Journal of Bodywork & Movement Therapies (2014) 18, 591e598

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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 , 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 endings, it appears has a role in logical conditions, manipulation, treatment) makes the , muscle tonicity, and generation. fascial system a subject of investigation using techniques (Schleip et al., 2005) Pathology and injury of fascia could ranging from direct imaging and 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 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 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 , 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 includes , 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, , mast cells, , and ture system for fascia, defining it as “sheaths, sheets or transient cells (plasma cells, , , other dissectible aggregations” and , , , and macrophages); v) providing a long list of terms related to their definition the fibroblasts (which synthesize the ECM) are the most (: international anatomical abundant type in connective tissue proper (Ross et al., terminology, 1998). 2011; , 2008a). Based on location, the FCAT describes the following fasciae: i) in relation to the body regions: fascia of and , 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 , organizing gel-like ground substance (e.g., /fascia these connective tissue aggregations topographically, with 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 , 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 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, capsules, muscular septa, , reti- strains (calcaneal , supraspinatus tendon) remodel nacula, aponeuroses, , myofascia, neurofascia and the and turn over at a signif- other fibrous collagenous tissues as forms of fascia, insep- icantly higher rate than others ( 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 and form specialized connective tissue/ 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 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 in the iological unit to support the living body. , leading to , 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 editorial 593 named for the muscle that is covered (e.g., obturator fascia, stability, and characterized by higher concentrations of ). The pelvic visceral fascia directly ensheaths the contractile and proprioceptive fibers (Schleip et al., 2005; pelvic organs, forming the adventitial layer of each. The van der Wal and Pubmed Exact, 2009; Yahia et al., 1992). parietal and visceral layers become continuous where the For example, the (TLF) acts as a sig- organs penetrate the pelvic floor. Here the parietal fascia is nificant dynamic structure for spinal stability and is densely thickened, forming the tendinous arch of pelvic fascia. The innervated (Vleeming et al., 1995; Yahia et al., 1992; anteriormost part of this tendinous arch (puboprostatic lig- Loukas et al., 2008). The dynamic division is composed of ament in males and pubovesical in females) con- fasciae of muscles (fascia of individual muscle), and fasciae nects the to the pubis in the male, or the fundus of of the trunk (Terminologia Anatomica: international the bladder to the pubis in the female (Moore et al., 2014). , 1998). The passive division is The endopelvic fascia, the abundant connective tissue acted on by other extramuscular tissues to maintain con- between the parietal and visceral layers is considered tinuity throughout the body or form tunnels, and muscular extraperitoneal or subperitoneal fascia. This fascia makes sheaths (van der Wal and Pubmed Exact, 2009; the connective tissue matrix or packing material for the Terminologia Anatomica: international anatomical pelvic viscera. Some of it is an extremely loose areolar terminology, 1998). The passive division incorporates tissue to accommodate the expansion of the urinary fasciae of muscles (muscle sheaths), fasciae of head and bladder and rectal ampulla as they fill. Other parts of the neck, fasciae of limbs, aponeuroses, tendinous arches, and endopelvic fascia have a much more fibrous consistency, retinaculae (Terminologia Anatomica: international containing an abundance of collagen and elastic fibers, and anatomical terminology, 1998). This group can act as a scattering of fibers. These parts are often muscular insertion points like the epicranial , described as “fascial condensations” or pelvic “ligaments” and joint linkages like retinaculae and tendinous arches, (Moore et al., 2014). providing proprioceptive information (van der Wal and Pubmed Exact, 2009). The passive linking fasciae can only transmit in a very particular position of the joint when it is How to classify this long list of terms? Our stretched and loaded, while dynamic can theoretically act effort more autonomously (Schleip et al., 2005; van der Wal and Pubmed Exact, 2009). In an effort to organize the nomenclature of fascia, an The linking fascia is richly innervated by the mechano- original classification has been developed, that includes four receptors. For example, the thoracolumbar linking fascia is functional categories of fascia: linking, fascicular, populated by the large Pacini corpuscles and smaller Paci- compression, and separating fasciae (Kumka et al., 2012). niform corpuscles, which respond to rapid pressure and These categories were developed from the three main per- vibration (Yahia et al., 1992). The result of stimulation of spectives: gross anatomy, , and with these receptors is for movement control, of kines- an emphasis on function. It is also proposed that all fascial thesia (Loukas et al., 2008; Schleip, 2003a). There are also related terminology provided in the Terminologia Anatomica interstitial myofascial types III and IV receptors, responsive can be classified accordingly into these four fascial cate- to rapid and sustained pressure changes, result of their gories (Table 1)(Terminologia Anatomica: international stimulation is vasodialtion (Loukas et al., 2008; Schleip, anatomical terminology, 1998; Kumka et al., 2012). 2003a). Ruffini’s bodies are located primarily in the pas- While forms of fascia in opposing categories will still sive linking fascia, and respond to tangential forces and posses similarities, thus highlighting the continuity of this sustained pressure resulting in stimulation of inhibition of tissue, sufficient unique characteristics have been observed sympathetic activity (Loukas et al., 2008; Schleip, 2003a). to separate them. The emphasis on function is to make this There is much similarity between these two sub-types, system applicable to musculoskeletal specialists. however the main difference is the concentration of con- This is an effort to improve consensus and international tractile and nerve fibers and subtle differences in function. communications between educators, researchers and cli- Both dynamic and passive will connect proximal regions of nicians in their teaching, research, and clinical practice the body to distal regions supporting fascia’s main role of related to fasciae. creating continuity.

Linking fascia Fascicular fascia

The linking category is predominantly dense regular paral- Fascicular fascia forms adaptable tunnels which bundle lel ordered unidirectional connective tissue proper with a fascicules within muscle, tendon, , nerve, and vessel, significant amount of collagen type I (Terminologia and plays an important role in organization, transport, Histologica, 2008b). This includes fasciae of muscles, strength and locomotion. This category is organized as fasciae of regions (head & neck, trunk, limbs), , mixture of both loose and dense regular multidirectional aponeuroses, retinaculae, and neurovascular sheaths connective tissues (Terminologia Histologica, 2008b). Types (Terminologia Anatomica: international anatomical I and III collagen are the major components of these tissues terminology, 1998). with small amounts of types V, VI, XII, and XIV (Purslow, This category is subdivided into dynamic and passive 2002). divisions. The dynamic division includes major fascial Fascicular fascia of the muscle is addressed as the three groups more strongly related to movement and joint distinct layers of intramuscular connective tissue (IMCT): FASCIA SCIENCE AND CLINICAL APPLICATIONS: RESPONSE 594 M. Kumka

Table 1 Fascial categories: function, terms, and histological features. Fascial category Function Examples Terminologia Terminologia histologica Histological anatomica (Terminologia (Terminologia features (Ross Anatomica: international Histologica, 2008b) et al., 2011; anatomical terminology, Gordon et al., 1998) terms completed by 2010) region Linking Dynamic - Plays crucial role Fasciae of muscles Dense regular parallel Collagen types: in movement & (investing layer) & fasciae ordered I, XII, XIV stability and of individual muscles: Unidirectional Smooth muscle autonomously creates Connective tissue cells significant pretension Axillary fascia Proper Free nerve in musculature Supraspinatus fascia endings Brachial fascia Fasciae of trunk: Thoracolumbar fascia Diaphragmatic fascia fascia Passive - Maintains continuity, Fasciae of muscles Dense regular woven & Collagen types: passive force trans- (muscle sheath) multidirectional parallel I, III, XII, XIV mission & propriocep- ordered connective tive communication Head & Neck tissue proper throughout the body Ligamentum nuchae Ligamentum flavum Fasciae of limbs/ membrorum Intermuscular septae Anterior talofibular ligament Aponeuroses Erector spinae aponeurosis Plantar aponeurosis Retinaculae Extensor & flexor retinaculae of Extensor & flexor retinaculae of Superior & inferior fibular retinaculae Tendinous arches Muscular & vascular spaces/ lacunae Iliopectineal arch Tendinous arch of soleus Fascicular - Provides myofascial Intramuscular & Loose connective tissue Collagen types: force transmission & extramuscular fasciae. Dense regular I, III, IV, V, proprioceptive feed- Neurovascular sheaths Multidirectional parallel XII, XIV for movement ordered Golgi tendon control Connective tissue organs - Maintains protection of Endotendon Dense irregular nerves and vessels Peritendon connective tissue - Allows vascular sheaths Paratendon to be in continuity with FASCIA SCIENCE AND CLINICAL APPLICATIONS: RESPONSE Kumka’s response to Stecco’s fascial nomenclature editorial 595

Table 1 (continued) Fascial category Function Examples Terminologia Terminologia histologica Histological anatomica (Terminologia (Terminologia features (Ross Anatomica: international Histologica, 2008b) et al., 2011; anatomical terminology, Gordon et al., 1998) terms completed by 2010) region Myotendinous junction Bone perforating Sharpey’s fibers Periodontal ligament Compression - Provides stocking, Fasciae of limbs Dense regular woven & Collagen type I compression & tension Brachial fascia multidirectional parallel Elastin compartmental effects ordered connective Ruffini’s - Influences Dorsal fascia of hand tissue proper corpuscles venous return Fascia lata - Enhances propriocep- of /crural tion, muscular effi- fascia ciency and Dorsal fascia of foot coordination Separating - Compartmentalizes or- Parietal Fascia Loose connective tissue Collagen types: gans and body regions Cervical pleura and dense irregular III, V, VII to maintain structural Fibrous fusocellular connective Extracellular and functional tissue. matrix: relationships Parietal reticular and - Responds to Endoabdominal fascia elastic fibers stretch and distention Endopelvic fascia Reticular fibers - Promotes sliding Visceral fascia provide a and reduces friction Visceral pleura cellular during Serous pericardium framework - Provides physical Visceral peritoneum Elastic fibers support and Visceral abdominal are arranged in absorption Visceral pelvic fascia a branching - Limits the spread Extraserosal fascia pattern to form of Sternopericardial ligaments a 3-D network Bronchopericardial and allow membrane stretch Pulmonary ligaments Pacinian Extraperitoneal fascia corpuscles, Investing fascia Ruffini’s Subcutaneous tissue of corpuscles : /Scarpa’s & fatty layer/Camper’s Membranous layer of /Colle’s Lesser omentum

epimysium surrounding whole muscles, perimysium sepa- lymphatics (Langevin et al., 2009; Purslow, 2002). The rating fascicles or bundles of muscle fibers within the fascicular fascia of the muscle converges into a dense muscle, and endomysium covering the individual ,muscle regular connective tissue link at the myotendinous junction fibers. (Purslow, 2002) Forming the muscle architecture, to become fascicular fascia of the tendon, such as endo- this network of collagen fibers can be seen as an extensive tendon, peritendon, and epitendon (van der Wal and matrix of tunnels that connects and dissipates force within Pubmed Exact, 2009). In this junction fascicular fascia is muscle, provide intramuscular pathway and mechanical richly innervated by the Golgi tendon organs which are support for large and small nerves, vessels, and stimulated by that leads to tension in FASCIA SCIENCE AND CLINICAL APPLICATIONS: RESPONSE 596 M. Kumka

the tendon, and through the reflex action decreases tonus It has been noted, that muscle contraction causes the in related striated motor fibers. Other Golgi receptors are sliding movements in between the connective tissue layers located in attachment areas of fascicular fascia, e.g., of fascia with some amount of resistance (van der Wal and aponeuroses, and responsive to strong stretch only Pubmed Exact, 2009). As a result, the small elevation of (Schleip, 2003a, 2003b). intracompartmental pressure increases the contractile ef- Many therapies address the tissues at the junction be- ficiency of muscles within the compartment, and aids in tween muscle and bone. Defining the architecture and venous return of blood to the (Purslow, 2002). classifying this type of fascia may help in understanding how such therapies work in various places where the fascicular fascia is located. Separating fascia The fascicular fasciae allow forces to be transferred not only between synergistic muscles, but also via the extra- Separating fascia is generally loose connective tissue and muscular pathway (neurovascular sheaths) so that load can dense irregular fusocellular connective tissue (van der Wal reach the antagonistic muscles (Huijing et al., 2007). and Pubmed Exact, 2009; Terminologia Histologica, 2008b). Therefore forces, causing movement limitations in people The reticular type III collagen fibers and elastic fibers are with spasticity, may come from antagonistic muscles trans- the major components of the ECM of separating fascia with mitting load to the tendons of synergistic muscles. It has small amounts of collagen types V, VII (Ross et al., 2011). been suggested that clinical of the affected While the reticular fibers provide a supporting framework spastic muscle, without , may be sufficient to for the cellular constituents, the elastic fibers form a three disrupt this pathway and provide a clinical improvement e dimensional network to allow separating fascia to (Huijing, 2007). respond to stretch and distention (Ross et al., 2011). The fascicular fascia forms the connective tissue Separating fascia divides the body in visible sheets and envelop for nerve fascicles and whole peripheral nerves, layers of varying fibers allowing it to take up forces and perineurium and respectively (Ross et al., friction in all directions. It includes FCAT’s terms: parietal 2011). The perineurium serves as a metabolically active fascia, visceral fascia, extraserosal fascia, investing/sub- barrier that contributes to the formation of a cutaneous fascia formerly known as fascia superficialis blood-nerve barrier. The blood vessels that supply the (Terminologia Anatomica: international anatomical nerves travel in the epineurium. These two layers of the terminology, 1998). This category also includes synovial fascicular fascia are innervated by ‘nervi nervorum’ which sheaths and fasciae of limbs. Parietal fascia lies outside the can evoke nociception, and are likely responsible for nerve parietal layer of serosa such as pericardium, pleura, peri- trunk pain (Bove, 2008). An inflammation of the ‘nervi toneum, and lines the wall of a (Terminologia nervorum’ causes the inflammatory reaction of the nerve’s Anatomica: international anatomical terminology, 1998). fascial envelops to induce the mechanical sensitivity, which Visceral fascia lies immediately outside the visceral layer of can express either as local pain or as radicular pain (Bove, the serosa, and surrounds the viscera (Terminologia 2008). Most peripheral nerves can be directly moved and Anatomica: international anatomical terminology, 1998). palpated; therefore their fasciae deserve full diagnostic Extraserosal fascia lies within the space between the and therapeutic attentions. visceral and parietal fasciae (Terminologia Anatomica: international anatomical terminology, 1998). This fascia class is a vibrant living connective tissue matrix, Compression fascia ensheathing everything from body cavities to individual organs (Coppieters et al., 2006). It separates, supports, Compression fascia is a mix of dense regular woven and compartmentalizes organs and regions in order to maintain multidirectional parallel ordered connective tissue layers proper structural and functional relationships throughout that wrap around, and ensheaths whole limbs to create a the body. This group of fascia has a much different stocking effect (Terminologia Histologica, 2008b). This appearance and texture upon observation which can range fascial category plays an important role in locomotion and from a transparent woven sheet to a fuzzy cotton candy venous return due to its influence on compartmental consistency (Hedley, 2010). It is highly adaptable, and just pressure, muscle contraction, and force distribution. For as susceptible to forming adhesions as muscular types of example, the crural fascia is composed of two or three fascia which we classically tend to think of as having this layers of parallel ordered collagenous fiber bundles, each problem (Stilwell, 1957). The innervation of separating layer being separated by a thin layer of loose connective fascia is focused primarily in sensing distension and tissue (Stecco et al., 2009b). The spatial orientation of the compression of tissues and less on pure nociception. Paci- collagen fibers changes from layer to layer (Stecco et al., nian corpuscles have been shown to be more frequent in 2009b). As a result, the mechanical response of a single the parietal and visceral fasciae (parietal and visceral layer differs if the layer is loaded along the direction of the layers of peritoneum, endoabdominal fascia), extraserosal collagen fibers or along another direction. The presence of fascia (visceral ligaments) (Stilwell, 1957). Deep sustained loose connective tissue interposed between adjacent layers pressure is necessary for manual practitioners to affect this permits local sliding, allowing the single layers to respond treatable , and is a strategy utilized by practi- more effectively to different traction (Stecco et al., tioners who engage in visceral manipulations. Despite 2009b). Trauma or overuse syndromes can alter this inter- acting to compartmentalize the body this system of fascia is layer sliding that changes the force distribution within the still important in connecting deeper visceral structures to fascia. extramuscular fascia. FASCIA SCIENCE AND CLINICAL APPLICATIONS: RESPONSE Kumka’s response to Stecco’s fascial nomenclature editorial 597

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