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Fascial Anatomy in Manual Therapy: Introducing a New Biomechanical Julie Ann Day, PT Model

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Fascial Anatomy in Manual Therapy: Introducing a New Biomechanical Julie Ann Day, PT Model Fascial Anatomy in Manual Therapy: Introducing a New Biomechanical Julie Ann Day, PT Model Centro Socio Sanitario dei Colli, Physiotherapy, Padova, Italy ABSTRACT detailed studies pertaining to specific areas suggested.17 Deep fascia is a well-vascular- Background and Purpose: Fascial of fascia are important, they do not pro- ized tissue often employed for plastic sur- anatomy studies are influencing our under- vide a vision of the human fascial system as gery flaps,18 and it responds to mechanical standing of musculoskeletal dysfunctions. an interrelated, tensional network of con- traction induced by muscular activity in dif- However, evidenced-based models for nective tissue. A few authors consider its ferent regions.19 It has an ectoskeletal role manual therapists working with move- 3-dimensional (3D) continuity8-10 but these and can potentially store mechanical energy ment dysfunction and pain are still devel- holistic models do not always provide spe- and distribute it in a uniform manner for oping. This review presents a synthesis of cific indications for treatment. A functional harmonious movement. The mechanical one biomechanical model and discusses model for the entire human fascial system properties of the fascial extracellular matrix underlying hypotheses in reference to some that correlates dysfunctional movement itself can be altered by external mechanical current trends in musculoskeletal research. and pain is in its infancy with regards to stimuli that stimulate protein turnover and Method: The author conducted principally evidence-based investigations and studies. fibroblastic activity.20,21 These characteris- a search of the health sciences literature This paper will examine a 3D bio- tics and the reported abundant innervation available on PubMed for the years 1995 to mechanical model for the human fascial of deep fascia indicate that it could have 2011, and consulted published texts con- system that takes into account movement the capacity to perceive mechanosensitive cerning this model. Findings: Some of the limitation, weakness, and pain distribution signals.22 hypotheses proposed by this model have during the analysis of musculoskeletal dys- The correct embryonic development been investigated via anatomical dissec- functions. While the interaction between of the musculoskeletal system requires the tions that have addressed the connections all fascial layers is contemplated within this coordinated morphogenesis of muscle, mus- between deep fascia and muscles, the his- model, this paper will focus on the part that cular fascia, tendon, and skeleton. In the tology of deep fascia, and its biomechanical addresses the deep fascia, which appears to embryo, muscle tissue and its fascia form as characteristics. These dissections have led to be principally implicated in musculoskeletal a differentiation of the paraxial mesoderm new anatomical findings. This model may activity. that divides into somites on either side of also present new challenges for research in The model is the result of 35 years of the neural tube and notochord. The carti- fields such as peripheral motor control and study and clinical practice by Luigi Stecco, lage and bone of the vertebral column and proprioception. Clinical Relevance: This an Italian physiotherapist.11,12 Developed ribs develops from the ventral part of the information could introduce new perspec- specifically for manual therapists working somite, the sclerotome, whereas the dorsal tives for clinicians involved in the manual with movement dysfunction and pain, the part of the somite, the dermomyotome, treatment of musculoskeletal dysfunctions. chief focus of this model is the relationship gives rise to the overlying dermis of the between muscles, deep fascia, and its compo- back and to the skeletal muscles of the body Key Words: deep fascia, fascial anatomy, nents (epimysium, perimysium, and endo- and limbs.23 It is now known that muscu- manual therapy, myofascial unit mysium). More recently, this work has been lar connective tissue is critical for the form supported by a series of extensive anatomi- and function of the musculoskeletal system, INTRODUCTION cal dissections of unembalmed cadavers. muscle development, and muscle regenera- One tissue gaining increasing attention Histological, biomechanical, and functional tion in general. For example, in mammals, in manual therapy is the connective tissue studies have also been undertaken to verify fetal connective tissue fibroblasts express the known as fascia. While there is still on- some of the underlying hypotheses concern- transcription factor Tcf4, which is essential going discussion about how to categorize ing the architecture of the fascia, its innerva- for proper muscle development. Studies and name the various fascial layers1 it is, tion, its relationship with muscle fibers, and indicate that Tcf4-expressing cells actually nevertheless, possible to distinguish 3 differ- the possible mechanisms of action of the establish a pre-pattern in the limb meso- ent types of human fasciae, namely, superfi- manual technique itself. derm that determines the sites of myogenic cial, deep, and visceral fascia. Each of these differentiation, thereby shaping the basic has its own anatomical and biomechanical Deep Muscular Fascia pattern of vertebrate limb muscles.24 Other characteristics and specific relationships to Studies of deep muscular fascia sup- studies demonstrate that the absence of surrounding structures. Most studies con- port its role in epimuscular myofascial specific transcription factors in muscle con- cerning fasciae focus on the anatomy and force transmission13,14 although the degree nective tissue disrupts muscle and tendon pathology of specific areas, such as the to which it is involved in in-vivo muscle patterning in limbs, and that to understand thoracolumbar fascia,2 abdominal fascia,3 movements is still not clear.15 Deep fascia the etiology of diseases affecting soft tissue the Achilles tendon enthesis organ,4 plan- is implicated in deep venous return16 and formation a focus on connective tissue is tar fascia,5,6 and the iliotibial tract.7 While its possible role in proprioception has been required.25 68 Orthopaedic Practice Vol. 23;2:11 As muscle cells differentiate within Myofascial Unit Center of coordination the mesoderm, each single muscle fiber is Six myofascial units (MFU) are consid- Within the deep muscular fascia of each progressively surrounded by endomysium, ered to govern the movement of the body MFU, a specific small area called the center groups of fibers by perimysium, whole mus- segments on the 3 spatial planes. An MFU of coordination (CC) is identified. A CC is cles are enclosed by epimysium and deep is described as a functional unit composed defined as a focal point for vectorial forces fascia encloses groups of muscles. The con- of motor units innervating monoarticular produced by monoarticular and biarticular nective tissue that accompanies the develop- and biarticular muscle fibers, the joint that muscle fibers of an MFU acting on a body ment of muscle fibers and nerve components they move in one direction on one plane, segment during a precise movement and are facilitates the different innervations and the deep fascia that unites these fibers, and often situated within the deep fascia overly- functions of the muscle fibers within each the nerve components involved in this ing a muscle belly. In reference to the MFU muscle belly. Furthermore, the fascia unites movement. One example is the MFU for for knee extension mentioned previously, all of the fibers of a single motor unit that knee extension where fibers from medial the CC is located between the vastus latera- are often distributed throughout a muscle and lateral vasti are the monoarticular com- lis and rectus femoris, halfway on the thigh in non-adjacent positions, allowing for syn- ponents and fibers from the rectus femoris (see Figure 2). ergy between recruited fibers and separation provide the biarticular component (Figure Through clinical observation and stud- from nonrecruited fibers. Fascia can there- 2). Myofascial units are considered to be the ies comparing acupuncture points, myo- fore adapt to variations in form and volume functional building blocks of the myofascial fascial trigger points, and the sum of the of each muscle according to muscular con- system. In this model, it is postulated that vectorial forces involved in the execution traction and intramuscular modifications deep fascia is a potentially active component of each segmental movement, Stecco12 (pp 325- induced by joint movement. in movement coordination and peripheral 326) noted that impeded gliding of the deep This fascial-based organization allows motor control and that, due to its innerva- fascia commonly occurs at these intersect- each single muscle fiber to slide somewhat tion, the fascial component of each MFU ing points of tension. The term center of independently from its adjacent fibers. In is a possible source of directional afferents coordination is used to infer the possible addition, deep muscular fascia has signifi- that could contribute to proprioceptive involvement of deep fascia in monitoring cant characteristics that allow it to perceive information. movement of a related segment via its con- muscle fiber tension. Many muscle fibers nections to muscle spindles, Golgi tendon attach directly onto fascia,26 and it also con- organs, and other mechanoreceptors. nects with muscle fibers via intermuscular septa, fascial compartments, and tendon
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