Guiding Principle I: Discussion and rationale

The idea that a huge percentage of chronic pain is not caused by the immediate structures (such as inflammation, nerve compression or mechanical impingement) but is secondary, mediated through the fascia and skeletal muscle … somehow. In other words the body intelligently ‘refers’ pain to the site of mechanical dysfunction or potential injury. So the pain is just the messenger. A very intelligent and intentional messenger.

I have come to this conviction simply because every week in a clinical setting I am resolving chronic pain that has a clear mechanical or physiological explanation. For example the DOA in the knee joint is obvious even to the uneducated observer. The enlarged femoral and tibial plateaus make the joint look, not swollen, but ‘bigger boned’ than the healthy knee. It has been like that for years now. Yet manipulation to muscles and tendons that act on that joint resolve the pain. Pain that we all assumed was inflammatory or mechanical just wasn’t.

Strength, range of movement and proprioception . . .

To continue with the fascinating observations, when the muscles and tendons are skilfully, even briefly, manipulated not only is pain resolved but strength improves – markedly. Range of movement improves – dramatically. And proprioception improves considerably. (Improvement in proprioception is most obvious in the scenario of the peroneal myofascial complex and ankle stability).

What we are observing is clearly the resolution of a deliberate inbuilt mechanism of the body that refers pain, restricts movement, ‘dumbs down’ proprioception and reduces strength. All of these symptoms are traditionally treated separately and with other methods.

• For the pain – anti-inflammatories, pain killers, steroidal injections and so on.
• For the proprioception and strength – strength and coordination exercises to ‘build up’ the weak muscles.
• For the range of movement – stretching and massage.

Deliberate shutdown . . .

Yet all of these aspects find lasting improvement in the space of a few minutes with the right manipulation.

Are we then dealing with smaller, weaker muscles that require strengthening or are we dealing with muscles that have been ‘deliberately temporarily shut down’ by 30 per cent through a built-in physiological mechanism?

Are we dealing with a loss of proprioception due to simply to underuse or are we dealing with joint and muscle mechanics that have been ‘deliberately temporarily decreased’ through a built-in physiological mechanism?

Are we dealing with restricted movement that has simply occurred due to underuse or are we dealing with a ‘deliberate temporary restriction to ROM’ through a built-in physiological mechanism?

In most cases of chronic pain there is mechanical fault, injury or structural degeneration present however to immediately ascribe the pain, weakness and restriction directly to that visible structural dysfunction is a mistake. The body is simply smarter than that.

What is the mechanism?

Many years ago I grew convinced through my clinical experience that fascia (somehow) mediates pain, biomechanical restrictions and retards proprioception. To my delight, the more I read the latest research the more this hypothesis seems to have support.

What are the scientists saying?

The young and fertile field of functional anatomy and fascial mechanics is fascinating. Only a handful of years ago the International Fascia Congress was inaugurated. This conference brings body workers and scientists together. The scientists present their latest research and the practitioners present their clinical observations. The content shared at this conference provides some of the best theories and evidence based research into the anatomy and function of the fascia. The book Fascia – The Tensional Network of the Human Body (Schleip, Findley, Chaitow, Huijing) is a compilation of several of the papers presented at these conferences and is a brilliant asset. I refer to it often.

Fascia – Wow, this stuff is rich.

Fascia, that substance that has historically been viewed as a benign connective substance that ‘just holds stuff together’, is gradually gaining recognition as our ‘most important perceptual organ’ (Schleip 2003). Langevin (2006) stated ‘It is likely that the connective tissue continuum of fasciae and fascial structures serves as a body-wide mechanosensitive signalling system with an integrating function analogous to that of the nervous system.’

Other scientists have found that compared with the skeletal muscle system, the interconnected fascial network not only has a much greater surface area than skeletal muscle, skin or any other body tissue but it is also innervated by approximately six times as many sensory nerves as the skeletal muscle system.

The myriad of tiny unmyelinated proprioceptive and free nerve endings are found almost everywhere in the fascial tissues providing proprioception (movement and coordination feedback) and very likely nociception (pain feedback). Little experiments have demonstrated that joint fixations traditionally thought to be due to fascial ‘adhesions’ only released by force would in fact ‘relax’ under anaesthetic. This suggests that the fascia is not a lifeless adhesive ‘scar tissue’ type substance but is, at least in part, connected to the nervous system, able to relax and contract in some respect.

As a result ‘…today an increasing number of practitioners are basing their concepts to some extent on the mechanosensory nature of the fascial net and its assumed ability to respond to skilful stimulation of its various sensory receptors….’

Most of the sensory nerves in fascia are near the surface.

Now it gets really exciting for you as a body therapist. Immediately underneath the skin, epidermis and dermis is an enveloping layer of dense and areolar connective tissue and fat called the ‘superficial fascia.’ Marwan Abu-Hijleh et. al. explain that not only does this subcutaneous tissue (fascia) connect the skin to the underlying deep, dense fascia which invest muscles and aponeurosis throughout the body (1) but other scientists explain that this layer appears to be endowed with an exceptionally rich density of proprioceptive nerve endings (2). In other words, the ‘thinking’, highly responsive fascia is literally just under the skin.

Manipulate the fascia, not the muscle!

I am convinced through my clinical experience that fascia (somehow) mediates intelligent and deliberate biomechanical restrictions, pain and retards proprioception.

 

I am convinced that when I perform a deliberate and specific cross-fibre manipulation that creates tension / friction between the skin and the underlying muscle or bone, I am stimulating the fascial system rather than directly ‘loosening muscle’. 

 

This thinking has radically influenced the way I work, and my clinical results seem to back it up.

I am not pushing on muscle to ‘soften or stretch’ the muscle. I am not mechanically repositioning tendons. I am stimulating the fascia which in turn communicates (again, somehow) to the skeletal muscle to relax or lengthen. I am stimulating the fascia which in turn responds by ‘switching off’ the local tenderness. I am stimulating fascia which in turn restores proprioception.

If this is true then the clinical implications are huge . . .

If this is true then we may find that specific and brief manipulation to the fascia may communicate to a muscle to ‘release’ and lengthen eliminating the need to ‘massage the muscle loose’. If this is true then we may find that less is more; that time following a brief manipulation, giving the fascia opportunity to respond, may be more valuable than constant massage for 30 minutes.

I do believe that pain, and for that matter restricted movement and proprioceptive retardation, are intelligent messengers wired into the body designed to activate intentionally and as such can be ‘switched off’ and I believe that the fascial network may just be the anatomy of the body that somehow mediates these effects.

So really, this is not the end of the conversation but just the beginning.

References

1. Abu-Hijleh MR, Roshier AL, Al-Shboul Q, et al. 2006. The membranous layer of superficial fascia:evidence for its widespread distribution in the body. Surg. Radiol. Anat. 28, 606-619

2. Tesarz J, Hoheisel U, Wiedenhoefer B, et al. 2011. Sensory innervation of the thoracolumbar fascia in rats and humans. Neuroscience 194, 302-308