What happens in the Fascia when we treat with vibrations?
Fascia creates a three-dimensional network in the body of alternating loose and dense connective tissue that enables all cells and organ systems in the body to collaborate as an integrated whole. Simply put, Fascia can be described as having a solid part and a fluid part. The solid part consists of fiber proteins, mostly collagen, while the fluid part is a water-binding gel that largely consists of hyaluronic acid but also other molecules. Together, these solid and fluid parts are known as the extracellular matrix (ECM), which is what exists outside the cells. Embedded in the ECM are the cells, such as fibroblasts, which produce the components of the ECM and direct the machinery by constantly communicating with their surroundings and producing proteins and other molecules as needed.
The solid part, collagen, contributes to structure and strength and controls Fascia’s mechanical properties on a macro level. The fluid gel controls Fascia’s properties on a micro level, such as communication and transport between cells at the molecular level.
Fascia is incredibly adaptable and changes its composition and properties according to the needs and stresses placed upon it. This happens very quickly at the molecular level in the fluid gel. It responds to changes in load (such as excessive physical exercise or inactivity), to injuries, overexertion, physiological changes due to age, hormones, temperature, pH, and more.
As described above, cells constantly communicate with the extracellular matrix (ECM), the material outside the cells. The cells are connected to and in contact with the ECM through their cell membrane and their so-called cytoskeleton. Every small movement and change in ECM load directly signals to the cell’s nucleus through the cytoskeleton. A complex chain of processes starts within the cell to adapt and change the production of different molecules. The same applies in the opposite direction; changes in the cell’s function directly signal adaptation and change in ECM. Especially during growth and tissue regeneration, a significant restructuring occurs locally in the ECM, on the micron scale, to enable the necessary cell adaptation and movement for the regeneration of fascia tissue. All these changes in cells and ECM result in changes in the structure and homeostasis of tissues and organs.
Excessive and prolonged loading or direct trauma to the fascia triggers micro and macro changes in the ECM to facilitate healing and repair. The immune system is also involved in taking care of and breaking down damaged cells. An acute inflammation process starts, which is a normal healing process that is usually short-lived. Inflammation leads to increased sensitivity of nociceptors, signaling pain to the brain, all to allow our body to heal. If we continue to expose our body to overload and harmful movement patterns, or lack of movement altogether, inflammation can instead persist and become chronic. This creates harmful levels of inflammation-promoting molecules that break down tissue and can also affect fibrosis formation by excessive proliferation of fibroblasts that produce too much collagen.
In the loose connective tissue of fascia, there are large amounts of hyaluronic acid (HA) which binds water and creates a gel in the spaces between collagen fibers. HA can exist in varying molecular sizes, with vastly different properties depending on size. In healthy, functional fascia, there is plenty of high molecular weight HA, which binds a lot of water and keeps the fascia lubricated, allowing for easy gliding function. Hyaluronic acid is also a substance that plays a role in inflammation processes and increases in concentration at sites of injury. It can quickly change in molecular weight due to oxidative processes and enzymes called hyaluronidases, which break down hyaluronic acid. HA has a turnover time of 1.5 – 2 days, depending on the tissue type. Constant production and breakdown of HA maintain balance in the tissue. Cowman et al. have shown that an increase in concentration of hyaluronic acid can trigger self-aggregation of HA, which leads to a dramatic increase in viscosity in the ECM. The increased viscosity causes densification in the fascia and increased impact on the large number of nociceptors present, lowering their threshold for activation, leading to oversignaling of pain to the brain. Luomala et al. have shown with ultrasound and elastography that this densification coincides with movement dysfunction and palpable stiffness in muscle and fascia.
Menon et al. have used special MRI techniques (T1rho) to find that there is more unbound water in the loose connective tissue of fascia in tissues with pain and dysfunction. The aggregated hyaluronic acid cannot bind water, so the water becomes unbound and trapped in clusters like in a honeycomb. They showed that the unbound water disappeared after manual fascial treatment, as did the pain and increased range of motion. A similar study was done in 2019 by Menon et al., where they used the same MRI technique (T1rho) to show that unbound water disappeared after injecting hyaluronidase, an enzyme that breaks down hyaluronic acid.
Fascia densification is a reversible process that can be treated with fascia treatment. If left untreated, the hyaluronic acid will eventually thicken and form a thicker endomysium around the muscle fibers, reducing their ability to move. Eventually, more collagen will be formed in the endomysium, creating fibrosis, and the muscle fibers will atrophy. The fibrosis is now irreversible. In a thickened tissue, communication, flow in and out of cells, communication between cells, flow in lymphatic vessels and lymphatic system, signaling through nerve receptors, blood capillaries, and more, become difficult or stop. The fascia and hyaluronic acid surround everything, not just muscle cells, but also nerve cells, lymphatic and blood capillaries, larger vessels, lung tissue, in and around muscles, nerve fibers, etc. When parts of the body are exposed to higher loads, imbalances, due to injury, compensation, work posture, etc., some parts will have higher pressure while other parts are underloaded.
When the flow does not work optimally, it also affects the immune system. For the immune system to function, flow throughout the body must function properly so that the transport of immune cells works and the cells receive the correct information. Immune cells, white blood cells, must be produced and transported around without hindrance.
This shows the importance of treating repeatedly in good time when the patient experiences pain and decreased mobility so that the hyaluronic acid can disperse and regain its water-binding and lubricating properties. Vibrations and other manual treatments can separate the aggregated hyaluronic acid molecules, and the pressure on muscle fibers and nerve receptors disappears, and movement is regained. Flow in ECM, lymphatic system, and blood circulation works better, and even breathing improves with reduced pressure from the surrounding tissue. Field, 2017, conducted a review of research describing the incredibly many benefits of massage.
Manual therapy and vibrations effectively increase the flow of hyaluronic acid. Manual oscillating movements increased the flow pressure 3-6 times compared to constant sliding pressure over the tissue, depending on the frequency of oscillation (2-4 Hz). However, it is a laborious movement for the therapist. When using mechanical perpendicular vibration against the tissue with 15 Hz and 60 Hz, the flow pressure of hyaluronic acid increased to 17 and 71 times, respectively, compared to constant sliding pressure. The increased flow in the tissue creates increased pressure between the layers of fascia, which increases the volume between the layers and improves the gliding function (similar to a car tire and hydroplaning), (Roman et al, 2013).
Normal, varied daily movement in moderate doses is needed to maintain the flow in all of the body’s tissues, and then we are in balance. When it stops somewhere for various reasons, the machinery starts to creak and wear out, and more energy is required for movement, and we start to overload incorrectly. It is best to try to solve the imbalance and release the resistance in time so that we can return to healthy movement patterns. Unfortunately, most of us return to poor, monotonous work postures and subject the body to improper loading.
In addition to movement of the fascia and flow, proper nutrition is also required, so that building blocks are available for the production of cells, fascia, and other tissues. Unfortunately, this is an area where most doctors and veterinarians have poor knowledge. Fortunately, a holistic approach and functional medicine are beginning to receive more attention.
- Cowman et al, 2015. Viscoelastic Properties of Hyaluronan in Physiological Conditions.
- Field, 2017. Massage therapy research review.
- Luomala et al, 2014. Case study: Could ultrasound and elastography visualized densified areas inside the deep fascia?
- Matteini et al, 2009. Structural behavior of highly concentrated hyaluronan.
- Menon et al, 2019. Quantifying muscle glycosaminoglycan levels in patients with post‐stroke muscle stiffness using T(1ρ) MRI.
- Menon et al, 2020. T1ρ‐Mapping for Musculoskeletal Pain Diagnosis: Case Series of Variation of Water Bound Glycosaminoglycans Quantification before and after Fascial Manipulation® in Subjects with Elbow Pain
- Mense, S.; Hoheisel, U. Evidence for the existence of nociceptors in rat thoracolumbar fascia.
- Roman et al, 2013. Mathematical Analysis of the Flow of Hyaluronic Acid Around Fascia During Manual Therapy Motions.
- Stecco et al, 2011. Hyaluronan within fascia in the etiology of myofascial pain.
- Stecco et al, 2013. Fascial components of the myofascial pain syndrome.
- Stecco et al, 2014. Ultrasonography in myofascial neck pain: Randomized clinical trial for diagnosis and follow‐up.
- Stecco et al, 2018. The fasciacytes: A new cell devoted to fascial gliding regulation