Faculty Bibliography

Introduction: Lateral Elbow Pain (LEP) is a common painful condition affecting the working population, however, its aetiology and best treatments remain as yet unknown. Wrist extensor intratendinous modifications are commonly reported (Obuchowicz & Bonczar 2016), although changes in the innervation and vascularization of the fascial layers superficial to the tendon itself have been observed too (Spang & Alfredson 2017). Common treatment of LEP includes exercise therapy, targeting the wrist extensor's tendinopathy (Cullinane et al 2014). Fascial Manipulation (FM) is a manual method for the treatment of musculoskeletal painful conditions (Day et al 2009). Its purpose is to normalize restricted fascial gliding through deep friction over specific points of the deep fascia, thus restoring the physiological afference to the nervous system and the distribution of forces around the periarticular tissues. The objective of this research is to verify the efficacy of FM in addition to a program of eccentric exercise, compared with eccentric exercise only. Methods: 29 patients (15M 14F, mean age 47) with clinical diagnosis of LEP were recruited and randomly assigned to two groups. The intervention group (n=17) underwent an individual 27-day eccentric exercise program and 3 sessions of FM, distributed over one month. The control group (n=12) underwent 30 sessions of eccentric exercise only. Outcome measures were Maximum Grip Strength and Pain Free Grip measured with a hydraulic dynamometer, Pain Pressure Threshold measured with a pressure algometer on the common extensor tendon, and function measured with the DASH scale. Assessments were performed by a blinded examiner before and after the intervention and at a follow-up of 1 and 3 months after completion of the treatment. The protocol conformed to the Declaration of Helsinki. Results: Both groups significantly improved in all outcomes at 3-months follow-up (p<0.05). The intervention group improved more than the control group at all follow-ups, but a significant difference was reached for DASH scale at 1-month follow-up (p=0.025) and for Pain Pressure Threshold after the treatment (p=0.029) and at 3-months follow-up (p=0.045). Conclusion: Eccentric exercise over one month has been shown to be effective for all outcome measures. The data trend seems to indicate that adding FM to exercise may add further benefits for pain relief. However, the small sample size stands as a limitation and hinders further statistical significance. References: Cullinane FL, Boocock MG, Trevelyan FC. Is eccentric exercise an effective treatment for lateral epicondylitis? A systematic review. Clin Rehabil. 2014 Jan;28(1):3-19. Day JA, Stecco C, Stecco A. Application of Fascial Manipulation technique in chronic shoulder pain-- anatomical basis and clinical implications. J Bodyw Mov Ther. 2009 Apr;13(2):128-35. Obuchowicz R, Bonczar B. Ultrasonographic Differentiation of Lateral Elbow Pain. Ultrasound Int Open. 2016 May; 2(2): E38-E46. Spang C, Alfredson H. Richly innervated soft tissues covering the superficial aspect of the extensor origin in patients with chronic painful tennis elbow - Implication for treatment? J Musculoskelet Neuronal Interact. 2017 Jun; 17(2): 97-103.

Rotator cuff tear is a common disease affecting patients after stroke. It's a cause of pain and dysfunction that may compromise normal stroke rehabilitation. For many cases there is still controversy between whether to use surgical or conservative intervention. Treatment for cuff tears range from physical therapy to surgery. This paper describes for the first time the effect of Fascial Manipulation(R) (FM(R)) on rotator cuff tear in a post stroke patient. A 69 year old female stroke patient with full absence of distal components of the tendons of the rotator cuff, functional limitations on active movement of shoulder flexion and abduction of the left arm and perceived pain scored 10/10 on the Visual Analogic Scale, was assessed and treat with one session of FM(R) A basic theory that explains the healing results of FM(R) is that mechanoreceptors, such as spindle cells and other receptors, are located in the deep fascia and activated when movement are performed. Increased viscosity of the deep fascia and muscles due to increased viscosity of hyaluronic acid (HA) molecules prevents the normal gliding of fascia during movement inhibiting normal proprioception and muscle function.

BACKGROUND & PURPOSE: Neck and low back pain (NLBP) are global health problems, which diminish quality of life and consume vast economic resources. Cost effectiveness in healthcare is the minimal amount spent to obtain acceptable outcomes. Studies on manual therapies often fail to identify which manual therapy intervention or combinations with other interventions is the most cost effective. The purpose of this commentary is to sample the dialogue within the literature on the cost effectiveness of evidence-based manual therapies with a particular focus on the neck and low back regions. METHODS: This commentary identifies and presents the available literature on the cost effectiveness of manual therapies for NLBP. Key words searched were neck and low back pain, cost effectiveness, and manual therapy to select evidence-based articles. Eight articles were identified and presented for discussion. RESULTS: The lack of homogeneity, in the available literature, makes difficult any valid comparison among the various cost effectiveness studies. DISCUSSION: Potential outcome bias in each study is dependent upon the lens through which it is evaluated. If evaluated from a societal perspective, the conclusion slants toward "adequate" interventions in an effort to decrease costs rather than toward the most efficacious interventions with the best outcomes. When cost data are assessed according to a healthcare (or individual) perspective, greater value is placed on quality of life, the patient's beliefs, and the "willingness to pay."

BACKGROUND: Postsurgical physiotherapy programs after total hip arthroplasty (THA) show important differences between types and numbers of treatment sessions. To increase functional recovery in postsurgical patients, manual therapy can be added to traditional physiotherapy programs. Fascial Manipulation (FM) has been demonstrated to be effective in decreasing pain and increasing muscular capacity. OBJECTIVE: To compare the effectiveness of FM when added to a standard protocol of care. DESIGN: Randomized controlled trial. SETTING: Rehabilitation center. PATIENTS: A total of 51 patients were recruited after total hip arthroplasty. Inclusion criteria were first THA surgery, posterior-lateral access, and onset of pain within a maximum 2 years. Exclusion criteria were previous hip or knee prosthesis, congenital hip dysplasia, elective THA secondary to trauma, real leg-length discrepancy (>/=1.5 cm), cognitive impairment, concomitant rheumatic pathology in acute phase, and serious comorbidities such as cardiac, respiratory, and/or neuromuscular pathologies. METHODS: Patients were randomized into 2 groups; both followed a standard protocol based on 2 daily sessions of active exercises for 45 minutes. In the study group, 2 sessions were replaced by FM. MAIN OUTCOME MEASURES: Functional outcome measures were collected before and after treatment and at the end of the rehabilitation program. The measures included the Harris Hip Score; Timed Up-and-Go test; articular range of motion in abduction, flexion, extension, and bilateral external rotation with heels together; and verbal numerical scale. RESULTS: Statistically significant differences were observed in degrees of flexion between the study and control group with 25.4 (+/-11.3) and 18.7 (+/-9.5), respectively (P = .04); for abduction with 16.8 (+/-7.0) and 11.1 (+/-6.1), respectively (P = .005); for extension with 16.2 (+/-4.9) and 9.3 (+/-3.8), respectively (P = .001); for bilateral external rotation with heels together with 8.3 (+/-4.3) and 5.5 (+/-4.6), respectively (P = .04); for the Harris Hip Score 23.3 (+/-8.9) and 14.5 (+/-8.5), respectively (P = .002); and for verbal numerical scale score 1.1 (+/-2.1) and 0.5 (+/-1.1), respectively. CONCLUSIONS: This study demonstrates that 2 FM sessions are able to significantly improve several functional outcomes in patients compared to usual treatment after THA.

In the past 15 years, multiple articles have appeared that target fascia as an important component of treatment in the field of physical medicine and rehabilitation. To better understand the possible actions of fascial treatments, there is a need to clarify the definition of fascia and how it interacts with various other structures: muscles, nerves, vessels, organs. Fascia is a tissue that occurs throughout the body. However, different kinds of fascia exist. In this narrative review, we demonstrate that symptoms related to dysfunction of the lymphatic system, superficial vein system, and thermoregulation are closely related to dysfunction involving superficial fascia. Dysfunction involving alterations in mechanical coordination, proprioception, balance, myofascial pain, and cramps are more related to deep fascia and the epimysium. Superficial fascia is obviously more superficial than the other types and contains more elastic tissue. Consequently, effective treatment can probably be achieved with light massage or with treatment modalities that use large surfaces that spread the friction in the first layers of the subcutis. The deep fasciae and the epymisium require treatment that generates enough pressure to reach the surface of muscles. For this reason, the use of small surface tools and manual deep friction with the knuckles or elbows are indicated. Due to different anatomical locations and to the qualities of the fascial tissue, it is important to recognize that different modalities of approach have to be taken into consideration when considering treatment options.

BACKGROUND: The therapeutic approach to chronic aspecific low back pain (CALBP) has to consider the multifactorial aetiology of the disorder. International guidelines do not agree on unequivocal treatment indications. Recommendations for fascial therapy are few and of low level evidence but several studies indicate strong correlations between fascial thickness and low back pain. This study aims at comparing the effectiveness of Fascial Manipulation(R) associated with a physiotherapy program following guidelines for CALBP compared to a physiotherapy program alone. METHODS: 24 subjects were randomized into two groups, both received eight treatments over 4 weeks. Outcomes were measured at baseline, at the end of therapy and at a 1 month and a 3 months follow-up. Pain was measured with the visual analogue scale (VAS) and the brief pain inventory (BPI), function with the Rolland-Morris disability questionnaire (RMDQ), state of well-being with the short-form 36 health-survey (SF-36). The mean clinical important difference (MCID) was also measured. RESULTS: Patients receiving Fascial Manipulation(R) showed statistically and clinically significant improvements at the end of care for all outcomes, in the short (RMDQ, VAS, BPI) and medium term for VAS and BPI compared to manual therapy. The MCID show significant improvements in the means and percentage of subjects in groups in all outcomes post-treatment, in the short and medium term. CONCLUSION: Fascial tissues were implicated in the aetiology of CALBP and treatment led to decreased symptomatic, improved functional and perceived well-being outcomes that were of greater amplitude compared to manual therapy alone.

The cervical fasciae have always represented a matter of debate. Indeed, in the literature, it is quite impossible to find two authors reporting the same description of the neck fascia. In the present review, a historical background was outlined, confirming that the Malgaigne's definition of the cervical fascia as an anatomical Proteus is widely justified. In an attempt to provide an essential and a more comprehensive classification, a fixed pattern of description of cervical fasciae is proposed. Based on the morphogenetic criteria, two fascial groups have been recognized: (1) fasciae which derive from primitive fibro-muscular laminae (muscular fasciae or myofasciae); (2) fasciae which derive from connective thickening (visceral fasciae). Topographic and comparative approaches allowed to distinguish three different types of fasciae in the neck: the superficial, the deep and the visceral fasciae. The first is most connected to the skin, the second to the muscles and the third to the viscera. The muscular fascia could be further divided into three layers according to the relationship with the different muscles.

The etiopathogenesis of Carpal Tunnel Syndrome (CTS) is multifactorial and most cases are classified as idiopathic (Thurston 2013). A randomized controlled trial was performed to compare the effectiveness of Fascial Manipulation((R)) (FM) and Low-Level Laser Therapy (LLLT) for CTS. This prospective trial included 42 patients (70 hands with symptoms) with clinical and electroneuromyographic diagnosis of CTS. The patients were randomly assigned to receive multiple sessions of FM or multiple session of LLLT. The Visual Analogic Scale (VAS) and Boston Carpal Tunnel Questionnaire (BCTQ) were performed at baseline, end of treatment and after three months. The group that received FM showed a significant reduction in subjective pain perception and an increased function assessed by BCTQ at the end of the treatment and follow-up. The group that received LLLT showed an improvement in the BCTQ at the end of the treatment but the improvement level was not sustained at the three month follow-up. FM is a valid alternative treatment for CTS.