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The need for the field of massage/manual therapy (MMT) research to determine how effects are produced (i.e., mechanisms of action) has been identified unequivocally.


April 13, 2012
By Cathy Ryan


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The need for the field of massage/manual therapy (MMT) research to determine how effects are produced (i.e., mechanisms of action) has been identified unequivocally.

RSinLabCut.jpg  
 Dr. Robert Schleip in his laboratory at Ulm University.


 

In my previous article, entitled “Bridging the Evidence Divide” (Massage Therapy Canada, Winter 2012 issue, pp. 6-10), I stated that in order to understand MMT mechanisms of action, we need relevant research to be conducted with MMT in mind. This requires clinician/scientist collaboration.

Bidirectional collaboration is needed in order to avoid poorly constructed research designs or methodologies that lead to flawed or limited conclusions.

As both a clinician and a scientist, Dr. Robert Schleip, PhD, is well positioned to conduct relevant MMT research as bidirectional collaboration can occur within his own lab – and arguably, in his own head! Dr. Schleip is an International Rolfing Instructor (certified since 1978) and Fascial Anatomy Teacher. He holds an MA degree in psychology and has been a Certified Feldenkrais Teacher since 1988. He established the Fascia Research Project at Ulm University – this is where his lab is located. He was the co-initiator and organizer of the first International Fascia Research Congress at the Harvard Medical School in Boston in 2007, and is a co-author of Fascia – The Tensional Network of the Human Body: The science and clinical applications in manual and movement therapy (Churchill Livingstone 2012).

The recent boom in fascia research (including research being conducted by Schleip et al. at Ulm University) is providing important and viable MMT-related evidential information – including plausible mechanisms of action.

Under the umbrella of “Fascial Fitness,” Dr. Schleip and Tom Myers – an LMT and author of Anatomy Trains – are currently travelling the globe providing an efficient translation of pertinent fascial research findings to practitioners in the field (e.g., various types of manual therapists and sport/conditioning trainers). Myers describes this as “Funneling Relevant Research.”

In the following interview with Dr. Schleip, we will explore some of the “evidence to support” mechanisms of action applicable to exercise and training, and relevant to MMT as well.

Massage Therapy Canada: Dr. Schleip, can you give us a brief explanation of fascia’s sponge-like squeezing and refilling mechanism and its importance?

Robert Schleip: Our Fascia Research Group (University of Ulm) recently showed that when fascial tissues are stretched, a significant amount of the water in the tissue is pushed out, and then returns during the following minutes or hours (to a greater degree than prior to stretch). This is similar to what is seen in squeezing a sponge. Fluid dynamics/hydration influences tissue stiffness (providing tensional support and stabilizing capabilities) and elasticity (which factors into tissue resilience and kinetic storage capabilities). These properties augment tissue health, promote sound functioning and lower incidence of injury. 

MTC: Can this mechanism be influenced manually and subsequently achieve improved tissue hydration?

RS: We suspect that similar effects do occur as a result of manual myofascial therapies and by gently and slowly rolling your iliotibial tract or other fasciae over a foam roller. When done properly, such tissue-squeezing effects may be helpful to increase and renew the water content of hardened and drier tissue zones. This could also explain why adequate unloading times are essential in sport/exercise in order to prevent viscoelastic creep deformation.

The use of particular foam rollers may allow the application of localized tissue stimulations with similar forces and possibly offer benefits similar to those derived through a manual myofascial release session (Chaudhry, et al. 2008). It is important to note that the stiffness of the roller and application of the body weight needs to be adjusted and monitored for each person. To foster sponge-like tissue dehydration with subsequent renewed local hydration, only slow-motion-like subtle changes in the applied forces and vectors are recommended. In addition, the localized tissue stimulation may serve to stimulate and fine-tune possibly inhibited or desensitized fascial proprioceptors in more hidden tissue locations (i.e., tissue not frequently stimulated by the individual’s day-to-day activities).

As an exercise example, most runners would do well to introduce brief walking periods of one to three minutes into their jogging training, possibly followed by active sprints of a few seconds afterwards. This way they can maintain their youthful elastic properties during the whole time, whereas if they run for 20 minutes or longer without such brief walking periods, they run the risk of the fascial tissues losing resilience, due to the sponge-squeezing effect but lack of refilling, or rehydration, effect. In the worst case – their bones and cartilages bump against each other, due to inadequate rehydration and the loss of the tensile properties in the fascial web.

MTC: Fluid dynamics is a hot topic right now. In addition to what you just covered, Dr. Schleip, might fascia fluid dynamic research provide some answers to other long-standing questions regarding plausible MMT mechanisms of action?

RS: Yes this is indeed possible. Recent studies have shown, that fluid shear is an even stronger stimulation for fibroblasts than mechanical tension is. In our laboratory, we are looking now at how Rolfing-type myofascial manipulation is influencing the extracellular as well as intracellular water content. This can be nicely assessed with electrical impedance. We hope to be able to present our respective findings (thus far) at the upcoming Third International Fascia Research Congress in Vancouver.

Also, the work of Gerald Pollack (a keynote speaker in at the third FRC) and others has shown that a large proportion of the water in connective tissue is liquid water in a bound state in which the molecules are regularly arranged in a similar manner to that in a liquid crystal. This is the case whenever water molecules are in close proximity to a hydrophilic substance (e.g., collagen or hyaluronan) or to a hydrophobic fibre, such as elastin.

Such bound water has totally different viscoelastic properties than regular unbound water.  It will be exciting for us to understand how different forms of manual therapies may change and influence the respective water-binding qualities in the tissue.

MTC: Can you describe the role of proprioceptors in deeper, joint-related tissues (capsule and ligament) versus receptors in more superficial tissue (skin and superficial fascia)?

RS: Previously, proprioception was believed to be fed primarily from so called ‘joint receptors,’ with the additional help of muscle spindles and skin receptors. However, new measurements suggest that the joint receptors mostly work as limit detectors, being stimulated only near the end range of movement and not during most parts of the available physiological motion (Lu et al. 1985).  In contrast, the sensory receptors in fascia have recently been quantified according to their density in superficial versus deeper layers. Here it was found, that most of the sensory nerve endings are located in the superficial fascia or in the smooth transition zone between it and the underlying deeper fascia. This suggests a high priority of these superficial fascia layers in proprioception.

MTC: What are some implications of fascia as a proprioceptive organ and how can we better augment proprioceptive refinement?

RS: Well, it could easily explain the dramatic improvements that modern skin taping procedures have shown in sports medicine and rehabilitation. It could also mean that adhesions between the superficial fascia and the underlying deeper fascia – such as I frequently find around the so-called dowager’s hump in many adult patients (around C7/T1) – could attenuate their internal body perception in posture and movement.

As a practitioner of the Rolfing method of structural integration, I used to take pride in the belief that I work deeper than ‘massage therapists,’ for example when working on the psoas muscle. However, these new findings now make me wonder, whether a more skin-oriented working approach could be even more powerful – resulting in the stimulation of the proprioceptive receptors in the superficial fascia, which in turn loosens some of the adhesions below the skin. For yoga or Pilates practitioners, this could also mean that it may work better to direct the proprioceptive attention of their clients to the stretch and shearing sensations below their skin, rather than at the deeper joint tissues, as superficial tissues are more densely populated with mechanoreceptive nerve endings than tissues situated more internally/deep (Stecco et al. 2008). 

Proprioceptive nerve endings that are located in the more superficial layers are more optimally situated – here even small angular joint movements lead to relatively distinct shearing motions that may impact adhered/fibrosed tissues that restrict motion, impede proper proprioceptive functioning, increase the incidence of injury and impact tissue functioning/health overall.

spring_fig.jpg  
Figure 1: Illustration adapted from Kawakami et al. 2002 – used with kind permission from Schleip et al: Fascia: The tensional network of the human body – Edinburgh 2012, Elsevier.
(A) Length changes of fascial elements and muscle fibres in an oscillatory movement with elastic recoil properties.
(B) Changes during conventional muscle training.
The elastic tendinous (or fascial) elements are shown as springs, the myo-fibres as straight lines above. Note that during a conventional movement (B) the fascial elements do not change their length significantly, whereas the muscle fibres clearly change their length. During movements like hopping or jumping, however, the muscle fibres contract almost isometrically, whereas the fascial elements lengthen and shorten like an elastic yo-yo spring.
 

One final note on collagen elasticity (springiness) and kinetic storage:
RS: It has been determined that human fascia has a similar kinetic storage capacity to that of kangaroos and gazelles (Sawicki et al. 2009).  The importance of this is that a significant part of the energy for movement (e.g., walking, running, jumping, swinging a golf club, etc.) comes from the “springiness” of our fascia (see Figure 1). 

The lengthening and rebound of the plantar fascia and achilles tendon are potentially a far greater source of propulsion amplitude and efficiency than muscular power. Having a very long/healthy achilles tendon has been shown to augment kinetic storage and rebound capabilities (e.g., as is seen with the barefoot runners of Kenya). Kinetic storage/rebound (like a yo-yo or super ball) requires far less energy and this translates into less ATP demand, greater fatigue resistance and reduced incidence of injury (Ryan, C. (2012): Fascial Fitness – Restructuring your Architecture – Interview with Thomas Myers. Massage Matters Magazine, Winter 2012.)

Viscoelasticity is the ability of fascia to be both mobile and supportive at the same time. Creep refers to the tendency of tissue to deform permanently (i.e., elongate) when placed under sustained, consistent stress or load. 

Muscle spindle response to detectable stretch can be altered if myofascia (e.g., endo- or perimysium) is too rigid (due to viscoelastic changes, fibrosis and restriction). In such cases, normal firing of the muscle spindles can be altered. Afferent signal alteration results in lack of muscle co-ordination along the myokinetic chain causing abnormal biomechanics, eventual abnormal muscle compensation and pain (Stecco 2004).


Cathy Ryan, RMT, has maintained a diverse, treatment- oriented massage therapy practice and an extensive postgraduate training roster since 1990. Cathy is a longstanding member of provincial massage therapy associations and has served as a subject matter expert and examiner trainer at the CMTO’s provincial licensing examinations. Currently residing and working in beautiful B.C., Cathy maintains a private practice, teaches and writes massage therapy related material and is the managing editor for TouchU.ca; an online source providing accredited continuing education for touch professionals and students. Cathy can be reached at: cryanrmt@gmail.com or via www.touchu.ca.


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