Role of Fascia in Human Function

 

Dr. Jibu George Varghese1, G. A. Geetha Hari Priya2*

1Professor, Orthopaedic Physiotherapy and Vice-Principal, Saveetha College of Physiotherapy,

Saveetha University, Chennai

2II Year MPT, Saveetha College of Physiotherapy, Saveetha University, Chennai

*Corresponding Author E-mail: geethaskumar04@gmail.com

 

ABSTRACT:

Fascia has both generalised and specialised function in humans. It is a subject of wide range of scientific research with many specialisation of focus and emphasis. Recent scientific research in the field of the human fascia has resulted in several significant findings. Fascia is a sheath of fibrous connective tissue found throughout the body binding together muscles, organs and other soft structures of the body. Fascia consists of three fundamental fibrous connective tissue layers namely, superficial fascia, deep fascia and epimysium apart from visceral fascia. Superficial fascia is formed by collagen and elastic fibres and deep fascia is formed by a connective membrane that sheaths all muscles. This  review also discuss about the dysfunction involving the deep fascia which due to trauma or inflammation may shorten and what was previously a pain free range of motion may become painful and restricted. Before even considering nerve compression, an analysis of myofascial sequence reveals densification of the fascia along its course. Hence this type of fascial manipulation being a potential pain reliever proves that fascia responds systemically as well as locally. Dysfunction such as alteration of the mechanical coordination, proprioception, balance, myofascial pain, and cramps are more related to the deep fascia and epimysium. Understanding of  deep fascia is  essential for stability and movement- crucial in high performance, central in recovery from injury and disability and ever-present in our daily life from our embrological beginning to the last breathe we take. Understanding the deep fascia provides ample knowledge   about various treatment approaches linked to its musculoskeletal dysfunction.

 

KEYWORDS: Superficial fascia, deep fascia, myofascial sequence, myofascial pain, densification, fascial manipulation, range of motion

 

 

 


INTRODUCTION:

Fascia is a tissue that occurs throughout the body. In fact, according to the American Heritage Stedman’s Medical Dictionary (2007), a fascia is “a sheet or band of fibrous connective tissue enveloping, separating, or binding together muscles, organs, and other soft structures of the body”1.However, different kinds of fascia exist. In any general classification system, it is important to recognize a superficial fascia, a deep fascia and a visceral fascia.

 

Many authors recognize additionally the existence of epimysium and perimysium within deep fasciae2,3,4.

 

Fascial Manipulation   is a treatment technique created by Luigi Stecco over the last 40 years in northern Italy. There has been a growing increase in the study of fascia in the recent past as evident from the increasing number of research articles and greater participation in the congresses focussing on fascia. Active role of fascia in lymphedema, etiology of pain , posture maintenance, proprioception- intimate relation of fascia with afferent system- free nerve endings, muscle spindle, mechanoreceptors, in force transmission, as well as, coordination , improvement in range of motion  and in function of the organs and glandular systems- both normal and pathologic, explains the importance of fascia and its significance.

 

The superficial fasciais a fibrous layer that divides the subcutis into a superficial and deep loosely organized adipose-rich layer. It is formed by loosely packed interwoven collagen fibers mixed with abundant elastic fibers5.  This distinction of the fascial layers is not always so clearly defined, since one or more layers sometimes disappear, or are strongly connected with each other, as in the palmar and plantar regions where the adhesion of the superficial to the deep fascia forms a single connective layer called the palmar aponeurosis and plantar fascia/aponeurosis respectively. The superficial fascia is present throughout the body, and according to Abu-Hijleh et al, the superficial fascia has arrangements and thickness that vary according to the region of the body, according to the body surface, and also to differences that exist between genders6. The superficial fascia is tightly connected with superficial veins and lymphatic vessels. Within the superficial fascia the subcutaneous plexus that function for thermoregulation is also found. Some muscular fibers found in superficial fascia are platysma muscle in the neck and musculo aponeurotic system in the face.

 

Deep fascia is formed by a connective membrane that sheaths all muscles. It surrounds all the muscles, ligament, bone, nerves, blood vessels, envelopes various glands and organs and binds all these structures together. The deep fascia duplicates itself to form deep lamina in some regions of the trunk and limbs. The superficial and deep layers are richly supplied with free nerve endings. The paccinian corpuscles and ruffininerve endings are found to respond to mechanical forces when the fascia is stretched.

 

A layer of hyaluronic acid (HA)-secreting cells have been identified on the inner layer of deep fascia, apparently the source of the lubricant hyaluronic acid. The HA appears to provide a lubricating surface as fascia glides smoothly over muscles and tendons7. It is possible to distinguish two major types of muscular fascia, according to their thickness and to their relationships with underlying muscles: the aponeurotic fasciae and the epimysial fasciae. The term aponeurotic fasciae mean all the “well defined fibrous sheaths that cover and keep in place a group of muscles or serve for the insertion of a broad muscle”.

 

Fascia extends to all fibrous connective tissues, including aponeuroses, ligaments, tendons, retinaculae, joint capsules, organ and vessel tunics, the epineurium, the meninges, the periosteum and all the endomysial and intermuscular fibers of the myofascia.

 

The fascia of the human body was traditionally thought to be a passive structure to hold tissues together and to transmit mechanical forces. But at present this concept is considered outdated and recent study has proven how fascia contributes to movement, coordination, pain and injury. The connections between muscles and deep fasciae are constant and have precise organization. So, according to the various movements, specific muscles are activated, stretching of selective portions of the deep fascia occurs by the action of specific myofascial expansions.

 

BACKGROUND OF STUDY:

Movement analysis of a case of frozen shoulder showed restriction of internal rotation, abduction and external rotation similar to a capsular pattern of restriction. Careful examination along myofascial sequence corresponding to the referred pain away from the joint and fascial manipulation of specific points on the deep fascia causes symptomatic relief of pain. No significant restriction in the range of motion was noted after manipulation of deep fascia of arm. Hence interestingly, deeper understanding of fascial contractility and its implications on different musculoskeletal pathologies attracts future interest in fascia from research community.

 

THE SUPERFICIAL FASCIA:

The superficial fascia is comprised of loose connective tissue with collagen and elastic fibers. Interesting to know that superficial fascia is absent in the face, palm of hand and sole of the feet. Its arrangement and thickness vary according to body structure, gender and region. It is thicker in the lower extremity than in the upper extremity, on the posterior than on the anterior aspect, more in females than in males. The superficial fascia blends with the deep fascia at the retinacula of the wrist and ankle and continues with the galeaaponeurotica over the scalp. The gliding of the skin above deep fascia is facilitated by its thermal and cushioning property. Cutaneous vessels and nerves lie within the superficial fascia. Any alteration in the superficial fascia can cause lymphedema. Collection of fluid in the superficial fascia can cause fibrosis of the fascia and honey comb appearance of superficial fascia in a MRI study9. Functionally, the superficial fascia may play a role in the integrity of the skin and support for subcutaneous structures, particularly veins, by ensuring their patency. The superficial fascia and all the skin ligaments can easily be observed with computerized tomography (CT), magnetic resonance (MR) and ultrasound.

 

Stecco et al confirmed that the superficial fascia covers all the major superficial veins of the lower limbs along its entire length10. The strong anatomic relationship between the saphenous veins and the superficial fascia may have an important role both in daily clinical practice and in the pathophysiology of varicose disease. First, the tension of the superficial fascia strongly influences the saphenous vein caliber and consequently modulates the blood flow within it. Secondly, the superficial fascia may prevent the saphenous vein from excessive pathological dilatation, can also explain why greater dilatation occurs in the saphenous tributaries in primary varicosities. The table below shows thetypes of fascia, contents of the fascia and resulting dysfunction of fascia.

 

Table 1: Types of fascia, its contents and disorder of fascia

Types of fascia

Contents

Disorders of fascia

Superficial fascia

Related to lymph vessels and nerves

Lymphedema

Deep fascia

Nociceptors

Pain

 

Proprio

Ceptors

Change in vibration sense and coordination of joints

 

Mechano

Ceptors

Change in movement & stability

 

Thermo

Ceptors

Change in temperature

 

THE DEEP FASCIA:

The deep fascia is a well organised, fibrous connective sheath that surrounds the muscles, nerves, vessels, bones binding all structures together as a continuous mass. The deep fascia is termed as periosteum (over the bones, around the tendon it forms paratend on and around the nerves and blood vessels it forms neuromuscular sheath. Around the joint it strengthens the capsule and ligaments. They are considered specialised structures of deep fascia in addition to similar histological features also. The deep fascia of the limb are well defined lamina of connective tissue namely the fascia lata with a thickness of 1mm, the crural fascia and brachial fascia. Deep fascia is richly innervated by sensory receptors namely nociceptors, proprioceptors, mechanoreceptors, chemoreceptors and thermoceptors which senses pain, change in movement, vibration, chemical change and temperature  respectively. But deep fascia is avascular.

Cells containing ASMA (alpha smooth muscle actin) stress fibers are known to be either contractile smooth muscle cells or to be a contractile phenotype of fibro blasts with smooth muscle-like features, now known as myofibroblasts11. Myofibroblasts certainly occur in Dupuytren’s contracture, congenital fascial dystrophy, “frozen shoulder”, scars and other fascial disease and probably cause the increase in fascial basal tension, for example, in chronic compartmental syndrome influencing the biomechanics of the myofascial system12. Pathological fascial contracture found in Dupuytren’s contracture is mediated by proliferation and contractile activity of myofibroblast.13 there is considerable difference between long term contracture and temporary contraction of fascia. In frozen shoulder fascial contraction improves spontaneously by rapid release of cellular contraction.

 

According to SteccoC, the retinacula are formed by the muscle action in the deep fasciae, which may create various  types of lines of force particularly along the main axis of the limb or obliquely to it in the limbs. Around the joints the  deep fascia are reinforced by the retinacula, which acts like a pulley , holding the tendon close to the underlying bone during movement. The retinacula is a highly innervated structures rich in free nerve endings, Ruffini and Pacini corpuscles. Retinaculum plays an important role not only in joint stability, but also joint proprioception and peripheral motor coordination. A rupture of the ankle retinacula or asymmetrical thickness can result in ankle instability and patellofemoral malalignment14,15,16. This may result in poorly coordinated joint movement and nociceptors activation, resulting in inflammation. A treatment focused on restoring normal fascial tension may improve

the outcome of ankle sprain.

 

The region where a tendon, ligament or joint capsule attaches to a bone (enthesis) is an area of great stress concentration, for it represents the meeting point between hard and soft tissues. Consequently, entheses are designed to reduce this stress concentration and flare out at their attachment site to gain a wide grip on the bone. From the tendon of short head of biceps, the fascial expansion from bicipital aponeurosis encircles the flexors of the forearm muscles and blends with antebrachial fascia and dissipates the load away from bicipital tendon17. Similarly examples of expansion can be found from Achilles tendon continuing with the plantar aponurosis to the back of heel and expansion from quadriceps up to the upper pole of patellar tendon18.

 

The epimysium lies beneath the deep fascia and in some areas it glides freely and in other regions it binds with the deep fascia. The epimysium subdivides the muscles into various bundles: within the bundle the endomysium few elastic fibres and no adipose tissue and outside the bundle it contains many elastic fibres and adipose tissues.

 

Numerous researchers have found various muscular insertions in the fascia itself. According to Marshall, all fascial insertions provide an excellent illustration of how the thickness and strength of fasciae precisely mirror the forces generated by muscular action. Indeed, when these muscles contract, they not only move the bones but, they also stretch the deep fascia. The connections between muscles and deep fasciae are constant and have precise organization.

 

Epimysial disorders results when immobilisation causes changes in the endomysium and perimysium by causing increased deposition of collagen fibers, substantial increase in the number of perpendicularly oriented collagen fibers. Hence changes in the intramuscular connective tissue decrease function and diminished biomechanical properties of immobilized skeletal muscle.

 

Even though the epimysial fascia lacks free nerve endings like paccini and Ruffinicorpuscles, its close relation with muscle spindle reveals the role of epimysium in peripheral coordination and proprioception. If epimysial fascia is over stretched, it is possible that the muscle spindles connected to this portion of the fascia could become chronically stretched and over activated. This implies that the associated muscular fibers will be constantly stimulated to contract and develops trigger points. It also causes muscular imbalances, recurrent cramps, and result in movement of joints. This may represent a typical case where there is limitation of joint range of motion and associated joint pain.

 

Conversely, when the epimysial fascia becomes too rigid, and consequently the muscle spindle are not activated because they are embedded in a rigid structure. This emphasizes the fact that normal muscular function is dependent on normally well-hydrated functioning fascia. If the epimysial fascia is densified, some parts of a muscle will not function normally during movement, causing an unbalanced movement of the joint, with resulting uncoordinated movement and eventual joint pain. The epimysial fasciae could be considered as a key element in peripheral motor coordination.


 

Figure 1: Pathophysiology of Fascia

 

Figure: 2 Fascial manipulation technique

 

 


DISCUSSION:

The anatomical and physiological properties of fascia explain the structure of fascia, different layers namely superficial, deep, and visceral fascia apart from epimysicial fascia. The superficial fascia is made up of loose connective tissue layer, closely related superficial veins and lymphatics. It is thicker in the trunk than in the limbs and thinner towards the lower extermities. At some bony prominence the superficial layer adheres to the deep fascia. Functionally, the superficial fascia may play a role in the integrity of the skin and support for subcutaneous structures, particularly veins, by ensuring their patency. Some of the muscle fibres namely platysma, can be found in superficial fascia. The deep fascia is composed of collagen and elastic fibres. It forms an exoskeleton to the muscles, tendons and ligaments.

 

Under the deep fascia, the muscles are free to slide because of their epimysium. Loose connective tissue rich in hyaluronic acid lies between the epimysium and the deep fasciae responsible for free gliding of the deep fascia with epimysium.19 many muscular insertions are found in deep fascia. Manipulation does not reach the microscopic level, but intervenes in maintaining the fluidity of the ground substance of the deep fascia, epimysium, perimysium so that the various fascicles of muscles can contract at different levels20. The deep fascia and epimysium requires more pressure to reach them, hence the knuckle or elbow is used.

 

CLINICAL IMPLICATIONS:

Fascia is not only a static structure to transmit only muscular forces but also it is responsible for venous return, joint proprioception, coordination of agonist, antagonist and synergists, improved range of motion and postural maintenance. Manipulation has an effect on the fascia because it is the tissue that is easily accessible and possesses a strong capacity for repairing and regenerating itself. Based on the fact that a stimulus applied to proximal part of the fascia will naturally have effect in distal part of the body only if the stimulus is directed at the appropriate point which can result in improved range of motion. Manipulation must act on densified points for friction against the fascia to produce heat. The deep friction on these points aims at restoring the physiological gliding properties of the fascia and lead to immediate pain reduction, increased range of motion, improved function that maybe objectively evaluated by the therapist.

 

Because of the intimate relationship of the fascia, not only within the locomotor system, but also with the visceral, glandular and vascular systems, it can be found to play a role in the manifestation and treatment of pain in women conditions21. The anatomy and physiology of the fascia, externally and internally, can be affected by hormonal changes as is evident with pregnancy, menopause, as well as, trauma associated delivery and breast surgery. Symptoms can present locally, in the pelvis or chest wall, and can present distally also, within the extremities. Fascial Manipulation focuses on addressing the restrictions in the fascia and after careful assessment, treating the areas responsible for the dysfunction restoring normally gliding of the tissue. The belief of the patient in the treatment has been cited as a possible mechanism for nonspecific effects observed in acupuncture trials. Fascia responds to tissue stimulation, which causes responses at a distance from the site of stimulation, specifically demonstrated this effect using acupuncture needling22. We can say that fascial manipulation has a sort of dissolving effect or, in scientific terms, it normalises the hydration of the ground substance. With this normalisation, an obvious improvement in muscular and articular function is achieved because the correct contraction of the muscular fibres allows for the ailing joint to recover its physiological range of movement.

 

CONFLICT OF INTEREST:

We declare there is no conflict of interest.

 

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6    Abu-Hijleh MF, Roshier AL, Al-Shboul Q, Dharap AS, Harris PF. The membranous layerof superficial fascia: evidence for its widespread distribution in the body. Surg Radiol Anat.2006 Dec;28(6):606-619. Epub 2006 Oct 24. PubMed PMID: 17061033.

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Received on 08.05.2017             Modified on 15.06.2017

Accepted on 30.06.2017           © RJPT All right reserved

Research J. Pharm. and Tech. 2017; 10(8): 2759-2764.

DOI: 10.5958/0974-360X.2017.00489.9