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forms of fascial dysfunction and pathology, whether acquired or inherited. ADAPTATION: OVERUSE, MISUSE, DISUSE, AND TRAUMA Leaving aside fascia-related pathology, the effects of overuse, misuse, disuse, and trauma—resulting in pain and/or musculoskeletal dysfunction—are the features most likely to be brought to the attention of therapists and practitioners who employ manual and movement therapies. Pain and dysfunction represent the acute or chronic effects of adaptation, compensation, decompensation, and maladaptive changes that manifest in the musculoskeletal system. Such changes almost always involve structural and functional changes in connective tissues. In some circumstances, the normally well-organized functioning of fascial sheets, planes, bands, and fibers will have modified their force transmission/ load transfer activities, along with the reduced sliding potentials, possibly due to the evolution of areas of densification, adhesion, restriction, fibrosis, or scarring. 1 Klingler observes that "painful contractures and reduced range of motion are frequently associated with rigid collagenous tissue within and surrounding skeletal muscle, as well as other connective tissue involved in force transmission. The fascia/function, such as that involving joint capsules, tendons, or epi- and endomysium may be disrupted by trauma and/or inflammation." 2 Such changes may occur locally, or might involve more widespread, sometimes global, postural distortions, associated with a redirection of the vectors of mechanical force, potentially leading to musculoskeletal restrictions and pain, as well as modified circulatory and drainage effects. While many other causative factors may also be involved in symptom production and maintenance, the major features of fascia- related dysfunction are likely to include: • Modified, usually reduced (but sometimes increased) local or general ranges of motion associated with altered tissue viscoelasticity and resilience (potentially involving joints), as well as soft-tissue structures, and commonly associated with pain, usually perceived on movement. • Altered load transfer features, potentially producing symptoms at a distance from the origins of the problem. • Loss of sliding potential between tissue surfaces. • Postural deviations and misalignments, frequently involving chain reactions of adaptation and compensation—commonly associated with impaired coordination and motor control—usually evident during the performance of normal daily activities. • Myofascial (i.e., trigger-point related) pain. • Autonomic imbalance, including sympathetic arousal or chronic fatigue. All or any of these (and other) adaptive changes, signs, and symptoms might evolve gradually over time. However, they may also appear rapidly—for example, soon after inflammation-inducing events. CAUSES, EFFECTS, AND PREVENTION Now let's talk about these examples of the evolution of fascia-related dysfunction and disease, under the following subheadings: • Densification and loss of fascial sliding function • Load transfer/force transmission issues • Fascia and aging • Myofascial pain • Trauma and wounds DENSIFICATION AND LOSS OF FASCIAL SLIDING FUNCTION A clinically underexplored function of many soft tissues involves their ability to slide, glide, and generally accommodate the movements of adjacent structures. Loose connective tissue (also known as areolar or superficial fascia) is relatively less structurally organized, as compared with dense connective tissue layers. Pilat notes that the processes involved in the thickening and densification of the loose connective tissues and their extracellular matrix (ECM) appear to correspond to the loss (or reduction) of sliding potential between dense fascial layers and adjacent structures. 3 This view is supported by Stecco et al., who note, "Ultrasound indicates that the main alteration in the deep fasciae is increased loose connective tissue between 82 m a s s a g e & b o d y w o r k m a r c h / a p r i l 2 0 1 9 Key Point Understanding adaptation is important to explain the etiology of dysfunction and to help determine appropriate therapeutic choices. So that manual and tool-assisted therapeutic interventions can be as clinically effective as possible, particular attention should be given to the evidence relating to the effects of different degrees and types of applied load. Different degrees, durations, and directions of applied load (for example, compression, shear force, stretch, etc.) have different neurological and biomechanical effects, with potential usefulness in different conditions and situations. Underlying all the considerations regarding clinical decision-making for the causes and maintaining features of fascial dysfunction, it is suggested that two useful questions be kept in mind: • How might etiological adaptive demands be minimized or eliminated? • How might function be improved so that adaptive demands can be better managed by self- regulating mechanisms?