Less than a decade ago, myofascial release (MFR) was little known in the UK or Europe in either the therapy or research fields. Nowadays most gyms have foam rollers or rumble rollers. If this isn’t enough, people are going to see sport and massage therapists, such as Human Kinetics author, Ruth Duncan.
Ruth Duncan, author of Myofascial Release has spent over 15 years learning and developing her work, reading and applying research into her practice to enhance the outcomes of the treatment, as well as helping clients with self-care and home rehabilitation programmes.
Ruth has written a blog for Human Kinetics, giving us expert insight into myofascial release, with an explanation of how it works. Ruth begins by describing the anatomy with the fascial system and structure.
The fascial system
This fascial web spreads three-dimensionally throughout the body as it enfolds and embraces all other soft tissue and organs of the body. No tissue exists in isolation but acts (is bound and interwoven) with other structures. In fact, it could be argued that there is no such thing as a muscle. Fascia is the immediate environment of every cell in the body.
The human framework is dependent on this single network of connective tissue. Deformation and distortion of any part of this network impose negative stresses on distant aspects and on the structures which it divides, envelopes, enmeshes, supports and with which it connects. In treating fascia, we cannot but influence the whole body. Fascia is dynamic in nature as it constantly undergoes change.
Traditionally when we discuss fascia, we are discussing the connective tissues of the muscular system. However, a more encompassing definition was developed at the 2012 International Fascial Congress in Vancouver, Canada. The term ‘fascia’ now describes not only the muscular fascia of the endomysium, perimysium and epimysium but all the soft tissue components of the connective tissue system which permeate the human body forming part of the body wide tensional force transmission system. Therefore, fascia now also includes aponeurosis, ligaments, tendons, joint capsules and certain layers of bone, organ and nerve as well as the dura mater surrounding the central nervous system, the epineurium which is a fascial layer around peripheral nerves and bronchial connective tissues and the mesentery of the abdomen. (Huijing and Langevin ,2009).
The terminological clarification, or nomenclature, was a huge topic of debate at the 2015 Fascia Research Congress in Washington DC, where Dr Carla Stecco announced that a general committee had been set up to further define fascia as – “A fascia is a sheath, a sheet or any number of other dissectible aggregations of connective tissue that forms beneath the skin to attach, enclose and separate muscles and other internal organs.” (Stecco, 2015)
In comparison, Prof. Jean-Claude Guimberteau, a prominent French hand surgeon, has described the fascia as one ‘multimicrovacular collagenic absorbing system’ capable of dynamic movement, gliding capacity and constitutes the primary network of the human body.
Most anatomy texts describe the fascia as the connective tissue surrounding and permeating muscle fibres (muscle fascia). The epimysial layer surrounds the entire muscle whilst the perimysial layer surrounds each muscle fascicle. A further inner layer of fascia, the endomysium, wraps around individual muscle fibres.
The epimysium and the perimysium of muscle converge on to the muscle tendon mechanically connecting them to surrounding structures by means of the fascial network. The endomysium of muscle, the subdivision of the perimysium, which surrounds the muscle fibres, does not connect onto the muscle tendon.
However, fascia is far greater than just the muscular fascia alone, fascia is ubiquitous. The human framework depends upon fascia to provide form, cohesion, separation and support and to allow movement between neighbouring structures without irritation. Every muscle, organ, bone, nerve, and blood vessel is covered in a thin film of fascia, yet all these fascial pockets are interconnected to form a continuous, integrated fascial matrix covering the whole body from the top of the head to the tip of the toes. Since fascia is a single structure, the implications for body-wide repercussions of distortions are clear.
Fascia, a connective tissue, develops in the mesoderm layer of the growing embryo in the early weeks of life. Both biodynamic and biokinetic (development and movement) processes within the embryo and within its surrounding environment, influence the nature of the connective tissues. Ultimately, compression, loading and traction of these tissues determine what specialised cells the connective tissue will become.
Fascia is composed of cells including fibroblasts, chondrocytes, mast cells, macrophages, adipocytes, osteoblasts and telocytes along with an extra cellular matrix (ECM). The ECM contains the protein fibres collagen and elastin surrounded by a ground substance made up primarily of acid and water.
The collagen fibres provide strength and stability, guarding against overextension when mechanical stress is applied. Elastin provides an elastic quality, which allows the connective tissue to stretch to the limit of the collagen fibre’s length while absorbing tensile force.
Fascia supplies restraining mechanisms by the differentiation of retention bands, fibrous pulleys and checks ligaments as well as assisting in the harmonious production and control of movement. Specialised fascia is interwoven with tendinous and ligamentous structures. It enables adjacent tissue to move upon each other while providing stability. When in a healthy, well-lubricated state fascia ensures that adjacent structures glide against each other allowing free movement. It enhances the body’s postural balance allowing for free and efficient movement. The ensheathing layers of deep fascia, as well as the intermuscular septum and the interosseous membranes, provide vast areas used for muscular attachment.
The ground substance of the ECM is a viscous, gel-like substance (a polysaccharide gel complex) composed of hyaluronic acid (hyaluronan) and proteoglycans, that lubricate the fibres allowing them to glide over one another. (Chaitow and DeLany, 2008, Barnes, 1990). Hyaluronan is also hydrophilic (water loving), and draws water into the tissue. This provides a cushioning effect to the tissues as well as maintaining space between the collagen fibres. This gel is designed to absorb shock and disperse it through the body.
The ground substance also provides the medium through which other elements are exchanged (gases, nutrients, hormones, cellular waste, antibodies and white blood cells). The condition of the ground substance can affect the rate of diffusion throughout the body and therefore the health of the cells it surrounds. (Chaitow and DeLany, 2008, Juhan, 2003).
What role does this 3D network have in pain and dysfunction?
Emotional upset/trauma (psychogenic pain), physical trauma, an inflammatory or infectious process, structural imbalances of any kind, poor posture as well as scar tissue and adhesions may all create inappropriate fascial strain. Such strains can slowly tighten, causing the body to lose its physiological adaptive capacity. Over time the thickness spreads like a pull in a sweater or stocking crowding or pulling the osseous structures out of proper alignment, resulting in compression of joints, producing pain and/or dysfunction.
Neural and vascular structures can also become trapped in these restrictions causing neurological or ischemic conditions. Shortening of the myofascial fascicle can limit its functional length (reducing its strength, contractile potential and deceleration capacity). Flexibility and spontaneity of movement are lost, setting up the body for more trauma, pain and limitation of movement. These powerful fascial restrictions pull the body out of its three-dimensional alignment with the vertical gravitation axis, causing biomechanical inefficiency, highly energy-consuming movement and posture (Barnes 1990).
Restrictions present at a time of trauma prevent the forces from being dispersed properly and areas of the body are then subject to an intolerable impact, with injury being the result. Compensations through muscular spasm and fascial restrictions ultimately produce symptoms.
Tensile strength of up to 2000lbs per square inch (Katake 1961) is applied to pain-sensitive structures. Circulatory vessels are impeded.
At tissue level the following changes occur:
- tissue dehydration due to less water content
- less lubrication production= narrowing between tissue layers = less space and gliding between tissue
- increased collagen production
- randomly laid down collagen
- less strength, less specificity to function
- cross linkages between cells increases = less tissue mobility and increased tissue stiffness
- the weakening of all tissues = degradation of their mechanical properties
- less vascular supply
- muscle shortening and stiffening
- lack of movement/contraction = increased pooling of fluid and tissues.
The tough, resistant, and confining characteristics of deep fascia can create problems such as compartment syndromes. Trauma with haemorrhage in the anterior compartment of the lower leg can cause swelling that is detrimental to the sensitive neural structures within the compartments. Frequently, fasciectomy is necessary to relieve the compression on the neural elements.
Fascia is the major arena of the inflammatory process. By virtue of its fibroblastic activity, connective tissue aids in the repair of injuries by the deposition of collagenous fibres (scar tissue).
The histiocytes of connective tissue comprise an important defence mechanism against bacterial invasion by their phagocytic activity. Fluid and infectious processes often travel along the fascial planes. They also play a part as scavengers in removing cell debris and foreign material. Connective tissue represents an important ‘neutraliser’ or detoxicator to both endogenous toxins (those produced under physiological conditions), and exogenous toxins. The anatomical barrier presented by fascia has important defensive functions in case of infections and toxaemia.
Myofascial Release approaches for the treatment of acute and chronic pain
Restoring the ground substance to a more soluble consistency by applying energy (manual therapy) will create a softening of the fascia (piezoelectricity, a low load pressure over a sustained length of time will create a physical and chemical reaction within the tissue).
There will be an increase in water volume enhancing the quality of the ground substance and fluid exchange. With the energy input, there will be a subsequent improvement in local circulation (waste and nutrient exchange). The energy input will help improve (as far as possible) the tissue’s starting shape.
Fascial cross-linkages are broken down. Fascial planes are realigned and the soft tissue proprioceptive sensory mechanism will reset. This will re-programme the central nervous system, enabling a normal functional range of motion without eliciting the old pain pattern.
Recent research into the role of fascia on the immune system, in particular, the T3 cells has highlighted that during the sympathetic fight and flight response, a substance called transforming growth factor beta (TGFbeta) is released into the fascial network and has been found to be responsible for fascial tonicity. TGFbeta is a potent stimulator of myofibroblast contraction, wound contracture, the making of scar tissue and fibrosis, all negatively affecting the immune system making fascial tissue feel more restricted and less bouncy. Myofascial Release influences the autonomic nervous system, with its slow sustained pressure, creating a mental and manual shift from the sympathetic flight and fight response to parasympathetic tone counteracting TGFbeta, improving immune system response (Bhowmick et al., 2009).
Also, Meltzer and Standley’s research focuses on interleukin, a cytokine crystalline communicatory protein promoting tissue healing (Meltzer K and Standley P., 2007). He showed that, when using MFR on damaged tissue, levels of interleukin reduced with fascial holds of less than three minutes, that interleukin eight, which regulates inflammatory responses, was not stimulated until fascial holds reached three minutes and also more than doubled at five minute holds. Interleukin three, which regulates blood cell production, increases after four-minute fascial holds. This study shows the positive effects of the use of MFR to encourage tissue healing as long as the MFR is performed for at least five minutes.
Myofascial Release techniques are performed in conjunction with specific symptomatic treatment. Due to the three-dimensional system-wide network of the fascia, total body treatment is necessary. The goal of treatment is to remove fascial restrictions and restore the body’s equilibrium.
With MFR, always find the pain and look elsewhere for the cause. This is due to the system wide matrix, its tensile forces and subsequent loading of the entire matrix when an injury occurs.
How does Myofascial Release work?
- Sol to gel of the ground substance – thixotrophy and visco=elasticity
- Piezo-electricity, the collagen and elastin fibres are semi- conductors and the fascia is a liquid crystalline matrix where information is passed along its array with regards to tissue tonus
- Mechanotransduction, the Pacini, Ruffini, Golgi and Interstitial sensory nerves respond to different types of mechanical stimuli which can alter tissue tonus.
- The fascial network has a 10X higher quality of sensory nerve receptors compared to its red muscle counterpart (van der Wal 2009).
- Nerves conduct at 50 m per second whilst mechanical loading and force travels at 1500 m per second
- Arndt Schulz Law – weak stimuli accelerate physiologic activity, medium stimuli inhibit physiologic activity, and strong stimuli halt physiologic activity
- Fluid dynamics, infra-red energy (heat) creates a change in the water of the ECM making it more gel-like offering fascia more bounce and ‘give’
- Force transmission, if 30-50% of force is transmitted via the fascial network, treating the fascial network is also necessary in order to promote musculoskeletal efficiency
- Slow sustained MFR slows down the release of TGFbeta and fibroblastic activity
- Slow sustained MFR triggers the autonomic nervous system, the rest and digest system
- The release of interleukin 3 and 8 (cytokines involved in inflammatory regulation) are only stimulated with sustained fascial holds of more than 3 minutes in duration and holds of 5 minutes increased tissue healing.
Fascial restrictions do not show up on CAT scans, MRI’s or X-Rays, therefore, many patients are suffering unresolved physical and emotional pain due to undiagnosed fascial trauma. Conditions are a label for a symptom. Traditional health care treats the symptom, MFR with its whole body approach treats the cause at the deepest level.
Myofascial Release Therapy, like many alternative therapies, promotes the philosophy that the mind and body work together to maintain health. Effectively this supports the understanding that the mind and body are one and the same. The body has the ability to remember postural positions, actions and emotions without the brain reminding it to do so. Throughout the body’s fascial system flow microscopic cells containing energy which have the ability to retain memory.
Therapists are taught to feel and stretch slowly into the fascial network. Collagen means glue producer so therapists are taught to feel for this glue like texture which when dense, thick or hard defines a fascial restriction. The MFR technique is very different to that of massaging muscles, tendons and the ligaments of the body. A time component also exists, coupled with the fluidity of the therapist’s hands in applying pressure and moving through each and every fascial restriction. The time element is a vital factor, the fascia cannot be forced as it will naturally meet that force in return. Hence the MFR therapist provides a sustained, gentle, pressure for five to eight minutes allowing the fascia to elongate naturally and return to its normal resting length restoring health and providing results that are both measurable and functional.
The MFR therapist not only takes into consideration what they see in the patient’s postural assessment but works directly with what they feel and sense from palpating and treating the body.
Once we understand the nature of the fascial network, how it functions and how fascial dysfunction can affect the entire structure, we can begin to understand how symptoms, pain, imbalance and dysfunction develop. In many cases, traditional healthcare focuses on the symptom and where the pain is, then labels the dysfunction. For many people, this does not offer an effective solution.
MFR offers a positive solution for many pain suffers and has become a treatment of choice for both healthcare providers and patients.
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Chaitow, L., and DeLany, J. 2008. Clinical application of neuromuscular techniques, volume 1: The upper body, 2nd ed. Philadelphia, Pennsylvania: Churchill Livingstone.
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