When we think of pain, it is usually in connection with injury, accident or some kind of physical trauma. These are acute conditions that require a medical diagnosis and treatment. There are other pains which have a gradual onset (chronic) and develop because of our inefficient ways of standing and moving in the gravity. Common chronic pains and dysfunctions (lower back pain, neck pain, carpal tunnel syndrome, rotator cuff tendinitis,tennis elbow, golfer’s elbow, piriformis syndrome, knee pain, fibromyalgia) are poorly understood conditions causing disability, loss of vitality and loss of productive time in the work force. In this article we want to investigate the pathophysiological mechanisms leading to chronic myofascial pain. ANATOMY OF THE FASCIA All the structures of the body , muscles, bones, joints, nerves, blood vessels and organs, are embedded in a matrix of soft connective tissue called fascia. The fascial sheet protects all these body components from direct abrasion by surrounding structures and provides a pathway through which neurovascular bundles can easily penetrate. Fascia is a continuos network throughout the whole body. There are 4 primary fascial layers: 1) superficial fascia is mainly composed of loose connective tissue and fat and surrounds the entire torso and the extremities except over the orifices.

2) deep to the superficial layer is the deep fascia composed of denser and irregular connective tissue investing muscles, tendons, ligaments, aponeurosis, bones and joint capsule. The soft connective tissue associated with the muscles can be referred to as muscle fasciae (myofasciae).

Each individual muscle is surrounded by epymisium, a layer that is continuous with the tendons attaching to the periosteum, the connective tissue investing the bone. The perimysium is a continuous network dividing the muscle into muscle fiber bundles. Within each bundle, the endomysium is a continuous web of connective tissue that separates individual muscle fibers. chronic myofascial pain 3) meningeal fascia which surrounds the nervous system. chronic myofascial pain 4) visceral fascia surrounding the body cavities and packing around the organs. chronic myofascial pain chronic myofascial pain FASCIA DYSFUNCTION AND ITS ROLE IN THE MYOFASCIAL PAIN As we have seen the muscle is structurally linked to the myofascial tissues. So dysfunctional myofascial structures can provoke dyfunctions in the activity of the muscles.Pathological cross-links in the intramuscular connective tissue (endomysium and perymisium) create an intramuscular shortening , that means that the local muscle fibers are in a persistent contraction condition (contraction knot). Pathological cross-links in the intermuscular connective tissue (epymisium) create intermuscular fascial adhesions that lead to restricted movement between adjacent muscles. Persistent contraction in local muscle fibers is a myofascial trigger point (mTrP). This permanent contraction requires more energy (ATP). Furthermore knots compress the local blood vessels and the reduced blood flow (local ischemia) causes a local oxygen deficit (hypoxia). These local biochemical changes will induce a local energy crisis that irritates the sensory receptors located in the myofascial tissues. This pattern of local irritation activates a basic sensorymotor response: the reflex arc. chronic myofascial pain The reflex arc is a nervous system device by which a muscular movement can be initiated by some change in the peripheral sensation. A simple example is the case of burning your finger. The input from the skin receptors is obviously increased suddenly! The reaction is immediate: muscular contraction to withdraw your hand from the source of burning pain. This is our basic defensive sensorymotor device. A local irritation in the myofascial tissues leads to more muscle contraction. That means more constricted blood circulation (local ischemia). A poor blood flow is the cause for the accumulation of metabolic wastes in the tissues and that means increased irritation and more emergency measures.

A local inflammatory process begins and it will lead to the formation of a connective tissue scar (like in the wound healing process) that means more collagen cross-links. A further shortening of the intramuscular connective tissues will prevent the decontraction of the local muscle fibers. This is the first stage of the myofascial chronification: a chronic pain cycle is activated! chronic myofascial pain All these disorders in the myofascial system don’t remain locally restricted but they spread globally in the fascial network. So myofasciae changes will affect the whole body movement patterns. Let’s now investigate the causes for pathological changes in the myofascial structures. FORCE OF GRAVITY As living beings we are continually in a dynamic relationship with the force of gravity. As we struggle to move in the gravity field, the fascial web adapts to support our movement patterns. chronic myofascial pain Myofasciae can thicken and increase its stiffness in some areas of the body in response to local tensions and microlesions in the muscles due to chronic myofascial pain All these factors can change the body fascial network. Any distortion in some area of the web will propagate through the whole body, much as a local strain in a sweater distorts the whole sweater! chronic myofascial pain Our unique overall pattern of distortions determines our unique body organization. Structure is the spatial relationship between the body segments. It’s the macroscopic organization of the whole fascial network. If the body structure is well organized, its various segments must be aligned one on the top of the other: pelvis, abdomen, chest and head balance easily when their centers of gravity are in line. chronic myofascial pain When the body structure is inefficiently organized, effort is required to resist the pull of gravity! That means that some muscles are working too much. This chronic overload will start a chain of local disorders in the myofascial tissues (described above) that ends in a chronic myofascial pain condition (Myofascial Pain Syndrome).

An effective treatment for chronic myofascial pain conditions must include a series of structural bodywork sessions for re-organizing the balance and the movement of human body in the gravity.

In our Chronic Pain Management programs at the Pakua Integrative Health Center, the therapeutic process focus also on visceral manipulation (Chi Nei Tsang and Karsai Nei Tsang) because the visceral fascia surrounding the organs is structurally linked to the myofascial tissues. It’s really important to explore and release all the organs tensions and restrictions especially in the therapeutic treatment of painful conditions which developed after some physical trauma (car accidents, fall on the back, see the article on “Trauma: a structural approach”). Structural balance is an important component of our integrative approach to health.

At Pakua Integrated Health center therapeutic bodywork well combines with our medical treatments based on Allophatic Medicine, Traditional Chinese Medicine and Energy Medicine in a comprehensive holistic approach to healing and well-being.

by Stefano Beconcini, MSc Physics, Therapeutic Bodywork, Pakua Integrative Health Clinic

sbeconcini@hotmail.com References: “Neuromuscular Therapy”, Jack Baker

“Myofascial pain and dysfunction”, Travell and Simons

“Trigger points as a fascia-related disorder”, Roland Gautschi, from the book “Fascia: the tensional network of human body”