Recently, I spent a weekend at Johns Hopkins Medical Center in Columbia, MD learning Fascial Manipulation Level 1 from Dr. Antonio Stecco MD, PhD. Dr. Stecco is a member of the notorious Stecco family from Italy, the dream team of researchers in fascia. When I found out he was teaching nearby, I had to jump on the opportunity, even if it meant driving to Maryland after driving from Pennsylvania to Richmond, VA earlier that day. Don't get me wrong, I paid for it later but it was so worth it. I'm excited to share what I've learned.
First of all, what is fascia? Fascia is loose connective tissue (with water) mixed with fibrous tissue (collagen and elastin fibers) that covers and connects everything in our body. We used to think it was just a "filler" in the body, which is why in dissection class we cut it away as soon as we saw it so we could get to the important stuff. Now, we are understanding so much more from the help of researchers like Dr. Stecco and his family. We understand that fascia helps us transmit load throughout the body since it runs in varying directions and connects different muscles together. This gives us a much higher capacity to accept higher loads. An example that Dr. Stecco gave was that 80% of glute max tension is transmitted into the neighboring tensor fascia latae muscle instead of just the tendon, which connects muscle to bone. With this myofascial expansion, we are able to perform complex movements instead of moving like robots. Through free nerve endings, fascia is able to sense how much tension is needed to perform a task and adjust accordingly. Fascia creates compartments in our body, which is helpful for keeping infections local.
But this is where it gets juicy... one of the components of the extracellular matrix in fascia is called hyaluronan. It is created by these newly discovered cells called fasciacytes in response to mechanical stress (i.e. body movement) and other signals such as inflammatory markers. Hyaluronan binds to water up to 100x's it's weight! This helps our fascial layers slide and glide against each other as well as provide shock absorption in the areas of our body that are moving (2). When the environment is not ideal, hyaluronan will aggregate, or change its properties and create chains to other hyaluronan molecules, so that water can't bind to it, leaving water free in our tissue. This is experienced to us as stiffness, decreased range of motion (1), and pain because the area is now more viscous and the fascial layers can't slide and glide. After a prolonged period of this densification of fascia, fibrosis occurs which is when pathology is present. What is amazing is that in the research, they have seen this hyaluronan aggregation happen in the liver and other organs before fibrosis is observed. So this cascade happens in many places in our body!
What are some contributing factors that result in hyaluronan aggregation and therefore thickening of our fascia? In the research, they have found the following:
Decreased temperature from immobilization. Think of times when you have to wear a cast or a sling and can't move your limb for a while. Or if you are very sedentary.
Infection
Surgery and other physical trauma. Overuse trauma is included.
Hormonal therapy because fascia has receptors for estrogen and progesterone. Dr. Stecco speculates this is why women on hormonal therapy after breast cancer have pain in many areas of their body or why women on birth control might experience headaches.
Hyperglycemia where there are high levels of sugar in our blood.
Inflammatory markers
Decreased pH, meaning the environment is more acidic. This can happen with prolonged exercise where lactic acid is produced, therefore making the environment more acidic. As you adapt to physical training, your lactic threshold improves so this cascade will be delayed. In class, I asked Dr. Stecco if this would indicate another reason to follow an alkaline diet (3,4). He said they have not researched this yet. In theory, following an alkaline diet would promote a higher pH in our internal landscape (less acidic, more basic), which in turn would nurture healthy fascia. Something to think about!
What can we do with this information to promote happy fascia in our bodies? Move often and in different ways so that your fascia is challenged to slide and glide in various directions. Eat well with fruits and veggies and minimize your meat, dairy, and alcohol intake. Seek hands-on treatment periodically from a manual therapist, Rolfer, or massage therapist. If training for something, give your fascia time to adapt to the training with a gradual increase in load and scheduled rest breaks. In a future blog post, I will discuss the latest research about massage tools. Stay tuned!
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