fascia(근막)의 수축과 load bearing 능력에 관한 2010년 최신 논문

[문형철]

정적인 자세에서 근육은 거의 수축하지 않는다. 그렇다면 어떤 기능이 자세를 유지하는가?

20년전에는 titin이 elasticity가 높아 그 기능을 할 것이라고 추정했었다. 

10년전 연구에 의하면 그 기능을 결합조직(perimysium)이 한다고 결론이 나고 있다. 

passive muscle stiffness

resting length

muscle tension relationship

muscle의 기능을 다양한 방식으로 쪼개서 이해하기 위한 노력이다. 

결국 인체는 근육이라는 effector로 움직일 수 있기 때문에 그 무엇보다 이 문제를 정확하게 이해하는 것이 중요하다

그러한 관점에서 볼때, muscle fascia의 기능은 무엇인가? load bearing capacity! 골격의 유지. 재생... 등 이러한 관점에서 더욱더 깊은 공부가 완성되어야 한다. 

facial network 근막의 load bearing capacity.pdf

The fascial network: an exploration of its load bearing capacity and its potential role as a pain generator

Robert Schleip, Fascia Research Project, Institute of Applied Physiology, Ulm University, Ulm, Germany

Adjo Zorn, Fascia Research Project, Institute of Applied Physiology, Ulm University, Ulm, Germany

Frank Lehmann-Horn, Fascia Research Project, Institute of Applied Physiology, Ulm University, Ulm, Germany

Werner Klingler, Department of Anesthesiology, Ulm University, Germany

Keywords: Fascial tonicity, fascial innervation, myofibroblasts, lumbar fascia, microtearing

Objectives

While fasciae have been treated as the virtual ‘cinderella tissue of orthopedic research’ during recent decades, new methodological findings and hypotheses suggest that the bodywide fascial network may play a more important role in musculoskeletal medicine than is commonly assumed. 

- fasciae가 지난 세기동안 정형외과 연구에서 신데렐라와 같이 천대받는 조직으로 대우됨. 최신 논문에 의하면 bodywide fascial network는 근골격계 의학에서 매우 중요하게 인식되고 있음. 

However, in the literature there is great diversity as to which tissues are to be included under the term ‘fascia’ – be it the superficial fascia, the endomysium, perineurium, visceral membranes, aponeuroses, retinaculae or joint/organ capsules. Following the proposed comprehensive terminology of the 1st Fascia Research Congress, this brief review considers all collagenous connective tissues as ‘fascial tissues’ whose morphology is dominantly shaped by tensional loading and which can be seen to be part of an interconnected tensional network throughout the whole body (Findley & Schleip 2007). 

- 하지만 논문에서 아주 다양한 이름으로 불리워짐. superficial fascia, endomysium, perineurium, visceral membrane, aponeuroses, retinaculae, joint capsule  등

- 2007년에 첫번째  Fascia Research Congress에서 fascial tissue로..

While morphological differences between aponeuroses and lattice-like or irregular fasciae can still be properly described with this terminology, it allows seeing specific tissue – e.g. septae, capsules and ligaments – as local adaptations of this ubiquitous network based on specific loading histories. What are the biomechanical functions of this fascial network, and what role do they play in musculoskeletal dysfunctions? 

- aponeuroses와 격자모양, 또는 irregular fasciae의 형태학적 차이는 위와같은 용어로 묘사하는게 적합할 수 있음. 

- fascial network의 생체역학적  기능은 무엇인가? 그리고 근골격계 기능부전에서 그들은 어떤 역할을 하는가? 

This brief literature review will highlight the load-bearing function of different fascial tissues and also their tendency to microtearing during physiological or excessive loading.  It will review histological studies indicating the proprioceptive as well as nociceptive innervation of fascia. Finally the potential role of injury, inflammation and/or neural sensitization of the posterior layer of the human lumbar fascia in nonspecific low back pain will be explored.

- 이 논문은 different fascial tissue의 load bearing 기능에 초점을 맞추어 review

-  그리고 fascial tissue가  physiological or excessive loading동안 미세 손상을 입는 경향성에 대해 review

Fig. 1: Layers of lumbar fascia in a horizontal cross section of the human trunk at the layer of L4.

Note the large distance between the posterior layer of the lumbar fascia (PLF) and the axis of spinal flexion, making this layer susceptible to large strain deformations during forward bending. Note also the close association of the transversus abdominis (innermost abdominal muscle) with the middle layer of the lumbar fascia (MLF). 

ES: erector spinae. PS: psoas. QL: quadratus lumborum. ALF: anterior layer of lumbar fascia. Illustration adapted from the NPAC/OLDA Visible Human Viewer [17] with permission.

Findings

Fascial force transmission is an important player in human biomechanics 

While the tensional load bearing function of tendons and ligaments has never been disputed, recent publications from Huijing et al. revealed that muscles, via their epimysia, also transmit a significant portion of their force to laterally positioned tissues such as to adjacent synergistic muscles and also – more surprisingly - to antagonistic muscles (Huijing 2009). 

- 건과 인대의 tensional load bearing 기능이 논쟁되지 않는 동안, 휴징의 최신연구에서 근육이 결합조직을 통해 그들 힘의 상당부분을 전달한다는 것을 밝혀냄. 

- 그 힘을 전달하는 방법은 adjacent synergistic 근육과 같이 옆에 위치한 조직에 전달. 놀랍게 길항근에도 힘을 전달함. 

The reported contribution of M. transversus abdominis to dynamic lumbar spinal stability has been associated with the load-bearing function of the middle layer of the lumbar fasciae in humans (Barker et al. 2007). Similarly, EMG based measurements of the ‘flexion-relaxation phenomenon’ suggest a strong tensional load-bearing function of dorsal fascial tissues during healthy forward bending of the human trunk. This load shifting is reportedly absent in low back pain patients (Shirado et al. 1995.

- 요추 동적안정성에 복횡근의 역할담당은 middle layer of lumbar fasciae의 load bearing function과 연관되어 있음. 

- 마찬가지로 flexion-relaxation phenomenon의 EMG검사 결과를 보면 건강한 사람이 몸통을 앞으로 구부릴때 dorsal fascial tissue의 strong tensional load-bearing function을 보여줌. 

- 이러한 load shifting은 요통환자에게서 사라지는 것으로 보고됨. 

Recent 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. 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).

- 최신 초음파연구에 의하면 fascial tissue는 걷기, 점프하기, 달리기와 같은 변동성 움직임 동안 dynamic energy storage를 위해 사용된다고 함.

- 이러한 움직임 동안 근골격계 근육은 좀더 등척성으로 수축하고, 부하가 주어진 fascial element는 탄력성있는 스프링과 같이 늘어나고 짧아짐. 

Fascial tissues are prone to deformation

Fibrous collagenous connective tissues are prone to viscoelastic deformations such as creep, hysteresis and relaxation. Such temporary deformations alter fascial stiffness and complete recovery may take up to several hours. Load-bearing tests also reveal the existence of a gradual transition zone between reversible viscoelastic deformation and complete tissue tearing. Various degrees of microtearing of collagenous fibers and their interconnections have been documented to occur within this transition zone (Butler et al. 1978).

- fibrous collagenous connective tissue는 creep, hysteresis, relaxation과 같은 viscoelastic deformation 경향을 보임. 이러한  일시적인 변형은 fascial stiffness를 바꾸고, 완전한 회복은 몇시간이 소요됨. 

- load bearing 검사는 정상화 가능한 viscoelastic deformation과 완전한 조직손상 사이에 gradual transition zone의 존재를 보여줌. 다양한 콜라겐 섬유의 미세손상의 정도와 그들의 연결성은 이 transition zone내에서 일어난다고 보고함. 

The fascial network serves as a sensory organ

Fascia is densely innervated by myelinated sensory nerve endings which are assumed to serve a proprioceptive function. These include Pacini (and paciniform) corpuscles, Golgi tendon organs and Ruffini endings (Stecco et al. 2010). In addition they are innervated by free endings. When including periosteal, endomysial and perimysial tissues as part of a bodywide interconnected network, this fascial net can be seen as our largest sensory organ. It is definitely the richest sensory organ for the the so called sixth sense, the sense of proprioception (Schleip 2003).

- 근막은 두텁게  myelinated sensory nerve endings에 의해 innervated되어 있어, 고유수용감각기능을 담당하는 것으로 추정됨. 근막은 파치니 소체, GTO, 루피니 엔딩을 포함함. 또한 free nerve ending이 신경지배함. 

- bodywide interconnected network의 일부로서 periosteal, endomysial and perimysial tissues를 포함할때, 이 fascial net(근막의 망)은 우리 몸의 largest sensory organ으로 관찰될 수 있음. 분명하게 6번째 감각인 고유수용감각이 풍부한 기관임. 

Fascia can be a source of nociception

More recent histological examinations have shown that some of the free nerve endings in fascia are substance P containing receptors which are commonly assumed to be nociceptive (Tesarz 2009). Delayed onset muscle soreness (DOMS) can be induced by repetitive eccentric contraction. Interestingly, a recent experimental study revealed that the epimysial fascia of the affected musculature plays a major role in the generation of DOMS related pain symptoms (Gibson et al. 2009).

- 최신의 조직학적 연구에서 근막에 있는 free nerve ending의 일부는 물질 P를 포함하는 수용기이고 유해자극으로 인정되고 있음. DOMS는 반복적인 원심성 근수축에 의해 유도될 수 있음. 흥미롭게 최근 실험연구는 다음과 같은 사실을 보여줌. affected musculacture의 epimysial fascia은 DOMS와 연관된 통증 발생에서 중요한 역할을 한다고 함. 

The human lumbar fascia as potential generator of low back pain

Panjabi’s new explanatory model of low back pain injuries suggests that a single trauma or cumulative microtrauma causes subfailure injuries of paraspinal connective tissues and their embedded mechanoreceptors, thereby leading to corrupted mechanoreceptor feedback and resulting in further connective tissue alterations and neural adaptations (Panjabi 2006).

- 판자비의 요통에 관한 새로운 설명모델은 다음과 같이 제안함.  single trauma or cumulative microtrauma는 paraspinal connective tissue와 embedded mechanoreceptor의 subfailure 손상을 야기함. 그래서 corrupted mechanoreceptor feedback을 야기하고 neural adaptation과 connective tissue alteration을 야기함. 

Our group subsequently proposed an extension of that model which includes the posterior layer of the lumbar fascia as a potential focus of such microtrauma and resulting muscle control dysfunction. Factors raised in support of that explanation include the long distance of this layer from the axis of spinal flexion (Fig. 1) as well as its lesser stiffness compared with spinal ligaments (Schleip et al. 2007).

- 우리 연구그룹은 이어서 확장된 모델을 제시함. muscle control dysfunction을 초래하고 microtrauma의 가능성으로서 lumbar fascia의 post layer를 포함....

- 이 설명을 지지하는 요소는 그림1에서 보여지는 요추굴곡 축으로부터 long distance of this layer를 포함. 뿐만아니라 spinal ligament와 비교하여 lesser stiffness..

Langevin reports that the posterior layer of the lumbar fascia tends to be thicker in chronic low back pain patients. In addition it expresses less shear motion during passive trunk flexion (Langevin et al. 2009). Surgical examinations of the posterior layer of the lumbar fascia revealed frequent signs of injury (Bednar et al. 1995) and of inflammation (Dittrich 1963, Dittrich 1964) in low back pain patients.

- Langevin은 요추근막의 post layer는 만성요통환자에서 좀더 굵어지는 경향이 있다는 것을 보고

- 게다가 수동적인 trunk flexion동안 less shear motion(전단력이 덜한 움직임)을 표현함

- posterior layer of the lumbar fascia 수술 연구는 요통환자에서 염증과 손상의 흔한 sign으로 보여줌.

 In addition new histological examinations at our laboratory have shown a high density of myofibroblasts, the existence of which is usually associated with excessive loading or injury repair – in the same fascial layer (Schleip et al. 2007). And finally, injection of the inflammatory agent Freund Adjuvans solution into the rat lumbar muscles resulted in a dramatic increase in the proportion of dorsal horn neurons with input from the posterior lumbar fascia (Taguchi et al. 2009).

- 새로운 조직학적 연구에서  high density of myofibroblasts를 보여주는데, 이 존재는 손상회복 또는 과도한 부하와 연관됨. 

Conclusions

Fascial tissues serve important load-bearing functions. Severe tensional loading can induce temporary viscoelastic deformation and even microtearing. The innervation of fascia indicates a potential nociceptive function. Microtearing and/or inflammation of fascia can be a direct source of musculoskeletal pain. In addition, fascia may be an indirect source of physical problems such as back pain due to a sensitization of fascial nerve endings associated with inflammatory processes in other tissues within the same segment. 

- 섬유막은 중요한 load bearing 기능을 가짐. 

- 반복적인 장력부하는 섬유막의 일시적인 점탄성 변형과 심지어 미세손상을 야기함. 

- 섬유막의 신경지배는 통증기능을 의미함. 

- 섬유막의 미세손상, 염증은 근골격계의 직접적인 통증 요인임. 

- 게다가 섬유막은 요통과 같은 문제의 간접적인 원인임. 

Acknowledgements

The authors would like to recognize the financial support provided by the International Society of Biomechanics, the Rolf Institute for Structural Integration, the European Rolfing Association, and the 2006 Vladimir Janda Award for Musculoskeletal Medicine.

References

Barker PJ, Urquhart DM, Story IH, et al. 2007 The middle layer of lumbar fascia and attachments to lumbar transverse

processes: implications for segmental control and fracture. Eur Spine J 16(12): 2232-7

Bednar DA, Orr FW, Simon GT 1995 Observations on the pathomorphology of the thoracolumbar fascia in chronic

mechanical back pain. A microscopic study. Spine 20(10): 1161-4

Butler DL, Grood ES, Noyes FR, et al. 1978 Biomechanics of ligaments and tendons. Exerc Sport Sci Rev 6: 125-81

Chang Y-J, Coddington P, Hutchens K: Viewing the Visible Human using Java and the Web. In: Yang Y, Li M, Ellis A

(Eds.) Web Technologies and Applications, Proceedings of the Asia Pacific Web Conference (APWeb) 1998,

International Academic Publishers, Tokyo, p.121-129 (1998)

Dittrich RJ 1963 Lumbodorsal fascia and related structures as factors in disability. J Lancet 83: 393-8

Ditrrich RJ 1964 Lumbodorsal fascia and related structures as factors in disability. Appl Ther 6: 923-7

Findley TW, Schleip R (eds.) 2007 Fascia research – basic science and implications for conventional and

complementary health care. Elsevier GmbH, Munich

Fukunaga T, Kawakami Y, Kubo K, et al. 2002 Muscle and tendon interaction during human movements. Exerc Sport

Sci Rev 30(3): 106-10

Gibson W, Arendt-Nielsen L, Taguchi T, et al. 2009 Increased pain from muscle fascia following eccentric exercise:

animal and human findings. Exp Brain Res 194(2): 299-308

Huijing PA 2009 Epimuscular myofascial force transmission: a historical review and implications for new research.

International Society of Biomechanics Muybridge Award Lecture, Taipei, 2007. J Biomech 42(1): 9-21

Langevin HM, Stevens-Tuttle D, Fox JR, et al. 2009 Ultrasound evidence of altered lumbar connective tissue structure

in human subjects with chronic low back pain. BMC Musculoskelet Disord 10: p.151

Panjabi MM 2006 A hypothesis of chronic back pain: ligament subfailure injuries lead to muscle control dysfunction.

Eur Spine J 15(5): 668-76

Schleip R 2003 Fascial plasticity – a new neurobiological explanation: Part 1. Journal ofBodywork and Movement

Therapies 7: 11-19

Schleip R, Vleeming A, Lehmann-Horn F, et al. 2007 Letter to the Editor concerning „A hypothesis of chronic back

pain: ligament subfailure injuries lead to muscle control dysfunction“ (M.Panjabi). Eur Spine J 16: 1733-35

Schleip R, Klingler W, Lehmann-Horn F 2007 Fascia is able to contract in a smooth muscle-like manner and thereby

influence musculoskeletal mechanics. In: Findley TW, Schleip R (eds.) 2007 Fascia research – basic science

and implications for conventional and complementary health care. Elsevier GmbH, Munich, p.76-77

Shirado O, Ito T, Kaneda K, Strax TE 1995 Flexion-relaxation phenomenon in the back muscles. A comparative study

between healthy subjects and patients with chronic low back pain. Am J Phys Med Rehabil 74(2):139-44

Stecco C, Macchi V, Porzionato A, et al. 2010 The Ankle Retinacula: Morphological Evidence of the Proprioceptive

Role of the Fascial System. Cells Tissues Organs, Epub ahead of print, PMID 20197652

Tesarz J 2009 The innervation of the fascia thoracolumbalis. In: Huijing PA, Hollander P, Findley TW, Schleip R (eds.)

2009 Fascia research II – basic science and implications for conventional and complementary health care.

Elsevier GmbH, Munich, p.37

Taguchi T, Tesarz J, Mense S 2009 The thoracolumbar fascia as a source of low back pain. In: Huijing PA, Hollander

P, Findley TW, Schleip R (eds.) 2009 Fascia research II – basic science and implications for conventional

and complementary health care. Elsevier GmbH, Munich, p.251

Published in:

Vleeming A et al.: Proceedings of the 7th Interdisciplinary World Congress on Low Back & Pelvic

Pain, Los Angeles, November 9-12, 2010, ISBN 978-90-816016-1-0, page 215-218

Further information: www.fasciaresearch.com

E-mail contact: robert.schleip@uni-ulm.de

[여인호]

읽기

[문형철]

섬유막은 중요한 load bearing 기능을 가짐.
- 반복적인 장력부하는 섬유막의 일시적인 점탄성 변형과 심지어 미세손상을 야기함.
- 섬유막의 신경지배는 통증기능을 의미함.
- 섬유막의 미세손상, 염증은 근골격계의 직접적인 통증 요인임.
- 게다가 섬유막은 요통과 같은 문제의 간접적인 원인임.

[문형철]

Fascia is densely innervated by myelinated sensory nerve endings which are assumed to serve a proprioceptive function. These include Pacini (and paciniform) corpuscles, Golgi tendon organs and Ruffini endings (Stecco et al. 2010). In addition they are innervated by free endings. When including periosteal, endomysial and perimysial tissues as part of a bodywide interconnected network, this fascial net can be seen as our largest sensory organ. It is definitely the richest sensory organ for the the so called sixth sense, the sense of proprioception (Schleip 2003).

- 근막은 두텁게 myelinated sen