Morning session – fascia in surgery and recovery

• Dr Mick Kreulen, a plastic surgeon, showed an example of FCU reattachment to the extensor side in the case of someone with Cystic Fibrosis. There is now more emphasis on taking the fascia along with the tendon. The reattachment has to take into account the length / force curve so that the new location has an optimal range of motion. There is the need to assure that the existing FCU hypertonicity doesn’t change the previous hyperflexion to a later hyperextension.
• Willem Fourie is a South Aftrican PT who specializes in post-op rehabilitation, especially post-mastectomy. His insightful presentation showed many of the operative techniques, excavations, cannibalisms, sacrifices, amputations, collateral damage and subsequent residual damage from sewing this all back up. He showed that 67% of the post-mastectomy patients had reduced shoulder ROM, 34% developed lymphodema within three years post-op and 72% had residual pain. A cytokine, TGFb is active in the inflammatory process of scar repair but can actually go into overdrive helping exacerbate fibrosis. He quoted a study by Nicole Bouffard that showed that a single one minute gentle (20%) static stretch of the tissue could help reduce the scarring and fibrosis.
• A panel of five proponents of clinical therapies then demonstrated their techniques under the critical eyes of 3 scientists, who were to later make their comments and recommendations.
  • The five techniques included Accupuncture, TrP-Dry Needling, the Graston technique, Fulford Percussion and Functional Fascial Taping (FFT) were demonstrated by video.
  • Comments from the scientists were as follows;
    • Irnich published a study in the BMJ in 2001 showing acupuncture to be better than massage for the relief of chronic neck pain. On the other hand a large German study on acupuncture (reference needed) has shown it only to be as effective as sham-acupuncture. Placebo may be important here.
    • The Shah study confirming the ‘biochemical milieu’ surrounding the TrP is still the most compelling proof to date of noxious trigger point activity. Dry needling may destroy 800 muscle fibers per centimeter traveled to get to the trigger point. After deactivating the TrP with this violent trauma how do you then solve the problem of central sensitization?
    • Of the others; Graston techniques is also a violent abrasion of the skin and superficial fascia probably stimulating fibroblast activity; Fulford uses a device like an orbital sander to also stir up fascia and FFT may work by quickening the reaction time of low back structures.
  • All scientists were bothered by the outstanding efficacy claimed by each and attribute much of this to placebo (this not being a bad thing). The word epiphenomenon came up, which I like.

Afternoon sessions – choice of Fascia Biomechanics and Physiology, or Pathology and Treatment – I chose the latter (maybe not such a good choice).

• The seven 15-minute bites varied from the silly to the thought provoking.
  • Silly included Roptrotherapy, yet another cross fiber technique (sometimes not even knowing the right fiber direction); non-invasive surgery for ACL repair (without divulging the method of this manual surgery); a demonstration of techniques for phantom limb pain which looked suspiciously like treatment using TrP referral zones; removal of ligatures on the proximal sciatic nerve of a poor rat which still had pain afterward,
  • Middling was a so-called Fascial Distortion Model (FDM) that uses 15 minutes of excruciatingly deep and painful pressure to solve most problems in just one treatment. In this the patient was probably exposed to so much more pain than they came in with that they only needed one treatment to realize that they weren’t so bad off after all. They described ‘Body Language’ a tool for interpreting distortions and used two interesting terms; trigger band – to describe a burning or sweeping sensation; herniated point – something that is protruding thru a fascial plane
  • Contrasting to these was a gem presentation. Antonio Stecco (see an earlier review of crural fascia with Carla Stecco), are prolific researchers, authors and presenters from Italy. This time the discussion concerned a study that measured how long it took to make positive changes to fascia that will drop pain by 50%. In sub-acute pathologies (<3 months) the average time is 2.2 minutes, in chronic tissue it is 3.24 minutes. Wow – so accurate. We’ll set our stopwatches shall we? They got their results using 3 areas of the back that commonly give LBP symptoms. They found correlations with tissue condition, age and gender. They have a book ‘Fascial Manipulation – Practical Part’ to explain more of the treatment side of things. Plenty to come on this body of work.

The afternoon was rounded off with the double act of Geoffrey Bove from Portland ME and Patrick Coughlin from Philly who entertained us on peripheral nerve palpation.

• First was some basic nerve anatomy and physiology. Did you know that a nerve cell can be up to a meter in length but only 1 micron (1 millionth of a meter) wide? That’s a million times longer than it is wide! They also carry positive pressure, have an endoneurium that is filled with a CSF-like fluid, and can be fasciculated like muscle
• Peripheral nerve palpation (and mobilization) is dear to my heart. We don’t practice it enough. Coughlin gave us the chance to practice a few easy ones like the ulnar nerve and the common fibular nerve. Hoppenfeld, Petty and Moore, and Barrall have much more information on this in their texts. I will be writing more on this in due course.