeurosis, 328 fascial “cap,” 328–9 fascial compartments of the maxillofacial and interior regions of the neck, 335 fascial relations of the buccinator muscle, pharynx, and skull, 334 fascial system, 328–9, 331f main features, 331–6 forward head posture and slumping, 367–80

loose areolar connective tissue, 328 masseteric fascia, 332–3 myodural connections, clinical relevance, 365–7 myofascia of the occipitofrontalis, 334–5 myofascial induction external pterygoid muscle, 405f hard palate, 407f internal pterygoid muscle, 406f masseter, 403f ocular area, 398f scalp, 400f suboccipital triangle, 412f temporal area, 402f vomer, 408f zygomatic area, 399f neural exit foramina, 346 occipitofrontalis muscles, myofascia, 334–5 orbicularis oculi, aponeurosis, 335 orofacial pain (OP), 342–3, 344–5t otalgia, 343, 346f platysma, 333–4 postisometric induction, 410f skull structures, views of, 396f stylomandibular ligament, 335, 337f suboccipital region, 361–4, 365f superficial musculoaponeurotic system, 331–2 system, 330f temporal area myofascial induction of, 402f transverse stroke applied to, 401f temporomandibular disorder (TMD), 341–2 temporomandibular induction, 409f temporoparietal fascia, 333f, 334f temporoparietal fascia (temporal surface layer), 332 trigeminocervical complex, 340, 341f wound healing processes, 341 craniomandibular muscles, 338 cross hands procedure applied to biceps brachii, 535f applied to forearm, 530f applied to triceps brachii, 538f induction, 283, 284f back, 463f chest, 464f cruciform ligament, 397 Cruz-Montecinos, C, 162 CSF see cerebrospinal fluid (CSF) CT see computed tomography (CT) cubital fossa left upper limb, 87f myofascial induction of, 531f upper extremity, 497–9 vascular system in, 496f cubital lymph nodes, 474 cubital nerve, 163f Cuesta-Barriuso, R, 251 Cullen, DK, 134 Curl, RF, 143 cutaneous ligament, 329 cytokines, 123, 158, 159, 181 fascial trauma and dysfunction, 196, 198, 199

proinflammatory, 199 see also inflammation cytoskeleton see intracellular matrix

D

Damadian, RV, 379 d’Avella, A, 469 de Bruin, M, 160–1 de Lange, F, 181–2 deep adipose tissue (DAT), 39, 433 deep fascia anterior thoracic wall, 434–41 aponeurotic, 78, 79f, 80–1, 82f arrangement throughout the body, 74f back, 353f, 446f behavior of the deep fascial system, 73, 75 chest, 433 deep layer (DL), 434, 487–94 distribution, 76f endomysium, 84 epimysial, 82–3, 83f, 84, 86f fascial anatomy of neck, 349f gluteal, 434 key features, 71 links with superficial fascia, 48, 49f, 50, 51f, 52f, 53t, 55f, 57f, 58, 59f, 60f in lower limb, 74f middle layer, 434 morphology, 71–2, 73f, 74f, 75f myofascia, 76, 77f neck, 349f, 354–61 deep lamina, 355, 361 middle lamina, 349, 355, 357–60 superficial lamina, 349, 355–7, 356f neurofascia, 76 perimysium, 84 purposes and functions, 72, 75t superficial layer, 434, 486, 487f supraspinatus fascia, 488–9, 545f as a system, 71–96 terminology and classification, 75–85 unembalmed cadavers, dissection of, 85–96 upper extremity, 474, 480f, 481f, 482t, 484t visceral fascia, 76 see also endomysium; epimysium; perimysium degranulation, 202 degrees of freedom, 467 Delage, JP, 165 deltoid fascia, 487 deltopectoral area, upper extremity, 475, 477, 482f deltotrapezial fascia (DTF), 164 deltotrapezoid fascia, 475 dental discharge splints, 337 deRugy, A, 469 Descartes, R, 16 diaphragm, 440–1 differentiation, cellular, 101 discomalleolar ligament, 343, 346f dissection using unembalmed cadavers see unembalmed cadavers, dissection of

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dissections, 1, 2, 9, 11 abdominal, 58 anatomical and functional aspects, 27, 39, 50, 58 of breast, 432 breast, 433 “clean,” 156f of elbow, 498 embalmed cadavers see embalmed cadavers, dissection of experience with dissection of unembalmed cadavers, 40–8, 85–96, 348 female cadavers, 433 male cadavers, 433 of neck, 352f, 353f temporomandibular joint (TMJ), 328 of temporomandibular joint (TMJ), 330f temporomandibular joint (TMJ), 330f of tertiary perimysium, 180 of thoracic complex, 443f unembalmed cadavers see unembalmed cadavers, dissection of of wrist, 501f DNA double helix, 7, 124, 189 Domaszewska, K, 250 Dorko, BL, 286 Dorland’s Illustrated Medical Dictionary, 78 dorsal thoracic fascial system, 441–54 deep layer (DL), 451, 453f, 454, 454f middle layer, 447–8, 450–1, 451f, 452f, 453f superficial layer, 443, 445, 446, 449f dorsal–ventral (D–V) axis, embryology, 103 dualism, Cartesian reasoning, 4, 5, 8 Dupuytren’s disease, 502 dura mater cervical spine, 365, 366, 367 continuity and transition of nervous system, 179 induction technique, 287 mediator between brain and skull, 109, 327 myodural connections, 365 neural exit foramina, 346 posterior aspect, 366 spinal flexion movement, 165 structure, 397 suboccipital region, 361 temporomandibular disorder (TMD), 342 tension, 367, 371t, 379 venous sinuses, 328 see also arachnoid mater; meninges; pia mater durotaxis migration process, 105, 129 dynamic stability assessment, 213, 215, 216–17t, 301, 302–3t dysfunction see trauma and dysfunction, fascial dyskinesia, 450, 451

E

EBM/EBP see evidence-based medicine (EBM)/ evidence-based practice (EBP) ECM see extracellular matrix (ECM) ecological theory, 215 ectoderm, 102, 105

ectomeninx, mesenchyme, 109 edema, 47f Ekman, M, 181–2 elasticity, 45, 159f, 273t connective tissue (CT), 159 increased, 252 loss of, 201 nerve, 181 original, 150 psoas muscle, 236f and tensegrity, 149, 150 Young’s modulus (modulus of elasticity), 124, 125 see also viscoelasticity, changes in elastin, 124–5 elastography, 161 elastosis, 30, 32, 32f elbow anterior elbow retinaculum (lacertus fibrosus), 497–8 anteromedial area, 497, 498f cross-section, 496f histological aspects, 116, 121f longitudinal, 497 morphology of the superficial fascia, 38f posterior elbow retinaculum, 498, 499f see also arm; hand electrolyte and acid-base balance, 123 electromyography (EMG), 162, 504 electron microscopy research, 131 electronic microscopes, 115 electrophysiological studies, 178 Elliott, BG, 498 embalmed cadavers, dissection of, 1, 7, 27 anatomical studies, 467 breast, 433 neck, 350f superficial fascia, 39 upper extremities, 467 see also dissections; unembalmed cadavers, dissection of embryology, 101–14 anteroposterior axis (A–P), 103 blastocyst and trilaminar embryonic disc, 105, 106f cell migration, 103, 104f cellular differentiation, 101 cellular migration, 104–5 cellular reorganization, 101–2 chemotaxis, 103, 105 concentration gradients of chemoattractants, 103 dorsal–ventral (D–V) axis, 103 durotaxis migration process, 105 ECM-mediated contact guidance, 104–5 ectoderm, 102, 105 embryonic induction, 102 embryonic polarization, 103, 105f endoderm, 102, 105 fascial tissue, embryological development, 107–8 fertilization of ovum, 101 formation of embryo, 103

glial cells and neurodevelopment, 111–12 gyrification (folding of brain), 110–11 integration of the neurocranium and brain, 109 intersutural permeability, 109 mechanical control of nervous system development, 109–11 mechanobiology and embryogenesis, 103–5 mesoderm, 102, 105, 107 morphogenesis, 104, 108 morphogenetic control, 103 neurodevelopment, 103, 111–12 ontology tree, 106f organogenesis and ECM, 105, 107 pattern of expression, 103 process of, 102f relevance of ECM in mature and developing nervous system, 111 responding tissue, 102 soluble morphogens, 103–4 Emmerich, D-G/Emmerich structure, 140–1 emotions, and interceptors, 182–4 empiricism, 244 enactive approach, 5–6 endocrine communication, 130 endoderm, 102, 105 endomeninx, mesenchyme, 109 endomysia, 151f, 157, 159 endomysium, 8, 134, 155, 157, 165 deep fascia, 75t, 76, 82, 84 endomysium–endotendon pathway, 159 endomysium–endotendon pathway, 159 endoneurium, 171 endotendon, 155f, 156f, 157 endomysium–endotendon pathway, 159 energy medicine, 276 Engel, GL, 4–5 entrapment neuropathies axillary nerve entrapment, 505 carpal tunnel syndrome, 505–6 long thoracic nerve entrapment, 505 median nerve entrapment, 312, 313t, 505–6 posterior interosseous nerve syndromes, 506–7 pronator teres syndrome, 505 radial nerve entrapment, 312, 313t radial tunnel syndrome, 506–7 suprascapular nerve entrapment, 504–5 ulnar nerve entrapment, 314t, 506 see also nerve entrapment syndrome entropy 148 negative, 20 system, 19–20 environment and clothing, 262–3 epicranial aponeurosis, 328 epicritic sensitivity, 178 epimuscular force transmission epimysial transmission paths, 160 extramuscular pathway, 162–3 intermuscular pathway, 160–2 stabilization, 163–5 epimysial fascia/epimysium, 80, 82–3, 83f, 84, 86f epimysial transmission paths, 160

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INDEX continued epimysium, 8, 155, 165 deep fascia, 75t, 76, 82, 84 epineurium, 166, 173, 180 equilibrium, 21, 150 ergonomics, 263 esophageal disorders, 231 evidence-based medicine (EBM)/evidence-based practice (EBP) criticisms, 245–6 distancing from basic sciences, 246 empiricism, 244 hermeneutics, 244 phenomenology, 244 philosophical basis of, 244–5 within a philosophy of science framework, 244–7 previous beliefs, whether existence of, 244 upper quadrant, 294 excitatory synaptic transmissions, 181 extensor carpi radialis brevis, 498 extensor carpi radialis longus, 498 external pterygoid muscle, myofascial induction, 405f exteroception, 150 extracellular matrix (ECM), 122–3 aging, 195f application of mechanical forces, 192f, 193f biomechanical carcinogenic properties, 135 Cajal–Retzius cells, 112 cancer progression, 135 cellular migration and mechanical guidance, 104–5 collagenous network, 8 components of connective tissue in, 122 connection with muscle fibers, 155 connective tissue, 122f contemporary body movement analysis, 115 and craniofacial region, 327 ECM-mediated contact guidance, 104–5 fascial system and immunomodulation, 198 fibrils, 105 functions, 7–8 glycosaminoglycans, 123 hyaluronan (HA), 123, 197 information transmission through, 274f interaction with cytoskeleton, 145 intercommunication, 116, 122–3 macromolecules, 122, 123 mechanical and biochemical behavior, 8, 102 and mechanobiology of the nervous system, 111–12 mechanotransduction and scarring process, 202 and mesenchyme, 108 normal structure and function, 195f and organogenesis, 105, 107 proteoglycans, 123, 127 relevance of in the mature and developing nervous system, 111 remodeling, 107, 123, 127, 128–9, 134, 135, 199, 280 resistance/reciprocal resistance, 192f, 193f rigidity, 7, 105, 111, 135, 145, 150 and scarring, 200 senescent, 199 significance, 136 stiffness, 105, 199

and tensional homeostasis, 128–9 and wound healing, 201 wounded/fibrotic, 195f see also connective tissue (CT); intracellular matrix; intranuclear matrix extramuscular pathway, 162–3

F

face anterior-lateral area and SMAS, 331 eyebrows, raising, 335 facial fascia, 329 muscles of facial expression, 338 “retention system” for, 329 right anterolateral aspect, 357f, 361f see also craniofacial region facial nerve, 354, 360 facial rejuvenation, 332 falx cerebri, 109 Fan, C, 164 Farina, S, 6 fascia composition, 116 concepts and definitions, 3–6, 7 biomedical model, 4 biopsychosocial model, 4–5 body perception and movement, 6 enactive approach, 5–6 fascia as a system, 7, 16 functional, 15–16 morphological, 15 and movement, 153 see also conceptual analysis and terminology “destabilized,” 196 fascial system as an architectural continuum, 261 immunomodulation and fascial system, 198–9 matrices see extracellular matrix (ECM); intracellular matrix; intranuclear matrix as a mechanosensitive structure, 9 metabolic aspects of fascial system, 6–7 negative adaptability of system, 191 neurodynamics see neurodynamics of fascia nomenclature, 27–8 plasticity, 108 as a system see systems systemic approach to therapeutic movement and health care, 6 as a tensegrity system, 149–50 terminology, 35 and therapeutic movement, 7–10 thoracolumbar see thoracolumbar fascia (TLF) vascularization of the fascial system, 177–9 viability (positive adaptability) of system, 191 see also deep fascia; fascial architecture; fascial network; histological aspects of the fascial system; superficial fascia; tensegrity fascia musculorum, 28 see also myofascia Fascia Nomenclature Committee, 15 fascia superficialis, 28

fascia visceralis, 28 see also visceral fascia fascial architecture, 2–3 fascial network, 1, 2f continuous, 7–9 mechanical properties of, 8–9 see also thoracolumbar fascia (TLF) fascial sheaths, 171 fascial tendinous transmission, 159 fascial unwinding, 284–6, 287t, 288f fatty tissue, 6 FCAT see Federative Committee on Anatomical Terminology (FCAT) fear-avoidance beliefs questionnaire (FABQ), 247 Federative Committee on Anatomical Terminology (FCAT), 15, 27 Fernández-de-las-Peñas C, 379, 506 Fernández-Lao, C, 251 Fernández-Pérez, AM, 252 Ferreira, LA, 332 Ferreira, LM, 39 ferromagnetism, 275 fibers (muscular microstructure), 124–7 Aδ (group III) fibers, 179, 183f C (group IV) fibers, 9, 179, 183f longitudinal, 501 matrices, 124–7 microvacuolar, 147 oblique, 497 orthodromic, 178 palmar aponeurosis, 501, 502 platysma, 354 sensory, 178 sympathetic, 178 transverse, 501 fibrillin, 130 fibroblasts and astrocytes, 133–4 body movement, 127–8 and collagen, 126 contracture and retraction, 129 and embryonic mesenchymal stem cells, 108 endoneurium, 181 in intrinsic fascial compartment, 197 perineurium, 171–2 remodeling, and changes in tissue viscoelasticity, 128 structural and functional communication, 131–2 tenocytes (tendon fibroblasts), 132, 133, 196 tensional homeostasis and remodeling, 128–9 and three matrices, 116 extracellular matrix (ECM), 8 in vivo and ex vivo studies, 128 fibromyalgia, scientific evidence for MIT, 249–50 fibronectin, 129 fibrosis circulatory deficiencies, 70 excess collagen production, 127–8 versus remodeling, 196–7 and trauma, 191 filopodia, 109 Findley, T, 471

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Finni, T, 162 Firth, J, 296 Fitzcharles, MA, 175 flexion reflex, 165 flexor carpi ulnaris muscle, 160 flexor digitorum superficialis, 505 focal adhesion, 145 foot dorsal aspect, 92f posterolateral aspect, 60f force transmission aponeurotic fascia, 80 conceptual confusion, 154 deep fascia, 86, 88, 89f, 90f, 91f epimuscular, 160–5 gliding, 165–6 intramuscular, 157–60 lateral, 499 and movement, 153–69 myofascial, 471 in the myofascial unit, 154–6, 157f neurovascular tract and lateral transmission of forces, 180 routes, 156 scapular dyskinesis, 471 transmission of lateral force in the skeletal muscles, 158 forearm cross hands procedure applied to, 530f cross-section, 486f cubital fossa, myofascial induction of, 531f deep fascia, 496f dorsal aspect, 116, 122f, 502f extensors, longitudinal stroke applied to, 529f fascial compartments, 478, 484–5t, 484f, 485–6, 485f, 486f fascial continuity in transverse section, 29f flexors longitudinal stroke applied to, 528f transverse stroke applied to, 527f longitudinal stroke applied to extensors, 529f applied to flexors, 528f structures, 475f, 476f, 477f, 494–9 superficial fascial system (SFS), 50f superficial vascular and nervous structures, 479f transverse stroke applied to flexors, 527f ultrasound imaging, 163f ventral aspect, 84f, 91f, 157f, 161f, 162f, 172f, 500f of distal third, 522f left forearm, 92f forward head posture and slumping, 338, 359, 367–80 biomechanical analysis, 367–8 chronology of development, 368, 370–8t mechanoreception and proprioception of the suboccipital fascial system, 379 myodural bridges and behavior of cerebrospinal fluid, 379–80 radiological findings, 368–9t sequence of dysfunction/chronology of development, 368, 370–8t

Franze, K, 109 free radicals, 196 Frère, J, 469 friction reduction, 96 frontalis muscle, 329 frozen cadavers, 433 see also embalmed cadavers, dissection of Frymann, VM, 285 functional tests, 235, 236f

G

Galán del Río, F, 250 galea aponeurotica see epicranial aponeurosis gallbladder and sphincter of Oddi (SO), disorders of, 231 gap junctions and collagen synthesis, 132–3 sustained systemic procedures, 280 Gardetto, A, 39 gastrocnemius muscles, 161, 162 gastroduodenal disorders, 231 gastroesophageal reflux disease (GERD), scientific evidence for MIT, 251 gastrointestinal dysfunctions (Rome IV) criteria, 229, 230f anorectal, 231 bowel disorders, 231 centrally mediated disorders of gastrointestinal pain, 231 childhood functional, 231, 232 esophageal disorders, 231 gallbladder and sphincter of Oddi (SO), 231 gastroduodenal disorders, 231 gastrulation, 105 Gauns, SV, 247–8 gene expression, 126, 133–4 General System Theory, 4, 5 definition and characteristics of a system, 16 synergy, upper extremities, 467, 469–73 geodesic structures, 140, 142, 147 Gilbert, KK, 166 Giuriati, W, 472 glial cells, 111–12, 180 astrocytes, 134 and neurons, 112 physiopathology of nerve and glial response, 180–1 gliding adaptation and facilitation, 165–6 MIT longitudinal technique, 251 global pectoral induction, 551f glossopharyngeal nerve, 360 glutamate neurotransmitter, 181 gluteal area superficial fascia, 51f surface blood vessels in, 69f gluteus maximus muscle, 158f, 162 glycoproteins, multifunctional, 123 glycosaminoglycans, 123, 135 glymphatic system, 379 Godbout, C, 132

Goebal, A, 204 Goldsmith, EC, 191 Golgi tendon organs, 472 Golgi–Mazzoni corpuscles, 472 Gómez-Jáuregui, V, 142 Gracovetsky, S, 148 Gray, G, 276 Gray’s Anatomy, 27, 450 great auricular nerve, 310 great saphenous vein, 66 longitudinal view, 68f transverse view, 68f The Great Soviet Encyclopedia, 75–6 Grinnell, F, 128–9 Grodin, AJ, 10 Grodinsky, M, 354 Grodzinsky, AJ, 275 ground substance matrix composition, 134 metalloproteinases (MMPs), 134–5 group III muscle afferents, 9 group IV muscle afferents, 9 growth factors, 107, 123, 127 in cancer, 135 nerve growth factor (NGF), 202 platelet-derived growth factor (PDGF), 200 regulation, 136 transforming growth factor beta (TGF° ), 133, 134, 200 transforming growth factor beta 1 (TGF° 1), 128, 158, 280 Guimberteau, J-C, 127, 147, 165 Gurudut, PV, 247–8 Guyon’s canal, 506 gyrification (folding of brain), 110–11

H

Hagberg, M, 503 Hamed, K, 30 Hameroff, SR, 8 hand dorsal fascia, 502 fingers, telescopic induction applied to, 517f induction cross hands see cross hands procedure myofascial, 516f, 518f telescopic, 517f intermetacarpal space, myofascial induction of, 518f isometric forces of muscles, 469 palmar area, 57f, 87f, 499, 516f, 522f skin and superficial fascial connections, 478f structures, 499, 501–2, 515f thumb longitudinal stroke applied to, 520f pain and paresthesia, 506 pronator teres syndrome, 505 synovial sheaths, 519f see also arm; elbow; wrist hard palate, myofascial induction, 407f Hartman, K, 5

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INDEX continued Haskins, R, 293, 294 head, 45, 63 complex mobility, 328 sagittal section, 411f see also forward headache, 342 cervicogenic, 367, 379 episodic, 379 tension-type, 359, 379 head–neck complex, basic postures, 367, 368–9t health care, systemic approach to, 6 Helme, RD, 504 hematopoietic stem cells, 108 hemodynamics, 441 hemophilic arthropathy, ankle, 251 Henley, CE, 252 Heredia-Rizo, AM, 252 Herlin, C, 39 hermeneutics, 244 Hernando, A, 251 Herranz, P, 200 Hester, P, 505 heterocellular contacts, 132 Hicks, M, 250 hierarchical theory (top-down organization), 213, 215 Hinrichs, RN, 165 hippocampus, 182 histological aspects of the fascial system, 115–38 and biology, 115 plasticity, 116 see also connective tissue (CT); extracellular matrix (ECM); matrices history taking, 209–11 upper quadrant, 296–7 Ho, M-W, 8, 276, 277 Hoheisel, U, 134, 472 Holyoke, E, 354 homeostasis afferent homeostatic pathway, 182 characteristics of a system, 21 interoception and afferent homeostatic pathway, 182 and nerve fibers, 179 tensional, 128–9, 192f traditional principle, 181 homocellular contacts, 132 “hourglass biceps,” 534f Howell, JB, 429 Howick, J, 245 Hu, J, 178 Hug, F, 469 Huijing, PA, 156, 158, 160, 162, 471 Huxley, AF, 8, 154 hyaluronan (HA), 123, 134 hyaluronic acid (HA), 197 hydraulic amplification, 165 hyoid region, 359, 420f hyoid bone, 338, 339f, 358 hyperalgesia, 175 hyperlordosis, 337

hypertrophic scar (HS), 201, 202 hypodermis, 39 see also superficial fascia hypoglossas nerve, 360 hypoxia, 70

I

ideomotor movement, 286 immunodermatosis, 202 immunogenicity, 197 immunoglobulins, 123 immunohistochemical studies, 178 immunomodulation, and fascial system, 198–9 immunoscenescence, 199 impairment syndrome, 216t in vivo and ex vivo studies, 128, 162 induction cross hands, 283, 284f back, 463f chest, 464f embryonic, 102 global pectoral, 551f horizontal, of masseter, 403f infrahyoid, 424f intraoral, of masseter, 404f longitudinal, of ocular area, 398f myofascial see myofascial induction/Myofascial Induction Therapy (MIT) of myofascial complex of the tongue, 422f postisometric, 410f suprahyoid, 424f telescopic see telescopic induction temporomandibular, 409f transverse, of ocular area, 398f transverse plane hyoid, 424f vertical, of masseter, 403f inflammation local, 179 mediators, 196 neurogenic, 134, 174, 175 pain, 174, 175 pathological scarring, 202 remodeling versus fibrosis, 196 subcutaneous prepatellar bursa, 60f superficial fascia, 47f see also cytokines infrahyoid muscles, 359 inframammary fold, 433–4 inframammary ligament, 432 infraspinatus fascia, 489, 490f, 491–3, 544f tension line structures, 492f Ingber, DE, 105, 107, 144 inguinal ligaments, 228 inguinal lymph nodes, 233 injuries and scarring, 199–200 innervation breast, 434 craniofacial and cervical, 340 neurovascular and lymphatic structures, 428f, 429, 473

peptidergic cutaneous, 202 and vascularization of fascial system, 177–9 insular cortex (IC), 182 integrins, 123, 130f, 131, 145 intercostal fascia, 439–40 intercostal muscles, 440, 441f intermediate filaments, 123 intermetacarpal space, myofascial induction of, 518f intermuscular pathway alterations in movement patterns, 160–1 analysis of muscle dynamics in healthy subjects, 161–2 see also extramuscular pathway intermuscular septa, 495, 497f internal pterygoid muscle, 335 myofascial induction, 406f International Association for the Study of Pain (IASP), 343 interoception and afferent homeostatic pathway, 182 and central sensitization, 184–5 emotion and behavior, 182–4 interoceptive awareness, 184 interoceptive pathway, 182 tensegrity, 150 interpterygoid fossa, 335 interstitial cells, 9, 132, 135 interstitium, and diffusion of liquids, 135–7 intersutural permeability, 109 intervertebal discs, 367 intracellular matrix, 116, 123 remodeling, 128 intracranial pressure (ICP), 379 intranuclear matrix, 116, 123–4 intraoral induction, of masseter, 404f Ioganson, K/Ioganson structure, 140–1 ion channels, 133 isometric stress, 129

J

Järvinen, TA, 473 Jaspers, RT, 162 joints, adhesions around, 58 J-stroke, 269t palpation, 268, 270f technique, 268, 271f Jull, G, 5 juxtracrine communication, 130

K

Kakizaki, F, 429 Kalichman L, 247 Kandaswamy, M, 499 Kandel, ER, 109 Kaya, CS, 161 Keener, JD, 498 keloid scar (KS), 32, 201, 202 kidney, cranial–caudal displacement, 223 Kiloh–Nevin syndrome (anterior interosseous nerve syndrome), 315t

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Kim, SJ, 248 Kim, YE, 164 Kinesio Taping® (KT), 252 kinesthesia see proprioception Kirchgesner, T, 472 Klein, DM, 93 knee anterior aspect, 59f, 93f anterolateral aspect, 93f anterolateral knee complex, 164 cross-section of joint, 120f extensor muscles, 161 lateral aspect, left knee, 81f sagittal section, 60f sagittal plane, section of knee joint in, 44f transverse section of joint, 93f Kok, P, 181–2 Komiyama, O, 340 Kreulen, M, 160 Kroto, HW, 143 Kumar, P, 40 Kupffer cells, 226, 320

L

lacertus fibrosus, 86, 89f, 480f, 497–8 Lamoureux, P, 109 Lang, S, 275 Langer, K, 32 Langer’s lines, 32–4, 42, 200 Langevin, HM, 108, 116, 128, 131, 135 Langman’s Medical Embryology, 108 Latash, M, 213, 215 lateral axillary lymph nodes, 474 lateral force transmission, 499 latissimus dorsi muscle, 80, 162, 434 separated from left trapezius, 445, 450f Lazorthes, G, 365 Lee, JH, 248 Lee, S, 75 left inguinal area, 62f left lymphatic duct, 62, 233 left parascapular area, 443, 448f left posterior thoracic fascia, 453f left posterolateral scapulothoracic area, 492f left scapular area, 443, 448f, 491f associated muscles, 494, 495f inferior angle, 85f posterior view, 489f posterolateral view, 489, 490f left trapezius, 443, 448f, 449f, 451f separated from latissimus dorsi, 445, 450f left upper extremity, deep fascia, 494, 496f leg anterior aspect, 41f, 92f anterolateral aspect, 81f close-up, 59f arrangement of the fascial compartments, 96f cross-section of fascial compartments, 95f lateral aspect, 50f, 88f, 119f

posterior aspect, 52f, 64f, 116, 120f posterolateral aspect, 60f, 91f venous valves in, 65f see also foot; knee; right leg; thigh Leonard, JH, 251 lesser occipital nerve, 310 levator scapulae, myofascial induction, 547f Levental, K, 135 Levin, S, 144 ligaments, 223, 338 acromioclavicular, 164 anterolateral, of knee, 164 arcuate ligament of Osborne, 506 atlantoaxial, 397 “to be named” (TBNL), 366 carpal, 156f collagenous features, 165 Cooper’s (suspensory), 35, 45, 320, 321f, 433 coracoclavicular, 487 cruciform, 397 cutaneous, 329 discomalleolar, 343, 346f inframammary, 432 inguinal, 228 nuchal, 164, 328, 353f, 356, 365, 397, 451 oblique popliteal, 164 overstretched, 47f palmar carpal, 506 part of fascia, 335 pericardium, 427 sacrotuberous, 249 sphenomandibular, 335, 337f, 346f spinoglenoid, 489 stabilizing behavior, 164 Struthers’, 313t stylohyoid, 359 stylomandibular, 335, 337f supraspinous, 356, 362, 364, 445, 451 suspensory, Cooper’s, 35, 45, 320, 321f suspensory, of axilla, 432, 437 suspensory, of Giraldés, 431 transverse carpal ligament (TCL), 499, 502 transverse retinacular, 506 vertebral anterior longitudinal, 361 yellow, 165 zygomatic, 329 ligamentum nuchae (LN), 252, 350, 361–3, 363f, 365, 371f, 445 Lincoln, A, 3 lipids, 7, 62, 232, 320 lipid bilayers, 123 Liptan, G, 250 liquid crystals and energy medicine, 276 Lockwood, TE, 41 locomotor system, dynamics, 148–9 long thoracic nerve entrapment, 505 longitudinal induction, ocular area, 398f longitudinal stroke, 270, 272, 273t applied to back (cross hands induction), 463f applied to breathing structures, 465f applied to external mouth floor, 421f

applied to forearm extensors, 529f flexors, 528f applied to intercostal spaces, 462f applied to posterior cervical complex, 426f applied to thoracolumbar fascia in quadruped position, 461f applied to thoracolumbar fascia in sitting position, 460f applied to thumb, 520f applied to triceps brachii, 537f technique, 273f Lotan S, 247 Loukas, M, 450 low back pain (LBP), 223 scientific evidence for MIT, 247–8 see also chronic low back pain (CLBP) lower extremity dysfunction, scientific evidence for MIT, 249 lower maxillary nerve, 360 lower quadrant fascial continuity in, 37f lymphatic system assessment, 234–5 lymphatic nodes, 233–4 neural tests, 218, 225f lumbar area, surface blood vessels in, 69f lumbosacral movement, 164 lumbosacral plexus, common entrapments, 218, 224f lymph nodes biomechanics, 234 cubital, 474 disease development, 320 inguinal, 233 intercostal, 429 lateral axillary, 474 left inguinal area with, 62f of lower quadrant, 233–4 parasternal, 429 popliteal, 233 of upper quadrant, 320 lymphatic system abdomen, 233–4 anatomy, 232–3 assessment of lower quadrant, 234–5 biomechanics of lymphatic nodes, 234 breast, 434 capillaries, 233 deep lymphatic vessels, 474 essential anatomy/behavior, 62–3, 63f fascial hardening, 70 lymphatic drainage areas, 63f lymphatic duct, 63 left lymphatic duct, 62, 233 right lymphatic duct, 62, 233 and neurovasculature, 429 red flags, 235 schematic representation, 61f and superficial fascia, 61–3, 320–1 superficial vessels, 474 thoracic duct, 233

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INDEX continued lymphatic system (Continued) thorax complex, 428f, 429 upper extremity, 474 see also abdomen

M

Macchi, V, 332 McKay, E, 341 macromolecules, ECM, 122, 123 macromotions, 285 magnetic resonance imaging (MRI), 39, 162, 342, 504 UPRIGHT® Multi-Position™, 379 Mallick, A, 63 mammary gland, 432 mammograms, 433f Mammoto, T, 105, 107 Manheim, C, 10 manual therapy methods, 247, 252 MIT as a manual therapy approach, 261–2, 263 scarring, 341 temporomandibular disorder (TMD), 342 see also myofascial induction/Myofascial Induction Therapy (MIT) Marchuk, C, 108 Marinho, HVR, 162 Marshall, R, 250 Martínez Rodríguez, R, 250 Martínez-Hurtado, I, 251 Martínez-Jiménez, EM, 251 masseter intraoral induction, 404f myofascial induction, 403f masseteric fascia, 332–3 mastication, muscles of, 335, 336f, 337f, 343 matrices cellular communication, 129–33 composition, 134 concept of the systemic pattern, 123 fibers, 124–7 fibroblast dynamics and body movement, 127–8 ground substance, 134–5 intercommunication, 116, 122–4 extracellular matrix, 116, 122–3 intracellular matrix, 116, 123 intranuclear matrix, 116, 123–4 interstitium and diffusion of liquids, 135–7 microvacuolar system, 127–8 tensional homeostasis, 128–9 water, importance, 134 see also connective tissue (CT); extracellular matrix (ECM); fibroblasts; histological aspects of the fascial system May, A, 334 McGill pain questionnaire, 247 MDB see myodural bridges (MDBs) mechanical guidance, embryogenesis, 104–5 mechanical induction, collagen, 135 mechanobiology and embryogenesis, 103–5 ECM and mechanobiology of nervous system, 111–12

mechanochemical coupling of myofibroblasts, 132 mechanochemical reaction, 280 mechanoreceptors, 1, 2, 177 acting as proprioceptors, 379 activity and role, 2, 9 allostasis and fascial system, 181 distribution, 177 and hyaluronan (HA), 134 interstitial, 9 skin, 30 techniques and procedures, 266, 274, 281 tensegrity, 147 and touch, 264 type III and IV, 379 viscerofascial dysfunctions criteria, 320 mechanosensitive cells astrocytes, 134 central sensitization, 175 in the ECM, 8 fascia as a mechanosensitive structure, 9 mechanosensitive aspects of fascial system, 237, 280 nervous system, 177 target tissue mechanosensitivity, 237 mechanosensitive ion channels, 133, 178, 179 mechanotransduction, 133–4, 204 adaptive response and injury, 191 direct, 133 intercellular and intracellular communication, 280, 287 intersutural permeability, 109 and MIT, 261 perimysium and neuromuscular spindles, 472 processes, 109, 115, 123, 193f, 201, 226 scarring, 202–3 techniques and procedures, 266 tensegrity, 146 viscerofascial dysfunctions criteria, 320 medial gastrocnemius (MG) muscle, 159, 160 median nerve entrapment, 312, 313t, 505–6 Medical Subject Headings (MeSH), 331 Meissner corpuscles, 1, 180 meninges, 109, 173, 179, 300t continuity with osteoarticular system, 397 cranial, 379 and nervous system, 112 skull, 327–8 and suboccipital region, 361, 362 Mense, S, 134, 174, 472 Merkel’s receptors, 1 Merriam-Webster’s Medical Dictionary, 75 mesenchymal stem cells, 108, 131, 145 mesenchyme, 108, 109 mesoderm, 102, 105, 107 histological aspects, 116 mesoderm-prechordal plate, 116 mesoneurium, 173 Messina, G, 338 metabolism and fascial system, 6–7 metacognition, 293 metalloproteinases (MMPs), 134–5, 198, 199

microfilaments, 123 microgliosis, 181 microtubules, 123 microvacuolar system, 127–8, 147 migration, cellular, 104–5 Minasmy, B, 286 Mingels, S, 379 MIT see myofascial induction/Myofascial Induction Therapy (MIT) Mitz, V, 331 Miyamoto, J, 202 mobility assessment, 207 movement synergy, 218, 221–2t range of motion, 217–18, 219–20t, 298, 304, 305–6t upper quadrant, 304–7 Montaldo, BC, 429 morphogenesis, 104, 108 morphogenetic control, 103 morphogens, soluble, 103–4 morphology deep fascia, 71–2, 73f, 74f, 75f characteristics of fascial layers, 28 myofascia, 77–8 fascial layers and morphological characteristics, 28, 29f morphogenetic control, 103 morphological definition of fascia, 15 myofascia, 28, 77–8 superficial fascia, 35, 36f, 37f, 38f, 42, 51f, 52, 53f, 54f, 55f Moseley, GL, 5 motion see movement motor control, 153, 213, 216t, 217t motor learning, 153 Motro, R, 142 mouth breathing through, 372t burning mouth syndrome, 345t cleft lip, 341 closed/closing, 332, 341 floor of draining, 382 innervation, 360 muscles, 358f hard palate, myofascial induction, 407f longitudinal stroke applied to the external floor, 421f open/opening, 305t, 308t, 309t, 336–8, 341, 395f temporomandibular open-mouth behavior, 337 orofacial pain (OP), 342–3, 344–5t postisometric induction, 410f vomer, myofascial induction, 408f see also tongue movement, body allostasis and fascial system, 181 alterations in patterns, 8, 160–1 APTA definition, 6 and body perception, 6 as a complex biological suprasystem, 153 complex biological suprasystem, 154 contemporary analysis, 190 context, 153

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distortion, 217 facilitated, 274 and fibroblasts, 127–8 and force transmission see force transmission head, 328 ideomotor movement, 286 intrinsic mobility, 427 motor control, 153, 213, 216t, 217t motor learning, 153 movement system, 6 Newtonian analysis, 8 and perception, 6 synergy, 218, 221–2t, 306–7, 308–9t therapeutic see therapeutic movement see also locomotor system; range of motion (ROM) MRI see magnetic resonance imaging (MRI) multifunctional glycoproteins, 123 multiple sclerosis (MS), 379 muscle formation patterns, 108 group III muscle afferents, 9 group IV muscle afferents, 9 internal structure, 77f macrostructure, 155 musculoskeletal disorders, introduction of biopsychosocial model to, 5 schematic representation of assembly, 84 separation, 95f, 96f compartments, 94 interosseus septa, 96 see also specific body areas muscular differentiation, 131 musculotendinous junction, 85, 86f, 155 musculotendinous unit, 155 Myers, T, 10 myoaponeurotic junction, 158 myoblasts, 108 myodural bridges (MDBs), 365, 366, 367, 379–80 sagittal section of head and upper neck showing, 411f myodural connections anatomical and physiological findings, 365–7 clinical implications, 367 myofascia classification, 77–8 concept of myofascial system, 150 morphology, 28, 77–8 terminology, 76, 77f see also myofascial dysfunction syndrome; myofascial force transmission; myofascial induction/Myofascial Induction Therapy (MIT) myofascial dysfunction syndrome, 208, 210–11 myofascial force transmission, 9 myofascial induction syndrome (MDS), 208 myofascial induction/Myofascial Induction Therapy (MIT) applied to bicipital groove, 534f breathing structures longitudinal stroke, 465f

transverse plane procedure, 466f complementary treatments, 241 concept, 10 contraindications, 289 craniofacial region craniocervical area, 419f external pterygoid muscle, 405f hard palate, 407f internal pterygoid muscle, 406f masseter, 403f ocular area, 398f scalp, 400f suboccipital triangle, 412f temporal area, 402f vomer, 408f zygomatic area, 399f cubital fossa, 531f deep neck flexors, 417f flowchart, 267f general procedures, 241 indications for, 10, 261, 289 intermetacarpal space, 518f levator scapulae, 547f as a manual therapy approach, 261–2, 263 mechanical characteristics, 266 myofascial bridge, 413f objectives, 241, 242 omohyoid, 423f orofacial pain, 342–3 other myofascial approaches compared, 10–11 and pain, 179 palmar fascia, 516f pectoral and clavipectoral fascia, 548f, 549f rotator cuff infraspinatus fascia, 544f subscapular fascia, 543f supraspinatus fascia, 545f scalenes, 418f scapular triangle, 541f scientific evidence see evidence-based medicine (EBM); evidence-based practice (EBP); scientific evidence for MIT serratus anterior muscle, 550f specific treatment goals, 242 sternocleidomastoid, 416f sustained force procedures, 266 viscerofascial dysfunctions criteria, 226–9, 230f, 320 see also therapeutic considerations myofascial loading, 471 myofascial release (MFR), 247, 249, 251 myofascial trigger points (MTrPs), 248 myofascial unit, force transmission in, 154–6 myofibrils, 8, 154, 155, 158f myofibroblasts, 129, 132, 146 disappearance see apoptosis myosin, 8 myotendinous junction, 158 myotendinous transmission, versus fascial tendinous transmission, 159 myotomes, 108

N

Nakajima, H, 39, 52 Nash, LG, 45 National Cancer Institute, 321 neck anterior aspect, 350, 352f, 353f, 430, 431f anterolateral cervical area see anterolateral cervical area continuity of fascial structures, 347–8 deep fascia, 349f, 354–61 deep lamina, 355, 361 middle lamina, 349, 355, 357–60 superficial lamina, 349, 355–7, 356f deep muscles, 365 deep neck flexors, myofascial induction, 417f dysfunction, scientific evidence for MIT, 247–8 fascial anatomy, 348–9, 350f, 351f fascial compartments, 380f lateral aspect, 352f left side, 364, 365f posterior left aspect, 364f posterolateral, 363f maxillofacial and interior regions, fascial compartments, 335 middle lamina, 357–60 platysma, 350–1, 353f, 354, 354f posterior aspect, 352f, 364f postural control, 360 right side, 233 posterolateral aspect, 362f right anterolateral aspect, 355f, 357f, 358f, 361f right lateral view, 311f, 357f sagittal section of upper neck, 411f superficial fascia, 350, 352f topographic areas, 380 transverse section, 350f triangles of, 359t, 380–3, 381f boundaries, 381, 382 contents, 381, 382 divisions, 381, 382 observations, 381–3 X-rays, 367 nerve conduction studies (NCS), 503, 504 nerve entrapment syndrome, 218, 224f, 249 median nerve entrapment, 312, 313t, 505–6 radial nerve entrapment, 312, 313t upper quadrant, 311–12, 313t, 314t, 315t, 316t, 317t, 318t see also entrapment neuropathies nerve growth factor (NGF), 202 nervi nervorum, 174, 179 nervous system compressed nerves, 504 continuity and transition of, 179–80 craniofacial region, 397 fascial anatomy associated with, 441 mature and developing, relevance of ECM in, 111 mechanical control of development, 109–11 mechanobiology of, 111–12 mechanosensitive cells, 177

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INDEX continued nervous system (Continued) nerves of cervical plexus, 310 nervous tissue as a source of pain, 174–5 neurobiomechanics, 165 physiopathology of nerve and glial response, 180–1 see also brain; nerve entrapment syndrome; neurocranium and brain, integration of; neurodevelopment; neurodynamics of fascia; neurofascia; specific nerves of the body neural crest, ectodermal, 116 neural edema, 179 neural exit foramina, 346 neural tests, 223f nerve entrapment syndrome, 218, 224f performing, 218, 225f red flags, 314 upper quadrant, 312, 318f, 319f neuraxis, 165 neuroblasts, 112 neurocranium and brain, integration of, 109 neurodevelopment, 103 and glial cells, 111–12 neurodynamic tests, 503 neurodynamics of fascia, 171–88 afferent homeostatic pathway, 182 allostasis and fascial system, 181–2 central sensitization, 175–7, 184–5 innervation and vascularization of fascial system, 177–9 interoception, 182 nervous tissue as a source of pain, 174–5 neurofascial architecture, 171, 172f, 173, 174f neurovascular tract and lateral transmission of forces, 180 peripheral sensitization and pain, 175 physiopathology of nerve and glial response, 180–1 see also nervous system; neurocranium and brain, integration of; neurodevelopment; neurofascia; pain neuro-endocrine-immune balance, 202 neurofascia/neurofascial system (NFS), 177, 180 cervical plexus, 307, 310 morphological characteristics of fascial layers, 28 neurofascial architecture, 171, 172f, 173, 174f neurofascial components, 307 terminology, 76 neurogenic differentiation, 131 neurogenic inflammation, 134, 174, 175 neurological disorders scientific evidence for MIT, 251 upper quadrant, 295 neuromeningeal procedures, 286–7 neuromuscular spindles, 472 neurons, 174, 180 and glial cells, 112 neuropathic pain, 174 neuropeptides, 174, 200 neuroprotective response, 237, 394f neuroscience education (NE), 176 neurosensory receptors, 280

neurovascular structures blood supply, 473–4 innervation, 473 neurovascular tract and lateral transmission of forces, 180 Newton’s laws, 96, 154 Nicholson, H, 10 nociceptors, 174 mechanosensitive ion channels, 178 nociceptive pain, 199 proprioceptive inhibition, 367 in TLF, 179 nociplastic pain, 175 nonotogenic otalgia, 343 Norton, NS, 327 notochord, 107, 116 nuchal ligament (NL), 164, 328, 353f, 356, 365, 397, 451

O

oblique popliteal ligament, 164 obliquus capitis inferior (OCI), 365, 366 obstructive sleep apnea, 359 occipitofrontalis muscles, myofascia, 334–5 ocular area, myofascial induction, 398f O’Leary, DP, 287, 289 omohyoid, myofascial induction, 423f ontogenesis (cell division process), 105 oral sphincter, revitalization, 332 orbicularis oculi, aponeurosis, 335 orbicularis oris muscle, 341 organogenesis and ECM, 105, 107 orofacial pain (OP), 342–3, 344–5t Oschman, JL, 276, 277 osteoarthritis (OA), 176 osteoblasts, 109 osteogenic cells, intersutural, 109 osteogenic differentiation, 131 otalgia (ear disorder), 343, 346f Overduin, SA, 307 overstimulation, fascial, 264 ovum, fertilization, 101

P

Pacinian corpuscles, 1, 471, 472 pain assessment, 211 benefits of MIT, 179 biomedical model, 4 biopsychosocial model, 5 and central sensitization, 175–7 cervical, 343 chronic or persistent disorders, 184 enactive approach, 5 gastrointestinal, centrally mediated, 231 impairment of stability, 211 irritability, 211 low back pain (LBP), 223, 247–8 measures of, 247 musculoskeletal, 178 neck dysfunction, 247–8

nervous tissue as a source of, 174–5 neuropathic, 174 nociceptive, 199 nociplastic, 175 nonspecific arm pain, 503–4 orofacial, 342–3, 344–5t and peripheral sensitization, 175 in polymyalgia rheumatica, 472 and posture, 212 severity, 211 stage of disease, 211 during treatment, 283 see also International Association for the Study of Pain (IASP) pain neuroscience education (PNE), 247 painful shoulder syndrome, 451 palmar aponeurosis, 501, 502 palmar carpal ligament, 506 palmar fascia, myofascial induction, 516f Palomeque-Del-Cerro, L, 365 palpation abdominal, 228 J-stroke, 268, 270f palpatory tests, 235–7 tension explored through, 237 visceral procedures and tests, 228 panniculus adiposus, 28, 350 panniculus carnosus, 48f paracrine communication/signaling, 108, 130 parascapular area, 452f parasternal lymph nodes, 429 parasympathetic nervous system, 251, 252 paratenon, 94 paraxial mesoderm, 107 parenchyma, 379 parotid gland/fascia, 332, 357 parotideomasseteric fascia, 332 Partridge, BL, 495–6 Pastor MF, 164 patellofemoral joint, 116, 120f pathogenesis, 191 pectoral area anterior aspect, 438f anterolateral view, 121f aponeurotic fascia, 82f and clavipectoral fascia, myofascial induction, 548f, 549f epimysial fascia over pectoralis major, 84f myofascia, 77f right pectoral area, anterior aspect, 438f skin ligaments over, 45f superficial fascia, 49f pectoralis fascia, 434–5 pectoralis major, 434 pectus excavatum, 429 pelvic floor dysfunction, scientific evidence for MIT, 248–9 pelvis, posterior aspect, 90f Penrose, R, 8 peptidergic nociceptors, nervi nervorum, 174 Pérez-Llanes, R, 251

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pericardium ligaments, 427 perimysium, 8, 84, 155, 165 deep fascia, 75t, 76, 82, 84 and neuromuscular spindles, 472–3 rigidity, 473 perineurium, 171–2, 180 peripheral nervous system (PNS), 165, 171, 179, 507 continuity, 397 cross-section of peripheral nerve, 172f, 173f epineural layers, 287 injury of peripheral nerve, 175, 176, 181 peripheral nerve sheaths, 173, 174 and spinal root connective tissue, 174f upper quadrant, peripheral nerves, 312, 315–17t see also central nervous system (CNS) peripheral neuropathy, 504 peripheral sensitization and pain, 175, 179 perimysium, rigidity, 472, 473 Peyronie, M, 331 phantom limb pain, 184 pharyngobasilar fascia, 334 pharynx, 334 phenomenology, 244 phenotype, 128 philosophy of science framework, EBM with, 244–7 phrenic nerve, 310, 441 pia mater, 179, 397 see also arachnoid mater; dura mater; meninges piezoelectricity, 275, 276, 280 Pilat, A, 10 “Fascial anatomy of the limbs,” 38f, 87f, 474f “Myofascial induction approach,” 279f “Myofascial Induction approaches,” 29f, 502f “Myofascial Induction approaches for patients with headache,” 415f, 416f, 420f, 421f “Myofascial Induction approaches in temporomandibular disorders,” 333f, 352f, 401f, 409f Terapias miofasciales: Inducción miofascial, 159f, 369f, 378f plasticity, 108, 116 developed or preserved, 191 platelet-derived growth factor (PDGF), 200 platysma, 49f, 333–4 fascial anatomy of neck, 350–1, 353f, 354, 354f integrated into superficial fascia, 431, 432f muscle spindles in, 334 muscular fibers, 354 PNS see peripheral nervous system (PNS) Poitevin, LA, 434 polymodal receptors, 281 polymyalgia rheumatica, 472 polypeptide chains, 123 popliteal lymph nodes, 233 positron emission tomography (PET), 182, 184 posterior cervical complex longitudinal stroke applied to, 426f transverse stroke applied to, 425f posterior elbow retinaculum, 498, 499f posterior interosseous nerve syndromes, 506–7 postisometric induction, 410f

postmenopausal conditions, 251 post-traumatic conditions, 184, 505 posture assessment, 212 cervical flexion, 337 cervical lateroflexion, 336 hyperlordosis, 337 neck, control of, 360 see also forward head posture and slumping practitioner, ergonomics for, 263 Prajapati, RT, 128 pressure pain threshold (PPT), 252 pretracheal fascia, 358 pretracheal space, 380 prevertebral fascia, 361 primary hyperalgesia, 175 procollagen, 126 pronator syndrome, 313t pronator teres syndrome, 497, 505 proprioception and fascia, 472 scapular dyskinesis, 471–2 suboccipital region, 379 Prósper, F, 108 proteases, 123 proteoglycans, 123, 127 protomyofibroblasts, 129, 131, 145 proton pump inhibitors (PPIs), 251 protopathic sensitivity, 178 psoas muscle, 236f pterygoid fossa, 335 pterygomandibular raphe, 334 ptosis, 432 pulmonary compliance, 429 Purslow, PP, 84–5, 158 pyroelectricity, 275

R

radial nerve entrapment, 312, 313t radial tunnel syndrome, 506–7 radiculopathy, 312, 318f Radu, BM, 132 Raiteri, BJ, 159 Ramaswamy, KS, 471 Ramos-González, E, 251 Randhawa, A, 158 randomized control trials (RCTs), 245, 248, 249, 250, 251 range of motion (ROM) assessment, 217–18, 219–20t force transmission, 158 local and global, 298 upper quadrant, 304, 305–6t RCTs see randomized control trials (RCTs) reactive gliosis, 379 rectus capitis anterior (RCA), 365 rectus capitis posterior major (RCPma), 365, 366, 367 rectus capitis posterior minor (RCPmi), 342, 365, 367 red flags lymphatic system, 235, 322 neural tests, 314

visceral procedures and tests, 232 reductionism see biomedical model reflex theory, 213 regional fascial specializations (RFS), 78 Rehnke, RD, 433 remodeling active, 128 of collagen, 134, 135, 198 collective, of myofibroblasts, 132 continuous, 73 of cytoskeleton, 128 defining, xxvi dynamic, 107, 191 of ECM, 107, 123, 127, 128–9, 134, 135, 199, 280 of fibroblasts, 128, 191, 193f versus fibrosis, 196–7 functional, xxiii, 191, 196–7 mechanical induction, collagen, 135 in MIT, 10 nucleus, 197 passive, 128 and repair, 196–8 and scarring, 200, 201f, 203 of tenocytes, 133 of thoracic wall, 429 tissue, 107, 132, 134, 178, 191, 198, 280 connective tissue, 135 functional, 196 manual, 11 renal fascia, 223 reorganization, cellular, 101–2 repair intrinsic and extrinsic compartments in function of, 197 and remodeling, 197–8 repetitive strain injury (RSI), 196 research, development and innovation (R & D and I), 3 reticulin (type III collagen), 126–7 retinacula cutis (skin ligaments), 42 retinaculum cutis profundus, 39, 433 retinaculum cutis superficialis (septa network), 39 retrohyoid procedure, deep neck flexors, 417f retropharyngeal space, 380 rhomboid fascia, 437, 488f, 495f rhomboid minor (Rmi), 365 Richmond, FJR, 365 Richtsmeier, JT, 109 right clavipectoral fascia, 439f right insular cortex, 6 right leg, 92f, 94 see also right thigh right lymphatic duct, 62, 233 right mandibular branch test, 319t right parascapular area, 450f right sacroiliac joint, 116, 121f right thigh, 66, 67f right anterior thigh, 214t right thoracic duct/cavity, 63, 233, 320 see also thoracic duct right upper extremity, 82, 84f see also upper extremity

571

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INDEX continued rigidity aponeurosis of tibialis anterior muscle, 159 cellular environment, 129, 131, 133, 134 chest, 430 collagen, 275 connective tissue (CT), 157 of ECM, 7, 105, 111, 135, 145, 150 perimysium, 472, 473 triangular modules, 140, 141f Rodríguez-Fuentes, I, 247, 248 Rodríguez-Huguet, M, 247 Rohrich, RJ, 432 Roland Morris disability questionnaire, 247 Rolf, I, 10 Rome IV criteria see gastrointestinal dysfunctions (Rome IV) criteria Roquelaure, Y, 503 Rosch, E, 5 rotator cuff assessment, 542f infraspinatus fascia, 489, 490f, 491–3, 544f subscapular fascia, 493, 543f supraspinatus fascia, 488–9, 545f rubber hand illusion, 184 Ruffini receptors, 1, 471

S

sacrotuberous ligaments, 249 Sahrmann, S, 6 Saíz-Llamosas, JR, 252 Santos Heredero, X, 200 saphenous fascia, 66 saphenous vein, 67f great and small, 66, 68f scalenes dysfunction, 383 hyperactivity, 376t muscles, 383 myofascial induction, 418f scalene triangle, 382 Scali, F, 366 scalp, 332, 335, 340, 350 myofascial induction, 400f sliding and mobility, 332 scapular area, 122f associated muscles, 494, 495f behavior, 470 histological aspects, 122f location of, 470 posterior aspect of left area, 489f posterolateral aspect of left area, 490f see also left parascapular area; left scapular area; right parascapular area scapular dyskinesis, 470–3 fascia and proprioception, 472 myofascial force transmission, 471 perimysium and neuromuscular spindles, 472–3 proprioception, 471–2 scapular triangle assessment, 539f

basic anatomy, 540f myofascial induction, 541f scapulocostal syndrome, 451 scapulohumeral dyskinesis, 470 scapulothoracic bursae, 493 Scarpa’s fascia, 35 Scarr, G, 109, 327 scarring age, 200 alteration of processes, 201–2 anatomical location, 200 atrophic scar, 201 brain–skin connection, 202 healing process, 200–3, 341 hypertrophic scar, 201, 202 and injuries, 199–200 keloid scar, 32, 201, 202 manual treatment, 341 mechanical, 200 mechanotransduction, 202–3 pathological, 202 post-C-section, 250 racial differences, 200 and remodeling, 200, 201f, 203 scientific evidence for MIT, 250 surgical, 199–200 tensional changes on and within skin, 30, 31f, 32 wound healing processes, 341 wound size and local contamination, 200 Schleip, R, 15, 128 Schwann cells, 173 basal lamina, 171 scientific evidence for MIT, 243–57 application of MIT, 247–51 Aristotelian reasoning, 244 cancer survivors, 250–1 cardiac and vascular dysfunction, 251 empiricism, 244 evidence and the scientific method, 245–6 examples of research conducted on healthy subjects, 251–2 false truths, 243 fibromyalgia and chronic fatigue syndrome, 249–50 gastroesophageal reflux (GERD), 251 hermeneutics, 244 laboratory research, 243 low back pain (LBP), 223, 247–8 meta-analyses, 245 myofascial therapy and scientific evidence, 246–7 neck dysfunction pain, 247–8 neurological disorders, 251 other epistemological streams, 244–5 pelvic floor dysfunction, 248–9 phenomenology, 244 philosophy of science framework, EBM with, 244–7 previous beliefs, whether existence of, 244 propositions, 244 randomized control trials (RCTs), 245, 248, 249, 250, 251 scarring, 250 scientific validity, meaning, 244 systemic approach to, 245

upper extremity, 249 see also evidence-based medicine (EBM); evidence-based practice (EBP) sclerotic gaps, brain, 379 SCM see sternocleidomastoid (SCM) secondary hyperalgesia, 175 selectins, 123 Seliktar, D, 135 sensitization central, 175–7, 184–5 and pain, 175–7, 179 peripheral, 175, 179 see also neurodynamics of fascia; pain Seo, H, 33 Serra-Añó, P, 250 serrati fascia, 448 serratus anterior muscle, myofascial induction, 550f serratus posterior inferior (SPI), 448, 450, 451 serratus posterior superior (SPS), 365, 448, 450, 451 SFS see under superficial fascia Shacklock, M, 166 Shah, Y, 252 Shapiro, HH, 380 Shenoy, PD, 246 shoulder complex structures/shoulder girdle fascial system, 486–94 deep fascia, 72f deep layer (DL), 487–94 deltoid fascia, 487 kinematics of the shoulder girdle, 470 levator scapulae, myofascial induction, 547f myofascial structures, assessment, 546f posterior aspect, 488f rhomboid fascia, 488f, 495f rotator cuff assessment, 542f infraspinatus fascia, 489, 490f, 491–3, 544f myofascial induction, 543f, 544f, 545f subscapular fascia, 493, 543f supraspinatus fascia, 488–9, 545f scapular triangle, assessment, 539f scapulothoracic bursae, 493 superficial layer of deep fascia, 486, 487f see also scapular area; scapular dyskinesis Shumway-Cook, A, 212 Sills, F, 285 Simmons, RM, 8, 154 single-hand contact, 284, 286t application, 286f Sirén, V, 131 skin, 28–34 attached to superficial fascia, 34f brain–skin connection, 202 characteristics, 29, 31t complex fascial system surrounding, 327 dermis, 29, 34 epidermis, 29 injuries and scarring, 31f Langer’s lines, 32–4, 42, 200 ligaments, 39, 42–3, 45 overstretched, 47f link with superficial fascia, 42, 45–6, 45f, 47f, 48

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purposes and functions, 29, 30t receptors, 29–30, 31f cutaneous somatosensory, 30f, 31t under-skin synergy, 147–8 tensional changes on and within, 30, 31f, 32 see also scarring skin–fat envelope, 50 skin–subcutaneous complex, 34 skull, 334 dura mater as mediator with brain, 109, 327 integration of the neurocranium and brain, 109 meninges, 327–8 neurobiodynamic model, 327 views of structures, 396f sliding platform concept, 470 sliding procedures general considerations, 269f J-stroke, 268, 269t, 270f longitudinal stroke, 270, 272, 273f, 273t sliding platform concept, 470 therapeutic considerations, 266–72 transverse stroke, 270, 271t, 272f small saphenous vein, 66 Smalley, RE, 143 SMAS see superficial musculoaponeurotic system (SMAS) Smeulders, MJ, 160 snapping scapula syndrome (“washboard syndrome”), 470 Snelson, K, 140, 141, 142 somatosensory afferents, 343 somatosensory receptors, 177 Sommer, G, 50 sonoelastography, 250, 342 spasticity, 160, 161 sphenomandibular ligament, 335, 337f, 346f SPI see serratus posterior inferior (SPI) spinal dura mater (SDM), 366 spinal flexion movement, 165 spinal root, 174f spine anterior rami of spinal nerves, 429 cervical spine/spinal nerves, 343, 429, 505 lumbar spine, 154, 163 sensory and sympathetic fibers, 178 spinoglenoid ligaments, 489 spinous processes, longitudinal axis, 57f SPS see serratus posterior superior (SPS) stability assessment, 207 dynamic, 213, 215, 216–17t, 301, 302–3t ecological theory, 215 hierarchical theory, 213, 215 posture, 212 reflex theory, 213 static, 212–13, 214t, 298, 299–300t, 300–1 system theory, 215 upper quadrant, 298, 299–300t, 300–1, 302–3t stabilization deep fascia, 93f, 94 epimuscular force transmission, 163–5 Stanborough, RW, 10 Standring, S, 327

static stability assessment, 212–13, 214t upper quadrant, 298, 299–300t, 300–1 Stecco, A, 134, 162, 190, 197 Stecco, C, 15, 75, 108, 472, 498, 502 Stecco, L, 10, 15 stem cells, mesenchymal, 108, 131 sternocleidomastoid (SCM), 248, 310, 358, 362 bilateral, 252 fascial envelope, 356–7 myofascial induction, 416f, 418f sternum, 430 stiffness ankle joint, 159 matrices, 128, 131, 132 extracellular matrix (ECM), 105, 199 tendons, 159 viscera, 320 see also rigidity Still, AT, 10 Stilwell, P, 5 stratum membranosum, 28 stroke J-stroke, 268, 269t, 270f longitudinal see longitudinal stroke transverse see transverse stroke Struthers’ ligament, 313t stylohyoid ligaments, 359 stylomandibular ligament, 335, 337f subclavius, 436–7 subcutaneous bursae, 58 subcutaneous fascia, 39 see also superficial fascia submandibular glands, 357 suboccipital fascial system, 379 suboccipital region, 361–4, 365f, 367, 397 suboccipital triangle, 412f subscapular fascia, 493, 543f substance P (SP), 202 sucking feet, 136 superficial adipose tissue (SAT), 39, 433 superficial dorsal thoracic fascia, 441–3 superficial fascia anterior thoracic wall, 430–4 back, 353f, 446f breast dissections, 433 cervicopectoral and arm regions, 116, 121f circulatory system, and superficial fascia blood vessels, 60 functionality of the venous and lymphatic systems, 60–1 circulatory system and superficial fascia, 60–70 arterial vascularization, 69–70, 85f circulatory deficiencies, 70–2 lymphatic system, 61–3, 322 venous system, 63–8 docking structures (adhesions), 56 fascial anatomy of neck, 350, 352f and gliding, 165 key features, 34 skin attached to, 34f superficial dorsal thoracic fascia, 441–3, 444–6f superficial fascial system (SFS), 34–60

adipofascial layers, 56 adipose tissue, 39, 41, 42, 43t architecture, 40t, 41–2, 43t, 44f behavior, 35, 39 close-up of three-dimensional network of deep layer, 49f deep adipose tissue (DAT), 39 deep layer (DL), 41, 42, 46f, 48f, 50f, 58f, 62 fascial layers, 58, 59f links between skin and superficial fascia, 42, 45–6, 45f, 47f, 48 links between superficial and deep fascia, 48, 49f, 50, 51f, 52f, 53t, 55f, 57f, 58, 59f, 60f lower quadrant, 37f morphology, 35, 36f, 37f, 38f, 42, 51f, 52, 53f, 54f, 55f numbers of layers, 39 obesity, 47f photomontage, 47f purposes and functions, 40t septa, fibrous, 39, 46 subcutaneous bursae, 58 superficial adipose tissue (SAT), 39 superficial layer (SL), 41, 42, 46f, 50f, 62 terminology and classification, 39–40, 41 upper extremity, 474, 475f, 476f, 477f, 478f, 479f path along upper extremity, 476f superficial lamina (investing layer), neck, 355–7 superficial musculoaponeurotic system (SMAS), 331– 2, 333, 350, 351 superior transverse notch, 505 supraclavicular nerves, 310 supracondylar process syndrome, 313t suprascapular bursae, 493, 494f suprascapular nerve entrapment, 504–5 supraspinatus fascia, 488–9, 545f supraspinous ligament, 356, 362, 364, 445, 451 suspensory ligaments of axilla, 432, 437 Cooper’s, 35, 45, 320, 321f of Giraldés, 431 sutures, continuity of meninges with, 397 Svensson, P, 340 Swedish Council on Health Technology Assessment, 503 sympathetic nervous system (SNS), 9, 252 synergy kinematic synergies, 467 local and distant muscle, 161 movement, 218, 306–7, 308–9t neuromuscular synergies, 467 under-skin, 147–8 upper extremity absolute and relative synergies, 470 as part of General System Theory, 467, 469–73 upper extremity as a synergistic structure, 470 usefulness of muscle synergies, 469 systemic procedures, sustained, 273–83 barrier, 274 biology, 275 biotensegrity of fascial system, 280 cell mechanotransduction, 280 communication through gap junctions, 280

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INDEX continued systemic procedures, sustained (Continued) cross hands induction, 283, 284f crystalline formations, 275 facilitated movement, 274 fascial unwinding, 284–6, 287t, 288f induction process, mechanisms, 277, 278f, 279f, 280–1 integrin participation, 280 intercellular and intracellular communication, 280 local and global sustained procedures, 283–6 modalities, 281–3 between the molecule and the organism, 275–7 neuromeningeal procedures, 286–7 neurosensory receptors, 280 neurotransmission/other communication channels, 280 piezoelectricity, 275, 280 pyroelectricity, 275 sensitivity to stimulation, 281 single-hand contact, 284, 286f, 286t thixotropic reaction, 277, 280 transverse plane induction, 284 procedure, 285f visceral procedures, 287, 289 viscoelastic response, 280–1 systems, 280 biological, 22–3 classification, 17–20 closed, 17–18, 20t comparison of open and closed, 20t complex versus complicated, 154 concepts and definitions, 7, 16–21 conceptual basis of a system, 16–21 definition of terms, 16 dynamic equilibrium, 21 fascia as a system, 7, 16, 21, 22f biological entities, 22 classic orthodox model, 22 as a complex biological system, 22–4 deep fascia as a system, 71–96 mechanosensitive aspects, 237 as a tensegrity system, 149–50 General System Theory, 4, 5, 467, 469–73 homeostasis, 21 hypothesis for considering human body as a system, 21 levels of complexity, 17 main characteristics, 20t, 21 open, 17–20 steady state equilibrium, 21 subsystem, 17 suprasystem, 17 system entropy, 19–20 system theory, 215, 276–7

T

T lymphocytes, 181, 199 Taberner Ferrera, R, 199 Takeshita, K, 164, 363 talin, 130 TCC see trigeminocervical complex (TCC)

TCs see telocytes (TCs) tela subcutanea (subcutaneous tissue), 28, 39 telescopic induction fingers, 517f upper limb, 552f, 553f telescopic unwinding, 286 telocytes (TCs), 108 cellular communication, 132 cytoplasmic prolongations, xxvii deep fascial system, 73 defining, 132 telopods (protoplasmic expansions), 132 temporal area myofascial induction of, 402f transverse stroke applied to, 401f temporomandibular disorder (TMD), 328, 341–2 temporomandibular induction, 409f temporomandibular joint (TMJ), 329f, 336 coronal view, 334f dissection, 328, 330f as a ginglymoarthrodial complex, 328 temporoparietal fascia (TPF), 332, 333f, 334f Tenberg, S, 200 tendons, 127, 134, 155 abductor pollicis longus and extensor pollicis brevis, 519f Achilles tendon, 162 carpal tunnel, 486 collagen structures in healthy tendon, 197 and deep fascia, 82, 84f, 88, 90, 93, 94, 96 and elastin, 124 flexor, 486, 500f, 502 Golgi tendon organs, 472 longitudinal sliding, 93 palmaris longus, 499, 501 pathophysiology, 197 and remodeling, 196, 197 retraction of, 505 sheaths, 96 SMAS as a “central tendon” for the facial muscles, 332 stiffness, 159 tendinous mobility, 165 triceps, 498 see also endotendon; tendon-to-periosteum attachment; tenocytes (tendon fibroblasts) tendon-to-periosteum attachment, 155, 156f tenocytes (tendon fibroblasts), 132, 133, 196 tensegrity, 139–51 in biology, 144–8 canonic, 142, 149 compression-based structures, 139–40 and cranial vault, 110f craniofacial region, 327 dynamics of locomotor system, 148–9 elasticity, 149, 150 in engineering, 141–3 fascia as a tensegrity system, 149–50 and force transmission, 155 geodesic structures, 140, 142, 147 and microvacuolar absorption system, 127–8 in organic chemistry, 143

origin of concept, 139 principle of, 109 under-skin synergy, 147–8 tensional tensegrity-integrity, 140–1 tensile load test, 237 tensional homeostasis, 128–9, 192f tensor fasciae latae muscle, 88, 90f tensor tympani, 343 tensor veli palatini, 343 tensotaxis, 129 tentorium cerebelli, 109 Terminologia Anatomica, 75 Tesarz, J, 473 textus connectivus, 28 Thacker, M, 5 Thales of Miletus, 244 theories biomechanical models, 336 ecological, 215 hierarchical, 213, 215 reflex, 213 system, 215 therapeutic considerations, 261–92 analysis of touch, 264–5 cancer survivors, 250–1 complementary treatments, 241 environment and clothing, 262–3 ergonomics, 263 and fascia and therapeutic movement, 7–10 frequency of treatments, 264 intention of practitioner, 265 MIT as a manual therapy approach, 261–2 objectives for treatment, 262 principles of treatment, 262–5 sequence of treatments, 263–4 sliding procedures, 266–72 specific goals of MIT, 242 starting and ending the session, 265 sustained systemic procedures (indirect application), 273–83 systemic approach to therapeutic movement and health care, 6 techniques and procedures, 266–89 therapeutic touch, 9–10 see also myofascial induction/Myofascial Induction Therapy (MIT) thigh anterior aspect, 52f, 56f, 69f, 71f, 81f, 89f close-up of three-dimensional network, 49f cross-section, 38f, 56f, 163f deep fascia, 71f fascial continuity in transverse section, 28f lateral aspect, 73f longitudinal view, 68f and microvacuolar system, 127 multilayered structure of fascia, 83f photomontage, 68f posterior aspect, 56f, 90f transverse view, 68f of proximal third, 67f see also leg; right thigh

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thixotropic reaction, 277, 280 Thomas test, 208, 236f Thompson, E, 5 Thompson, J, 336 thoracic craniocervical mandibular system, 336, 338f thoracic duct, 62, 233, 320 see also right thoracic duct thoracic-cervical-cranial-mandibular system, 336 thoracolumbar fascia (TLF), 80f, 94f, 134, 248 and brachial fascia, 494 connective tissue (CT), 197 epimuscular force transmission, 164 in experimental animals, 134, 178 and gluteus maximus, 162 longitudinal stroke applied to quadruped position, 461f sitting position, 460f neurogenic inflammation, 134 nociceptors in, 179 pathological scarring, 202 posterior layer, 445 release, 251–2 sensitization, 175 stabilizing role on lumbar spine, 154, 163 ultrasound imaging, 247 thorax complex, 430–41 anatomical considerations, 427–54 anterior aspect, 430, 431f anterior-posterior dimensions, 440 assessment, 459f blood supply, 428f, 429 breathing, 427 connection, 427 deep dorsal thoracic fascia, 443–54 deep layer, 454f middle layer, 453f superficial layer, 443, 445, 446, 449f distal thoracic spine, 443, 447f dorsal aspect, 364f, 442f dorsal thoracic fascial system, 441–54 deep layer (DL), 451, 453f, 454, 454f middle layer, 447–8, 450–1, 451f, 452f, 453f superficial layer, 445, 446, 449f dysfunctions related to, 427–66 functions, 427 innervation, 428f intercostal muscles, 441f intrinsic mobility, 427 left dorsal wall, 442, 445f left side of dorsal thoracic area, 448f lifting trapezius from, 364 longitudinal stroke applied to intercostal spaces, 462f applied to thoracolumbar fascia in quadruped position, 461f applied to thoracolumbar fascia in sitting position, 460f lymphatic system, 428f, 429 mechanics, 429–30 neurovasculature and lymphatic system, 429 pathological remodeling of thoracic wall, 429

protection, 427 structure, 427–8 superficial dorsal thoracic fascia, 441–3, 444–6f thorax as an integrated system, 428–9 see also left posterior thoracic fascia TLF see thoracolumbar fascia (TLF) TMD see temporomandibular disorder (TMD) “to be named” ligament (TBNL), 366 tongue and chewing, 340 extrinsic and intrinsic muscles, 359 forward head posture, 373t, 378t motor innervation, 360 myofascial system, 338, 339f myofascial complex, induction of, 422f prolongation, hyoid serving as, 359 tongue–mandible–hyoid system, 338, 360 see also mouth Toro-Velasco, C, 252 touch analysis of, 264–5 as communication, 9–10 see also therapeutic touch Tozzi, P, 223, 248 transcutaneous electrical nerve stimulation (TENS), 252 transfacial veins, 64 transverse abdominal (TrA) muscle, 248 transverse carpal ligament (TCL), 499, 502 transverse cervicis, 310 transverse induction/transverse plane induction, 284, 285f, 398f, 466f transverse retinacular ligament, 506 transverse stroke, 270, 271t, 272f applied to back (cross hands induction), 463f applied to biceps brachii, 533f applied to carpal tunnel, 523f applied to flexors of forearm, 527f applied to posterior cervical complex, 425f applied to synovial sheaths of thumb, 519f applied to temporal area, 401f applied to triceps brachii, 536f physiological effects, 268f trapezius muscle, 116, 122f trauma and dysfunction, fascial, 189–205 adaptive response and injury, 191 causes of dysfunctional process, 190f cell differentiation, 191 cell migration, 191 collagen remodeling and repair, 198 common nature of, 189–90 “destabilized” fascial system, 196 dysfunctions criteria gastrointestinal, 229, 230f, 231–2 viscerofascial, 226–9, 230f and ECM, 192f, 193f, 195f fascial system, trauma to, 191–8, 195f gastrointestinal (Rome IV criteria), 229, 230f, 231–2 immunomodulation, 198–9 matrix and application of mechanical forces, 192f, 193f nerve damage, 180 pathogenesis, 191

permanent tissue damage, 196–7 post-traumatic conditions, 184, 505 remodeling, 196–8 tumor, 194f viscerofascial dysfunctions, criteria in myofascial induction, 226–9, 230f treatment see myofascial induction/Myofascial Induction Therapy (MIT); therapeutic considerations triangles, neck, 380–3 anterior, 381–2 posterior, 382–3 triceps brachii cross hands procedure applied to, 538f longitudinal stroke applied to, 537f transverse stroke applied to, 536f trigeminocervical complex, 341f trigeminocervical complex (TCC), 340, 341f, 342 trophoblast, 105 trunk posterior aspect, 57f vascularization and mechanical continuity of superficial fascia, 36f tympanomastoid cleft, 332 tympanomastoid fascia, 332–3

U

ulnar nerve entrapment, 314t, 506 ulnar fossa, vascular system, 60f ultrasound imaging, 158–9, 163f, 247, 504 sham therapy, 249 Ünal, M, 247 unembalmed cadavers, dissection of, 1, 2, 85–96 extramuscular pathway, 163 force transmission, 86, 88, 89f, 90f, 91f, 155 increase in muscular insertion surface, 94 muscle separation, 95f, 96f compartments, 94 friction reduction, 96 interosseus septa, 96 Newton’s laws, 96 protection, 86, 87f, 88f reinforcement, 90, 92f, 93–4 stabilization, 93f, 94 studies, 7, 9, 27 superficial fascial system (SFS), 39, 50 see also dissections; embalmed cadavers, dissection of unwinding, fascial, 284–6, 287t, 288f upper extremity anatomical considerations related to continuity of fascial system, 468f, 473–86 anatomical features, 468f arm and forearm structures, 475f, 476f, 477f, 494–9 assessment, 526f, 532f brachial fascia, 487f, 494–5, 496f, 497, 497f clinical features of myofascial dysfunction, 503–7 deep fascia, 72f, 474, 480f, 481f, 482t, 484t deep layer (DL), 487–94 superficial layer, 486, 487f deltoid fascia, 487

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INDEX continued upper extremity (Continued) dysfunctions, 467–553 clinical features of myofascial dysfunction, 503–7 elbow anterior elbow retinaculum (lacertus fibrosus), 480f, 497–8 posterior elbow retinaculum, 498, 499f entrapment neuropathies, 504–7 fascial compartments, 475, 477–8, 481f, 482f, 485–6 arm, compartments of, 477, 478, 482t, 483f deltopectoral area, 475, 477, 482f forearm, 478, 484–5t, 485–6, 486f innervation, 473 neurovascular and lymphatic structures, 473–4 right upper extremity, posterolateral aspect, 477f scapular dyskinesis, 470–3 scientific evidence for MIT, 249 shoulder complex structures/shoulder girdle fascial system, 486–94 deep layer (DL), 487–94 deltoid fascia, 487 superficial layer of deep fascia, 486, 487f sliding platform concept, 470 superficial fascia, 474, 475f, 476f, 477f, 478f, 479f synergy absolute and relative synergies, 470 as part of General System Theory, 467, 469–73 upper extremity as a synergistic structure, 470 usefulness of muscle synergies, 469 see also arm; forearm; hand; left upper extremity, deep fascia; shoulder complex structures/ shoulder girdle fascial system upper limb anterior aspect, 162f see also arm upper quadrant algorithm, 297f assessment, 293–325 functional, 297, 299t, 300t global functional, 298–307 mobility, 304–7 neural tests, 312, 318f, 319f neurofascial components, 307, 310–12 process of, 296–322 stability, 298, 300–1 viscerofascial components, 318, 320 biomechanical aspects, 295 characteristics, 295–6 clinical reasoning process, 293–4 cognitive aspects, 295–6 deep fascia, 72f fascial continuity in, 37f as a functional complex, 296 history taking, 296–7 lymphatic and superficial circulatory components, 320–1

metacognition, 293 neural tests, 312, 318f, 319f neurofascial components brachial plexus, 310–11, 312f cervical plexus, 307, 310 nerve entrapment syndrome, 311–12, 313t, 314t, 315t, 316t, 317t, 318t neurological aspects, 295 peripheral nerves, 312, 315–17t red flags, 322 right upper quadrant, 233, 320 upper trapezius (UT), 248, 357, 365 Urresti-López, FJ, 248 Useros, AI, 251

V

vagus nerve, 360 van der Wal, J, 2 Vaquero Rodríguez, A, 251 Varela, FJ, 5 vascular dysfunction, scientific evidence for MIT, 251 vascularization of fascial system, 177–9 Vásquez, C, 249 venous system epifascial system, 64 essential anatomy/behavior, 64–6, 67f, 68f great saphenous vein, 66 photomontage, 64f saphenous fascia, 66 small saphenous vein, 66 subfascial system, 64 and superficial fascia, 63–8 vertebral anterior longitudinal ligament, 361 “vertebrodural ligament” (VDL), 366 Vesalius, 432 video stereophotogrammetry, 341 Vieira, ELC, 162 Vilensky, JA, 450, 451 vinculin, 130 visceral fascia continuity, 223 morphological characteristics of fascial layers, 28 procedures see visceral procedures terminology, 76 tests see visceral tests visceral procedures and tests, 287, 289 algorithm sequence, 225f continuity of visceral fascia, 218, 223 gastrointestinal dysfunctions criteria (Rome IV criteria), 229, 230f, 231–2 palpation, 228 red flags, 232 structures likely to be affected by dysfunctions, 229t

viscerofascial dysfunctions criteria, 230f, 320 visual examination, 227 viscerofascial components, upper quadrant, 318, 320 viscerofascial dysfunctions criteria, 226–9, 230f, 320 viscoelasticity, changes in, 128, 280–1 Vleeming, A, 162 vomer, myofascial induction, 408f von Bertalanffy, L, 4, 16, 21, 245 Vorländer, D, 276

W

Waddell, G, 5 Waggett, AD, 132 Wakeling, JM, 158 Wang, JH, 133 Ward, R, 10 washboard syndrome, 470 Wasserman, JB, 249–50 water, importance, 134 Weiss, P, 104–5 Weygand, C, 276 whiplash-associated disorder (WAD), 379 Wilke, J, 200, 472 Willard, FH, 163–4 Windisch, G, 498 Wolff’s Law, 275 Woollacott, MH, 212 World Health Organization (WHO), definition of health, 3 Worrall, J, 245 wrinkles, 47f wrist flexion torque in, 160–1 palmaris longus tendon, 501 ventral aspect, 501f see also hand

X

Xu, Q,

366

Y

Yaman, A, 161 yellow ligament, 165 Yoshitake, Y, 165, 471 Young’s modulus, 124, 125 Yu, WS, 161

Z

Zhang, C, 158 Zheng, N, 365 zones of adherence, 52, 432, 433 zygomatic arch, 332 zygomatic area, myofascial induction, 399f zygomatic ligament, 329

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