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Kumka's Response to Stecco's Fascial Nomenclature Editorial

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Kumka's Response to Stecco's Fascial Nomenclature Editorial Journal of Bodywork & Movement Therapies (2014) 18, 591e598 Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/jbmt FASCIA SCIENCE AND CLINICAL APPLICATIONS: RESPONSE Kumka’s response to Stecco’s fascial nomenclature editorial Myroslava Kumka, MD, PhD* Canadian Memorial Chiropractic College, Department of Anatomy, 6100 Leslie Street, Toronto, ON M2H 3J1, Canada Received 12 May 2014; received in revised form 13 May 2014; accepted 26 June 2014 Why are there so many discussions? response to the direction of various strains and stimuli. (De Zordo et al., 2009) Embedded with a range of mechanore- The clinical importance of fasciae (involvement in patho- ceptors and free nerve endings, it appears fascia has a role in logical conditions, manipulation, treatment) makes the proprioception, muscle tonicity, and pain generation. fascial system a subject of investigation using techniques (Schleip et al., 2005) Pathology and injury of fascia could ranging from direct imaging and dissections to in vitro potentially lead to modification of the entire efficiency of cellular modeling and mathematical algorithms (Chaudhry the locomotor system (van der Wal and Pubmed Exact, 2009). et al., 2008; Langevin et al., 2007). Despite being a topic of growing interest worldwide, This tissue is important for all manual therapists as a controversies still exist regarding the official definition, pain generator and potentially treatable entity through soft terminology, classification and clinical significance of fascia tissue and joint manipulative techniques. (Day et al., 2009) (Langevin et al., 2009; Mirkin, 2008). It is also reportedly treated with therapeutic modalities Lack of consistent terminology has a negative effect on such as therapeutic ultrasound, microcurrent, low level international communication within and outside many laser, acupuncture, and extracorporeal shockwave therapy. health professions and affects collaboration in research Pathological characteristics of fascia have been observed (Wendell-Smith, 1997). As Alfredo Ercoli explains on the with special imaging techniques such as ultrasonic elas- topic of pelvic fascia, the lack of common definitions and tography that allows a non-invasive estimation of tissues nomenclature hinders communication between those stiffness (Piedade et al., 2008; Lin et al., 2006; Kiritsi et al., involved in the process of diagnosis and treatment of pelvic 2010). pathologies in everyday practice (Ercoli et al., 2005). This Myofascial force transmission is a phenomena of loco- sentiment could potentially be seen in many medical fields, motor function whereby fascia transmits force amongst posing a serious problem for patient care and research. multiple antagonist and synergistic muscle groups across joint capsules, as well as adjacent groups of fascia (van der Definition of fascia and classifications Wal, 2009). As an innervated, vascular, contractile and highly adapt- able structure, fascia shows a capacity to remodel in Fascia has been a known anatomic entity for centuries; however consistent international terminology to classify and categorize this tissue has not been formally established (Langevin et al., 2009; Mirkin, 2008). The gross anatomy of * Tel.: þ1 416 482 240x175. fascia demonstrates an array of characteristics based on E-mail address: [email protected]. location, density, fiber direction, and its relationship to http://dx.doi.org/10.1016/j.jbmt.2014.06.003 1360-8592/ª 2014 Elsevier Ltd. All rights reserved. FASCIA SCIENCE AND CLINICAL APPLICATIONS: RESPONSE 592 M. Kumka surrounding structures. (Stecco et al., 2009a; Vleeming ground substance includes glycosaminoglycans, pro- et al., 1995) The Federative Committee of Anatomical teoglycans, and adhesive gycoproteins; iv) the cellular Terminology (FCAT) in the 1998 edition of Terminologia component is grouped into fixed cells such as fibroblasts, Anatomica pointed out significant flaws in the nomencla- adipose cells, pericytes, mast cells, macrophages, and ture system for fascia, defining it as “sheaths, sheets or transient cells (plasma cells, lymphocytes, neutrophils, other dissectible connective tissue aggregations” and eosinophils, basophils, monocytes, and macrophages); v) providing a long list of terms related to their definition the fibroblasts (which synthesize the ECM) are the most (Terminologia Anatomica: international anatomical abundant cell type in connective tissue proper (Ross et al., terminology, 1998). 2011; Terminologia Histologica, 2008a). Based on location, the FCAT describes the following fasciae: i) in relation to the body regions: fascia of head and neck, fascia of trunk, and fascia of limbs, ii) in relation What are the differences and why? to the surrounding structures: subcutaneous fascia, fascia of muscles, visceral fascia, parietal fascia, and fascia Depending on gross anatomical location and functional extraserosalis that represents any other fascia which lies properties of fasciae, the ratio of the cellular and extra- inside the parietal fascia and outside the visceral fascia cellular components and the orientation of fibers vary: (Terminologia Anatomica: international anatomical loose v/s dense, regular v/s irregular. For example, loose/ terminology, 1998). areolar connective tissues are composed of a loose Gray’s Anatomy describes fascia as including all masses arrangement of fibers and dispersed cells embedded in a of connective tissue visible to the unaided eye, organizing gel-like ground substance (e.g., subcutaneous tissue/fascia these connective tissue aggregations topographically, with nerves and vessels which supply the cells with oxygen emphasizing their compartmentalizing feature, and clinical and nutrients). This tissue also contains many transient relevance (Standring, 2008). This approach is important cells responsible for inflammation, allergic reactions, and when identifying regional fascia and its pathology, however the immune response (Ross et al., 2011). it does not take into account fascia’s microscopic continu- Dense connective tissue contains most of the same ity and many of its characteristics (Langevin et al., 2009; components found in loose connective tissue, except that it Mirkin, 2008). has many more fibers and fewer cells. The organization of The First International Fascia Research Congress (2007) the fibers varies from parallel cylinders or sheets that resist formulated a comprehensive definition of fascia as the soft tensile forces, to a meshwork that resist stress from all tissue component of the connective tissue system, directons (Ross et al., 2011). Function and response to emphasizing its uninterrupted, three-dimensional web like stresses are the leading factors that influence connective connective tissue matrix and highlighting its functional as- tissue organization. It has been observed that myotendi- pects (LeMoon, 2008). The Congress goes on to include joint nous junctions that characteristically undergo greater capsules, organ capsules, muscular septa, ligaments, reti- strains (calcaneal tendon, supraspinatus tendon) remodel nacula, aponeuroses, tendons, myofascia, neurofascia and the extracellular matrix and turn over collagen at a signif- other fibrous collagenous tissues as forms of fascia, insep- icantly higher rate than others (biceps brachia tendon) arable from its surrounding connective tissues (Coppieters (Barnes, 1997). Under significant states of compression the et al., 2006). same fibroblasts can develop into chondrocytes and form specialized connective tissue/cartilage with solid mineral deposition (Milz et al., 2005). These examples illustrate the My point of view significant influence biomechanical stresses play on fascia. Patients exhibiting dysfunctions in posture, flexibility, I think the broad definition of fascia, as other connective strength and coordination, it may be argued, may have tissue proper, supports the standpoint that fascia constitutes fascial involvement, when all other appropriate factors are a “system” similar to the other human body systems, such as ruled out (deWitt and Venter, 2009). Abnormal amounts of the respiratory, cardiovascular, and nervous systems. tension projecting to distal muscle groups as a result of From my perspective, the fascial system is a set of their deep fascial connections could lead to dysfunction or connected parts and layers that form one functional phys- pain (Stecco, 2004). For example, increased strain in the iological unit to support the living body. plantar fascia, leading to plantar fasciitis, affects the regional nerves and vessels causing plantar heel pain (Coppieters et al., 2006). What are the similarities? The fascial system may include every connective tissue Terms proper. Having various gross anatomical, histological and mechanical properties, the fascial system components A conspicuous feature of fasciae, continuity, creates a long possess similarities, as follow: i) they form a continuum list of terms which reflects the interrelationship and the with various tissues and organs to maintain a functionally contiguousness of fasciae throughout the body. integrated body; ii) they are composed of cells and extra- For example, the pelvic fascia, a continuation of the cellular matrix (ECM), and the ECM consists of ground sub- endoabdominal fascia, has been described as having parietal stance and fibers (collagen, elastic, reticular); iii) the and visceral layers. Specific parts of the parietal fascia are FASCIA SCIENCE AND CLINICAL APPLICATIONS: RESPONSE Kumka’s response to Stecco’s fascial nomenclature
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