Traumatic Scar Tissue Management (054-104)

CHAPTER 1
Introduction
We are not just treating scars; we are treating people with scars
Pamela Fitch BA, RMT
In the developed world alone, a total of 100 million people develop scars
each year as a result of 55 million elective operations and 25 million
operations after trauma (Sund 2000). Current statistics estimate that over
50% of postsurgical patients will experience scar-related complications
(Diamond 2012).
Millions of people worldwide are afflicted with non-fatal burn injuries.
Although mortality and morbidity from burns have diminished significantly
over the past several decades, these statistics do not reflect the overall
impact on the burn survivor and how well they carry on with their life and
manage post-burn deformities, contractures and other disabilities that
collectively present with aesthetic and functional considerations (Goel &
Shrivastava 2010).
The prevalence of occurrence, complications and sequelae associated with
problematic scars, of varying etiology, present important clinical, economic
and social considerations.
The occurrence of excessive scarring has been documented for centuries,
dating back to the Smith papyrus around 1700 BC (Berman & Bieley 1995).
The documented use of manual techniques in the treatment of wounds can
be traced back to the 1550s; Paré, a French surgeon, administered massage
to relieve joint stiffness and improve wound healing following surgery. It
has also been documented that during the World Wars, military nurses and,
sometimes, doctors provided massage as a component of scar treatment as a
result of unplanned events and planned trauma (surgery).
Nowadays it is common to see massage noted in medical literature, as part
of the recommended postsurgical care for scars, as a means to improve
wound healing outcomes (e.g. better scar aesthetics and more pliant, less
restrictive scars). However, ironically in the present day, specific protocols
for the management of scars typically do not include massage therapy (MT)
and specific referrals and patient accessibility to MT lag, presenting a
paradoxical conundrum for the profession and those who could benefit from
the treatment.
In part this lag falls to the responsibility of the MT profession itself.
According to Cho and colleagues (2014):
Evidence to support the use of scar massage is inconclusive. There is

much variability and inconsistency with regard to when treatment
should be initiated, the appropriate treatment protocol and duration,
and evaluation and measurement of outcomes.
In order to improve the position of MT as a viable treatment consideration

within the spectrum of mainstream medical care, the profession needs
educational materials that guide the clinician’s delivery of safe and effective
care in order to achieve measureable, predictive and consistent clinical
outcomes. This book is intended to support this initiative and be a go-to
resource for manual scar tissue management, shaped to teach massage
therapists how to work safely and confidently with people with scars.
Evolution is Fundamental
Health care is an ever-evolving environment. As healthcare providers
within the field of manual therapy, we are continually learning new
discoveries about the body’s response to trauma, injury, healing and touch.
Newer technologies that aid imaging (e.g. high definition real-time
ultrasound and endoscopy) and advances in research have been instrumental
in expanding our understanding of important clinical considerations and in
supporting the development of evidence-based practice guidelines.
Additionally, the higher levels of educational preparation currently
available to MT practitioners aid in the ability to find, critically evaluate
and utilize best available evidence.
Evidence-based practice (EBP) emerges from evidence-based medicine
(EBM), which Sackett et al. (1996) define as integrating client values with
clinical expertise and the best available research evidence. Best research
evidence encompasses best available clinical, client-centered research that
examines the accuracy, safety, efficacy and cost effectiveness of diagnostic
and assessment procedures, prognostic markers and therapeutic
interventions. Clinical expertise encompasses the therapist’s ability to use
clinical skills and past experience to both identify each client’s unique
health status and the potential risks and benefits of the proposed
interventions. Client values speak to the individual’s unique preferences,
goals and expectations within the therapeutic relationship (Andrade 2013).
Evidence for massage is information on massage practice that researchers
and therapists collect in a systematic manner (Sackett et al. 2000). In
practice it is desirable to be as evidence-based as possible, and be evidence
informed when definitive evidence does not exist (Fritz 2013).
Haraldsson (2006) states:
Patient Oriented Evidence (POE) asks the important question; ‘Does

this new evidence impact the patient by changing the prognosis of the
illness/impairment or increase the quality of life?’ As a profession, we
need to come together and create evidence-based practice guidelines
to improve our practices and keep up with the changing health care
environment.
A Reasonable Nexus
Precise etiologic factors driving excessive/abnormal scar formation remain
somewhat elusive, with the exception of tissue trauma, further complicated
by factors such as excessive or prolonged inflammation and excessive
wound tension mediated by fibroblasts/myofibroblasts.
By better understanding the wound healing process (physiological and
pathophysiological), what our hands can effect (e.g. anxiety, pain,
inflammation and tissue tension) and how our hands can induce desired
outcomes (mechanisms of action), we can better devise strategies for
improved delivery of care and achieve improved and more reliable clinical
outcomes.
Although it is widely accepted within health care that massaging a scar
improves outcomes, there is a paucity of well-designed clinical trials to
establish a solid evidence base for achieving productive results. And so, this
book is written with the objective of establishing a reasonable nexus
between available sound-science and achieving consistent clinical
outcomes. In such this nexus, coupled with the authors’ extensive clinical
experience, will help shape guidelines for working with scar tissue and
people with scars.
When properly developed, communicated and implemented, guidelines
improve the quality of care that is provided and patient outcomes.
Guidelines are intended to support the healthcare professional’s critical
thinking skills and judgment in each case.
In addition to guiding safer, more effective and consistent outcomes, the
authors can only dare to dream that these guidelines will also support better
constructed MT research methodology and designs, ultimately leading to
the inclusion of MT professionals in mainstream interprofessional
healthcare.
What Defines Traumatic Scarring?

The American Psychological Association defines trauma as an emotional
response to a terrible event like an accident, sexual assault or natural
disaster (APA 2015).
Scar or cicatrix, derived from the Greek eschara – meaning scab – is the
fibrous replacement tissue that is laid down following injury or disease
(Farlex 2012).
Scars are not obligated to be problematic – where would we be without our
body’s natural ability to heal itself following a wound? However, normal
physiological processes can be altered in a variety of ways and, when
altered, this constitutes what is termed pathophysiology.
Abnormal or pathophysiological scars can impact function within and
beyond their physical borders and present considerations outside of the
physical/physiological aspect of the scar tissue (Lewit & Olsanska 2004,
Bouffard et al. 2008, Valouchová & Lewit 2012, Bordoni & Zanier 2014).
Problematic scarring following planned and unplanned trauma can be
accompanied by serious physiological and psychological considerations
and, as such, this brings us to traumatic scars as defined by the authors:
pathophysiological scars further compounded by traumatic emotional

sequelae and other comorbidities.
Traumatic scars can occur as a result of accidents, acts of violence and other
catastrophic events (e.g. disease, burn accident and surgery).
Over the last several decades, advancements in medical technology have led
to improved surgical techniques and emergency care (Blakeney & Creson
2002). Simply put, more people are surviving injuries that would have been
fatal 20 or 30 years ago, and an increase in survival rate means an increased
need for professionals skilled in treating people with scars. Working
successfully with traumatic scars requires expert navigation, not only of the
physicality of the scar material but also inclusive of the whole clinical
presentation. This book will provide the information needed to help guide
the development of that expertise.
Given the complexity of traumatic scars, where such presentations and/or
appropriate treatment fall outside of the MT profession’s scope of practice,
suggestions will be provided for appropriate referral resources to support
the patient’s best possible biopsychosocial outcomes.
It is the authors’ intention that the end product will comprehensively cover
both the physiological/physical and empathetic elements of MT and in
doing so honour both the art and science of the work. Like interprofessional
collaboration, integration of art and science are essential for excellence in
contemporary healthcare and achieving the best possible patient-focused
outcomes for people with scars.
Overview of Chapters
Individual chapters will cover normal/abnormal scar formation; the role of
various systems in wound healing; the impact of pathophysiological scars
and associated sequelae; the biochemical and emotional impact of trauma;
communication skills (including interprofessional communication);
assessment and treatment protocols; client/therapist self care and shared
experiences from therapists and people with scars.
In order to assist with research translation, throughout this book
pathophysiological and clinical considerations will be interspersed as Boxes
where it makes sense to do so.
The views expressed in these pages are founded on the result of

several years of close observation, study, and experiment. It is
possible some of my deductions are erroneous, but at least they are
capable of being argued and are not merely arbitrary.
J.B. Mennell (1920)
References
Andrade CK (2013) Outcome-based massage: putting evidence into practice. 3rd edn Baltimore Md:
Lippincott Williams & Wilkins.
APA (2015) American Psychological Society. Available at: https://apa.org/topics/trauma/index.aspx
[Accessed 16 February 2015].
Berman B, Bieley HC (1995) Keloids. Journal of American Academy of Dermatology 33: 117–23.
Blakeney P, Creson D (2002) Psychological and physical trauma: treating the whole person.
Available at: http://www.jmu.edu/cisr/journal/6.3/focus/blakeneyCreson/blakeneyCreson.htm
[Accessed 10 December 2014].
Bordoni B, Zanier E (2014) Skin, fascias, and scars: symptoms and systemic connections. Journal of
Multidisciplinary Healthcare 7: 11–24.
Bouffard NA, Cutroneo KR, Badger GJ et al (2008) Tissue stretch decreases soluble TGF-β and type
I procollagen in mouse subcutaneous connective tissue: evidence from ex vivo and in vivo models.
Journal of Cellular Physiology 214: 389–395.
Cho YS, Jeon JH, Hong A et al (2014) The effect of burn rehabilitation massage therapy on
hypertrophic scar after burn: a randomized controlled trial. Burns 40(8): 1513–20.
Diamond M (2012) Scars and adhesions panel. Third International Fascia Research Congress,
Vancouver.
Farlex (2012) Medical Dictionary for the Health Professions and Nursing. © Farlex 2012.
Fritz S (2013) Mosby’s Fundamentals of therapeutic massage, 5th edn. St Louis, Elsevier, p 45.
Goel A, Shrivastava P (2010) Post-burn scars and scar contractures. Indian Journal of Plastic
Surgery: official publication of the Association of Plastic Surgeons of India 43(Suppl): S63.
Haraldsson BG (2006) The ABCs of EBPs. How to have an evidence-based practice. Massage
Therapy Canada. Available at: http://www.massagetherapycanada.com/content/view/1402/[Accessed
7 December 2014].
Lewit K, Olsanska S (2004) Clinical importance of active scars: abnormal scars as a cause of
myofascial pain. Journal of Manipulative and Physiological Therapeutics 27(6): 399–402.
Mennell JB (1920) Physical treatment by movement, manipulation and massage, 2nd edn.
Philadelphia: Blakiston.
Sackett DL, Rosenberg W, Gray JA et al (1996) Evidence based medicine: what it is and what it isn’t.
BMJ 312(7023): 71–72.
Sackett DL, Strauss SE, Scott Richardson W et al (2000) Evidence-based medicine: how to practice
and teach EBM, 2nd edn. New York, Churchill Livingstone.
Sund B (2000) New developments in wound care. London, PJB Publications.
Valouchová P, Lewit K (2012) In: Schleip R, Findley T, Chaitow L, Huijing P (eds) Fascia the
tensional network of the human body. Edinburgh: Churchill Livingstone Elsevier, p 343.
CHAPTER 2
Skin and fascia

Nothing in life is to be feared, it is only to be understood. Now is the
time to understand more, so that we may fear less
Marie Curie
The delivery of safe and effective scar tissue management requires an

understanding of the structure and function of the organs and systems we are
working with and of the wound-healing process.
The aim of this chapter is to provide a solid base for understanding skin and
fascia sciences (structure and function).The role of skin and fascia in wound
healing and the impact of abnormal wound healing on them will be covered
in greater detail in Chapters 5 and 6.
Skin and Fascia: Overview

Skin and fascia are highly complex and diverse systems. This book provides
an overview of each, favoring relevance to massage therapy (MT) and is
comprehensive enough to guide treatment protocol and clinical best practice.
Although we will explore these systems individually, the various layers of
the skin and underlying fascia are connected, support each other structurally
and functionally, and continuously engage in the exchange of information.
We begin with an overview of the extracellular matrix (ECM) as it
constitutes the sum total of extracellular substance within skin and fascia.
General Histology
Extracellular Matrix Structure and Function
The extracellular matrix structure (ECM) is a complex blend of structural
and functional macromolecules (see Table 2.1).
The ECM comprises (*covered in more detail):
• *Structural proteins, e.g. collagen and elastin (covered in greater detail on
pp. 15–16)
• *Non-collagenous/cross-link proteins, e.g. fibrillin, fibronectin and
laminin
ECM Examples and function

constituents
Structural Collagen and elastin: structural struts that while flexible, provide strength and stability
proteins
Non- Fibrillin, fibronectin and laminin: structural struts providing flexible-stability and a
collagenous pathway for transfer of mechanical strain/tensional loading information from cell to
cross-link cell
proteins
GS Amorphous, hydrophilic gel, comprised of PGs and GAGs: an important metabolic
interface that fills the space between cells and fibers
GAGs and PGs Glucosamine, chondroitin, HA: highly negatively charged macromolecules that attract
water and perform a variety of physiological and mechanical functions, such as
lubrication to improve slide/glide between various structural proteins
Polysaccharides Starch, glycogen, cellulous: an important class of biological polymers that provide
primarily a storage or structure related function
Table 2.1
The extracellular matrix (ECM)
• *Ground substance (GS)

• *Ionized water
• Glycosaminoglycans (GAGs, e.g. chondroitin, *hyaluronan) and
proteoglycans (PGs)
• Polysaccharides play a role in energy, storage and ECM structure.
Non-collagenous/cross-link proteins
Non-collagenous/cross-link proteins, where normal, healthy cross-link
proteins bind collagen fibers to the cell membrane, creating the pathway for
mechanical strain/tensional loading information to transfer from the tissues
to the cell. Additionally, normal cross-link proteins augment collagen fiber
stability.
Clinical Consideration
Vitamin C has been identified as an important component in the

formation of healthy cross-links. Here we can see the importance of
adequate intake during tissue remodeling following exercise and
trauma (Boyera et al. 1998).
Pathophysiological Consideration
Abnormal or pathological cross-links, instigated by various

pathophysiological circumstance (e.g. diminished GS), can adversely
impact tissue mobility and lead to tissue contracture and shortening
(Van den Berg 2010, 2012). Changes to the ECM (adhesions between
microfilaments, i.e. pathological crosslinks) are seen in scarred fascia
(Kozma et al. 2005, Chirasatitsin & Engler 2010).
Ground substance
Ground substance (GS), the amorphous gel-like component of the ECM, is
an important metabolic interface that fills the space between cells and fibers.
GS influences tissue development and cellular migration, proliferation,
shape and metabolic functions.
Constituents within the GS (e.g. GAGs and PGs) perform a variety of
functions that can influence tissue development and cellular migration,
proliferation, shape and metabolic functions (Van den Berg 2012). One
important feature of these constituents is their ability to attract and bind
water, which factors significantly into fascia’s viscoelastic properties and in
lubrication, thereby reducing friction between moving or sliding fibers,
tissues and layers.
Water
Water plays an important role in viscoelasticity and lubrication. Water also
serves as a transport system and solvent. Up to 80% of the human body is
water (in bound and unbound states).
In addition to tissue dehydration seen with trauma, our water volume

tends to diminish as we age. Under-hydration may play a role in age-
related collagen changes and the pain and dysfunction that
accompanies such changes (Purslow & Delage 2012). The clinical
significance of the impact of tissue dehydration is discussed further
throughout this chapter.
Age-related changes seen in fascia show some similar characteristics to

those seen in injured fascia such as tangled pathological cross-links,
less coherent collagen fiber arrangement, under-hydrated and less wavy
or crimped collagen (‘collagen crimp’). Such changes can impact tissue
slide and glide, elasticity and mobility, and can impact proprioceptive
functioning (e.g. balance, motor control and sensory awareness).
Hyaluronan
This hydrophilic, viscous lubricant is found throughout fascia, skin and
neural tissue. Hyaluronan (HA) is involved in a variety of physiological and
mechanical functions such as wound healing, lubrication, cellular signaling,
maintaining osmotic balance and tissue hydration (Liao et al. 2005, Matteini
et al. 2009).
HA helps reduce the impact of compressive forces in synovial-joint related
tissues and improves slide/glide between various structural proteins and
layers of adjacent tissue (e.g. between various layers of fascia and between
muscle fibers) (McCombe et al. 2001, Stecco et al. 2011). HA and the
sliding mechanism will be covered in greater detail later in this chapter.
It is suggested that alterations in HA amount and organization may
play a role in tissue changes (e.g. tissue softening and improved
slide/glide) following fascial manipulations (Evanko & Wight 1999).
HA and its fragments may play crucial roles in the skin wound-healing
process by modulating the expression of fibroblast genes involved in
remodeling and repair of ECM (David-Raoudi et al. 2008).
Collectively the ECM defines the shape and form of our cells. It provides a
framework to which the cells can adhere, move about in and communicate
through. The ECM creates a medium by which appropriate balance can be
maintained between porosity, hydration and ionic environment, thus
allowing nutrients and metabolites to diffuse freely into and out of our cells.
The ECM acts as an immune barrier. It is also a repository for metabolites
and toxins, and for storing fat.
The ECM plays an important role in wound healing and repair. It serves as a
repository for signaling molecules and mediates signals from other cells to
promote cell proliferation and differentiation.
The ECM is responsive to mechanical strain and tensional loading (tissue
deformation). Mechanical forces exert influence on the tissue structural
elements (microfilaments) and the molecular composition of the ECM
(Benjamin & Ralphs 1998, Milz et al. 2005). Strain type, degree, direction
and duration can influence ECM composition and impact fibroblast
functions that guide healing and adaptation responses (Purslow 2002, Ingber
2003, Standley & Meltzer 2008, Stecco et al. 2009, Blechschmidt & Gasser
2012). The clinical relevance of this feature of the ECM will be noted
throughout this book.
One of the mechanisms by which cells sense changes in mechanical
strain/tensional load is via specialized (matrix adhered) transmembrane
receptors (integrins). Integrins play a role in defining cellular shape,
mobility, regulating the cell cycle and mediating cell-to-cell and cell-to-
ECM signals. Via integrins, mechanical stimulus can evoke a biochemical
response, which, in turn, can trigger a variety of cellular responses and
activities. Conversion of mechanical stimulus into biochemical response is
called mechanotransduction. The integrin–mechanotransduction
communication system works much faster than neurally transmitted signals,
allowing cells to make rapid and flexible responses. In addition to evoking
biochemical responses, the internal to external and cell-to-cell linkage
mechanism provides the means by which the organism can sense and
respond to mechanical demand or forces placed upon it – monitoring and
regulating ‘enough tension’ to ensure the shape and integrity of any given
cell and the entire musculoskeletal/myofascial system.
Figure 2.1
Layers and components of skin.
Skin Structure and Function
In order to better understand the formation of scar tissue, we need to look at
the marvelous organ that is our skin.
Along with the glands, hair and nails, skin makes up the integumentary
system. On average, skin constitutes 10% of human body mass. Skin acts as
a barrier to the outside world and plays an important role in homeostasis.
The skin, our outer layer of protection, is susceptible to infections, injuries,
growths, rashes, cysts, boils, discoloration, burns, adhesions and scars.
Skin Histology
The skin comprises:
• Epithelium
• Connective tissue (CT).
Epithelium
There are three basic types of epithelial tissue: squamous, cuboidal and
columnar – arranged in either a one-layer (simple) or multilayer (stratified)
configuration. Epithelium forms many glands and lines the cavities and
surfaces of structures throughout the body (e.g. the epidermis consists of
stratified squamous keratinizing epithelium) (Marieb et al. 2012).
CT
Considered a system, CT consists of several different types of cells (e.g.
fibroblasts and adipocytes), protein fibers (elastin and collagen) surrounded
by the gelatinous ECM (Schleip et al. 2012a, Andrade 2013).
CT is a continuous bodywide system that plays a well-identified role in
integrating the functions of diverse cell types within each tissue it invests
(e.g. skeletal muscle, tendon, bone, viscera (Langevin 2006)). CT is highly
variable in its presentation. Various terms are used to describe CT typology,
for example:
• Dense and loose are used to describe how dense, tightly or spread out the
fibers are packaged within an array of tissue
• Regular, irregular, unidirectional, multidirectional, parallel ordered and
woven are used to describe fiber orientation and configuration within a
particular sheet, layer or area of tissue (Terminologia Histologica 2008).
As CT is intimately associated with other tissues and organs it may
influence the normal or pathological processes in a wide variety of
organ systems (Findley et al. 2012).
CT, fascia and the sliding mechanism

One of the more recent discoveries in the world of fascia research is the
sliding/gliding that occurs throughout the CT and fascial systems, which
facilitates unimpeded, frictionless movement (McCombe et al. 2001,
Guimberteau & Bakhach 2006, Stecco et al. 2008, Wang et al. 2009). Some
suggest that sliding layers are interspersed between CT and fascial layers;
however, Guimberteau suggests that rather than separated or superimposed
layers there exists a singular, highly hydrated, tissular architecture which can
maintain the necessary space between structures to facilitate optimal sliding
and tissue excursion (Guimberteau & Bakhach 2006, Guimberteau 2012) –
see Figure 2.2.
Whether the presentation is layers between layers or a singular architecture,
the sliding mechanism comprises loose CT – consisting of predominantly
fine collagen strands, adipocytes and an abundance of HA.
The sliding mechanism occurs bodywide on both a macro and micro level;
between interfascial planes, endofascial fibers, endomuscular fibers and
intracellular fibers (Guimberteau et al. 2005, Ingber 2008, Stecco et al. 2008,
Wang et al. 2009, Langevin 2010). The impact of traumatic scarring on the
sliding mechanism and clinical considerations will be noted throughout this
book.
Figure 2.2
The delicate, well-hydrated, loose network of connective tissue that augments tissue excursion
and movement. The sliding mechanism/system comprises a continuous structure composed of
billions of microvacuolar components (polyhedron ‘bubbles’) that allow for structures to move
freely without anything else moving around them. Collagen and elastin fibrils form the
framework of the microvacuolar bubbles. (Reproduced from Guimberteau and Armstrong:
Architecture of Human Living Fascia, 2015, published by Handspring Publishing with kind
permission from Dr J-C Guimberteau & Endovivo Productions.)
Skin layers and Functions (Marieb et al. 2012)

The skin comprises two primary layers:
• Epidermis
• Dermis.
Epidermis
As thin as a sheet of paper, the epidermis is the tough, outermost layer of the
skin. Most of the cells in the epidermis are keratinocytes, which constitute
the first immune barrier, acting essentially as sentinels. Keratinocytes
produce the structural protein keratin, which supports the skin’s ability to
protect the rest of the body. Other cells include melanocytes and immune
cells (e.g. Langerhans and T-lymphocytes) (Adameyko et al. 2009, Sidgwick
& Bayat 2012, Bordoni & Zanier 2014).
The outermost portion of the epidermis is pretty much waterproof and helps
to keep most bacteria, viruses and other foreign substances from entering the
body. The epidermis, working in concert with the other skin layers, also
protects our internal organs, muscles, nerves, and blood vessels against
trauma.
Dermis
The dermis is made up of layers of fibrous and elastic fibers (collagen and
elastin). Collagen supports and stabilizes while elastin allows for stretch and
absorbs tensile forces – collagen and elastin will be covered in greater detail
further on in this chapter.
The dermis is often described as the workhorse of the skin because it
contains lymph vessels, nerve endings, sweat glands, sebaceous glands, hair
follicles, and blood vessels.
Nerve endings in skin sense pain, touch, pressure and temperature and relay
information to the brain (Kiernan & Rajakumar 2013, Bordoni & Zanier
2014). Mechanoreceptors in skin provide information on posture, positioning
and movement (Macefield 2005, Bordoni & Zanier 2014, Mouchnino &
Blouin 2013). As with all systems of the body, nerve receptors in skin and
fascia can evoke sympathetic nervous system (SNS) responses that can
impact each other and all the other systems.
The sweat glands produce sweat in response to heat and stress. Sweat is
composed mainly of water and salt. When sweat evaporates, it helps to cool
the body. There are specialized sweat glands in the armpits and the genital
region that secrete a thick, oily sweat that produces body odor when the
sweat is digested by the skin bacteria.
The sebaceous glands secrete oil called sebum into hair follicles. Sebum
keeps the skin moist and pliable and helps create a barrier against foreign
substances.
The hair follicles produce various types of hair found throughout the body.
Hair contributes to a person’s appearance, helps regulate body temperature,
provides protection from injury and enhances sensation. At the base of each
hair follicle are sensory nerve fibers that wrap around the hair bulb. Moving
or bending the hair stimulates the nerve endings, which allow a person to
feel their hair has been moved. A portion of the follicle also contains stem
cells capable of regenerating a damaged epidermis.
Functions of the skin: Summary

Collectively, the layers of the skin perform a variety of functions (Marieb
2003):
• The skin provides a protective barrier against microorganisms, pathogens,
most bacteria and viruses and protection from the elements (e.g. rain,
cold, heat)
• Thermoregulation is carried out through sweating and regulation of blood
flow
• The skin prevents fluid loss, distributes essential nutrients to the body and
provides a medium for absorption (e.g. the outermost layer of skin cells
are almost exclusively supplied by external oxygen, and various
medications or agents can be administered topically)
• Salts and small amounts of wastes can be excreted through the skin (e.g.
ammonia and urea)
• The skin provides a storage reservoir for lipids and water and synthesizes
vitamin D
• The skin houses sensory receptors that provide information to the brain
pertaining to pain and movement perception, non-verbal communication
and convey indicators of state of well-being and health (e.g. mood,
emotions and pigmentation changes – as is seen with jaundice).
The number of sweat glands, nerve endings, sebaceous glands, hair follicles
and blood vessels vary throughout the body. These variations serve a
functional role; for example, the palms of our hands have less hair than the
top of our head. As the head is generally more exposed, hair can provide
warmth and UV protection. Another example would be the concentration of
sensory nerve endings – a high concentration is found on the fingertips to
assist with dexterity (Marieb 2003).
Fascia Structure and Functions

In the field of MT, the terms fascia and myofascia are commonly used to
describe the various tissues that play a significant role in locomotion
(Chaitow 1980, Schleip et al. 2012a).
In human biological sciences the skin and CT proper have been studied in
great detail; however, fascia has been largely unconsidered. Historically,
fascia has been viewed as an inert shaping and binding tissue. More recent
research has shown that fascia plays a significant role in human locomotion
and may be a source of soft-tissue pain and dysfunction.
The fascial system is now recognized as a pain-generating tissue and

significant proprioceptive organ (Mitchell & Schmidt 1977, Yahia et al.
1992, Schleip 2003, Stecco et al. 2008, Benjamin 2009, Taguchi et al.
2009, van der Wal 2009, Findley et al. 2012)
Current (mainstream) protocols for assessment, treatment and recovery time

for ‘musculoskeletal’ issues (including scarring) do not take the fascia into
consideration. This oversight will be addressed throughout this book.
The International Fascia Research Congress (FRC) has been instrumental in
shedding light on this long overlooked tissue. The research presented at and
generated by this initiative provides the world of MT with some
foundational knowledge needed to work safely and effectively with the
impact of scars and burns on this tissue.
In order to better facilitate understanding of this section, the following key
terms/concepts are briefly described:
• What is fascia? Definitions vary; this book offers an amalgam of the most
current. Fascia is described as all fibrocollagenous CT whose morphology
is influenced by mechanical strain/tensional loading (Schleip et al. 2012a).
The term ‘fascia’ is inclusive of various presentations (e.g. dense and
loose) that are innervated, vascularized and continuous (fascia envelops
and invests all other soft tissues, bones, nerves, circulatory vessels and
organs), functioning as an organ of stability and locomotion (Findley &
Schleip 2007, Schleip et al. 2012a, Kumka & Bonar 2012). Fascia can
present in many forms depending upon its location, density, fiber
orientation or configuration, required role and relationship with other
structures or tissues (Terminologia Histologica 2008). Different terms are
used to describe more accurately fascia’s various histological, mechanical,
topographical and functional properties (e.g. epimysium, perineurium,
periosteum, aponeuroses, retinaculae, viscera membranes) (Langevin &
Huijing 2009, Schleip et al. 2012a). Although in the world of fascia there
is much debate, it is universally agreed upon that fascia’s fundamental
characteristic is its continuity – an uninterrupted, viscoelastic network that
three-dimensionally envelops and invests all structures of the body from
head to toe (Chaudhry et al. 2008, Grinnell 2008, Benjamin 2009, Stecco
& Stecco 2009, van der Wal 2009, Schleip et al. 2012a). Fascia is a highly
innervated tissue and is considered to be the most extensive
mechanosensitive organ in the human body (Benjamin 2009, Hoheisel et
al. 2011, Schleip et al. 2012a).
• Viscoelasticity: a viscoelastic material (e.g. collagen) can both resist strain
or deformation and return to its original state following deformation. The
viscoelastic nature of fascial collagen provides a means by which this
tissue can be both mobile (elastic) and supportive (firm/more viscous) at
the same time. Fascia is the only tissue that can instantly change its
property in response to demand (e.g. mechanical strain). Fascia’s
viscoelastic properties can be rapidly modified by shifting its fluid
dynamics; this is mediated by the nervous and vascular systems and
specialized cells within fascia (e.g. fibroblasts and MFBs) (Klingler et al.
2004, Barnes 1997, Pischinger 1991, Reed et al. 2010).
The viscoelastic nature of fascia can only be observed in hydrated
tissue, which underscores the importance of adequate hydration and the
potential pathophysiological consequences of dehydration.
• Locomotor system (Chaitow 1980): constitutes the bones, joints, capsules,

ligaments, fasciae, aponeuroses and all the tissues surrounding and
investing skeletal muscles and their tendinous expansions. So as to aid
functional understanding, Myers (2014) subdivides the tissues of the
locomotor system into outer and inner layers. The outer constitutes the
myofascial layer that surrounds and invests the 600 or so muscles in the
human body. The inner layer consists of joint capsules, ligaments and
periostea. The outer and inner layers are not segregated but are a
continuous, organized network that serves to augment force transmission
and regulate movement.
• Force transmission: collectively, muscle fibers/bundles and the collagen-
rich intramuscular CT (myofascial envelopes) are now appearing (as a
unit) to be functionally significant with regard to force transmission. A
significant proportion of muscular force is simultaneously transmitted
multidirectionally (e.g. obliquely, laterally, linearly) in a shearing fashion
onto adjacent fascia and associated muscular synergists and antagonists
(Huijing 2007, 2009, Maas & Huijing 2009, van der Wal 2009, Maas &
Sandercock 2010).
• Biotensegrity or tensegrity (Myers 2014, Chaitow 2011, Levin & Martin
2012): fascia, considered a biotensegrity system, displays a particular
bioarchitecture composed of two primary elements – compressional and
tensional.
• Compressional: described as struts, non-continuous structures that
exhibit the fundamental behavior of resisting compression (bones).
• Tensional: described as bands or sheets, continuous tissues capable of
transferring forces across the vast network of all other bands/sheets
(fascia) (Fuller 1961, Kumka & Bonar 2012).
Although each element exhibits a fundamental behavior, compression
and tensional properties co-exist in bones and fascia such that structural
integrity is maintained by continuous balance of tension and
compression forces. The ability to support (resist compression) and
share the load (distribute/transfer forces) is seen on a macro (bodywide)
and micro (ECM and cellular) level (Ingber 2008, Levin & Martin
2012). In a biotensegrity system, loading of one segment of the
structure effects the whole. It is with this concept in mind that
bodywork and movement modalities are considered most effective
when considered and applied globally in addition to locally.
Biotensegrity properties and functional capabilities differ in healthy
verses unhealthy tissues (Levin & Martin 2012).
• Myokinetic/myofascial chains or meridians: terms used to describe a
grouping or sequence of tissues/structures – structurally and
neurologically linked together to support functional and perceptive
continuity. According to Richter (2012), ‘the locomotor system is to be
considered one continuous unit that functions as a whole’. The linkage
of various tissues and structures is supported by the work and/or
research of many (for example Benjamin, Busquet, Cantu, Huijing,
Ingber, Kabat, Mass and Sundercock, Mazieres, Myers, Pilat, Rolf,
Stecco and van der Wal) and is well illustrated in Myers’ Anatomy
Trains (2014) and in Stecco’s Fascial Manipulation for
Musculoskeletal Pain (Stecco 2004) and Fascial Manipulation - the
Practical Part (Stecco & Stecco 2009).
Pain referral patterns associated with myofascial trigger points will
sometimes distribute along the myokinetic or myofascial chain
associated with the involved muscle.
Histology
Fascia comprises:
• ECM (covered previously)
• Cells
• Fibrous proteins.
Cells
The most prominent cellular components of fascia include:
• Mast cells and macrophages
• Adipocytes
• Fibroblasts.
Mast cells and macrophages play a role in wound repair and immune
response.
Adipocytes play a role in heat preservation, storage, protection from
physical trauma and also serve as a ‘spacer’ separating adjacent layers of
fascia (Stecco et al. 2008).
Fibroblasts, the predominant cell type, are highly adaptable and noted for
their ability to:
– remodel in response to mechanical strain
– produce biochemical responses, and
– differentiate into various cell types (e.g. myofibroblasts) (Eagen et al.
2007, Mammoto & Ingber 2009, Stecco et al. 2009, Meltzer et al.
2009).
Fibroblasts synthesize the components of the ECM and play a significant
role in soft-tissue remodeling.
Changes in fibroblast shape and subsequently function occurs in
response to a variety of signals, including mechanically applied tension
or strain (Eagen et al. 2007, Mammoto & Ingber 2009, Stecco et al.
2009, Meltzer et al. 2009). This feature of fibroblasts enables fascia to
alter its fiber configuration in response to mechanical demands or
stress placed upon it (e.g. movement, exercise, posture, work-related
activities). Additionally, this provides a plausible explanation for the
mechanism by which fascial specific therapies (e.g. structural
integration/Rolfing, myofascial massage and acupuncture) produce
therapeutic results (Langevin et al. 2004).
Manual therapy techniques treat the fascial layers by altering density,

tonus, viscosity and the arrangement of fascia (Findley et al. 2012).
Myofibroblasts (MFBs): differentiation of fibroblasts into MFBs is triggered

in response to mechanical strain/tensional loading and certain cytokines (e.g.
transforming growth factor beta-1; TGF-β1). MFBs play an important role in
inflammation, remodeling and fibrosis (Cathie 1974, Powell et al. 1999,
Tomasek et al. 2002, Hinz & Gabbiani 2003, Schleip et al. 2007,
Nekouzadeh et al. 2008, Hinz 2013).
Fascia plays a significant role in conveying mechanical tension, in

order to control an inflammatory environment (Bordoni & Zanier
2014).
Transforming growth factor beta-1 (TGF-β1) is known to stimulate
collagen synthesis and proliferation. Collagen is the predominant fiber
found in fascia and the predominant type of fiber laid-down during
soft-tissue repair/remodeling – more on this in Chapter 5.
MFBs can contract in a smooth muscle-like manner providing fascia with
contractile capabilities independent of muscle contraction (Spector 2002,
Schleip et al. 2005, Schleip et al. 2006).
MFB contraction plays a major role in wound healing/remodeling,
pathological fascial contractures and fibrosis (e.g. Dupuytren disease, plantar
fibromatosis, frozen shoulder, ChLBP and abnormal scar formation)
(Gabbiani 2003, Langevin et al. 2009). Therefore higher than normal
concentrations of MFBs are typically present in injured or traumatized
fascia.
The presence of higher than normal concentration of MFBs in injured

and scarred fascia further accentuates its ability to contract/influence
tension (e.g. contractures, fibrosis) resulting in subsequent pain and
dysfunction.
It is suggested that MFBs also play a role in issues associated with decreased
myofascial tension or hypermobility (e.g. peri-partum pelvic pain due to
pelvic instability, sacroiliac joint force closure dysfunction or back pain due
to spinal segmental instability) (Schleip et al. 2012).
MFBs are also present in normal healthy fascia implying a valid –
homeostatic –functional purpose (Wilson & Dahners 1988, Murray &
Spector 1999, Ralphs et al. 2002). For example, MFBs provide fascia with
the ability to remodel itself in response to normal daily movement and
activity demands (adaptation). Recall from page 12: fibrocollagenous tissue
morphology is shaped by tensional loading. Demand (mechanical/tensile
forces) invokes MFB proliferation and therefore (normally) higher
concentrations of MFBs are typically present in dense presentations of fascia
commonly subjected to higher tensional demands (e.g. those that play a
significant role in stability and support, fascia lata, plantar, crural and
thoroacolumbar fascia, perimysium).
Biomechanically, interactions between MFBs and the ECM contribute to
whole body mobility and tensional integrity or biotensegrity (Schleip et al.
2005, Guimberteau 2007, Ingber 2008, Levin & Martin 2012).
Fibrous Proteins
Fascia is constructed from two predominant fiber types:
• Collagen
• Elastin.
Collagen
Collagen is the most abundant fiber type found throughout fascia. Various
types of collagen occur in the human body (Type I is the most predominant)
(Gelse et al. 2003, Gartner & Hiatt 2007, Gordon & Hahn 2010, Ross &
Pawlina 2011, Kumka & Bonar 2012).
Collagen cross-linking, a chemical bond between adjacent collagen fibers,
plays a significant role in tissue integrity. Physiological linkage augments
mechanical stability, however excessive (pathological) cross-links can
interfere with slide potential and contribute to mobility restrictions.
Conversely, insufficient or unstable bonds can result in diminished tissue
integrity.
Collagen provides tensile strength, guards against over extension and can
‘store and release’ energy (can store and release an equal amount of energy
while stretching only 100th the amount of elastin) (Zorn 2011). This is often
referred to as catapult or rebound effect. Collagen fibers are somewhat firm
yet pliant and able to yield to force (e.g. they can bend, twist and lengthen).
Collagen’s elastic-stiffening potential (viscoelastic property) is considered to
be one of its defining features (Zorn & Hodeck 2011). Normal healthy
collagen fibers display a distinctive ‘wavy/crimped’ formation which factors
into normal healthy functioning (e.g. force transmission and energy
facilitation).
Adequate hydration is vital to collagen health and functioning. Dehydration
has been identified as an initiator of inflammatory response in collagen and
once present, inflammatory mediators can contribute to tension held in
collagenous tissues (e.g. skin and fascia). As previously noted, dehydration
also decreases the fluid-bulk of GS which can result in pathological collagen
cross linking, diminished lubrication and reduced tensile strength.
Type I collagen is the fiber type typically laiddown during tissue remodeling.
Under healthy normal circumstances, collagen turnover (reconstruction
phase of healing) lasts from 300 to 500 days, meaning it takes that length of
time for collagen to fully mature – an important consideration in post-trauma
recovery and rehabilitation (van den Berg 2010).
Kumka and Bonar (2012) note that if function changes (e.g. increased
mechanical strain, insufficient mechanical strain or prolonged
immobilization), pro-collagen in the fibroblasts will change types (e.g.,
collagen type I into collagen type III), or undifferentiated cell types may
adapt towards a more functionally appropriate lineage (e.g. chondrocyte)
(Benjamin & Ralphs, 1998, Bank et al. 1999, Jarvinen et al. 2002, Milz et al.
2005, Mammoto & Ingber 2009). Therefore, a tissue that is exposed to
unusual demand may remodel into a form or presentation that is atypical to
its fundamental nature.
Significant compression can ultimately culminate in tissues changing

their morphology (e.g. tissue that was once populated with fibroblasts,
becomes invested predominately with chondrocytes – forming
cartilage, along with its mineral deposition (Benjamin & Ralphs 1998,
Bank et al. 1999). These adaptations have been demonstrated in the
supraspinatus tendon (aka calcific tendonitis), transverse acetabular
ligament, transverse ligament of atlas, as well as various other
ligaments and tendons throughout the body (Bank et al. 1999, Milz et
al. 2005). What once was pliant mobile tissue exhibits entirely different
functional capabilities and palpable feel (Kumka & Bonar 2012). Here
we can envision the potential for unfavourable outcomes as a result of
improperly stimulated tissue during the repair/remodeling stage of
healing.
Timing is everything – more on this in Chapter 05.
Elastin
Elastin, which are stretchy, rubber-like fibers, vary in prevalence and amount
throughout skin and fascia depending upon functional demand. Elastin fibers
tend to branch, creating a net-like architecture (Van den Berg 2012). When
placed under tensional force, these fibers lengthen and when the force is
removed they enable tissue to return to its normal, resting length. When
dehydrated, elastin becomes brittle but when well hydrated it is elastic and
flexible. Elastin fibers can be stretched up to 150% their resting length
without causing any injury (20 to 30 times more than collagen can
withstand) and like collagen can store or release energy. When placed under
sustained stretch-demand, elastin has been shown to lose some of its recoil
potential.
Within the tissues of the locomotor system, collagen and elastin are often
intertwined.
Fascia Layers and Functions

Fascia taxonomy varies almost as widely as fascia itself. Which is likely
why (at least in part) at the FRC 3 in 2012, Dr Paul Standley proclaimed,
‘We need a Rosetta Stone of manual therapy.’
In an attempt to simplify functional understanding and create a conceptual
visual, favoring relevance to MT, this book will briefly cover two of the
most current classification systems: Willard’s (2012a, 2012b) layer/structural
classification system and Kumka and Bonar’s (2012) functional
classification system.
Layer Classification
Willard (2012a) suggests four primary categories: superficial/panniculus
(loose), deep/axial (investing), meningeal and visceral (Swanson 2013).
Only the superficial and axial layers will be covered in more detail – as the
techniques covered in subsequent chapter predominantly target the
superficial and deep fascial layers. The meningeal layer will be covered (in
some detail) in Chapter 4, the visceral layer will not be covered in much
detail in this book. For more information on visceral work please see the
recommended references and reading suggestions provided at the end of the
chapter.
Superficial/panniculus fascia (SF)

Although not a universally accepted term, in many textbooks superficial
fascia is used to describe the subcutaneous loose CT layer (Platzer 2008,
Standring 2008, Netter 2011, Tank 2012).
Continuous with the dermis, the SF lies directly beneath the skin, supporting
the skin’s structural integrity. Essentially, the SF surrounds the entire torso
and the extremities and mostly comprises loose CT and adipocytes.
According to Langevin and colleagues (Langevin et al. 2009), there are two
typical presentations of SF:
• Loose/areolar CT often embedded with adipocytes
• A fine mesh of dense irregular CT with areolar CT and adipocytes within
the mesh.
There is often an abundance of elastin fibers in SF which augments its recoil
capabilities (i.e. its ability to expand and return to its previous state). The SF
is the intermediary between the skin and the deep fascia – interspersed
sliding layers allow for independent motion of the various layers (e.g. skin,
superficial and deep fascia).
The SF serves as an insulator, a reservoir for fat storage, and provides a
passageway for larger nerves, blood and lymphatic vessels. The SF supports
the patency (openness) of these passageways (i.e. neurovascular tracts) and
the neurovascular structures within (Stecco et al. 2009). Many nerves track
through the SF and Pacinian corpuscles (i.e. deep pressure receptors) and
nociceptors are found within it.
Superficial and deep layers of the thoracolumbar fascia may be a
source of nociceptive input in low back pain (Yahia et al. 1992, Bednar
et al. 1995, Taguchi et al. 2009, Tesarz et al. 2011).
Figure 2.3
Fascial membranes and rentinacula cutis fibers. Cross-section from the skin to musculature,
showing fascial membranes and retinacula cutis fibers (RCF). (Adapted from Stecco et al.
2013.)
Retinacula cutis fibers (RCF)

Fibrous strands that invest and are continuous throughout the skin,
superficial and deep fasciae layers. RCF play a role in tissue connectivity
and mobility.
When thickened, as a result of injury or trauma, these vertical septa can
restrict and impact function. Any undue ‘tugging’ of bound tissue (e.g.
during ‘normal’ movement) can lead to hypersensitization and
consequent pain (Stecco 2004, 2009, Muscolino 2012).
Deep/axial fascia (DF)

Deeper scars (e.g. following surgery or due to penetrating puncture wounds)
will impact the deep fascia layer and, potentially, the underlying muscular
fascia (epi, peri and endomysium).
Generally speaking, DF presents throughout the body as a multilayer
organization, typically 2–3 dense collagen bundle layers interspersed with
loose CT layers that contain collagen, adipocytes and are rich in HA. The
dense layers serve to augment force transmission and the loose layers
augment slide/glide.
In each dense layer the collagen bundles are arranged in parallel with
adjacent (above or below) layers arranged at a 78° angle to one another. This
configuration (interspersed with sliding layers) allows for multidirectional
movement and the ability of fascia to counter/resist tension
multidirectionally (see Fig. 2.4).
DF displays some distinct regional differences:
Figure 2.4
The multilayer organization of deep axial fascia (DF). (Adapted from Stecco C et al. 2009.)
• Trunk/torso: the superficial layer of the DF is thinner than that found in

the limbs (except for the thoracolumbar fascia – TLF). In some areas this
thin layer envelops the underlying muscles (meaning there is no distinct
epimysium). This presentation is seen in conjunction with the pectoralis
major, latissimus dorsi, trapezius, deltoid and gluteus maximus and
functionally serves as a means to connect the limbs to the trunk/torso. In
this presentation the fascia and muscles move (or not) together (hence the
greater potential for undifferentiated movement patterns in the
trunk/torso).
• Limbs: in general the DF of the limbs is not very elastic, although the
upper limb contains more elastin than the lower (providing greater tissue
compliance or a wider range of movement). In the limbs there is a sliding
layer between the DF and underlying epimysium. The DF and underlying
muscles can therefore move independently of one another and when they
do not – pain/dysfunction often ensue. This particular presentation
supports force transmission and perhaps the greater variety of movement
potential seen in the limbs (in comparison to the trunk/torso) (Stecco et al.
2008, Stecco et al. 2011).
Functional Classification
According to Kumka and Bonar (2012), the functional properties of fascia
are reliant on the composition of the ECM, specific cells and filaments,
including but not limited to the ratio of collagen types.
Kumka and Bonar (2012) suggest four primary functional categories:
linking; fascicular; compression; and separating (see Table 2.2).
Linking
Linking fascia is sub-divided into dynamic and passive components:
• Dynamic fascia can contract autonomously (embedded with MFBs) and
plays a role in locomotion, force transmission and biotensegrity.
• Passive fascia displays noci and proprioceptive capabilities and can only
transmit forces when it is stretched/loaded.
• Linking fascias play a primary role in augmenting bodywide functional
and perceptive continuity.
Classification Functional role and examples

Linking Connects various tissues/structure for the purpose of augmenting bodywide functional and
perceptive continuity. Dynamic presentation can contract autonomously and plays a role
in locomotion, force transmission and biotensegrity. Passive presentation displays noci
and proprioceptive capabilities and can only transmit forces when it is stretched or loaded.
Examples include tendon, ligament, retinaculae and aponeuroses. Note: some forms of
linking fascia facilitate energy generation and/or storage
Fascicular Augments continuity and force transmission, provides proprioceptive feedback and
protection of nerve, blood vascular and lymph vessels. Examples include vascular tunics,
neurofascia and myofascia
Compression Forms a pressurized compartment to augment vascular function and enhances
proprioception, muscular efficiency and coordination. Examples include compartments
such as in the lower leg
Separating Provides structural support, helps absorb shock, limits the spread of infection and creates
space which reduces friction and augments slide/glide between articulating
structures/surfaces. Examples include the loose/well-hydrated sliding layers
Table 2.2
Summary of fascia’s functional classifications and roles
Fascicular
Fascicular fascia augments continuity and force transmission, provides
proprioceptive feedback and protection of nerve, blood vascular and lymph
vessels.
Perimysium plays a significant role in force transmission. Perimysium
is commonly thicker in postural muscles, tends to display a higher
concentration of MFBs and can adapt more readily to changes in
mechanical tension. The driving force behind long-term, sustained
contracture and pronounced muscular ‘stiffness’ could be explained in
part by the presence of MFBs in fascia – in particular in the
perimysium. Surgical reconstruction processes (e.g. distraction
osteogenesis, psoas lengthening) are frequently accompanied by
increased muscle stiffness, shown to correlate with a significant
increase in perimysial thickness – a response to the (sudden) increased
tissue stretch (Schleip et al. 2005, Huijing 2007).
Muscle spindles are embedded in the endomysium. If the enveloping

fascia is too rigid (e.g. fibrosis, contracture), this may alter the stretch
of the muscle spindle and adversely affect its normal firing (Stecco
2004).
Compression
Compression fascia forms a pressurized compartment to augment vascular
function (e.g. venous return) and enhances proprioception, muscular
efficiency and coordination.
Separating
Separating fascia provides structural support, helps absorb shock, limits the
spread of infection and reduces friction and augments movement between
articulating structures and surfaces. The loose well-hydrated sliding layers
also fall into this category.
Functions of Fascia: Summary

Fascia physiology in brief: as a component of the locomotor system, fascia
performs essentially three mechanical functional roles: separation,
connection and energy facilitation.
Fascia as a tissue of separation: creates space which serves as an interface
for ease of sliding and gliding of structures and tissues in relation to one
another. Spatial separation supports unimpeded motion and motion
ensures the healthy functioning of tissues and structures and the sliding–
gliding interface.
Fascia as a tissue of connection: links together various anatomical
components (bones, joints, muscles etc.) thereby creating an architecture
that augments the transfer of forces across a broader array of
tissues/structures. Connection enhances strength, stability and efficient
coordinated movement. Bodywide perceptive and functional continuity
affords linked tissues the ability to function and, potentially, dysfunction
together.
Fascia as an energy facilitator: healthy, springy or crimped collagen is a
potential energy generator or storehouse rather than an energy consumer,
such as muscle. When stretched, collagen will rebound, augmenting
propulsion (especially flatter, sheet-like fascia and tendons, e.g. Achilles
tendon and Achilles aponeurosis) (Schleip & Müller 2013). Ultrasound-
based measurements indicate that fascial tissues are commonly used for a
dynamic energy storage (catapult action) during oscillatory movements,
such as walking, hopping or running, and during such movements the
supporting skeletal muscles contract more isometrically while the loaded
fascial elements lengthen and shorten like elastic springs (Fukunaga et al.
2002). The rebound/catapult potential of fascia decreases the need for
muscular energy – resulting in greater efficiency and endurance.
Myokinetic/Myofascial Chains and Meridians

The continuity seen throughout the fascial system is a key functional
characteristic. It is agreed upon by many that dysfunction (scarring,
densification, fibrosis) anywhere along the chain or meridian can impact
function in other regions.
When challenged by stretch or movement dense and/or restricted fascia may
alter proprioceptive afferent signals that lead to eventual abnormal
biomechanics, aberrant movement patterns, muscle compensation, joint
distress and pain (Bouffard et al. 2008).
In the absence of normal physiological elasticity, receptors embedded within
the fascia may also be in an active state even at rest. Any further stretching,
even that produced by normal muscular contraction, could cause excessive
stimulation with consequent propagation of nociceptive afferents.
Furthermore, over a certain threshold (i.e. consistent stimulus over time), all
receptors can potentially become algoceptors (pain receptors) in response to
consequent propagation of nociceptive signals (Ryan 2011).
Chain/meridian clinical considerations will be covered in greater detail in
Chapter 9.
Fascia supports and functions in tandem with our skin and all of our
soft and hard tissues. Therefore it is reasonable to suppose that some
degree of fascial involvement may be seen in conjunction with any
functional loss and pain associated with scarring – as well as the milieu
of compensatory musculoskeletal disorders that often accompany burns
and problematic scars (e.g. cumulative trauma/overuse syndromes,
chronic low back pain (ChLBP) and/or dysfunction and compression
syndromes). In the field of MT we commonly encounter fascial
changes associated with acute injury and trauma, chronic strain
(physical or emotional), immobilization and the spectrum of
subsequent sequelae (e.g. adhesions, fibrosis, myofascial trigger points,
diminished gliding within the sliding layers, neural and circulatory
consequences).
According to Lewit and Olsanska (2004), scars may contribute to the
formation of myofascial trigger points in adjacent tissues along with
the potential for pain in other regions (e.g. low back pain associated
with appendectomy).
As the impact of a scar can reach far beyond its physical borders, in addition
to the degree or depth of the scar – from a MT perspective – it is also
important to consider how a scar in one region of the body can impact
functioning in distant (seemingly unrelated) tissues or areas.
According to Bordoni and Zanier (2014):
Every element or cell in the human body produces substances that

communicate and respond in an autocrine or paracrine mode,
consequently affecting organs and structures that are seemingly far
from each other. This applies to the skin and subcutaneous fasciae.
When the integrity of the skin has been altered, or when its healing
process is disturbed, it becomes a source of symptoms that are not
merely cutaneous. Additionally, the subcutaneous fasciae is altered
when there is a discontinuous cutaneous surface. The consequence is
an ample symptomatology, which is not limited to the body area where
the scar is located.
In this light it is also prudent to consider the impact of scarring on the

circulatory, lymphatic and neural structures servicing and travelling
throughout the skin and fascia.
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Resources and Further Reading
Barral Institute: http://www.barralinstitute.com/
Charter Society of Physiotherapy: http://www.csp.org.uk/events/manual-therapy-abdominal-viscera
Upledger Institute: http://www.upledger.com/
CHAPTER 3
The lymphatic system

‘Milk me’
Client statement upon entering the clinic room ready for her second
Manual Lymph Drainage session
The lymphatic system is a lesser known yet important system of the body that
chugs along, quietly assisting the blood vascular and immune systems. In brief,
it is a low pressure, pump-less system that transports lymphatic fluid (lymph).
Lymph is formed in the digestive system and is taken up by the specialized
lymph vessels known as lacteals (Choi et al. 2012). When functioning
normally, it is the squeeze–release action of the skeletal muscles and the
changes in pressure during breathing that pushes or ‘milks’ the lymph toward
its destination (Marieb 2003).
While the blood vascular system has been studied extensively, the lymphatic
system has had little scientific and medical attention, likely due to its elusive
morphology and mysterious pathophysiology. Over the past decade a number of
new studies have begun to change the misconception that the lymphatic system
is secondary to the more essential blood vascular system and, indeed,
substantiate the view that the lymphatic system is an integral and equal partner
in supporting homeostasis, immunity, and wound healing (Choi et al. 2012).
Utilizing the information that is currently available, the aim of this chapter is to
provide a solid understanding of the lymphatic system. Particular relevance to
this book is the lymphatic system’s role in creating a favorable environment for
wound healing and healthy scar formation and the consequences associated
with impaired lymphatic function (Marieb 2003).
Discovery of the Lymphatic System
The lymphatic system has been documented since early recorded history:
• Hippocrates (460–377 BC) talked about vessels containing ‘white blood’
• Aristotle (384–322 BC) described vessels containing a ‘colorless fluid’, or
‘white blood’
• The French anatomist Marie Sappey (1810– 1890) used subcutaneous
mercury injections to graphically represent the anatomy of the lymphatic
system.
Hippocrates spoke of white blood cells, introduced the term chyle and defined a
lymphatic temperament (Chikly 2002). Chyle – a milky-colored fluid – consists
of lymph, emulsified fats and free fatty acids.
In 1627 Gasparo Aselli discovered lymphatic vessels, calling them lacteae
venae, or milky veins. In 1652 Thomas Bartholin, a Danish physician and
anatomist, called the vessels vasa lymphatica and is credited with giving the
lymphatic system its name.
Early comprehensive study of the intricate and complex lymphatic system
began at the beginning of the twentieth century but slowed significantly
because of the lack of specific lymphatic markers, and the histogenetic origin of
lymphatic vessels remains a controversial issue (Oliver & Detmar 2002).
The most accepted understanding of the development of the lymphatic system
was put forth by Dr Florence Sabin in the early twentieth century (Sabin 1902,
Sabin 1904). Sabin injected ink into the lymphatic system of pig embryos and
cataloged the results. Sabin concluded that isolated primitive lymph sacs
originate from endothelial cells that bud from the veins during early
development. It was proposed that the two jugular lymph sacs developed in the
junction of the subclavian and anterior cardinal veins by endothelial budding
from the anterior cardinal veins (Sabin 1902, Sabin 1904). According to Sabin,
the remaining lymph sacs originate from the mesonephric vein and those in the
dorsomedial edge of the Wolffian bodies in the junction of the subclavian and
anterior cardinal veins. Sabin’s early findings have been validated through more
recent research (Wilting et al. 2003).
Lymphatic, Hematic and Immune Systems

The lymphatic, hematic (blood vascular) and immune systems play a shared
role in supporting homeostasis, defending the body against disease and helping
wound repair and healing.
Homeostasis is a continual balancing act of the body systems to provide a
‘steady state’ – an internal environment that is compatible with life. The two
liquid tissues, blood and lymph, have separate but interrelated functions in
maintaining this balance and function in tandem with the immune system to
protect the body against pathogens that could threaten the organism’s viability.
Only a brief overview of the hematic and immune systems will be provided in
this book as these systems are extensively studied and ample resources are
available.
Hematic System
The heart, blood vessels and blood constitute the main components of this
closed-loop system with the heart as its central pump.
The part of the hematic system that delivers blood to and from the lungs is
known as the pulmonary circulation, and the flow of blood throughout the rest
of the body is administered by the systemic circulation. The hematic system
plays an integral role in the removal of waste products associated with
metabolism and the transportation of gases (oxygen and carbon dioxide),
chemical substances (e.g. hormones, nutrients, salts), and cells that defend the
body. Additionally, this system helps regulate the body’s fluid and electrolyte
balance, pH and body temperature, and helps protect the body from infection
and loss of blood by the action of clotting.
As noted in Chapter 2, the hematic system plays an important role in wound
repair and healing. In the early stages of wound healing angiogenesis, the
formation of capillary-sized microvessels ensure the delivery of blood-borne
cells, nutrients and oxygen to areas undergoing remodeling.
Immune System
The immune system is a collection of cells (e.g. mast cells, macrophages,
neutrophils), tissues and organs (e.g. skin, bloodstream, lymph nodes, thymus,
spleen, mucosal tissue) with the skin constituting the first ‘line-of-defense’.
All immune cells originate from precursors in the bone marrow and develop
through a series of changes that occur in various tissues and organs.
Immune response protects the body against pathogens that could threaten the
organism’s viability. As noted in Chapter 2, the immune system plays an
important role in wound repair/healing.
Lymphatic System Structure and Function

The lymphatic system consists of fluid (lymph) and structural components
(vessels, tissues, nodes, organs) (Marieb 2003).
Lymph
When the interstitial fluid enters the lymphatic system, it is termed lymph.
Lymph is generally clear and transparent, or milky in appearance when
emulsified fats are present (chyle) (Zuther 2011). Before returning to the blood
vascular system, lymph travels through a successive number of lymph nodes,
which filter out impurities.
Lymphatic Vessels (Chikly 2002, Zuther 2011)

The lymphatic system develops in parallel with the blood vascular system.
Lymphatic vessels are typically not present in avascular structures such as
epidermis, hair, nails, cartilage and cornea, nor in some vascularized organs
such as brain and retina (Oliver & Detmar 2002).
The general structure of lymphatic vessels is similar to that of blood vascular
vessels presenting in various sizes (lymph capillaries, lymphatic collectors).
Additionally, larger lymphatic vessels are trilaminar:
• Tunica intima: the innermost layer consists of endothelial cells and is
equipped with valves that direct the flow of lymph, preventing back flow.
• Tunica media: the intermediate layer consists of smooth muscle and elastin.
• Tunica adventitia: the outermost layer consists of collagen and elastin.
Lying on the exterior surface of the adventitia are the vasa vasorum, a petite
collection of arteries, veins, lymphatics and nerves that service the vessels
themselves.
Nerves, blood vascular and lymphatic vessels are wrapped in layers of

connective tissue (CT) or fascia – considered to be a form of CT. Recent
studies indicate that CT can dynamically regulate its tension (Langevin et
al. 2013) suggesting that changes in tissue tension could affect the
functioning of the surrounding enveloped structures. Releasing undue
tension may improve neural function and fluid flow.
Lymphatic vessels contain more valves and more frequent anastomoses than
blood circulatory vessels, thereby reducing back flow and creating an
extensive, connected network of tubes (Marieb 2003, Macdonald et al. 2008).
The smaller, thin-walled lymph capillaries are slightly larger than those seen in
the blood vascular system. Unlike the tightly joined endothelial cells lining
blood vascular capillaries, lymph capillary endothelial cells loosely overlap,
augmenting porosity thereby facilitating the collection of larger molecules.
Afferent lymphatic vessels: carry unfiltered lymph into the nodes, where
waste products and some of the fluid is filtered out.
Efferent lymphatic vessels: carry the filtered lymph out of the node to
continue its return to the circulatory system.
Lymph Nodes
The lymph node (see Fig. 3.2) is part of the many types of lymphoid organs in
the body. There are between 600 and 700 lymph nodes present in the average
human body. It is the role of these nodes to filter the lymph before it can be
returned to the circulatory system. Although these nodes can increase or
decrease in size throughout life, any nodes that have been damaged or
destroyed do not regenerate.
Lymph nodes contain macrophages that destroy bacteria, viruses and other
substances before the lymph is returned to the blood vascular system (Marieb
2003).

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CHAPTER 1

Evidence to support the use of scar massage is inconclusive. There is

In order to improve the position of MT as a viable treatment consideration

Patient Oriented Evidence (POE) asks the important question; ‘Does

What Defines Traumatic Scarring?

pathophysiological scars further compounded by traumatic emotional

The views expressed in these pages are founded on the result of

Skin and fascia

The delivery of safe and effective scar tissue management requires an

Skin and Fascia: Overview

ECM Examples and function

• *Ground substance (GS)

Vitamin C has been identified as an important component in the

Abnormal or pathological cross-links, instigated by various

In addition to tissue dehydration seen with trauma, our water volume

Age-related changes seen in fascia show some similar characteristics to

CT, fascia and the sliding mechanism

Skin layers and Functions (Marieb et al. 2012)

Functions of the skin: Summary

Fascia Structure and Functions

The fascial system is now recognized as a pain-generating tissue and

Current (mainstream) protocols for assessment, treatment and recovery time

• Locomotor system (Chaitow 1980): constitutes the bones, joints, capsules,

Manual therapy techniques treat the fascial layers by altering density,

Myofibroblasts (MFBs): differentiation of fibroblasts into MFBs is triggered

Fascia plays a significant role in conveying mechanical tension, in

The presence of higher than normal concentration of MFBs in injured

Significant compression can ultimately culminate in tissues changing

Fascia Layers and Functions

Superficial/panniculus fascia (SF)

Retinacula cutis fibers (RCF)

Deep/axial fascia (DF)

• Trunk/torso: the superficial layer of the DF is thinner than that found in

Classification Functional role and examples

Muscle spindles are embedded in the endomysium. If the enveloping

Functions of Fascia: Summary

Myokinetic/Myofascial Chains and Meridians

Every element or cell in the human body produces substances that

In this light it is also prudent to consider the impact of scarring on the

The lymphatic system

Lymphatic, Hematic and Immune Systems

Lymphatic System Structure and Function

Lymphatic Vessels (Chikly 2002, Zuther 2011)

Nerves, blood vascular and lymphatic vessels are wrapped in layers of

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