Guiding Principle III: Discussion and rationale

This article discusses what may be happening in the myofascial system when cross-fibre manipulation is applied.

Cross-fibre manipulation.

I explained in part 1 that this manipulation involves ‘locking’ your thumb or fingers onto the skin and firmly and slowly gliding across the perpendicular fibres of the muscle beneath.

In my opinion what you are really ‘affecting’ is the fascia between the skin and the underlying muscle. You are affecting this fascia both via downward pressure and cross-fibre stretch, so to speak. The amazing thing is that stimulating the fascia in this way will release its longitudinal range of movement.

What is going on?

Good question. Welcome to the $64,000 question.

One thing I can say for sure is there are many things going on. The answer to this question is not simple. The scientific research into the properties of fascia in relation to pain and movement is pioneering.

We could talk about the concept of ‘biotensegrity’ (1) that describes fascia as a three-dimensional mesh that is loaded with prestress. We could talk about the proprioceptive properties of fascia and how it appears to think and remodel in response to the forces placed on it (2) or we could talk about fluid dynamics within the fascia (3), nociception or the concept that fascia is a communication system (4). All of these topics have very credible and current research behind them.

But I am not a scientist so let’s just look at some concurrent clinical observations and effective techniques regarding fascia.

Functional Fascial Taping (FFT)

Ron Alexander is an Aussie guy who has worked extensively in the Australian ballet industry. Ballet is a painful full-time career with musculoskeletal injuries common. The industry engages many therapists and is always seeking effective tools to combat and prevent injury because ‘the show must go on’.

Ron has developed a technique by which he uses strapping tape to create tension on the skin overlying the site of injury, be it acute or repetitive strain in nature. He has found astoundingly, that a skilful application of tape creating tension in a specific direction overlying the site of pain can eliminate the pain completely.

Now note: the tape is not used to limit limb movement. It is applied in a way that permits full movement but reduces the pain. The effect is somehow mediated by the tension on the skin, not the mechanical restriction of the limb. Even more fascinating is the fact that if the tape is applied consistently so that the athlete can resume normal training pain-free then over time the injury heals – whilst in use!

He has rightly named the technique:

Functional – because movement appears to empower the healing response stimulated by the tape.

Fascial – because it would appear it is the fascia under the skin and overlying the muscle that is copping most of the load or distortion.

Taping – because it is!

Is the fascia the source of pain? Is the superficial fascia the pain pathway? And is the tape, superficial as it may be enabling the fascia to ‘remodel’?

Check out FFT. Participating in FFT training and gleaning Ron’s insights have helped me think through what my technique may be doing under the surface. I suspect it is something similar to his.

FFT has gained recognition so widely because it is so effective. FFT has been subject to the scrutiny of a public randomised controlled trial in relation to non-specific low back pain and has had numerous articles published in peer reviewed journals.

Other fields are observing that fascia can ‘remodel’ itself.

Now consider the fact that the latest exercises being prescribed for Achilles tendinopathy and Plantar fasciopathy are no longer ice or stretch remedies but ‘load’ remedies. Yes if you are up with it, you will know that research has figured out that an Achilles tendinitis is no longer an itis because that lump you can feel in the tendon is not ‘inflammation’. It is a degenerative symptom in the tendon. Solution: load and shorten. Why? Because the fascial substrate in the tendon responds to the static or slow load by literally remodelling.

Are Ron’s taping techniques then physiologically causing a similar effect? Though it may be taping a hip or a shoulder, is the ‘load’ created by the tape causing a remodelling of fascia?

Does the recent popularity of ‘Rock Tape’ and ‘Kinesio Taping’ mean anything. Apparently it gets results.

Dynamic Dry Needling.

One more thing worth mentioning is what I call dynamic dry needling.

I exclusively use press needles if I do any dry needling. A press needle is a very small needle embedded in a little round band-aid and stuck on the skin. The longest press needle is 1.5mm. I use these regularly on areas where I can palpate fascial restriction that has failed to respond to manual manipulation.

I call this form of needling ‘dynamic’ because the press needle is left on the skin for 4-5 days whilst the patient goes about their routine activity. Although these needles are so small (they do not even reach the muscle) they regularly effect profound changes. I believe this is due to some effect the needle has on the superficial fascia.

Clearly the needle is not affecting any mechanical manipulation. It’s tiny. The only possibility, in my opinion, is that the superficial fascia is somehow stimulated by the presence of the needle. This stimulation combined with dynamic movement, in day-to-day activity, triggers some kind of remodelling.

Does it sound so weird?

If FFT, Kinesio and Rock tapes can simply create tension on the skin and load on the underlying fascia affecting movement and healing, could a skilfully placed needle in the skin, that is present during movement affect a remodelling response and healing within the fascial substrate?

Is the cross-fibre technique I have been describing that seems to get such amazing results just another way of creating a deliberate temporary load on the fascia between the skin and underlying muscle? And more importantly is the fascial substrate SO sensitive that it would respond with permanent postural change after only minutes, even seconds of very specific manipulation?

In my clinical experience it would seem the answer is yes.

Why cross fibre?

I don’t know, but I will guess.

Firstly if a muscle, its surrounding muscles, epimysium, superficial fascia and skin act as more of an integrated system than we have previously realised then introducing an external tension to the skin will influence the structures underneath.

Now if fascia is a three-dimensional matrix as the biotensegrity model suggests (1), rather than strands of in-line collagen fibres, then firstly the fascia can be deformed and affected with simple downward pressure. Static ‘ischemic compression’ will have an effect. (Whether it is the ischemic hypoxia or the mechanical distortion of the fascia that creates the change, who knows?) But nonetheless, static pressure will ‘flex’ the fascial matrix, and when applied in a specific location could promote healing.

Now skeletal muscles do move in lines of pull. Although we now know that this does not happen in a ‘detached’, individualistic way as previously imagined – but in a much more integrated way where a muscle exerts force not only on the tendons at either end but on adjacent muscles, fascia and skin – we could say it is still generally true that fascia around and within a given muscle is primarily subjected to load in one direction. Let’s describe that as north to south.

Now if the fascial complex, including the muscle, epimysium, superficial fascia and skin complex had bound or tightened in a dysfunctional way I suggest that to distort the skin and superficial fascia in a perpendicular, that is ‘east-west’ direction, may stimulate a healing response. Consider that this force can only be exerted upon the fascia by an external application. The natural movement of the body cannot distort the skin and fascia in this direction. Could this be why FFT as well as cross-fibre manipulation are so effective. What physiologically is this manipulation triggering? I don’t know. But the clinical observations, the increasing number of techniques and therapies that are subscribing to various means of cross-fibre stretch, taping or manipulation are growing. And the reason why they are growing is because the body responds so incredibly well to these techniques.

Where would you rather be than on the front line of musculoskeletal science? I know where I want to be.

References

Levin SM, 1986. 30th Annual Meeting of the Society for General Systems Research. The icosahedron as the 3-D model for biological support. Intersystems Publications, USA, G14-G26.
Tomasek JJ, Gabbiani G, Hinz B, Chaponnier C, Brown RA. Myofibroblasts and mechano-regulation of connective tissue remodelling. Nat Rev Mol Cell Biol [Internet]. 2002 May;3(5):349-63. PubMed PMID: 11988769
Meert GF, 2006 Das venose und lymphatische System aus osteopathischer Sicht. Elsevier, Munich
Langevin H, Yandow J. Connective tissue: A body-wide signalling network? Med. Hypotheses [Internet]. 2006 Feb 17; 66 (6): 1074-7. PubMed PMID: 16483726