9/5/2015

1

Vital Importance of the

Connective Tissue System

DaPrato, DPT, SCS 2015

IASTM: Taking the sore thumb out of manual therapy

Disclosures

• UCSF Assistant Clinical Professor

• Outpatient Sports-Ortho perspective

• Created the approach Myofascial Decompression Techniques

Objectives:

• Describe the layers and subunits of the connective tissue system. (CT)

• Summarize the role collagen, ground substance, and other CT elements may be affecting movement patterns

• Define the terms tensegrity, thixotropy, as they relate to stress-strain curves

• Distinguish the effect of stretching on length-tension vs. CT elements

• Describe common IASTM interventions to improve mobility of the CT system

Integument

Skin layers Epidermis: thin skin

9/5/2015

2

Epidermis: thick skin Dermis

Connective tissue development• Ectoderm and Mesoderm gives rise to the

CT of skin and fascia above and around

muscle tissue.

Fascial Layers• Superficial

• Deep = Aponerotic & Epimysial

TLF, TFL, rectus sheath…

• Intermuscular

• Visceral

Living tissue is hydrated and dynamic

analogous…

9/5/2015

3

Dynamic nature of living tissue

• The way we think about movement in the human body is clouded by the way we learned anatomy

▫ Cadaver tissue, hard muscles, web like fascia

▫ Surgery observation; as soon as you cut into it you have changed it.

▫ AND what we observe in surgery = tourniquets used; even though living tissue, not the same

Functions of muscles

• We learn action but as we move in real world multiple

▫ ERs become IRs past 90 degrees

Jean-Claude GUIMBERTEAU, MD: strolling under the skin

Skin: more complex that we learned

Retinacula Cutis 4th International Fascia Congress

• Benchmark sciences filling in the gaps of traditional anatomy

9/5/2015

4

Skin layersWhat is understood in radiology?

▫ Fascial herniations

▫ Morelle-Lavale lesions

▫ Compartment syndrome; fasciotomy

▫ Gr 4 AC joint

Kumar 2014Weiss 2015

Fascial Components

• Fibroblasts▫ Make and secrete all fibers of areolar connective tissue

• Collagen fibers▫ Strongest and most abundant; cross linking leads to immense

tensile strength

• Elastic fibers▫ Rubber like proteins which allow tissue to return to original shape

• Reticular fibers▫ Connect vessels and nerves; have more give than collagen

• Ground substance▫ Extracellular matrix that holds interstitial fluid via sugar-protein

molecules that soak fluid like a sponge; with increased inflammatory response it becomes more viscous

The Colloidal Matrix

Viscoelastic properties of skin Fascial Contributions

• Support structure, tension, and suspension for tissues; “scaffolding”

• Fluid mobility; high amount of plasticity

• Connecting multiple muscles = functional kinetic chain

• Has been shown to have myofibroblasts

▫ Contraction of myofibroblasts influences movement?

9/5/2015

5

Muscles within the Fascial layers

• Twitch of skin – horse, cow, pig…

• Hair stand up - Arrector Pili

• Myofibroblasts

Viscoelastic properties: Collagen

• Dermis is made up of 80% collagen, dry weight, and of that collagen, 85% is type I

• Type 3 collagen is ~15% of dermal collagen, but is higher in immature tissue

• With age, ratio of type 1:3 collagen increases

• Increased collagen fiber density with age= decreased ground substance space

Viscoelastic properties Viscoelastic properties:

Ground substance – with GAGs

• Glycosaminoglycans

▫ Proteoglycans and repeating disaccharide units

▫ Commonly hyaluronan and chontratin sulfate; including dermatan sulfate

▫ Bind water in normal healthy tissue and proteins

▫ In aged skin, less binding to water and bind more to elastoic material= thickened

Viscoelastic properties: Thixotropic

Effect• Thixotropy is the property of certain gels or

fluids that are thick (viscous) under normal

conditions, but flow (become thin, less viscous) over time when shaken, agitated, or otherwise stressed.

Viscoelastic properties:

Creep and Hysteresis

• In relation to manual therapy, creep is the distortion of tissues as a function of pressure

over time

• Hysteresis is the exchange of heat and energy as tissues are distorted; permanent deformation. Microtrauma.

• With MFR 90-120 seconds is the time for generally the first barrier (R1) to release and push into new range of extensibility.

• Tendon Hysteresis in 5-10 minutes(Kubo 2001)

9/5/2015

6

Stress-strain curves; human tissueWhat really happens when we

stretch?• Sensory endpoint theory (Weppler & Magnusson 2010)

▫ Very little evidence that Torque/angle curves shift; even w/ 8 weeks

▫ More likely that the perception of the stretch sensation occurs later in the application of similar force

▫ PF stretch doesn’t change relfex pathway (Hayes 2012)

Stretching Soft tissue mobility: Folding

• CT ability to compress upon itself

• Shoulder Elevation= inferior capsule and axillary fold stretched, but also superior and anterior structures need to fold

• End Range hip flexion in supine = hams and

glute flexibility, but also anterior hip folding

Fascia encapsulates and supports Fascia encapsulates and supports

9/5/2015

7

TensegrityTensegrity

• “Tensional integrity”

• Fuller 1950’s first visualized by the sculptor Kenneth Snelson (Snelson, 1996).Fuller defines tensegrity systems as structures that stabilize their shape by continuous tension rather than by continuous compression

• Micro: studies of both cultured cells and whole tissues indicate that cell shape stability depends on a balance between microtubules and opposing contractile microfilaments

Tensegrity Mechanical CT Changes

Inflammation or Trauma

ECM response

Collagen cross-linkingCollagen

cross-linking

Ground substance viscosity

Tensegrity affected

Secondary movement

dysfunctions

Cascade of events:• Ge et al. 2008 studied involvement of central

sensitization mechanisms in local pain syndromes

• pain perception may result from a deregulation in peripheral afferent and central nervous system pathways- “chronic excitability”

Trigger Points

• Lower levels of oxygen, nutrients, blood perfusion

• Increased calcium levels, leading to excessive chronic muscle contracture, spasms

• Stress can lead to abnormal excess afferent stimulation

• Can have shortening of sarcomeres

9/5/2015

8

Fascial mechanics• Translating forces =“Slings”

• Lats to TLF to contra glute max and down lateral thigh =ITB Tx

Myofascial Lines

• Work of Thomas Myers

• Myofascial Tracks= muscles, tendons, ligaments and fascia

• Bony Stations= joints or insertional sites at bony landmark

• Can be static or motion driven▫ Picture: Pec minor, biceps,

coracobrachialis, rectus abdominis

▫ Or ab scar restricting shoulder or lumbar motion

Superficial Back Line

Includes:

Plantar fascia

Achilles tendon and Gastrocnemius

Hamstings

Sacrotuberous ligament

Thoracolumbar fascia

Erector spinae

Scalp fascia

Superficial Back Line

Lateral Line

• Often involved with leg length differences and pelvic obliquities

Includes:

Peroneals

Anterior ligament of the head of fibula

ITB and TFL

Superior fibers of glute max, medius

External and internal obliques

Splenius capitis and SCM

Lateral Line

9/5/2015

9

The Spiral Line

The Serape=double spiralIncludes:

Splenius capitis and cervicis

Rhomboids

Serratus anterior

Ext/Int obl. & ab aponerosis

TFL and ITB

Tib anterior

Peroneals

Bicep femoris to sacrotuberousligament

Lumbar fascia and erector spinae

Myofascial Lines

• Fascial planes and CT restrictions affect dynamic movement – scar adhesions

• Body takes the path of least resistance

• Interventions with traditional manual therapy

• Interventions with negative pressure applications: www.MyofascialDecompression.com

• Interventions with IASTM

• Manual therapy for lymphatic flow

Both picture thoracic extension; but may be restricted for different reasons

Compensations and Adaptations

“A best-practice model for managing patients with musculoskeletal complaints has yet to be identified.”-Tim Flynn (JOSPT 2007)

Consider hip strength for runners with foot pain, or

Use of foot othosis as a method of treating PFPS

Why does IASTM work?

• Bridge to the IASTM picture

• Mechanical connective tissue change

• Fascial plane restriction and scar adhesions

• Trigger points and metabolic exchange

• Fluid mobility

• Counterirritant; C fiber instead of A fiber; Gated

Pain generating mechanisms

• Receptors in TL Fascia (Schilder 2014 Pain)

▫ Muscle pain could be more akin to projection hyperalglesia, and not an “issue in the tissue.”

• IE: PF pain – likely cartilage or other soft tissue restrictions?

▫ Grooves in PF joint in cadavers

• OR IE: THR patients that have the same hip pain come back 6 months later

9/5/2015

10

IASTM = Instrument Assisted STM

• Mostly a Pro-inflammatory approach

▫ Some techniques are for flushing in acute phases

• Effect at the superficial fascia level, deep fascial membrane, epimyseum

▫ mechanoreceptors

Where are the Pacinian corpuscles?

=

Where are the Meisner corpuscles?

=

Where are the Ruffini corpuscles?

=

IASTM• ASTYM

• Graston

• SASTM

• FAKTR

• Iamtools

• GuaSha Orthopedic

• Target Point

• Fuzion Tool

• BioEdge

= GuaSha

IASTM• Self trigger point tools – theracane, TrP tools…

• Snowman with a hat, PAs

• Belt techniques for hip and shoulder

▫ Are you just moving the joint? Or are you also with an inferior hip glide pushing through RF trigger point region, and other contractile tissue that may reset sensitivity thresholds

• Negative pressure devices

Negative Pressure

Ultrasound With Myofascial Decompression

9/5/2015

11

MFD Techniques Negative Pressure

Negative Pressure Negative Pressure

Proof of Concept Study Proof of Concept Study

9/5/2015

12

GuaSha and IASTM

Basic Steps:• Watch the area with movement

patterns

• Sweep area with hands/fingers

• Trace and isolate with Vectoring

▫ 4 directions, find most limited.

▫ Compare contralateral

▫ Add in rotational vector as well

IASTM techniques

• Superficial scrape

▫ Sense percussive info from tool

• Scrape parallel fibers

▫ Into the motion barrier = direct = subacute and chronic

▫ Away from motion barrier =indirect = acute or irritable

• Diagonal and perpendicular

• Add movement

Contraindications

• Eyes; genitalia?• Unhealed wounds• Hemophilia, leukemia, active TB• Thrombocytopenia• Later stages of pregnancy• Influenza of fever• Moderate/severe anemia• Moderate/severe cardiac

conditions, high BP• Vasculitis• Cancer active• Skin elasticity disorders-EDS??

Precautions-Patients that are over eager

- addictive personalities, chronic pain?

-Blood thinners-Healing or thin skin

▫ Elderly, Psoriasis

-Pregnancy-Areas of ecchymosis

▫ Previous STM-Venous stasis and varicose veins-DM; tissue healing and neuropathy-Swollen tissue

▫ especially pitting edema

Results? Outcomes?

9/5/2015

13

Future Studies

• Perfusion and Diffusion MRI with MFD vs Grastonvs ASTYM vs other tools/techniques/modalities

• Pre, during, and 8-48 hrs after for different Tx

• Fascial changes on magnified MRI

• Local metabolic change; on a nano level

▫ IE: why does US work in some patients?

ReferencesBooks: • Functional Atlas of the Human Fascial System, Carla Stecco MD, 2015, 1st

Edition• The Endless Web. Fascial Anatomy and Physical Reality. L. Schultz, R.

Feitis, 1996. North Atlantic Books. • Anatomy Trains. Thomas Myers, 2008, 3rd editionJournals: • Abbott RD, et. Al. Stress and matrix-responsive cytoskeletal remodeling in fibroblasts.

J Cell Physiol. 2013 Jan; 228(1):50-7• Ates, F, et al. Muscle lengthening surgery causes differential acute mechanical effects

in both targeted and non-targeted synergistic muscles. Journal of Electromyography and Kinesiology, 23, 1198-1205, 2013

• Ballyns, Jet al. , Objective ultrasonic measures for characterizing myofascial trigger points associated with cervical pain. J. Ultrasound Med., vol. 30, pp. 1331-1340, 2011

• Bhattacharya V, et. Al. Detail microscopic analysis of deep fascia of lower limb and its surgical implication. Indian J Plast Surg. 2010 Jul;43(2):135-40

• Bonilla-Yoon, et al. The Morel-Lavallée lesion: pathophysiology, clinical presentation, imaging features, and treatment options. Emerg Radiol. 2014 Feb;21(1):35-43.

• Borgini E, Stecco A, Day J. A., Stecco, C. How much time is required to modify a fascial fibrosis? J Bodyw MovTher, 2010 Vol 14(4): 318 – 325

• Cao TV, Hicks MR, Standley PR. In vitro biomechanical strain regulation of fibroblast wound healing. The Journal of the American Osteopathic Association. Nov 2013;113(11):806-818

References• Ge HY,et al. Topographical mapping and mechanical pain sensitivity of myofascial trigger

points in the infraspinatus muscle. Eur J Pain. 2008 Oct;12(7):859-65 • Findley, T., Chaudhry, H., & Dhar, S. (2014). Transmission of muscle force to fascia during

exercise. Journal of Bodywork and Movement Therapies. In press 2014• Holm L, et al. Contraction intensity and feeding affect collagen and myofibrillar synthesis

rates differently in human skeletal muscle.Am J Physiol (Endo), 298: E257-E269, 2010• Kim KT, Kim YJ, Lee JW, et al.. Can necrotizing infectious fasciitis be differentiated from

nonnecrotizing infectious fasciitis with MR imaging? Radiology 2011;259(3):816–824• Kubo K, et. al. Is passive stiffness in human muscles related to the elasticity of tendon

structures? Eur J Appl Physiol. 2001 Aug;85(3-4):226-32 • Kumar S, Kumar S. Morel-Lavallee lesion in distal thigh: A case report. J Clin Orthop Trauma.

2014 Sep;5(3):161-6• Langevin HM, Nedergaard M, Howe AK. Cellular control of connective tissue matrix tension.

J Cell Biochem. 2013 Aug; 114(8):1714-9• May DA, et. al. Abnormal signal intensity in skeletal muscle at MR imaging: patterns, pearls,

and pitfalls. Radiographics. 2000 Oct;20 Spec No:S295-315• Schilder A, et al. Sensory findings after stimulation of the thoracolumbar fascia with

hypertonic saline suggest its contribution to low back pain. Pain 155:222-231, 2014• Schleip R. et al. Passive muscle stiffness may be influenced by active contractility of

intramuscular connective tissue. Medical Hypotheses 2006; 66(1): 66-71• Weppler CH, Magnusson SP. Increasing muscle extensibility: a matter of increasing length or

modifying sensation? Phys Ther. 2010 Mar;90(3):438-49 • Willard FH,et al. The thoracolumbar fascia: anatomy, function and clinical considerations. . J

Anat 2012; 221(6):507-36

Other recommended CE work

• www.ptrehab.ucsf.edu/education/continuing-education

• Janda courses or Movement Links• MyofascialDecompression.com• Kaiser Residency and fellowship• IPA PNF and FM• Great Lakes MFR course• Kinetacore.com• Spinalmanipulation.org• Myopain seminars• Systemicdryneedling.com

Thank You!!