8/17/2018 Fascia The Forgotten Tissue Darrin D’Agostino, DO, MPH, MBA Executive Dean and VP of Health Affairs Kansas City University of Medicine and Biosciences "I know of no part of the body that equals the fascia as a hunting ground. I believe that more rich golden thoughts will appear in the mind’s eye as the study of the fascia is pursued, more than any other division of the body." A.T. Still, DO, MD What is Fascia? The First International Fascia Research Congress (2007) formulated a comprehensive definition of fascia as the soft tissue component of the connective tissue system, emphasizing its uninterrupted, three-dimensional web-like extensions and highlighting its functional attributes 1 8/17/2018 Fascia Connective tissues that plays an important role in human function 16% of total body weight and stores 23% of total water composition It connects all the tissues of the human body together including the muscles, organs nerves and vessels of the body Fascia is a dynamic connective tissue that changes based on the stresses placed on it Roles of Fascia The fascia plays a major role in circulation of blood and lymph The fascia is important for the nutrition and metabolism of every cell in the body The fascia is the first line of defense in immune function Disruptions and restrictions within the fascia are associated with disease and movement impairments. Cells flow through it to get to target tissue Interrupts the flow of blood and lymph Can cause pain and poor compensatory patterns Roles of Fascia The fascia is a major contributor to proprioception and sensory nerves Matrix of communication between all cells, organs and whole body systems Provide a tensile support for muscles important to generate force Embryology helps explain how all the fascial system connects all major systems including the nervous system The cells in early development differentiate into 3 germ layers Ectoderm: nervous system and the skin Mesoderm: bones, muscles , fascial tissue and CV system Endoderm: various internal organs and endothelial linings 2 8/17/2018 Trophoblast Differentiation • Trophoblast give rise to – Ectoderm: • • • • Mesoderm Ectoderm skin sensory Receptors nervous system – Mesoderm: • Bone, • Muscles • connective tissue – Endoderm: • respiratory airway • digestive system (most) – Early reticular fibers (Future Fascia) • connecting the 3 layers • will eventually be replaced with stronger collagen fibers Endoderm Mesoderm encapsulates the endoderm (anteriorly) and (posteriorly) The space between developing structures is filled with connective tissue such as fascia The Fascia Milieu 3 8/17/2018 Mechanical Properties of Fascia Collagen fibers: • Give tensile strength • Elastic fibers contribute recoil Ground substance: The amount of collagen, elastic and ground substance varies per tissue Collagen, elastin and ground substance absorb forces • Allows the fascia to compress and expand Types of Fascia Superficial Fascia Deep Fascia Visceral Fascia AKA: Subserous Fascia Brain and Spine Fascia Which can be Inter-Structural Structural All Three Represented 4 8/17/2018 In the BBQ World: Silver Skin/Silver Membrane Kansas City Dry Rub: 2 cups brown sugar 1/2 cup dry mustard 1 tablespoon cayenne pepper 1 tablespoon smoked paprika 1 tablespoon garlic powder 1 tablespoon onion powder 1 tablespoon salt 2 teaspoons freshly ground black pepper Superficial Fascia - Inter-Structural The cobweb-like fascia found within the body Inter-Structural Fascia penetrate every system of the body surrounding the Fat is adherent to this and helps regulate temperature (among other things) Brain Visceral organs Cartilage Blood vessels Nerves The Inter-Structural Fascia is highly adhesive When adherent it sticks to Fibers within the structure Surrounding structures Multiple Structures image from Second International Fascia Research Congress 28 Oct ‘09 – P. Purslow p 20 5 8/17/2018 Superficial Fascia: Inter-Structural Visceroelastic properties Additionally it contains/encapsulates: Subcutaneous muscles in the face, neck, scrotum Mammary gland Deep sweat glands Localized groups of sweat nodes Cutaneous nerves and vessels Function of Superficial Fascia Govern movement Absorb forces Stretch to accommodate fat deposition Facilitates movement of skin Is a soft medium for nerves and vessels to pass through (protect movement) Conserves body heat (fat is a bad conductor) Function of the structure is significantly impacted with pathology Superficial Fascia Superficial fascia: a fascial sheet lying directly beneath the skin. Syn. Hypoderm, subcutaneous tissue. H y p o d e r m (Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier) epimysium perimysium endomysium 17 Superficial Fascia Large Adipose Lobules Septa of the Retinaculum Cutis superf. Superficial Fascia Deep fascia 18 6 8/17/2018 Let’s talk about motion Remember this Pic… Fascial Perforation: Triad = vein, artery and nerve Deep Fascia – Structural Most extensive of all fascia tissue Long strands of thicker, denser fascia that run throughout the body Structural Fascia has the ability to contract, relax and stretch Has the ability to pull the skeleton as well as surrounding structures Intricate series of connective sheets and bands Strands run throughout the body Therefore, can impacts function Wraps muscle groups and muscle fibers Holds muscle and other structures in place Avascular (essentially), except at its bone attachments Rich supply of sensory receptors (especially at the bone attachements) High density of elastin which helps determine extensability and thus, functional capacity 7 8/17/2018 Layers Epimysium, perimysium, and endomysium At joints in the body, where muscle tissue ends Names given to different layers of fascia also seen in superficial fascia These layers extend beyond the muscle tissue and gather together to form tendons Tendons are thick cords of fascia that attach muscles to bones Epimysium, perimysium, and endomysium are names given to different layers of fascia At joints in the body, where muscle tissue ends, these layers of fascia extend beyond the muscle tissue and gather together to form tendons Visceral Fascia - Subserous Fascia Gelatin quality fascia surrounding organs Found mostly in abdominal cavity Only Fascia with the ability to change properties Membrane-like Heart = Pericardium Lungs = Pleura Abdomen = Peritonea Brain = Meninges VF interacts with all tissues and other fascia Fills voids in tissue and suspends organs Highly protective When lax…can get prolapse of organ When tight (hypertonic)...get restricted motility 8 8/17/2018 Lungs = Pleura In the BBQ World: Silver Skin/Silver Membrane Kansas City Dry Rub: 2 cups brown sugar 1/2 cup dry mustard 1 tablespoon cayenne pepper 1 tablespoon smoked paprika 1 tablespoon garlic powder 1 tablespoon onion powder 1 tablespoon salt 2 teaspoons freshly ground black pepper Abdomen = Peritoneum 9 8/17/2018 Heart = Pericardium Brain and Spine Fascia Fascial Layers wrap the brain and spine Fibrous and dense Dura is contiguous throughout the CNS Creates the thecal sac Encases the spinal cord like a straw Dural folds separate sections of the brain Thinner layers branch out and “wrap” around and connect brain cells The other forms of fascia connect to this and erupt from the spinal fascia creating a network of connectors throughout the abdominal cavity Fascia of the Brain The fascial layers wrapping the brain and spinal cord Dural folds separate different sections of the brain Thinner layers of fascia branch out from these dural folds Dura surround and connect all brain cells 10 8/17/2018 Fascia of the Brain Can the Fascia Feel? Fascial Receptors Fascia roles as a sensory organ was originally postulated by A. T. Still in 1899 Proprioception (Sensory) gives the brain the ability to understand position in 3 dimensions 4 major types of intra-fascial mechanoreceptors Golgi Pacini Ruffini Interstitial 11 8/17/2018 Mechanoreceptors Pacini: Respond to rapid pressure changes Located in deep capsular layers, muscle tendon They play a major spinal ligaments, and role in proprioceptive feedback Stimulate them with: High velocity manipulation Articulation Vibratory tools and rhythmic joint compression Mechanoreceptors Ruffini : respond to lateral shearing Inhibit sympathetic activity Location: Ligaments of peripheral joints Dura mater Outer capsular layers Slow steady shearing pressure is needed Suboccipital release Fascia release Mechanoreceptors Golgi: located in muscle capsules Stimulated tendons, aponeuroses, ligaments and joint with slow sustained stretching Active (vs. passive) movements stimulate golgi Myofascial may be more effective to techniques (especially active) Myofascial unwinding 12 8/17/2018 Mechanoreceptors Interstitial: Smaller multimodal receptors Thermal Chemo-receptors Pain Mechanoreceptors 50 % of mechanoreceptors are high threshold pressure (HTP) 50% of mechanoreceptors are low threshold pressure units (LTP) respond to gentle stimulation They are highly Stimulation They are concentrated in the periosteum vasodilatation and enhance tissue nutrition influenced by Neurotransmitters, neuropeptides and cytokines Fascia and Healing Contact Activation Pathway Tissue Factor Pathway Clotting Cascade Intrinsic Pathway Extrinsic Pathway Surface Contact Collagen FXII activator F XII Tissue/Cell Defect F XIIa F XI F VIIa F XIa Ca2+ F IX F VIII Ca2+ F VIIIa Platelet Factor 3 Factor F X F IXa Ca2+ Macrophage attack Factor F Xa F Va Prothrombin I F XIIIa Crosslinked Fibrin Meshwork Ca2+ Ca2+ F VII F III (Tissue Thromboplastin) Ca2+ Factor F X FV Thrombin F XIII Fibrin polymers Fibrin monomers Fibrinogen Torkian, B 2004 13 8/17/2018 The Orchestra “Tunes Up” Phases of Healing Hemostasis Inflammation Proliferation Remodeling Platelets Neutrophils Fibroblasts Col. Crosslinking Growth Factors Macrophages Growth Factors Col. Degradation Cytokines Growth Factors Collagen Deposition Proteases Endothelial Cells Proteases Epithelial Cells Scar Strength Cytokines Growth Factors Vascularity Fibrin Endothelial Cells Fibronectin Growth Factors Note: Regulation accomplished by growth factors and cytokines that affect cell migration, proliferation and protein production. Cells enter the wound site by migration, which involves recognition of cell surface integrins and adhesion ligands on matrix proteins. e Torkian, 2004 Relative amount and timing of two key cells of healing and the resultant collagen accumulation. Growth factors and cytokines specific for the cell are represented (not in order of importance or relative concentrations) in the area under the curve. Relative Amount of Cells in Wound Macrophage Fibroblasts IGF-1 -FGF TGF- PDGF KGF Collagen Accumulation TNF- TGF- IL1- HB-EGF TGF- -FGF 0 1 3 Inflammation 5 7… 14 21 28 35… Time Post-Injury (days) Proliferation (days 4 - 42) Maturation (days 21 – 3 years) TNF-=Tumor Necrosis Factor-alpha; TGF-= Transforming Growth Factor-alpha; TGF-= Transforming growth Factorbeta; IL1-= Interleukin-1-beta; HB-EGF=Heparin Binding-Epidermal Growth Factor; -FGF=beta-Fibroblast Growth Factor; IGF-1=Insulin-like Growth Factor-1; PDGF=Platelet Derived Growth Factor; KGF=Keratinocyte Growth Factor Adapted, in part, from Witte, 1995, and a review of the literature. D’Agostino, 2003 14 8/17/2018 Time 0 of wounding Relative amount and timing of two key cells of healing and the resultant collagen accumulation. Growth factors and cytokines specific for the cell are represented (not in order of importance or relative concentrations) in the area under the curve. Relative Amount of Cells in Wound Macrophage Fibroblasts IGF-1 -FGF TGF- PDGF KGF Collagen Accumulation TNF- TGF- IL1- HB-EGF TGF- -FGF 0 1 3 Inflammation 5 7… 14 21 28 35… Time Post-Injury (days) Proliferation (days 4 - 42) Maturation (days 21 – 3 years) TNF-=Tumor Necrosis Factor-alpha; TGF-= Transforming Growth Factor-alpha; TGF-= Transforming growth Factorbeta; IL1-= Interleukin-1-beta; HB-EGF=Heparin Binding-Epidermal Growth Factor; -FGF=beta-Fibroblast Growth Factor; IGF-1=Insulin-like Growth Factor-1; PDGF=Platelet Derived Growth Factor; KGF=Keratinocyte Growth Factor Adapted, in part, from Witte, 1995, and a review of the literature. D’Agostino, 2003 3 Days after wounding 15 8/17/2018 Relative amount and timing of two key cells of healing and the resultant collagen accumulation. Growth factors and cytokines specific for the cell are represented (not in order of importance or relative concentrations) in the area under the curve. Relative Amount of Cells in Wound Macrophage Fibroblasts IGF-1 -FGF TGF- PDGF KGF Collagen Accumulation TNF- TGF- IL1- HB-EGF TGF- -FGF 0 1 3 5 7… 14 21 28 35… Time Post-Injury (days) Inflammation Proliferation (days 4 - 42) Maturation (days 21 – 3 years) TNF-=Tumor Necrosis Factor-alpha; TGF-= Transforming Growth Factor-alpha; TGF-= Transforming growth Factorbeta; IL1-= Interleukin-1-beta; HB-EGF=Heparin Binding-Epidermal Growth Factor; -FGF=beta-Fibroblast Growth Factor; IGF-1=Insulin-like Growth Factor-1; PDGF=Platelet Derived Growth Factor; KGF=Keratinocyte Growth Factor Adapted, in part, from Witte, 1995, and a review of the literature. D’Agostino, 2003 17 days after wounding Relative amount and timing of two key cells of healing and the resultant collagen accumulation. Growth factors and cytokines specific for the cell are represented (not in order of importance or relative concentrations) in the area under the curve. Relative Amount of Cells in Wound Macrophage Fibroblasts IGF-1 -FGF TGF- PDGF KGF Collagen Accumulation TNF- TGF- IL1- HB-EGF TGF- -FGF 0 1 3 Inflammation 5 7… 14 21 28 35… Time Post-Injury (days) Proliferation (days 4 - 42) Maturation (days 21 – 3 years) TNF-=Tumor Necrosis Factor-alpha; TGF-= Transforming Growth Factor-alpha; TGF-= Transforming growth Factorbeta; IL1-= Interleukin-1-beta; HB-EGF=Heparin Binding-Epidermal Growth Factor; -FGF=beta-Fibroblast Growth Factor; IGF-1=Insulin-like Growth Factor-1; PDGF=Platelet Derived Growth Factor; KGF=Keratinocyte Growth Factor Adapted, in part, from Witte, 1995, and a review of the literature. D’Agostino, 2003 16 8/17/2018 30 days after wounding How are Forces Accommodated? Epimysium, perimysium, and endomysium are names given to different layers of fascia At joints in the body, where muscle tissue ends, these layers of fascia extend beyond the muscle tissue and gather together to form tendons 17 8/17/2018 And then there is shear Forces are transmitted through the thickness of the endomysium Translaminar Shear Shear linkage is easy to conceptualize in series muscle fibers Lateral cytoskeletal linkages to myofibrils are clearly involved Transmission of forces during muscle contraction Soleus muscle at the Ankle 50% MG Muscle at the Ankle 49% Extensor Muscle at the Elbow 49% Flexor Muscle At the Elbow 50% Ratio of Radial stress to Longitudinal stress for different locations in the body Findley, et al. http://dx.doi.org/10.1016/j.jbmt.2014.08.010 18 8/17/2018 Clinical Implications Sarcomere length NOT uniform BOTH lengthening and shortening may occur within the same muscle External forces affect sarcomere deformation Fascia absorbs the forces through the network of collagen fibers and fluid dynamics Clinical Implications There is Fascial continuity between layers to fibrils within muscle cell Forces transmitted by shear at endomysium Cells respond to extracellular forces Fibers within cell connect to fibers outside the cell Intra cellular structures support tension and compression Should we modify our treatments to address these shear forces? Force transmission and absorption The Fascia is Not Dry 19 8/17/2018 Flow of Hyaluronic Acid (HA) in Manipulation The model of fascia and HA during manual therapy is consistent with squeeze film lubrication theory of fluid mechanics • HA has viscous (slow movement) and elastic (fast movement) properties…very important characteristics This pressure can lift the upper boundary of the tissue much like water lifting a car tire leading to hydroplaning. • Causing it to lose traction with the road surface • The faster the car is moving, the greater the fluid pressure U y z h0 h1 x Figure 1 Figure 2 Fluid film Hydroplane Concept Fascia sliding function Fascia “gives all muscles help to glide over and around all adjacent muscles and ligaments” Movement of muscle fascicles Movement of adjacent muscles Containment of groups of muscles Movement of groups of muscles 20 8/17/2018 Connecting and Disconnecting Hyaluronan forms sliding/gliding layer Compressing this layer by sliding your fingers on underlying tissue pushes fluid forward and laterally Therefore you are NOT working under your fingers, but NEXT to them Hyaluronan breakdown products are highly inflammatory Dysfunction can escalate to inflammatory pain triggering How is Force Accommodated? Orientation of fibers in fascia affects change with application of pressure, stress, compression and shearing From anatomy you can deduce possible function Biotensegrity a) A low fiber angle increases tube with b) A high fiber angle increase tube length c) The optimum fiber angle of 54.44o balances both influences d) Left and right handed helixes cause tube rotation and shortening in directions biased toward the highest fiber angle 21 8/17/2018 Medial region of the elbow The presence of loose connective tissue interposed between adjacent layers permits local sliding So mechanical, the single layers can be considered independently Clinical Implications About 50% of humans have a fascial structure with perpendicular fibers, which lengthens and stiffens as internal pressure increases Osteopathy and Fascia 22 8/17/2018 Andrew Taylor Still , MD 1828-1917 Called himself an “Anatomy Mechanic” Physician Surgeon Author Inventor Private clinic in Kirksville MO Rejected ineffectual drugs of the day 1892 opened first osteopathic school 1899 published “Philosophy of Osteopathy” Heavy metals were common American School of Osteopathy in Kirksville, Missouri Body Principles of AT Still Human Body functions as a total biologic unit Body possesses self healing and regulatory mechanisms Structure and function are interrelated Abnormal pressure in one part of the body produces abnormal pressures (and strains) in other parts of the body Key Fascial Concepts of AT Still Fascia as a covering Fascia terminology Fascia and sliding Fascia and fluid flow Fascia innervation Fascia and respiration Fascia and cancer It took 100 years for science to catch up with A.T. Still’s concepts of fascia 23 8/17/2018 Fascia terminology Naming fascia by the organ it interacts with make invisible the inherent continuity of the layers Compartmentalizing tissue minimizes its beauty Q: How many muscles do we have in our body? A: 650 Do we have 650 muscles or do we have 1 muscle in 650 fascial compartments??? Thank You 24
