The fascial element in Osteopathic practice 2 – part two

ASOMI College of Sciences is engaged in osteopathy and health. Therefore, ACS adopted a scientific paper by Dr. Paolo Tozzi about the fascial element in Osteopathic practice. The article at the hand is the second part of the adaptation of the scientific paper by Dr. Tozzi. If you missed the first part of the article, click here to read it. This second and the last part includes also the bibliography. About the author: Paolo Tozzi, Master (Hons) Science in Osteopathy at Dresden International University and Bachelor (Hons) Science in Osteopathy at the European School of Osteopathy and a Bachelor Science (Hons) Physiotherapy at the Catholic University of Rome – Head of Academics Osteopathy at ACS Asomi College of Sciences / Asomi Academy of Osteopathy. Fascia in osteopathic treatment There are 3 main manual approaches to the fascia in osteopathic practice: direct approach – the affected tissue is brought against the functional barrier that is maintained until tensions melt; indirect approach – the dysfunctional pattern is exaggerated while a position of ease is found and maintained up to a release; combined approach – a point of ease and a barrier are consecutively or simultaneously engaged (Ward, 2003). Although myofascial release and fascial unwinding are probably the most common osteopathic fascial techniques in osteopathic practice (Johnson and Kurtz, 2003), there is a multitude of fasciae related techniques in osteopathic treatment due to the ubiquitous distribution of fascial tissue: from BLT to strain & counter strain, from articulatory to cranial and visceral techniques, including soft tissue work, from inhibitory pressure to effleurage maneuvers. Nevertheless, fascial osteopathic treatment has been proved on its efficacy, mainly at a post-operative stage (Stiles, 1976), for various conditions ranging from joint injury (Eisenhart et al, 2003) to sexual dysfunction (Martin, 2004). However, the majority of these studies were conducted on small population samples, or as pilot studies, or single clinical case studies, usually with a short follow-up, and occasionally with a poor control design (Tozzi, 2012). Up to now, any documented cases of injuries following osteopathic fascial treatment in the literature are available (Vick et al, 1996), whereas as a side effect, a myalgic flare may occur within the first 12 hrs after manual work (Ward, 2003). Major counterindications remain open wounds, fracture, gross joint instability, recent surgery or injury, deep vein thrombosis, aortic aneurysm, malignancy, and infections (O’Connell, 2010). Mechanisms underlying fascial release There may be several mechanisms underlying fascial release during or following osteopathic treatment:

• neuromuscular mechanism: especially indirect type of fascial techniques may unload muscle spindles while loading Golgi tendon organs (Van Buskirk, 2006). This may result in a modulation of muscle tone and of related fascial tension, which in turn may quiet the nociceptors and the correspondent facilitated spinal level (Kakigi and Watanabe, 1996), with a consequent modulation of ANS activity on blood and lymphatic flow;
• structural change: evidence suggests that the structure of the collagen matrix can be changed by manual therapy (Pohl, 2010). In people with chronic LBP, myofascial release of the thoracolumbar fascia has shown a scanned increase of its thickness, with the persistence of such changes for at least 24 hrs (Blanquet et al, 2010). However, a 3D mathematical model for fascial deformation has excluded that palpable sensations of tissue release following manual therapy may be due to plastic deformations of firm type of fascia, as fascia lata and plantar fascia, whereas this may be possible in thin and more elastic fasciae such as the nasal one (Chaudhry et al, 2008);
• viscoelastic change: the increase in sliding of the fascial layers, together with a decrease in pain following manual fascial work may be due to a transformation of the ground substance from its densified to a more fluid state (Findley, 2009). This would enhance the production of hyaluronic acid, together with the interfacial flow of various inflammatory mediators (Schultz and Feltis, 1996). Consequent modulation of ANS and primary afferent fibers activity may occur, possibly leading to a reset of aberrant reflexes underlying somatic dysfunction (Lund et al, 2002);
• fluid change: fascial work may increase the interplay of unbound water oscillations and calcium ion concentration while promoting interstitial fluid flow and bringing oxygenation and nutrients in tissues up to a normal concentration (Lee, 2008). This may in turn stimulate fibroblast proliferation and collagen production/alignment (Hinz et al, 2004);
• cellular response: manual loading of the fascia may cause changes through activation of fibroblasts response and different receptors present in the fascial tissue, leading to corrections of fascial hypertonicity and/or abnormal tissue collagen crosslinking (Khan and Scott, 2009). Note that fibroblast is highly responsive to direction, frequency, and duration of a therapeutic load, differentially regulating fibroblast and myofibroblast activity, ion conductances, and gene expression that may all come into play in the clinical efficacy of fascial treatment (Eagan et al, 2007). The finally therapeutic load may stimulate connective tissue repair and remodeling (Kjaer et al, 2009);
• chemical change: via an anandamide effect, fascial work may influence the endocannabinoid system – an endorphin-like system constituted of cell membrane receptors and endogenous ligands (McPartland et al, 2005). This system affects fibroblast remodeling, reduces nociception and inflammation in myofascial tissues, together with provoking cardiovascular changes, smooth muscle relaxation, and possible mood changes through its influence on the central nervous system (Ralevic et al, 2002). Fascial work may also produce the enhancement of cytokine pools from active fascial fibroblasts (Willard et al, 2010). In turn, cytokines may reduce edema, pain, fibrotic materials, even at sites distant from where the manual treatment is applied;
• autonomic mechanism: therapeutic touch may produce stimulation of pressure-sensitive mechanoreceptors in the fascia, followed by a parasympathetic response (Schleip, 2003). Under the parasympathetic influence, a change in local vasodilatation and tissue viscosity, together with a lowered tonus of intraracial smooth muscle cells may occur. Finally, in response to the proprioceptive input, the central nervous system may change muscle tone, allowing the therapist to follow myofascial paths of least resistance up to when release is gained. Fascial work may also produce modulation of hyperempathetic activity (Rivers et al, 2008) or upregulation of parasympathetic (Queré et al, 2009) normalizing various hemodynamic functions;
• epigenetic factors: mechanical signals, including therapeutic load, seem to be crucial regulators of cell behavior and tissue differentiation by affecting gene regulation at the epigenetic level, therefore producing a heritable reduction of DNA methylation (Arnsdorf et al, 2010). This process may regulate extracellular matrix composition and fibroblast activity involved in tissue repair and function (Bavan et al, 2011);
• other influences: most of the osteopathic fascial techniques require respiratory cooperation by the patient that seems to play a role in myofascial relaxation (Cummings and Howell, 1990), even in non-respiratory muscles (Kisselkova, 1976). In addition, oscillation and vibration are usually integrated during the application of many fascial techniques. It has been demonstrated that manual low-frequency oscillations can induce muscle relaxation, provoking a significant change in motoneuron excitability and an inhibitory effect on vestibular nuclei, inducing a psychogenic relaxation (Newham and Lederman, 1997). Oscillations may also promote inter-compartmental fluid flow through hydraulic mechanisms (Lederman, 1997), which may have a possible modulating effect on spinal excitability and the pain gate mechanisms in the CNS (Coghill et al, 1994.). Finally, vibration has been demonstrated to be a critical epigenetic factor in regulating the microenvironment of the extracellular matrix, thus providing a basis for reducing tissue adhesions and improving function. (Kutty and Webb, 2010)

In other words

To conclude, it seems evident that various factors may interplay with myofascial function and its ability to respond to treatment. However, the connective tissue may serve as a trait uniting all these elements, potentially sustaining an integrated understanding of the whole picture: ‘Since connective tissue plays an intimate role in the function of all other tissues, a complex connective tissue network system integrating whole-body mechanical forces may coherently influence the function of all other physiological systems. Demonstrating the existence of such a “meta-system” would therefore change our core understanding of physiology’ (Langevin, 2006).

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