Faculty Bibliography

Background and objectives: The aims of this study were to delineate the contribution of specific fascial layers of the myofascial unit to myofascial pain and introduce the use of ultrasound-guided fascial layer-specific hydromanipulation (FLuSH) as a novel technique in the treatment of myofascial pain. Materials and Methods: The clinical data of 20 consecutive adult patients who underwent myofascial injections using FLuSH technique for the treatment of myofascial pain were reviewed. The FLuSH technique involved measuring the pain pressure threshold using an analog algometer initially and after each ultrasound guided injection of normal saline 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^®). The outcome measured was the change in pain pressure threshold after injection of each specific fascial layer. Results: Deep fascia was involved in 73%, superficial fascia in 55%, and muscle in 43% of points. A non-response to treatment of all three layers occurred in 10% of all injected points. The most common combinations of fascial layer involvement 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. Conclusions: The data support the hypothesis that multiple fascial layers are responsible for myofascial pain. In particular, for a given patient, pain may develop from discrete combinations of fascial layers unique to each myofascial point. Non-response to treatment of the myofascial unit may represent a centralized pain process. Adequate treatment of myofascial pain may require treatment of each point as a distinct pathologic entity rather than uniformly in a given patient or across patients.

Persistent scar pain associated with healed surgical incisions after a trauma is a common and potentially debilitating type of fascial pain. At present, there is no universally effective treatment for persistent surgical or post-trauma scar pain. Herein we describe the successful objective diagnosis of debilitating scar pain by Ultrasound (US) imaging. The sonopalpation of the fasciae and subcutaneous tissues seems to be relevant to diagnose the real cause of the pain and why not to monitor the treatment.

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 T_1ρ 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 T_1ρ-mapping evaluations, one before and one after the series of Fascial Manipulation^® (FM) treatments. After the first MRI evaluation, a Disability of the Arm, Shoulder and Hand (DASH) questionnaire was administered to quantify the symptoms and pain intensity. Patients then received three sessions of FM, once a week for 40 min each. A statistically significant difference was found between bound and unbound water concentration before and after FM treatment. Our preliminary data suggest that the application of the manual method seems to decrease the concentration of unbound water inside the deep fascia in the most chronic patients. This could explain the change in viscosity perceived by many practitioners as well as the decrease of symptoms due to the restoration of the normal property of the loose connective tissue. Being able to identify an altered deep fascial area may better guide therapies, contributing to a more nuanced view of the mechanisms of pain.

Objective: An inter and intra rater reliability (INTERR and INTRAR) study was designed.Methods: 71 subjects, with primary hip coxarthrosis, were included and randomly divided in a study group (SG= 36) and a control group (CG= 35) to assess the efficacy of the Fascial Manipulation® (FM®) method. The primary objective was the assessment of INTERR and INTRAR about movement verification (MV) and palpation verification (PV) of FM® performed by two physiotherapists (PtA and PtB). The secondary objective was evaluate the efficacy of FM® through MV, PV and pain score. Pain was assessed using the Numeric Rating Scale (NRS). SG received three weekly sessions of FM® byPtA. PtB re-evaluated all the subjects at the end of the study.Results: Results of the INTERR analysis showed for SG: MV (ICC= 0.92, k= 72.7%); PV (ICC= 0.91, k= 75.7%). For CG : MV (ICC= 0.95, k= 84.2%); PV (ICC= 0.90, k= 75%). Results of the INTRAR analysis for SG reported: MV (ICC= 0.82, k= 74,8%); PV (ICC= 0.60, k= 46.8%); for CG: MV (ICC= 0.93, k= 78.7%); PV (ICC= 0.84, k= 53.3%). Statistical significance were reported in NRS (p = 0.001), MV (p = 0.0003) and PV (p < 0.0001) with better results for SG using "Intention To Treat" method.Discussion: This study demonstrates that FM® assessment procedures have a high reliability even if applied by practitioners with basic experience. Furthermore FM® treatment can improve pain and ROM in individuals with primary coxarthrosis.

The assessment of soft tissue stiffness is important to evaluate many neuromusculoskeletal conditions. Several tools have been proposed for the assessment of stiffness, but ultrasonography appears to be most practical. The reflection of ultrasound waves as it travels through tissue enables assessment of tissue echogenicity, which is influenced by the characteristics of the sound wave as well as the characteristics of the tissue through which it passes, such as the amount of fat and fibrous tissue. However, tissue stiffness is not directly proportional to its echogenicity. Hence evaluation of echogenicity, as a stand-alone technique, is inadequate to describe its mechanical properties. The aim of this manuscript is to present a method of combining echogenicity evaluation by ultrasound and stiffness evaluation by palpation to better describe the mechanical properties of muscle using a stiffness-echogenicity matrix.

Chronic ankle instability (CAI) is one of the most common syndromes that occurs following an initial ankle sprain. Sprains are often correlated with recurrent sprains, loss of range of motion (ROM) and deficits in proprioception and postural control. The objectives were to evaluate the effectiveness of Fascial Manipulation^® (FM) as a preventative measure in semi-professional athletes with CAI, and to monitor the symptomatology, equilibrium and ROM of the injured ankle. A single-blinded randomized controlled trial was conducted in the rehabilitation department of a medical centre. Twenty-nine semi-professional male footballers were recruited. Nine subjects with no previous symptomatology, were assigned to a baseline group, twenty symptomatic subjects were randomized into either the study or the control group. All three groups followed a specific training program. The control group followed normal training protocols and received standard medical care. The study group received an additional three FM treatment sessions. Symptomatology and ROM outcomes were recorded for all players at baseline, before each treatment for the treatment group, and at 1-, 3-, and 6-month follow-ups. At one year, an additional follow-up on was performed via phone. Four severe ankle traumas and one mild ankle trauma were reported in the control group during the trial period. The 6-month outcomes in the study group showed statistically significant improvements. The 1-year follow-up reported the absence of any reported trauma in the study group. FM was effective in improving ROM and symptomatology in footballers with CAI. FM intervention was effective in preventing injury in the study sample.

Introduction: Pain, atrophy, and skin depigmentation are known side effects of corticosteroid injection, which can result in dysfunction of the superficial and deep fascia. Increase of stiffness in the superficial fascia can generate an entrapment of the cutaneous nerves with consequential alteration of the fat and skin (Stecco et al 2016), while stiffness of the deep fascia can irritate the nociceptor and generate decrease of sliding with the underlying muscle (Stecco et al 2013). We describe a case study of Fascial Manipulation (FM) to the superficial and deep fascia, resulting in the resolution of soft tissue atrophy and skin depigmentation at the injection site as well as decreased pain after a steroid injection into the pes anserine bursa. A 23-year-old female presented with three years of left medial knee pain that started abruptly after a fall. The patient was treated with a pes anserine bursa injection of triamcinolone. Three months after the injection, the patient developed an indentation and discoloration on the medial aspect of the left knee. Fourteen months post-injection the patient began FM. Methods: Ten sessions of FM targeting the superficial and deep fascia were performed. Results: The patient had near resolution of the discoloration and indentation at the pes anserine bursa with minimal to no pain at twenty-one month follow-up. Conclusion: FM is a potential treatment for the known side-effects of pain, atrophy, and skin depigmentation following an extra-articular soft tissue corticosteroid injection. References: Stecco, A., Gesi, M., Stecco, C., Stern, R., 2013. Fascial components of the myofascial pain syndrome. Curr Pain Headache Rep. 8, 352. Stecco, A., Stern, R., Fantoni, I., De Caro, R., Stecco, C., 2016. Fascial Disorders: Implications for Treatment. PM R. 8, 161-168.

Introduction: Spasticity, muscle stiffness, and contracture cause severe disability after central nervous system injury. However, current treatment options for spasticity produce muscle weakness which can impede movement and do not directly address muscle stiffness. Here we propose that the accumulation of hyaluronan within muscles promotes the development of muscle stiffness and report that treatment with the enzyme hyaluronidase increases upper limb movement and reduces muscle stiffness without producing weakness. Methods: 20 patients with unilateral upper limb spasticity received multiple intramuscular injections of human recombinant hyaluronidase with saline at a single visit. The safety and efficacy of the injections, passive and active movement, and muscle stiffness at eight upper limb joints were assessed at four time points: pre-injection (T0), within 2 weeks (T1), within 4- 6 weeks (T2), and within 3-5 months post-injection (T3). There were no clinically significant adverse effects from the injections. Results: Passive movement at all joints and active movement at most joints increased at T1, and persisted at T2 and T3 for most joints. The modified Ashworth scores also declined significantly over time post-injection. Conclusion: Hyaluronidase injections offer a safe and potentially efficacious treatment for muscle stiffness in neurologically impaired individuals. These results warrant confirmation in placebo-controlled clinical trials.