fascia

Fascia: 8 Things You Always Wanted to Know (But Couldn’t Spell It)

August 5, 2013 by James Bogash

In addition to doing blog posts into the wee hours of the morning, I have a chiropractic office in Mesa, AZ. I have always hung my hat on the fact that we’re different.

Different from many of my colleagues who rely on just the adjustment. Different from the physical therapists who use electric stim and exercises. Different from the primary care docs who blindly give anti-inflammatories. Different from the pain management clinics who inject steroids into the spine.

For me, I think the journey started was back in school when I took a weekend seminar based on Trigger Point Therapy from Dr. Ray Nimmo. Later in practice I took Dr. Peter Levy’s Neuromuscular Re-education course. Then Graston Technique came along to completely change the breadth of what I could treat. My soft tissue techniques were further refined by FAKTR-PM training with Dr. Greg Doerr and Dr. Tom Hyde.

Shortly after this training, the 1st International Fascial Conference happened at the Harvard Medical School in October of 2007 that has changed the world as we know it as it relates to the treatment of structural problems. Research brain trusts and clinicians from across the globe came together to share ideas and further our understanding of the vastly important but little understood tissue, the fascia.

A few years ago I begun the foray into Dr. Luigi Stecoo’s work on Fascial Manipulation. His books have reminded me of how critical an understanding of the fascia is as well as how incredibly complex this tissue system is.

While the learning is lifetime, I have developed a strong appreciation for how much the soft tissues of the human body play a role in what brings patients into our office. unfortunately, it’s difficult for me to explain to patients what this tissue known as fascia is. It is incredibly complex and does not have any good analogies to the world around us that I can use to explain.

Luckily, this particular article does a fantastic job of summing it all up from the viewpoint of Dr. A.T. Still (the founder of osteopathy). I’ve boiled it down to 5 easy bullet points:

Fascia surrounds and connects every muscle and ALL organs in your body, interconnecting everything. It includes aponeuroses, joint capsules and the muscular envelopes that surround your muscle fibers.
In regards to movement, the fascia is intricately tied in with every muscle in order to move a joint, which involves the contracting muscle, the opposing muscle as well as the bone. This means that when we look at a problem with a joint, we can not just look at a problem in a muscle or muscle group (such as the quadriceps), but we have to look at almost the entire region to see why the knee may be hurting.
Injured the lateral collateral ligament of the knee? What if I told you there is no such thing? That ligaments and tendons were actually the condensing and continuation of the fascia surrounding an area rather than a distinct structure?
The fascia is heavily imbedded with receptors feeding up to and back down from the brain. This system is what gives us our incredible agility and allows us to find tune every movement or every joint either singly or during whole body movements.
The cells of the fascia are dynamic, able to change chemically because of stresses placed upon it (the basis for treatment with Graston or Fascial Manipulation) as well as electrically, capable of passing along electrical signals as well.
Different layers of fascia allow muscle fibers, muscles and organs to slide along one another with near-frictionless movement. Injuries and the use of anti-inflammatories can turn a frictionless surface into stuck layers of gunk (my technical term).
The fascia contains and controls the vast majority of interstitial (not inside of the cell) fluid in your body. After an injury, fluid flow can increase 100 fold due to the fascia.
The fascia is also heavily embedded with nerve and pain fibers. Because of this, problems in the fascia can lead to movement problems as well as pain.

While this list may be a little technical, just understand that the fascia is critical to you feeling on top of your game. If you have a problem that is not responding to the “normal” channels, maybe it’s time to try someting different. Ask your doctor or therapist about the fascia. If he or she mentions that they just painted the trim on the house this weekend, maybe you’re not in the right place…

Warning–That Episode of Low Back Pain Will Likely Be Back

May 29, 2012 by James Bogash

As a chiropractor, this issues hits near and dear to my heart. When someone develops an episode of low back pain for the first time in their lives, one of three things happens. The patient ignores it hoping it will go away. Or, they see a non-chiropractor (PCP, ortho, PT, massage therapist, etc..) for that episode. Or, they choose to see a chiropractor.
Which one you choose may well determine what happens for the rest of your life.

The prevailing wisdom states that most cases of acute low back pain will resolve spontaneously within 4-6 weeks. And that’s it. No more worries.

However, what do many people do in this situation? The typical response may include rest, maybe some ice and some type of over the counter analgesic. If it’s not better in a few days or weeks, a trip to urgent care, the ER or the primary care physician may result with a high likelihood of these getting a morphine derivative prescription inappropriately (such as Percocet, hydocodone or Vicodin).

Let me relay a personal experience that happened recently. My 10 year old pug got pushed down an entire flight of stairs by my 55 pound muscled pit bull mix. I watched in horror as he literally rolled end over end and crashed on the landed. He could barely move. I immediately picked him up and settled him down, but he was having much difficulty with walking on both back legs and his right front leg. Not good. Xrays were imminent if this did not resolve quickly.

No ice. No OTC pain meds. I did adjust him that night. He also refused to sit still and continued to follow me through the house as he normally did.

Within 3 days you’d have no idea anything had happened to him.

How would most of us have handled a tumble down a full flight of stairs? Quite differently, I’m sure. But how much of our “typical” behaviors following an episode of low back pain actually promote chonicity? This particular study sheds some light on how untrue our assumptions about what happens to those who suffer their first episode of low back pain are.

In this study of 605 patients who sought care for an episode of acute low back pain:

8% declared sick leave
13% experienced chronic pain at 6 months
19% experienced chronic pain at 2 years
At 6 months, 54% had experienced at least 1 LBP recurrence
Another 47% had experienced at least one flare up in the next 18 months

These are not good numbers. This is my personal opinion based on my own experience, but I feel that these numbers are so high because there was no actual treatment designed to address the problem. Anti-inflammatories do not address the problem (after all–did you have inflammation and THEN an injury?) and are very, very likely to make it worse because they interfere with the normal healing process.

Rest is extremely bad for acute episodes because it allows any injury to the fascia to thicken and perpetuate the dysfunction. Although the pain goes away, the changes to the fascia are sitting there, just waiting for the next “wrong” movement.

The answer? Get into your chiropractor ASAP. This is not my opinion as the evidence suggests that this produces better outcomes. Get treatment that includes soft tissue methods combined with adjusting to address all aspects of your condition and get back to activity as quickly as possible. Make sure you’re in the OTHER 50%…

CONSIDERING SURGERY FOR YOUR KNEE PAIN?

December 28, 2011 by James Bogash

Knee pain is something we see commonly in our office. Unfortunately, I think these are many more cases because patients have been told that their knee pain is arthritis and there is nothing that can be done. This could not be further from the truth.

From a treatment viewpoint, the knee is really not a complex joint. Basically it is referred to as a ginglymus (“hinge”) joint with a slight degree of rotation. There are ligaments, meniscus, muscles, the joint itself and….most importantly…the fascia!

While it is difficult to describe, I generally refer to the fascia as the sheath that our joints and muscles are encased in. It is far more complicated than that, but it seems to get the point across. Many patients come in concerned that they may have torn a ligament in their knee and may even have an MRI to back up the idea. However, current theories are actually debunking the idea that ligaments truly exist.

Rather, they are thickenings of the fascia along areas of a joint that provide increased stability. We have called them ligaments and have seen them on cadavers because anatomists have dissected out what they were looking for. In other words, they were looking for a ligament so, as they dissected out a region they actually created the ligament from the fascia surrounding that area. So, this thickening of tissue exists, but it is actually the continuation of the fascia from the area above and below it.

So what does this mean?

It means that the fascia surrounding a joint may be the most critical tissue that needs to be addressed for joint pain. This can be addressed with fascial manipulation, Graston technique or Rolfing. Laser, chiropractic adjusting, ultrasound, strengthening exercises and any number of other techniques are not going to address the problems that occur in the fascia and may not be as effective for relieving knee pain.

The fascia is also a major source of pain in the knee. Because of this, patients develop knee pain, their primary care doctors orders X-rays (or worse-an MRI) done before any treatment, and they are told they have arthritis. They try some pain meds, maybe a short course of physical therapy, but don’t notice much of a difference. At this point they are resigned to wait until the pain gets debilitating enough for a knee replacement. Sounds like a great plan, huh?

It is common for this patient to come into my office, only to leave 2 or 3 visits later with much less pain in their knees. Did the arthritis suddenly get fixed? Of course not. Rather, the pain was not coming from the joint itself, but rather from the fascia surrounding the knee.

So what does all of this have to do with this particular study?

Because of the marked increase in the number of knee replacements being done in the US, researchers look to confirm that this increase was due to the increased obesity and the increasing age of the population. This was not what they found. Rather, knee pain increased independently of age and BMI.

Of extreme importance is what they did NOT find.

They did NOT find an increase in arthritis of the knee. So, our country is performing more and more knee replacements. This is not due to obesity (obesity did play a role, but it was a smaller one) or age. And there was not more arthritis found. So basically, we are replacing perfecting good knee joints because of problems likely due to fascia surrounding the joint that was never effectively treated.

The bottom line is that anyone with knee pain should first be evaluated by a chiropractor that specializes in the treatment of the soft tissues that surround a joint (in this case, the knee). If pain persists after several visits, then an evaluation by a surgeon may be warranted, but certainly not before.

DID YOU INJURE YOUR NECK AT WORK?

September 26, 2011 by James Bogash

Ever injured your neck in a car accident or at work? Here in AZ, many patient are sent by their employers to occupational medical clinics. The first option here is usually some medications and a “watch and wait” approach. So what’s wrong with that?

Well, if you understand injuries and the way that the soft tissues of the body work, then you know that this is probably one of the worst approaches to take. The anti-inflamatories usually used actually interfere with the healing process and the inactivity that is recommended allows the fascia at the heart of the injury tightens up. With time (and no treatment), these tight areas become permanent.

Alterations in the fascia’s ability to slide affects the muscles. The muscles then aren’t able to move properly and support the joints they are associated with. Then the joints lose movement and become painful and send pathological signals up to the brain. Quite the mess.

So, back to the original question; what’s wrong with anti-inflamatories and rest immediately after an injury? It creates an ideal situation to make the problem chronic.

Which brings us to this study, which further supports this concept, finding that in those who had a work related neck injury, they had almost 2 1/2 times the risk of having “troublesome” neck pain 6 or 12 months later. By this time the injury is much more difficult to treat to resolution.

The bottom line is that it is never a good idea to limit movement after an injury (provided a fracture or more serious injury has not occurred) and that, if possible, you should seek care sooner rather than later. And make sure you find a provider who is going to work on both the muscles, fascia AND the joints to make sure that injury has the greatest likelihood of being put behind you.