Anyone who has spent long hours engaged in a heated discussion over Facebook knows the frustration that comes along with it. These discussions have forced me to question many of my long held beliefs about the fascial system and myofascial release. There is evidence that myofascial release is an effective technique for a number of injuries.
However, when it comes to anything fascia related the professional community is divided with fundamentalist views on both sides.
To some myofascial release is a panacea and others regard fascia as ‘dead tissue’ with no clinical significance.
With some of the research and reading I’ve done, I have wanted to dispel myths and simplify research.
Fascial Anatomy For Massage Therapists
If you look at these early illustrations they present the fascia and muscles as one continuous soft tissue structure.
Fast forward to the 20th century (texts we study) most opt to omit fascial structures in order to depict muscles in a cleaner fashion. Recently there has be a resurgence of this ‘forgotten tissue’ and anatomy textbooks have made an effort to include fascial structures in their depictions and descriptions.
An example of this is The Functional Atlas of the Human Fascial System by Carla Stecco, an Orthopedic surgeon and a professor of human anatomy at the University of Padua in Italy, the same University that once employed Andreas Vesalius in the early 1500’s.
Another example is Anatomy Trains by Thomas Myers, in this book Myers presents conceptual ‘myofascial meridians’, a recent systematic review confirmed a number of these continuous soft tissue structures.
What is Fascia?
To better understand the possible actions of myofascial release, there is a need to clarify the definition of fascia and how it interacts with various other structures: muscles, nerves, vessels.
Simply speaking all fascial tissue is connective tissue, but all connective tissue is not fascial tissue.
The primary job of connective tissue is to support, connect or separate different types of tissues and organs in the body. For the purpose of brevity, connective tissue proper can be divided into dense connective tissue and loose connective tissue. Simply put fascia is a combination of dense and loose layers of connective tissue. As, for the definition of fascia, there are many different ways that fascia is defined, see What is ‘fascia’ A review of different nomenclatures. In this article the definitions of fascia that I use is “Fascia is fibrous collagenous tissue which are part of a body wide tensional force transmission system”
What Are Massage Therapists Doing With Myofascial Release?
The thing is, myofascial release is not well defined, it is a broad term covering a wide variety of techniques.
This includes osteopathic techniques, rolfing, structural integration, massage therapy, cupping and IASTM. My interpretation of myofascial release may differ from others, but in this post I am referring to myofascial release as a manual technique that tensions soft tissue structures and is accompanied by active or passive movement, to promote relative tissue motion.
I have divided the response to myofascial release into three categories, in reality the response likely represents a response of multiple overlapping systems:
- Contextual Responses to Myofascial Release
- This is likely to play a role in any therapeutic intervention, the way we present ourselves and present our techniques has influence on the treatment. The magnitude of a response may be influenced by mood, expectation, and conditioning.
- Neurological Responses to Myofascial Release
- Fascia is highly innervated by mechanoreceptors, this was document by Robert Schleip in 2003. His article Fascial plasticity – a new neurobiological explanation Part 1– Part 2, this is an interesting and very readable two-part article laying out a possible neurological explanation for the beneficial effects of myofascial release.
- Mechanical Responses to Myofascial Release
- The literature of Robert Schleip, Carla Stecco, Antonio Stecco and Thomas Findley support the idea that along with the neurological response and contextual response massage therapy has a mechanical effect on the fascial system. A summary of the proposed mechanisms includes but is not limited to
Any type of massage therapy is actively engaging the nervous system by stimulating mechanoreceptors at the level of the skin, as well as at deeper level fascial layers. Deep slow myofascial release techniques stimulate sensory ending known as the ruffini endings. Stimulating these slow adapting sensory receptors has the ability to alter the motor output and the experience of pain.
“Fascia and the autonomic nervous system appear to be intimately connected. A change in attitude in myofascial practitioners from a mechanical perspective toward an inclusion of the self-regulatory dynamics of the nervous system is suggested.”
-Fascial plasticity – a new neurobiological explanation: Robert Schleip
Are Massage Therapists Breaking Adhesions?
With such a lengthy post on myofascial release I would be remiss if I did not address the notion of breaking down adhesion. “An adhesion is an attachment of tissue at unusual non-anatomic sites which can be, vascular or avascular, innervated or not innervated.”
There is little to no research that I am aware of that would indicate that massage therapy can manually break down mature adhesions. There is however literature to support the idea that massage therapy may be able to break down immature postoperative adhesions.
Research by Geoffrey Bove and Susan Chapelle has demonstrated that manual therapy has the ability to break down immature adhesions. A recent case study demonstrated the effect of manual therapy on immature postoperative adhesions. Susan Chapelle has posted a well put together summary of the latest evidence of massage therapy and the effect on scars and adhesions Susan Chapelle- Understanding and Approach to Treatment of Scars and Adhesions.
What is the Clinical Relevance Of The Fascial System In Massage Therapy?
The “fascial system” serves to provide a conceptual model by which to explain the function of the global fascial net during movement, including the interconnections of fascial tissues with joint capsules, nerves and intramuscular connective tissues.
One of the proposed dysfunctions is an alteration of loose connective tissue that may adversely affect the sliding motion of fascial layers, this may be due to age, trauma or inflammation. This alteration of loose connective tissue is described as a densification In The Functional Atlas of the Human Fascial System.
Is a fascial densification the same thing as fibrosis?
Stecco makes a distinction between a pathological fibrosis and densification:
- Densification refers to an alteration of the loose connective tissue (adipose cells, glycosaminoglycans and hyaluronic acid) Densification can involve an alteration in the quantity or quality of the components of loose connective tissue and an alteration in fascial viscosity.
“Densification may affect the sliding and gliding of tissue. The different layers of the body 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. Gliding function may be lost because of trauma, inflammation or aging, resulting in fibrosis, thickening, densification.” -Pavan et al 2014
- Fibrosis is defined as an alteration of dense connective tissue, specifically a rearrangement of the composition and structure of the dense connective tissue.
Many cases of peripheral nerve entrapment occurs following a traumatic injury, this is often the case with the sciatic nerve in proximal hamstring syndrome. It could be argued that this thickening and entrapment of peripheral nerves is a development process, could manual therapy play a role in slowing or reversing this progression?
Over the last couple of months I have spent a lot of time reading and reviewing fascial research, this has changed the way I that I communicate with therapists and patients. Myofascial release is an effective treatment technique, the catch is that it may not work in the way some were taught. Over time the supportive theories behind techniques evolve or change completely, myofascial release is an example of this. Is the name myofascial release better used as an analogous term to describe a palpable change in tissue that is likely due to many overlapping responses? Namely:
- Contextual Responses
- Neurological Responses
- Mechanical Responses
These combined responses results in an increased pliability of soft tissue structures that often translates clinically into improved proprioception, increased range of motion and decreased experience of pain.
I am no longer frustrated when I get in heated discussions on Facebook, if someone can present a convincing argument I am willing to change some of my long standing views. Something I am still frustrated with is that there is a lack of resources available for massage therapists, hopefully this will change over time.