The Science of Fascia

Excuse all the ‘scientific’ language here, I will attempt to explain the narrative as well as possible. Educating you is free.

Fascia is ‘connective tissue’, the ‘white sing wrap’ as seen below around the leg.

Fascia is organized as an interconnected, multi-dimensional network. It wraps around every cell, tissue and organ. Think of it like a web that supports the bones, muscles, etc.; without it the body would fall apart. Fascia is formed by collagen fibers and elastic fibers arranged in distinct layers, and within each layer the fibers are aligned in a different direction. Due to its undulated collagen fibers, fascia can be stretched and, thanks to its elastic and ‘smooth muscle’-like fibers, it can then return to its original resting state.

While part of the fascia is anchored to bone, part is also always free to slide. The free part of the fascia allows the muscular traction, or the muscular effort you are using to move, to converge at a specific point. It is hypothesized, that the richly innervated fascia could be maintained in a resting state of tension due to the different muscular fibers that insert onto it. Due to this optimal resting state, or starting tension of the fascia, the free nerve endings and receptors within the fascial tissue are primed to perceive any variation in tension and, therefore, any movement of the body,whenever it occurs.

So what happens when fascia gets tight, distorted or rigid?

Well, that is where that tight feeling in your hamstrings comes from, it even can create those lumpy looking chunks in your rear end, and cause pain like plantar fasciitis of your heel.

As you age, workout and sit; still your fascia becomes a little more sticky, rigid and creates adhesions. These adhesions can restrict movement, create a tight feeling around the muscle like wearing jeans that are way too tight, and lead to injury and pain if left untreated.

Cellulite (medical name gynoid lipodystrophy) is found in 85% of post-adolescent women (Rossi & Vergnanini 2000, Avram 2004, Khan et al. 2010, de la Casa Almeida 2013). Gynoid lipodystrophy (GLD) is a structural, inflammatory, and biochemical disorder of the subcutaneous tissue causing alterations in the topography of the skin. Commonly known as “cellulite,” GLD affects up to 85% of women, practically in all stages of the life cycle, beginning in puberty. It is a clinical condition that can considerably affect the patients’ quality of life.

Cellulite is normally categorized into 3 grades (4 if you include no cellulite). The grades are important as several studies have shown patients can normally be improved by 1 grade (Schlaudraff et al 2014). The grades are (grade 0 is no dimpling even with pressure applied):

Dimpling when pressure applied
Dimpling visible standing but not lying down
Dimpling visible even when lying

Cellulite usually develops in different people in different areas, most commonly the thighs, buttocks, abdomen and upper arms, and if well enough developed becomes visible (often referred to as “orange peel” in appearance).

Cellulite is characterised by an irregular, dimpled skin surface with thinning of the epidermis/dermis and the presence of nodular clusters of fat cells (Rossi & Vergnanini 2000, Avram 2004, Khan et al. 2010, de la Casa Almeida 2013).

The development of cellulite is said to be related to various predisposing factors, such as biotype, heredity, ethnic background, body weight, age, hormonal changes, smoking, and genetic predisposition (Rossi & Vergnanini 2000, Avram 2004, de la Casa Almeida 2013, Emanuele et al. 2010, Stavroulaki et al. 2011).

Four main hypotheses of cellulite development have emerged:

Different anatomical conformation of the subcutaneous tissue (altered connective tissue septae with sclerotic fibrous tissue septae responsible for ‘mattress’ appearance) in women compared with men; (Nurnberger & Muller, 1978, Rosenbaum et al, 1998)
Changes in the biomechanical properties (skin compliance or elasticity) of epidermal and dermal tissues; (Rosenbaum et al, 1998)
Excessive hydrophilia of the extracellular matrix increasing interstitial pressure and causing oedema of the fatty tissue; (Smalls et al, 2005)
Alterations in both microvascular and lymphatic circulation resulting in the often painful protrusion of subcutaneous adipose tissue into the lower reticular dermis, causing distinctive mattress-like surface irregularities. (Lotti et al, 1990)

However, the skin and underlying structures are likely more complex than we originally thought (Lotti et al, 1990) and each explanation could be thought of as mutually conflicting (Schlaudraff et al, 2014).

Recently inflammation has been said to contribute to the formation of cellulite (Terranova et al, 2006, Avram et al, 2005).

How does shockwave reduce cellulite?

Already used to treat fibrotic scar tissue, treatment with extracorporeal
shockwaves is an effective therapeutic means for noninvasive
treatment of GLD. The shockwaves reach the tissue’s surface
and cross the homogeneous barrier without damaging
other areas, which increases the blood flow in the target site.

Cellulite’s cause involves the deterioration of the dermal
vasculature, which causes edema and tissue hypoxia.
Subsequently, there is a thinning and sclerosis of the fibrous septa of the subcutaneous area, which are permeated by a chronic inflammation. Do you suffer from those painful trigger points at the base of your neck-shoulders? Because they form in exactly the same process.

Many articles have described potential mechanisms for shockwave to reduce cellulite. Research has suggested pressure or acoustic waves are effective in disrupting the sclerotic fibrous tissue septa or fascial scar tissue, responsible for much of the uneven appearance of cellulite (Siems et al 2005).

However other effects have been postulated; Braun et al (2005) said the stimulation of blood and lymph circulation, increased membrane permeability, and the stimulation of the exchange of blood lipids. Angehrn et al (2007) said shockwave stimulated the metabolism of fat cells and increased expression of vascular endothelial growth factor, endothelial nitric oxide synthase, and proliferating cell nuclear antigen. Christ et al (2008) said reduced oxidative stress. Siems et al (2005) thought increased antioxidants (including ascorbic acid). Kuhn et al (2008) described induction of neocollagenogenesis and neoelastinogenesis. Ferraro et al (2012) thought increased angiogenesis and apoptosis of fat cells triggered by inflammation, and activation of C nerve fibers in the skin and release of substance P according to Schlaudraff et al (2014). Lots of science here!

There are many reports of successful treatment of cellulite with acoustic and radial shockwave therapy (RWST) in the literature (Sattler et al, 2008, Russe-Wilflingseder et al, 2013, Christ et al, 2008, Christ et al, 2008, Adatto et al, 2010) most showing RSWT can improve the clinical picture by one cellulite grade on average.

Schlaudraff et al (2014) said

“… in their clinical experience, the patient’s perception of their individual cellulite grade and consequently their satisfaction with the result of treatment for cellulite varies widely from one patient to another and is truly subjective. Normally, patients with low cellulite grades are more demanding and therefore more difficult to manage in their expectations, even if there is an objectively confirmed clinical improvement.”

They confirmed this in their analysis because patient satisfaction, the most important end point of any treatment for cellulite, did not correlate with improvement. There were patients with improvement by one cellulite grade who were very satisfied, whereas other patients with the same outcome were not satisfied at all.

They went further and said

“… For the clinical setting, this observation underlines the role of the therapist, who must correctly evaluate the suitability of the candidate for a cellulite treatment and must manage the patient’s expectations accordingly.”