The world of Soft Tissue Therapy has moved forward at a startling pace over the last decade with more and more people realising the virtue of its benefits. With this appreciation of the modality comes a more educated and demanding client who wants more than just relaxation, they want tangible results. Research and the techniques available are progressing at a rapid pace, meaning that we as therapists need to keep up to date with regard to these areas to ensure we are delivering effective treatments and real results for our clients.
One of the biggest areas of focus in recent times has been the role of Fascia within the body, and with that how to affect it using various forms of treatment. If you are still thinking of the body as simply a series of muscles that perform a set of prescribed actions then you are likely to be missing a trick when it comes to treating and rehabilitating your more complex clients. Let us take a look at Fascia, its role in the body and how we can use what we are learning to provide more effective and efficient treatment.
Fascia, also known as Connective Tissue is a dense network of collagen fibres that connect below the skin, around and through all organs, muscles, veins and bones. Fascia consists of collagen, elastin, water and cells, most of which are Fibroblast cells responsible for the maintenance and regeneration of the tissue1. In addition to its chemical make-up Fascia is extremely densely packed with sensory receptors. It is thought that there are about 6 times more mechanoreceptors in Fascia than in muscle making it highly responsive to stimulation2. The boundaries of where Fascia starts and where Fascia ends are unclear and have not been clinically defined in a consistent manner and hence are subject to a lot of research at the moment. It is commonly thought that Fascia has several layers all of which are interconnected providing one continuous organ that connects everything within the body. For example ligaments and tendons are now thought to be extensions of the Fascial network where tensional forces are exerted in a unilateral direction hence creating the thick and unidirectional collagen fibres that we see in these parts of the body yet remain connected to ‘the whole’ changing the way in which they function.
So why is this tissue so important to movement and quality of movement in our bodies? Musculoskeletal movement is not simply the transfer of force from muscle to tendons and onto bone but rather is via fascial connection. For a very long time we and the medical community have thought of the body as a series of muscles (approx. 600 named muscles) that contract concentrically, eccentrically or isometrically to create or support movement. These actions are thought of as the movement or stabilisation between two points – the origin and insertion of that muscle. What research has actually shown us is that up to 40% of the force generated in an action or movement is transmitted via Fascia into other muscles in their vicinity3,4,5,6&7. Movement is actually a complex combination of muscular and fascial contractions rather than a linear, isolated contraction of a muscle alone.
This has lead the thinking on movement and force transmission in the body to transition from the basic model of vectors and forces applied over joints to seeing the body as a tensegrity model. One connected structure or body that consists of individual components acting within a tensioned matrix allowing great agility and strength – ‘Biotensegrity’, a living tensegrity model8. Seeing the body in this way enlightens us on how Fascia connects the body highlighting how movement in a seemingly isolated part of the body has an impact on the body as a whole. It is clear that muscles do not work in isolation and that we as Soft Tissue Therapists need to start thinking of the body in this connected manner when treating our clients to ensure we are seeing the bigger picture.
Movement in Treatment & Homecare
Let us consider the main constituents of fascia – water, collagen, some elastin and fibroblast cells. One of the key features of fibroblasts is that when mechanically or biomechanically stimulated they produce more fibrous matrix within the fascia. As we use our bodies from day to day more and more fascia gets laid down in our patterns of movement aligned to the forces being exerted. Perfect, if we all moved, sat and stood in an aligned and strong manner but the reality is that we do not. We sit too much, we stand with poor posture, we crane our heads forward to look at our computers, phones, or televisions all of which are stimulating our fascia and thickening the fibres to hold us in these poor positions. This leads to overuse in muscles not designed for such loads, restrictions in movement and even injury.
The second element of Fascia that I would like you to consider is the neural aspect. With six times more mechanoreceptors than muscle fibre Fascia is one of our most sensory organs. These mechanoreceptors include Golgi, Pacini, Ruffini and Interstitial receptors meaning that fascia responds to shearing & stretch stimulation and also used heavily in proprioception9. This makes fascia a key integrator with the central nervous system. It is thought that stimulation of the fascia sends key information to the CNS which results in reduces tonus in the muscles around and through which the fascia runs hence how we can affect it using hands on therapies.
If we look at these two elements let us considerhow we apply this thinking in our treatments. Like muscles, fascia can become adhered, scarred and over developed causing restrictions in range of movement, pain and even dysfunction. This can of course be acute or chronic. Take a typical muscle tear or strain. Yes the muscle needs to be treated and rehabilitated, but in damaging the muscle fibres, the fascia will have also been damaged so as it heals alongside the muscle it too can become scarred and thickened and needs to be addressed alongside the muscular elements. With chronic complaints, we again see similar issues. Overused postures or patterns become thickened and restricted fascial connections. If correcting muscle alone, the fascia will keep pulling the body back out of shape and prove making long term change to our clients a resistant challenge.
There are many techniques out there that you can use to treat the fascia, and even some of the techniques we use to treat muscle fibres are already affecting the fascia. Some of these techniques include Structural Integration, Kinesis Myofascial Integration (KMI), Myofascial Release (MFR), CORE Bodywork, Active Fascia Release, Transverse Soft Tissue Release (Transverse STR) and Instrument Assisted Massage. Whether using gentle hand pressure, locking into deep fascial connections or deeper lock and stretch techniques what I find common throughout is the use of movement. Getting your client to add movement when releasing the fascia brings a new level of efficacy to the treatment. This is not just the straight forward contraction and stretch of the area/muscle you are working but adding functional and dynamic movement along a whole fascial plane. When working in the deep abdominal fascia add deep abdominal breathing with movement of the arms, leg and feet simultaneously. You will feel the pull on the fasica you are working, and can feel a greater level of release and change to the quality of movement you produce. Get your clients off the bed, get your client working, moving and releasing their own restricted fascia using you as the ‘scratching post’. I truly believe that if we can be a facilitator, coaching the client into releasing their own restrictions using movement they are not simply releasing adhesions but also re-educating and stimulating the mechanoreceptors to function more appropriately creating lasting results for the client.
Unfortunately, our job does not end at the clinic. Although great results can be achieved within the treatment, given the nature of fascia and indeed other soft tissues homecare will be key in correcting patterns. For too long we have focused on isolated movement and contraction as rehabilitation. There is of course a time when this is appropriate to heal and rehabilitate, but what can sometimes lack in rehabilitation is the next step to restoring the function of that muscle, tendon or joint as part of a functioning plane of movement within the body. This is where functional and dynamic movement involving rehabilitation of the fascial planes is critical to full and functional healing for our clients.
Let us consider how long it takes to make changes to the collagen within fascia. Studies show that the turnover of collagen tissues is 2-3 times slower than in muscle fibres, so changing or realigning your Fascia takes time and needs to be part of an ongoing process10. It can take days for some finer proteins to be replenished, where as denser collagen bundles can take years. Clearly creating functional fascia takes time and is a constant process. As we progress through the stages of rehabilitation it is time we moved away from isolated static exercise to creating a plan that involves movements that stimulate not only the muscle, but the surrounding fascia to ensure that we restore the load transmission and mechanical chains of function to our clients while educating them on better long term habits for maintaining postural and fascial health.
Understanding how we are connected into fascial chains can give you a firm base to start from in terms of functional rehabilitation. Some well documented examples that show how these planes function are Thomas Myers ‘Anatomy Trains’11, Kurt Tittels ‘Muscle Slings’ 12 or Leopold Busquet ‘Muscle Chains’13. These eloquent descriptions of the lines of engagement in various movements start to lay the foundations for what we are aiming for in making our clients ‘fascially fit’. When looking at functional weakness in certain muscles, we need to look at the whole chain for dysfunctional patterns. Equally when trying to rebuild function we need to look at restoring the strength and balance of the whole chain. Muller and Schleip produced a number of Fascia Oriented Training principles in their book Fascial Fitness Fascia Oriented Training for Bodywork and Movement Therapists14 which have been embraced by the therapy and fitness world. A worthy read in your next step to providing functional rehabilitation for your clients. We are also seeing a trend of moving towards this type of rehabilitation in our online tools and applications for example Exercise Lab www.exercise-lab.com – a favourite of mine, where you can build from stage 1 isometric contraction work, right up to stage 3 functional movements as part of your homecare plans. There is no excuse to still being stuck in old habits when it comes to prescribing homecare for clients.
We then move into the world of maintenance where these principles have been encompassed into Fascia Oriented Pilates, Yoga, Tai Chi, Plyomterics, Gymnastics and Martial Arts. These principles are being used more and more in sport specific training for injury prevention but also to a view to performance improvement. With a better understanding of the mechanics involved in specific sports, functionally specific movements and exercises are being developed to keep the key lines of movement for the sport healthy, elastic and strong to maximise performance. Football, running, golf and the martial arts seem to be leading the way in this respect and with this focus comes a better appreciation for the role of Soft Tissue Therapy in creating and maintaining Fascial Fitness.
In conclusion, it is time we in the therapy community moved forward in both our treatment approach and rehabilitation to using movement as a diagnostic tool, treatment approach and homecare programme. Restoring muscle function alone will not create functionally strong and fit clients. To ensure we are delivering the best treatment and advice for our clients we need to become adept with the role of fascia and its functional planes and start to deliver cutting edge service for our clients. Don’t get left behind.