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Creating Relationships at Southwest Symposium
The month of May brought many interesting activities. As I have said in many previous columns this year, this profession is moving in a very exciting direction. Make sure you are getting involved. If you're not, you just might get left behind.
News in Brief
Investigating the Cellular Impact of Mechanical Force; National Board Seats (Not-So) New Officers at Annual Meeting.
Q&A With the First VA Chiropractic Residents
As you may have read previously, a major step forward for the profession occurred in July 2014 when the Department of Veterans Affairs began piloting a chiropractic residency program at five locations.
An International Life: An Interview with Mary Elizabeth Wakefield
I met Mary Elizabeth Wakefield during her class last summer in Seneca Falls, New York at the Finger Lakes School of Chinese Medicine.
Chinese Doctors Poke Holes in Australian Study
A recent Australian clinical trial, published in the Journal of the American Medical Association (JAMA) in 2014 by Rana Hinman, et el., evaluating the effectiveness of both needle and laser acupuncture for chronic knee pain.
Meet Cheyenne: Your Future Colleague
Allow me to introduce you to Cheyenne (Chey), the daughter of some of our family's closest friends. We attend and serve at the same church together, and have known each other for many years.
The Three Heater Official
This Official, belonging to the element Fire, is responsible for maintaining and regulating the heating system of the body, mind, and spirit. It is named for its function. The trunk is divided into three "burning spaces" or "jiaos."
NCCAOM Video Contest
The NCCAOM is excited to announce the launch of the second annual video contest "Because it Works!" 2015.
Nomenclature and Classification of Lumbar Disc Pathology: Version 2.0
The Nomenclature and Classification of Lumbar Disc Pathology consensus, published in 2001 by the collaborative efforts of the North American Spine Society, the American Society of Spine Radiology and the American Society of Neuroradiology, has guided radiologists, clinicians and the public for more than a decade.
Key Changes and Updates to the 7th Edition CNT Manual
Acupuncture Today recently interviewed Jennifer Brett, ND, L.Ac. regarding the updates to the CNT manaul.
Integrative Medicine for the Underserved: A Seat at the Table
Numerous organizations have risen to the challenge of providing care to medically-underserved populations and here we feature one such group.
The Source-Luo Point Combination, Part 2
The Da Cheng includes symptoms for the source-luo points that indicate when to use them for treatment. Yang defines the method as the guest-host (it is one of a variety of acupuncture point combinations called guest-host).
Should You Change an Athlete's Natural Running Form?
Once past the ankle, impact forces travel at about 200 mph into the knee. In addition to allowing the quad to absorb force, bending the knee (E) prevents the hip and pelvis from moving up and down too much (F), which is important for injury prevention and efficiency.
Leg-Length Inequality and Pelvic Fixation: A New Approach to the Negative Derifield (Part 3)
A patient with sacroiliac fixation and dysfunction ordinarily demonstrates a noticeable leg-length inequality when placed in the prone position on the adjusting table.
Treatment of PTSD: An Opportunity for the Practice of Integrated Medicine
PTSD is widespread across America today. Not only do many of our honored men and women in uniform bring it home with them from the war zones they have been active in, but it often follows any life-threatening event people go through when their lives have been in danger.
Sports Medicine 101: Surgery or No Surgery?
In the world of sports medicine, many careers are saved by surgeries that correct traumatic damage to the body. Muscle tears, ligament damage, fractures, spinal disc herniations, and joint instabilities are a few of the issues frequently addressed with surgical intervention.
Marketing with a Microphone
When given an option, it stands to reason that people prefer to do business with those they know, like, and trust.
Free Yourself From the Pocketbook Practice
Let's take a journey together; there's an important lesson to be learned. Imagine a town or city just like yours.
Desert: A Metaphor from the Study of Genetics
In most of the human lives I know about, there are stretches of time which feel stagnant, or worse. We can feel adrift, or wounded and sidelined, and these times don't seem to carry much usefulness while they are unfolding.
I was sitting in a Pizza Hut in Peoria, Ill., with my friend Reggie, sometime in the spring of my senior year in college, when he started doodling on his paper placemat. In those days, the company had a picture of U.S. on the mats, showing all the locations of the "Huts" in the country.
The Risks I Took
We all take risks when we choose this profession. For some, it is not knowing if you can make a living practicing TCM. For others, it is parental or cultural disapproval.
We Have Much to Learn from Current Fascia Research
Fascia is fashionable. Over the past few years, you may have noticed the increase in conferences, congresses, symposia, workshops, online courses, books and articles that contain the word fascia in their title. Fascia was, for many years, seen as a sort of second-class tissue, a form of supportive wrapping, a nuisance during dissection, where it obscured the views of pretty muscles and joints. Fascia's increased visibility, due largely to the series of International Fascia Research Congresses, has attracted publication of a huge number of serious basic science research papers, as well as an avalanche of clinically related, fascia-related articles. These articles range from a focus on the fascial influences of foam-rolling, kinesiotaping, connective tissue massage, muscle-energy and other stretching techniques, myofascial release, a variety of exercise models (with plyometrics taking the lead), as well as a range of new trademarked approaches, led by the Italian export Fascial Manipulation.
One of the surprising features resulting from current fascia research (and there is an awful lot of it) is how little our increased understanding of fascia's functions has changed what manual therapists actually do – or need to do.
Rather, I believe, greater fascial awareness and understanding helps most therapists to do what they already do, more effectively, rather than having to relearn their skills. I have outlined a few examples of this here.
Before looking at examples of how emerging fascial knowledge refines, but doesn't necessarily change, what we do – it's important to establish a basic fact: It is impossible to treat fascia directly (short of actual surgery). In fact, all treatment approaches that target the soft tissues of the body, the muscles, ligaments, tendons and of course the joint-related tissues must involve fascial structures. The key message here is that it is not possible to "treat," - for example, a muscle (in any way whatever), without fascia being a feature of the process.
This elegantly phrased quote, from a research article by Weppler & Magnusson (2010), summarizes this point: "Skeletal muscles comprise contractile tissue intricately woven together by fibrous connective tissue that gradually blends into tendons...made of fibrous connective tissue [that] attach the muscle to bone. Although contractile tissue and tendons are sometimes evaluated separately for research purposes, they cannot be separated during routine clinical testing and stretching procedures, nor during functional activity," nor, of course, during manual treatment.
Five Clinically Relevant Examples
Note: This is not a definitive list. I have selected some key examples, there are many others!
Load transfer via fascia. Load-transfer research demonstrates how force is transmitted from one part of the body to another via fascial connections (described by some as "chains" and others or "trains"). For example, Carvalhais and colleagues (2013) demonstrated how contraction of latissimus dorsi – during adduction of the shoulder - produces external rotation of the contralateral hip via the superficial layer of the thoracolumbar fascia; while Stecco et al., (2013) showed how gluteus maximus contractions directly influence the knee via the iliotibial band. Potentially, therefore left-knee dysfunction could involve right latissimus dorsi behavior. Awareness of such links would not necessarily alter your treatment methods, but might well cause you to look at a wider set of possibilities when seeking causes of knee pain.
Fascia's sliding and gliding fascial functions. The different layers of the body - for example, between muscles or separating dense fascial structures from muscle or from other fascial layers – contain viscous loose connective tissues that allow a gliding, sliding function, protecting sensitive neural structures, as well as facilitating pain-free, efficient movement and force transmission, as described above. Gliding function may be lost because of trauma, inflammation or aging, resulting in fibrosis, thickening, densification. (Pavan et al 2014). Knowledge of the sliding functions of fascial tissues might not change what you do at all, but may help to explain why attention, lightly applied, as in myofascial release, can offer such dramatic benefits.
Mechanotransduction or changing cell behavior: for example, reducing inflammation and speeding healing of damaged tissues. Mechanotransduction describes the many ways in which cells respond to different degrees of load, such as pressure, tension, stretch, friction, etc. Research using important fascial cells (fibroblasts) that are largely responsible for the early stages of healing traumatized tissues, has shown that when these cells have been distressed by many hours of rapid movement, so that they start producing inflammatory chemicals, a brief period (a minute to 90 seconds) during which the cells are "treated" with the equivalent of myofascial release (MFR) or positional release (strain/counterstrain or SCS) – normalizes them. (Standley & Meltzer 2008.)
When MFR methods are applied to fibroblast cells in damaged tissues, a speeding up of the repair process is observed. (Hicks et al 2012). More recently, Cao et al (2015) conducted research on bioengineered tendons that had been artificially injured, to see how different degrees of light load (as in MFR) would effect the healing process. They tested a variety of degrees and durations of light stretching and identified that particular variations. For example, three minutes of stretch using around 6% of stretch, was effective in speeding up repair, while 12% for five minutes slowed it down. These percentages represent the degree of increased length of the tendon induced by stretching.
This remarkable research does not change the way gentle MFR or SCS are applied in manual therapy treatments of injured, painful, irritated, inflamed tissues – but helps explain why stronger degrees of stretch may not be as effective as light load.
Fluid dynamics and pain reduction. Manual methods that use isometric contraction – such as Muscle Energy Techniques (MET) – have the effect of improving fluid movement, particularly involving fascial fibroblast cells. Changes in the hydrostatic pressure in fascial tissues leads to improved drainage, reducing inflammatory chemicals (Langevin et al 2005, Fryer & Fossum 2009).
This is another example of fascial research indicating why (and how) mild stretching methods, particularly those involving isometric contractions, are effective in pain management. The information doesn't change the treatment methods, but it does clarify our understanding of what's happening.
Eccentric MET stretch and fibrosis, post-surgery. Remarkable clinical work in India, by orthopedic surgeons working in rehabilitation of individuals who have had recent hip or knee replacement surgery, or surgical repair of fractures, has demonstrated the value of slowly applied isotonic-eccentric stretching in such cases, thus reducing fibrosis and speeding recovery compared with traditional passive stretching methods. These MET variations have been successfully used for many years, by osteopaths and manual therapists in treatment of musculoskeletal dysfunction and have now been scientifically validated. Although this clinical research adds a wider range of application for MET, it does not change the way many of us already use this valuable method (Parmar, et al 2011).
The Bottom Line
Current fascia research is informing us, refining rather than revolutionizing what we do. Understanding the mechanisms of what we do in practice can help in the choice of what methods are best for particular clinical settings - how to best apply the multiple tools that manual therapists have for the optimal benefit of patients.
You may have noticed that the examples I have given in this article largely focused on biomechanical (and fluid related) effects of manual treatment. Apart from these there are, of course, important neurophysiological effects but that's a whole other story for another time.