Introduction To Manual Therapy PDF

Fascia (Osteopathic Point of View) By: Dr. Ahmed Abd El-Moneim Lecturer of Physical Therapy Beni-Suef University Coordinator of Prosthetics & Orthotics Technology...

Fascia (Osteopathic Point of View) By: Dr. Ahmed Abd El-Moneim Lecturer of Physical Therapy Beni-Suef University Coordinator of Prosthetics & Orthotics Technology Program (BTU) Diploma of Osteopathic Medicine, IAO (Belgium) Diploma of Therapeutic Nutrition, NNI  Definition and Aims of Manual Therapy  Manual therapy is a skilled, specific hand on approach to diagnose and treat soft tissue and joint structures for the purpose of: Decreasing pain Improving joint range and alignment Improving contractile and non-contractile tissue repair Improving extensibility and stability Facilitating function  Fascia  Fascia is the soft tissue component of the connective tissue system that permeates the human body, forming a whole-body continuous three-dimensional matrix of structural support.  It interpenetrates and surrounds all organs, muscles, bones, and nerve fibers, creating a unique environment for body systems functioning.  Fascia is a sheath, a sheet, or any number of other dissectible aggregations of connective tissue that forms beneath the skin to attach, enclose, and separate muscles and other internal organs.  Fascia  Connective tissue is the most diverse of the four major types of tissues.  Examples of connective tissue range from bone, which is rigid, to blood and lymph, which are fluid, to cartilage and adipose (fat), which are in between.  Another type of connective tissue is fascia. The term fascia in Latin means bandage or band. Fascial tissue is so named because like a bandage, it wraps around and connects structures.  Fascia  Every organ (the brain, the heart, the liver, the kidney, and each and every muscle) is contained in fascial sacs that contain each organ within its confines as well as allowing a lubricated movement between each organ and adjacent structures.  Types of Fascia  Fasciae are named, and subdivided, based on the region of the body where they are located. Fasciae are divided into: Myofascial tissue concerns itself with the fascia of the musculature. Arthrofascial tissue is the intrinsic fascial tissue of joints. It includes the fibrous joint capsule and ligaments. Visceral fascial tissue is involved with the internal visceral organs of the body cavities. Subcutaneous fascial tissue is the fascia located immediately deep to the skin.  Types of Fascia  Fasciae are divided into several types: 1) Fibrous fascia is called deep fascia or dense fascia. Fibrous fascia is denser, being composed of tough collagen fibers. It inhabits the bone and cartilage, as well as the ligaments, periostea, tendons, aponeuroses, and membranous coverings of muscle tissue that bind muscles to bones and other structures, as well as connect and ensheath muscle fibers. These examples of fibrous fascia are called muscular fascia or myofascia.  Types of Fascia  Important features about deep fascia: Dense connective tissue, well organized fibrous layer that covers the muscles. Deep fascia includes both the individual muscle pockets, and epimysium (covering the ends of the muscle), and also the broad, flat sheaths called aponeuroses (like the plantar aponeuroses- or the plantar fascia), that cover muscle groups. Function: A. Support and protect muscles and other soft tissue structures. B. Barrier against the spread of infection from the skin and superficial fascia into muscle compartment. Types of Fascia  Types of Fascia 2) Loose fascia is called areolar fascia or subcutaneous fascia. Loose fascia is composed of ground substance that mixes fluid, gel, and various types of collagen and elastin fibers, more loosely woven. This amorphous fascia is found in every area of the body, including the layer directly under the skin that acts to bind the dermis layer of the skin while allowing it to move easily in any direction. Loose fascia allows movement in the underlying visceral organs and between skeletal muscles.  Types of Fascia The tolerance of this tissue for movement is not limitless: areolar tissue becomes a very effective force transmitter when it reaches its elastic limit. Example: Put a finger on the opposite forearm and move the skin 1 cm in any direction; it will move easily. Now move the skin away from your wrist and toward your elbow 3 to 5 cm, and you will feel how the motion reaches a limit and suddenly you can feel the pull down to your wrist. This shows that areolar tissue, is in fact, a vital part of myofascial force transmission.  Types of Fascia  Important features about superficial fascia (Pannicular fascia): Directly underneath a slightly more superficial adipose tissue under the skin. Fibrous, elastic with variable fat content. Separates skin from muscles to allow sliding. Involved in thermoregulation, circulation and lymphatic flow. Connected to the deep fascia. Surrounds organs, glands, neurovascular bundles or fills unoccupied space. Superficial fascia is most distinct in the lower part of the anterior abdominal wall, perineum, and the limbs.  Types of Fascia It is very thin on the dorsal aspect of the hands and feet, sides of the neck, face, and around the anus. It is very dense in the scalp, palms, and soles. It contains: A. Subcutaneous muscles in the face, neck and scrotum B. Mammary gland C. Deeply situated sweat glands D. Localized groups of lymph nodes E. Cutaneous nerves and vessels  Types of Fascia  Although fibrous/dense and loose fascia seem quite different from each other, rather than being truly distinct, they share the same characteristic components and are actually a continuum of each other. Dense fascia contains a greater proportion of fibers; loose fascia contains a greater proportion of fluid/gel-like ground substance.  Types of Fascia 3) Meningeal fascia Surrounds the nervous system and the brain. The nerves responsible for proprioception are sensory nerves and they are embedded in the fascia (fascia can be thought of as the body’s largest sensory organ).  Types of Fascia 4) Visceral fascia Fascia surrounding the lungs, heart, and abdominal organs. Suspends the organs within their cavities and includes visceral ligaments that serve both to attach the organs to the body wall and allow for physiological motion. Visceral fascia is a protective double bag around each organ with a sliding layer in the middle to keep everything lubricated and moving. Types of Fascia  Components of Fascia  Fascia, like all connective tissues, is composed of three substances: 1) Cells 2) Fibers 3) Ground substance  The term extracellular matrix (ECM) is used to describe the fibers and ground substance of fascia, but the ECM includes other components of lymph, cytokines, and other cellular-exchange molecules. Components of Fascia  1) Cells  There are many different types of cells found in fascia.  Fibroblasts are the most common, and they come in several varieties.  There are also mast cells, macrophages, plasma cells and other white blood cells, and adipocytes.  1) Cells 1) Mast cells are responsible for the secretion of histamine, a chemical involved in inflammation. 2) Macrophages are phagocytic cells that engulf large substances including invading pathogenic microorganisms. 3) Plasma and other white blood cells are involved in fighting infection. 4) Adipocytes (also known as fat cells) store fat.  1) Cells 5) Fibroblasts (the most common). Fibroblasts have many functions: They produce the ground substance of fascia as well as the precursors for all the fibers that are found in fascia. They can resorb, or break down, fascia by secreting enzymes (proteinases, metallurases) that cut up and recycle old or damaged fascial arrays. They are involved in inflammation and wound healing, working to bring the edges of the wound back together.  1) Cells They are responsive to physical stresses placed on them. When physical stress is placed on fibroblasts, especially tensile (pulling) forces, fibroblasts respond by lining up along the line of pull and secreting proteins to make the collagenous arrays resistive to the force. 1) Cells  2) Fibers  Fibroblasts manufacture three types of fibers that are commonly found in fascia. They are collagen fibers, elastin fibers, and reticular fibers.  These fibers are impervious to water (hydrophobic); they are more-or-less wet all the time, like everything in the body, but they do not absorb or bind with water.  2) Fibers 1) Elastin fibers are responsible for the property of sustained elasticity, which is the ability to return to a shortened state after being stretched for a sustained period of time.  2) Fibers 2) Reticular fibers are a type of collagen fiber (Type III). They are given the name reticular fibers because they are cross linked to form a fine meshwork, also known as a reticulum. These immature collagen fibers are produced mostly in the embryo, though some survive into adulthood, but what their function is in the adult is not known.  2) Fibers 3) The most common fiber type found in fascia is collagen. There are approximately 26 different types of collagen fibers, named Type I, Type II, Type III, Type IV, and so on. Type I is the most common. It forms extremely strong fibrils that are inextensible, that is, they are highly resistant to tensile forces. Collagen is said to have great tensile strength. Because of its great tensile strength, collagen is the principal component of tendons, aponeuroses, and ligaments.  3) Ground Substance  The term ground substance is used to describe the medium in which the cells and fibers of fascia are located. It can be thought of as the background medium.  Ground substance ranges in quality from being a fluid to a gel. It is a essentially a fluid solution in which many large water-loving (hydrophilic) molecules are suspended.  The majority of these molecules are called proteoglycans because they have a protein and a carbohydrate component (proteo refers to protein; glycan refers to carbohydrate).  3) Ground Substance  Proteoglycan molecules have a feathery shape that resembles a fern (bottle brush) in appearance. They function to bind to and trap water in the spaces among them. By so doing, they keep the ground substance hydrated and prevent fascia from drying out and also provide a shock-absorbing viscosity.  3) Ground Substance  Keeping tissue hydrated creates the gel-like consistency that is characteristic of fascia, especially loose fascia. This gel-like consistency is important to lubricate fascial planes and its viscosity absorbs and dissipates forces that are placed on it, especially quick compression forces.  In dehydrated fascia, the ferns of the proteoglycans curl up, inhibiting glide and perfusion/hydration through the neighboring cells.  3) Ground Substance  Ground substance is also important for creating the fluid medium that is necessary for the transfer of nutrients and other substances between arterial, venous, and lymphatic capillary networks and cells (All the tissues of the body must dance be tween the viscosity required to stay together in a coherent shape and the hydration required for perfusion to and from the cells).  3) Ground Substance  The thicker gel-like consistency is also helpful in impeding the passage of pathogenic microorganisms that might cause infection.  The distinction between fibrous fascia and loose fascia is one of degrees of the relative proportions of fibers and ground substance. Some sources consider cartilage and bone tissues to be essentially more rigid forms of fascia.  The Fascial Web  From a larger design viewpoint, the various fasciae of the body interweave into one another to create a fascial web or fascial net.  Anatomy of The Fascial Web  The fascial web suspends and supports the entire body.  This web not only connects each of the regions of the body to one another, it also connects external with internal structures from just under epithelium of the skin deep into the bones, organs, and brain.  As Tom Myers, author and educator regarding fascial continuity, states, “This fascial web so permeates the body as to be part of the immediate environment of every cell.”  Physiology of The Fascial Web  The functions of the fascial web are many. 1) The ground substance of the web provides a fluid/gel medium through which nutrients, enzymes, cytokines, and neuropeptides perfuse to the cells, and carbon dioxide, waste, and messenger molecules pass back from each cell to the blood stream. 2) The sticky gel-like consistency of the ground substance provides an ideal setting in which the immune system’s “policemen” of white blood cells and phagocytic macrophages lie in wait to resist infection by pathogenic microorganisms if the skin barrier is broken.  Physiology of The Fascial Web  The two major body-wide functions of the fascial web are: 1) Creating a skeletal framework 2) Transmitting tension forces through the body  Skeletal Framework  The fascial web is a necessary complement to the skeletal frame work; together, the web and framework truly connect and support all parts of the body.  Cells do not simply float within the body but are instead held in place by several hundred types of these adhesive molecules. All cells are connected biomechanically to one another, and the messages of mechanics (tension and compression and their relatives, shear, bending, and torsion) that run through the fascial net are also transmitted to the cells.  Skeletal Framework  The fascial web extends down to the cellular level, creating a fine meshwork of intercellular fibers that attach to and connect every cell.  Skeletal Framework  The fascial web continues deeply to create an extracellular-to-intracellular web, connecting the fascia outside of the cells to the internal cytoskeleton framework within the cells.  These connections are made via internal cytoskeletal contractile actin filaments and compression-resistant microtubules attached to the cell’s membrane via larger internal focal adhesion molecules.  These focal adhesion molecules then attach to integrin molecules that traverse the cell membrane to then connect to fibronectin molecules just outside the cell.  These fibronectin molecules are attached in turn to collagen fibers in the fascial web. Skeletal Framework  Skeletal Framework  The fascial web is an intimate connecting network that communicates externally and internally with every cell of the body from the DNA to the coordination of organismic movement. These connections have already been shown to affect cell function and even gene expression within the cell.  Body movement (especially the organized body movement of exercise, stretching, walking, working, and sport) does more than just up the circulation to and metabolism of our cells; it can actually change how well the cells function.  Transmit Tension Forces  Not only does fascia function to transmit tension force locally (between a muscle belly and its bony attachment, or between 2 bones via a ligament), it distributes and disperses forces globally.  By virtue of the interconnectedness of the entire fascial web, forces are communicated through the body.  These transmitted forces are of two types: internal and external.  Transmit Tension Forces  Internal (endogenous) forces are created by the pressure and tension generated within the body (mostly by the contraction of the muscles). The jaw brings the teeth together with force that must be dissipated through the head. Breathing creates a series of forces that are handled by the bones, muscles, and fascia around the ventral cavity. The visceral organs are held to the body wall by fascial sacs and membranes, and in gait and sport, the momentum of the visceral organs must be absorbed by these fasciae and the biomechanical body.  Transmit Tension Forces  The myofascial web is likened to a series of ropes that interconnect the body.  Individual muscles may anchor at their attachment sites, but via the interconnected web, their forces transfer beyond and travel through the body.  Transmit Tension Forces  The muscles act as a contractile organs embedded within a body-wide fascial webbing. A myofascial meridian (an anatomy train) maps traceable tracks of muscles and fascia running in more or less straight lines within the body.  The muscles of a myofascial meridian are connected by fibrous fascia, so that they can act together synergistically, transmitting tension and movement through the meridian by means of their contractions.  Transmit Tension Forces  The external (exogenous) forces are often pulling forces that are placed on our body at a local spot. The application of these forces would cause damage to the body at the point where they were applied if the force were not resisted by the tensile force of fascia, as well as absorbed by being transferred and dissipated over more of the fascial web.  Transmit Tension Forces  These forces (gravity chief among them) also create compressive loads through the fascial web.  Example: Jumping off a stool creates large forces on the bottoms of the feet when we land; these forces are of course handled by the skeleton in part, but these forces are also distributed to the ligament, tendons, and other containing fascial sheets.