SUMMARY KEYWORDS fascia, chronic pain, pain, injury, pain receptors, nervous system, body, moving, massage, nerves, movement, skin, work, shockwave, interacting, superficial layer, stretch, physio, flight freeze response, pain reduction strategies For those of you who regularly take Yoga Orkney classes, discussion around fascia and chat around chronic pain is common. This is deliberate for a couple of reasons:
1 - that it is really, really common for people to suffer a bout of pain lasting 4 weeks of more or pain with no discernible cause and
2 - talking about it reduces stigma and can support reduction of pain experienced by people who have battled with pain for a while.
It is common to have chronic pain but because we don't really discuss it, it can make for a very isolating experience for people suffering with and from chronic back pain. It is also worth acknowledging here at the beginning that I know and understand that chronic pain is real and that it can be debilitating for many people. Not only this, chronic pain severely impacts not only on quality of life but longevity too.
What is fascia and what has that got to do with my back pain?
While there are lots off different experiences of chronic pain I will use back pain as the example here as it's the most common form of chronic pain. Around 85% of people with chronic pain have chronic back pain and so far there hasn't been a cure that is easy to replicate a reduction of symptoms from one person to the next.
In order to build a little understanding let's learn a bit about fascia in the body. You can see an example of what fascia is like when you're chopping a chicken breast up for your dinner, you'll see the white fibre like stringy substance that kind of sticks the skin or between the different parts of the chicken meat that get held together. Kind of Like a gooey spider's web.
Fascia - the gooey spider's web
Fascia is not reserved for chickens, we also have this fascia in our body too. We are still working out how fascia integrates into our bodies, while it's likely to be throughout, it helps to think of it in two or maybe three layers each type or layer is rich in nerves and has its own unique function in the body. We will discuss the deep fascia, which is the kind that holds the organs together and tells your nervous system where those organs are and basically keeps watch on what they're doing, where we are in space. This process is called nonioception which is essential for communication of pain. Then we can think of a more superficial layer, which just means closer to the skin, which helps skin move, keeps it nourished with fluid but also helps develop a sense of pressure, temperature and movement.
Research on fascia only began in earnest in the year 2000. There were a few studies already on fascial networks, particularly within research around massage and physio, but nobody had really looked into it in any detail or with a view to establishing what impact the fascia plays on our health and wellbeing.
Newer research from 2000 onwards has shown that fascia is made from collagen and elastin, which give the fascia both movement and elasticity. All the strands of fascia need to glide over one another and in relation to other tissues in the body like skin and muscles. in 2020 it was established that the gel like substance that helps this happen is hyaluronic acid (a wholly grail of anti-aging products) which is made by a cell we've just discovered called a fasciacyte as well as another cell we already new about called a fibroblast.
So that's what helps keep the fascia in good order and if your fascia is in good order, then it's fine, you probably won't really think too much about it. You might have done things like foam rolling, you might have heard of trigger points and if you have chronic case of pain or back pain or fibromyalgia then it seems likely that your fascia will play a big part in that pain.
So back to pain and another reminder, as a chronic pain sufferer myself, it is fundamental to understand that the pain is happening. The important thing about the research into fascia and how it relates to pain is that it changes how we think about the way chronic pain is caused and why it is so long lasting. It's not that the pain hasn't been caused by an injury because sometimes it is kicked off by an injury or virus or some other form of ill health but often the pain remains after the initial injury has long healed.
To help understand why the lower back might be so vulnerable to this type of chronic pain a clue lies in the kind of diamond shape of the muscles, connections and bone structures there. If you think about (or even trace with your hands) underneath your ribs down towards the lower back, many connections meet there in a big diamond shape above your butt (see the white shape in the picture to the left). We have lots of interacting muscles working there, we have lots of interacting ligaments, your tendons, and also this area of the body picks up movement from the arms, the legs, the upper back, the feet making it challenging to know where the initial injury or problem might have been and why the pain is referred to (or felt in) the back. There is a huge network of fascia and a huge volume of nerve endings in this area.
Research is beginning to uncover how the fascia can become stiffer and less able to circulate the fluids that keep it health or provide the shock absorbing support of a health rebounding tissue. This is thought to lead to increased susceptibility to chronic pain and inflammation and also signals to the nerves to send pain or distress signals to the brain, even when there appears to be no injury at the site of the pain.
This means that when the fascia is not operating well or in the way that it expects too, the nerves that are housed in the fascia keep the pain receptors switched on. In one study I read, an early indication is that the number of pain receptors (nociceptors) are quadrupled in the fascia compared with other tissues in the body. This helps in understanding why fascia can be linked with increase perceptions of pain which makes fascia an extremely important factor to recognise when dealing with chronic pain.
When we are living with chronic pain, in the back or otherwise, it often leads to those in pain with a fear of moving. Understandably given that when you have chronic pain, oftentimes you don't know what caused the injury, and you can develop some (natural) fear and hesitancy around exercise and movement. You may become worried about causing more pain or making an injury worse. We are now beginning to understand that while we are still in pain that the injury has often healed, however the nerves and pain receptors have decided to stay switched on regardless. If we become more hesitant to move (we are fearful of hurting ourselves more), we reduce our movement, which reduces movement of the fascia, which may make the pain feel worse. That creates a loop that is likely to reduce chances of minimising pain, or even making it worse.
So what can be effective in reducing negative symptoms associated with chronic pain?
Treatments being trialled or used medically now include, shockwave therapies, hyaluronic acid injections, hydrocortisone injections and physiotherapy. Some people use acupuncture potentially some people find massage works for them. There is no evidence to view how these help but in the case of a trained acupuncturist or massage therapist you may get some temporary relief and the risk of unwanted side effects is extremely low meaning they can be a great option.
There is some convincing research around gentle movement and stretching (as little as two bouts of 5 mins. Also some promising results from gentle movement and mindfulness approaches show that getting the nervous system to come out of its flight or flight mode, freeze mode and into a more relaxed state can support the reduction of symptoms associated with chronic pain. That's As we have done in our Yoga Orkney exercise and movement sessions through the last couple of years.
The role of the Nervous System in Chronic Pain
Our nervous system gets split into different parts we have a the sympathetic nervous system, which kicks off your fight or flight freeze response which may
cause the fascia to contract again. In this state or alertness (excitement, nervousness or stress) the nervous system sends the nerves to signal that there might be pain or sends a signal to the pain receptors as well. Boom - we are back in the pain cycle. We end up with this lasting inflammatory response to an injury that can create problems around joints, frozen joints, dislocations, and things like that. What do you think that will do for your fear of movement?
If you haven't tried it yet you could have a shot at the Body Scan relaxation session. It is guided which helps give the mind something to do. You can find it below.
Click the image to play the body scan exercise.
How do hormonal cycles impact Chronic Pain?
In women the hormone cycle can cause a variety of impacts on the fascia. Oestrogen in particular impacts collagen and elastin tissues in the body. So if you are a woman who experiences pain around your hormonal cycle or a particular time and that hormonal cycle, or if you're going through the menopause or any other treatment where the hormones are impacted this has a chance of impacting the experience of chronic pain for you. The reduction of blood oestrogen level is associated with reduction in strength of muscles, reduces the amount of collagen produced, how often and how healthy the collagen fibre is an dhow it bundles itself together. This can also increase degradation in tendon tissues, increasing the risk of injury and create a more severe inflammatory response after an injury (i.e increase the risk of chronic pain). So we may want to alter what type of exercises we do at which point in the hormonal life-cycle or seek hormone replacement during menopause, which is always a personal choice for the individual based on your own experience.
Overall movement strategies applied well can reduce pain symptoms and improve mental health as well as having many physical benefits to the body. Use trial and error to try and find some relaxation techniques that help you reduce overloads on the nervous system maybe it's yoga, pilates, tai chi, mindfulness, breathing exercises, walking the dog in nature or a swim. Something that prioritises deep relaxation over physical developments. A decent stretch can help decompress the fascia and don't rule out a little more support from a medicine, from a Doctor, a physio, or trained masseuse.