There has been a bit of buzz on the various news outlets and social media feeds about the “new organ” the interstitium. On March 27th an article appeared in Scientific Reports, an online peer-reviewed journal from the publishers of Nature. This work was presented by a team of researchers that utilized a new in vivo laser endomicroscopy technique that demonstrated this tissue is a matrix of collagen bundles and elastic fibers surrounded by fluid rather than the tightly packed layers of connective tissue that was previously observed on fixed slides . This submucosal layer was observed in the entire gastrointestinal tract, the urinary bladder, bronchus, dermis, bronchus and peri-arterial soft tissue and fascia. The authors state, “In sum, we describe the anatomy and histology of a previously unrecognized, though widespread, macroscopic, fluid-filled space within and between tissues, a novel expansion and specification of the concept of the human interstitium” Benias et al., 2018.
The only thing ‘new’ is the way that this group of scientists observed the tissue that until now has primarily been studied ex vivo. I find it rather humorous to note that it is mainstream news that histologists in the 21st century just realized that there is a difference in the architecture of living versus dead tissue. They noted a significant change in the appearance of tissue slides that were chemically fixed in the traditional manner when compared to studies of in vivo structures as well as fresh frozen samples. The researchers noted this tissue in the dermis as well as urinary system, gastrointestinal system and respiratory system. This further supports one of my favorite talking points presented in the visceral mobilization courses “fascia is fascia is fascia is fascia.”
As an instructor that presents entire courses around the importance of the fascial system within all structures of the body including the dermis, epimysium, all organs, and the adventitia of vessels, I am thrilled to see this layer of the fascial system receive recognition and garner the attention it deserves. However, to refer to the interstitium as a new undiscovered organ is to ignore the work of the International Fascia Research Congress as well as many other notable scientists. These researchers see the fascial system as the dynamic mesenchymal tissue that unites every cell in the body and allows for fluid and tissue movement.
French hand surgeon Dr. Jean-Claude Guimrberteau has documented this tissue utilizing microendoscopy on living subjects for the past 20 years. Dr Guimberteau created a brilliant DVD called Strolling Under the Skin, you can view an excerpt available on YouTube. Following the success of several videos, he went on to co-author the book Architecture of Human Living Fascia: The extracellular matrix and cells revealed through endoscopy.
Another brilliant researcher is Orthopedic Surgeon Dr. Carla Stecco. Her paper The Fascia: the forgotten structure is an excellent review of the three-dimensional continuity of the myofascia. Following multiple publications, she also authored the book The Functional Atlas of the Human Fascial System. Her work is limited to the myofascial layer and does not include the visceral fascia although she notes its presence in her published works. For those that would like to know more about this tissue, I highly recommend both of these authors. If you wish to explore how a physical therapist can utilize this information in clinical practice, join me for one of my courses on fascial manipulation. The fascial based treatment for pelvic dysfunction series includes:
Benias, P. C., Wells, R. G., Sackey-Aboagye, B., Klavan, H., Reidy, J., Buonocore, D., ... & Theise, N. D. (2018). Structure and Distribution of an Unrecognized Interstitium in Human Tissues. Scientific Reports, 8(1), 4947. https://:doi.org/10.1038/s41598-018-23062-6, 2018.
Stecco, C., Macchi, V., Porzionato, A., Duparc, F., & De Caro, R. (2011). The fascia: the forgotten structure. Italian journal of anatomy and embryology, 116(3), 127.
Today we get to hear from Ramona Horton, MPT, who teaches several courses with the Herman & Wallace Institute. Her upcoming course, Visceral Mobilization Level 1: Mobilization of Visceral Fascia for the Treatment of Pelvic Dysfunction in the Urologic System, will be taking place November 6-8, 2015 in Salt Lake City, UT.
This spring I reached a milestone in my career. I have been working as a licensed physical therapist for 30 years, of which the past 22 have been in the field of pelvic dysfunction. Other than some waitressing stents and a job tending bar while in college this is the only profession I have known. When I entered the US Army-Baylor program in Physical Therapy in the fall of 1983 nowhere was it on my radar screen that I would be dealing with the nether regions of men, women and children, let alone teaching others to do so. As time marches on, I find myself visiting my hair dresser a bit more frequently to deal with that ever progressive grey hair that marks the passage of these years…translation: I am an old dog and I have been forced to learn some new tricks.
Like many aspects of our modern life, the profession of physical therapy is under a constant state of evolution. The best example of this is the way we look at pain and physical dysfunction. I was educated under the Cartesian model, one that believed pain is a response to tissue damage. Through quality research and better understanding of neuroscience we now know that this simplistic model is, in a word, too simple. We have come to recognize that pain is an output from the brain, which is acting as an early warning system in response to a threat real or perceived. I wholeheartedly embrace the concept that pain is a biopsychosocial phenomenon; however I am not willing to give up my treatment table for a counselors couch when dealing with persistent pain patients.
As a physical therapist, I still believe that we need to educate, strengthen and yes, touch our patients. Given that paradigm, ultimately I am a musculoskeletal therapist and I believe that when a clinician is designing a treatment program for any patient, applying sound clinical reasoning skills means the clinician needs to take into consideration that there are three primary areas in the individuals life in which they may be encountering a barrier to optimal function: neuro-motor, somatic and psycho-social. After many years of developing and refining my clinical reasoning model, I have chosen to adopt the image of the Penrose triangle. My goal was to provide the clinician with a visual on which to focus their problem solving skills and a reminder to encompass the person as a whole. The goal is to convey the understanding that the barriers which present themselves rarely do so in isolation, and that the source to resolve of all barriers that impede human function, regardless of origin, is ultimately found within the brain.
Neuro-motor barriers include issues of muscle function to include motor strength, length, endurance, timing and coordination. These barriers are improved through therapeutic exercise training. Somatic barriers are those that are addressed through any number of manual therapy interventions which address issues found within multiple structures to include the fascia, osseous/articular tissue, lymphatic congestion, restrictions within the visceral connective tissue, neural/dural restrictions and challenges of the dermal/integumentary system. All of these barriers can contribute to nociceptive afferent activity. Lastly would be the psychosocial barriers which include history of trauma, clear behavior of hypervigilance, catastrophization, current life stressors, perceived threat which includes kinesiophobia (back to neuro-motor) ANS issues which present as autonomic dysregulation and lastly pain model misconceptions.
I suggest that we remember that the body is a self-righting mechanism. If we cut our skin, given the wound is kept free from infection (a barrier), the human body will heal the wound. As clinicians, I believe that we need to come to the realization that we don’t fix anything, we simply remove the barrier to healing and trust the body to do the rest. Our challenge is to recognize and address the barriers.
The following post was contributed by Herman & Wallace faculty member Ramona Horton. Ramona teaches three courses for the Institute; "Myofascial Release for Pelvic Dysfunction", "Mobilization of Visceral Fascia for the Treatment of Pelvic Dysfunction - Level 1: The Urologic System", and "Mobilization of Visceral Fascia for the Treatment of Pelvic Dysfunction - Level 2: The Reproductive System". Join her at Visceral Mobilization of the Urologic System - Madison, WI on June 5-7!
My physical therapy training and initial experience were in the US Army, so I had a strong bias toward utilization of manual therapy techniques based on a structural evaluation. When the birth of my 10 pound baby boy threw me head-long into the desire to become a pelvic dysfunction practitioner, I became plagued by the question: how do you treat the bowel and bladder, without treating the bowel and bladder? That, along with a mild obsession for the study of anatomy was the genesis of my desire to explore the technique of visceral mobilization.
The field of pelvic physical therapy has moved far beyond the rehabilitation of the pelvic floor muscles for the purpose of gaining continence, which was its origin. Now pelvic rehabilitation is a comprehensive specialty within the PT profession, treating a variety of populations and conditions (Haslam & Laycock 2015). Research has provided a greater understanding of the abdomino-pelvic canister as a functional and anatomical construct based on the somatic structures of the abdominal cavity and pelvic basin that work synergistically to support the midline of the body. The canister is bounded by the respiratory diaphragm and crura, along with the psoas muscle whose fascia intimately blends with the pelvic floor and the obturator internus and lastly the transversus abdominis muscle (Lee et al. 2008). The walls of this canister are occupied by and intimately connected to the visceral structures found within. These midline contents carry a significant mass within the body. In order for the canister to move, the viscera must be able to move as well, not only in relationship to one another, but with respect to their surrounding container. There are three primary mechanisms by which disruption of these sliding surfaces could contribute to pain and dysfunction: visceral referred pain, central sensitization and changes in local tissue dynamics.
Since the inception of physical therapy, manual manipulation of tissues has been a foundational practice within the profession. Manual therapy is a generic therapeutic category for hands-on treatment of a structural anomaly; it encompasses a variety of techniques which can be subdivided into either soft tissue based or joint based. Although the majority of manual therapy research has been on the musculoskeletal system, its effects are not exclusive to any particular region of the anatomy. The Orthopaedic Section of the American Physical Therapy Association (APTA) defines the technique of mobilization as "the act of imparting movement, actively or passively, to a joint or soft tissue" (Farrell & Jensen 1992). Visceral mobilization is a treatment approach focusing on mobilizing the fascial layer of the visceral system with respect to the somatic frame; it therefore falls under the classification of soft tissue based manual therapies. Soft tissue and or fascial based manual therapies have higher-levels of evidence to support their use for treating musculoskeletal pain and dysfunction (Ajimsha & Al-Mudahka 2014; Gay et al. 2013). Although many models have been proposed, the specific mechanisms behind the response of the musculoskeletal system to manual interventions are still not fully understood (Bialosky et al. 2009; Clark & Thomas 2012).
The previous model of manual therapy directly relieving local tissue provocation has given way to a recognition that the observed clinical improvement is not simply a result of the practitioner directly altering the structure beneath their hands through mechanical means. Rather this improvement is a combination of afferent input influencing the neurophysiologic output, changes in the endogenous cannabinoid system, and even a placebo responses simply because of touch (Bialosky et al. 2009; McParland 2008; Gay et al. 2014).
There is significant clinical evidence that issues of somatic pelvic pain, bowel, bladder and reproductive system dysfunction may be the result of visceral referred pain, central sensitization and restrictions in visceral tissue mobility which may further contribute to dysfunction within the canister of core muscles. The musculoskeletal framework is a mysterious, perplexing and complicated system. It is unique in that it offers us a variety of tissues and techniques from which to choose in order to help our patients from a manual therapy perspective. Science has acknowledged that the visceral structures and their connective tissue attachments indeed have an influence on the function of the somatic frame, the question is can we manually manipulate these structures and bring about an effect with a reasonable degree of specificity while producing a therapeutic outcome.
Part 2 of this report will discuss the evidence to support visceral mobilization.
Ajimsha M.S., Al-Mudahka N.R. & Al-Madzhar J.A. (2015) Effectiveness of myofascial release: Systematic review of randomized controlled trials. Journal of Bodywork and Movement Therapies 19, 102-112.
Clark B.C., Thomas, J.S., Walkowski S., Howell J.N. (2012) The biology of manual therapies. The Journal of the American Osteopathic Association 112 (9), 617-29.
Bialosky J., Bishop M. & Price D. (2009) The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Manual Therapy 14 (5), 531-538.
Gay C.W., Robinson M.E., George S.Z., Perlstein W.M. & Bishop M.D. (2014) Immediate changes after manual therapy in resting-state functional connectivity as measured by functional magnetic resonance imaging in participants with induced low back pain. Journal of Manipulative and Physiologic Therapeutics 37 (6), 614-627.
Haslam J. & Laycock J. (2015) How did we get here? The development of women’s health physiotherapy special interest groups in the UK. Journal of Pelvic Obstetric and Gynecological Physiotherapy 116 (Spring), 15-24.
Farrell J.P. & Jensen G.M. (1992) Manual therapy: a critical assessment of role in the profession of physical therapy. Physical Therapy 72, 843-852.
Lee D.G., Lee L.J. & McLaughlin L. (2008) Stability, continence and breathing: The role of fascia following pregnancy and delivery. Journal of Bodywork and Movement Therapies 12 (4), 333-348.
McPartland J M (2008) Expression of the endocannabinoid system in fibroblasts and myofascial tissues. Journal of Bodywork and Movement Therapies 12(2), 169-182.