In September of 2015 I had the great pleasure to attend the Fourth International Fascia Research Congress (FRC 4) in Reston, VA. Partly to help me process information, and partly to invite those who could not attend to feel at least peripherally involved, I took notes and posted them on my FB profile page in real time, marked by #FRC4
Later I pulled them all together, cleaned up the type-os and blatant misspellings, and added some additional information about the speakers.
Here then are my FRC 4 field notes, with the disclaimer that I didn’t understand everything that I heard, and I may have gotten things wrong. (Hey, you get what you pay for.)
A complete copy of the congress proceedings can be found for sale here:
FRC 5 will be in 2018, probably in Europe. Time to start saving those pennies; it will be worth it.
Welcome with Tom Findley, MD, PhD and Antonio Stecco, MD
An overview of the meeting to come
Anatomy Consensus in Nomenclature with Carla Stecco, MD
Several thought-leaders worked to try to come to consensus about anatomical nomenclature, particularly in light of an invitation to contribute to Terminologia Anatomica (TA), the international standard on human anatomic terminology. (This is a Big Deal, and opportunities like this don’t happen often.) This presentation led to a spirited discussion with Gil Hedley, who made an impassioned plea to include loose connective tissue in the nomenclature. I missed some of the nuance, but it sounds like two sets of nomenclature will be proposed; a very formal one for the TA, and one that is more clinically applicable, that will include Gil’s input.
Innervation of Fascia with Siegfried Mense, MD, PhD
A description of Dr. Mense’s work with demonstrating nociceptors in thoracolumbar fascia can be found here, under the “description” tag.
100,000 sensory neurons end (begin) in the fascia of an average limb.
Motor neurons in fascia mostly wrap around blood vessels. Sympathetic reactions reduce blood flow, cause ischemia and lead to pain.
DOMs pain seems to come from epimysium rather than muscles. Fascial nociception has been demonstrated both morphologically and functionally.
Chronic low back pain can be related to fascial micro injury.
Sensory Aspects of Fascia with Robert Schleip, PhD, MA
There are free nerve endings in fascia. No one knows for sure what they do.
Some spindles are located in fascial layers for proprioception.
Tissues that transmit force have fewer proprioceptors. (What’s up with that?)
Adhesions in fascia may impede proprioception. (Think about that for elders with poor stability—I see big implications there.)
We have neurons called wide dynamic range neurons. They are looking for stimulation—very low threshold for activation. They are involved in the sensation of spreading pain.
Tactile C fibers go to insula of the brain, connected to interoception—our internal sensation. IBS (irritable bowel syndrome) is a type of interoceptive disorder.
Therapies that are good at promoting interoception include yoga, self awareness, manual therapies that focuses on integration and incorporation. (Singin’ my song, how long have I been saying this?!)
It’s about the relationship between stiff ECM (extra cellular matrix) and the efficiency of sarcomere contraction.
He is focusing on lumbar fascia. Pain elicited in fascia lasts longer than ultrasound suggests.
Muscles appear to process pain signals for a shorter time than fascia. No correlation between thickness of fascia and sensitivity.
Injections of saline into fascia lead to wider pain field compared to injection into muscle.
Fascia is probably involved in the phenomenon low back pain. Fascia pain is described as beating, throbbing, singing, hot. Muscle pain is beating, throbbing, dull.
Effects of Scar Tissue on Force Transmission with Peter Huijing, PhD
Scar tissue on force transmission after surgery, rat model.
Measures are mass, joint angle, others. Walking on treadmill, Rat gait. Joints are measured in film of walking rat.
This is all in rats with imposed spasticity.
A surprising finding: the belly is shorter, the tendon is longer! The total # of sarcomeres decreased.
After a tendon transfer, there is an increase in total force. It is possible that scar fills to make up for loss of muscle belly length.
Rats are good at adapting to this surgery. Mass and bone length are same as controls… humans are very different.
Fascia and Manual Therapies, a panel led by Leon Chaitow, DO, PhD.
Responsiveness of the plantar fascia to vibration and/or stretch (Frenzel, P., Schleip R., Geyer A.)
Work on fascia increases ability to touch toes (reduces FGD, finger-ground distance), she asks why?
She used a MELT ball on 1 foot (n= 26), a vibrator on the other foot (n= 26). Looked for flexibility, local hydration.
Control group (n=35) got light massage on popliteal fossa.
Both groups had significant improvement. Vibration did not work as well as the stretch.
Conclusions: Plantar fascia reacts to treatment, which appears to act also on Achilles. Drainage effect appears to last. Finger-ground distance changed for both groups, so this might not be the best control.
Conservative treatment of carpal tunnel syndrome: comparison between laser therapy and Fascial Manipulation® (Pratelli et al.)
Manual therapy shows promise for CTS, especially because surgery or corticosteroid injections are inconsistent.
Sometimes the fascia becomes thicker, reduces glide and affects median nerve.
This is a single blind comparative study, manual therapy vs. laser therapy for CTS. Looking at post treatment EMG, a CTS questionnaire for function and VAS (visual analogue scale).
42 participants, total of 70 affected wrists.
Laser therapy is treatment as usual at this research hospital (in Italy).
Myofascial approach sounds incredibly regimented. 1/wk for 3 weeks, 45 mins
Results: at end and follow up (3 months) fascial manipulation was more effective for function and pain. Laser therapy was also effective, but not at the 3 month follow up.
Endothoracic moyofascial release technique: effects on the autonomic nervous system in an asymptomatic population. (Challand, et al).
Looked at heart rate, temp, BP, heart rate variability (HRV) in healthy subjects.
Subjects were blinded. Measures were taken before, during, just after treatment.
Significant outcomes for HRV and for endothoracic myofascial somatic dysfunction (whatever the HECK that is, especially starting with an asymptomatic population, but hey what do I know?).
Next steps, look at people with autonomic diseases.
Thoraco-abdominal pump technique does not enhance primary tumor growth and lung metastasis in a murine (mouse) model of osteosarcoma. (Trichet et al)
Lymph studies show clear movement of fluid. We tell people not to move lymph if a tumor is present. Is this a real concern?
Exercise appears to reduce tumor growth. Why wouldn’t therapy?
Using mice, induced osteosarcoma. (Some mice didn’t develop tumors at all, gee too bad)
Anesthetized mice are gently squeezed at the ribs/belly for 4 mins 1/day, 10 days.
No difference in tumor growth in each group. No signs of proliferation potential for cancer cells. No significant change of leukocyte population.
A good challenge to common wisdom!
To investigate the effects of functional fascial taping on pain and function in patients with non-specific low back pain: a pilot RCT. (Chen et al)
The point of taping is to take out the slack in skin, and create a graded load in the tissues.
N=21 in functional fascial taping (FFT)
N= 22 in sham taping.
Participants are blinded, data analysts are blinded.
Participants have low back pain and poor flexibility.
Measures are VAS, modified Owestry Disability Index.
Both groups got similar treatment, and exercise component.
2 weeks of treatment, follow up over 12 weeks.
Total of 430 treatments.
Effect size is good. Placebo was well hidden (that is, people didn’t know if they were in the intervention or placebo group).
FFT group had significant reduction in pain compared to sham. FFT can be a good complement to other interventions.
Mechanism is unknown, but he has some interesting ideas.
Osteopathic manipulative treatment in chronic coccydynia: a myofascial perspective (Origo D.)
Looking at osteopathic manipulative treatment (OMT) for chronic coccydynia, 2ndary outcome is radicular pain.
A comparison of OMT vs. PT vs. medication
Provocative testing can involve a blunt needle—Yikes– Looking for tenderness over coccyx, not from other causes. Standard treatment is drugs, massage, stretching.
50 patients with idiopathic or traumatic coccydynia.
Outcomes: VAS, walking, etc.
Group 1: tx as usual (drugs + PT)
Group 2 also got OMT (osteopathic manipulative treatment) all around abdominal structures.
Results on VAS and Owestry LBP Disability Index are very clear in favor of OMT.
These are case series, btw. No blinding, no control groups, but a good reason to look at this further.
Fasciatherapy and reflexology, compared to hypnosis and music therapy in stress management. (Payrau B, et al)
Fascia therapy and reflexology still lacking evidence. He’s citing some pro- reflexology studies that I’ve looked at, and didn’t like, mainly because we have good evidence that foot reflexology is deeply relaxing. We don’t have consistent evidence that reflexology is superior to a generic foot massage, or that it leads to changes in any of the targeted distant organs.
This is a prospective clinical trial: people could get reflexology, fasciatherapy, music therapy, hypnosis, or resting. Level of stress assessed pre and post treatment.
Every intervention shows decrease of stress, including rest.
Hypnosis, fasciatherapy, and reflexology all had about the same effect. All were better than music, or resting (although they too had improvement).
Pathology and Fascia panel. (Squeeee! My Favorite!)
Overactive bladder (OAB), comparison of three rehabilitative approaches. (Desiree et al)
OAB is common, with urgency, frequency, nocturia. Can be from poor micturation reflex, several problems. This study looked at 3 interventions:
- Perineal rehabilitation
- Fascial manipulation of perineal fascia
- Combination of 1+2.
10 sessions, 1 hr each.
Measures are VAS and questionnaires.
15 patients median age 66.
Improvement seems best in Group 1.
Group 3 had different improvements.
Conclusion, this approach could be a useful adjunct to other OAB therapies.
Fibrosis and densification: anatomical v. functional alteration of fascia. (Pavan et al)
Fascia responds to pain, stimulus of embedded receptors.
Hormones influence connective tissue. Women on hormone replacement therapy or hormonal birth control have less pliable ligaments.
Diabetes can alter connective tissue deposition (an RW aside: people with diabetes are much more likely to have frozen shoulder, related to fascial densification).
Age makes us stiffer.
FIBROSIS is what we see with Dupuytren contraction (tough, denser, difficult to reverse). Random production and deposit of excessive collagen.
DENSIFICATION= increase in density, affects function, not structure. Can impede sliding or gliding. Involves concentration of HA. Appears to be reversible with manual therapy.
So densification applies to loose CT; fibrosis to dense CT, trauma, surgery, aging, etc. hard to reverse.
Do corticosteroids treat or exacerbate tendinopathy? A study of substance P regulation by dexamethasone (Mousavizadeh R et al)
Tendinopathy is damage and inflammation. So it seems sensible to use corticosteroids to treat it.
Except, that’s wrong, inflammation is not a big issue in this situation, and coritcosteroids can cause damage.
Substance P is present at tendinopathy sites. It is possible that steroids interfere with substance P action, leading to pain relief.
Wonders if dexamethasone can inhibit substance P– evidently yes.
Take home: Dexamethasone can reduce substance P, cause pain relief. Could be future target in treatment of tendinopathy. Dexamethasone may also change angiogenesis that affects scar tissue growth.
Low-dosage intra-articular triamcinolone fails to reduce joint contracture. (Thiele et al)
Contractures are painful and expensive, we need preventive options.
This drug worked better than corticosteroids in induced contractures in rats.
Corticosteroids have side effects: in joints they can kill chondrocytes, bad news.
Triamcinolone works in a bunch of ways. It is a leukotriene inhibitor.
38 animals in 3 groups: control, triamcinolone, another anti- inflammatory.
They initiated knee injuries, followed for 21 days. At evaluation they measured the joint contracture in several ways.
Knee flexion angle was the same across 3 groups.
Triamcinolone was slightly more effective than others for contracture prevention. Adhesions are dominant lesion.
They want to find the sweet spot with good effect and minimal chondrocytes death.
Conclusion: it didn’t work. A null finding, a good presentation.
Stay tuned for parts 2 and 3 of this series!