Fascia is the soft tissue component of the connective tissue system that permeates the human body. It forms a whole-body continuous three-dimensional matrix of structural support1. Fascial pain is a common dysfunction with a lifetime prevalence affecting up to 85% of the general population2. Fascial pain can be the result of a variety of musculoskeletal injuries or conditions. These injuries or conditions over time can cause adhesions in the dermis and myofascia.
When the fascia is in its normal healthy state it is a relaxed and flexible. When it is restricted, it is more rigid and less pliable, and can create pulls, tensions, and pressure as great as 2,000 pounds per square inch3. Current treatment for fascial pain or adhesions includes traditional therapy methods and conventional medical treatments that include manual physical therapy, exercise and massage. Dermo-Myofascial Release technique℠ (DMR) is an innovative approach to treating musculoskeletal conditions. DMR releases and restructures scar tissue that connects the superficial layers to the deeper layers of myofascia, tendons, nerve, and bone—without causing further injury to healthy tissue.
Although there are a variety of treatment options available, the ability to quantify and visualize the impact of treatment has been elusive in the field of physical therapy. Today, an ultrasound technique, ShearWave Elastography™ (SWE) shows promise for its ability to evaluate, monitor and guide the treatment of fascial injuries.
ShearWave Technology
ShearWave Elastography, a non-invasive exam, offers information not only on muscle, tendon and tissue stiffness, but also facilitates real-time imaging of the changes in tissue stiffness due treatment.
A wide shear wave region of interest (ROI) gives a large view of the tissues and helps to localize abnormal zones. SWE provides millimeter resolution for the characterization of tissue and injuries, as well as qualitative and quantitative monitoring of tissue stiffness after patient therapy or surgery4.
SWE generates a two-dimensional, color-encoded map of tissue elasticity superimposed on a B-mode image of the same area for anatomical correlation. In the case of the Aixplorer® from Supersonic Imagine, pioneers of the technology, its family of transducers are designed to permit high resolution imaging of muscles, tendons and ligaments, including those located very superficially on the body.
Evaluating Treatment Efficacy
In an effort to evaluate the effectiveness of treatment of various conditions, we examined three cases using SWE representing a range of musculoskeletal problems: chronic meralgia parasthetica, chronic shoulder impingement pain and post-operative pain following five foot surgeries.
ShearWave Elastography was used to quantify tissue condition at the beginning, middle and end of therapy. Markings were used to precisely identify anatomical positioning. SWE identified areas of increased tissue stiffness with widespread fascial adhesions. The concomitant results guided manual treatment to reduce both tissue stiffness and pain. SWE provided a method to visualize fascial adhesions in real time. Outcomes also included improved elasticity and functionality.
Through the use of SWE, the percent decrease in fascia stiffness was able to be quantified. The results demonstrated a range of 63-75% decrease in tissue stiffness. In addition, a 90-100% increase in clinical improvement was observed. (See case studies below).
CASE STUDY: PRE/POST-TREATMENT OF CHRONIC MERALGIA PARESTHETICA
63% reduction in fascia stiffness; 100% clinical improvement
CASE STUDY:PRE/POST-TREATMENT CHRONIC SHOULDER IMPINGEMENT PAIN 64% reduction in fascia stiffness (right supraspinatus); 90% clinical improvement
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CASE STUDY: PRE/POST-TREATMENT FOOT SURGERY
75% reduction in fascia stiffness; 90% clinical improvement.
Clinical Impact
SWE has the potential to have a broad clinical impact on the practice of physical therapy. For the therapist, the real-time imaging requires no manual compression, which improves reliability and reproducibility by removing variation among user.
In addition, the ultrafast real-time imaging of SWE allows the therapist to visualize areas of fascial stiffness that may not have been identified by palpation. In doing so, treatment can be altered (again in real-time) to produce the most effective result for the patient. This also provides the therapist with an improved level of diagnostic confidence. The ability to identify, quantify and adjust treatment is an exciting concept in the physical therapy setting.
For the patient, the ability to see how the tissue has become adhered and circulation is reduced during a baseline assessment is enlightening. This is magnified throughout the course of treatment, when the patient can then see the direct impact of the intervention on stiffness and ultimately improved function. The technology also has an impact on the therapist/patient interaction, which cannot be understated. For example, a patient, who also happened to be a physician, was able to see how tissue stiffness normalized and her ability to function dramatically improved.
Conclusion
ShearWave Elastography introduces a new method to identify, visualize and monitor treatment therapies in real time. Therapists can now improve their effectiveness using objective tools to measure treatment outcomes which offer qualitative and quantitative monitoring of tissue stiffness following therapy or surgery.
The precision of this advanced technology provides diagnostic information that can directly impact patient care and outcomes that has until now been unavailable.
Although more studies are needed to demonstrate results across a wide variety of treatment therapies within the field of physical therapy, the initial results of our experience has been overwhelmingly positive.
References
- http://www.fasciacongres
- Myofascial Therapy for the Treatment of Acute and Chronic Pain. http://www.spine-health.com/treatment/physical-therapy/myofascial-therapy-treatment-acute-and-chronic-pain. Accessed on November 2, 2015.
- http://www.supersonicimagine.com/Aixplorer-R/General-Imaging/Musculoskeletal. Accessed on November 2, 2015.
