Faculty Bibliography

Introduction/Background Neurophysiological Mechanisms of Myofascial pain: The Role of Central Sensitization and Neurogenic Inflammation in the Pathophysiology of Myofascial Pain Syndrome by John Srbley Pathophysiology of Deep Fascia: Biochemical Alteration of the Extracellular Matrix and its Role in Sensitization by Antonio Stecco Spinal Segmental Sensitization in Myofascial Pain Syndrome: Integrating Pain Mechanisms with Objective Physical Findings and Treatment Strategies by Jay Shah WORKSHOP DESCRIPTION: This comprehensive session presents knowledge emerging from the pain sciences in a clinically accessible way. It will explore the roles that active myofascial trigger points (MTrPs), the three dimensional fascial system and its pathophysiology, the dynamic nature of sensitization, and the presence of quantitative, reproducible physical findings play in the evaluation and management of chronic myofascial pain and dysfunction. Spinal segmental sensitization (SSS) is a hyperactive state of the dorsal horn caused by persistent nociceptive bombardment. Painful MTrPs and stiff deep fascia are common sources of persistent nociception that cause SSS and chronic myofascial pain. Conversely, maladaptive changes in subcortical structures and dysfunctional descending inhibition may cause somatic tissue abnormalities. Common peripheral manifestations include dermatomal allodynia/hyperalgesia, sclerotomal tenderness, MTrPs within the affected myotomes, and dense deep fascia. Non-pharmacological treatments like dry needling, fascial manipulation, and acupuncture will be discussed. These techniques aim to deactivate MTrPs, decrease fascial stiffness, normalize the threshold of nociceptors, desensitize affected segments, and neuro-modulate subcortical dysfunction, providing long-term pain and symptom relief. The underlying physiology and clinical application and interpretation of the Windup Ratio (WUR) and the Mechanical Pain Threshold (MPT) Quantitative Sensory Testing (QST) outcomes for the assessment of central sensitization and the chronic myofascial pain patient will be discussed. The diagnostic and treatment techniques presented in this seminar apply to the management of various chronic musculoskeletal pain conditions. This underlying rationale and the resultant analytical process guide the clinician to identify the active MTrPs to be treated and reduce nociceptive bombardment from irritated nociceptors.

Introduction/Background Myofascial pain is a common clinical entity with a high prevalence (Skootsky, 1989). However, understanding of pain contributions from specific fascial layers of the myofascial unit (superficial fascia, deep fascia, and muscle) needs further elucidation (Gebhart, 1994). The objectives of this study were to delineate the contribution of specific fascial layers of the myofascial unit to myofascial pain using fascial layer-specific hydromanipulation (FLuSH), an ultrasound guided injection technique that can be used in the diagnosis and treatment of the specific fascial layers contributing to myofascial pain. Methods The clinical data of 20 adult patients who underwent myofascial injections using FLuSH technique for the treatment of myofascial pain were reviewed. The pain pressure threshold was measured using an analog algometer initially and after each ultrasound guided injection of normal saline (Kongsagul, 2019) into the specific layers of the myofascial unit (superficial fascia, deep fascia, or muscle) in myofascial points corresponding with Centers of Coordination/Fusion (Fascial Manipulation^®). Any change in the pressure algometer greater than 5.8 N/cm² of pressure in pressure tolerance was categorized as an improvement in pain response (De Meulemeester, 2017). Results Treatment of the deep fascia resulted in clinical improvement of pain pressure threshold in 73%, superficial fascia in 55%, and muscle in 43% of injected points. A non-response to injection of all three layers occurred in 10% of all injected points. The most common combinations of fascial layers contributing to pain in a given point were deep fascia alone in 23%, deep fascia and superficial fascia in 22%, and deep fascia and muscle in 18% of injected points. Each individual had on average of 3.0 ± 1.2 different combinations of fascial layers contributing to myofascial pain. Conclusion Multiple fascial layers likely contribute to myofascial pain. For a given patient, pain may develop from discrete combinations of fascial layers unique to each myofascial point, and each individual point may require treatment as a distinct pathologic entity rather than as a uniform process in a given patient or across patients.

Introduction/Background Diagnosis and management of musculoskeletal pain is a major clinical challenge. Following this need, the first aim of our study was to provide an innovative magnetic resonance technique called T1ρ to quantify possible alterations in elbow pain, a common musculoskeletal pain syndrome that has not a clear etiology. Five patients were recruited presenting chronic elbow pain (>3 months), with an age between 30 and 70 years old. Patients underwent two T1ρ

Introduction/Background The diabetic foot, in its various forms, represents a growing problem in the general population and an economical burden for our medical systems due to the correlated disability. Charcot foot represents a severe form of diabetes"™ podiatry complications. Diabetic neuropathy, peripheral vasculopathy, susceptibility to infections and anatomicalhistological alterations of soft tissues and bones contribute, most of all, to the development of progressive deformities which alter the biomechanics and functionality of the foot [1]. Increasing attention to this complication of diabetes has already expanded to the study of soft tissues in particular to the plantar fascia [2] but not the crural fascia. The purpose of this study was to measure and compare, by US imaging, the thickness of deep/muscular fasciae in different points of the foot and leg. Methods We enrolled 15 diabetic patients and 16 healthy volunteers and we assessed the Ankle-Brachial Index (ABI) and the Neuropathy Disability Score (NDS). Then the patients filled in the surveys SF-12 and Neuropathy Symptoms Score (NSS). We performed a series of ultrasound scans of the foot and leg in both groups. In according to Pirri et al [3], we measured the crural and the plantar fascia at different regions and levels. Results The results of the ultrasound imaging measurements of Charcot patients showed a statistically significant positive linear correlation (p<0.0001). Conclusion The study carried out shows that the plantar fascia is not the only fascial structure to be altered in Charcot"™s foot. The changes in fascial thickness appear to be early findings in the natural history of diabetic disease. Moreover, the thickening appears to be directly related to the development of diabetic complications. Ultrasound Imaging of the fasciae can be considered as a diagnostic assessment in the follow-up of the Charcot foot patient.

Introduction/Background Hypermobile Ehlers-Danlos syndrome (hEDS) is a heritable connective tissue disorder characterized by generalized joint hypermobility, joint instability, and skin changes. The hEDS population experiences a high burden of myofascial pain (Bénistan, 2019) with a complex pathophysiology. Myofascial pain may correspond to changes in the extracellular matrix (Menon, 2020). Understanding of how fascial stiffness and densification in the extracellular matrix correlates with the clinical presentation of myofascial pain in hEDS is lacking. The objective of this study was to investigate the structural changes in fascia in hEDS. Methods 1) A series of 65 patients (26 with hEDS, 39 subjects with neck, knee or back pain without hEDS) were examined prospectively. The deep fascia of the sternocleidomastoid, iliotibial tract, and iliac fascia were examined with sonoelastography. The thicknesses and strain indices (comparing fascia to muscle) were measured. One-way analysis of variance was used to compare differences between groups. 2) Three patients with hEDS underwent low-dose onabotulinumtoxinA injections for cervical dystonia (Simpson, 2016) at myofascial sites selected using Fascial Manipulation® diagnostic sequencing technique. Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) (Dashtipour, 2019) and thickness of the deep fascia of the sternocleidomastoid were measured pre and postinjection. Results hEDS subjects had a higher mean thickness (1.8±0.3mm) in sternocleidomastoid deep fascia compared with nonhEDS subjects. There was no significant difference in thickness of the iliac fascia and iliotibial tract between the groups. hEDS subjects had lower average strain indices (reduced differential in softening of the fascia structures compared with their associated muscles) compared with their non-hEDS counterparts with pain. After onabotulinumtoxinA injection, the patients clinically improved by 16 points on TWSTRS with 0.28mm decrease in thickness of the sternocleidomastoid deep fascia. Conclusion hEDS patients exhibited greater deep fascia thickness compared to non-hEDS counterparts. In myofascial pain, softening of the deep fascia may occur from increase in extracellular matrix content with a relative non-uniform increase in stiffness of the underlying muscle; this change is not as pronounced in hEDS. Low-dose onabotulinumtoxinA injections into sites of a myofascial continuity is a safe and effective treatment in hypermobile EDS patients and may influence pathological changes in the fascial system.

Introduction/Background Equestrian riders and their horses develop structural asymmetries(Ginés-Diaz et al., 2020) that are risk factors for injuries.(Cejudo et al., 2020; Ginés-Diaz et al., 2020) Whether these asymmetries develop from riding or prior to riding is unknown. The horse-rider interaction may play an important role in such asymmetries.(Martin et al., 2016) The purpose of this study was to explore the complex interplay of horse-rider asymmetries. Methods This study was IRB approved. Four riders and their horses and one trainer independently underwent a specific fascial assessment process"”the Fascial Manipulation® method (Stecco and Day, 2010)"”involving clinical examination of specific movements and palpatory verifications of specific myofascial points called Centers of Coordination (CCs) and Centers of Fusion (CFs). Dysfunctional segments were identified based on palpation and a hypothesis-driven differential by clinical history. The diagnosed fascial planes were compared between the horse and their riders. Results Three out of four riders had dysfunctional fascial planes identical to their horses. Of the three rider-horse couple with the same fascial plane dysfunction, 2 participated in the Hunter and Jumper disciplines and 1 in the Westernstyle riding disciplines. The 1 rider-horse couple that did not have the same dysfunctional plane participated in carriage driving. The trainer and a randomly selected horse did not have the same identified dysfunctional fascial sequence. Conclusion The correlation between riders and their horses"™ fascial dysfunctions suggest that horse-rider interaction may play an important role in the development of asymmetries(Gunst et al., 2019; Martin et al., 2016) and associated injuries.(Cejudo et al., 2020; Ginés-Diaz et al., 2020) The discipline of riding including additional forces applied to the horse (like carriages) may influence fascial line dysfunctions. This complex interplay of horse-rider fascial dysfunctions suggests that clinical interventions may need to address dysfunctions in both riders and their horses.

Low back pain (LBP) is the leading cause of disability worldwide. Most LBP is non-specific or idiopathic, which is defined as symptoms of unknown origin without a clear specific cause or pathology. Current guidelines for clinical evaluation are based on ruling out underlying serious medical conditions, but not on addressing underlying potential contributors to pain. Although efforts have been made to identify subgroups within this population based on response to treatment, a comprehensive framework to guide assessment is still lacking. In this paper, we propose a model for a personalized mechanism-based assessment based on the available evidence that seeks to identify the underlying pathologies that may initiate and perpetuate central sensitization associated with chronic non-specific low back pain (nsLBP). We propose that central sensitization can have downstream effects on the "myofascial unit", defined as an integrated anatomical and functional structure that includes muscle fibers, fascia (including endomysium, perimysium and epimysium) and its associated innervations (free nerve endings, muscle spindles), lymphatics, and blood vessels. The tissue-level abnormalities can be perpetuated through a vicious cycle of neurogenic inflammation, impaired fascial gliding, and interstitial inflammatory stasis that manifest as the clinical findings for nsLBP. We postulate that our proposed model offers biological plausibility for the complex spectrum of clinical findings, including tissue-level abnormalities, biomechanical dysfunction and postural asymmetry, ecological and psychosocial factors, associated with nsLBP. The model suggests a multi-domain evaluation that is personalized, feasible and helps rule out specific causes for back pain guiding clinically relevant management. It may also provide a roadmap for future research to elucidate mechanisms underlying this ubiquitous and complex problem.

Complex regional Pain Syndrome (CRPS) is a complex disease with articulate impact on the quality of life and its management is challenging. Ultrasound imaging can identify/assess different musculoskeletal structures that might have role in its pathogenesis. We present two cases of CRSP in whom B-mode ultrasonography and sonoelastography showed rigid retinacula associated with the symptomatology. Both patients were also/successfully treated with Fascial Manipulation®.

BACKGROUND:(FM), in comparison with conventional treatments in temporomandibular disorders (TMD) patients using a two-arm randomized controlled trial. METHODS:vs. Group 2: conventional TMD treatment). The Verbal Rating Scale (VRS), RDC/TMD, electromyography (EMG) and Pression/Pain Evaluation on Masseter and Temporalis Muscle were assessed with different times. RESULTS:= 0.001). CONCLUSIONS:can be used as an effective method for facial pain, being a rapid, safe and cost-effective approach to reduce pain, gain function and mouth opening that can be used prior to occlusion stabilization appliances.