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JAOA Vol 108 No 8 August 2008 379Chaudhry et al Original Contribution

Context: Although mathematical models have been devel-oped for the bony movement occurring during chiropracticmanipulation, such models are not available for soft tissuemotion.

Objective: To develop a three-dimensional mathematicalmodel for exploring the relationship between mechanical forcesand deformation of human fasciae in manual therapy using a

finite deformation theory.Methods: The predicted stresses required to produce plasticdeformation were evaluated for a volunteer subjects fascialata, plantar fascia, and superficial nasal fascia. These stresseswere then compared with previous experimental findings forplastic deformation in dense connective tissues. Using the three-dimensional mathematical model, the authors determined thechanging amounts of compression and shear produced in fas-cial tissue during 20seconds of manual therapy.

Results: The three-dimensional models equations revealedthat very large forces, outside the normal physiologic range,are required to produce even 1% compression and 1% shear

in fascia lata and plantar fascia. Such large forces are notrequired to produce substantial compression and shear insuperficial nasal fascia, however.

Conclusion: The palpable sensations of tissue release thatare often reported by osteopathic physicians and other manualtherapists cannot be due to deformations produced in thefirm tissues of plantar fascia and fascia lata. However, palpabletissue release could result from deformation in softer tissues,such as superficial nasal fascia.

J Am Osteopath Assoc. 2008;108:379-390

Fascia is dense fibrous connective tissue that connects mus-cles, bones, and organs, forming a continuous network oftissue throughout the body. It plays an important role intransmitting mechanical forces during changes in humanposture. Several forms of manual fascial therapiesincludingmyofascial release and certain other techniques in osteo-pathic manipulative treatment (OMT)have been devel-oped to improve postural alignment and other expressions

of musculoskeletal dynamics.1,2 The purpose of these thera-pies and treatments is to alter the mechanical properties offascia, such as density, stiffness, and viscosity, so that thefascia can more readily adapt to physical stresses.3,4 In fact,some osteopathic physicians and manual therapists reportlocal tissue release after the application of a slow manualforce to tight fascial areas.2,4,5 These reports have beenexplained as a breaking of fascial cross-links, a transitionfrom gel to sol state in the extracellular matrix, and otherpassive viscoelastic changes of fasciae.2,4,5

The question of whether the applied force and durationof a given manual technique (eg, myofascial) could be sufficient

to induce palpable viscoelastic changes in human fasciae isunresolved, with some authors1,5,6 supporting the likelihoodof such an effect and others7,8 arguing against it.

Our intent in undertaking the present study was to resolvethis question. Therefore, we present an original mathematicalmodel to determine if forces applied in manual therapy are suf-ficient to produce tissue deformation in human fasciae.

BackgroundThe mechanical properties of ex vivo rat superficial fascia(ie, subcutaneous tissue) under uniaxial tension have beenreported by Iatridis et al,9 who investigated the potentialimportance of uniaxial tension in a variety of therapies

involving mechanical stretch. The mechanical properties ofin vitro human superficial nasal fascia and nasal periosteumwere investigated by Zeng et al10 to determine under whichtissue layer silicon implants should be inserted for improvedresults in aesthetic surgical corrections of congenital saddlenose and flat nose. Similarly, the mechanical properties ofin vitro fascia lata and plantar fascia have been investigated byWright and Rennels.11 The results of each of these studies offascial mechanical properties can be used in determining thetypes and strengths of mechanical forces needed to producedesired deformations during manual therapy.

Three-Dimensional Mathematical Model for Deformationof Human Fasciae in Manual Therapy

Hans Chaudhry, PhD; Robert Schleip, MA; Zhiming Ji, PhD; Bruce Bukiet, PhD;Miriam Maney, MS; and Thomas Findley, MD, PhD

From the departments of Biomedical Engineering (DrsChaudhry and Findley),Mechanical Engineering (Dr Ji), and Mathematical Sciences (Dr Bukiet) atthe New Jersey Institute of Technology in Newark; the Department of AppliedPhysiology at Ulm University in Germany (MrSchleip); and the War-RelatedIllness and Injury Study Center at the Veterans Affairs Medical Center in EastOrange, NJ (Drs Chaudhry and Findley, Ms Maney).

This study was partially supported by a dissertation grant from the Inter-national Society of Biomechanics to Mr Schleips Fascia Research Project.

Address correspondence to Zhiming Ji, PhD, Department of MechanicalEngineering, New Jersey Institute of Technology, Newark, NJ 07102-1982.

E-mail: [email protected]

Submitted March 23, 2006; revision received June 20, 2006; accepted August10, 2006.

ORIGINAL CONTRIBUTION

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380 JAOA Vol 108 No 8 August 2008

In recommending further study of manual therapies,Threlkeld7 noted that the three-dimensional dispersion offorces in relatively intact regions of the human body had yetto be investigated. Although mathematical models have since

been developed for the bony movement resulting from applied

forces in chiropractic high-velocity manipulations with humansubjects,12-15 no such attempts have yet been madeto ourknowledgefor other manual therapies, including OMT.

This lack of a mathematical model motivated us to modelthe relationship between mechanical forces and deformationof human fasciae during manual therapy. We believe that thisnew mathematical model may be useful in future calculationsof the forces required to induce desired plastic tissue defor-mations in a manual therapeutic context, including in suchosteopathic manipulative procedures as soft tissue techniquesand fascial-ligamentous release.

MethodsBecause fasciae are known to experience finite strain,10 weused a finite deformation theory of elasticity16 to develop ourthree-dimensional model for exploring the relationship betweenmechanical forces applied on the surfaces of human fascia inmanual therapy and the resulting deformation of the fascia. Incontinuum mechanics, finite deformation theory is used whenthe deformation of a body is sufficiently large to overcomethe assumptions inherent in small strain theory.16 This is com-monly the case with elastomers and other fluids and biolog-ical soft tissue.16

We then applied this model to manual therapy in a lab-oratory setting to evaluate the mechanical forces needed to

produce specific types of deformation in fascia lata, plantarfascia, and superficial nasal fascia. We used previously reportedlongitudinal stress-strain data10,11 in the application of ourmodel.

The inclusion of superficial nasal fascia, which is muchsofter tissue than fascia lata and plantar fascia, allowed us totest whether our model equations could predict significantcompression and shear in pliable tissue compared with stifftissue. The present study was conducted with the approval ofthe Institutional Review Board at the Veterans Affairs MedicalCenter in East Orange, NJ.

New Mathematical Model

Our three-dimensional model (Figure 1) allowed us to deter-mine the mechanical forces applied on the surfaces of fascia thatresult in particular types of deformation. Because of the lackof more specific data on the structure of superficial nasal fasciaand its mechanical properties, we assumed for the purpose ofthis first mathematical model that this fascia was isotropic.We also followed the assumption that fascia lata, plantar fascia,and superficial nasal fascia are composed of incompressiblematerial,10 as are most soft biological tissues.

The basic kinematics and kinetics equations used to eval-uate the stresses under specified deformations are presented

below and in subsequent pages in equations(1-4, 10, 12, 13).16

The stress results from these equations were required to sat-isfy differential equations of equilibrium and boundary con-ditions, which in turn allowed us to determine the mechanicalforces needed to produce the specified deformations.

The metric tensorsgij andgij in the Cartesian coordinatesxi (i = 1, 2, 3) in the undeformed state are given by the fol-lowing:

xr xr xi xj(1) gij = , gij = , (r = 1, 2, 3; i, j = 1, 2, 3)

xi xj xr xr

The repeated index, r, in equation (1) means summation overr.

Similarly, the metric tensors Gij and Gij in the deformed-state Cartesian coordinatesyr (r = 1, 2, 3) are given by the fol-lowing:

yr yr yi yj(2) Gij = , Gij = , (r = 1, 2, 3; i, j = 1, 2, 3)

yi yj yr yr

From equation (1), we find that:

(3) gij =gij = ij (Kronecker delta),g = gij

In equation (3), gij is the determinant of the matrixgij. Thus,g = 1.

The metric tensors defined in the equations presentedabove are the measures of fascial deformation in three dimen-sionswhen the fascia are subjected to normal, longitudinal,and tangential forces. The physical meaning of these tensorscan be understood by their relation to the strain Eij in the fol-lowing equation:

Gij _gij(4) Eij =

2

Deformation of FasciaeWe assumed the manipulation-caused fascial deformations of shear and elongation along thex1-axis, extension along the x2-axis, and compression alongthe negative x3-axis (Figure 1) to be given by the following:

(5) y1 = x1 + k1x3 + k4x1,y2 = k2x2,y3 = k3x3,(k3 < 1, k1, k2, k4 > 0)

In equation (5), theyi-axes in the deformed state of the fasciacoincide with the xi-axes in the undeformed state of the fascia.

Also in equation(5), k1 denotes the shear ratio due to theapplication of the tangential force. The maximum shear occursat the surface of the fascia, where the fascial thickness is at itsmaximum. The shear is zero at the bottom of the fascia, wherefascial thickness is zero. In addition,k4 is the extension ratio dueto the applied longitudinal force, k3 denotes the compression

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JAOA Vol 108 No 8 August 2008 381

The strain invariantsI1,I2, andI3 (which are needed to eval-uate stresses) are given by the following:

G(8) I1 =grsGrs , I2 =grsGrs, I3 = g

In equation (8), G is the determinant of the matrix Gij, while Gfrom equation (6) is: k22 [(1 + k4)2 k32]. The invariants in equa-tion (8) are invariants in strain that do not change with the coor-dinate system.

Using equations (3) and (6) through (8), we get the fol-lowing:

(k32 + k12) 1 1(9) I1 = k12 + k32 + k22 + (1 + k4)2;I2 = + + ;(1 + k4)2 k32 k22 k23

GI3 = = k22 [(1 + k4)2 k32]g

Because the fasciae are assumed to be incompressible, wehave:

1I3 = 1, thus, k2 =

k3(1 + k4)

To determine the tensor Bij (which is needed to evaluatestresses), we can use the following equation:

(10) Bij =I1gij girgjsGrs

ratio due to the applied normal pressure, and k2 is the exten-sion ratio resulting from the compression caused by manualtherapy on the surface of the fascia.

Typically, in OMT and other forms of manual therapy,compression and shear are applied to most fasciae. However,

in some cases, such as with fascia lata, extension is also applied,such as by bending the lower leg at the knee. It should benoted that smaller values ofk3 mean more compression. Forexample, k3 = 0.90 means 10% compression. The values for k2can be determined in terms of k3 and k4 using the incom-pressibility condition described in equations(9) through (11).

Thus, using equations(2) and (5), we get the following (inwhich zero represents the value of the corresponding tensorelements):

(1 + k4)2 0 k1(1 + k4)(6) Gij = 0 k22 0

k1(1 + k4) 0 k12 + k32

(k32 + k12) k1 0 k32(1 + k4)2 k32(1 +k4)

(7) Gij = 10 0

k22

k1 1 0 (1 + k4)k32 k32



Normal Force

x2,y2

x1,y1

x3,y3

Face ADFE: x1=0Face BCGH: x1=aFace ABHE: x2=-bFace DCGF: x2=bFace EFGH: x3=0

Face ABCD: x3=c

A B

CD

E

F G

H

O

LongitudinalForce

TangentialForce

Figure 1. Three-dimensional model of fascial element subjected tonormal, tangential, and longitudinal forces in the undeformed state.The axes (x1, x2, x3) in the undeformed state coincide with the axes (y1,

y2, y3) in the deformed state. The six faces of this modeled fascial ele-ment are designated with capital letters. The symbols a, b, andc rep-resent the coordinate values of the faces along the x1, x2, andx3 axes.

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Therefore, using equations (3), (7), and (10), we obtain:

k12 + k22 + k32 0 k1(1 + k4)(11) Bij = 0 k12 + k32 + (1 + k4)2 0

k1(1 + k4) 0 k22 + (1 + k4)2

Stress EvaluationThe stresses placed on fascia can beevaluated by using the following equation13:

(12) ij = gij + Bij + pGij

In equation (12), we note the following:

W W W(13) = 2 , = 2 , p = 2

I1 I2 I3

In equation (13), Wis the strain energy function.

In our mathematical model, we used the form of the strainenergy function for isotropic soft tissues described byDemiray.17 This function is given by:

(14) W= C1[eC2(I13) 1]

In equation (14), C1 and C2 are mechanical parameters to bedetermined, with C1 analogous to the modulus of elasticity andC2 a dimensionless constant. These parameters are both anal-ogous to the elastic parameters in the small deformation theoryof elasticity.16 The values of these parameters can be deter-mined by curve fitting, as explained in Estimation of Mechan-ical Constants on page 383. In equation (14), e = 2.71828,

which is the base of an exponential function.Using equations (3), (5), (11), and (12), we find that the

stresses are given by the following set of equations (with thesuperscripts after representing indices in the tensor nota-tion):

(k32 + k12)11 = + (k12 + k22 + k32) + p

k32 (1 + k4)2

122 = + k12 + k32 + (1 + k4)2 + p()

k22

p(15) 33 = + k22 + (1 + k4)2 +

k32

12 = 21 = 0

23 = 32 = 0

pk113 = 31 = [k1(1 + k4)]

k32(1 + k4)

In these equations, p is a scalar invariant denoting the pressureused for incompressibility constraint.

Equations of EquilibriumIt should be noted that all ofthe stresses in our mathematical model are constants. There-

fore, the equations of equilibrium in Cartesian coordinatesare satisfied because p is a constant in the following:

p p p= = = 0

y1 y2 y3

To determine the value ofp, we used our model to make thenormal stress (33) vanish when there is no deformation(ie, when k1 = k4 = 0 and k3 = k2 = 1). Then, we find that p = (+ 2). Substituting this value ofp in the equations for otherstresses in (15), the stresses then reduce to the following:

k32 + k12 (k32 + k12)

11 = 1- + k12 + k22 + k32 - 2 k32 (1 + k4)2 k32 (1 + k4)2

1 222 = 1- + k12 + k32 + (1 + k4)2 -

k22 k22

1 2(16) 33 = (1- )+ (1 + k4)2 + k22 -

k32 k32

k1 2k113 = 31 = + - k1 (1+k4)

k32(1 + k4) k32(1 + k4)

12 = 21 = 23 = 32 = 0

For the stresses in equation(16), the following should be noted:

1k2 =

k3(1 +k4)

Boundary Conditions (Formulae for Applied Forces)Wenext determined the surface forces placed by manual therapyon the fascial faces that were initially located (ie, located beforedeformation) at x1 = a, x2 = b, and x3 = c (Figure 1). All the fas-cial faces become curved in the deformed state during manualtherapy, so the directions of the unit normal to these faces (ie,the vectors perpendicular to the faces) change.

For the face that was initially located at x1 = a, the unitnormal vector in the deformed state is given by the following:

G1 = G11

In the above equation, G1 is the contravariant base vector.



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On the face that was initially located at x3 = c (Figure1), theapplied normal force (N) can be evaluated as the following:

(19) N= k3233 = (k32 1) + [k22k32 + (1 + k4)2k32 2]

Because k3

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In equation (25), is the longitudinal Eulers stress, andE is theGreens strain tensor.18 Greens strain tensor is the strain tensorreferring to the undeformed coordinates, whereas Eulersstrain tensor refers to deformed coordinates. The stress corre-sponding to Eulers strain is Eulers stress.18 Greens straintensor can be calculated by the following:

1(26) E = (2 1)

2

In equation (26), is the stretch ratio. In equation (25), and,which were taken from one of the in vitro human superficialnasal fascia specimens (n10js) reported in Zeng et al,10 are: =16.85, = 1.99. We chose this specimen, which was the softestof all four specimens of fascia reported by those researchers,10

to determine if our model equations could predict significantcompression and shear in such an extreme case.

We also used the longitudinal stress-strain relation for

incompressible material16 in our model. This relation isexpressed by the following set of equations:

1 2(27) = 2C1C2(2 )eC2(I13), with = 0, I1 =2 + ,

1

using 12 = 2, 22 = 32 =

We next used the theoretical stress given by equation (27)and the experimental stress given by equation(25) to calculatethe values ofC1 and C2 that would allow the theoretical andexperimental curves of stress-stretch ratio to be as close to

each other as possible (Figure2). Our model minimized the sumof the squares of difference between the theoretical and exper-imental values of stress by using the least-square method19

directly on equations (25) and (27), in conjunction with a finite-difference method adapted from Newtons method for non-linear equation systems.20 The computed value ofC1 was0.0327 MPa, and that ofC2 was 8.436 MPa.

Following the above procedure in conjunction with theavailable in vitro longitudinal stress-strain data from Wrightand Rennels,11 we determined the values of the elastic constant,C1, and the dimensionless constant, C2, for fascia lata andplantar fascia (Table 1). The mechanical constants for superfi-cial nasal fascia were determined based on Zeng et al.10

Model Equations in the Laboratory SettingWe used our model equations to evaluate the deformationsproduced as a result of manual therapy in a subjects fascia lata,plantar fascia, and superficial nasal fascia. These fascia weresubjected to normal pressure and shear forces (ie, without thelongitudinal force). Fascia lata and plantar fascia are commonsites for soft tissue osteopathic manipulative techniques inpatients.21

The subject in our laboratory setting was the lead authorof the present study (H.C.). Manual therapy was provided by

Jason DeFillipps, a rolfer who trained at the Rolf Institute inBoulder, Colo. Rolfing, which is also referred to as structuralintegration in osteopathic medicine, is a manual technique inwhich the practitioner is trained to observe both obviousmovement of the skeleton and more subtle motion evidenced

by slight muscle contraction visible through the overlyingskin.1,22 Rolfers are not trained in diagnosis and treatment ofspecific conditionsas are osteopathic physiciansbut ratherin therapies to improve posture and general ease of func-tion.1,22

First, we conducted a laboratory test on the superficialnasal fascia of the subject to determine the amount of com-pression and stretch that is produced under the measuredvalues of normal pressure and shear force. This test allowedus to compare the elastic properties of the subjects nasal fasciawith that of the in vitro nasal fascia specimen reported byZengetal.10 For this test, the subject lay supine on a rigid plat-

form on a force plate of the EquiTest computerized dynamicposturography apparatus (SmartEquitest System 2001; Neu-roCom International Inc, Clackamas, Ore), which is capable ofmeasuring the vertical ground reaction force and the shearforce with a resolution of 0.89 N.

The therapist manipulated the nasal fascia of the subjectwith two fingers oriented caudally at a 30-degree angle to thesurface of the skin just superior to the cartilaginous structureof the nose. Both normal and tangential pressure were appliedwith the rolfing technique (ie, structural integration).1 Thistechnique is generally regarded as the form of manual therapythat uses the greatest pressure.1 The ground reaction and shearforces were collected with the EquiTest device for 20 seconds,

sampled at a rate of 100 Hz, both before and during myofas-cial manipulation. Because we encountered technical prob-lems with the initial synchronization in data collection forsuperficial nasal fascia, we did not use the data collectedduring the first 4 seconds for this tissue. In the case of fascia lata,however, we were able to use the data generated through theentire 20-second collection period.

ResultsMeasurements of Compression and ShearThe values at any time, t, during the 16-second collectionperiod for change in ground reaction forces before and duringmyofascial manipulation of the subjects superficial nasal fascia

are plotted inFigure 3A (applied normal force) andFigure 3B(applied shear force). The change in the measurements showninFigure 3A andFigure 3B is the normal force and the tan-gential (ie, shear) force, respectively, applied by the manualtherapist. These forces were converted into the normal pressureand the tangential stress by dividing the forces by the area ofpressure application, which was 1.27 in2 (8.18 cm2).

The predicted values ofk3 and k1 (the compression andshear ratios, respectively) at any time, t, during the 16-secondcollection period for superficial nasal fascia were determinednumerically by solving the set of nonlinear equations (22) and



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(shear force). The plots for values of the compression ratio (k3)and shear ratio (k1) for fascia lata are not presented because they

were negligibly small under the applied loads. In the case offascia lata, a predicted normal load of 9075N (925 kg) and a tan-gential force of 4515 N (460 kg) are needed to produce even1% compression and 1% shear. Such forces are far beyond thephysiologic range of manual therapy.

Although the shear force applied to the subjects plantarfascia was measured using the EquiTest apparatus, it was notpossible to measure the normal force on the plantar fasciausing this device (ie, the normal force is parallel to the surfaceof the devices platform). For measuring the normal force, we

(23). These values are plotted inFigure3C (k3) andFigure3D (k1).The applied pressure, on average, was 52 kPa.

Figure3A illustrates that a maximum applied compressiveforce of approximately 100N occurs at the time of aboutt = 7.25seconds. The force at this time must produce the maximumobserved compression of the subjects superficial nasal fascia.This conclusion can be verified from the data in Figure 3C,which shows that a maximum compression of k3 = 0.91(ie, 9% compression) also occurs at about t = 7.25 seconds. Asimilar relation between the timing and amount of maximumapplied shear force (Figure 3B) and maximum shear produced(Figure 3D) was also observed.

These data allowed us to compute the time history ofcompression and stretch of superficial nasal fascia producedduring manual therapy. The resulting theoretical predictions

based on our mathematical model are physiologically rea-sonable. Thus, as much as 9% compression and 6% shear can

be achieved in superficial nasal fascia with forces in the rangetypically applied during manual therapies.

The same laboratory procedure and mathematical mod-eling used for the subjects superficial nasal fascia was alsoapplied to the subjects fascia lata and plantar fascia, basedon equations (22) and (23).

The plots of applied normal force and applied shear forcefor the subjects fascia lata during the 20-second data collectionperiod are presented inFigure4A (normal force) andFigure4B



Stress,

MPa

Stretch Ratio ()

Experimental Stress-Stretch RatioTheoretical Stress-Stretch Ratio

1.0

0.2

0

1.00 1.05 1.10 1.15 1.20

0.4

0.6

0.8

Figure 2. Experimental and theoretical stress-stretch ratio curves for superficial nasal fascia.

Table 1

Mechanical Constants for Fasciae,Based on In Vitro Stress-Strain Data

Mechanical Constant, MPa*

Fascia Type C1 C2

Fascia lata11 2.883 32.419

Plantar fascia11 0.931 61.775Superficial nasal fascia10 0.033 8.436

* C1 is a constant analogous to modulus of elastcity; C2 is a dimensionlessconstant.

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used the Xsensor pressure mapping system (X3 Lite SeatSystem, Version 4.2.5; XSENSOR Technology Corp, Cal-gary, Canada). This system can also be used to measure themaximal therapeutic pressure application to an area of fascia

(Figure 5), a measurement that is useful to the manual thera-pist in patient treatment. The plots of normal and shear forcesapplied to the plantar fascia are presented inFigure4C (normalforce) andFigure 4D (shear force).

As with fascia lata, the plots for values of the compressionratio (k3) and shear ratio (k1) for plantar fascia are not pre-sented because they were negligibly small under the appliedloads. We found that, for plantar fascia, a normal load of8359 N (852 kg) and a tangential force of 4158 N (424 kg) areneeded to produce even 1%compression and 1% shear. Theseforces are far beyond the physiologic range of manual therapy,

as were the forces that were needed to produce compressionand shear in fascia lata. Thus, we conclude that the dense tis-sues of fascia lata and plantar fascia both remain very stiffunder compression and shear during manual therapy.

It was also observed, from equations (22) and (23), that fora specified value of compressive stress Nand shear stress T, thevalues ofk3 (compression) and k1 (shear) are not independent.If the values ofk3 and k1 are specified, the values of compres-sive stress and shear stress depend on each other. The relation

between these variables is given by the following:

k32 1N/T=

k1k3


Figure 3. Measured forces and predicted force values during a 16-second myofascial release technique applied to superficial nasal fascia:(A) applied normal force, (B) applied shear force, (C) predicted valuesof compression ratio (k3), and (D) predicted values of shear ratio (k1).

Smaller values of the compression ratio mean more compression,consistent with the pattern of normal force. The pattern of shearratio follows the pattern of shear force.


NormalForce,N

Time, s Time, s

ShearForce,N

ShearRatio(k1)

Superficial Nasal Fascia

CompressionRatio(k3)

A B

C D

100

90

80

70

60

50

40

30

20

10

0

0 2 4 6 8 10 12 14 160 2 4 6 8 10 12 14 16

1

0.99

0.98

0.97

0.96

0.95

0.94

0.93

0.92

0.91

35

30

25

20

15

10

5

0

0.07

0.06

0.05

0.04

0.03

0.02

0.01

0

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force values) in our model because there is a wide variation inthe cross-sectional area of fasciae, and the thickness in the areaof cross section (ie, width multiplied by thickness) has a neg-ative correlation with subject age.23 The experimental stressvalues used in our model were evaluated by dividing the

force values (246N-623 N) by the estimated area of cross sec-tion (0.312 cm2).23

To compare our predicted stress range for the plasticdeformation of 3% to 4.13%, based on our equation (24) in athree-dimensional setting and with an experimental stressrange provided by Threlkeld,7 we calculated the longitudinalstressF for the two dense fasciae (fascia lata and plantar fascia)using the following values:

k1 = 0 (no shear), k3 = 1 (no compression), k4 = 0.03-0.0413(for extension)

Similarly, the relation between compressive stress andshear stress from equations (22) and (24) can also be estab-lished. Thus, the manual therapist cannot apply the forcesarbitrarily if the fascia is to remain intact.

Comparison of Predicted Stresses for PlasticDeformation Under Longitudinal ForceWe find from experimental measurements by Threlkeld7 oftherapeutic pressure on fascia lata, which is plotted inFigure5,that plastic deformation in the range of 3% to 4.13% elongationin the microfailure region of connective tissue occurs in thestress range of 788N/cm2 to 1997 N/cm2. It is important to notethat inFigure 5, 3% elongation can be observed at 4 mm dis-placement when microfailure begins, and 4.13% elongation isinterpolated when microfailure ends, at 5.5mm displacement.

We used experimental stress values (but not experimental



Figure 4. Measured forces during a 20-second myofascial release tech-nique applied to fascia lata ([A] applied normal force, [B] applied

shear force) and plantar fascia ([C] applied normal force, [D] appliedshear force).

NormalForce,N

Time, s Time, s

ShearForce,N

Fascia LataA B

80

70

60

50

40

30

20

10

0

-10

45

40

35

30

25

20

15

10

5

0

0 2 4 6 8 10 12 14 16 18 20 0 2 4 6 8 10 12 14 16 18 20

ShearForce,

N

35

30

25

20

15

10

5

0

NormalForce,

N

80

70

60

50

40

30

20

10

0

-10

C DPlantar Fascia

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The ranges of predicted stress values we found for plasticdeformation of fascia lata and plantar fascia are provided inTable 2, with comparison to the known experimental fascial

stress range reported by Threlkeld.7 Also in Table 2 are thepredicted values of compression and shear ratios. Predictedresults for superficial nasal fascia are not included in Table 2

because superficial nasal fascia is not dense fascia and, thus,should not be compared with known experimental stressranges for dense fascia.

The differences between our predicted values for plasticdeformation of fascia lata and plantar fascia and the experi-mental values for plastic deformation of general fascia7 can beattributed to the fact that mechanical properties of the fasciaeof our subject (H.C.) may be different from those of the in vitrosample of connective tissue reported by Threlkeld.7 More-over, Threlkeld7 obtained his experimental values for stress

range by assuming a linear stress-strain relation, whereas ourpredictions are based on the actual nonlinear stress-strain rela-tion observed in our volunteer subject.

We also note that for superficial nasal fascia, the predictedstresses for plastic deformation are very low (3.46-4.92 N/cm2)as would be expected because superficial nasalfascia consists of very soft tissues.

CommentOur mathematical model of deformation of human fasciacan also be used for fascia that is deformed by elongation only

(k3 = 1, k1 = 0), compression only (k4 = k1 = 0), or shear only(k3 = 1, k4 = 0).

We can use the values of the mechanical parameters

obtained in the present study to perform finite element anal-yses on the actual irregular shape of fasciae. As previouslynoted, the mathematical model we present in the current studyis based on the assumption that fascia is an isotropic material.However, in some parts of the body, there are clear direc-tional differences in fascial structural propertiesdifferencesthat are often exploited by surgeons in planning skin inci-sions.24 If fascia is anisotropic, then the elastic properties ofanisotropic fascia in three dimensions must be determined infuture calculations to obtain accurate predictions of tissuedeformation under applied force.

We used available in vitro data for dense fasciae7,11 toevaluate the magnitude of forces required to produce specific

deformations in these fasciae. We concluded that the magni-tude of these evaluated forces is outside the physiologic rangeof manual therapy. This conclusion is supported by the find-ings of Sucher et al6 that in vitro manipulation of the carpaltunnel area on human cadavers leads to plastic deformationonly if the manipulation is extremely forceful or lasts for sev-eral hours.

Ward25 describes manual techniques central to osteo-pathic medicine (integrated neuromusculoskeletal release,myofascial release) that are designed to stretch and reflex-ively release restrictions in soft tissue. These techniques incor-



Figure 5. Plot of experimental measurements of max-imal therapeutic pressure application (N/cm2) on fascialata,7 generated with the Xsensor pressure mapping

system (X3 Lite Seat System, Version 4.2.5; XSENSOR Tech-nology Corp, Calgary, Canada).

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pable effects are more likely the result of reflexive changes inthe tissueor changes in twisting or extension forces in thetissue.25

The mechanical forces generated by OMT and other formsof manual therapy may stimulate fascial mechanoreceptors,which may, in turn, trigger tonus changes in connected skeletalmuscle fibers. These muscle tonus changes might then be felt

by the practitioner.8 Alternatively, in vivo fascia may be ableto respond to mechanostimulation with an altered tonus reg-ulation of its ownmyofibroblast-facilitated active tissue con-tractility.26,27 Such alternative explanations for fascial responseto OMT and other manual therapies require further investi-gation.

AcknowledgmentsWe thank Jason DeFillipps, certified rolfer, for performing manual

therapy in the present study.

References1.Rolf IP. Fasciaorgan of support. In: Rolf IP. Rolfing: Reestablishing the Nat-ural Alignment and Structural Integration of the Human Body for Vitality andWell-Being. Rochester, Vt: Healing Arts Press; 1989:37-44.

2.Ward RC. Myofascial release concepts. In: Basmajian JV, Nyberg RE, eds.Rational Manual Therapies. Baltimore, Md: Williams & Wilkins; 1993:223-241.

3. Smith J. The techniques of structural bodywork. Structural Bodywork.London, England: Churchill Livingstone; 2005.

4. Stanborough M. Direct Release Myofascial Technique: An Illustrated Guidefor Practitioners. London, England: Churchill Livingstone; 2004.

5. Stecco L. Fascial Manipulation for Musculoskeletal Pain. Padova, Italy: PiccinNuova Libraria; 2004.

6. Sucher BM, Hinrichs RN, Welcher RL, Quiroz L-D, St Laurent BF, MorrisonBJ. Manipulative treatment of carpal tunnel syndrome: biomechanical andosteopathic intervention to increase the length of the transverse carpal lig-ament: part 2. Effect of sex differences and manipulative priming.J AmOsteopath Assoc. 2005;105:135-143. Available at: http://www.jaoa.org/cgi/content/full/105/3/135. Accessed July 29, 2008.

7.Threlkeld AJ. The effects of manual therapy on connective tissues. Phys Ther.1992;72:893-902. Available at: http://www.ptjournal.org/cgi/reprint/72/12/893.Accessed July 29, 2007.

8. Schleip R. Fascial plasticitya new neurobiological explanation: part 1.J Bodywork Movement Ther. 2003;7:11-19. Available at: http://www.somatics.de/FascialPlasticity/Part1.pdf. Accessed July 29, 2008.

(continued)

porate fascial compression, shear, traction, and twist. Ourresults indicate that compression and shear alone, within thenormal physiologic range, cannot directly deform the dense

tissue of fascia lata and plantar fascia, but these forces canimpact softer tissue, such as superficial nasal fascia.

ConclusionsWe have developed a three-dimensional mathematical modelfor establishing the relationship between the mechanical forcesand fascial deformations produced in manual therapy. Theexperimental results for the longitudinal stress-strain relationfor fascia lata, plantar fascia, and superficial nasal fascia pre-viously reported10,11 were compared with our original data.Because fascia is known to experience finite strain when sub-

jected to longitudinal force,10 a finite deformation theory16

was used to predict the magnitude of the mechanical forces

applied on the surface of fascia subjected to a specified finitedeformation. Thus, with the help of the equations developedin the present study, the amount of deformation produced infascia subjected to a known mechanical force can be deter-mined. Conversely, if the amount of deformation is known, themagnitude of force needed to produce it can be determined.

The mathematical model described in the present studyshould be of great value to osteopathic physicians and othermanual therapists, helping them determine the amount offorce required to deform connective tissue to a given extent. Inaddition, we used our new model to determine changes inthe amount of compression and shear produced with manualtherapy over time. These calculations were made possible by

using the EquiTest computerized dynamic posturographyapparatus and the Xsensor pressure mapping system.

Our calculations reveal that the dense tissues of plantarfascia and fascia lata require very large forcesfar outsidethe human physiologic rangeto produce even 1% com-pression and 1% shear. However, softer tissues, such as super-ficial nasal fascia, deform under strong forces that may be atthe upper bounds of physiologic limits. Although some manualtherapists3,4 anecdotally report palpable tissue release in densefasciae, such observations are probably not caused by defor-mations produced by compression or shear. Rather, these pal-



Table 2Stress Ranges for Plastic Deformation of In Vitro Fasciae,

With Compression and Shear Ratios

Fascia Type Stress Range, N/cm2 Compression and Shear Ratio Under Stress

Fascia lata* 1275.00-1949.00 Negligibly small

Plantar fascia* 869.65-1454.00 Negligibly small

General Fascia 788.00-1997.00 Data not provided

* Predicted stress range based on the authors original calculations. Experimental stress range based on analysis by Threlkeld7 using Xsensor pressure mapping system (X3 Lite Seat System,

Version 4.2.5; XSENSOR Technology Corp, Calgary, Canada).

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9. Iatridis JC, Wu J, Yandow JA, Langevin HM. Subcutaneous tissue mechan-ical behavior is linear and viscoelastic under uniaxial tension. Connect TissueRes. 2003;44:208-217.

10.Zeng YJ, Sun XP, Yang J, Wu WH, Xu XH, Yan YP. Mechanical propertiesof nasal fascia and periosteum.Clin Biomech (Bristol, Avon). 2003;18:760-764.

11.Wright DG, Rennels DC. A study of the elastic properties of plantar fascia.J Bone Joint Surg Am. 1964;46:482-492.

12.Keller TS, Colloca CJ, Bliveau JG. Force-deformation response of thelumbar spine: a sagittal plane model of posteroanterior manipulation andmobilization. Clin Biomech (Bristol, Avon). 2002;17:185-196.

13. Solinger AB. Theory of small vertebral motions: an analytic model com-pared to data. Clin Biomech (Bristol, Avon). 2000;15:87-94.

14.van Zoest GG, Gosselin G. Three-dimensionality of direct contact forces inchiropractic spinal manipulative therapy. J Manipulative Physiol Ther.2003;26:549-556.

15. van Zoest GG, van den Berg HT, Holtkamp FC. Three-dimensionality of con-tact forces during clinical manual examination and treatment: a new measuringsystem. Clin Biomech (Bristol, Avon). 2002;17:719-722.

16.Green AE, Zerna W. Theoretical Elasticity. Oxford, England: Clarendon Press;

1968.17.Demiray H. Stresses in ventricular wall.J Appl Mech. 1976;43:194-197.

18. Fung YC.A First Course in Continuum Mechanics. 3rd ed. Upper SaddleRiver, NJ: Prentice Hall; 1994:64-144.

19.Dahlquist G, Bjrck A. Approximation of functions. Numerical Methods.Mineola, NY: Dover Publications; 2003:81-136.

20.Gerald CF, Wheatley PO. Solving nonlinear equations.Applied NumericalAnalysis. 6th ed. New York, NY: Addison Wesley Pub; 1999.

21. Ward RC, ed. Foundations for Osteopathic Medicine. Baltimore, Md:

Williams and Wilkins; 1997:792-793.

22. Rolf Institute of Structural Integration Web site. Available at:http://www.rolf.org/. Accessed July 29, 2008.

23.Goh LA, Chhem RK, Wang SC, Chee T. Iliotibial band thickness: sono-graphic measurements in asymptomatic volunteers. J Clin Ultrasound.2003;31:239-244.

24.Cerda E. Mechanics of scars.J Biomech. 2005;38:1598-1603.

25.Ward RC. Integrated neuromusculoskeletal release and myofascial release.Foundations for Osteopathic Medicine. 2nd ed. Philadelphia,Pa: Lippincott,Williams & Wilkins; 2003:931-965.

26. Schleip R, Klinger W, Lehmann-Horn F. Active fascial contractility: fasciamay be able to contract in a smooth muscle-like manner and thereby influ-ence musculoskeletal dynamics. Med Hypotheses. 2005;65:273-277.

27. Schleip R, Naylor IL, Ursu D, Melzer W, Zorn A, Wilke HJ, et al. Passive musclestiffness may be influenced by active contractility of intramuscular connectivetissue. Med Hypotheses. 2006;66,66-71.



Principles to an Osteopath means a perfect plan and specification to build in form a house, anengine, a man, a world, or anything for an object or purpose. To comprehend this engine of lifeor man which is so constructed with all conveniences for which it was made, it is necessary toconstantly keep the plan and specification before the mind, and in the mind, to such a degree thatthere is no lack of knowledge of the bearings and uses of all parts.

Andrew Taylor Still, MD, DOPrinciples from Philosophy of Osteopathy (1899)

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