Fascial Manipulation therapy in a treatment room at The Boxgrove Clinic
Fascial Manipulation

How Fascial Manipulation could help with Chronic Pain

Chronic pain is a hugely complex area to study. With so many different factors potentially involved – including one’s emotional state, beliefs about pain, complications from injury / illness / surgery / disease and many others it can be a mine field to unpick and treat it effectively.

But with the explosion of research into fascia over the past few years, several different authors have published papers that prove the fascia layers in our bodies are flooded with nerve endings for perception but also pain receptors that we didn’t know were there before. This is a complete game changer for us ‘hands-on’ therapists and will help us to treat our patients with chronic pain more effectively.

Although most, if not all, our pain feels like its deep in our muscles their research is showing that it could potentially come from any (or all) of three distinct areas in the body.

From superficial to deep these layers are:
1. The superficial fascia
2. The Deep muscular fascia
3. The muscle tissue itself

Looking at each layer in turn……

Superficial fascia (SF)
This is a layer of tissue that wraps around the whole body just under the skin – it is also known as subcutaneous tissue or the hypodermis.

In the areas of the body that have been tested so far it has been found to be the second most innervated tissue second only to the skin (Caterina Fede et al 2022: Innervation of the human superficial fascia).

It’s job is to perceive what’s happening from our inside whereas our skin perceives what’s happening from the outside environment. Interoception is the processes by which the body senses, interprets, integrates, and regulates signals from within itself, and includes sensations arising from connective tissue deep to the skin.

It is highly innervated with sensory nerves and nerves associated with our autonomic nervous system – to regulate our body’s heat via contraction / dilation of our blood vessels. This goes some way to explaining why even light touch or gentle hug for some people is so painful!

Deep muscular fascia (DMF)
The Deep muscular fascia (DMF) has direct attachment to the muscles – 38% up to 100% of our muscles start or finish in this fascia layer. The DMF’s roles include being a force transmitter from muscle pull, an energy storage system, it houses the cells that form scar tissue, and it regulates the flow of substances throughout the body.

The DMF has pain, stretch, pressure, hormone and cannabinoid receptors in it to help us perceive our bodies better and also to recognise how hard our muscles are pulling.

This layer can be affected a long way from where we actually feel our pain – patients that have tension of the DMF around the hip / low back regularly present to us with neck / shoulder pains and visa versa!

Muscle tissue
These muscles that all too often we are unable to relax usually respond well to massage and heat but sadly with chronic pain the positive relaxation effects are often very short lived.

Our muscles are directly connected to the Deep Muscle Fascia and this fascia permeates through the muscle surrounding each muscle fibre and even ‘holds’ the muscle spring that sets the tone of the muscle. So when there is a ‘problem’ in our DMF we can have stubbornly stiff muscles.

Schilder, A. Et al- published in 2014: stimulated each of these layers and recorded the pain description for each layer:

1. The SF ‘skin’ layer gives a sharp or stiff pain
2. The DMF layer – a aching or burning pain and
3. The deep muscle a dull pain

Schilder, A. Et al: Sensory findings after stimulation of the thoracolumbar fascia with hypertonic saline suggest its contribution to low back pain. Pain 2014, 155, 222–231.

The Stecco’s 2020 study showed that after injection of saline water into each of the layers the:

1. SF was involved in 55% of pain
2. DMF in 73% and
3. Deep muscle in 43% of pain in the people they tested.
Abstracts from Article paper: MDPI 2020:
Myofascial Injection Using Fascial Layer-Specific Hydromanipulation Technique (FLuSH) and the Delineation of Multifactorial Myofascial Pain

These fascinating results can explain why historically clinicians have struggled to effectively treat chronic pain.

We need to fully assess from super light touch for the superficial fascia layer through to mid-range pressure for the DMF – depending on the depth of the muscle.

The deep muscle tissue we historically already treat really well as this is the depth most of us have been taught to treat and it’s the layer we ‘percieve’ our pain comes from!

I am so excited that we are making inroads into understanding more about the complexity of chronic pain and now thanks to great research coming from all round the world now we are being better equipped with tools to start the journey of recovery and a life without pain!

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The Boxgrove Clinic

Based just outside of Chichester, The Boxgrove Clinic is a physiotherapy led clinic that brings together a team of expert therapists that collaborate to provide you with a joined up treatment plan. They tailor comprehensive and effective treatment and exercise programmes for you to achieve your goals, whether that be to relieve your pain, improve your mobility, or to recover from an injury or a recent surgery.