섬유막 가소성 이해를 위한 신경생리학적 기초 - 정리중..

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fascia 치료에 대한 이론적, 기계적 효과에 대한 탐구

NEUROPHYSIOLOGICAL BASIS FOR FASCIAL PLASTICITY

The purpose of this chapter is to examine the known and theoretical mechanical effects of therapeutic myofascial treatment on fascia. Older models relying predominantly on mechanotransduction have failed to fully explain the observed changes in the viscoelastic property of fascia when treated using manual myofascial therapy. Recent research has shifted the focus away from a mechanical body concept and instead has moved toward a cybernetic model in which the clinician's intervention is seen as stimulation for self-regulatory processes within the patient.

- 이 챕터의 목적은 섬유막에 대한 근막이완치료의 이론에 근거한 신경학적, 기계적 효과를 탐구하는 것. 

- mechanotransduction으로 설명하는 모델은 수기 근막치료를 사용할때, 섬유막의 점탄성 특성변화를 완전히 설명하지 못함. 

The concept of tissue plasticity and ideas throughout this chapter are based on the extensive work of Schleip (2002a, 2002b). Most theories (thixotropic based) account for the changes in fascia's physical properties following treatment as resulting from the application of energy (Barnes, 1990; Cantu Et Grodin, 1992; Chaitow, 1980; Paoletti, 1998; Rolf, 1977; Ward, 1993). This energy can take the form of heat (hot pack) application or mechanical compression (e.g., trigger point therapy). The result is a change in ground substance/matrix consistency from a solid gel state to a more fluid state (Zaner Et Val berg, 1989). 

- 이 챕터에서 설명하는 조직 가소성 개념은 Schleip 의 탐구에 의함. 

- 점탄성완전성(틱소트로피)는 에너지 적용의 결과에 따르는 섬유막의 물리적 특성변화를 설명함. 

- 여기서 말한 에너지는 열 적용 또는 기계적 압박을 말함. 

- 결과는 기질/조직 점조도가 단단한 젤상태에서 좀더 유동성있는 졸(sol)상태로 변화하는 것을 말함. 

Researchers argue that thixotropy cannot explain the short-term changes occurring in fascial tissue during times of stress or treatment, but can account only for the long-term changes that fascia undergoes in adapting to stresses placed upon it. Thixotropy does not provide support for the immediate changes (less than 2-3 minutes) seen following treatment by a trained health-care practitioner. In fact, it has been demonstrated that a lengthy amount of time and a higher amount of force are required to permanently deform connective tissues, including fascia (Currier Et Nelson, 1992). 

- 틱소트로피는 섬유막 조직에서 일어나는 짧은 기간변화를 설명할 수 없지만 긴 시간변화를 설명할 수 있음. 

- 틱소트로피(점탄성완전성)은 2-3분이내의 즉각적인 변화를 설명할수 없음. 

- 사실상, 긴시간과 강한 힘은 결합조직을 영원히 변화시키는데 필요함. 

Threlkeld (1992) did a study that specifically looked at "time and force dependency of connective tissue plasticity" and verified that considerable time and force were required for deformation of connective tissue fibers to occur (Threlkeld, 1992). A I to 1.5% percent fiber elongation for over an hour, or a forceful stretch of 3 to 8% fiber elongation over a shorter period of time, was required to deform the collagen fibers permanently with no reversibility (Threlkeld, 1992). For this latter point, it took approximately 60 kg of force to elongate the iliotibial band by 18 mm. In addition, the thixotropic effect in colloidal substances lasts only as long as energy is applied; once the energy is removed, the tissue returns to its original physiology. Thus, thixotropy cannot explain these short-term changes.Another model has to be used to explain this short-term plasticity of fascia following treatment.

1992년 트렐캘드는 "결합조직 가소성의 시간과 힘의 의존성"을 발견. 

- 1시간 동안 1~1.5% 또는 짧은 시간동안 3~8%가 늘어나는 강한 스트레치는 콜라겐 섬유의 가역적 변화없이 영원히 변형시키기 위해서 필요함. 

- 이 기준에 따르면 장경인대를 18mm 늘리기 위해서 대략 60킬로그램의 힘이 필요함. 

- 게다가 교질물질에서 점탄성완전성 효과가 나기 위해서는 에너지가 적용되어야 함. 일단 에너지가 제거되면, 조직은 원래 생리로 되돌아감. 그래서 점탄성 완전성은 이러한 짧은 시간의 변화를 설명할 수 없음. 다른 설명모델이 필요함. 

Piezoelectricity has been used to explain the plasticity changes occurring following treatment. Living organisms and tissue, including fascia, usually have some type of electrical charge. Researchers have speculated that connective tissue cells, specifically fibroblasts (collagen producers), are sensitive to electrical changes within the tissue (Oschman, 2000; Athenstaedt, 1974). Mechanical pressure from treatment can either increase or decrease the electric charge, stimulating fibroblasts to produce more collagen fibers and matrix macromolecules in the area. 

- 피에조전기는 수기치료에 따른 가소선 변화를 설명하는데 이용되어왔음. 섬유막을 포함한 살아있는 기관과 조직은 음전하 또는 양전하의 type을 가짐. 

- 연구자는 다음과 같이 추론함. 콜라겐 섬유를 생성하는 섬유아세포를 포함한 결합조직은 조직내에서 전하에 민감함. 

- 치료를 위한 기계적 압력은 전하를 바꾸고, 섬유아세포를 자극하여 좀더 많은 콜라겐 섬유와 기질 분자를 생성함. 

참고) electric charge(전하)

Electric charge is the physical property of matter that causes it to experience a force when placed in an electromagnetic field. There are two types of electric charges – positive and negative. Positively charged substances are repelled from other positively charged substances, but attracted to negatively charged substances; negatively charged substances are repelled from negative and attracted to positive.

Although this theory is currently speculative, other tissues like bone are capable of undergoing osteogenesis and remodeling following mechanical stress as a result of the piezoelectric properties of collagen (Silva et aI., 2001). 

- 이 이론은 순전히 사변적이지만, 뼈와같은 조직의 뼈형성과 자극에 따른 재형성은 콜라겐의 피에조전기 특성의 결과임. 

                                                   bone trabecular(골소주) 

In addition, studies have shown that the half-life of normal collagen fibers ranges between 400 and 500 days, while the ground matrix has a half-life of approximately 2-8 days (Cantu Et Grodin, 1992). Even though halflife is for normal tissue, injured fascia may be similar, although this length of time does not correlate to the sometimes immediate effects of fascial tissue treatment. Another traditional model that attempts to account for a full explanation of the viscoelastic changes occurring to tissue in a manual therapy treatment session is biomechanical and will be discussed in the following section.

- 정상 콜라겐 섬유의 반감기는 400~500일, 기질의 반감기는 대략 2~8일

- 비록 반감기는 정상조직을 위한 개념이지만, 손상된 섬유막은 거의 비슷함. 비록 때때로 섬유막조직 치료의 즉각적인 효과와 시간이 연관성이 없을지라도..

- 수기치료로 변화하는 점탄성 변화의 완전한 설명은 생화학적임. 앞으로 논의될 것임. 

FASCIAL TISSUE MECHANICAL BEHAVIORBIOMECHANICAL MODELS

The mechanical response of dense connective tissue that gives rise to ligaments, tendons, and fascia is reviewed here. The purpose is to provide a framework for discussion of the clinical effects of myofascial therapy on connective tissue like fascia. 

- 치밀결합조직인 인대, 힘줄, 섬유막의 기계적 반응이 여기에서 논의됨. 

- 섬유막과 같은 결합조직에 근섬유막 치료의 임상적 효과에 대한 기본틀을 제공하기 위함. 

Fascial Anatomy Fascia is comprised predominantly of fibroblasts and collagen fibers. Fascia consists of collagen bundles organized into multilayered sheets or lamellae. The bundles within individual layers are roughly parallel but often have some undulations or waviness. This wave formation allows collagen fibers to stretch during compression. The amount of waviness or crimping is affected by aging (Figure 4- 1 ).

- 섬유막은 몇개의 층으로 조직된 콜라겐 다발로 이루어짐. 이 해부학적 공간에는 섬유아세포와 콜라겐이 우세하게 존재함. 

- 각 층의 콜라겐 다발은 러프하게 보면 수평이지만 때로는 물결처럼 되어 있음. 이러한 물결형태는 압박동안 콜라겐 섬유가 늘어나도록 함. 물결 또는 구부러짐의 정도는 나이에 의해 영향을 받음. 

Fiber bundles in adjacent layers may not have the same direction, although fibers will often pass between adjacent layers as well as into adjacent loose connective tissue. The fibroblasts found in fascia and aponeuroses are sparse and variable in shape. Ground substance and elastin content are low in fascia.

- 인접조직에서 섬유다발은 같은 방향을 가지지 않음. 섬유가 비록 성긴결합조직뿐 아니라 근처 조직층까지 배열될 수 있을지라도.

- 섬유막과 건막에서 발견되는 섬유아세포는 성기고 형태가 다양함. 기질과 탄력섬유는 섬유막에서 적음. 

Mechanical Response of Fascia to External Loading

The crimping of the collagen fibers in fascia accounts for a variable amount of slack. When a tensile force is applied, such as during a myofascial stretch, the superficial fascia is loaded asynchronously. Only after most of the collagen bundles that make up the superficial fascia are placed in a stretch will the superficial fascia undergo deformation. The resistance of fascia to deformation can be graphically represented using a stress-strain curve (Figure 4-2).

- 섬유막에서 콜라겐 섬유의 구부러짐은 다양한 느슨함의 정도(amount of slack)를 결정함. 

- 근막스트레칭과 같은 장력이 적용될때, 천층 섬유막은 비동시적으로 부하가 주어짐. 오직 콜라겐 다발의 대부분이 늘어난 후에 천층 섬유막의 변형이 일어날 수 있음. 

- 변형에 대한 섬유막의 저항은 아래 그림에 있음. 

Periarticular connective tissue structures such as fascia are typically tested under tensile loading to determine their maximal mechanical behavior. Tensile testing of connective tissue produces a stress-strain curve that represents the load and resulting connective tissue deformation, and this curve has been divided into several functionally important regions.

- 섬유막과 같은 관절옆 결합조직구조는 그것의 최대기계적행동이 장력부하가 주어진 상태에서 전형적으로 검사됨.

- 결합조직의 장력검사는 부하와 그에 따른 결합조직 변형으로 표현되는 장력-응력 커브를 생성함. 그리고 장력-응력 커브는 몇가지 기능적으로 중요한 지점으로 나뉘어짐. 

The clinical test region is the same as the toe region shown in Figure 4-2 and represents the level o f load and deformation at which crimping is being taken out of the connective tissue structure. The presence and shape of the stress-strain curve in the toe region are variable and dependent on the internal structural organization of the tissue. The more regular and parallel the collagenous bundle in the superficial fascia, the shorter the toe segment. In myofascial therapy, the act of elongating connective tissue through the toe region is known as taking out the slack. The graded mobilizations that are  intended primarily to relieve pain but not to elongate connective tissue are supposedly conducted in this range.

- 임상적 검사지점은 그림에서 보는 바와같이 앞부리 지점(toe region)이고, 결합조직구조의 물결지점에 주어진 부하와 변형단계를 표시함. 

- 앞부리지점에서 장력-응력커브의 형태는 조직의 내부구조배열에 의존하여 다양함. 

- 근막이완치료에서 앞부리지점을 통한 결합조직의 늘어남은 느슨함으로 알려짐. 

- 단계적 가동은 주로 통증을 경감시키기 위함이고, 결합조직의 늘어남은 아님. 

The physiological loading region of the stress strain curve represents the range of forces that usually act on connective tissue in vivo and implies that primarily elastic deformation occurs at these loads . 

- 생리적 부하지점은 결합조직에 작용하여 1차 탄성변형이 일어나는 지점임.

The region of microfailure overlaps the end of the physiologic loading zone. Microfailure represents the breakage of the individual collagen fibers and fiber bundles that a replaced under the greatest tension during progressive deformation. The remaining intact fibers and bundles that may have not been directly aligned with the force, or those that had more intrinsic length, absorb a greater proportion of the load. The result is progressive, permanent (plastic) deformation of the connective tissue structure.

- 미세파열지점은 생리적부하지점의 끝과 오버랩됨. 미세손상은 개별 콜라겐 섬유와 섬유다발이 손상되는 것을 표현함. 손상된 콜라겐 섬유는 진행되는 변형동안 가장 큰 장력하에 놓여짐. 

- 남은 손상되지 않은 콜라겐 섬유와 다발은 힘과 함께 직접적으로 배열되지 않을 수 있거나 본래고유길이를 가지고, 부하의 많은 부분을 흡수함.  

- 그 결과는 진행하여 결합조직구조의 영원한 가소성 변형임. 

 If the force is released, the broken fibers will not contribute to the recoil of the tissue. A new length of the connective tissue (CT) structure is established that reflects the balance between the elastic recoil of the remaining intact collagen and the resistance of the intrinsic water and glycosaminoglycans (GAGs) to compression. Microfailure is a desired outcome of some manual stretching techniques that are intended to produce permanent elongation of the fascia. 

- 만약 힘이 제거되면, 파열된 콜라겐 섬유는 조직의 반동에 공헌하지 못할 것임. 결합조직구조의 새로운 길이가 정해지고, 압박에 물과 글리코스아미노글리칸의 고유저항과 손상되지 않은 콜라겐이 남아 있음으로 탄성반동균형을 반영함.

- microfailure은 수기 스트레칭 테크닉의 훌륭한 결과물이고 섬유막 늘어남 결과로 얻어짐.

The breaking of collagen cross- lnks, which are responsible for the fibrotic scarring and myofascial trigger points established throughout superficial and deep fascia, will be followed by a  cycle of inflammation, repair, and remodeling that should be therapeutically managed to maintain the desired fascia elongation.

- 콜라겐 교차링크 손상은 천층과 심층근막 전체에 염증, 수복, 재형성 사이클을 동반하는 섬유막 손상과 근막통에 공헌함. 이는 반드시 치밀하게 계획된 섬유막 늘어남을 치료적으로 달성해야 함. 

Plastic deformation should not be confused with the phenomenon of creep. Creep is a time-dependent deformation that occurs over a prolonged period rather than suddenly. This deformity occurs to relieve stress, and the result is permanent. 

 소성변형은 크립현상과 혼돈해서는 안됨. 

- 크립은 갑자기 일어나기 보다는 오랜기간에 걸쳐서 일어나는 시간의존성 변형임. 크립은 stress를 경감시키기 위해 발생하고, 그 결과는 영원함.

On the other hand, plastic deformation occurs following elastic deformity of tissues. Here, the change in shape is temporary under low stress and within the elastic limits of the tissue, causing the tissue to return to its original shape once the load is removed. However, if the stress load exceeds the elastic limits of the material, permanent plastic deformation results(Figure 4-3).

- 반면에 소성변형은 조직의 탄성변형을 따라서 발생함. 그래서 작은 부하와 조직의 탄성한계내에서 형태의 변형은 일시적임. 하지만 주어진 부하가 물질의 탄성한계를 넘어 지속되면, 영원한 소성변형이 일어남. 

In biological tissues, the phenomenon of creep primarily represents the redistribution of water from the tissue to the anatomical spaces surrounding the tissue. Some elongation of tissues that results from manual stretching and massage techniques may reflect impermanent creep deformation . To detect this phenomenon , clinical research designs examining manual therapy techniques should in corporate several repeated measurements of elongation up to 24 hours after application of the myofascial stretch.

- 생물학적 조직에서 크립현상은 조직에서 조직을 둘러싼 해부학적 공간의  조직으로부터 물의 재배열을 표현함. 

- 수기 스트레칭과 마사지 테크닉 등의 결과로 조직의 늘어남은 영원하지 않은 크립변형을 반영할 수 있음. 이러한 현상을 관찰하기 위해, 근섬유막 스트레치적용 후에 24시간이 지난 늘어남 수치를 반복해서 측정해야 함. 

Effect of Iniury and Immobilization on Myofascial Trigger Points

An acute injury to myofascial connective tissue will be followed by inflammation and subsequent fibrosis, resulting in a remodeled connective tissue with lower tensile stiffness and a lower ultimate the strength than normal tissue. This weakening is caused by the more randomized collagen fiber direction , by the inability o f collagen bundles to slide easily past one another (cross- linking and loss of water), and possibly by the substitution of collagen types that are not as strong as the original collagen.

- 근섬유막조직의 급성손상은 염증과 그에 수반한 섬유화를 일으켜, 정상조직보다 강도가 약하고 장력이 약한 결합조직으로 재구성됨. 

- 이 약화는 세가지 원인

1) 콜라겐 섬유방향의 규칙없음때문에 야기되고, 

2) 콜라겐 섬유다발 inability(cross- linking and loss of water)때문에 발생함.

3) 원래 콜라겐 섬유의 강도를 가지지 못하는 type 3콜라겐으로 대체되기 때문.

Mechanical Effects of Fascial Manual Therapy

Manual soft tissue technique such as myofascial and/or active release use the examiner's hands to reestablish motion between fascial planes, thus reducing fibrous adhesions and reestablishing neural and myofascial glide between tissues. These techniques work on the presumption that they preload the fascia by taking slack out through alternating active patient muscle contraction with passive stretching. The end result should allow the collagen fiber crimping to be removed from the connective tissue and for some amount of creep deformation to occur. 

- 근막 이완과 능동이완은 연부조직 수기치료는 검사자의 손을 이용하여 섬유막 면과 움직임을 재형성함. 그리하여 섬유성 유착을 줄이고, 조직사이의 신경과 섬유막 활주를 재형성함. 

- 이러한 치료테크닉은 다음 가정에 의함. 수동적인 스트레칭과 함께 환자의 능동적 근수축을 교대로 시행하는 섬유막의 느슨함에 전부하를 주는 것..

- 마지막 결과는 콜라겐 섬유 구부러짐이 결합조직으로부터 제거되고 크립변형이 일어남. 

These are temporary lengthening phenomena demonstrating a damped elastic response, and they can easily be misinterpreted as permanent lengthening. Plastic deformation does not take place until the forces within the tissue reach a higher level . All of this research leads to a simple thought experiment.

- 축축한 탄성반응을 보이는 일시적인 늘어남 현상이 있고, 치료사는 흔히 영원한 늘어남으로 착각할 수 있음. 소성변형은 치료하려는 조직에 강한 단계의 힘이 주어지기 전까지 일어나지 않음. 모든 연구들은 이러한 실험에 따름. 

In everyday life, the body is often exposed to pressure similar to the application of manual pressure in a myofascial stretch or active release therapeutic technique. While the body naturally adapts structurally to long-term furniture use, it is impossible to conceive that adaptations could occur so rapidly that any uneven load distribution in sitting would permanently alter the shape o f your pelvis within a minute.

- 인체는 매일 일상생활에서 근막스트레칭이나 능동적 이완테크닉의 수기압력과 비슷한 압력에 노출되고 살아감. 

Since no theory exists as to how fascia adapts to short-term changes, many have turned to the nervous system to explain this phenomenon. Fascia is closely related to the nervous system; it is traversed by nerves, it envelops the nervous system, and fascial plasticity is reliant upon the nervous system . Studies have shown that without a p roper neural connection, the tissue does not respond as well to treatment as it does under normal neuronal functioning (Schleip, 1989).

- 섬유막이 어떻게 짧은 시간의 변화를 일으키는지 이론이 없기 때문에, 이 현상을 설명하는 많은 신경계 시스템이 있음. 

- 섬유막은 신경계와 매우 밀접하게 연관되어 있음. 섬유막사이로 신경이 지나가고, 섬유막은 신경계를 둘러싸고, 섬유막 가소성은 신경계 시스템에 의존함. 

Neurophysiological Dynamics of Fascia

Studies involving the use of human cadavers and immunohistochemical technology on animal and/or human fascia have revealed some interesting findings. The chronological development of the neurophysiology of fascia has been studied as early as in prenatal ontogeny. The first neural fibers have been seen in as early as 8- to 9-week-old embryos.

Cholinesterase and catecholamines are detected in nerves of the vegetative neural system in the 11th to 12th week of intrauterine life, thus demonstrating the appearance of a functioning autonomic nervous system. 

Mechanoreceptors have appeared in the fascia of 3- to 3.5-month-old fetuses. During prenatal ontogenesis, the neural fibers start increasing in number and become more complex with cholinergic and adrenergic nerve fibers forming plexuses in fascia. Electron photomicrography of the fascia cruris, which encases the lower leg, has shown nerves innervating the fascia (Figure 4-4). 

기계적 수용기는 수정후 3~3.5개월에 나타나기 시작함. 

Additional studies have shown the presence of adrenergic nerve fibers along with blood vessels penetrating the fascia at points similar to acupuncture pressure points (Figure 4-5).

Furthermore, the neural structure of the shoulder capsule of mice has revealed the ultrastructure and location of nerve endings, along with lamellated Pacini - type and Ruffini -type mechanoreceptors in the fibrous fascia sheath of the shoulder capsule. The presence of small, uniformly shaped, lamellated corpuscles of the Pacini type in qualitatively different areas of surrounding tissue implies that they are susceptible to different kinds of mechanical stimuli. 

The clinical implications of discovering the presence of both mechanoreceptors and sensory receptors in fascia could possibly account for myofascial pain . If a clinician using manual therapy or any other adjunct therapy could influence the response of these fascial receptors, then therapeutic outcomes could be clinically significant. Additionally, the direct neural connection between fascia and the autonomic nervous system may be responsible for fascial tonus, which can have  ramifications for biomechanics, transmission of muscular force, circulation (blood, lymph), and soft tissue pain.

- 섬유막에 있는 기계적 수용기와 감각수용기의 임상적 의미 발견은 근막통을 설명할 수 있음. 

- 수기치료나 기타 치료를 시행하는 임상가가 이런 섬유막 수용기반응에 영향을 줄 수 있다면, 치료적 결과는 임상적으로 상당한 의미가 있음. 

- 게다가 섬유막과 자율신경계 사이의 직접적 신경연결은 섬유막 긴장을 책임질 수 있고, 이는 생체역학의 분지, 근육힘의 전달, 혈관 림프관의 순환, 연부조직 통증을 가질 수 있음. 

THE NERVOUS SYSTEM

The nervous system consists of all the nervous tissue in the body. It can be divided into the central nervous system (CNS) and the peripheral nervous system (PNS). The CNS consists of the brain and the spinal cord; the PNS is composed of cranial and peripheral nerves, collections of nerve cells outside the CNS known as ganglia, and both motor and sensory nerve endings. Nerves consist of bundles of myelinated neuronal a axons that may carry either sensory i n formation to the CNS (afferent) or motor information from the CNS (efferent).

- 신경계는 인체 전체에 신경조직으로 이루어짐. 

- 중추신경과 말초신경계로 나눌 수 있음. 중추신경계는 뇌, 척수를 구성하고, 말초신경계는 12신경과 말초신경, 중추신경밖의 신경세포 집합인 ganglia, 운동과 감신신경 종말을 포함함. 

Central Nervous System

The entire CNS is protected by a bony encasement; the cranium, which surrounds the brain , and the vertebral column, which surrounds the spinal cord. Between the bone and the soft tissue of the CNS is a protective set of membranes, the meninges. There are three layers of meninges (from the outside in ) : the duramater, the arachnoid mater, and the piamater. While the dura is thick and collagenous, the arachnoid and piamater are both thin and transparent. 

The duramater is divided into a cranial and a spinal portion to form one continuous membrane composed of a thick, dense, fibrous collagen structure with some elastic fibers. The collagen fibers are densely packed in fascicles. Although the dura mater is mainly acellular, there is evidence of fibroblasts distributed throughout the tissue. The cranial duramater is composed of an outer (endosteal) and an inner (meningeal) layer. The endosteal layer is continuous with the pericranium through the cranial sutures, the fora mina , and the orbital periosteum t h rough the orbital fissure; the meningeal layer envelops the 12 cranial nerves (I-XII), attaching to their respective epineuria as they pass through the various cranial foramina. 

The meningeal layer also forms septa that divide the brain into smaller compartments. These four septa are the falx cerebri, the tentorium cerebelli, the falx cerebelli, and the diaphragma sellae.

Cerebrospinal fluid (CSF) is a clear, colorless liquid containing different electrolytes and traces of protein molecules. It bathes and circulates w it h in the hollow ventricles of the brain, the central canal of the spinal cord, and in the subarachnoid space surrounding the entire CNS . The choroid plexus situated within the four ventricles of the brain (two lateral, third, fourth) produces the CSF and the cilia found on ependymal cells and circulates the fluid within the skull. Pulsatile movements of the various arteries, found in and around the meningeal layers,  create CSF movement within the spinal cord.

As the cranial dura mater exits the foramen magnum,it forms the anterior and posterior atlanto-occipital membranes. Inferior to the foramen magnum , the spinal duramater forms a tube t h a t surrounds the spinal cord. The superior (upper) end is attached to the edges o f the foramen magnum, to the posterior surfaces of the second and third vertebral bodies, and to the posterior longitudinal ligament (PLL).

The inferior end of the spinal dura mater merges into a conical filum terminale that is attached onto the coccygeal periosteum. Once again, more proof that connective tissues in our bodies are not limited by borders, but form an extensive network throughout the body. Within the vertebral canal and between the periosteum/ligaments and the spinal dura mater lies the extradural space, which contains loose connective tissue, adipose tissue, and venous plexi.

The middle layer of the meninges, the arachnoid mater, consists of both a cranial and spinal portion. The cranial part of this mater surrounds the brain but does not enter fissures or sulci of the brain. The space between the arachnoid and pia mater is known as the sub  rachnoid space; it contains the CSF as wel l as blood vessels and cranial nerves entering the brain.

Within the arachnoid mater, particularly within fissures and sinuses, a regranulations and villi that project onto a collagenous framework to move the CSF into the bloodstream by vesicular transport through the sinus endothelium. The spinal part of the

arachnoid mater is continuous with the crania!" portion. As nerves and vessels enter and exit the spinal cord, the arachnoid mater envelops them and adheres to the perineurium or adventitia of the vessel, once again forming a complex interconnection.

The deepest meningeal layer, the one that is closest to the brain, is the pia mater. The pia mater is a delicate, thin membrane composed of loose connective tissue only 2 to 3 cells thick; it invests the surfaces of the brain and follows a l l irregular contours (sulci, gyri) of the brain and spinal cord. Being highly vascular, the pia mater supports the vessels that nourish the underlying cells of the CNS. The pia mater is specialized within the w a l ls of the ventricles, where it contributes to formation of the choroids plexus along with arachnoid mater. The spinal portion of pia mater forms lateral extensions known as ligamentum denticulatum (dentate liga ments) that separate the ventral from the dorsal roots.

These extensions attach the spinal cord to the dura mater. It has been demonstrated that dentate ligaments change in form and position during movement-particularly movement o f the vertebral column.

Peripheral Nervous System

The peripheral nervous system consists only of cranial and spinal nerves that convey impulses to and from the central nervous system to the rest of the body. The 12 pairs of cranial nerves arise from the inferior surface of the brain. The cranial nerves, except for the vestibulocochlear nerve, all pass through foramina of the skull to in nerve structures of the head , neck, and visceral organs o f the trunk. The names of the cranial nerves a re associated with their primary function or the general distribution of the fibers:

1 . Sensory (cranial) nerves: olfactory (I), optic (II), and vestibulocochlear (VIII)

2. Motor and sensory nerves: trigeminal (V), glossopharyngeal (IX), and vagus (X)

3. Motor nerves: ophthalmic (III), trochlear (IV), abducens (VI), facial (VII), accessory (XI), and hypoglossal (XII); only the sensory fibers of these are proprioceptive

The spinal nerves consist of 31 pairs of nerves formed by the union of the anterior (ventral) a n d posterior (dorsal) spinal roots that emerge from the spinal cord through the intervertebral foramina. The spinal nerves are grouped according to the levels o f the spinal column from which they arise, a n d they are numbered in sequence. Each spinal nerve consists of a posterior and a n terior root o f sensory fibers. The posterior root contains an enlargement called the dorsal root ganglion (sensory), where the sensory neurons are located. The axons o f sensory neurons convey sensory impulses through the posterior root and into the spinal cord. The anterior root consists of axons of motor neurons that carry impulses away from the CNS.

Just beyond the i ntervertebral foramen, each spinal nerve divides i n to several branches including the m e n i ngeal b ranch, posterior ramus, and anterior ramus. The s m a l l m e n ingeal b ra nch reenters the verteb ral canal to i n nervate the m e n i nges, vertebrae, and vertebra lligaments. The posterior ramus innervates muscles, joints, and the skin of the back

along the vertebral column. The anterior ramus innervates the muscles and skin on the lateral and anterior side of the trunk. The anterior rami of the spinal nerves (except T2-T 1 2) combine a n d then split again as networks o f nerves called plexuses.

There are four plexuses of spinal nerves : cervical, brachial , lumbar, and sacral . Nerves that emerge from these p le xuses a re n amed accord i ng to structures they i nnervate or the general course they take. Nociceptors are part of the peripheral nervous system . They are widely spread throughout t h e body and, depending on their location, respond to various stimuli. The stimulus of pain is transmitted by nociceptors to the eNS, where the thalamus processes the information and relays it to other areas of the brain.

Autonomic Nervous System

Neurons of the peripheral nervous system that conduct impulses away from the CNS a re motor or efferent neurons. There are two divisions of motor neurons: somatic and autonomic. Somatic motor neurons (cranial and spinal nerves) have their cell bodies within the CNS a n d send axons to skeletal muscles, which are usually under voluntary control. The autonomic nervous system is under involuntary control. The types of tissues receiving autonomic innervation include cardiac muscle, smooth muscle, and glands.

Autonomic motor control involves two neurons in the motor pathway-unlike somatic motor control, which involves only one axon from the spinal cord to the neuromuscular junction . The first of these neurons has its cell body in the brain or spinal cord, where its axon does not directly innervate the target organ but instead synapses w ith a second neuron w i t h i n an autonomic ganglion. This neuron is known as the preganglionic neuron, and the neuron that extends from the ganglion onto the target tissue is known as the postganglion ic neuron. The autonomic nervous system (ANS) is divided into a sympathetic and a parasympathetic division.

The sympathetic dvision activates the body to "fight or flight" through adrenergic effects, while the parasympathetic division often exerts a antagonistic actions ("rest and digest") through cholinergic effects.

Nerves of the peripheral system (cranial , spinal, and autonomic) branch away from the  CNS and spread throughout the body, innervating a wide array of structures. These nerves pierce muscles and fascia, and they travel with various vessels (arteries, veins, lymphatics) during their course through the human body. Embryologically, the growth and migrations of the nervous system are l inked to the fascial system, and fascia also plays a critical supportive role for the nervous system .

THE REFLEX ARC AND REFLEXES

Specific nerve pathways provide routes by which impulses travel through the nervous system. The simplest type of nerve pathway is the reflex arc, which involves an automatic, involuntary, quick, protective response to a potentially threatening stimulus. The conduction pathway of a reflex arc consists of the following five components :

1. Receptor

2. Sensory neuron

3. Center

4. Motor neuron

5. Target tissue/organ

The effect on the target organ is called a reflex action or a reflex. There are two types of reflexes: visceral and somatic. Visceral reflexes, also known as autonomic reflexes, cause smooth muscle to contract or glands to secrete fluids. Therefore, these reflexes help control the body's many involuntary movements such as heart rate, respiratory rate, blood flow, and digestion. 

- 두가지 형태의 반사가 있음

- 내장성 반사와 체성반사

- 내장성 반사는 자율신경반사라고 알려져 있고, Smooth muslce이 수축하여 분비선에서 fluid를 분비하는 역할. 

- 그래서 내장성 반사는 인체의 많은 비자발성 움직임 "심박수, 호흡수, 혈압, 소화"등의 움직임을 조절하는데 도움을 줌.

Somatic reflexes involve contraction of skeletal muscles. The three main types of somatic reflexes involve the stretch reflex (monosynaptic reflex), the flexor/withdrawal reflex (polysynaptic reflex), and the crossed extensor reflex ( reciprocal inhinnbition). Fascial plasticity is seen with somatic reflexes, particularly the stretch reflex, and they are a major component in explaining the immediate, short-term effects seen following soft tissue manipulation.

- 체성반사는 골격근의 수축과 연관됨. 세가지 형태의 체성반가 있음. monosynatic reflex, polysynaptic reflex, reciprocal inhibition 

- 섬유막 가소성은 체성반사 특히 스트레치 반사에서 보임. 이는 연부조직 수기치료후에 빠른기간 효과, 즉각적인 효과를 설명하는 주요 개념임. 

FASCIAL SENSORY RECEPTORS(섬유막의 감각수용기)

A receptor is part of the conduction pathway necessary to convert a stimulus to a nerve impulse. Sensory receptors are specialized structures located at the distal tips of the peripheral processes of sensory neurons. Structurally, sensory receptors can be dendritic  endings of sensory neurons that are either free (free nerve endings) or encapsulated within nonneural structures. 

- 수용기는 자극을 신경 임펄스로 전달하는데 필수적인 전기도로의 부분.

- 감각신경은 말초의 감각신경과정의 말단끝에 위치하는 특별한 구조임. 구조적으로 감각신경은 수지상 끝을 가지고 free  또는 encapsulated된 비신경구조내에 존재함. 

Encapsulated receptors can be further classified into groups according to function. Exteroreceptors react to stimuli from the external environment (touch, temperature, smell) and from within the body (e.g., filling or stretch of the bladder or blood vessels). 

- 캡률로 쌓여진 수용기는 기능에 따라 몇가지로 분류함. 

- exteroreceptor는 외부자극(터치, 온도, 냄새)과 몸자극(스트레치, 방광의 꽉 참)으로부터 반응함. 

Proprioceptors, on the other hand, react to stimuli from within the body (similar to enteroreceptors) but provide sensation of body position and muscle tone/movement.

- 고유수용감각 수용기는 인체 내부의 자극에 반응함. 하지만 근육 긴장도/움직임과 몸위치 감각을 제공함. 

Fascia has different types of nerve endings dispersed through it, including free nerve endings, thermoreceptors (temperature stimulus), chemoreceptors (chemical stimulus), mechanoreceptors (touch/ pressure stimulus), and proprioceptors.  

- 섬유막에는 자유신경종말, 온도수용기, 화학수용기, 기계적수용기, 고유수용감각기 등을 포함한 다양한 형태의 신경종말이 지배함. 

One type of proprioceptor, Golgi receptors (type I b ), have been found to exist in dense connective tissue including ligaments, tendons, and joint capsules. Golgi tendon organs (GTO) are receptors that respond to tension (on the muscle) rather than to length (Watanabe et aI., 2C04).

- 고유수용감각기, 골지수용기는 치밀결합조직인 "인대, 건, 관절낭"에 많음. 

- 골지건기관은 근육길이보다는 근육의 장력에 반응하는 수용기. 

They are high-threshold receptors that exert inhibitory effects on agonist muscles and facilitative effects on antagonist muscles. When the forces of muscle contraction and those resulting from external factors reach the point where injury to the muscle tendon or bone becomes possible, the GTO inhibits agonist motor units. Due to this function of GTOs, researchers have speculated that this action causes tissue relaxation during soft tissue manipulation (Cottingham, 1985). 

- 골지건기관은 높은 역치 수용기로 주동근육에 억제반응과 길항근육의 촉진효과가 존재함. 

- 근육수축힘과 외부요소로부터 결과가 근육건 또는 뼈 손상지점에 도달할때, 골지건기관은 주동근 운동단위를 억제함. 

- 골지건기관의 이러한 기능때문에 연구자들은 다음과 같이 추정함. 이러한 기능은 연부조직 수기치료동안 조직이완을 야기함. 

However, evidence does suggest stimulation of Golgi tendon organs by muscle contraction and not by passive stretch of tissue. Jami (1992) showed that passive joint extension (not direct tissue pressure) did not stimulate GTO activation. Furthermore, the population of GTOs in tendons is small ( 10%) in comparison to the number found within muscle fibers (90%). Consequently, any relationship of GTOs to fascial plasticity is only hypothetical.

- 하지만 증거는 조직의 수동적 스트레칭에 의한 것이 아니라 근육수축에 의한 골지건기관의 자극임. 

- 자미는 ... 수동적 관절신전(직접적인 조직압력을 가하지 않음)은 골지건기관 활성을 자극하지 않음. 게다가 힘줄에 있는 골지건기관의 양은 10%임. 근육섬유내에 90%가 발견됨. 

- 결국, 골지건기관에 의한 섬유막 가소성은 오직 가설임. 

Many mechanoreceptors are found within fascia. Specifically, two types of mechanoreceptors have been identified : Pacinian corpuscles and Ruffini endings. Both these receptor types can be found in  a variety of tissue, including myofascia, tendons, ligaments, and joint capsules; however, each type does have higher tendencies for certain tissues (Yahia, 1 992).

- 섬유막에는 많은 기계적 수용기가 있음. 특히 파치니 소체, 루피니 종말.. 두 수용기는 근막, 건, 인대, 관절낭에 흔하게 존재함. 

Pacinian corpuscles (type II sensory fibers) are receptors that adapt rapidly to sudden changes in pressure and vibration. These receptors are located most frequently within tendons, deep layers of joint capsule, deeper spinal ligaments, and in enveloping fascia. 

- 파치니 소체(type 2 감각섬유는 압력과 진동의 갑작스러운 변화에 순응하는 수용기

- 파치니 소체 수용기는 힘줄, 관절낭의 심부층, 척추 인대, 섬유막에 많이 존재함. 

These large, ovoid sensory organs consist of concentric layers of connective tissue surrounding a nerve ending. Examples of enveloping fascia include antebrachial, crural, abdominal, lateral compartment of the thigh, plantar, palmar, peritoneum, medial/lateral ligaments of the knee, and fascia of the masseter (Stilwell, 1 9 57).

- 파치니 소체는 둥근 감각기관으로 신경말단을 둘러싼 결합조직의 층을 구성함. 섬유막을 둘러싼 예를 보면 전완, 뒷다리, 복부, 대퇴의 외측부, 발바닥, 손바닥, 복막, 무릎의 내외측 인대, 교근의 근막 등을 포함함. 

Ruffini endings (type II sensory fibers) a re slowly adapting receptors that respond to more constant pressure, such as mechanical displacement of a adjacent collagen fibers during lateral stretching (Kruger, 1987). These ovoid receptors a re enclosed in a dense sheath of connective tissue within which the nerve endings end in small, circular knobs. Van den Berg a n d Capri ( 1 999) also discovered that Ruffini endings might influence the sympathetic nervous system by decreasing its activity. 

- 루피니 종말(type 2감각섬유)는 지속적인 압력에 반응하여 천천히 적응하는 섬유임. 

- 루피니 종말은 dense sheath of connective tissue within which the nerve endings end in small, circular knobs를 둘러쌈. 

- 버그와 카프리는 루피니종말이 루피티종말 억제에 의해서 교감신경계에 영향을 줄 수 있음을 발견함. 

According to Schleip (2003a), "This seems to fit the common clinical finding that slow deep tissue techniques tend to have a relaxing effect on local tissues as well as the whole organism." These receptor types are found in superficial layers of the joint capsule, dura mater, ligaments of the peripheral joints, anterior/posterior ligaments of knee, and the deeper dorsal fascia of the hand (Table 4- 1 ; Schleip, 2003a).

- 쉴레이프에 따르면 "루피니 종말은 흔한 임상적 상황에 적합함. slow deep tissue 테크닉은 전제기관 뿐아니라 국소조직의 이완하는 역할을 가짐"

- 루피니 종말은 관절낭, 경막, 관절의 인대, 무릎의 전후십자인대, 손의 깊은 dorsal fascia에서 흔히 발견됨. 

A NEW TYPE OF RECEPTOR

In the study conducted by Yahia (1992), it was found that a third sensory receptor is present in fascia. Pacinian corpuscles, Ruffini endings, and Golgi tendon organs all belong in the type I and II sensory fibers. Nonetheless, research has shown that these receptors account for approximately 20% of all sensory fibers (Schleip, 2003a, b). The other 80% belong to type III (myelinated) and type IV (unmyelinated) afferent fibers, also known as interstitial receptors (Mitchell Et Schmidt, 1977). 

- 야히아 연구에 의하면 섬유막에는 third sensory 수용기가 발견됨. 

- 파치니안 소체, 루피니 종말, 골지건기관은 type 1, 2감각섬유임.

- 그럼에도 불구하고, 연구자들은 다음과 같은 결론 "이러한 수용기는 인체 모든 감각섬유의 대략 20%을 담당함"

- 나머지 80%는 type3(수초화된), type4(탈수초화된) 구심섬유에 속하고 이는 "내장수용기 interstitial receptor"로 알려짐. 

These interstitial receptors are slower than type I or type II fibers. They originate in free nerve endings, and they are associated with the ANS. Studies show that interstitial receptors affect blood pressure, respiration, temperature, and heart rate ( M itch ell Et Schmidt, 1 9 77; Coote Et Perez-Gonzales, 1 970). Furthermore, they can be divided into low- and high-threshold pressure receptors, depending on their sensitivity to various a mounts of pressure.

- 이러한 내장수용기는 type 1, 2섬유보다 느림. 내장수용기는 자유신경종말에서 기원하고, 자율신경과 연관됨.

- 내장수용기는 혈압, 호흡, 체온, 심박수에 영향을 줌. 

- 게다가 내장수용기는 낮은 - 그리고- 높은 역치 압력수용기로 나눌 수 있고, 다양한 압력에 의존함. 

Thus, although interstitial receptors can be classified as mechanoreceptors, they are also nociceptors. As previously mentioned, nociceptors are part of the peripheral nervous system . They  are widely spread throughout the body and, depending on their location, respond to various stimuli. The stimulus of pain is transmitted by nociceptors to the CNS, where the thalamus processes the information and relays it to other areas of the brain .

- 내장수용기가 기계적 수용기로 분류될 수 있지만, 그것은 또한 통각수용기임. 앞에서 언급한바와 같이, 통각수용기는 말초신경의 일부분임. 

- 내장수용기는 인체전체에 퍼져있고, 그것의 위치에 의존하여 다양한 자극에 반응함. 

- 통각자극은 통각수용기에 의해서 중추신경계로 전달됨. 

NOCICEPTIVE STABILITY AND PLASTICITY

Neural plasticity plays an im portant role in generating and perpetuating pain and hyperalgesia , including the increased efficiency of synaptic transmission and resulting in central hyper excitability. In the past, attention to nervous system  plasticity has focused on the CNS. However, it is now becoming evident that the "peripheral nociceptive system is also capable of plasticity and that this may represent a crucial process that precedes generation and

maintenance of C N S plasticity" (Koltzenburg, 1 995).

- 신경가소성은 통증생성과 악화, 과통각에 중요한 역할을 함. 

- 지난날, 신경계 가소성은 중추신경계에만 집중되어 연구됨. 하지만 말초신경시스템 또한 가소성을 가질 수 있고, 말초신경 가소성은 중추신경가소성의 유지와 생성에 중요한 역할을 함. 

Several lines of evidence suggest that changes in the excitability of primary nociceptive afferents in fact may be the single most important factor in generating and maintaining acute chemogenic pain or chronic neuropathic pain in humans

(Koltzenburg, 1 995). 

- ...1차 통각 구심성 흥분의 변화는 급성 통증과 만성 신경변증성 통증을 유지하고 생성하는데 중요한 요소. 

Important nociceptor changes occur immediately after tissue injury, including reduced threshold. Following inflammation, the responsiveness of nociceptive receptors is doubled when exposed experimentally to a given mediator stimulus. Another important observation is that nociceptors can increase their receptive field and thereby incorporate a nearby area of tissue injury. This receptive field expansion suggests that more nociceptors can be activated by a given stimulus, resulting in spatial summation of the afferent barrage to the C N S (Koltzenburg, 1 995).

- 조직 손상후에 통각 역치를 낮추는 것을 호함한 중요한 통각 구심성 변화가 일어남. 

- 이어서 나타나는 염증은 통각 수용기 반응이 배가됨. 

- 또다른 중요한 관찰은 .. 이러한 통각수용기는 수용야를 넓힐 수 있고, 그 결과 조직손상이 일어나지 않은 부위까지 통증 발생.

- 이러한 수용야 팽창은 통각수용기는 주어진 자극보다 더 활성화될수록, 중추로 구심자극은 공간적 중합이 일어남. 

Most importantly, research has found a new class of  nociceptive afferent neurons-termed sleeping nociceptors, silent afferents, or mechanically insensitive afferents-that may comprise up to 25% of deep somatic tissues (Koltzenburg, 1 995) . 

- sleeping nociceptor(silent nociceptor)의 개념이 최근 제시됨. 깊은 체성 조직의 25%넘게 존재함. 

According to Koltzenburg, these afferents aggressively respond to inflammatory chemicals, remaining active for prolonged periods of time after exposure and causing adverse plastic changes in the CNS. Minor tissue trauma results in temporal summation and increased responsiveness of nociceptors to a stimulus. Spatial summation, which may range from the acquisition of new receptive properties to the expansion of receptive fields, enhances the overall activity of nociceptors.

- 콜첸버그에 의하면 이 구심섬유는 염증성 화학물질에 반응하여 중추신경에서 반소성변화를 일으킴....

- 작은 충격은 작은 중합을 일으켜 통각자극에 반응이 증가

- 공간적 중합은 수용야의 확장특성이 일어남. 그래서 통각수용기 활동이 전체적으로 증가함. 

Recruitment of sleeping nociceptors requires time and tissue injury and represents a response of the peripheral nociceptive system to significant chemical tissue injury ( inflammation), with implications for the development of persisting pain. While most of the changes in nociceptive function are resolved  when tissue injury heals, the potential exists for permanent alteration of nociceptor activity that can result in prolonged, increased excitability of the peripheral nociceptive system and thereby exert continuous influence on central excitability (Koltzenburg, 1 995).

- 수면 통각수용기의 동원은 조직손상과 시간이 필요함. 이 반응과정에서 염증 시스템은 지속적인 통증발달을 일으킴. 

After tissue injury, nociceptive receptors respond to released chemical mediators that promote inflammation and stimulate nociceptive pathways. When the affected area in a surrounding tissue is placed in a relaxed position, the result is improved vascular and interstitial circulation that may assist in removal of the chemical mediators reducing further release and decreasing m uscle guarding. Studies have demonstrated that deep pressure exerted on soft tissue creates a reduction in muscle activity; von Euler and Soderberg ( 1 958) discovered that light touch can affect skin temperature and reduce gamma motor neuron activity (Johansson, 1 962; Folkow, Gelin, Lindell, Stenberg, Ct Thoren, 1 962; Koizumi Ct B rooks, 1 97 2;

Von Euler Ct Soderberg, 1 958). 

- 조직손상후 유해자극수용기는 염증을 촉진하는 화학적 중개물질을 분비하고 통각전도를 자극함. 

Some of these studies have discovered an increase in vagal tone during slow, deep pressure application. The increase in vagal fiber activity will lead to autonomic changes-particularly an increase in parasympathetic activity, resulting in some of the following effects : decreased heart contraction, coronary blood vessel constriction, bronchial constriction, peristalsis stimulation, and conservation of glycogen. In addition, increased vagal tone stimulates the hypothalamus and results in a generalized global reduction in muscle tone. 

- 탐구에 의하면 slow, deep pressure 적용동안 vagal tone이 증가함을 발견함. vagal tone증가는 부교감 활성을 일으켜...

- 심장수축감소, 관상동맥 수축감소, 기관수축감소, ...

- 증가하는 vagal tone은 시상하부를 자극하여 muscle tone감소를 야기함. 

The opposite, muscle contraction, can be seen with quick deep-pressure application ( Eble, 1 960). Simultaneously, Ruffini endings have been associated with sympathetic nervous system suppression (Van den Berg Ct Capri, 1 999).

- 근수축은 빠른 deep pressure 적용과 함께 볼 수 있음. 

- 동시에 루피지 종말은 교감신경 억제와 연관되어 있음. 

Finally, interstitial fibers (fibers III and IV) affect  diffusion of blood plasma from the vascular vessels into the extracellular matrix (ECM); the result is a lower viscosity of the ECM (Cottingham, 1 985).

- 결국 내장섬유는 혈장확산, 세포외기질 확산에 영향을 주고. 그 결과는 세포외기질의 낮은 점탄성임 

Using this fact, along with some of the other characteristics of interstitial fibers, Schleip (2003b) developeda flowchart of the processes involved in the neural dynamics of immediate tissue plasticity in myofascial manipulation (Figure 4-6).

INTRAFASCIAL CELLS CONTROL CONTRACTILITY

On closer inspection of Figure 4-6, it is evident that the flowchart includes a pathway that has not yet been discussed. Studies have shown the presence of "smooth muscle cells" (myofibroblasts) within fascial tissue (Staubesand Et Li, 1 996) . This is how many researchers have explained the fact that fascia can actively contract, or regulate "intrafascial pre-tension. "

Myofibroblasts are elongated, spindly, connective tissue cells speculated to be derivatives of fibroblasts. The reason for this speculation is that the two cells are physiologically similar. However, myofibroblasts also have dispersed actin filaments similar to a smooth muscle cell, even though these two cells are dissimilar. While a smooth muscle cell is surrounded by an external lamina, myofibroblasts do not have such a covering.

There are theories that postulate that regulation of these intrafascial cells occurs through the sympathetic nervous system, vasoconstricting substances, and neurotransmitters (Schleip, 2003b). It is known that smooth muscle cells are usually under the regulatory control of postganglionic neurons of the ANS. 

Therefore, it would make sense that in order for fascia to contract, or provide tension, the sympathetic system would be stimulated. This system is responsible for the fight-or-flight response, in which muscles need to push off their fascial surroundi ngs to Function properly. Therefore, fascia has to be tensioned, up to a point, to perform its various Functions.

However, heightened sympathetic system stimulation, or suppressed parasympathetics, can create prolonged tension that affects the fluidity of connective tissue. In focusing on Figure 4-6, it can be seen that stimulation of sensory fibers (Pacinian corpuscles, Ruffini endings, and interstitial fibers) can affect the ANS, which will then normalize intrafascial cell activity. This sequence of events is another plausible explanation for the i m mediate short-term changes seen with soft t issue manipulation.

Interestingly, evidence suggests that these intrafascial cells a re also control led by substances such as carbon dioxide (a vasoconstrictor) and a number of neurotransmitters. In one study, high levels of carbon d ioxide led to i mmediate smooth muscle cell constriction (Staubesand Et Li, 1 996). Furthermore, there is evidence that serotonin and h o rmones released

by the posterior p it u i t a ry ( m ai nly oxytocin) have been l i nked to smooth muscle cell stimulation. 

It is stimulants l i ke these (vasoconstrictors a n d neurotransmitters) that many experts in the field use to explain some of the myofascia-rel aged conditions and injuries seen. For example, Schleip (2003b) explains how hyperventilation (increased carbon

dioxide) and high levels of serotonin i n the cerebrospinal fluid of fibromyalgia patients a re possible  causes for the generalized signs and symptoms of tension and pain felt by these patients.

Summary

This chapter a t tempts to e x p l a i n the neurophysiology of fascial plasticity other than that based on shortcomings of t h i xotropy a n d piezoelectricity. A detailed examination of the structure of fascia a n d the nervous system h a s shown a direct connection of fascia with the autonomic nervous system (ANS) such that manipulation of the fascia a ffects the ANS and organs connected to it.

The network of mechanoreceptors in fascia is dense, a n d the degree of manual manipulation of fascia affects the involvement of d i fferent receptor types. Ruffini receptors respond to deep, slow pressure whereas Pacinian receptors react to rapid application

o f compress ion. Furthermore, the presence of smooth muscle cells embedded i n fascia accounts for tissue contract i o n . Therapists who a re fam i l i a r w i t h t h e physiology a n d a n atomy of t h e nervous system can i m p rove their m anual therapeutic techniques for a better tissue response.

[문형철]

정상 콜라겐 섬유의 반감기는 400~500일, 기질의 반감기는 대략 2~8일
- 비록 반감기는 정상조직을 위한 개념이지만, 손상된 섬유막은 거의 비슷함. 비록 때때로 섬유막조직 치료의 즉각적인 효과와 시간이 연관성이 없을지라도..
- 수기치료로 변화하는 점탄성 변화의 완전한 설명은 생화학적임. 앞으로 논의될 것임.