Fascia & Pain: What We Know (with Dr Helen Langevin):
In this episode of the Thinking Practitioner podcast, Dr. Helen Langevin sheds light on an essential but often overlooked aspect of pain—myofascial tissues.
In this episode of the Thinking Practitioner podcast, Dr. Helen Langevin sheds light on an essential but often overlooked aspect of pain—myofascial tissues.
Full transcript provide here (click me!)
The Thinking Practitioner Podcast:
Episode 71: Fascia & Pain: What We Know (with Helene Langevin)
Whitney Lowe:
The Fascia Research Society invites listeners of The Thinking Practitioner Podcast to the 6th International Fascia Research Congress in Montreal, September 10th through 14th, 2022. Eight keynote speakers, including our special guest today, and over 60 parallel session talks and posters, 15 workshops, including one from Til on September 11th, and the full Congress schedule is now out. Register for the 6th International Fascia Research Congress today at fasciaresearchsociety.org. Hi, Til. How are you? And we have a special guest today. Who is it that's with us?
Til Luchau:
I'm great. Thanks, Whitney. I am really pleased to have Dr. Helene Langevin with us today. She is the Director of the National Center for Complimentary and Integrative Health, the NCCIH, the US federal government's lead agency for scientific research on the diverse medical and healthcare systems, practices, and products that are not generally considered part of conventional medicine. Her own research interest, she's also a researcher, include the role of connective tissue in chronic musculoskeletal pain and the mechanisms of acupuncture, manual, and movement-based therapies. Her more recent work has focused on the effects of stretching on the resolution of inflammation, a topic of great interest to me, within connective tissue. And we'll ask her more about that in today's conversation. Dr. Langevin, thanks for joining us. I'm so pleased to have this bit of time with you, and I appreciate you taking that. Anything else you want people to know about you or what you're bringing to the conversation today?
Helene Langevin:
I'm just very, very excited and honored to be on this show. Thank you.
Til Luchau:
Oh, thank you. The honor is ours. Anyway, the Boston Globe said you're a celebrity in the world of acupuncture and that your work has... And I know from my own experience that your work has made you a celebrity of sorts within the world of fascial therapies, which is my bailiwick. And your research has included topics that are pertinent and interesting to manual therapists. You ask some really interesting questions apparently, and then you go find out about it or write about it in ways that help us all learn more of what's going on on that level. For example, the role of some of your topics that are really interesting and relevant seem to be the role of tissue stiffness and pain, which has lots of implications. Is stiff tissue painful tissue, and how does that relate? The effects of stretching on cell function and on inflammation resolution... Can you actually change inflammatory processes or cell functioning through stretching? And your research has some really interesting observations. And you've also written on the science of interoception and proprioception and tissue qualities, really interesting topics. So I want to get into specifics about at least a couple of those, but first, before we do that, what would you say are the common threads here? What kind of big picture questions did you have or your background or perspectives did you have that prompted you to choose these lines of inquiry
Helene Langevin:
Well, I would say the biggest threat that runs through my entire career, it's really... I think connective tissue is kind of a metaphor for connections, things that connect, things that we typically sometimes think of as not connected. So that really intrigued me very early on. I actually stumbled upon connective tissue by accident. I was interested in acupuncture, and we found out pretty early in my lab, the first couple of years I was doing research, that actually when you insert an acupuncture needle and then you manipulate the needle, there's a very, very interesting mechanical relationship or reaction that occurs in the tissues in response to the manipulation of the needle. And then what we found out is that this is actually the connective tissue kind of responding and being sort of moved around essentially like a little micro manipulator. And that-
Til Luchau:
You're showing us with your hand a kind of twisting motion. For those people that don't know much about what acupunctures do with needles, how would that go?
Helene Langevin:
Acupuncturers don't simply insert needles. They actually manipulate them. They rotate, sometimes they push and pull, and they feel for something responding in the tissue. That's what tells them what to do and when to stop manipulating when a certain response has occurred. And pretty early on, we figured out that it was essentially establishing a mechanical coupling between the needle and the tissue. And so there was a small force essentially being connected, communicated to the tissue through the needle. And the connective tissue was responding to that. And that really made me think about, well, what is connective tissue? And I found out there was actually very little research on connective tissue at the time. This was back in the 1990s, late '90s. And if you looked at textbooks of orthopedics or rheumatology where connective tissue should be, there's almost nothing there. So it's sort of a tissue that had fallen through the cracks. But meanwhile, there were a lot of-
Til Luchau:
I like that.
Helene Langevin:
But there was a lot of practitioners, manual therapists in particular, who cared a great deal about what they were talking about. Connective tissue and fascia, people were starting to talk about that. And as though it was important clinically, but there was really very little research on it. So the combination of the two things, the fact that this was a tissue that's all over the body that is very poorly understood but may have very sort of some clinical importance, that was very intriguing to me right from the start. So that's really kind of a thread that's been through a lot of things that I've done.
Til Luchau:
It's fascinating. And I think, I don't remember which one it was, but I remember hearing about your work, and then I believe hearing you speak at some of the previous fascial research congresses that were really eye-opening for me. And they were great for me as a clinician to see how scientists and researchers were thinking about these questions. And I'm going to ask about one study you did in particular where you used ultrasound to show that people with chronic low back pain had thoracolumbar fascia that was stiffer, say, than those without lower back pain. Can you tell us something about what we know or what you're learning about this relationship between tissue stiffness and pain?
Helene Langevin:
We actually did not measure the stiffness of the tissue because it's important. We measured the thickness of thoracolumbar fascia. And then we measured what we call shear strain. Shear's the relative motion between one layer of fascia and the layer immediately next to it. And so we use ultrasound. It's a technique derived from ultrasound elastography, where you're actually measuring the movement of the tissue in response to a specific input motion. In this case, the human subject was lying on a table, on motorized table. And the table was bending back and forth and such that the thoracolumbar fascia was kind of put under stretch. And we wanted to see how much-
Til Luchau:
Like a sliding between layers or something like that.
Helene Langevin:
Exactly. So it's difficult. There are other techniques that can measure stiffness in tissue. One of them is what we call shear wave elastography, which is where you send an ultrasound pulse through the tissue, and then there's a ultrasound wave that propagates. And then the speed of propagation of the ultrasound wave correlates with the stiffness of the tissue. We didn't do that. We were interested in the shear plane motion. And the reason for that is because we know that fascia is organized in layers and that these layers have independent motion. We were actually really surprised when we did this testing on the ultrasound with the subject on the table. With normal human subjects, we observed shear strain of an average of 75%. That's a lot of shear strain. So imagine you put your two hands on front on top of each other like that and slide them completely all the way off. That's 100% shear.
Til Luchau:
Sliding them apart from each other. 100% shear is completely perfect.
Helene Langevin:
100% shear is when the whole two little sort of pieces of tissue... Well, you can look at this for a specific segment of tissue when the two segments would completely sort of separate.
Til Luchau:
Displace, yeah.
Helene Langevin:
But in a normal human subject, on average, it was 75% shear. That's a lot. That really intrigued us. This is an important component or quality of the thoracolumbar fascia is that all of these layers that are composing this fascia, they all are aponeuroses of different muscles that have different directions of pull. Some of these muscles have a rostrocaudal, right, top to bottom direction of pull. And some of them have a lateral direction of pull, like the obliques, for example. It makes sense that these aponeuroses would not all be stuck together. So we were actually very happy to see that we were able to measure that. So then we looked at people who had back pain, and we found that on average, that shear strain was reduced to 50%. So that was a big difference.
Til Luchau:
Not as much sliding between the layers within the tissue.
Helene Langevin:
Not sliding, which means that the motion, the relative motion of the layers was less independent, which suggested that there was perhaps a sort of, kind of, almost an adhesion that was starting to take place. We're not able to know that this was taking place in humans because you cannot go and take a biopsy of somebody's thoracolumbar fascia. But we tested that hypothesis in an animal experiment where we found that indeed layers were more adherent.
Whitney Lowe:
Do you have any theoretical ideas or more thoughts about whether that loss of that is a result of the pain that those individuals were experiencing or if that was a cause?
Helene Langevin:
It's a really good question. And we don't know. The only sort of, slightly sort of indirect way that we were able to test that was in that animal experiment where, I mentioned, where we reduced the amount of stretching that the animal was able to do. And in response to that, the layers became more essentially stuck together, which suggests that if somebody moves less, for whatever reason, it could be because they have pain or it could be simply because they don't move, they're sedentary, they don't stretch a lot or move a lot, then that will then reduce a result in a reduction in their thoracolumbar fascia, shear strength, or mobility. So it could be, we don't know. It could be a chicken or egg, right? And then once somebody's fascia becomes less mobile and they move less and then maybe that will kind of make their pain worse, but we don't know which comes first.
Whitney Lowe:
Yeah. Fascinating.
Til Luchau:
What's an important question, Whitney, is the stiffness preceding the pain or a result of the pain? And I really appreciate your answer.
Helene Langevin:
It could be because imagine that you have certain habits of posture of movement that then result in remodeling of their connective tissue that then kind of could also lead to pain on their own, right, because entrapment of little nerve fibers in these glued up layers then can maybe lead to pain. We don't really know. Whatever reason, there may be pain in these tissues but then not change the movement pattern of the person. People move differently when they have pain. So there could be these kind of reinforcing circles that we don't really know where they start, so.
Til Luchau:
And then there's the question of, how do we change those cycles? What can we do that might influence that?
Helene Langevin:
Right, stop this from happening, so a lot of these therapies, they can act either locally or centrally. You can, for example, instruct people on how to become aware of their movement patterns through awareness, sort of these sort of movement therapies, where you help people to get out of these sort of stuck movement patterns that they have. They're always moving the same way. Or you can get your hands on the person, feel where they have areas where there's restriction, perhaps mobilize some of the tissues, some of the connective tissue that has become sort of stuck. Or you can help people who have contracted muscles, help them to relax those muscles in order to improve the movement. So there's a lot of techniques that can be used, both manual techniques and also movement-based techniques. What we don't know is a lot of the mechanisms of how these techniques work. There's a lot of experience among clinicians as to how to apply those techniques but very little research on this.
Til Luchau:
And then I know in some of your other writings, like you're writing about interception or proprioception, there's a lot we don't know about how perception happens or how the experience of pain is generated from that, too.
Helene Langevin:
That's right. Most of what we know about pain comes from the skin, right, or nerve injury models, very little understanding of the sensory innovation of deep tissues. When we're talking about muscle skeletal system, fascia, muscles, etc., we know that there are sensory nerves in these tissues, but we know very little about what type of sensations these sensory nerves transmit. How do you feel? My favorite example of this is that imagine you take your forearm and you grab your forearm and then you twist it and you hold it. What kind of sensations are you feeling? These sensations are definitely... You can feel stretching. Maybe if you twist hard enough, you may feel even a little pain, but you certainly feel something. And this sensation is coming from your deep tissues. And we don't know what sensory neurons are carrying on these sensations.
Helene Langevin:
So this is just an area that's almost a little bit of a black box. And when we have back pain or neck pain or shoulder pain, some of these sensations are probably arising from these tissues that we know very little about. So this is one of the reasons why at NCCIH, we're starting to really pay a lot of attention to the kinds of research methods that you need to better understand, sources of musculoskeletal pain, including myofascial pain. So we recently had a workshop on this, and we developed some funding opportunities to encourage people to develop better methods to do imaging and different types of functional kind of testing of these tissues to better understand what's wrong. When people have myofascial pain, can you measure it? And also if you treat it, does the pathology get better? And what are the objective measurements that you can make in order to see whether a particular treatment is ameliorating the actual condition of the muscle in addition to the patient hopefully feeling better?
Til Luchau:
Well, a lot of us are on the edge of our seats as you go through these questions and find the little tidbits that come out, sometimes major tidbits. I was just looking at your 2021 paper, fascia and mobility proprioception of myofascial pain. And I want to recommend it to our listeners. We'll put a link to it in the show notes, and also just really appreciate, and thank you, Dr. Langevin, being so clear about what we know and what we don't know and making room in that, too, for the possibilities of what those implications might be in wonderful ways, but not overextending ourselves into realms where we're starting to lose practicality or lose a sense of what we're up to.
Til Luchau:
Anyway, I just really appreciated both the information you shared and the way you constructed your narrative through that. Thanks very much. Well, can I ask about inflammation? And by the way, before I do that, thank you for correcting my use of the word stiffness in terms of what you found in the thoracolumbar fascia because, yeah, you you found shear strain, you found movement differences and thickness differences, but stiffness, as I understand at least, is something that would happen over time, a change over time. Or viscoelastic changes, things like that, could be stiffness. It could-
Helene Langevin:
Yeah.
Til Luchau:
Yeah?
Helene Langevin:
And it's something that needs to be measured in a different way and-
Til Luchau:
Measured a different way.
Helene Langevin:
In fact, some of the techniques that we discussed at the workshop on myofascial pains would be able to measure stiffness. So for example, the shear wave elastography that I mentioned is such a technique. And so we're very much hoping that some of the research that will occur in the future might be able to address that.
Til Luchau:
Well, your various research findings and then of course others have really influenced the way I practice my manual therapy. I'm thinking much more in the last decade, say, about sliding, about shearing, rather than just the stiffness instead of what's stiff in terms of what I'm working with. So like I said, we're waiting in the edge of our seats. And then when we get to something like inflammation, which is a process that's so pervasive or linked with so many of the complaints we see in our practices, again, you have a fascinating tidbit that your researches have shown where stretching can actually influence inflammation in certain circumstances. Could you tell us something about that?
Helene Langevin:
Well, what we know is only from some animal models. But in those animal models, we did find that gentle stretching, and I repeat, gentle, can have an effect on inflammation that it reduces inflammation in these animal models. And what we think is happening is that stretching is actually helping the animal to promote what we call the resolution of inflammation. It's not suppressing the inflammation, it's helping the inflammation to resolve. And there's an important difference between the two.
Helene Langevin:
If you take, for example, Advil or some other anti-inflammatory agent, it suppresses both the inflammation part but also the resolution part. But if you have your sort of natural built-in inflammation resolution, which occurs in any scenario, say, if you cut yourself and you have initially for the first three or four days, the cut is red and sort of tender and painful, and eventually it kind of stops being painful, and then the swelling resolves, that's inflammation resolution. It's part of the inflammatory response. From the very beginning of the inflammatory response, there's a program that starts itself in order to terminate it so that inflammation doesn't keep going on forever. And what we found is that stretching encourages that, that resolution.
Til Luchau:
Encourages that resolution, that cycle to continue through. And the gentle qualifier you gave is also really interesting because for a long time, there have been explanations of manual therapies' effects that we might provoke inflammation or we might stimulate fibroblast activities to repair. They were essentially damaging perhaps tissue in a way to reboot an inflammatory response. And you're giving us a whole different map. You're saying a gentle stretch seems to help resolve.
Helene Langevin:
Yeah. I can't comment on efforts to increase inflammation. All I can say is that whenever you do a manual or a therapy or stretching or if you impart a mechanical force, that's large enough to be injurious. That will increase inflammation, I mean, because you're creating an injury. What we noticed is that regardless of if you do the kind of stretching that we do in the lab or even when you do the acupuncture that I talked about at the beginning, where you gently manipulate the needle, you don't see swelling. You don't see increasing neutrophils in the tissues the next day. You don't see evidence of increased inflammation. If anything, you see reduction.
Whitney Lowe:
And I'm assuming, too, that that type of intervention, you wouldn't have a stretching procedure that would speed or have an inflammatory resolution occur prior to when the body kind of said, essentially, we still need to have something going on here. It's not going to speed it up so much to a point that it's decreasing the therapeutic benefits of the inflammation.
Helene Langevin:
Right. So what it's doing is it's kind of working in concert with the body's natural efforts to resolve the inflammation. And the reason why we think we can say that is because we can measure specific compounds called pro-resolving mediators. They're derived from lipids, from omega-three fatty acids. And our body starts with these lipids that we take in our diet, like from fish and stuff. And then it makes these compounds called pro-resolving mediators or resolvins, for example, at one time. And those are compounds that are several-fold more active than the omega-three fatty acid themselves in resolving inflammation, very, very active compound. And so we think that the stretching and the movement sort of cooperates with that, with that response. It kind of encourages it. And because we can measure the level of these pro-resolving mediators and the tissues in response to stretching, and they're up. They're increased.
Til Luchau:
So why does inflammation not resolve? What gets in the way of it actually doing that on its own?
Helene Langevin:
It's a little mysterious. And so this is a lot of the work of Dr. Charles Serhan, whom I was fortunate enough to collaborate at Brigham and Women's Hospital in my previous job. And what he talks about is the balance between the pro-resolving and the pro-inflammatory mediators. It's a complicated picture because it's very dynamic. There's not just one. You have a lot of different inflammatory mediators that are contributing to the overall picture of whether the end result is going to be more inflammatory or more resolving. And in the end, depending on that balance, that you get what you get, either you get a non-resolving inflammation, which continues, or you get a resolving inflammation, which just kind of, it ends the inflammation.
Til Luchau:
Wraps it, winds itself up, and it's done.
Helene Langevin:
Yeah the heat-
Til Luchau:
Acute phase starts to resolve. Yeah.
Helene Langevin:
Right. Otherwise, it turns into chronic inflammation.
Til Luchau:
It sticks around and keeps doing its good and bad things, right, in a way that's not good.
Helene Langevin:
Right. And we know that the end result of chronic inflammation is deposition of collagen and fibrosis and adhesions. And this was very, very nicely demonstrated in a wonderful animal model, so, wonderful study done by Mary Barb and Jeff Boles at Temple University where they did a repetitive motion model injury on rats that trained them to pull a lever many, many, many times a day to get a reward. And they kept increasing the force that it took to pull the lever. And these rats actually developed chronic inflammation in their forepaw.
Helene Langevin:
And what they then did is they did manual therapy on these rats, if you can believe it. They massaged the animals. And they found that the animals that had the daily manual therapy kept their function. They were still able to do the movement without getting the inflammation as nearly as much. So this is very interesting. You can see how these rats were getting chronic inflammation and the manual therapy helped to... They didn't measure the pro-resolving mediators in that experiment, but the amount of inflammation is certainly diminished.
Til Luchau:
That was a really interesting study when that came out. It's been a while since I've read it, but I think, if I remember, they were actually observing the neurons or the cells within the nervous system to try to measure inflammatory response in some-
Helene Langevin:
That's right, yeah. They looked at the connective tissue surrounding the nerve because, and this is important again, normally, right, talking about shear plane motion, a nerve has a sheet of connective tissue around it. And the sheet of connective tissue should be mobile. The nerve should not be stuck and attached to the surrounding muscles. But when you have fibrosis, you can get fibrosis around the nerve, which then makes the nerve essentially lets mobile. It's less shear strength between the nerve and the surrounding tissue. And what they found is that there was less fibrosis surrounding these nerves in these animals. And they measured this... They graded myoinvasive protein in the nerves. And it was elevated in the non-massaged rat, and it was near normal in the massaged rat. So the nerve injury was prevented.
Til Luchau:
So we have that interesting evidence or interesting study in rats about massage and manual therapy's ability to help resolve inflammation. What can we extrapolate from that or guess, or what do we know about our ability to influence resolution? That's the question behind all this. But what do we know about our ability to influence that?
Helene Langevin:
We don't know a whole lot, other than there's a lot of effort in the pharmaceutical industry to develop compounds that you could take, resolve it, to improve inflammation, resolution. So far, I mean, for example, omega-three fatty acids, a lot of people think that by taking fish oil, that you could improve inflammatory conditions. The one condition where that has been shown is the rheumatoid arthritis. Patients with rheumatoid arthritis who take a supplement of fish oil have been show to have reduced inflammation, but not other conditions. People have tried with other, like asthma and inflammatory bowel disease. And it's not the cure that people are hoping.
Whitney Lowe:
Yeah. So I want to kind of take off from what you were saying, too. This is fascinating about these rat studies, and the changes that they found from soft tissue manipulation. From your perspective and the work that you've done, what do you see to be some of the most significant effects of manual soft tissue manipulation on the fascial system? What do you kind of sense to be the most impactful or powerful of those effects?
Helene Langevin:
I would say that one of the important things I already alluded to is that more is not necessarily better, right, that you have to be very careful about how much you do. Whether it's movement, exercise, or manual therapy, the dose matters. And we need to understand better how to apply by these forces without further injuring the tissues. And the other thing that's really important is to make sure that we understand the status of the underlying tissue. Imagine you have somebody who has either hypo or hyper mobility, right? We've described a situation of hypomobility, whereas layers are stuck together. But what if there's hypermobility? Patients who already have very loose connective tissue, for example, Ehlers-Danlos syndrome or the sort of generalized hypermobility disorders, which are quite common. What do you do in a situation like that, where somebody has pain and their tissues are already very mobile? You're not going to want to stretch them more, right?
Til Luchau:
They can be looking for more shear strain or more mobility necessarily.
Helene Langevin:
Yeah. Yeah. You could damage the tissues, and sometimes this happens, people who have hypermobility, they'll go, and they do yoga, and they injure themselves because they're trying to stretch, and they're already too much mobile. So the important is to be able to be judicious about when do you need to increase mobility via either stretching or what you may need, in a lot of cases, the strengthening the muscles so that they can support the tissues. More importantly, they may be a combination of the two. You may have somebody who's hypermobile generally, but who've had some injuries because a lot of people who are hypermobile have had a lot of injuries. And then in some cases, locally, you may have some areas of hypomobility. So you may have a mixture. People may need to be mobilized in some areas if they're stuck or they have a scar or an injury or an adhesion, but not everywhere. So this is where the art of a therapist comes in and be able to really understand that by palpating and feeling the tissues and watching how the patient moves.
Til Luchau:
Well, you've spoken eloquently in a couple different places about contextual effects or nonspecific effects of our work, too. So when we think about some of hypermobility, it's not like our only tool is loosening or more shear strain or something like that. There's many ways that we can leverage someone's experience besides tissue mobility.
Helene Langevin:
Yeah. Every therapy has contextual or, what we call, nonspecific effects, right?
Til Luchau:
Yeah.
Helene Langevin:
The interaction with the person, being in the presence of somebody who cares, who has a physical presence and sort of a support, and especially somebody who puts their hands on you, right? And then there's a lot of communication that can happen non-verbally through somebody's hands, but also talking. And when people feel that somebody who is a good therapist is actually physically kind of contacting the area that actually hurts in a way that's supportive and caring and intentional, that's very powerful psychologically. So yes, there's a lot of contextual effects, and these effects are part of the treatment. They're very important.
Til Luchau:
So are those real, or are they imaginary? I'm sorry. I get that. I'm sorry to ask that question. I didn't want to ask that.
Helene Langevin:
There's nothing imaginary about what I just described, right? This is all real. This is happening, whether it's happening in the person's nervous system. There's some incredible studies right now that are being conducted with a... They're mainly in the acupuncture world. That's fascinating. A patient and a practitioner that are being... Functional MRI scanning simultaneously, it's called hyperscanning. It's unbelievable. So what they do is they do sort of simulated treatment where the practitioner, I don't begin to understand the intricacies of these experiments, but basically this is just to show that there's... The therapeutic alliance between a patient and a practitioner is reflected in both of their brains at the same time. So there's this amazing communication that occurs in the nervous system during a treatment between the patient and the practitioner. And that's real. That's measurable.
Til Luchau:
Thank you.
Helene Langevin:
So, yeah, it's real.
Til Luchau:
Right. I mean, in some ways, no surprise, something's happening in both. There's brain and in other ways, so great that it's measurable and observable, and that someone like yourself can be a spokesman both for the mechanical effects on the tissue level but also saying, this is happening within a context. And let's not leave that out, too. What do you think, Whitney? Anything else?
Whitney Lowe:
Yeah, it does seem like there is a continuum there of those things. I remember seeing some other things written about acupuncture, about looking at effectiveness and saying that there were sometimes cultural factors and things like that that made it more effective with certain patient populations than others. And a lot of that had to do with belief in the treatment and things like that. And it is fascinating to see that intersection between what are potentially some of the more grounded, physiological effects and some of those other context effects that may also be interacting with the systems as well.
Helene Langevin:
And they're all very real. When we talk about what placebo effects are, I like to think of placebo effects as healing responses, self-healing responses that a person can activate in response to being in certain circumstances. And you can do a fake treatment, but there's still a treatment happening. There's still something that the person interprets as being some kind of trigger to help them to activate some healing responses that can happen even with placebos. So, yeah.
Til Luchau:
I'm glad you mentioned placebos because there's so much complication around that hypothetical question I asked you, is that real? And you've just made a really great case for how it's real, not only real, but it's part and parcel of what we offer.
Helene Langevin:
It's important. It's important that we understand what it is. Yeah.
Til Luchau:
Nice.
Helene Langevin:
And there's some excellent placebo research happening right now all over the world. This is an area of research that really needs more attention. It's very important.
Whitney Lowe:
Well, these are certainly fascinating topics. And I know we could go on for days digging into some of these things, but tell us a little bit, what will you be talking about at the Fascia Research Congress?
Helene Langevin:
I'll be talking about fascia. I'll probably, I mean, I don't have my entire talk mapped out at the moment, but one of the things I will very likely talk about is some of the new initiatives that NCCIH is leading. One is, I already mentioned, myofascial pain, developing technology to measure and especially imaging technologies to better understand myofascial tissues. We think this is absolutely crucially important. Another important initiative is something called RE-JOIN. And what that means is that, imagine a joint, right? Imagine somebody has pain in their knee, and their knee hurts. Well, you assume, right, that this person was saying, "Well, I have pain in my knee. It must be arthritis. It must be because my cartilage is kind of rubbing."
Helene Langevin:
People talk about bone on bone, that kind of thing, that's why you have pain. But there's a lot of things in the knee and around the knee besides cartilage. There's joint capsule. There are ligaments. There's fascia. There's muscles. How do you know, if you have pain in your knee, where your pain is coming from? You don't. And we know a lot less about what we call the periarticular structures around the knee than the articulate structures, the cartilage, the synovium, the bone because that's where we've been looking, we've been looking at. We have ways to image those structures, but we don't yet have very good ways to image what we call the soft tissues.
Helene Langevin:
So we think that by improving our ability to understand myofascial pain, this is also going to improve our ability to understand joint pain because we think that myofascial pain could be a big component of joint pain. And that problem with myofascial tissues may actually lead to joint pain because if your myofascial tissues are not healthy, if you have reduced mobility, if you have imbalance in your muscles, your joint may become misaligned. The mechanical forces on the joint are going to not be correct, and you're going to get wear in your articular surfaces. So by addressing the myofascial tissues, the periarticular tissues early, you might be able to prevent joint pains. So we think this is a really important area. I'm going to be talking about that.
Whitney Lowe:
Wonderful. Thank you so much for that. So with our audience being predominantly those doing soft tissue manipulation of various one form or another, is there anything else you'd like to leave to this audience to tell us before we wrap up today, last words of wisdom for those people doing this type of work?
Helene Langevin:
Well, a lot of what I talked about is about putting things together. I talked about connective tissue connecting the whole body. I talked about understanding the relationship between the musculoskeletal system and the immune system, right, inflammatory responses occurring within connective tissues, and also talked about the importance of what we call whole person health, which means paying attention to all of the different factors that kind of contribute to somebody being more versus less healthy, nutrition, physical activity, and also psychological factors like stress and sleep. All of these factors are important, and they're important no matter what part of the body you look at.
Helene Langevin:
So at NCCIH, our new strategic plan is really focused on this, on whole person health, and really understanding the factors that influence whether somebody is going to move towards disease or back towards health because we think this is an important piece. We're really focused a lot more on what we call pathogenesis, which is the creation of disease, as opposed to salutogenesis, which is the creation of health. We need to understand much better how to promote that, how to encourage healing of tissues and resilience and health restoration. So these are the components of whole person health or what the whole person, meaning, the whole, and health, which is moving towards the health directions.
Whitney Lowe:
Wonderful. Thank you so much. That's wonderful inspirational ideas for, I think, a lot of people who are doing this type of work.
Til Luchau:
And where would you send our listeners if they wanted to know more about your work?
Helene Langevin:
Well, the first thing I would suggest is that people visit our website at NCCIH.org, .NIH, right?
Speaker 4:
NCCIH.NIH.gov.
Helene Langevin:
.NIH.org, .gov, excuse me, what am I talking about? .gov.
Til Luchau:
.gov.
Helene Langevin:
And that to check out a lot of the presentations that I talked about are on my Director's Page. We also have links to videocast of the workshops that I mentioned that are all listed on our website. We also have a lot of information on various different kinds of therapies that we have. A lot of our science pages have many, many different information for practitioners, for consumers, for researchers. So it's a really good resource. And follow us on social media, Twitter, etc., so.
Whitney Lowe:
Well, that certainly sounds wonderful. And thank you again so much for your time today, Dr. Langevin. And we know you're very busy, and we really appreciate you taking the time out to speak with us and our listeners. So keep in mind, The Thinking Practitioner Podcast is supported by ABMP, the Associated Bodywork and Massage Professionals. ABMP membership gives professional practitioners like you a package including individual liability insurance, free continuing education and quick reference apps, legislative advocacy, and much more.
Til Luchau:
ABMP's CE courses, podcast, and massage and bodywork magazine always feature expert voices and new perspectives in the profession, including me, Til, and Whitney Lowe, were both there. Thinking Practitioner listeners can save on joining ABMP at abmp.com/thinking.
Whitney Lowe:
And we would like to say thank you to all of our sponsors. And to you, the listeners, we thank you for hanging out with us here today. Be sure to check out the Fascia Research Congress on their website there. You can stop by our sites for show notes where you can learn more about connecting with the Fascia Research Congress. So over there, show notes, transcripts, and any other extras, you can find that from my site at academyofclinicalmassage.com. And Til, from your site, where can people find that?
Til Luchau:
advanced-trainings.com. If there are questions or things you want to hear us talk about, e-mail us at [email protected] or look for us on social media just under our names, mine remains, Til Luchau. Whitney?
Whitney Lowe:
And mine's still today is Whitney Lowe. You can rate us on Apple podcasts as it helps other people find the show. And you can hear us on Spotify, Stitcher, Google Podcast, or wherever else you happen to listen. And please do share the word and tell a friend. It does help us get the word out and get other people exposed to it. So thank again, everybody. Thank you so much again, Dr. Langevin, for spending some time with us here today.
Til Luchau:
Thank you.
Whitney Lowe:
This is a wonderful, inspiring talk with everybody.
Helene Langevin:
Pleasure.
Episode 71: Fascia & Pain: What We Know (with Helene Langevin)
Whitney Lowe:
The Fascia Research Society invites listeners of The Thinking Practitioner Podcast to the 6th International Fascia Research Congress in Montreal, September 10th through 14th, 2022. Eight keynote speakers, including our special guest today, and over 60 parallel session talks and posters, 15 workshops, including one from Til on September 11th, and the full Congress schedule is now out. Register for the 6th International Fascia Research Congress today at fasciaresearchsociety.org. Hi, Til. How are you? And we have a special guest today. Who is it that's with us?
Til Luchau:
I'm great. Thanks, Whitney. I am really pleased to have Dr. Helene Langevin with us today. She is the Director of the National Center for Complimentary and Integrative Health, the NCCIH, the US federal government's lead agency for scientific research on the diverse medical and healthcare systems, practices, and products that are not generally considered part of conventional medicine. Her own research interest, she's also a researcher, include the role of connective tissue in chronic musculoskeletal pain and the mechanisms of acupuncture, manual, and movement-based therapies. Her more recent work has focused on the effects of stretching on the resolution of inflammation, a topic of great interest to me, within connective tissue. And we'll ask her more about that in today's conversation. Dr. Langevin, thanks for joining us. I'm so pleased to have this bit of time with you, and I appreciate you taking that. Anything else you want people to know about you or what you're bringing to the conversation today?
Helene Langevin:
I'm just very, very excited and honored to be on this show. Thank you.
Til Luchau:
Oh, thank you. The honor is ours. Anyway, the Boston Globe said you're a celebrity in the world of acupuncture and that your work has... And I know from my own experience that your work has made you a celebrity of sorts within the world of fascial therapies, which is my bailiwick. And your research has included topics that are pertinent and interesting to manual therapists. You ask some really interesting questions apparently, and then you go find out about it or write about it in ways that help us all learn more of what's going on on that level. For example, the role of some of your topics that are really interesting and relevant seem to be the role of tissue stiffness and pain, which has lots of implications. Is stiff tissue painful tissue, and how does that relate? The effects of stretching on cell function and on inflammation resolution... Can you actually change inflammatory processes or cell functioning through stretching? And your research has some really interesting observations. And you've also written on the science of interoception and proprioception and tissue qualities, really interesting topics. So I want to get into specifics about at least a couple of those, but first, before we do that, what would you say are the common threads here? What kind of big picture questions did you have or your background or perspectives did you have that prompted you to choose these lines of inquiry
Helene Langevin:
Well, I would say the biggest threat that runs through my entire career, it's really... I think connective tissue is kind of a metaphor for connections, things that connect, things that we typically sometimes think of as not connected. So that really intrigued me very early on. I actually stumbled upon connective tissue by accident. I was interested in acupuncture, and we found out pretty early in my lab, the first couple of years I was doing research, that actually when you insert an acupuncture needle and then you manipulate the needle, there's a very, very interesting mechanical relationship or reaction that occurs in the tissues in response to the manipulation of the needle. And then what we found out is that this is actually the connective tissue kind of responding and being sort of moved around essentially like a little micro manipulator. And that-
Til Luchau:
You're showing us with your hand a kind of twisting motion. For those people that don't know much about what acupunctures do with needles, how would that go?
Helene Langevin:
Acupuncturers don't simply insert needles. They actually manipulate them. They rotate, sometimes they push and pull, and they feel for something responding in the tissue. That's what tells them what to do and when to stop manipulating when a certain response has occurred. And pretty early on, we figured out that it was essentially establishing a mechanical coupling between the needle and the tissue. And so there was a small force essentially being connected, communicated to the tissue through the needle. And the connective tissue was responding to that. And that really made me think about, well, what is connective tissue? And I found out there was actually very little research on connective tissue at the time. This was back in the 1990s, late '90s. And if you looked at textbooks of orthopedics or rheumatology where connective tissue should be, there's almost nothing there. So it's sort of a tissue that had fallen through the cracks. But meanwhile, there were a lot of-
Til Luchau:
I like that.
Helene Langevin:
But there was a lot of practitioners, manual therapists in particular, who cared a great deal about what they were talking about. Connective tissue and fascia, people were starting to talk about that. And as though it was important clinically, but there was really very little research on it. So the combination of the two things, the fact that this was a tissue that's all over the body that is very poorly understood but may have very sort of some clinical importance, that was very intriguing to me right from the start. So that's really kind of a thread that's been through a lot of things that I've done.
Til Luchau:
It's fascinating. And I think, I don't remember which one it was, but I remember hearing about your work, and then I believe hearing you speak at some of the previous fascial research congresses that were really eye-opening for me. And they were great for me as a clinician to see how scientists and researchers were thinking about these questions. And I'm going to ask about one study you did in particular where you used ultrasound to show that people with chronic low back pain had thoracolumbar fascia that was stiffer, say, than those without lower back pain. Can you tell us something about what we know or what you're learning about this relationship between tissue stiffness and pain?
Helene Langevin:
We actually did not measure the stiffness of the tissue because it's important. We measured the thickness of thoracolumbar fascia. And then we measured what we call shear strain. Shear's the relative motion between one layer of fascia and the layer immediately next to it. And so we use ultrasound. It's a technique derived from ultrasound elastography, where you're actually measuring the movement of the tissue in response to a specific input motion. In this case, the human subject was lying on a table, on motorized table. And the table was bending back and forth and such that the thoracolumbar fascia was kind of put under stretch. And we wanted to see how much-
Til Luchau:
Like a sliding between layers or something like that.
Helene Langevin:
Exactly. So it's difficult. There are other techniques that can measure stiffness in tissue. One of them is what we call shear wave elastography, which is where you send an ultrasound pulse through the tissue, and then there's a ultrasound wave that propagates. And then the speed of propagation of the ultrasound wave correlates with the stiffness of the tissue. We didn't do that. We were interested in the shear plane motion. And the reason for that is because we know that fascia is organized in layers and that these layers have independent motion. We were actually really surprised when we did this testing on the ultrasound with the subject on the table. With normal human subjects, we observed shear strain of an average of 75%. That's a lot of shear strain. So imagine you put your two hands on front on top of each other like that and slide them completely all the way off. That's 100% shear.
Til Luchau:
Sliding them apart from each other. 100% shear is completely perfect.
Helene Langevin:
100% shear is when the whole two little sort of pieces of tissue... Well, you can look at this for a specific segment of tissue when the two segments would completely sort of separate.
Til Luchau:
Displace, yeah.
Helene Langevin:
But in a normal human subject, on average, it was 75% shear. That's a lot. That really intrigued us. This is an important component or quality of the thoracolumbar fascia is that all of these layers that are composing this fascia, they all are aponeuroses of different muscles that have different directions of pull. Some of these muscles have a rostrocaudal, right, top to bottom direction of pull. And some of them have a lateral direction of pull, like the obliques, for example. It makes sense that these aponeuroses would not all be stuck together. So we were actually very happy to see that we were able to measure that. So then we looked at people who had back pain, and we found that on average, that shear strain was reduced to 50%. So that was a big difference.
Til Luchau:
Not as much sliding between the layers within the tissue.
Helene Langevin:
Not sliding, which means that the motion, the relative motion of the layers was less independent, which suggested that there was perhaps a sort of, kind of, almost an adhesion that was starting to take place. We're not able to know that this was taking place in humans because you cannot go and take a biopsy of somebody's thoracolumbar fascia. But we tested that hypothesis in an animal experiment where we found that indeed layers were more adherent.
Whitney Lowe:
Do you have any theoretical ideas or more thoughts about whether that loss of that is a result of the pain that those individuals were experiencing or if that was a cause?
Helene Langevin:
It's a really good question. And we don't know. The only sort of, slightly sort of indirect way that we were able to test that was in that animal experiment where, I mentioned, where we reduced the amount of stretching that the animal was able to do. And in response to that, the layers became more essentially stuck together, which suggests that if somebody moves less, for whatever reason, it could be because they have pain or it could be simply because they don't move, they're sedentary, they don't stretch a lot or move a lot, then that will then reduce a result in a reduction in their thoracolumbar fascia, shear strength, or mobility. So it could be, we don't know. It could be a chicken or egg, right? And then once somebody's fascia becomes less mobile and they move less and then maybe that will kind of make their pain worse, but we don't know which comes first.
Whitney Lowe:
Yeah. Fascinating.
Til Luchau:
What's an important question, Whitney, is the stiffness preceding the pain or a result of the pain? And I really appreciate your answer.
Helene Langevin:
It could be because imagine that you have certain habits of posture of movement that then result in remodeling of their connective tissue that then kind of could also lead to pain on their own, right, because entrapment of little nerve fibers in these glued up layers then can maybe lead to pain. We don't really know. Whatever reason, there may be pain in these tissues but then not change the movement pattern of the person. People move differently when they have pain. So there could be these kind of reinforcing circles that we don't really know where they start, so.
Til Luchau:
And then there's the question of, how do we change those cycles? What can we do that might influence that?
Helene Langevin:
Right, stop this from happening, so a lot of these therapies, they can act either locally or centrally. You can, for example, instruct people on how to become aware of their movement patterns through awareness, sort of these sort of movement therapies, where you help people to get out of these sort of stuck movement patterns that they have. They're always moving the same way. Or you can get your hands on the person, feel where they have areas where there's restriction, perhaps mobilize some of the tissues, some of the connective tissue that has become sort of stuck. Or you can help people who have contracted muscles, help them to relax those muscles in order to improve the movement. So there's a lot of techniques that can be used, both manual techniques and also movement-based techniques. What we don't know is a lot of the mechanisms of how these techniques work. There's a lot of experience among clinicians as to how to apply those techniques but very little research on this.
Til Luchau:
And then I know in some of your other writings, like you're writing about interception or proprioception, there's a lot we don't know about how perception happens or how the experience of pain is generated from that, too.
Helene Langevin:
That's right. Most of what we know about pain comes from the skin, right, or nerve injury models, very little understanding of the sensory innovation of deep tissues. When we're talking about muscle skeletal system, fascia, muscles, etc., we know that there are sensory nerves in these tissues, but we know very little about what type of sensations these sensory nerves transmit. How do you feel? My favorite example of this is that imagine you take your forearm and you grab your forearm and then you twist it and you hold it. What kind of sensations are you feeling? These sensations are definitely... You can feel stretching. Maybe if you twist hard enough, you may feel even a little pain, but you certainly feel something. And this sensation is coming from your deep tissues. And we don't know what sensory neurons are carrying on these sensations.
Helene Langevin:
So this is just an area that's almost a little bit of a black box. And when we have back pain or neck pain or shoulder pain, some of these sensations are probably arising from these tissues that we know very little about. So this is one of the reasons why at NCCIH, we're starting to really pay a lot of attention to the kinds of research methods that you need to better understand, sources of musculoskeletal pain, including myofascial pain. So we recently had a workshop on this, and we developed some funding opportunities to encourage people to develop better methods to do imaging and different types of functional kind of testing of these tissues to better understand what's wrong. When people have myofascial pain, can you measure it? And also if you treat it, does the pathology get better? And what are the objective measurements that you can make in order to see whether a particular treatment is ameliorating the actual condition of the muscle in addition to the patient hopefully feeling better?
Til Luchau:
Well, a lot of us are on the edge of our seats as you go through these questions and find the little tidbits that come out, sometimes major tidbits. I was just looking at your 2021 paper, fascia and mobility proprioception of myofascial pain. And I want to recommend it to our listeners. We'll put a link to it in the show notes, and also just really appreciate, and thank you, Dr. Langevin, being so clear about what we know and what we don't know and making room in that, too, for the possibilities of what those implications might be in wonderful ways, but not overextending ourselves into realms where we're starting to lose practicality or lose a sense of what we're up to.
Til Luchau:
Anyway, I just really appreciated both the information you shared and the way you constructed your narrative through that. Thanks very much. Well, can I ask about inflammation? And by the way, before I do that, thank you for correcting my use of the word stiffness in terms of what you found in the thoracolumbar fascia because, yeah, you you found shear strain, you found movement differences and thickness differences, but stiffness, as I understand at least, is something that would happen over time, a change over time. Or viscoelastic changes, things like that, could be stiffness. It could-
Helene Langevin:
Yeah.
Til Luchau:
Yeah?
Helene Langevin:
And it's something that needs to be measured in a different way and-
Til Luchau:
Measured a different way.
Helene Langevin:
In fact, some of the techniques that we discussed at the workshop on myofascial pains would be able to measure stiffness. So for example, the shear wave elastography that I mentioned is such a technique. And so we're very much hoping that some of the research that will occur in the future might be able to address that.
Til Luchau:
Well, your various research findings and then of course others have really influenced the way I practice my manual therapy. I'm thinking much more in the last decade, say, about sliding, about shearing, rather than just the stiffness instead of what's stiff in terms of what I'm working with. So like I said, we're waiting in the edge of our seats. And then when we get to something like inflammation, which is a process that's so pervasive or linked with so many of the complaints we see in our practices, again, you have a fascinating tidbit that your researches have shown where stretching can actually influence inflammation in certain circumstances. Could you tell us something about that?
Helene Langevin:
Well, what we know is only from some animal models. But in those animal models, we did find that gentle stretching, and I repeat, gentle, can have an effect on inflammation that it reduces inflammation in these animal models. And what we think is happening is that stretching is actually helping the animal to promote what we call the resolution of inflammation. It's not suppressing the inflammation, it's helping the inflammation to resolve. And there's an important difference between the two.
Helene Langevin:
If you take, for example, Advil or some other anti-inflammatory agent, it suppresses both the inflammation part but also the resolution part. But if you have your sort of natural built-in inflammation resolution, which occurs in any scenario, say, if you cut yourself and you have initially for the first three or four days, the cut is red and sort of tender and painful, and eventually it kind of stops being painful, and then the swelling resolves, that's inflammation resolution. It's part of the inflammatory response. From the very beginning of the inflammatory response, there's a program that starts itself in order to terminate it so that inflammation doesn't keep going on forever. And what we found is that stretching encourages that, that resolution.
Til Luchau:
Encourages that resolution, that cycle to continue through. And the gentle qualifier you gave is also really interesting because for a long time, there have been explanations of manual therapies' effects that we might provoke inflammation or we might stimulate fibroblast activities to repair. They were essentially damaging perhaps tissue in a way to reboot an inflammatory response. And you're giving us a whole different map. You're saying a gentle stretch seems to help resolve.
Helene Langevin:
Yeah. I can't comment on efforts to increase inflammation. All I can say is that whenever you do a manual or a therapy or stretching or if you impart a mechanical force, that's large enough to be injurious. That will increase inflammation, I mean, because you're creating an injury. What we noticed is that regardless of if you do the kind of stretching that we do in the lab or even when you do the acupuncture that I talked about at the beginning, where you gently manipulate the needle, you don't see swelling. You don't see increasing neutrophils in the tissues the next day. You don't see evidence of increased inflammation. If anything, you see reduction.
Whitney Lowe:
And I'm assuming, too, that that type of intervention, you wouldn't have a stretching procedure that would speed or have an inflammatory resolution occur prior to when the body kind of said, essentially, we still need to have something going on here. It's not going to speed it up so much to a point that it's decreasing the therapeutic benefits of the inflammation.
Helene Langevin:
Right. So what it's doing is it's kind of working in concert with the body's natural efforts to resolve the inflammation. And the reason why we think we can say that is because we can measure specific compounds called pro-resolving mediators. They're derived from lipids, from omega-three fatty acids. And our body starts with these lipids that we take in our diet, like from fish and stuff. And then it makes these compounds called pro-resolving mediators or resolvins, for example, at one time. And those are compounds that are several-fold more active than the omega-three fatty acid themselves in resolving inflammation, very, very active compound. And so we think that the stretching and the movement sort of cooperates with that, with that response. It kind of encourages it. And because we can measure the level of these pro-resolving mediators and the tissues in response to stretching, and they're up. They're increased.
Til Luchau:
So why does inflammation not resolve? What gets in the way of it actually doing that on its own?
Helene Langevin:
It's a little mysterious. And so this is a lot of the work of Dr. Charles Serhan, whom I was fortunate enough to collaborate at Brigham and Women's Hospital in my previous job. And what he talks about is the balance between the pro-resolving and the pro-inflammatory mediators. It's a complicated picture because it's very dynamic. There's not just one. You have a lot of different inflammatory mediators that are contributing to the overall picture of whether the end result is going to be more inflammatory or more resolving. And in the end, depending on that balance, that you get what you get, either you get a non-resolving inflammation, which continues, or you get a resolving inflammation, which just kind of, it ends the inflammation.
Til Luchau:
Wraps it, winds itself up, and it's done.
Helene Langevin:
Yeah the heat-
Til Luchau:
Acute phase starts to resolve. Yeah.
Helene Langevin:
Right. Otherwise, it turns into chronic inflammation.
Til Luchau:
It sticks around and keeps doing its good and bad things, right, in a way that's not good.
Helene Langevin:
Right. And we know that the end result of chronic inflammation is deposition of collagen and fibrosis and adhesions. And this was very, very nicely demonstrated in a wonderful animal model, so, wonderful study done by Mary Barb and Jeff Boles at Temple University where they did a repetitive motion model injury on rats that trained them to pull a lever many, many, many times a day to get a reward. And they kept increasing the force that it took to pull the lever. And these rats actually developed chronic inflammation in their forepaw.
Helene Langevin:
And what they then did is they did manual therapy on these rats, if you can believe it. They massaged the animals. And they found that the animals that had the daily manual therapy kept their function. They were still able to do the movement without getting the inflammation as nearly as much. So this is very interesting. You can see how these rats were getting chronic inflammation and the manual therapy helped to... They didn't measure the pro-resolving mediators in that experiment, but the amount of inflammation is certainly diminished.
Til Luchau:
That was a really interesting study when that came out. It's been a while since I've read it, but I think, if I remember, they were actually observing the neurons or the cells within the nervous system to try to measure inflammatory response in some-
Helene Langevin:
That's right, yeah. They looked at the connective tissue surrounding the nerve because, and this is important again, normally, right, talking about shear plane motion, a nerve has a sheet of connective tissue around it. And the sheet of connective tissue should be mobile. The nerve should not be stuck and attached to the surrounding muscles. But when you have fibrosis, you can get fibrosis around the nerve, which then makes the nerve essentially lets mobile. It's less shear strength between the nerve and the surrounding tissue. And what they found is that there was less fibrosis surrounding these nerves in these animals. And they measured this... They graded myoinvasive protein in the nerves. And it was elevated in the non-massaged rat, and it was near normal in the massaged rat. So the nerve injury was prevented.
Til Luchau:
So we have that interesting evidence or interesting study in rats about massage and manual therapy's ability to help resolve inflammation. What can we extrapolate from that or guess, or what do we know about our ability to influence resolution? That's the question behind all this. But what do we know about our ability to influence that?
Helene Langevin:
We don't know a whole lot, other than there's a lot of effort in the pharmaceutical industry to develop compounds that you could take, resolve it, to improve inflammation, resolution. So far, I mean, for example, omega-three fatty acids, a lot of people think that by taking fish oil, that you could improve inflammatory conditions. The one condition where that has been shown is the rheumatoid arthritis. Patients with rheumatoid arthritis who take a supplement of fish oil have been show to have reduced inflammation, but not other conditions. People have tried with other, like asthma and inflammatory bowel disease. And it's not the cure that people are hoping.
Whitney Lowe:
Yeah. So I want to kind of take off from what you were saying, too. This is fascinating about these rat studies, and the changes that they found from soft tissue manipulation. From your perspective and the work that you've done, what do you see to be some of the most significant effects of manual soft tissue manipulation on the fascial system? What do you kind of sense to be the most impactful or powerful of those effects?
Helene Langevin:
I would say that one of the important things I already alluded to is that more is not necessarily better, right, that you have to be very careful about how much you do. Whether it's movement, exercise, or manual therapy, the dose matters. And we need to understand better how to apply by these forces without further injuring the tissues. And the other thing that's really important is to make sure that we understand the status of the underlying tissue. Imagine you have somebody who has either hypo or hyper mobility, right? We've described a situation of hypomobility, whereas layers are stuck together. But what if there's hypermobility? Patients who already have very loose connective tissue, for example, Ehlers-Danlos syndrome or the sort of generalized hypermobility disorders, which are quite common. What do you do in a situation like that, where somebody has pain and their tissues are already very mobile? You're not going to want to stretch them more, right?
Til Luchau:
They can be looking for more shear strain or more mobility necessarily.
Helene Langevin:
Yeah. Yeah. You could damage the tissues, and sometimes this happens, people who have hypermobility, they'll go, and they do yoga, and they injure themselves because they're trying to stretch, and they're already too much mobile. So the important is to be able to be judicious about when do you need to increase mobility via either stretching or what you may need, in a lot of cases, the strengthening the muscles so that they can support the tissues. More importantly, they may be a combination of the two. You may have somebody who's hypermobile generally, but who've had some injuries because a lot of people who are hypermobile have had a lot of injuries. And then in some cases, locally, you may have some areas of hypomobility. So you may have a mixture. People may need to be mobilized in some areas if they're stuck or they have a scar or an injury or an adhesion, but not everywhere. So this is where the art of a therapist comes in and be able to really understand that by palpating and feeling the tissues and watching how the patient moves.
Til Luchau:
Well, you've spoken eloquently in a couple different places about contextual effects or nonspecific effects of our work, too. So when we think about some of hypermobility, it's not like our only tool is loosening or more shear strain or something like that. There's many ways that we can leverage someone's experience besides tissue mobility.
Helene Langevin:
Yeah. Every therapy has contextual or, what we call, nonspecific effects, right?
Til Luchau:
Yeah.
Helene Langevin:
The interaction with the person, being in the presence of somebody who cares, who has a physical presence and sort of a support, and especially somebody who puts their hands on you, right? And then there's a lot of communication that can happen non-verbally through somebody's hands, but also talking. And when people feel that somebody who is a good therapist is actually physically kind of contacting the area that actually hurts in a way that's supportive and caring and intentional, that's very powerful psychologically. So yes, there's a lot of contextual effects, and these effects are part of the treatment. They're very important.
Til Luchau:
So are those real, or are they imaginary? I'm sorry. I get that. I'm sorry to ask that question. I didn't want to ask that.
Helene Langevin:
There's nothing imaginary about what I just described, right? This is all real. This is happening, whether it's happening in the person's nervous system. There's some incredible studies right now that are being conducted with a... They're mainly in the acupuncture world. That's fascinating. A patient and a practitioner that are being... Functional MRI scanning simultaneously, it's called hyperscanning. It's unbelievable. So what they do is they do sort of simulated treatment where the practitioner, I don't begin to understand the intricacies of these experiments, but basically this is just to show that there's... The therapeutic alliance between a patient and a practitioner is reflected in both of their brains at the same time. So there's this amazing communication that occurs in the nervous system during a treatment between the patient and the practitioner. And that's real. That's measurable.
Til Luchau:
Thank you.
Helene Langevin:
So, yeah, it's real.
Til Luchau:
Right. I mean, in some ways, no surprise, something's happening in both. There's brain and in other ways, so great that it's measurable and observable, and that someone like yourself can be a spokesman both for the mechanical effects on the tissue level but also saying, this is happening within a context. And let's not leave that out, too. What do you think, Whitney? Anything else?
Whitney Lowe:
Yeah, it does seem like there is a continuum there of those things. I remember seeing some other things written about acupuncture, about looking at effectiveness and saying that there were sometimes cultural factors and things like that that made it more effective with certain patient populations than others. And a lot of that had to do with belief in the treatment and things like that. And it is fascinating to see that intersection between what are potentially some of the more grounded, physiological effects and some of those other context effects that may also be interacting with the systems as well.
Helene Langevin:
And they're all very real. When we talk about what placebo effects are, I like to think of placebo effects as healing responses, self-healing responses that a person can activate in response to being in certain circumstances. And you can do a fake treatment, but there's still a treatment happening. There's still something that the person interprets as being some kind of trigger to help them to activate some healing responses that can happen even with placebos. So, yeah.
Til Luchau:
I'm glad you mentioned placebos because there's so much complication around that hypothetical question I asked you, is that real? And you've just made a really great case for how it's real, not only real, but it's part and parcel of what we offer.
Helene Langevin:
It's important. It's important that we understand what it is. Yeah.
Til Luchau:
Nice.
Helene Langevin:
And there's some excellent placebo research happening right now all over the world. This is an area of research that really needs more attention. It's very important.
Whitney Lowe:
Well, these are certainly fascinating topics. And I know we could go on for days digging into some of these things, but tell us a little bit, what will you be talking about at the Fascia Research Congress?
Helene Langevin:
I'll be talking about fascia. I'll probably, I mean, I don't have my entire talk mapped out at the moment, but one of the things I will very likely talk about is some of the new initiatives that NCCIH is leading. One is, I already mentioned, myofascial pain, developing technology to measure and especially imaging technologies to better understand myofascial tissues. We think this is absolutely crucially important. Another important initiative is something called RE-JOIN. And what that means is that, imagine a joint, right? Imagine somebody has pain in their knee, and their knee hurts. Well, you assume, right, that this person was saying, "Well, I have pain in my knee. It must be arthritis. It must be because my cartilage is kind of rubbing."
Helene Langevin:
People talk about bone on bone, that kind of thing, that's why you have pain. But there's a lot of things in the knee and around the knee besides cartilage. There's joint capsule. There are ligaments. There's fascia. There's muscles. How do you know, if you have pain in your knee, where your pain is coming from? You don't. And we know a lot less about what we call the periarticular structures around the knee than the articulate structures, the cartilage, the synovium, the bone because that's where we've been looking, we've been looking at. We have ways to image those structures, but we don't yet have very good ways to image what we call the soft tissues.
Helene Langevin:
So we think that by improving our ability to understand myofascial pain, this is also going to improve our ability to understand joint pain because we think that myofascial pain could be a big component of joint pain. And that problem with myofascial tissues may actually lead to joint pain because if your myofascial tissues are not healthy, if you have reduced mobility, if you have imbalance in your muscles, your joint may become misaligned. The mechanical forces on the joint are going to not be correct, and you're going to get wear in your articular surfaces. So by addressing the myofascial tissues, the periarticular tissues early, you might be able to prevent joint pains. So we think this is a really important area. I'm going to be talking about that.
Whitney Lowe:
Wonderful. Thank you so much for that. So with our audience being predominantly those doing soft tissue manipulation of various one form or another, is there anything else you'd like to leave to this audience to tell us before we wrap up today, last words of wisdom for those people doing this type of work?
Helene Langevin:
Well, a lot of what I talked about is about putting things together. I talked about connective tissue connecting the whole body. I talked about understanding the relationship between the musculoskeletal system and the immune system, right, inflammatory responses occurring within connective tissues, and also talked about the importance of what we call whole person health, which means paying attention to all of the different factors that kind of contribute to somebody being more versus less healthy, nutrition, physical activity, and also psychological factors like stress and sleep. All of these factors are important, and they're important no matter what part of the body you look at.
Helene Langevin:
So at NCCIH, our new strategic plan is really focused on this, on whole person health, and really understanding the factors that influence whether somebody is going to move towards disease or back towards health because we think this is an important piece. We're really focused a lot more on what we call pathogenesis, which is the creation of disease, as opposed to salutogenesis, which is the creation of health. We need to understand much better how to promote that, how to encourage healing of tissues and resilience and health restoration. So these are the components of whole person health or what the whole person, meaning, the whole, and health, which is moving towards the health directions.
Whitney Lowe:
Wonderful. Thank you so much. That's wonderful inspirational ideas for, I think, a lot of people who are doing this type of work.
Til Luchau:
And where would you send our listeners if they wanted to know more about your work?
Helene Langevin:
Well, the first thing I would suggest is that people visit our website at NCCIH.org, .NIH, right?
Speaker 4:
NCCIH.NIH.gov.
Helene Langevin:
.NIH.org, .gov, excuse me, what am I talking about? .gov.
Til Luchau:
.gov.
Helene Langevin:
And that to check out a lot of the presentations that I talked about are on my Director's Page. We also have links to videocast of the workshops that I mentioned that are all listed on our website. We also have a lot of information on various different kinds of therapies that we have. A lot of our science pages have many, many different information for practitioners, for consumers, for researchers. So it's a really good resource. And follow us on social media, Twitter, etc., so.
Whitney Lowe:
Well, that certainly sounds wonderful. And thank you again so much for your time today, Dr. Langevin. And we know you're very busy, and we really appreciate you taking the time out to speak with us and our listeners. So keep in mind, The Thinking Practitioner Podcast is supported by ABMP, the Associated Bodywork and Massage Professionals. ABMP membership gives professional practitioners like you a package including individual liability insurance, free continuing education and quick reference apps, legislative advocacy, and much more.
Til Luchau:
ABMP's CE courses, podcast, and massage and bodywork magazine always feature expert voices and new perspectives in the profession, including me, Til, and Whitney Lowe, were both there. Thinking Practitioner listeners can save on joining ABMP at abmp.com/thinking.
Whitney Lowe:
And we would like to say thank you to all of our sponsors. And to you, the listeners, we thank you for hanging out with us here today. Be sure to check out the Fascia Research Congress on their website there. You can stop by our sites for show notes where you can learn more about connecting with the Fascia Research Congress. So over there, show notes, transcripts, and any other extras, you can find that from my site at academyofclinicalmassage.com. And Til, from your site, where can people find that?
Til Luchau:
advanced-trainings.com. If there are questions or things you want to hear us talk about, e-mail us at [email protected] or look for us on social media just under our names, mine remains, Til Luchau. Whitney?
Whitney Lowe:
And mine's still today is Whitney Lowe. You can rate us on Apple podcasts as it helps other people find the show. And you can hear us on Spotify, Stitcher, Google Podcast, or wherever else you happen to listen. And please do share the word and tell a friend. It does help us get the word out and get other people exposed to it. So thank again, everybody. Thank you so much again, Dr. Langevin, for spending some time with us here today.
Til Luchau:
Thank you.
Whitney Lowe:
This is a wonderful, inspiring talk with everybody.
Helene Langevin:
Pleasure.
"Imagine somebody has pain in their knee, and their knee hurts. Well, you assume, right, that this person was saying, 'Well, I have pain in my knee. It must be arthritis. It must be because my cartilage is kind of rubbing.'
People talk about bone on bone, that kind of thing, that's why you have pain. But there's a lot of things in the knee and around the knee besides cartilage. There's joint capsule. There are ligaments. There's fascia. There's muscles. How do you know, if you have pain in your knee, where your pain is coming from? You don't. And we know a lot less about what we call the periarticular structures around the knee than the articulate structures, the cartilage, the synovium, the bone because that's where we've been looking, we've been looking at. We have ways to image those structures, but we don't yet have very good ways to image what we call the soft tissues.
People talk about bone on bone, that kind of thing, that's why you have pain. But there's a lot of things in the knee and around the knee besides cartilage. There's joint capsule. There are ligaments. There's fascia. There's muscles. How do you know, if you have pain in your knee, where your pain is coming from? You don't. And we know a lot less about what we call the periarticular structures around the knee than the articulate structures, the cartilage, the synovium, the bone because that's where we've been looking, we've been looking at. We have ways to image those structures, but we don't yet have very good ways to image what we call the soft tissues.
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So we think that by improving our ability to understand myofascial pain, this is also going to improve our ability to understand joint pain because we think that myofascial pain could be a big component of joint pain. And that problem with myofascial tissues may actually lead to joint pain because if your myofascial tissues are not healthy, if you have reduced mobility, if you have imbalance in your muscles, your joint may become misaligned. The mechanical forces on the joint are going to not be correct, and you're going to get wear in your articular surfaces. So by addressing the myofascial tissues, the periarticular tissues early, you might be able to prevent joint pains. So we think this is a really important area."
-Helen Langevin, from the discussion |
Let’s summarize some key takeaways from Dr. Langevin’s discussion:
The Active Role of Fascia
Far from being just a passive tissue, fascia actively coordinates movement and pain responses in the body. Dr. Langevin's early research into acupuncture revealed that connective tissue responds mechanically when needles are manipulated, indicating that fascia is highly responsive to external forces. This discovery points to fascia’s significant role in pain relief techniques like acupuncture and manual therapy.
The Active Role of Fascia
Far from being just a passive tissue, fascia actively coordinates movement and pain responses in the body. Dr. Langevin's early research into acupuncture revealed that connective tissue responds mechanically when needles are manipulated, indicating that fascia is highly responsive to external forces. This discovery points to fascia’s significant role in pain relief techniques like acupuncture and manual therapy.
Formation of a connective tissue “whorl” with needle rotation.
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Acupuncture points (AP) are often located where connective tissue planes meet, allowing the needle to interact with more connective tissue and create a stronger grasp response.
Connective tissue spools around a twisting acupuncture needle, creating a mechanical coupling and a localized stretch.
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Fascia and Chronic Low Back Pain
In one study, Dr. Langevin and her team explored the link between fascia and chronic low back pain using ultrasound imaging. They found that individuals with low back pain had 50% less shear strain in their thoracolumbar fascia compared to healthy individuals. This means that the layers of fascia in those with pain were less mobile, potentially contributing to stiffness and discomfort.
In one study, Dr. Langevin and her team explored the link between fascia and chronic low back pain using ultrasound imaging. They found that individuals with low back pain had 50% less shear strain in their thoracolumbar fascia compared to healthy individuals. This means that the layers of fascia in those with pain were less mobile, potentially contributing to stiffness and discomfort.
Fascia shear strain in chronic low back pain
These ultrasound videos are comparing the ability of fascia and muscle layers in the layers of the lower back to shear and glide during movement. The first is an example from the group that reports no back pain, and the second is an example from the group that does:
These ultrasound videos are comparing the ability of fascia and muscle layers in the layers of the lower back to shear and glide during movement. The first is an example from the group that reports no back pain, and the second is an example from the group that does:
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107 human subjects, 47 with no lower back pain (first video), 60 with chronic lower back pain over 1 year (second video).
The next image shows the ultrasound transducer imaging through the lumbar to make the videos above, with the different fascial layers color coded. Taken from this study (discussed further in video that follows below).
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Stretching and Inflammation
One of Dr. Langevin’s most intriguing findings is that gentle stretching complements the body’s natural healing processes by promoting the resolution of inflammation. This approach can work alongside other therapeutic methods to support recovery in a more holistic way. Watch the video below to learn more about this and about the study mentioned above.
One of Dr. Langevin’s most intriguing findings is that gentle stretching complements the body’s natural healing processes by promoting the resolution of inflammation. This approach can work alongside other therapeutic methods to support recovery in a more holistic way. Watch the video below to learn more about this and about the study mentioned above.
Key Research & Sources:
- Fascia Mobility, Proprioception, and Myofascial Pain
- Reduced thoracolumbar fascia shear strain in human chronic low back pain
- The Science of Acupuncture
- Mechanical signaling through the connective tissue: a mechanism for the therapeutic effect of acupuncture
- Relationship of acupuncture points and meridians to connective tissue planes
Compiled by Joe Liguori
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