Week 10

Deep Fascia and Chronic Pain ppt

Musculoskeletal conditions are leading cause is disability worldwide - 1.7 billion people

In US and Canada, musculoskeletal conditions are also the leading health care cost

Fascia:

  • 3D continuum of soft collagen containing loose and dense fibrous CT

  • Regulation of nearby structures through force transmission

  • Proprioception

  • Nociceptive

  • 2 types:

    • Deep

      • Surrounds bone, muscles, nerve and blood vessels

      • Aponeurotic= large, thick sheaths that envelope and connect muscles to other structures

      • Empysial= candy wrapper around muscles

      • plays a role n chronic conditions across the body

    • Superficial

      • Lymphatic, vascular, thermoregulation pathologies

Inclusion Criteria:

  • pathology known to be a potential cause of pain

  • Corresponding pain stems from itching fascia

  • Pathology has chronic nature

    • Low back pain, chronic neck, Dupuytren’s Disease, Palmer Fasciitis and polyarthritis, plantar fasciitis, fibromatosis of plantar fascia, ITB syndrome

Thoracolumbar fascia (TFL) and low back pain

  • TLF = Deep fascia of lower back consisting of several layers separating paraspinal muscles from muscles off posterior abdominal wall

  • LBP has estimated lifelong prevalence of 50-80%

    • Majority of cases are non-specific or idiopathic

  • Presence of Nociceptive in TFL

  • Main pathological hypotheses

    • Fibrotic process and/or inflammatory process

  • Langevin, et al., Patients with LBP has a decrease in shear strain about 20% (they could tolerate less strain)

    • Hypothesis:

      • Increased stiffness causes long-term inflammation

      • Fibrotic process led to tissues contracture and pain

  • Other animal studies suggested that local injury and decrease in movement may cause TFL stiffness

  • Myofibroblasts have been associated with fibrotic conditions and have been found in the TFL

Fibrotic process:

  • Stecco, et al., proposed that stiffer tissue could stretch nerve endings leading to excitation, causing pain

Inflammatory process

  • increased stiffness can cause long term inflammation when can cause chronic pain

    • Schiller, et al., injected hypersonic saline into human TFL

      • Nociceptive stimulant

      • Led to longer pain durations than injections into subculture adjacent muscle tissues

      • pain descriptions of subjects included burning, throbbing, stinging

        • matches the descriptions of symptoms found in patients with LBP

    • Nociceptive stimulants are released during inflammatory processes

Deep Cervical Fascia (DCF) and Chronic Neck Pain (CNP)

  • DCF composed of investing, pre-tracheal, and pre-vertebral layers of fascia

  • Safari et al, found there was ~ 288.7 million cases on chronic neck pain in 2017 alone

  • Stecco, et al., studied healthy individuals and those with chronic neck pain in an RCT. Those with CNP had:

    • Significantly reduced ROM indicating tissue stiffness

    • Increased fascia thickness

    • Responded positively with fascia manipulation therapy

Palmer Fascia and Dupuytren’s Disease (DD)

  • palmer fascia = deep fascia on palm of hand

  • Most common condition associated with this fascia is DD

    • Affects 8.2% of the world population

    • Characterized by tightening of fascia & formulation of nodules along longitudinal lines of tension

    • Fibromatosis = benign growth of fibroblasts and myofibroblasts

    • Idiopathic

      • Genetic factors

      • Environmental factors: manual laborers, smoking, alcohol

      • Underlying conditions: diabetes

      • Possible autoimmune

    • Many researchers have found increased densities in free nerve endings in affected individuals

      • Despite this, most do not have debilitating pain

    • But pain can be seen in some during beginning onset of condition

    • Macrophages, myofibroblasts & pro-inflammatory cytokines have also been found

      • Leads to tissue stiffness

    • Alterations ECM

      • Decreased collagen I to collagen III ratio

      • Sign of unresolved chronic inflammation

Plantar Fasciitis (PF)

  • deep fascia of sole of foot

  • Most common plantar fascia

  • Idiopathic

    • Possibly excessive overload and strain

      • Micro trauma leading to inflammation / degeneration

  • Nerve endings in plantar fascia

  • Idea of PF being an inflammatory condition has been challenged

    • Many studies have found a lack of inflammatory markers in PF cases

    • Perhaps a degenerative process without inflammation - Fasciosis

  • May also be a local inflation in early stages of a localized trauma

    • Inflammation does not present in later stages

    • Most research focuses on late-stage patients

  • May also be characterized by collagen composition

    • Type III vs Type I

  • Tends to happen ore in people with flat feet

  • Responds well to Fascia manipulation, Gastroc/soleus release, eccentric exercise, shoe modifications

ITT and ITB syndrome

  • Deep fascia of outer thigh

  • IT band syndrome is considered an overuse syndrome

    • Common in runners

      • Rate of 5-14%

  • Believed to result from increased compression between ITT and lat. fem condyle

  • Free nerve endings in ITT

  • Patients have increase in Collagen III

  • Responds well to fascia manipulation

  • Stretching the Tensor Fascia Latae, glute med. stretching and bracing

    • Trying to stretch ITB is futile

  • Patients may also complain of snapping hip superiorly

    • Band snapping over the greater trochanter

  • And lateral knee Pain

    • Insertion on Gerdy’s tubercle (Lateral condyle of tibia)

What is Fascial Manipulation?

  • manual treatments of myofascial tissue

  • Includes but is not limited to IMHO

    • Instruments assisted soft tissue mobilization (IASTM)

    • Cupping

    • Pin & stretch (ART if you’re certified)

    • Post isometric relaxation (PIR)

    • Dry needling and acupuncture

    • Some people may include K-taping