This past weekend of November 11-13, 2016, I was in Vancouver taking a course called, you guessed it, Mobilisation of the Myofascial System, MMS. The course was taught by a physiotherapist and massage therapist, Doreen Killans and Betsy Ann Baron, respectively. Both work out of Montreal and are fascinated with fascia (see what I did there). I have heard Doreen's name before as she was an examiner and chief examiner for the Canadian Physiotherapy Association's Orthopaedic Division. I have been helping out and starting to teach in the Orthopaedic Division courses, as you have seen in a few of my previous blog posts.
This course was put on the PABC, Physiotherapy Association of British Columbia. I am a proud member of this organization and they do great work hosting courses and promoting my profession.
Why would I take a course like this? Simple. I do not really know much about fascia. When I was in physiotherapy school, fascia was discussed minimally. It was thought to simply be there and give the muscle its shape. Also, it was thought that fascia did not have any nerve input and that it was simply there. I recently learned that those assumptions are just not true.
We now know that fascia is there and supports the muscle shape. However, fascia is much more than simply the casing on the sausage. Every part of the muscle is surrounded by fascia. Muscle cells are surrounded by fascia which links them together to other muscle cells. This creates myofibrils which attach to other myofibrils via fascia. These form muscle fibres, which attach to other muscle fibres to form the muscles. The outer layer of fascia covers the muscle and links to other fascia covering other muscles. This leads to the different fascial chains/trains throughout the body. Image source
I also learned that fascia does have nerve innervation. What does that mean? It means that fascia can be a source of pain and restriction. Fascia is innervated by nociceptors and mechanoreceptors. Nociceptors are responsible for sending warning signals to the brain in which the brain can interpret the signal as painful or not. Mechanoreceptors tell the body about movement, and when something is touching the body/skin. Fascinating.
So what is fascia? Here is the official definition:
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.
There are 4 basic types of cells that make up fascia, neural (I talked about that above), muscular (also see above), epithelial, and connective tissue. Epithelial cells attach the fascia to the skin. The connective tissues play a role with the structure, defensive, trophic and the shape of the fascia.
Fascia is composed cells and extracellular matrix. What does extracellular matrix mean? Extracellular matrix is the stuff outside the cell. It is made up of ground substance, collagen, water and elastin.
Ground substance, I never really understood what this was when I was in school, is a viscous transparent gel made up of proteins. It is produced by the fibroblasts and mast cells. It is the ‘fluid’ outside of cells that hold everything together and allows for the exchange of metabolites/substances. The ground substance is thixotropic, yes, just like ketchup. Any substance that is thixotropic means that when at rest the substance is difficult to get moving. But once it is moving, the substance just moves along. Think of getting the ketchup moving in a bottle. Difficult to get moving but once it is moving it comes out easily and sometimes too fast. Getting all over your fries, plate and table.
Collagen makes basically everything in the body. There are 12 different types of collagen. Skin, muscles, ligaments, tendons, lungs, membrane, transparent cornea of the eye and fascia are all made of collagen.
Elastin is a substance that has the properties of being elastic. Some ligaments in the body have more elastin in them so they ‘spring’ back into shape after being deformed. Fascia quickly moves back into its original shape after it is stretched out.
When fascia gets stuck it can have some crazy effects on the body and restrict movement. Ever wear a shirt and someone pulls on one corner of the shirt and you feel the restriction on the other side of the shirt? That is similar to what can happen with fascia. It was interesting that sometimes during the course, I would be working on someone’s hip and they would feel it pulling in their opposite shoulder.
What is the role in the body of having something like fascia? One thing it does is that it gives the muscles the shapes in which they have. For example, fascia makes a bicep muscle look like a bicep. Without the fascia, all the muscles would look the same. In addition, it can help to support our posture without the use of muscles. The way we stand and sit is partly supported by the fascia. One final thing, is that it can act as a shock absorber, spreading the force from an impact over a larger area. This can help protect our bodies.
There are many different fascial lines or trains in the body. These have been dissected out of the body. In fact some of the deep lines actually go through the tissues that surround the heart (pericardium)! The names of the lines are: superficial back line, superficial front line, lateral line, spiral line and the deep front line.
The lines tend to go from the top of the body to the bottom. For example, the superficial back line ‘starts’ at the head; scalp fascia, occipital ridge, down the erector spinae muscles, to the lumbo-sacral fascia, sacrum, sacrotuberous ligament, hamstrings, gastrocnemius, Achilles tendon, plantar fascia and short toe flexors. This complete line has been dissected out of a human body. Very interesting stuff!! (well at least to me...)
So what does fascia pain feel like? The pain does not follow any myotomal or dermatomal/nerve patterns. There is disturbed sleep with morning stiffness for a couple of hours. The quality of pain is usually dull and aching being low grade to severe. I found this not to be very specific. What I found more specific was the pain has been chronic. If there is only a joint that is fixated/stuck, then they get manipulated to get them moving. If there is only a muscle strain/pull, treating the muscle and exercise will work wonders. When fascia is involved, the joint will become stuck again for no apparent reason. Or maybe a recurrent calf strain, that seems to happen a few times a year and never seems to go away. Maybe certain poses in yoga always give a more global pull throughout the body. Those are the types of things that seem to implicate a fascial restriction.
One final little bit of theory that stood out to me is that about 75% of the body is water. Most people know that. But what you did not know is that 67% of the body water is contained in the fascia! I have read/heard that we, as society, are in a constant state of dehydration. That can play a huge role on the fascial system. This video is called Strolling under the Skin. It was done by a French plastic surgeon, Jean-Claude Guimberteau. It highlights how much water is in the fascia. I believe this fascia, is in a living human. Very cool.
That was a good part of the theory of the course, which was mostly on the first half day but there were sprinklings throughout the course.
Most of the 3 days were spend observing and then working on the different fascia testing/ treatment areas in the lower body. We started with along the spine, top to bottom, and moved into the thoracolumbar fascia. The techniques for the most part are quite painless. However, when a tight fascial spot is found, I felt that the two points were connected, even though working on opposite sides of the low back.
Areas covered on the course, were the spine, low back, back of the leg, front of the leg, lateral side of the leg, bottom of the foot and the medial side of the leg.
We also learned from Betsy Ann, not just a number of techniques but also Postural Somatic Awareness or PSA. What the heck is PSA you ask? PSA is about getting the client ‘in touch’, or put another way, being aware with their body. The therapist gets the client to standing a posture that is comfortable and familiar. Then the therapist simple asks the client questions about what the client is sensing. For example, where are your shoulders? Another question might be, where is the weight on your right foot? There are no right or wrong answers. Then a treatment is given to the client and the questions are asked again, with the client in a standing posture. It gets the client to start to think about their posture more and get better proprioception of their body. We practiced this throughout the course before and after each technique. It was interesting of how some of the course participants perception of themselves changed over this one weekend. Image source
Overall it was a very good course and I learned a lot of new theory but more importantly many new techniques to work with fascia in different ways. I am looking forward to taking the Level 2 for this course in 2017. The level 2 course are all the techniques for the upper body. That would include the head and the crazy fascia connections. I could see that being very helpful to a number of my clients to help them with their recurring headaches that go away for a few weeks after a treatment and slowly start to return.
If you have any questions about fascia or want to comment on this blog post, please do.
Do you and your fascia need to be assessed? Call New Leaf Physiotherapy for your inhome/mobile physiotherapy needs. 250-826-7300 to talk with Lyndsey, a certified Rehabiliation Assistant, to help you book your assessment.
New Leaf Physiotherapy is a mobile physiotherapy service that sees clients in West Kelowna, Kelowna and Lake Country.