Faculty Bibliography

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.

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.

Hyaluronan (HA) is a high molecular weight glycosaminoglycan of the extracellular matrix (ECM), which is particularly abundant in soft connective tissues. Solutions of HA can be highly viscous with non-Newtonian flow properties. These properties affect the movement of HA-containing fluid layers within and underlying the deep fascia. Changes in the concentration, molecular weight, or even covalent modification of HA in inflammatory conditions, as well as changes in binding interactions with other macromolecules, can have dramatic effects on the sliding movement of fascia. The high molecular weight and the semi-flexible chain of HA are key factors leading to the high viscosity of dilute solutions, and real HA solutions show additional nonideality and greatly increased viscosity due to mutual macromolecular crowding. The shear rate dependence of the viscosity, and the viscoelasticity of HA solutions, depend on the relaxation time of the molecule, which in turn depends on the HA concentration and molecular weight. Temperature can also have an effect on these properties. High viscosity can additionally affect the lubricating function of HA solutions. Immobility can increase the concentration of HA, increase the viscosity, and reduce lubrication and gliding of the layers of connective tissue and muscle. Over time, these changes can alter both muscle structure and function. Inflammation can further increase the viscosity of HA-containing fluids if the HA is modified via covalent attachment of heavy chains derived from Inter-alpha-Inhibitor. Hyaluronidase hydrolyzes HA, thus reducing its molecular weight, lowering the viscosity of the extracellular matrix fluid and making outflow easier. It can also disrupt any aggregates or gel-like structures that result from HA being modified. Hyaluronidase is used medically primarily as a dispersion agent, but may also be useful in conditions where altered viscosity of the fascia is desired, such as in the treatment of muscle stiffness.

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.

BACKGROUND: Treatment of pubescent postural hyperkyphosis commonly includes postural exercises and auto-elongation. Myofascial imbalances can be involved in functional, sagittal plane deviations of spinal curves. This pilot-study assesses the effects of one manual therapy approach that addresses fascial dysfunctions (Fascial Manipulation((R))) in pubescent subjects with postural hyperkyphosis. METHODS: 17 subjects (mean age 11.8 DS 0.8; 9 males, 8 females) were evaluated for familiarity; psychological aspects; sport; pain; anteposition of shoulders, head, and pelvis; distance C7 and L3 from plumb-line; distance fingers to floor on forward bend. Each subject received 2-4 weekly sessions of Fascial Manipulation((R)). Parameters were evaluated before and after manual treatment, with a follow-up at 7 months. RESULTS: A statistically significant difference (p < 0.05) was present in all the parameters analysed before and after treatment and at a 7 month follow-up. CONCLUSIONS: Results suggest that Fascial Manipulation((R)) could represent an approach to integrate into treatment of postural hyperkyphosis in pubescent subjects.

CONTEXT: Osteopathic manipulative medicine techniques involve compressive and tangential forces to target the fascia. These forces are transmitted to the skin and adipose tissue before the fascia is encountered. Knowing the extent of deformation of these 2 tissue layers relative to the fascia will assist osteopathic physicians in evaluating techniques for manual therapies and adjusting these therapies to reduce patient discomfort and improve results. OBJECTIVE: To determine the magnitude of the forces transmitted to the skin, adipose tissue, and fascia, and to determine the magnitude of deformation produced in the skin and adipose tissue relative to the fascia using a mathematical model. METHODS: The large deformation theory of elasticity, valid for 3-dimensional deformations, was used to evaluate the forces that need to be applied such that a specified deformation is produced in any region of the skin, adipose tissue, or fascia layers. Similarly, if the forces are specified, then the deformation produced can be determined. RESULTS: The normal and tangential forces required to produce a deformation of 9% compression and 4% shear for the skin were 50 N and 11 N, respectively. Normal and tangential forces of about 100 N and 22 N were found for a similar deformation of fascia. For adipose tissue, these forces were 36 N and 8 N, respectively. In addition, the skin experienced more compression and shear-about 1.5 times as much as the fascia, and the adipose tissue experienced about 2.5 to 3.5 times the deformation of the fascia and 50% more than the skin when a given force was applied to the skin. CONCLUSION: The forces applied to the surface of the skin were transmitted through this layer and the adipose layer entirely to the fascia. Therefore, the skin and adipose tissue experienced the same magnitude of force as the fascia. However, the skin and adipose tissue experienced more compression and shear than the fascia.

Histolopathological studies have demonstrated a generalized increase in extracellular connective tissue in spastic muscles. It is known that increased connective tissue in an immobilized and contracted muscle reduces its compliance and could reduce the threshold for stimulation of spindle receptors in the muscle. Various authors have investigated how increased stretch-induced stimulation of spindles in muscles with stiffer connective tissue can contribute to spasticity. In this review, we compile evidence for the idea that the primary injury to the central nervous system that leads to muscle paresis also triggers changes in the viscosity of the extracellular matrix due to abnormal turnover of hyaluronic acid. Hyaluronic acid is a complex molecule that exhibits non-Newtonian behavior at higher concentrations, leading to altered connective tissue viscosity, which begins a vicious circle that exacerbates spasticity through reduced tissue compliance and potentiation of reflex mechanisms and fibrosis, and contributes to abnormal limb posturing, pain symptoms, and decreases in activities of daily living. The rationale for emerging treatments to break this vicious circle are discussed