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Physio Blog

An ongoing series of informative articles

What is fascia and why is myofascial release so important?

April/19

Over the last several years, through treatment of hundreds of bodies, I started to realize that a) treating the muscles and tissues of the body as discrete, separate units is erroneous, and b) a vital system in the body has generally been overlooked and discounted in contemporary medical education. This system is called the fascial system.

What is fascia?

Fascia used to be - and is still often – considered by many educators and practitioners to simply be a “wrapping” substance that had no real importance in the body or in our understanding of anatomical function. This was certainly how I was taught: there was a basic description of fascia taught to us, but our cadavers had all been stripped of their observable fascial tissue prior to our dissections and was never discussed in any of our gross anatomy laboratory examinations.

Science and research over the years has gradually come to support the hugely important role of fascia in our bodies and is now confirming the fascial system as a major source of pain and dysfunction in the human body when it is not maintained in a fluid and healthy state.

Fascia is connective tissue that surrounds every cell in the body and is responsible for its health and function. The fascia creates the extra-cellular environment and is composed of collagen, elastin, and ground substance. Essentially, this matrix “distributes the mechanical stresses on tissues and provides the structural environment for the cells embedded in it”(1). This system should be mobile and fluid. As taken from C. Stecco’s(1) comprehensive text on the human fascial system, connective tissue (ie. fascia) has many important functions:

1.Provides structural support for the body and maintains the anatomical form of the organs and systems: essentially, it maintains our body’s shape in space.

2.Connects the body’s tissues together.

3.Protects, cushions, and separates organs from surrounding structures, which allows necessary movement of these organs. It also fills space between organs, preventing friction, damage, and even collision with surrounding structures.

4.Provides a nutritive role: all nutrients for the cell must pass from the blood through the connective tissue to cells and other tissues. Similarly, all waste from the cell must pass through fascial tissue to be removed by the blood stream.

5.Storage of energy.

6.Regulation of diffusion of substances.

7.Formation of scar tissue.

Although fascia is a web-like matrix, we do know that there are certain “fascial planes” – these planes are lines of fascial tension that under normal circumstances tend to assist in movement function and stabilization. These fascial planes connect seemingly “unrelated” areas of the body to one another.

The fascial system is complex and can be injured through physical and emotional trauma. Physical trauma to the fascial system can occur over time (as with repetitive postures or activities) or with direct impact. The fascial system can also be affected by emotional trauma as these traumas can have direct effects on muscle tone, and the nervous system.

When the fascial system is traumatized it can have profound effects on our whole body function, pain, and movement capabilities. Fascia should be fluid and mobile, but when injured, begins to thicken and harden – this causes restrictions or scar tissue. These restrictions in turn can cause huge amounts of pressure and crushing forces on not only the nearby structures (ie. blood vessels and nerves), but also anywhere else in the system (it’s all connected, remember)! Often where we feel the pain or symptoms, is not the true source of the injury or restriction. There are many ways to visualize the effect of trauma to the fascial system. One easy to understand example would be a snag in a sweater: imagine you caught your knit sweater on something and continued to walk away. You would see disruption in the entire weave of the fabric and the shape of the sweater would change – the whole sweater “system” might be affected from that one little snag!

Why is Myofascial Release important?

Myofascial release is so important because it restores the health to a system that is continuous throughout the whole body and is responsible for the health and function of each and every cell and structure. Myofascial release involves long sustained holds and positions during which patient feedback is paramount. This approach is patient-led in that we do not try to “force” the fascial tissue to lengthen or loosen, but gradually allow it to soften, ensuring that the patient does not feel the need to guard against the applied pressure. It is an excellent technique for anyone who is particularly sensitive to aggressive treatments, or who has found limited success with traditional therapies that can be painful and may put high amounts of force through joint and soft tissue structures.

Through my own patient care over the years, and treatment of my own body, I find this technique to be the most gentle yet the most effective I have experienced. In many cases, the effects are immediate and can be lasting with few treatments. Myofascial release can help an individual recover from anything from a trauma that happened yesterday to birth traumas. I have been incredibly fortunate to have had the opportunity to train under John F. Barnes’ Myofascial Release Approach and am hopeful that science and our medical community will continue to confirm and accept the incredible importance of this amazing and traditionally overlooked bodily system.

1.Stecco, C (2015). Functional Atlas of the Human Fascial System. Toronto, Ontario. Elsevier.

Posture: What is it and why does it matter?

Nov 10/18

When people hear the words “good posture” it often evokes images of people walking with books on their heads or school marms yelling at slouchy pupils, but good posture is actually key to maintaining good health and muscle balance.

What is posture? Posture is essentially the position in which we hold our bodies to keep ourselves upright against the pull of gravity. Ideal posture is so important because it is the position in which the least amount of stress is applied to our joints and ligaments and the position in which our weight is most centered and balanced within our base of support. When you have poor posture, the muscles are no longer at their “happy” neutral positions and are therefore made to contract in either lengthened or shortened positions. This in turn causes abnormal wear and tear on the joints and soft tissue structures, and symptoms then often present such as pain, burning, aching, etc. with movement and even at rest. Similarly, ligaments can become too taut or lax and do not support the joints properly when poor posture persists. Also, poor posture can cause our body weight to fall outside our base of support which can make us more unstable as we move through space. Finally, all these issues make our movement and static positions (ie. standing, sitting) more energy-consuming and inefficient.

What is ideal posture? Most people have a good understanding of what our ideal posture should be, but the anatomical standard (in sideways position) is described as a line of gravity that starts at the ear lobe, passes through the shoulder joint, passes through the midline of the trunk, through the hip joint, slightly forward of the knee joint, and slightly forward of the outer ankle bone. A slight S-shape to the spine should be maintained in this position.

Why is ideal posture so hard to achieve? The answer to this all comes down to the positions we repetitively place ourselves in for work and daily life. Seated desk work, driving, and prolonged electronics usage are the biggest culprits when it comes to poor posture. This is because these activities make it difficult for people to maintain neutral neck, upper back, and shoulder posture. As a result, we see that people’s upper backs become more rounded, the shoulders creep forward, the head and neck start sitting forward of the spine, and the hip flexors get short and tight pulling on the hips and low back.

What can be done? As you might have guessed, the answer to this is EXERCISE! Take regular breaks to stretch and move the body so that muscles don’t have an opportunity to get too tight or too stretched. Integrating strengthening to balance tightness that might develop with work or home activities goes a long way to maintaining good posture. Some key stretches that anyone doing prolonged sitting during their day should do include:

1.Pec stretches

2.Biceps stretches

3.Upper back extensions

4.Hip flexor stretches

Strengthening exercises to balance forward head and shoulder positioning might include:

1.Rows

2.Rear flies

3.Upper back extensions

4.Chin retractions

5.Hip extension/gluteal strengthening

Many of these exercises can be easily found online.

Finally, I often get asked “what is the best posture or position to be in?” To quote one of my wise professors “the next posture is your best posture.” This means that, simply put, we are not meant to be in any position for extended lengths of time – the body is meant to move!

This information is meant for educational purposes, and hopefully it is helpful! Feel free to contact me if you have any questions!

"I thought it would just get better on its own..."

July 10/18

... possibly the most popular statement I hear in this biz. Chances are if you have had unchanged or worsening pain for several months, it isn’t going to get better on its own, and there are a few reasons for this. In order to explain why the body can’t always heal itself appropriately, let’s first gain a basic understanding of the healing process:

The body goes through three stages of healing with an injury:

1)Inflammatory/Acute Phase (1-7 days) – this is the stage when the injury has just occurred and cell damage causes substances to be released into the surrounding tissue to form a clot, deliver nutrients, protect against infection, and begin the complex repair cascade. This stage causes fluid to be drawn to the area (swelling) and will also result in heat and redness. Rest, ice, elevation, compression and activity modification are often the main goals during this period.

2)Proliferation/Sub-acute Phase (3 days to less than 3 weeks) – this is the stage where the tissues are starting to heal and rebuild as nutrients and tissue building-blocks are delivered to the injured area. Swelling and redness may continue and some pain may still be present. Exercise is important during this phase at it helps proper tissue alignment (ie. scar minimization) and helps the body regain appropriate strength and function. Exercise also helps with flushing swelling out of an injured area by improving circulation and in some cases acting as a “pump”.

3)Maturation/Remodelling Phase (1-6+ weeks) – this is the stage where the newly repaired tissues are further strengthened and swelling and redness subsides. Depending on the tissue injured, this phase can take up to a year or more (ie. bones). Exercise and activity are important during this phase as proper and controlled loading of the tissues builds tensile strength, among other benefits.

Most times with an injury, this process happens smoothly with minimal intervention required on our part, but sometimes the natural progression gets stunted with obstacles such as: poor posture or joint loading, muscle imbalance, immobilization, and improper activity modification among other things. Chronic abnormal joint loading and muscle imbalance are the most commonly seen reasons for chronic pain and inflammation: when a joint or tissue is under repetitive abnormal stress, the tissues are chronically “micro-injured” which causes the inflammatory chemicals to persist in the area creating a toxic environment to the tissues. This in turn prevents the healing cascade from progressing normally.

Immobilization or conversely improper activity modification can also cause poor healing. If a joint or tissue is immobilized for too long, the tissues do no get the movement they need to appropriately rebuild and scar tissue can develop which may further impair normal function. Conversely, if high impact activities (ie, running, sports, etc.) continue during the acute phase, the injured tissues are at high risk of further injury, setting back the healing process and stunting it at the inflammatory phase.

Another reason the healing process might not progress as you expect is that some tissues have poor or no blood supply (ie. meniscus). Therefore, once damaged, such tissues cannot repair themselves.

So, all that being said, if you have had an injury that has lasted months and months, it is time to seek medical assistance (ie. physio!!). At the very least, a physiotherapist can give you some strategies to heal an injury appropriately. We are specialists when it comes to rehab and the human body and can usually get you back on track within a matter of a few weeks. I always tell my patients that they should consider the “3 day rule” (which I have developed from years of experience): if the body is to heal itself, an injured area should start to feel some improvement within three days. If not, time to seek help for a better (hopefully quicker) recovery!

Again, this information is meant as a guide and some injuries are more complex than others. As always, feel free to contact me with any questions!

My Doctor says "it's just arthritis"...

June 9/18

AHHHHH!!! How many times have I heard this over the years from patients? Too many! It makes me want to tear my hair out for several reasons, which I will elaborate on further in this post. I felt the need to write this to educate patients of the facts that a) arthritis can only be diagnosed with a thorough history and physical examination, and that b) although arthritis can be painful, the pain experienced in a joint is often due to abnormal loading which stimulates the inflammatory process. Before proceeding further, I do want to state that the information provided here is in relation to osteoarthritis which is an entirely different diagnosis than rheumatoid arthritis, which is a more rare and systemic condition.

Let’s begin by talking about what arthritis actually is. The word arthritis comes from “arthro” = joint, and “itis” = inflammation. Most people with the diagnosis experience the primary type of arthritis which happens over time with wear and tear, as opposed to the secondary type which is a result of a trauma (ie. fracture, infection, etc.). Arthritis involves a sequence of physiological changes to the internal structures of the joint, beginning with disruption of the cartilage matrix. When the matrix is disrupted, fragments of collagen and other molecules are released into the joint fluid which causes further irritation and degradation of the cartilage. As the cartilage becomes thin, the joint space can narrow, and small bony outgrowths (bone spurs) can develop around the perimeter of the joint (on rare occasions, also internally). These can eventually cause irritation on the surrounding soft tissue such as tendons. If the cartilage loss is severe enough, a “bone-on-bone” situation can occur where there is no longer a cartilage layer acting as a buffer in the joint.

In order to be properly diagnosed with osteoarthritis, an individual would need to exhibit the following findings on examination:

-Reduced range of motion of the affected joint

-Joint swelling (this can present as a cyst, ie. “Baker’s cyst" in the knee. As a side note, a Baker’s cyst

is fluid from inflammation becoming trapped in the joint space and pushing outward on the capsule to create the appearance of a bulge or cyst.)

-Crepitus (crunching, cracking, or grinding sensation with movement)

-Heat, redness, or enlargement of tissues around the joint

-Muscle atrophy (in later stages)

-Radiographic findings (xray): joint space narrowing, bone spurring, joint fibrillation or thickened/rough joint edges

An important point here is that if you have not had a physical examination and/or do not have these findings it is probably NOT ARTHRITIS! For some reason arthritis has become an increasingly popular diagnosis that people readily accept as an inevitable result of aging: IT ISN’T!! In addition, much of the pain associated with arthritis is, again, due to abnormal loading or inflammatory chemicals in the joint. If you remove the abnormal stress and normalize joint forces (ie. with exercises), and reduce/minimize the amount of inflammation in the joint, you may well end up being pain free! To follow this rationale, here is an excerpt from a popular resource we tend to use with patients:

“Studies have shown that when x-rayed, up to 85% of adults with no actual knee pain, have xrays that show knee arthritis. This means that there is little correlation between the degree of arthritis seen on xray, and actual pain.

In fact, one study showed that 48% of healthy professional basketball players had meniscal (cartilage) ‘damage’ on their knee MRIs.”

*From APTEI, www.aptei.com

My goal with sharing this information is that a) patients will question whether they should simply accept the arthritis diagnosis as a sentence to live the rest of their life with joint pain, and b) understand that exercise and rehab intervention can make a significant improvement in both pain and function for this issue. In my professional opinion, we should not ever think of pain and dysfunction as a normal part of the aging process (because it isn’t), and should always recognize the importance of movement and muscle balance in maintaining good joint health.

Hopefully this was informative – if you have any questions, as always, feel free to contact me!

Should I wear a brace?

Apr. 30/18

This is another question that I am commonly asked by patients who may be dealing with joint pain or tendinitis issues. My response to this question is typically “no” – here’s why:

1)Most chronic inflammatory conditions do not respond well to the application of compression: when a joint is inflamed as a result of abnormal loading or damage to internal structures such as ligament or cartilage, the result is increased fluid in the joint space, or pressure, which activates the nociceptors (pain receptors) in the tissue. Often when you put a brace on such a joint, the added compression causes a further pain response, and sometimes decreases the circulation to the affected area. Decreasing the circulation means that the body has a harder time bringing that fluid out of the inflamed area and prolonged pain can then result.

2)Braces are temporary supports that do not correct the problem: putting a brace on an area that has decreased range of motion or function does not in any way help to correct a muscle imbalance or dysfunctional movement patterns. You are always better off to address the underlying cause of the dysfunction through exercise and muscle re-education than to rely on a gadget to perform an action that your body should be capable of performing on its own. Tennis elbow and patellar tendon straps are a good example – they simply re-direct the forces on the tendons and do not correct the problem, all while at the same time applying a compressive and friction force to the tissues.

3)Braces often give a false sense of security: over-the-counter braces do not actually give a significant amount of stability to a joint, however, people often feel that they will. Typically, these braces offer little protection against the significant forces applied through sport and even through weight bearing. Wearing a brace does not mean that you can safely perform physical activity while injured.

So when is a brace helpful?

Braces are helpful in a number of circumstances:

1)Acute injury: if you have suffered an acute injury, involving the ligaments in particular, a brace can be helpful. Acute ligamentous injuries do cause joint instability and decreased ability of the body to sense joint position. In this case, a brace may help to protect and stabilize the joint while the ligaments or soft tissue are recovering. Using a brace during the acute phase of an injury, combined with rest, ice, and range of motion exercises can help with the recovery process.

2)Post-surgery: those recovering from surgery will often need a brace to help immobilize the joint to prevent undue stress to traumatized and healing tissues. Braces for this purpose are often medically prescribed or custom made to suit the individual.

3)Chronic instability: for those who have tried physiotherapy/rehab for an injury and not been able to achieve full recovery, and are left with residual instability (that has been appropriately assessed and diagnosed), a brace may be the only other non-surgical option. Sometimes a joint has been traumatized significantly and is unable to fully repair: in this instance, a brace may be appropriate and will often be recommended by your health care provider.

The information in this blog is a guide for brace usage – there are many types of injuries, and subsequent approaches that may be considered during the rehab process. It is always best to consult with your healthcare provider to come up with the best plan for your recovery!

OHIP and Physio Coverage: How it works

Apr. 16/18

Do you take OHIP?

This is one of the most commonly asked questions – and misunderstood topics encountered - when patients are seeking physiotherapy care. The truth is that our medical system does not do a great job of informing patients as to how receiving paramedical care actually works. Therefore, this article will hopefully shed some light on outpatient care and how payment is assigned and received for services.

Firstly, in the fall of 2014 the OHIP model for outpatient physiotherapy services was overhauled: many strictly OHIP clinics were closed and private practices were then able to apply to be OHIP providers, and therefore, enter into a contract with the government to receive public funding for their services. In Niagara, there are now only a small number of clinics that can accept OHIP prescriptions. Because of the limited funding provided for treatment, many of these clinics provide exercise- and modality-based therapies for OHIP patients and utilize support staff with the physiotherapist having more of a supervisory role in the patient care.

Secondly, there are criteria that must be met for patients to qualify for OHIP funded services, and they are:

•A doctor’s referral is required for all OHIP treatments

•You must be 19 or younger

•You must be 65 or older

•You are receiving benefits under the Ontario Disability Support Program or Family Works

•You have had a recent hospital stay for an issue requiring physiotherapy treatment

If you do not meet the above criteria, unfortunately, you do not qualify to receive services under OHIP. The College of Physiotherapy of Ontario has a good website that provides further resources and information regarding eligibility and locations of OHIP clinics:

https://www.collegept.org/patients/Accessing-Government-Funded-Physiotherapy

If OHIP doesn’t pay, who does?

If you are not eligible to receive OHIP-funded treatment, you do still have options. Most people through their work or a spouse have health benefits through private insurance corporations (ie. Sunlife, Manulife, etc.). Many people do not access these services regularly and often are unsure of what they are covered for – it is suggested that you take the time to familiarize yourself with your benefit package as you may be covered for a variety of services, and each plan often has varying levels of coverage and yearly maximums. The funding that these plans provide for services “renews” every year – sometimes that coincides with the calendar year and sometimes not: another reason to look into your plan.

Private clinics receive the majority payment for services from these health insurance plans, and will bill the insurers (directly in most cases) every time you attend a treatment. If you do not attend, the health care provider does not get paid.

If you do not have health insurance, and are not eligible for OHIP, then you may have to pay out of pocket for services. Depending on the clinic or practitioner, a reduced rate may be arranged to make receiving treatment more affordable if a patient would otherwise be unable to attend due to financial constraints.

Hopefully that helps to clear up the confusion about who pays for treatment and how OHIP funding works! For further information, please feel free to contact me!