Application of Fascial Manipulation^© technique in chronic shoulder pain—Anatomical basis and clinical implications

Summary

Classical anatomy still relegates muscular fascia to a role of contention. Nonetheless, different hypotheses concerning the function of this resilient tissue have led to the formulation of numerous soft tissue techniques for the treatment of musculoskeletal pain. This paper presents a pilot study concerning the application of one such manual technique, Fascial Manipulation^©, in 28 subjects suffering from chronic posterior brachial pain. This method involves a deep kneading of muscular fascia at specific points, termed centres of coordination (cc) and centres of fusion (cf), along myofascial sequences, diagonals, and spirals. Visual Analogue Scale (VAS) measurement of pain administered prior to the first session, and after the third session was compared with a follow-up evaluation at 3 months. Results suggest that the application of Fascial Manipulation^© technique may be effective in reducing pain in chronic shoulder dysfunctions. The anatomical substratum of the myofascial continuity has been documented by dissections and the biomechanical model is discussed.

Introduction

Shoulder pain is a common affliction that determines symptoms of pain, limited range of movement and varying degrees of functional impairment. It is the third most common musculoskeletal complaint after back and neck pain. In fact, in a randomised study conducted in Holland (Picavet and Schouten, 2003), it is reported that, in 1998, an estimated 21% of the population had shoulder complaints, of which 41% had consulted their primary care physician in the previous 12 months for this problem. About 50% of patients had consulted their physician 6 months after pain onset and more than 40% had on-going pain after another 12 months. Patients with a new pain episode often reported (46%) having had previous episodes of shoulder pain.

Despite the prevalence of this complaint, there is little overall evidence to guide physiotherapy treatments, whereas there is evidence to support the use of some interventions (i.e. supervised exercises and mobilisation) only in specific and circumscribed cases (e.g. rotator cuff disorders, mixed shoulder disorders and adhesive capsulitis) (Green et al., 2003).

There is wide agreement that alterations of the deep muscle fascia could be a source of musculoskeletal dysfunctions. Despite a relative lack of well-documented information, the necessity to provide scientific explanations for numerous, highly effective manual techniques has produced a number of clinical hypotheses, some working models and a series of on-going research (Rolf, 1997; Myers, 2001; Stecco, 2004; Langevin, 2006).

Nonetheless, attempts to study the functional anatomy of deep muscular fascia can be frustrating and confusing. Long overlooked by classical anatomy, and relegated to a role of mere contention and packing, in recent years this highly innervated and intricately structured tissue is gaining increasing attention. However, only a few regions have been studied in detail, namely the thoracolumbar fascia (Gracovetsky et al., 1985; Vleeming et al., 1995; Yahia et al., 1992; Loukas et al., 2007), the iliotibial tract (Birnbaum et al., 2004; Fairclough et al., 2006) and the plantar aponeurosis (Kitaoka et al., 1997; Yu, 2000).

When dealing with musculoskeletal disorders therapists are continuously faced with the dilemma of focus. What to focus on or, in other words, where best to apply massage, pressure, or friction becomes the key question when, undeniably, the shoulder, as any other joint, is part of an interrelated system and its relationship with the rest of the body is an essential part of its functionality.

One manual technique that provides a rationale for treatment of specific areas of muscular fascia, together with detailed indications for the localisation of these points, is Fascial Manipulation^©. This paper presents a pilot study of the application of this myofascial technique in chronic shoulder pain. Our attention focused on providing plausible anatomical explanations for the results obtained. The posterior myofascial sequence of the upper limb, termed the retromotion sequence (Figure 1) is examined in detail, and its anatomical substratum is illustrated. Some of the concepts of the Fascial Manipulation^© model are discussed and possible clinical implications are considered.

The manual therapy technique known as Fascial Manipulation^©, presents a biomechanical model to decipher the role of fascia in musculoskeletal disorders considering that the myofascial system is a three-dimensional continuum. Other authors present different models that all part from this basic concept of continuity (Busquet, 1995; Godelieve, 1996; Myers, 2001). In Fascial Manipulation^©, the body is divided into 14 segments: head, neck, thorax, lumbar, pelvis, scapula, humerus, elbow, carpus, digits, hip, knee, ankle, and foot. Each body segment is served by six myofascial units (mf units) consisting of monoarticular and biarticular unidirectional muscle fibres, their deep fascia (including epimysium) and the articulation that they move in one direction on one plane. A new functional classification is applied to body movements to facilitate analysis of motor variations. All movements are considered in terms of directions on spatial planes and are defined as follows: antemotion (AN), retromotion (RE), lateromotion (LA), mediomotion (ME), intrarotation (IR) and extrarotation (ER). Within each mf unit, in a precise location of the deep muscular fascia a specific point, termed centre of coordination (cc) is identified. Each cc is located in the point of convergence of the vectorial, muscular forces that act on a body segment during a precise movement. Biarticular muscles link unidirectional mf units to form mf sequences. One sequence is considered to monitor movement of several segments in one direction on the three planes. Sequences on the same spatial plane (sagittal, frontal, or horizontal) are reciprocal antagonists (i.e. AN is the antagonist of RE and vice versa) and are considered to be involved in the alignment of the trunk or limbs. Other points, termed centres of fusion (cf), located on the intermuscular septa, retinacula, and ligaments, monitor movements in intermediate directions between two planes and three-dimensional movements. The cf can interact either along mf diagonals or in mf spirals, according to the executed movement. Musculoskeletal dysfunction is considered to occur when muscular fascia no longer slides, stretches, and adapts correctly and fibrosis localises in these intersecting points of tension, known as cc and cf. Subsequent adaptive fibroses can develop as a consequence of unremitting non-physiological tension in a fascial segment.

Based on this functional classification, a systematic objective examination together with an analysis of three-dimensional movements of the implicated segments can pinpoint dysfunctional cc or cf. Comparative palpation then determines the selection of points requiring treatment in each individual case.

The manual technique itself consists in creating localised heat by friction by using the elbow, knuckle, or fingertips on the abovementioned points. The mechanical and chemical stress effects on connective tissue are well known and a local rise in temperature could affect the ground substance of the deep fascia in these specific points. Tensional adaptation can then propagate along an entire mf sequence, diagonal, or spiral, re-establishing a physiological balance. A fundamental element of this method lies in the fact that the myofascial sequence is not only a functional concept but has an anatomical substratum of fascial continuity and muscular expansions onto the fascia itself.